, November 17, 2004

Niacin Improves "Good" Cholesterol Level, Study Shows

< November 17, 2004 > -- A two-pronged approach to cholesterol management - using one medication to boost the good cholesterol and another to lower the bad - is more effective at slowing the progression of heart disease than one medication alone, according to a report in the medical journal Circulation.

Researchers, reporting at the American Heart Association meeting in New Orleans, say that adding extended-release niacin, a member of the vitamin B family, to cholesterol-lowering statins slowed the progression of atherosclerosis, or the dangerous buildup of plaque in the arteries.

The findings may signal a shift in the focus of current treatment, experts say.

High cholesterol is a known risk factor for heart disease and stroke, among other ailments.

Medications called statins have become the cornerstone of treatment for elevated low-density lipoprotein (LDL, or the bad cholesterol). High-density lipoprotein (HDL, or the good cholesterol), works by helping to remove dangerous fats from the blood vessels.

Combination Therapy May Help Some

"This is a combination which is very encouraging," says Dr. John C. LaRosa, president of the State University of New York Downstate Medical Center. "We're beginning to gather evidence that making HDL levels higher will, in fact, either arrest development and maybe even reverse some of the atherosclerosis that's already there.

"I don't think that means that you shouldn't lower LDL, but it does mean potentially that raising HDL will give you additional benefit," Dr. LaRosa says. "Most of the LDL-lowering trials still leave from two-thirds to one-half of patients going on to get another event, so it's not enough by itself [to only lower the LDL]."

Niacin is the most effective treatment to treat low HDL. One drawback of niacin is that it causes flushing, a sudden rush of redness in the face and upper body that some find difficult to tolerate.

This study, conducted by Walter Reed Medical Center researchers, involved 149 people with known coronary heart disease (some had suffered heart attacks) and low levels of HDL. All had been on a statin medication for about 4.5 years.

Study participants received either Niaspan, an extended-release, prescription niacin, or a placebo (inactive substance). The study was partially funded by Kos Pharmaceuticals, which makes the product.

After one year, HDL increased 21 percent in the niacin group while the carotid intima-media thickness (CIMT) was unchanged. CIMT is a measurement of plaque buildup in the carotid artery, which feeds the brain. In the placebo group, on the other hand, CIMT increased significantly.

Overall, combining niacin with a statin slowed disease progression 68 percent more than a statin alone. The combination treatment also resulted in a 60 percent reduction in heart attacks, deaths, strokes, and other coronary events.

The researchers did not focus on changes in the number of "events," such as heart attacks. Rather, the purpose was to find whether it had any effect on hardening of the carotid artery.

"The likelihood is that changes will be reflected in a lowering of events, but we don't have any direct evidence of that," Dr. LaRosa explains.

Niaspan causes less flushing than other forms of niacin. Taking the drug at bedtime with aspirin and a low-fat snack can reduce the flushing more.

"It reduces side effects, but it does not eliminate them," Dr. LaRosa notes.

Experts Say More Studies Needed

This type of focus on good cholesterol as opposed to bad cholesterol is likely to become more pronounced in the future.

"We're going to see a lot of this kind of thing now," Dr. LaRosa predicts. "There are three or four studies yet out in the field to see how far we can take LDL and still see benefits. Once those are done, I think attention is going to shift to additional benefit from reducing inflammation, raising HDL, and starting medication earlier in life.

"We have to figure out how much more benefit we can wring out of this cholesterol beyond LDL lowering," he says.

Dr. Stephen Siegel, a clinical assistant professor of medicine at New York University School of Medicine, says, "This study gives us scientific evidence to document that if you add Niaspan to an aggressive, good LDL-lowering program, it actually did make a difference. The trouble with the study is that it's such a small number of people."

A prescription form of niacin is an improvement, according to Dr. Siegel. Flushing has limited niacin's use in the past, but Niaspan "is a slow-release drug that you give at night, and most patients tolerate it well," he says.

Always consult your physician for more information.

Online Resources

(These links are provided for the education and convenience of our Neighbors. AAMC is not responsible for the content of Internet sites.)

American Heart Association

Centers for Disease Control and Prevention (CDC)

Go Red for Women Campaign, AHA

HealthierUS.Gov

National Heart, Lung, and Blood Institute

National Institutes of Health (NIH)

National Library of Medicine

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What is LDL (low-density lipoprotein) cholesterol?

This type of cholesterol is commonly called the "bad" cholesterol, and is a type of fat in the blood that contains the most cholesterol. It can contribute to the formation of plaque buildup in the arteries, known as atherosclerosis.

You want your LDL to be low. To help lower it:

• avoid foods high in saturated fat, dietary cholesterol, and excess calories
• exercise
• maintain a healthy weight
• stop smoking

What is HDL (high-density lipoprotein) cholesterol?

This type of cholesterol is known as the "good" cholesterol, and is a type of fat in the blood that helps to remove cholesterol from the blood, preventing the fatty buildup and formation of plaque.

You want your HDL to be as high as possible. Some people can raise HDL by:

• exercising for at least 20 minutes three times a week
• kicking the cigarette habit
• avoiding saturated fat intake
• decreasing body weight

For others, medicine may be needed. Because raising HDL is complicated, you should work with your physician on a therapeutic plan.

What is a healthy blood cholesterol level?

High blood cholesterol is a significant risk factor in heart disease. Lowering blood cholesterol through increased physical activity, weight loss, smoking cessation, and proper diet lowers that risk.

However, blood cholesterol is very specific to each individual and, for that reason, a full lipid profile is an important part of your medical history and important information for your physician to have. In general, healthy levels are as follows:

• LDL - less than 130 milligrams/per deciliter (mg/dL).
• HDL - less than 40 mg/dL puts you at higher risk for heart disease.
• A total cholesterol level below 200 mg/dL is considered desirable.

In some individuals who already have coronary heart disease (CHD) and/or who have an increased number of risk factors for coronary heart disease, a physician may determine that the LDL cholesterol level should be kept lower than 130.

Recent studies have shown that those who are at highest risk for a heart attack should lower their LDL cholesterol level to less than 100, and that an LDL cholesterol level of 70 or less may be optimal for those individuals at the very highest level of risk.

Always consult your physician for more information.