Niacin

Niacin is a required nutrient and is part of the B vitamin family. It is known as “nicotinic acid,” is found in red meat, chicken, turkey, beans, and grains. Taking niacin can cause a flushing or burning of your skin.

Niacin has many health benefits:

  • Increases high-density lipoprotein (HDL) by 20-35%. No other available over-the-counter treatments, and very few drugs, are as effective.
  • Decreases small LDL particles. Niacin is the most effective agent known for correcting this abnormal pattern.
  • Decreases triglycerides by 30%. Niacin is especially effective when taken with fish oil.
  • Decreases very low-density lipoprotein (VLDL) particles.
  • Decreases lipoprotein(a), or Lp(a). No other treatment approaches the power of niacin to reduce the genetically determined pattern of high Lp(a), which is among the most serious risk factors for heart disease.
  • Decreases low-density lipoprotein (LDL), usually by 20-40 mg/dL, or 5-25%.

Niacin’s benefits are not limited to its influence on blood markers of cardiovascular disease risk. It also reduces heart attack risk dramatically. The Coronary Drug Project was the first to establish that niacin is a powerful agent in lowering heart attack risk. When more than 1,000 heart attack survivors were given 3000 mg of (immediate-release/crystalline) niacin daily for six years, the incidence of recurrent non-fatal heart attacks was reduced by 27%, and the number of strokes was reduced by 26%.2

In the well-known HDL-Atherosclerosis Treatment Study (HATS), 160 participants were given niacin and simvastatin (Zocor®) or a placebo. Compared to the placebo group, the group receiving niacin and simvastatin experienced a 90% reduction in death and myocardial infarction over three years – coronary issues were nearly eliminated. Although the study sample was small, its results are striking. By comparison, statin drugs alone typically reduce heart attack risk by 25-35%. The 90% reduction achieved in the HATS trial thus is truly remarkable.

Despite niacin’s track record, many physicians have never learned how to use it effectively. Statin drugs have caused many physicians to forget how effective niacin can be. This is a shame, because niacin can be a powerful agent in combating heart disease, when used alone or in combination with other treatments, especially fish oil.

Niacin’s safety record is equally impressive. However, a brief foray into the use of very-slow-release niacin preparations in the 1980s taught us an important lesson: niacin is very safe, if the liver is exposed to it for only a few hours at a time. Niacin is, after all, just vitamin B3. However, 24-hour, day-after-day exposure to niacin over an extended period can be toxic to the liver. Thus, the very-slow-release niacin preparations that yielded sustained, high blood levels of niacin caused liver toxicity in 10-20% of people who used these preparations in the 1980s. Unfortunately, this learning experience left some physicians fearful of recommending niacin to their patients. For this reason, very-slow-release niacin should be avoided.

To raise HDL and correct small LDL, a dose of 750-1000 mg a day usually provides full benefit. Increasing this dose to 1500 mg a day may provide slightly greater benefit. To reduce LDL or Lp(a), higher doses (from 1000 mg up to 4000-5000 mg per day) are often used, with higher doses providing greater effects. However, doses this high should be taken only with a physician’s supervision. Keep in mind that it may take three months or longer to realize the full lipid-optimizing benefits of niacin.

As previously noted, the one common though generally harmless side effect of taking niacin use is hot flushes. Some people find them bothersome enough that makes them want to stop taking them.

The flush, which feels like blushing when one is embarrassed, combined with a heat feeling, is usually accompanied by a prickly sensation over the face, neck, and chest. Some women say it feels like the hot flashes of menopause. These flushes are usually short-lived, lasting no more than 20 minutes. Tolerance to this effect occurs with continued niacin use, usually after a few weeks or months. You may experience flushing at the start of your niacin program as well as when you increase your dose. In rare cases, a more marked flushing reaction may occur, resembling a rash or hives. If this occurs, speak to your doctor about whether you should continue using niacin.

You can employ several strategies to greatly minimize or even eliminate niacin-induced hot flushes:

  • Drink plenty of water. This is very important and especially helpful when you experience a hot flush: drink two 8- to 12-ounce glasses of water immediately, and the hot flush will almost always disappear within a few minutes. If you need to drink water to block hot flushes but find yourself getting up several times a night to urinate, take your niacin with dinner or breakfast. If you are restricting your fluid intake because of kidney disease, heart disease, water retention, or diuretic use, talk with your doctor before increasing your water intake
  • Take niacin after consuming a small handful of nuts, such as 5-10 raw almonds, walnuts, or pecans. This will slow niacin’s absorption in the body. You may want to skip this if you are limiting your calorie intake in order to lose weight. While some people recommend taking niacin with a low-fat snack, I discourage this approach, as low-fat snacks like crackers contribute to increased levels of dangerous small
  • Avoid alcohol and spicy foods when taking niacin. This strategy is not crucial for everyone, as only some people are sensitive to this phenomenon. You can consume alcohol and spicy foods apart from your use of niacin—for example, having a glass of wine at 7 p.m. and then taking niacin at 9 p.m. Only a few people will have more flushing due to the combination. Niacin may raise blood sugar by about 4-5 mg/dL at the beginning of therapy. This increase usually dissipates over a few months and is rarely clinically important. However, increases in blood sugar may be greater if you already have high blood sugar or diabetes. For this reason, niacin should be taken under medical supervision, with gradual increases in dosage, if you have high blood sugar. Having diabetes or pre-diabetes is not necessarily a contraindication to niacin use. In fact, people with these conditions are most likely to benefit from niacin, since diabetes and pre-diabetes are strongly associated with small LDL, low HDL, increased triglycerides, and other abnormalities that are corrected by niacin. Niacin therapy should be initiated in patients with low HDL levels (less than 40 mg/dL for men and less than 50 mg/dL for women), particularly if other risk factors are present. Niacin is among the most effective agents known for correcting the multiple causes of heart and vascular disease and has been shown to greatly diminish the risk of heart attack. Niacin is very safe and easy to use if used properly. In my experience, over 95% of people who follow these guidelines are able to take niacin with only minimal hot flushes. Potentially serious side effects are almost never seen.

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