Niacin: Myths and Facts

by William Davis, M.D. Health Professional

For a simple, available treatment that can dramatically reduce risk for heart attack, niacin has suffered more than its share of knocks, insults, and undeserved criticisms.

Is it deserved? Does this simple nutritional supplement, B vitamin, and component of food deserve this barrage of snubs? Or, can it be used intelligently to advantage-safely and effectively?

Niacin myths- From a health website:** A Cholesterol-Busting Vitamin?**

Niacin is safe - except in people with chronic liver disease or certain other conditions, including diabetes and peptic ulcer. . . It has numerous side effects. It can cause rashes and aggravate gout, diabetes, or peptic ulcers. Early in therapy, it can cause facial flushing for several minutes soon after a dose, although this response often stops after about two weeks of therapy and can be reduced by taking aspirin or ibuprofen half an hour before taking the niacin. A sustained-release preparation of niacin (Niaspan®) appears to have fewer side effects, but may cause more liver function abnormalities, especially when combined with a statin.

Strange. After a headline designed to pull readers in, the article then proceeds to scare the pants off you by articulating a litany of side-effects. Most readers would understandably be frightened of giving niacin a try after reading that list of dangers.

Are these warnings warranted? Is niacin as dangerous as they make it sound?

I would argue that it is not. In fact, I would argue that niacin is among the safest, most effective, and wonderfully inexpensive ways to correct the causes of heart disease and reduce the risk of future heart attack available today-when used properly.

Critics of niacin (perhaps more accurately described as those ignorant of the real power and usefulness of niacin) often complain about the frequent bothersome side-effects of niacin. Is niacin really that troublesome? No, it's not. In fact, if used properly, niacin is among the most effective and safe tools available for correction of low HDL, small LDL and other triglyceride-containing lipoproteins, and lipoprotein(a). By itself, niacin reduces risk of heart attack by 22-30%. If added to a statin agent, heart attack risk reduction can approach 90% (as demonstrated by the HATS Trial). Unlike widely-prescribed statin drugs that reduce LDL cholesterol particles across the board regardless of size, niacin lowers the amount of small LDL particles, the most damaging variety, much more than the less harmful large LDL particles.

Niacin facts

Despite the fact that niacin is:

  1. A vitamin-vitamin B3 (deficiency is called pellagra)

  2. One of the oldest cholesterol-reducing agents around with a long-standing track record of effectiveness and safety

  3. Available as a prescription drug as well as a variety of "nutritional supplements"

most physicians remains shockingly unaware of its benefits, effects, and side-effects. Most, in fact, are either ignorant or frightened of advising their patients on niacin use. As a result, I commonly have to ask my patients to resume the niacin that their primary care physician has (wrongly) stopped because of itchy feet, grumpiness, groin rash, urinary tract infections, nightmares, diarrhea, hair loss, runny nose, etc. All of these are REAL reasons doctors have advised patients to stop niacin (though none were actually due to niacin).

Statins are just too easy for doctors to prescribe. Niacin, on the other hand, requires a good 15-20 minutes explanation on how to use it. It could generate an occasional phone call from a patient who struggles with the annoying but largely harmless and temporary "hot-flush" feeling, a lot like a hot blush or menopausal hot flash. Given a choice, most doctors would simply choose not to be bothered. For this reason, I commonly see many, many people with uncorrected low HDLs, small LDL particles, and other patterns, all of which would improve dramatically with niacin but remain woefully neglected.

Niacin is as close as it comes to a solution that addresses most of the causes of heart disease. More, in fact, than any prescription drug available. Combine niacin with fish oil, and you've got a powerful combination strategy that reduces or eliminates an array of causes of heart disease. While niacin acts to raise HDL cholesterol, reduce small LDL, reduce triglycerides, and reduce lipoprotein(a), fish oil bolsters the triglyceride-reducing effect.

Have a serious discussion and press for confident answers if you hear your doctor reflexively telling you that the wart on your thumb should be blamed on niacin.

No flush, no effect

"Inositol Hexanicotinate is the true 'flushless niacin.' Unlike 'sustained-release' niacin, which is just regular niacin in a pill which dissolves more slowly, Inositol Hexanicotinate is a niacin complex, formed with the B-vitamin-like inositol. When you take an IHN supplement, the central inositol ring gradually releases niacin molecules, one at a time delivering true niacin. This, like "sustained-release" niacin, allows you to take niacin at clinically-proven doses without going crazy with the itch."

That above bit of nonsense adorns one manufacturer's sales pitch for its no-flush niacin. No-flush niacin is one of the biggest scams in the health food store.

Ordinarily, I love health food stores. There are lots of fun and interesting things available that pack real power for your health program. Unfortunately, there's also outright nonsense. No-flush niacin is smack in the category of absolute nonsense.

No-flush niacin is inositol hexaniacinate, or an inositol molecule complexed with 6 niacin molecules. So it really does contain niacin. However, although it works in rats, in my experience and that of many others who've used it, no-flush niacin exerts no effect in humans.

One typical example: A 41-year old woman came to my office for consultation because her doctor didn't know what to do with lipoprotein(a). She had seen a cardiologist who told her to take no-flush niacin. Both the cardiologist and the patient were therefore puzzled when lipoprotein(a) showed no drop and, in fact, was slightly higher while on the no-flush preparation.

The lack of any observable effect and no studies whatsoever showing a positive effect (there is one study demonstrating no effect), manufacturers continue to manufacture it and health food stores continue to push it as an alternative to niacin that causes the flush. It's also expensive, commonly costing $30-$50 for 100 tablets.

Don't fall for this gimmick. Niacin is among the most helpful of treatments for gaining control over heart disease risk. It raises HDL, corrects small LDL, reduces triglycerides (along with its friend, fish oil, of course), reduces lipoprotein(a), and dramatically contributes to reduced heart attack risk. No-flush niacin does none of this.

The same warning goes for other niacin scams like nicotinamide. Though it may look and sound like niacin, also called nicotinic acid, nicotinamide possesses none of the benefits of niacin.

Make it easy on yourself

Here are the steps I advise that really make taking niacin easy and tolerable:

  1. Take niacin with dinner or other substantial meal.

  2. Take with 2 extra glasses of water. If you experience the hot-flush later on, drink an additional 2 8-12 oz glasses of water, i.e., a total of 16-24 oz). Extra hydration is extremely effective for blocking the hot-flush. Conversely, people who are chronically underhydrated are most prone to bothersome hot flushes. (Of course, discuss this with your doctor if you are on any kind of fluid or salt restriction or have a problem with fluid retention.)

  3. Take a 325 mg, uncoated aspirin. This is usually necessary in the beginning or with any increase in dose; it is rarely needed chronically.

This is not to say that there aren't occasional people who are truly and genuinely intolerant to niacin. It does happen. But those people are a small minority, less than 5% of people in my experience. Niacin is far more effective and safe than most physicians would have you believe.

Besides prescription Niaspan
®, I've used the slow-release preparation SloNiacin
® which is available without a prescription in many pharmacies. Slow-release niacin preparations like Niaspan
® and SloNiacin
® should only be taken once per day. Beware of the slow-release preparations sold in health food stores, since the pattern of release of niacin is often not well-controlled. Just plain niacin, also called immediate-release niacin, is widely available but is more likely to cause the hot flush; however, this form can be taken twice a day in smaller doses. Increase the dose of immediate-release niacin very gradually (e.g., start with 100 mg twice a day and increase in 100 mg quantities).

Because of a small risk of liver and other more concerning side-effects, niacin treatment should be conducted with the help of your doctor, particularly if you take more than 500 mg per day.

William Davis, M.D.
Meet Our Writer
William Davis, M.D.

William R. Davis is a Milwaukee-based American cardiologist and author. He wrote for HealthCentral as a health professional for Heart Health and High Cholesterol.