If you're like most middle-aged Americans, you've been concerned about lowering your LDL or "bad" cholesterol.
But raising your HDL or "good" cholesterol might help even more.
The problem is that statins, like Crestor and Lipitor, which can lower LDL dramatically, have very little effect on HDL.
How can you boost your HDL?
By taking niacin, an inexpensive and widely available B vitamin also known as nicotinic acid.
In one recent study reported in the Journal of the American College of Cardiology, patients already taking statins to improve their cholesterol levels boosted their HDL by 23 percent when they took 2,000 milligrams of niacin per day. They also reduced the plaque buildup in their carotid arteries by about 1 millimeter over 12 months.
A study in the New England Journal of Medicine a few months earlier reported similar results. Patients who took 2,000 milligrams of niacin a day raised their HDL by 18.4 percent, and also reduced the plaque buildup in their carotid arteries.
Such results make niacin sound like a drug with enormous potential for reducing heart disease, and that's precisely how many physicians regard it.
"If we were to compare niacin against all the cholesterol medications, it far and away would have the best profile," said Dr. John J. Mentel of the Mayo Clinic in Jacksonville. "You get an HDL increase of 15 to 35 percent, depending on which study you look at. Your LDL falls by 10 to 25 percent. And you get a decrease of 20 to 50 percent in your triglycerides. It really is an ideal drug. I think it would be the No. 1 choice if it weren't for the side effects."
Niacin at high doses, such as those used in the study, can cause mild liver toxicity in some patients.
"It's not too different from Tylenol," Mentel said. "All cholesterol drugs have some liver toxicity associated with them. We monitor that with periodic blood tests. You have to check their cholesterol anyway to see if you're winning the battle, so you check their liver function at the same time."
But toxicity is not the only problem. Niacin causes about 10 minutes of intense skin flushing after each dose, which causes many people to stop taking it. Over-the-counter niacin, described as timed-release and "no-flush" forms, reduces this problem dramatically, but doesn't improve cholesterol levels significantly.
Abbott Laboratories markets an "extended-release" form of prescription-only niacin called Niaspan, which slows the delivery of niacin somewhat, but not so much that it compromises niacin's beneficial effects. The only problem is the cost. Whereas drugstore.com charges about 8 cents for a 500-milligram tablet of plain niacin, it charges about $2.36 for an equal dose of prescription Niaspan. Prescription drug plans with 90-day refills can offset a great deal of that cost, however.
Pharmacologically the two substances are identical.
"Nicotinic acid is nicotinic acid," Mentel said.
However, he regularly prescribes Niaspan for his patients because it allows them to take one pill a day with less flushing than they would experience with plain niacin. Also, since Niaspan is considered a drug monitored by the FDA, he can be confident his patients get precisely the dose he prescribes.
"I needed something reliable, and I needed something timed-release to avoid the side effect of flushing if I could," Mentel said. "Niaspan allows the patient to take one dose, usually at bedtime, which leads to better compliance. That's the No. 1 problem with using niacin to treat cholesterol: You get poor compliance."
If you want to take ordinary, inexpensive niacin, you can minimize the flushing by taking it with meals, and by avoiding alcohol, hot beverages or other substances that might cause flushing, according to Dr. Terry A. Jacobson of Emory University School of Medicine, author of How to Beat a Flush, in the most recent Mayo Clinic Proceedings. An ordinary aspirin taken 30 minutes before the niacin also helps reduce flushing, he says, and you can take the niacin just before going to bed so you sleep through the flushing.
Also, increasing the dose gradually over several weeks seems to help some people reduce the flushing, according to Mentel.
"We always start with a small dose and increase gradually," he said, "but if they build up tolerance and miss a dose or three and start back up again where they left off, they're going to have trouble again with flushing."
Before taking niacin, or switching types, talk with your doctor about what kind and how much niacin supplementation might be right for you.
Tom Valeo writes frequently about health matters. He welcomes reader mail but cannot respond to individual queries. You may write him at firstname.lastname@example.org.