•    In the Coronary Drug Project, a large-scale secondary prevention trial, niacin 3 grams/day reduced mortality 11% over placebo (Canner,
     1986 [A]).
 
•    Exerts favorable effects on all lipids and lipoproteins, good for mixed hyperlipidemia.

•    Crystalline niacin reduces triglycerides 20%-40%, increases HDL-cholesterol 15%-35%, and decreases LDL-cholesterol 6-25 percent.
 
•    Extended-release niacin reduces triglycerides 11%-35%, increases HDL-cholesterol 15%-26%, and decreases LDL-cholesterol 9%-17%.
 
•    Sustained-release niacin reduces triglycerides 10%-40%, increases HDL-cholesterol 5%-15% and decreases LDL-cholesterol 6%-50%
     (but this latter effect may be due to hepatic toxicity).

•    Long-term use of niacin is usually limited for many patients due to side effects. For this reason, Adult Treatment Panel III (ATP III)
     guideline recommends its use be reserved for those at highest short-term risk, i.e., those with CHD, CHD risk equivalents or 2+ risk factors
     with 10-year risk of CHD of 10%-20% or higher. Use of niacin for long-term prevention of CHD in patients with a 10-year risk less than
     10% is not well established and should be used more cautiously. For example, it is not known whether long-term use of niacin for lower-
     risk patients with isolated low HDL-cholesterol is beneficial.
 
•    Flushing and pruritis of face and upper trunk are common. Tolerance usually develops and patients are more accepting if they know what
      to expect. With crystalline niacin, flush and pruritis usually occur within 30 minutes and are gone in about that time. Flushing is reduced
      with SR niacin, but it still occurs.
 
•    Liver toxicity may be associated with niacin. Risk appears greater with SR niacin, and appears dose related (most occurring with doses of
     2 grams/day or higher). Hepatoxicity has occurred when patients switched from crystalline niacin to a SR form without a decrease in dose.
     Patients who are asymptomatic with only elevations in transaminases (to three times the upper limit of normal) may respond to dose
     reduction. If transaminases exceed three times the upper limit of normal or patients are symptomatic (e.g., nausea, vomiting, diarrhea,
     anorexia, fatigue and/or jaundice), niacin should be discontinued. With discontinuation, symptoms decline within two weeks and lab
     abnormalities should resolve within one to four months. In a long-term (59 weeks) study of niacin extended-release, median dose 2
     grams/day, less than 1 percent of participants with normal serum transaminases at baseline had elevations greater than three times the
     upper limit of normal.
 
•    GI complaints (nausea and abdominal pain) are more common with SR niacin; this can be minimized by taking with meals. Activation of
     peptic ulcer has occurred so history of peptic ulcer is a relative contraindication.
 
•    Uric acid may be slightly increased. Rarely, this may lead to acute gouty arthritis.
 
•    Serum glucose concentrations may be increased with higher doses (greater than 3 grams/day), especially in patients with NIDDM or
     glucose intolerance. Glucose monitoring is critical for use of niacin in these patients. Some adjustment in their hypoglycemic therapy may
     be needed. However, data from the Arterial Disease Multiple Intervention Trial (ADMIT) indicate that niacin can usually be safely used in
     patients with diabetes. Niacin use in patients with diabetes resulted in a small but significant change in HbA1c levels of 0.3% versus
     placebo.
 
•    Combination with a statin may increase risk of myopathy based on early experience with lovastatin. Subsequent controlled trials of statins
     with niacin have reported few or no cases.
 
•    There is compelling evidence niacin and statin therapy improves outcomes (Brown, 2001 [A]).