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No-flush niacin vs. cholesterol & triglycerides
Jan 14, 2011

Nelson, For those of us that can't stand the "niacin flush", is there any indication whether the no-flush niacin (inositol hexanicotinate) works as well as regular "live" niacin? I've been taking the no-flush niacin for many years and it was working well until I was switched to lexiva and norvir, and my triglycerides level skyrocketed. Subsequently switched from lexiva to reyataz and niacin doubled, and levels are back coming down. Larry

Response from Mr. Vergel

Larry

I am sorry it took me a while to reply. It took me a while to research this important question!

As you know, many people living with HIV have very low HDL (high density lipoprotein) blood levels. HDL is the "cleaning agent" that removes what the dirty guy (LDL) deposits in the blood vessels. Niacin is known to increase HDL better than any medication.

Regular over-the-counter niacin or nicotic acid, usually taken at a dose of 300-500 mg 3 x day, is a B3 vitamin shown to effectively increase good cholesterol, HDL, with some modest decrease in LDL. Many people take it along with a statin for best results. There have been concerns about liver toxicity and insulin resistance with niacin use, but HIV related studies have found no such problem. But it has a flushing effect can make you feel like your skin is burning and itching a lot, which usually goes away after 20 minutes. Some patients say that taking a baby aspirin (81 mg) 30 min to an hour before taking Niacin really helps to minimize the flushing. Start with lower dose of 250 mg a day and build up slowly up to 1000 mg per day. Get your doctor to check your fasting lipids (and liver enzymes) after a month of being on 1000 mg a day to see if this dose needs to be increased to 1500- 2000 mg a day.

Niaspan (KOS Pharmaceuticals) is a prescription form of extended release niacin. A placebo-controlled, double-blind trial in 122 HIV-negative patients with primary dyslipidemia compared Niaspan 1000 and 2000 mg/ day with placebo. Niaspan reduced LDL cholesterol significantly compared with placebo. In addition, triglyceride levels were decreased 21% with the 1000-mg/day dosage and 28% with the 2000-mg/day dosage. Approximately 85% of the patients taking Niaspan had some flushing, but this reaction did not differ in frequency, intensity, or duration between the two dosages. In two patients the aspartate transaminase level (liver enzyme) was more than twice the normal level, and in one the alanine transaminase level was elevated to more than three times normal.

Good sources of niacin include yeast, meat, poultry, red fishes (e.g., tuna, salmon), cereals (especially fortified cereals), legumes, and seeds. Milk, green leafy vegetables, coffee, and tea also provide some niacin.

Inositol hexanicotinate, a chemical cousin of nicotinic acid, is marketed as beneficially raising HDL cholesterol the same as nicotinic acid but without the skin flushing side effect. But critics argue that studies done to support the cholesterol-regulating properties of inositol hexanicotinate are out of date because they were conducted in the early 1960s. They also argue they were not conclusive.

There has been some debate as to whether or not flush-free niacin lowers cholesterol levels. In fact, there have not been enough studies to support or deny this. One study has indicated that up to 2,400 mg of flush-free niacin each day (in divided doses) is needed to lower cholesterol levels, whereas other studies have indicated that flush-free niacin is ineffective in lowering cholesterol.

One interesting study examining different forms of niacin measured the amounts of free nicotinic acid (the main compound in regular niacin) found in the blood after the no flush product was ingested. The study found that after 1.6 grams of inositol hexaniacinate was taken, only 0.6 micromoles/L of nicotinic acid was detected in the blood.

In comparison, taking one gram of the immediate-release nicotinic acid resulted in 240 micromoles/L detected in the blood, while taking two grams of sustained-release nicotinic acid resulted in an average of 31 micromoles/L detected in the blood, both of which are enough to lower cholesterol.

So, with very little nicotinic acid in the blood seen in this study, as well as the lack of evidence seen in other studies, it is doubtful that flush-free niacin is effective in lowering cholesterol.

Lexiva has shown some of the largest increases in lipids in the protease class.

Exercise and a low single carbohydrate diet may also lower triglycerides, but there are no studies using these two approaches in HIV+ patients using protease inhibitors like Kaletra or Lexiva, both well known triglyceride inducers. I doubt that a drug induced triglyceride increase can be managed completely with non prescription options.

I am glad you are on your way to control your lipids again! Just keep in mind that you may need higher doses of the no flush niacin, which in fact may cause the same side effects as regular niacin.

I hope this helps.

Nelson

Sources:

Dib JG, Dedeyan S. Purported benefits of niacin niacinate. Am J Health Sys Pharm. 2004;61:307-308.

No Flush Niacin Lowers Side Effects. But Is Cholesterol Lowered, Too? By Jennifer Moll, About.com Guide

Inositol hexaniacinate. Altern Med Rev. 1998;3:22-223.

Meyers CD, Carr MC, Park S, and Brunzell JD. Varying cost and free nicotinic acid content on over-the-counter niacin preparations for dyslipidemia. Ann Intern Med 2003;139:996-1002.

Norris RB. Flush-free niacin:dietary supplement may be benefit-free. Prev Cardiol. 2006;9(1):64-65.



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