Is it time to retire niacin?

Is it time to retire niacin?

An editorial published online in the New England Journal of Medicine asks, "Niacin at 56 Years of Age — Time for an Early Retirement?" Retirement may be the logical next step after publication of the AIM-HIGH trial, the National Heart Lung and Blood Institute's trial comparing niacin plus intensive statin therapy with intensive statin therapy alone in patients with established cardiovascular disease. The study was halted early when it was found that the addition of 1500-2000 mg of niacin per day to simvastatin, despite significantly raising HDL levels an average of 7 points, had no effect on the primary endpoint, which was a composite of the rate of death from coronary artery disease, nonfatal myocardial infarction, ischemic stroke, hospitalization for acute coronary syndrome, or symptom-driven coronary or cerebral revascularization (primary endpoint 16.4% niacin group, 16.2% placebo group; P = 0.79) (N Engl J Med published online November 15, 2011). The accompanying editorial suggests there is lack of evidence to support niacin as an add-on therapy in patients with cardiovascular disease who have well-controlled LDL cholesterol levels. Additionally, long-acting niacin is relatively expensive and frequently causes flushing — two additional factors that argue against continued use of the drug except, perhaps, in patients who are intolerant of statins (N Engl J Med published online November 15, 2011).