Niacin & Cholesterol

What you need to know
By Jonny Bowden, PhD, CNS, aka “The Rogue Nutritionist”

High triglycerides and oxidized LDL are way bigger risk factors for heart disease than total cholesterol. If you’ve read my book The Great Cholesterol Myth, you know that, already. That said, many folks—and many doctors—remain concerned when cholesterol goes too high. Though they’d like to see cholesterol come down, more and more of them are reluctant to reach for a statin drug (and with good reason)! What to do, what to do?

Ask a dozen nutritionists or integrative medical doctors about natural supplements for improving blood lipids (including cholesterol), and chances are 10 of them will say niacin. And for good reason: It has an impressive track record.

Mainstream media gets it wrong again

Not long ago, the results of a study known as the HPS2-THRIVE were widely (and incorrectly) reported by mainstream media as showing that niacin “isn’t effective.” This was yet another example of the media misunderstanding research and jumping to a conclusion that was in no way supported by the study.

What actually happened in the study was that patients who were already on statin drugs were given niacin in addition to the statin drug. For the most part, no additional benefits were seen, at least among the variables measured by the researchers.

But to conclude from that study that “niacin isn’t effective” is like saying that umbrellas aren’t effective at keeping you dry if you’re already indoors. If you’re already under a roof, opening an umbrella probably isn’t going to lower the amount of rain that hits you, since the roof does a very good job of keeping the rain from landing on your head by itself, thank you very much. But this tells us exactly nothing about the ability of an umbrella to keep you dry when you’re not indoors.

Statin drugs are like that roof. They keep the rain out (i.e., they lower cholesterol) just fine—but with considerable side effects (not to mention expense). Virtually all of the people in this study already had their cholesterol well under control with statins—the average LDL cholesterol of the folks on the study was a very low 71! For goodness sake, how low do you think you need to go anyway? Even the most conservative, traditional cholesterol believer would consider this a great number!

The National Lipid Association summed it up perfectly in their position paper: “HPS2-THRIVE tested a drug in patients who, on average, had no indication to take it.” With average patient LDL levels of 71(!), it’s not surprising that niacin didn’t add very much to the mix. The HPS2-THRIVE study says absolutely nothing about how niacin performs in a person who is not on a statin drug and would like to remain that way.

What is niacin, anyway?

Niacin—also known as vitamin B3 or nicotinic acid—plays a role in numerous metabolic pathways, but it really garnered a lot of attention in the 1950s when researchers discovered its lipid-improving abilities. Niacin can:

>>Lower low density lipoproteins (LDL)

>>Lower triglycerides

>>Improve high density lipoproteins (HDL)

>>Increase the ratio of large/small particle LDL

That last one is especially important. We now know that “LDL” isn’t just a single molecule—it actually comes in several “flavors” or subtypes. LDL-A is a large, fluffy molecule that is virtually harmless (unless it becomes damaged by oxidation). LDL-B, on the other hand, is a nasty little bugger—a hard, small, dense molecule that can definitely contribute to atherosclerosis.

In other words, your LDL number itself isn’t so important. It’s what subtype you have that can make the difference. Pattern A—where most of your LDL is of the fluffy type—is good. Pattern B—where most of your LDL is the hard, dense type—is not.

Niacin can shift the ratio so you have more LDL-A and less LDL-B, and that’s way more important than just reducing overall LDL.

Niacin: so many types, so many forms

But what kind of niacin should you take?

Glad you asked.

Niacin comes in a number of “flavors” but not all niacin is created equal. Niacinamide is one type of niacin widely used in multivitamins and B-complex formulas. Though it has plenty of benefits, it has exactly zero effect on cholesterol.

The most common form of niacin—nicotinic acid—kicks in immediately and is quite effective, but watch out. It creates that miserable flushing that conventional niacin is known for. It’s horrible, and over 40 percent of the population (including yours truly) can’t tolerate it.

Then there’s “no-flush” niacin, otherwise known as inositol hexanicotinate. There’s only one problem with it: It doesn’t work. Sorry.

Choosing the best form of niacin

OK, so niacin is great. But how do you choose the right kind? No-flush and niacinamide don’t work, and the regular old niacin creates intolerable flushing. What to do?

An interesting form of niacin called wax-matrix (i.e., extended-release nicotinic acid) solves the problem. As niacin bound in a wax matrix travels through your GI system, it softens, allowing superior absorption with no stomach upset, and providing niacin in a uniform dose. The steady, sustained dosing greatly reduces flushing and stomach irritation found in common niacin products.

Let’s go to the videotape: what does the research say?

A new study in the Journal of Clinical Lipidology compared “no-flush niacin” with a wax-matrix, extended-release nicotinic acid and a placebo.

The no-flush niacin performed no differently than the placebo in that both were totally ineffective. The wax-matrix niacin, on the other hand, yielded impressive results: It improved LDL as well as other lipid parameters like triglycerides and HDL.

The wax-matrix niacin also clearly demonstrated an extended release profile, with a significant rise in serum nicotinic acid within the first hour, followed by rises in each of the two metabolites.

“Clinicians have considerable scientific support for choosing this unique wax-matrix extended-release product as an effective and inexpensive option for niacin therapy,” said Joseph Keenan, MD, of the University of Minnesota, the lead researcher on the study. With respect to the no-flush niacin, he added, “patients are wasting money on a worthless remedy and may be delaying appropriate treatment for a potentially serious health problem.”

A bigger menace than cholesterol? You bet.

OK, new topic. Now I want to tell you about a molecule that’s far more damaging than cholesterol, one your doctor is probably not testing you for.

It’s called lipoprotein(a), and it’s a very big part of the niacin story.

Let me explain.

Lipoprotein(a), abbreviated Lp(a), is a risk factor for coronary heart disease, cerebrovascular disease, atherosclerosis, thrombosis, and stroke.

Cardiologist Stephen Sinatra, MD, my co-author on The Great Cholesterol Myth, calls Lp(a) “one of the most devastating risk factors for heart disease and one of the hardest to treat.”

Now Lp(a) isn’t all bad. It helps repair damaged blood vessels and promotes blood clotting. So far, so good: If you’re healthy, Lp(a) isn’t usually a problem.

But if your arteries need repair, your body produces more Lp(a), which deposits oxidized LDL into that damaged blood vessel wall. The resulting inflammation and plague buildup aren’t pretty.

To worsen matters, Lp(a) forms blood clots on top of the newly formed plaque, further occluding your blood vessel. Large enough clots can block your artery, leading to a heart attack.

It should hardly be a surprise then that people with elevated Lp(a) levels have a significantly higher risk for heart attacks. Given that, you’d think doctors would make Lp(a) testing a top priority. You’d also think the pharmaceutical industry would design a drug to lower Lp(a) levels.

Well, so far, no pharmaceutical interventions have worked to lower Lp(a). In fact, one of the many dirty little secrets about statin drugs is that they can increase Lp(a) levels!

In fact, researchers have only found one nutrient that absolutely lowers Lp(a). Can you guess which one it is?

Bingo. In fact, a study in the journal Atherosclerosis found that taking one gram of niacin twice a day reduced Lp(a) levels by a very impressive 36 percent.

Worried about your liver? Don’t be.

There have been concerns in the past about niacin and hepatotoxicity (liver problems) but new research has clarified the issues considerably. It’s now clear that any problems with liver enzymes observed in studies was not due to niacin itself, but rather to the dosing regimen. A moderate dose of 1,000 mg given three times a day may indeed be hepatotoxic for some patients—but that same 1,000 mg dose given only once a day produces no problems for the same patient.

We now also understand that people vary considerably in their reaction to niacin, with many patients getting terrific results with much smaller doses. The biggest lesson from the emerging research is that niacin is a safe and effective treatment, but dosing and supervision is important. Since effective dose and treatment regimens will be different for different people, therapeutic niacin should be not be self-administered but should be monitored by a physician.

Used like that, niacin is a very safe and effective treatment.

Prescription Niaspan vs. over-the-counter wax-matrix niacin. Which to use and why?

Prescription Niaspan and over-the-counter wax-matrix niacin (i.e., Endur-Acin) perform nearly identically in the research: both Niaspan and wax-matrix niacin have very similar “dissolution profiles,” meaning that the time it takes each to dissolve is nearly identical. And either one beats the pants off both placebo and the now-discredited “no-flush” niacin, inositol hexanicotinate.

The effects are comparable—the price, however, is not.

When insurance “pays for everything,” a patient probably doesn’t much care which of these two forms of effective niacin therapy his doctor prescribes. But with high deductibles and the dreaded “donut hole” in Medicare coverage, it’s worth noting that a month’s worth of Niaspan could easily add $300 to your pharmacy bill. Google wax-matrix niacin instead: You can order it directly from the manufacturer here in the US for about $10 per month!

Since wax-matrix niacin performs identically to Niaspan as far as effectiveness and tolerability (and in some unpublished research has a couple of advantages to boot), it seems like a much better choice to me.


Jonny Bowden, PhD, CNS, also known as “The Rogue Nutritionist,” is a board-certified nutritionist and the best-selling author of 13 books on health including The 150 Healthiest Foods on Earth, Living Low Carb, and his latest, The Great Cholesterol Myth, co-written with cardiologist Stephen Sinatra, MD.



Wax-matrix niacin study by the numbers

In the Journal of Clinical Lipidology study referenced earlier, Joseph Keenan, MD, performed a six-week blinded, placebo-controlled trial comparing wax-matrix niacin and “no-flush” niacin. There was a four-week diet lead-in period. Dosages were 1,500 mg per day.

There were 40 people in each group (placebo, wax-matrix, and no-flush) and those chosen for the study had LDL numbers from 130 - 190. At the end of the study the wax-matrix group had 11 percent lower total cholesterol, 18 percent lower LDL, 12 percent higher HDL, and 9.4 percent lower triglycerides. The no-flush and placebo groups showed no improvement.

Keenan writes, “This study is the fourth randomized clinical trial of wax-matrix extended release (WMER) niacin in persons with hyperlipidemia. The results from this study are consistent with previous trials in that the agent was well tolerated … and the 1,500 mg dose of WMER demonstrated significant lipid benefits … Side effect questionnaire results reported significantly greater incidence of flushing in WMER subjects, but this was generally rated as mild in subjects who completed the study at the 1,500 mg dosage. Safety monitoring of blood chemistries showed WMER did significantly increase baseline blood glucose levels by three percent over six weeks. However, a previous longer-term study of WMER (six months) demonstrated that blood glucose levels tend to return to baseline levels after an initial increase, and Grundy et al. showed that a dose of 1,500 mg of polygel extended release nicotinic acid was safe in type II diabetics … Previous trials of WMER have shown that many of the persons who appear intolerant of niacin because of either undesirable side effects or elevation of liver enzymes are often just more sensitive to the agent and do well at a reduced dosage.”

By Adam Swenson