Thursday, December 9, 2010

Is There a Niacin Substitute for Lowering Cholesterol?

A reader asks us about Niaspan as a substitute for over-the-counter niacin for lowering cholesterol, as well as how much niacin is too much for lowering cholesterol.

The reason niacin substitutes are an issue is that the amount of this B vitamin needed to lower cholesterol is typically about 3,000 mg a day, but taking very high dose of any vitamin, especially this vitamin, can throw other vitamins out of balance.

If you take high-dose niacin by itself, you may just be trading one factor for heart disease, high cholesterol, for another, high homocysteine. Taking more than 1,000 mg of niacin a day can raise homocysteine levels, especially if niacin is not balanced by folic acid (400-1,000 mg a day), vitamin B6 (10-50 mg a day), and vitamin B12 (50-300 micrograms a day). If you take more than 1,000 mg of niacin daily, you need additional B vitamins.

There have been no trials of niacin for lowering cholesterol in persons who have not had a heart attack, but the Coronary Drug Project followed 8,000 men who had had a heart attack for eight years. Taking 3,000 mg of nicotinic acid every day resulted in:

  • 10% lowering of total cholesterol,
  • 26% lowering of triglycerides,
  • 27% lowering of the rates of second heart attacks, and
  • 27% lowering of the rates of stroke.
Follow-up over 15 years found that men who took a form of niacin known as nicotinic acid were 11 per cent more likely to still be alive at the end of the study.

Other studies of both men and women have found that taking niacin raises HDL levels and transforms LDL cholesterol from the sticky apo-A form to the lighter, less harmful apo-B form. Taking beta-carotene, vitamin C, vitamin E, and selenium, however, reduced the benefits of niacin.

Unfortunately, a number of things can go wrong when you take niacin for your health health. Niacin side effects include:
  • Liver damage, detected by changes in blood tests for the cell damage markers ALT and AST, and, in extreme cases, by tenderness and enlargement of the liver. Like statin drugs, niacin sometimes damages the liver. Hepatitis has been observed from taking dosages as low as 500 mg a day for a period as short as two months, although most cases of liver damage occurred when the dosage was 3,000 to 9,000 mg for several years.
  • Higher blood sugar levels. Diabetics usually should not take high-dose niacin. The vitamin can cause insulin resistance and raise blood sugars.
  • Occasional side effects have included blurred vision, migraine, peptic ulcers, disturbances of heart rhythm, and gout.
And facial flushing with an outbreak around the nose resembling acne is very problem. (The answer to a common question, "Does niacin flush your system?" is that niacin doesn't flush, in the sense of detox, but it causes flushes, in the sense of blushing and redness.) A slower-release form of niacin, nicotinamide, does not cause flushing, but can aggravate diabetes and cause liver damage. This is true of both niacin and the slow-release form of the vitamin, Niaspan. The real difference is in other symptoms, such as palpitations, dizziness, and blurred vision. Niaspan is less likely to cause these symptoms, but if you are a diabetic, you probably should not use either high-dose niacin or Niaspan. There are many other ways to control cholesterol.

The best use of niacin for type 2 diabetics is in lowering very high triglyceride levels, so high that they are causing pancreatitis. In this case, however, the niacin is usually given by intravenous injection under a doctor's supervision.

Selected Reference:

Jialal I, Amess W, Kaur M. Management of hypertriglyceridemia in the diabetic patient. Curr Diab Rep. 2010 Aug;10(4):316-20.


  1. The other alternative to niacin are tocotrienols. They will lower LDL but have no effect on HDL or triglycerides.

    Tocotrienols are a form of Vitamin E. There are actually eight different types of natural vitamin E. The most commonly used form of vitamin E is alpha-tocopherol. The second most common form of natural vitamin E is gamma-tocopherol. However, neither of these forms have any effect on cholesterol. Tocotrienols are forms of vitamin E that do have a cholesterol-lowering effect. Alpha-tocopherol does blunt or eliminate the cholesterol-lowering effect of tocotrienols, so the best source of tocotrienols are from the Annato plant. This is the only source that lacks alpha-tocopherol. Tocotrienols also come from palm oil, but palm oil does contain a small amount of alpha-tocopherol, so the LDL-lowering effect is lessened. Look for a product that contains only delta-and gamma-tocotrienols. A bottle of 90 capsules can be purchased for around $15.

    References: Dose-Dependent Cholesterolemic Activity of Tocotrienols and α-Tocopherol, Teik, Theng & Rajendran

    Tocotrienol: A Review of Its Therapeutic Potential, Theriault, Chao, et al.

    Tocotrienols: Vitamin E beyond tocopherols, Sen, Khanna, Roy

  2. Thank you for very useful and very accurate information. Please feel free to recommend a brand if you would like. Robert