For high-risk heart disease, statin + niacin (a B vitamin) beats adding another drug (ezetimibe).

Twenty years ago, Robert E. Kowalski, PhD, drew widespread public attention to the value of niacin therapy for reducing heart disease. He pretty much made niacin a household word via his best selling book “The 8-Week Cholesterol Cure.” (The clinical use of niacin extends over 50 years, but Bob popularized the potential of this B vitamin when used in very high doses.) In the ensuing years, dozens of studies have established the heart healthy effects of niacin when used alone or when combined with a statin.

Bob was a good friend of mine and 20 years ago, based on his book and our long conversations, I decided to start myself on over-the-counter high-dose statin therapy. This seemed prudent given my family history of heart disease (from every side of my family!) and the fact I already had what today would be considered borderline high cholesterol. Today my LDL (bad cholesterol) is 28 and my HDL (good cholesterol) is 86. Is that good? My own doctor said I have a higher risk of being hit by a semi than having a heart attack. A cardiology friend put it more colorfully when he suggested that if my wife is waiting for me to drop dead she’s going to have to get a gun.

Clearly, I am biased in favor of niacin. With that disclaimer in full view, a new study reported at the 2009 American Heart Association Scientific Sessions is an important addition to the clinical literature on how to best treat people already on statin therapy but still not at their target cholesterol levels. Two approaches were evaluated in the ARBITER 6-HALTS study: adding extended-release niacin (Niaspan) to increase HDL levels or a different kind of LDL cholesterol-lowering drug called ezetimibe (known as Zetia). Not only did combining niacin with statin therapy produce superior outcomes, it appeared to cause disease regression as opposed to the niacin/ezetimibe combination which only halted the progression of cardiovascular disease.

In an editorial that accompanied the publication of the study in the New England Journal of Medicine, the authors (who were not part of the study) summarized the importance of ARBITER 6-HALTS. They said the findings provide “…support for the concept that the use of statins to reduce LDL cholesterol to target levels with the subsequent addition of a drug to raise HDL cholesterol levels (niacin), rather than a drug to lower LDL cholesterol levels (ezetimibe), is a more effective treatment for patients at high cardiovascular risk.” (Read the NEJM editorial here http://bit.ly/1T0Rru )

As much as I like not having to pay for a prescription drug, and telling myself that I am only taking a vitamin, I very much realize that at the levels of niacin required for effectiveness (in this trial, 2000 milligrams every day) this vitamin is powerful drug therapy. After all, the U.S. Recommended Daily Allowance for niacin is 20 milligrams per day! It’s hardly just a vitamin supplement when taken at 100 times the daily RDA every day for years (or decades!).

So, niacin is highly effective therapy, but remember: it is, for all intents and purposes, a drug and should be treated as such. Tell your doctor before you start taking it!