Imagine you are a heart disease researcher working for a major pharmaceutical company. Next, imagine you and your team have stumbled upon an inexpensive compound that did all of the following:
- Reduces LDL (bad) cholesterol (especially the harmful small LDL particles);
- Raises HDL (good) cholesterol;
- Lowers triglycerides;
- Lowers lipoprotein(a) levels (a new marker for early heat disease);
- Helps improve circulation.

And in addition to the above heart-healthy properties, it also:
- Reduces risk for developing Alzheimer’s;
- Lowers risk of developing cataracts;
- May reduce symptoms of osteoarthritis.

Oh, and did I mention that it can cure a little known disease called pellagra? You would probably think you had just discovered a new blockbuster drug. What you actually did was rediscover a simple vitamin – vitamin B-3, also known as nicotinic acid or, more commonly, niacin.

In fact, the body cannot maintain itself without niacin. Niacin plays a role in numerous bodily processes, including generating energy, nervous system function, gene expression, and sex and stress hormone synthesis. It also helps the body use fats and protein and is needed for healthy skin, hair, eyes, and liver.

What the medical studies say

Niacin provides many of its heart-healthy effects by blocking the release of fatty acids from fat cells. The liver uses fatty acids to manufacture very low-density lipopoteins (VLDL), the main ingredient in LDL (bad) cholesterol. When less VLDL is available, the liver produces less LDL cholesterol, less of the highly-atherogenic, small LDL particles and more of the good HDL cholesterol.

The Coronary Drug Project was among the first studies to find that niacin had the power to reduce heart attack risk. Over 8,000 heart attack sufferers were given 3000 mg of niacin over a six-year period. Total cholesterol levels were reduced by 10 percent and triglyceride levels dropped by 26 percent. Furthermore, participants experienced a 27 percent decrease in heart attacks and had 26 percent fewer strokes.

The ARBITER series of studies examined the effects of niacin on carotid plaque, which is similar to plaques in heart arteries. Niacin, when added to statin therapy, caused carotid plaque to regress.

The HDL-Atherosclerosis Treatment Study (HATS) was the landmark study that put niacin on the map as a powerful heart-health supplement. One hundred-sixty study participants with pre-existing heart disease were given different combinations of a statin, niacin or placebo. The group who received the statin and niacin enjoyed a 90 percent reduction in death and heart attack when compared to those receiving a placebo over three years.

More recently, the 2011 AIM-HIGH study found that those whose cholesterol was already controlled with a statin did not benefit from the addition of niacin (It also noted a slight increase in strokes on dual statin/niacin therapy). However, this does not discount the other studies, especially for those who prefer not to take a statin or for those whose cholesterol is not well-controlled with a statin alone. Also, statins will not lower triglycerides or lipoprotein(a), and only the newer statins have so much as a marginal effect on raising HDL (good) cholesterol.

The risks

Niacin is a powerful supplement and should be treated with respect. It should never be used without the direct supervision of your doctor. Here are some concerns that should be addressed with your doctor before considering the use of niacin:

  • There is some evidence to suggest that niacin taken with statins can increase the risk for liver toxicity and muscle pain. If you take a statin, your doctor is probably already monitoring your liver enzymes. There is additional evidence to suggest that taking Co-Enzyme Q10 can help alleviate the muscle pain.
  • Niacin may increase blood sugar levels in some individuals (usually no more than 5-10 percent). Those taking medications used to treat high blood glucose levels should monitor their blood sugar levels closely when taking niacin supplements.
  • Niacin and other B vitamins should not be taken with antibiotic tetracycline as it interferes with the absorption and effectiveness of this medication.
  • Certain anti-seizure medications may result in niacin deficiency, while niacin may increase the levels of other such drugs.
  • Be certain to discuss the use of any blood thinning medications with your doctors as niacin may increase both the effects of these drugs and the risk of bleeding. Also, those with a history of peptic ulcer, gastritis or other abnormal bleeding risks should discuss bleeding risks with their doctor.
  • Niacin can also increase the effects of blood pressure medications creating the potential for dangerously low blood pressure.
  • Gout may flare when niacin is used. Discuss niacin use with your doctor if you have a history of gout.

Hot flash: Niacin can cause a hot flush

If niacin is so wonderful, why isn’t everyone using it? Here is the deal: Niacin, for all its benefits, is often abandoned for one simple reason; it can cause a hot, itchy flush. I take 2,000 mg per day and have for many years, but, in the beginning, and whenever I stop taking it for a while, the flush comes back.

The sensation is different for many people. It is usually accompanied by redness in the chest and neck and a hot, itchy feeling that sometimes covers the entire body. I know one person who actually enjoys it. Their reaction is, “It lets me know it’s working!” On the other hand, one friend had to jump in the shower every time he took it and has stopped taking niacin for this reason. The good news is that if you can stand it for a few days, the flush usually stops as your body adapts to it. There are also a few tips and techniques to reduce or eliminate the flush effect.

Discuss taking aspirin 30 minutes before taking niacin with your doctor. The latest science suggests prostaglandin is involved in the flushing effect and aspirin reduces prostaglandin.

Try drinking two eight-ounce glasses of water before or immediately after the hot flush. Of course, be certain to discuss water intake with your doctor if you’re on a fluid restriction because of kidney disease, heart disease, or a history of water retention, or if you take a diuretic.

What are my options for taking niacin?

Niacin can be both safe and effective when used properly in in consultation with your doctor. There are three common forms of niacin available.

  • Immediate-release (sometimes called “crystalline”) niacin;
  • Slow-release niacin;
  • Extended (sometimes called “intermediate-release”) niacin.

Immediate-release niacin is available in virtually every health food or drug store.  Inexpensive and effective, its chief drawback is that it creates the most severe flushing effect. Some people will attempt to counter this problem by taking it in several smaller doses, but this dosing is considered by many to be the most dangerous in terms of liver toxicity.

Slow-release niacin attempts to get around the flushing effect in much the same way as taking multiple small doses of immediate-release niacin by trickling the dose out over time. Unfortunately, this dosing method creates the same problem of increased risk for liver toxicity. One exception that I have used is Slo-Niacin® marketed by Upsher Smith Pharmaceuticals. It has published data proving its safety (and was the product used in the HATS study I mentioned earlier). Your doctor should have the final say about whether this is the right product for you.

Extended-release niacin provides what may be the happy medium between immediate- and slow-release niacin. The only product currently available is Niaspan® (Kos Pharmaceuticals). It is what I currently use and has the advantage of being rigorously tested and is FDA approved. The only problem I have had with it is a short (one or two days) of mild flushing when I begin using it and a little stomach upset that I solved by taking it with food.

Don’t be fooled by niacin “wanna-be’s”

The hot flush side-effect has caused several misinformed or unscrupulous companies to offer what are often called “no flush” niacin products. Despite their “niacin-like” names, these products are not truly niacin and offer none of the benefits of real niacin. Some of the more commonly marketed niacin imposters include:

  • Nicotinamide: Yeah, sounds a lot like “nicotinic acid” but it’s not – it is the “amide” of nicotinic acid (an amide is created by adding a carbon, oxygen, and nitrogen atom to the base compound). The body converts a portion of niacin into nicotinamide but this compound has none of the heart-healthy properties of real niacin.
  • inositol hexaniacinate: Often known as “no-flush” niacin, it is similar to niacin in that it contains six niacin molecules attached to an inositol molecule. This compound works really well in some animals. Unfortunately, humans lack the enzyme needed to utilize the niacin-containing portion of this product.

The takeaway conclusion

Niacin can be a safe, effective, and powerful natural option for many looking to improve their heart health. However, it is important to note it should only be used under the supervision of your doctors. Remember, as Spiderman says, “With great power comes great responsibility!”

What are your experiences with niacin? Share them in this discussion thread.