II. Indications

  1. Older indications that should be reconsidered in light of AIM-High Study (Niacin did not appear effective in these cases)
    1. Low HDL Cholesterol
    2. Combination therapy with Statin for Hyperlipidemia
  2. Indications that are reasonable as of 2013
    1. Hypertriglyceridemia
    2. Hyperlipidemia Management in patients intolerant to Statins

III. Effects

  1. HDL increased (15-35%)
    1. No other agent raises HDL as much as Niacin
    2. However Niacin related HDL increase did not effect outcomes in 2011 AIM-HIGH study (prematurely stopped)
  2. Triglycerides decreased (20-50%)
  3. LDL Cholesterol decreased (10-25%)
    1. Significantly lowers LDL only at high dose
    2. Not a first-line agent for lowering LDL

IV. Efficacy

  1. Does not affect all cause mortality
  2. Statin with Niacin did not show benefit beyond Statin alone in AIM-HIGH study (2011)
  3. Studies since the 1980s to today have suggested coronary disease risk reduction, but benefit may be aside from affect on HDL Cholesterol
    1. Canner (1986) J Am Coll Cardiol, 8:1245 [PubMed]
    2. Lavigne (2013) J Am Coll Cardiol 61(4):440-6. [PubMed]

V. Adverse effects

  1. Flushing
  2. Pruritus
  3. Skin irritation of neck and face
  4. Gastrointestinal upset (Dyspepsia, Diarrhea)
  5. Blurred vision
  6. Fatigue
  7. Glucose intollerance
  8. Hyperuricemia and gout
  9. Peptic Ulcer Disease exacerbation
  10. Hepatic toxicity with sustained release forms
  11. Diabetes Mellitus (when Niacin is combined with a Statin)
    1. Increases risk of developing diabetes or worsening diabetes control
    2. (2014) N Engl J Med 2014 371:203-12 [PubMed]

VI. Adverse Effects: Compliance and tolerance

  1. Poor Compliance: 40% discontinue use
  2. Reduced Flushing and Pruritus reaction
    1. Use Aspirin or Ibuprofen pretreatment
    2. Take dose with food

VII. Contraindications

VIII. Preparations: Niacin

  1. Crystalline Niacin
    1. Dose: 1g PO tid ($5.50/mo) MAX: 6 g/day
    2. Example protocol (Use 500 mg tablets)
      1. Start: 250 mg at bedtime
      2. Titrate up over 6 weeks to 500 mg tid
    3. Pretreatment: Aspirin 81 mg before or Ibuprofen
  2. Niaspan (preferred)
    1. Safest of Niacins (only 4% GI side effects)
    2. More expensive than crystalline Niacin
    3. Example protocol for initiating doses
      1. One 500 mg tablet PO qhs for 1 month
      2. Two 500 mg tablets PO qhs for 1 month
      3. One 1000 mg tablet PO qhs for 1 month
      4. Check lFTs, Uric Acid, Glucose at 3 months
      5. Two 1000 mg tablets PO qhs
    4. References
      1. McBride (2003) New Therapeutics Lecture, Cable, WI
  3. Agents to avoid
    1. Avoid flush-free or no-flush Niacin
    2. Avoid Slow Niacin (Sustained Release)
      1. Decreased Safety due to hepatotoxicity

IX. Preparations: Niacin combined with other agents

  1. Advicor: Niaspan (500-1000 mg) and Lovastatin (20-40 mg)
  2. Simcor: Niaspan (500-1000 mg) and Simvastatin (20 mg)
  3. Cordaptive: Niacin (extended release) with Laropiprant (to reduce Flushing)

X. Monitoring: Monitor while checking dose

  1. Glucose
  2. Liver transaminases
  3. Uric Acid

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Cost: Medications

niacin (on 8/17/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
NIACIN ER 1,000 MG TABLET Generic $2.42 each
NIACIN ER 500 MG TABLET Generic $1.36 each
NIACIN ER 750 MG TABLET Generic $2.50 each

Ontology: Niacin (C0027996)

Definition (NCI_NCI-GLOSS) A nutrient in the vitamin B complex that the body needs in small amounts to function and stay healthy. Niacin helps some enzymes work properly and helps skin, nerves, and the digestive tract stay healthy. Niacin is found in many plant and animal products. It is water-soluble (can dissolve in water) and must be taken in every day. Not enough niacin can cause a disease called pellagra (a condition marked by skin, nerve, and digestive disorders). A form of niacin is being studied in the prevention of skin and other types of cancer. Niacin may help to lower blood cholesterol.
Definition (NCI) A water-soluble vitamin belonging to the vitamin B family, which occurs in many animal and plant tissues, with antihyperlipidemic activity. Niacin is converted to its active form niacinamide, which is a component of the coenzymes nicotinamide adenine dinucleotide (NAD) and its phosphate form, NADP. These coenzymes play an important role in tissue respiration and in glycogen, lipid, amino acid, protein, and purine metabolism. Although the exact mechanism of action by which niacin lowers cholesterol is not fully understood, it may act by inhibiting the synthesis of very low density lipoproteins (VLDL), inhibiting the release of free fatty acids from adipose tissue, increasing lipoprotein lipase activity, and reducing the hepatic synthesis of VLDL-C and LDL-C.
Definition (NCI_CRCH) Water-soluble vitamin that is a cosubstrate or coenzyme with numerous dehydrogenases for the transfer of the hydride ion. (DRI)
Definition (MSH) A water-soluble vitamin of the B complex occurring in various animal and plant tissues. It is required by the body for the formation of coenzymes NAD and NADP. It has PELLAGRA-curative, vasodilating, and antilipemic properties.
Definition (CSP) nicotinic acid (3-pyridinecarboxylic acid) and its derivatives; a water soluble B vitamin which is the precursor of NAD and NADP.
Definition (PDQ) A water-soluble vitamin belonging to the vitamin B family, which occurs in many animal and plant tissues, with antihyperlipidemic activity. Niacin is converted to its active form niacinamide, which is a component of the coenzymes nicotinamide adenine dinucleotide (NAD) and its phosphate form, NADP. These coenzymes play an important role in tissue respiration and in glycogen, lipid, amino acid, protein, and purine metabolism. Although the exact mechanism of action by which niacin lowers cholesterol is not fully understood, it may act by inhibiting the synthesis of very low density lipoproteins (VLDL), inhibiting the release of free fatty acids from adipose tissue, increasing lipoprotein lipase activity, and reducing the hepatic synthesis of VLDL-C and LDL-C. Check for "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=38351&idtype=1" active clinical trials or "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=38351&idtype=1&closed=1" closed clinical trials using this agent. ("http://nciterms.nci.nih.gov:80/NCIBrowser/ConceptReport.jsp?dictionary=NCI_Thesaurus&code=C689" NCI Thesaurus)
Concepts Organic Chemical (T109) , Vitamin (T127) , Pharmacologic Substance (T121)
MSH D009525
SnomedCT 419923002, 55013001, 273943001, 63639004
LNC LP14887-1, MTHU002113
English 3 Pyridinecarboxylic Acid, 3-Pyridinecarboxylic Acid, Acid, 3-Pyridinecarboxylic, Acid, Nicotinic, Nicotinic Acid, 3-Pyridinecarboxylic acid, Niacin, niacin, vitamins niacin, vitamins nicotinic acid, nicotinic acid (medication), niacin (medication), NIACIN, Niacin [Chemical/Ingredient], nicotinic acid, Niacin (substance), Vitamin B-3, Nicotinamide, Nicotinic Acid Amide, Antipellagra factor, Nicotinic acid, Niacin preparation, Nicotinic acid preparation, Nicotinic acid product, Niacin preparation (product), Nicotinic acid (substance), Niacin (substance) [Ambiguous], Niacin preparation (substance), NICOTINIC ACID
Swedish Nikotinsyra
Czech niacin, kyselina nikotinová, vitamin B3
Finnish Nikotiinihappo
Russian NIKOTINOVAIA KISLOTA, NIATSIN, НИАЦИН, НИКОТИНОВАЯ КИСЛОТА
Japanese 3-ピリジンカルボン酸, ニアシン, ニコチン酸, ピリジン-3-カルボン酸, ナイアシン
Spanish niacina (producto), preparado con ácido nicotínico, preparado con niacina (producto), preparado con niacina, niacina (sustancia), factor antipelagra, niacina (concepto no activo), niacina, preparado de niacina (sustancia), ácido nicotínico (sustancia), ácido nicotínico, Niacina, Ácido Nicotínico
Polish Kwas nikotynowy, Niacyna
Croatian NIJACIN
French Acide nicotinique, Nicotinique, acide
German Niacin, Nikotinsäure
Italian Niacina
Portuguese Ácido Nicotínico, Niacina

Ontology: Niacinamide (C0028027)

Definition (NCI_NCI-GLOSS) A nutrient in the vitamin B complex that the body needs in small amounts to function and stay healthy. Niacinamide helps some enzymes make energy in the cell. It is found in many plant and animal products. It is water-soluble (can dissolve in water) and must be taken in daily. It is being studied to increase the effect of radiation therapy on tumor cells.
Definition (NCI) The active form of vitamin B3 and a component of the coenzyme nicotinamide adenine dinucleotide (NAD). Niacinamide acts as a chemo- and radio-sensitizing agent by enhancing tumor blood flow, thereby reducing tumor hypoxia. This agent also inhibits poly(ADP-ribose) polymerases, enzymes involved in the rejoining of DNA strand breaks induced by radiation or chemotherapy.
Definition (MSH) An important compound functioning as a component of the coenzyme NAD. Its primary significance is in the prevention and/or cure of blacktongue and PELLAGRA. Most animals cannot manufacture this compound in amounts sufficient to prevent nutritional deficiency and it therefore must be supplemented through dietary intake.
Definition (CSP) B complex vitamin used in the prophylaxis and treatment of pellagra; functions as a component of the coenzyme NAD (Nicotinamide-Adenine Dinucleotide).
Definition (PDQ) The active form of vitamin B3 and a component of the coenzyme nicotinamide adenine dinucleotide (NAD). Niacinamide acts as a chemo- and radio-sensitizing agent by enhancing tumor blood flow, thereby reducing tumor hypoxia. This agent also inhibits poly(ADP-ribose) polymerases, enzymes involved in the rejoining of DNA strand breaks induced by radiation or chemotherapy. Check for "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=42044&idtype=1" active clinical trials or "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=42044&idtype=1&closed=1" closed clinical trials using this agent. ("http://nciterms.nci.nih.gov:80/NCIBrowser/ConceptReport.jsp?dictionary=NCI_Thesaurus&code=C2327" NCI Thesaurus)
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109) , Vitamin (T127)
MSH D009536
SnomedCT 61650007, 332374008, 58527004, 259657008, 86431009, 173196005, 55013001
LNC LP16218-7, MTHU007481
English Vitamin B3, Niacinamide, Nicotinamide, Vitamin PP, 3-Pyridinecarboxamide, Nicotinamide [skin], 3 Pyridinecarboxamide, Nicotylamide, Nicotinic Acid Amide, Pellagra-Preventing Factor, Nicotinamidum, VITAMIN B A 03, vitamin B3, vitamin PP, Nicotinamide preparation, niacinamide (medication), vitamins niacinamide, niacinamide, Niacinamide [Chemical/Ingredient], NIACINAMIDE, b3 vitamins, vitamin b3, vitamin b 3, b3 vitamin, vitamin pp, B3, Vitamin, B 3, Vitamin, Vitamin B 3, nicotinamide, Niacinamide [skin], Niacinamide (substance), Niacinamide [skin] (product), Vitamin B<sub>3</sub>, Vitamin B>3<, Nicotinic acid amide, Niacinamide preparation, Niacinamide preparation (product), Nicotinamide (substance), Niacinamide [Ambiguous], Niacinamide preparation (substance), Nicotinamide [skin] (substance), Nicotinamide product, Nicotinamide [skin] (product), Niacinamide product, VITAMIN B3, NIACIN (AS NIACINAMIDE)
Swedish Niacinamid
Spanish nicotinamida (uso dermatológico) (producto), nicotinamida (uso dermatológico), preparado con nicotinamida (producto), preparado con niacinamida, nicotinamida (producto), preparado con nicotinamida, niacinamida (uso dermatológico) (producto), niacinamida (uso dermatológico), niacinamida (sustancia), Vitamina B3, vitamina B<sub>3</sub>, vitamina B3, vitamina B>3<, nicotinamida (piel) (producto), nicotinamida (piel), nicotinamida (sustancia), preparado de nicotinamida (sustancia), nicotinamida, niacinamida, Nicotinamida, Niacinamida, Vitamina B 3, Vitamina PP
Czech vitamin B 3, vitamin PP, niacinamid, nikotinamid
Finnish Nikotinamidi
Russian NIATSINAMID, NIKOTINAMID, VITAMIN RR, VITAMIN B3, ВИТАМИН B3, ВИТАМИН РР, НИАЦИНАМИД, НИКОТИНАМИД
Japanese ニコチンアミド, ニコチン酸アミド, ニコチナマイド, ナイアシンアミド, ビタミンB3, ビタミンPP
German VITAMIN B A 03, Niacinamid, Nicotinamid, Vitamin PP, Vitamin B3
Polish Witamina B3, Witamina PP, Nikotynamid, Niacynamid
Croatian Not Translated[Niacinamide]
Portuguese Vitamina B3, Nicotinamida, Niacinamida, Vitamina B 3, Vitamina PP
French Nicotinamide
Italian Niacinammide