Niacin decreases myocardial infarction and total mortality in patients with metabolic syndrome: Results from the coronary drug project

Review: Use of nicotinic acid in patients with elevated fasting glucose, diabetes, or metabolic syndrome

This paper will focus on the use of nicotinic acid as a therapeutic option for cardiovascular risk reduction in patients with abnormal glucose metabolism and `atherogenic dyslipidaemia'. This is characterised by low levels of HDL-C, high triglycerides, and preponderance of small, dense LDL particles. Whilst nicotinic acid may increase plasma glucose in some patients, more recent studies show that the effect of nicotinic acid on glycaemic control is minimal in the majority of patients, and that nicotinic acid decreases the risk of cardiac events in patients with elevated fasting glucose, diabetes, or metabolic syndrome.

The long-term effects of feeding honey compared with sucrose and a sugar-free diet on weight gain, lipid profiles, and DEXA measurements in rats

To determine whether honey and sucrose would have differential effects on weight gain during long-term feeding, 45 2-mo-old Sprague Dawley rats were fed a powdered diet that was either sugar-free or contained 7.9% sucrose or 10% honey ad libitum for 52 wk (honey is 21% water). Weight gain was assessed every 1 to 2 wk and food intake was measured every 2 mo. At the completion of the study blood samples were removed for measurement of blood sugar (HbA1c) and a fasting lipid profile. DEXA analyses were then performed to determine body composition and bone mineral densities. Overall weight gain and body fat levels were significantly higher in sucrose-fed rats and similar for those fed honey or a sugar-free diet. HbA1c levels were significantly reduced, and HDL-cholesterol significantly increased, in honey-fed compared with rats fed sucrose or a sugar free diet, but no other differences in lipid profiles were found. No differences in bone mineral density were observed between honey- and sucrose-fed rats, although it was significantly increased in honey-fed rats compared with those fed the sugar-free diet.

[Treatment of dyslipidemia: how and when to combine lipid lowering drugs]

Familial combined hyperlipidemia (FCH) is a frequent familial lipid disorder associated with insulin resistance, low HDL cholesterol, high triglycerides and cholesterol levels with variable phenotypes within the same family. FCH is linked to a high risk for cardiovascular diseases. Treatment goals for lipid abnormalities are changing in recent years. Lowering elevated levels of LDL e Non HDL-cholesterol levels are primary targets of therapy. Lower LDL-C than 70 mg/dL seems to be useful to lower cardiovascular risk in patients with very high risk. Many statins are available, with different potencies and drug interactions. Combination therapy of statins and bile acid sequestrants or ezitimibe may be necessary to further decrease LDL cholesterol levels in order to meet guideline goals. High triglycerides and low HDL cholesterol are also important goals in the treatment of these patients, and frequently statins alone are insufficient to normalize the lipid profile. Combination therapy with fibrates will further lower triglycerides and increase HDL cholesterol levels; this combination is also associated with higher incidence of myopathy and liver toxicity; appropriate evaluation of patients' risk and benefits is necessary. Association of statin/niacin seems be very useful in patients with FCH, especially as niacin is the best drug to increase HDL cholesterol; this association is not linked to a higher frequency of myopathy. Niacin causes flushing, that can in part be managed with use of aspirin and extended release forms (Niaspan); niacin also may increase plasma glucose and uric acid levels. Evaluation of risks and benefits for each patient is needed.

Strategies for Modifying High-Density Lipoprotein Cholesterol: A Role for Nicotinic Acid

Statin-mediated lowering of low-density lipoprotein cholesterol (LDL-C) is regarded as the foundation of lipid-modifying therapy. However, the residual cardiovascular risk for statin-treated patients remains high, indicating the need for therapeutic intervention against other lipid targets as well as non-lipid risk factors. Low levels of high-density lipoprotein cholesterol (HDL-C) are established as a strong independent risk factor for cardiovascular disease. Intervention studies have also demonstrated clinical benefits associated with HDL-C raising. Although lifestyle modification does play an important role in raising HDL-C, most patients with a low HDL-C and at high risk of coronary events also require pharmacological treatment to achieve the target. Of the available treatment options, nicotinic acid is the most potent agent for raising HDL-C (by 26% at clinically recommended doses), while substantially lowering triglycerides and LDL-C. The addition of nicotinic acid to primary statin therapy is a logical approach to dyslipidaemia management, given their complementary mechanism of action, and is supported by recent clinical trials such as the Arterial Biology for the Investigation of the Treatment Effects of Reducing cholesterol (ARBITER) 2 study. Raising HDL-C will increasingly become an important secondary focus of dyslipidaemia management.

Nicotinic acid: the broad-spectrum lipid drug. A 50th anniversary review

Nicotinic acid has, like the Roman God Janus, two faces. One is the vitamin. The other is the broad-spectrum lipid drug. The Canadian pathologist Rudolf Altschul discovered 50 years ago that nicotinic acid in gram doses lowered plasma levels of cholesterol. From the point of view of treatment of the dyslipidaemias that are risk factors for clinical atherosclerosis nicotinic acid is a miracle drug. It lowers the levels of all atherogenic lipoproteins--VLDL and LDL with subclasses as well as Lp(a)--and in addition it raises more than any other drug the levels of the protective HDL lipoproteins. Trials have shown that treatment with nicotinic acid reduces progression of atherosclerosis, and clinical events and mortality from coronary heart disease. The new combination treatment with statin-lowering LDL and nicotinic acid-raising HDL is reviewed. A basic effect of nicotinic acid is the inhibition of fat-mobilizing lipolysis in adipose tissue leading to a lowering of plasma free fatty acids, which has many metabolic implications which are reviewed. The very recent discovery of a nicotinic acid receptor and the finding that the drug stimulates the expression of the ABCA 1 membrane cholesterol transporter have paved the way for exciting and promising new 50 years in the history of nicotinic acid.

Comparative effects of lipid-lowering therapies

The pharmacologic regulation of lipid metabolism in patients with dyslipidemia is unequivocally associated with significant reductions in risk for cardiovascular morbidity and mortality. A number of therapeutic drug classes have been developed in an effort to ever more precisely and intensively modulate lipid metabolism. Statins, fibrates, ezetimibe, and niacin exert their effects via different mechanisms and afford physicians the opportunity to beneficially impact multiple pathways in patients. When used alone or in combination, these drugs decrease risk for the development and progression of atherosclerotic disease. There are strong clinical trial data to support of the use of lipid-lowering therapies in the settings of both primary and secondary prevention. This article (1) discusses the mechanisms of action of antilipidemic medications, (2) reviews dosing regimens and the pharmacokinetic differences among drugs of the same class, (3) assesses risk for drug interactions, and (4) reviews the clinical trial evidence used to support the use of particular antilipidemic medications in specific physiologic settings. The incidence of dyslipidemia is rising worldwide. This trend portends an ever-growing need for the aggressive and judicious use of different antilipidemic medication(s) in patients at risk for all forms of atherosclerotic vascular disease.

Effects of lipid-altering treatment in diabetes mellitus and the metabolic syndrome

The metabolic syndrome (MS) poses an increased risk for the development of diabetes mellitus and cardiovascular events. The syndrome typically includes dyslipidemia, characterized by elevated plasma triglycerides and low high-density lipoprotein cholesterol concentrations. Retrospective analyses of coronary artery disease outcomes trials in patient subpopulations with diabetes or the MS indicate that lipid-altering therapies provide benefits for patients with the MS at least as much as observed in patients without diabetes or the MS. Analyses of the effects of lipid-altering therapy on the lipid profile in patients with the MS also indicate that beneficial lipid changes are similar in patients with the MS compared with those in patients without the MS. The benefits of statin treatment in patients with the MS have become increasingly clear, and it is likely that further improvements in treatment may be achieved with newer statins or a combination of lipid-altering drugs. Prospective data from clinical trials examining the preventive effects of lipid-altering therapy in MS patients are needed to better define potential benefits and optimal treatment in this population.

Niacin, lipids, and heart disease

Niacin is the most effective medication in current clinical use for increasing high-density lipoprotein (HDL) cholesterol. It has the broadest effect on the lipid profile, reducing all atherogenic apolipoprotein (apo) B and increasing all antiatherogenic apo AI-containing lipoproteins, resulting in significant reduction in atherosclerotic complications and total mortality in trials. Recent research indicates novel major target sites of action in the liver to 1) directly inhibit diacylglycerol acyltransferase 2 (DGAT2), explaining its effect on triglycerides and apo B lipoproteins, and 2) inhibit the HDL apo AI catabolism pathway, resulting in higher HDL levels. Such information may lead to new drug discovery and supply the rationale for combination with other lipid regulators that are known to have different mechanisms of action. Trial evidence shows that niacin is not only safe to use in persons with diabetes, but that its combination with 3-hydroxy-3-methyl-glutaryl coenzyme A (HMG CoA) reductase inhibitors (statins) is also safe and effective. Recently, a new formulation of niacin has made it easier to tolerate and administer. Clinical trials are needed to determine whether niacin in combination with other lipid-modulating agents decreases the risk of cardiovascular events beyond the approximately 30% that has been noted with monotherapy.

Once-Daily Niacin Extended Release/Lovastatin Combination Tablet Has More Favorable Effects on Lipoprotein Particle Size and Subclass Distribution Than Atorvastatin and Simvastatin

Standard lipoprotein measurements may not adequately reflect the increased atherogenic risk found in patients with abnormalities in lipoprotein particle size and subfraction distribution such as disproportionate amounts of small, dense low-density lipoprotein particles, small high-density lipoprotein particles, or large very-low-density lipoprotein particles. Measurement or anticipation of patients most susceptible to lipoprotein subfraction abnormalities may influence therapeutic choices for the optimal management of dyslipidemia. Previously, the ADvicor Vs. Other Cholesterol-modulating Agents Trial Evaluation demonstrated that niacin extended release/lovastatin provided greater global improvement in lipid parameters such as low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, lipoprotein (a), apolipoprotein B, and apolipoprotein A-I blood levels compared with atorvastatin and simvastatin monotherapies. In this report, niacin extended release/lovastatin was also more effective than atorvastatin and simvastatin monotherapies in reducing small, dense low-density lipoprotein particles and improving low-density lipoprotein phenotype pattern at relative starting doses, and was more effective in increasing the proportion of high-density lipoprotein in the potentially cardioprotective 2b subclass at all doses.

Therapeutic approaches to dyslipidemia in diabetes mellitus and metabolic syndrome

Type 2 diabetes mellitus and the closely related metabolic syndrome are associated with significant risk for cardiovascular disease. Recent evidence suggests that both conditions are increasing in epidemic proportions. Dyslipidemia is characterized by increased triglyceride-rich lipoproteins; low high-density lipoprotein cholesterol; small, dense low-density lipoprotein particles; increased postprandial lipemia; and abnormal apolipoprotein A1 and B metabolism. All these lipoprotein disturbances accelerate atherosclerosis in these patients. It is likely that many patients will need combinations of lipid-modifying therapy to achieve American Diabetes Association (ADA), Adult Treatment Panel III, and American Heart Association (AHA)/American College of Cardiology (ACC) guidelines to help prevent cardiovascular disease and death.