Why not niacin? It’s cheap and effective
Its main reaction is generally harmless
Think niacin, and one word comes to mind: flushing. The intense, cutaneous reaction to niacin has become its trademark, all but obliterating the drug’s demonstrated value as a cholesterol-reducing agent. The reaction, caused by a sudden outpouring of histamine, most commonly occurs early in niacin therapy and over time usually disappears. It’s generally harmless.
However benign, the flushing reaction has painted niacin as a troublesome product best avoided in the hospital setting. But some institutions are taking a second look at niacin, given its low cost and considering clinical studies showing it significantly increases high-density lipoproteins (HDLs), reduces total cholesterol, and works even better if given with a CoA reductase inhibitor (a "statin").
The key to successful niacin use in your hospital may be the intervention of a pharmacist. Successfully treating hyperlipedemia with niacin requires careful titration of the drug, making an extra pair of hands a necessity. For busy clinic physicians, it’s easier to write a prescription for something easily dosed and well-tolerated a statin.
The problem with statins is their expense. Niacin therapy costs pennies a day; statins, a few dollars. That’s the main reason niacin has found a comfortable spot on the formulary at the Veterans Affairs Medical Center in Amarillo, TX, according to Teresa Liston-Crain, PharmD, clinical pharmacy specialist. "We use it quite a bit actually," she says.
For a few dollars, patients get a 90-day supply of niacin about one-fiftieth the price of a comparable supply of a statin. While cost is the main rationale for use of niacin at the Amarillo VA, Liston-Crain says there are other good reasons, as well: "The high percentage of HDL [that results from niacin therapy] is a benefit. The other is its triglyceride lowering effect. So you can do with niacin what you can’t do with other drugs."
Pharmacist-run clinic key to success
Therapeutics aside, niacin use has dramatically increased at the Amarillo VA for one main reason: the pharmacist-run lipid lowering clinic. "Before the existence of the pharmacy-managed lipid lowering clinic, very little niacin was used," Liston-Crain says. "The statins are easier to prescribe. Niacin you have to titrate."
Plus, there are niacin’s side effects to contend with. Most notably, the alarming (but harmless) cutaneous flushing that occurs early in niacin therapy a side effect that frequently sends patients scurrying back to the doctor. Liston-Crain says a fairly high percentage of niacin patients at the Amarillo VA lipid clinic experience flushing, but most become tolerant once they’re on the drug for awhile.
And patients aren’t surprised when they turn lobster red, either, thanks to intensive education efforts by pharmacists. "A hand-out tells about the cutaneous reaction: that it’s expected and not harmful. [We say,] It’s not a side effect, it’s an expected reaction. This is how it’s going to happen. This is why. This is how long it will last.’" Patients who might panic over the reaction are advised to take a 5 grain aspirin tablet about an hour before the niacin dose. Aspirin seems to curb the reaction, Liston-Crain says.
But the relative lack of other side effects surprised pharmacists. "We expected a lot of GI problems and we haven’t seen it," Liston-Crain says. "We have seen our share of elevated uric acid and blood sugar levels." Patients with those side effects are usually not terminated from niacin therapy unless the levels persist or the patient is diabetic.
It’s not for everyone
And that raises an important point with niacin therapy: Some patients just shouldn’t take it. Liston-Crain says the category includes patients with active, untreated gout; any patient for whom a possible rise in blood sugar is a concern, such as diabetics; those with peptic ulcer disease; and anyone allergic to niacin. Gastroesophageal reflux disease (GERD) was once a contraindication to niacin therapy, but Liston-Crain says the drug doesn’t seem to bother those patients, after all.
Niacin has one important place in cholesterol therapy: as an adjunct to gemfibrozil use in patients with extremely high triglyceride and cholesterol levels. Gemfibrozil takes care of the former; niacin, the latter. Gemfibrozil use with the statins is discouraged, Liston-Crain says, because of an increased risk of rhabdomyolysis.
Niacin has a hard row elsewhere
Effective as it is, niacin isn’t welcomed everywhere. Doctors can order niacin off the formulary at the Family First Medical Center in Miami, but clinical pharmacist Mariola Vazquez Ortiz, PharmD, says only about 10% of patients use it. "I would say it’s mostly used in younger patients. But most don’t tolerate it well enough to get to the effective dose." About 60% of Family First cholesterol patients take statins, she says.
Niacin is also a formulary product at the National Naval Medical Center in Bethesda, MD, but it’s not used much, says Lt. Diana Renken, PharmD. With the pharmacy set to begin a three-month cholesterol clinic, Renken says the niacin-use issue will be "on the table" when discussions with physicians commence. "The doctors don’t use it because of side effects," she says. "We’d like to increase the use of it it’s cheap."
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