Nicotinic acid Lovastatin

Reaven P, Witztum JL. Lovastatin, nicotinic acid, and rhab-domyolysis. Ann Intern Med 1988 109(7) 597-8. 

Abbreviations AM, amlodipine AT, atorvastatin DS, diclofenac sodium EZ, ezetimibe FB, fenofibrate HAT, hydroxy atorvastatin IS, internal standard o-HAT, ortfio-hydroxy atorvastatin p-HAT, para-hydroxy atorvastatin HPLC-ESI-MS, high-performance liquid chromatography with electrospray tandem mass spectrometry LV, lovastatin NA, nicotinic acid NB, novobiocin FV, pravastatin RV, rosuastatin SV, simvastatin RT, roxethromycin UPLC, ultra performance liquid chromatography. 

It is clear from Equation (19.4) that saturated fat, not cholesterol, is the single most important factor that raises serum cholesterol. Some cases of hyperlipoproteinemia type IV (high VLDL) respond to low-carbohydrate diets, because the excess of VLDL comes from intestinal cells, where it is produced from dietary carbohydrate. Resins, such as cholestyramine and cholestipol, bind and cause the excretion of bile salts, forcing the organism to use more cholesterol. Lovastatin decreases endogenous cholesterol biosynthesis (see later), and niacin (nicotinic acid) apparently decreases the production of VLDL and, consequently, LDL. It also results in an HDL increase. Antioxidants that inhibit the conversion of LDL to oxidized LDL have also been used with some success. These are high doses of vitamin E and the drug probucol. 

Clinically important, potentially hazardous interactions with dicumarol, ezetimibe, lovastatin, nicotinic acid, statins, warfarin... 

Clinically important, potentially hazardous interactions with atorvastatin, bexarotene, cyclosporine, dicumarol, ezetimibe, fluvastatin, interferon alfa, lovastatin, nicotinic acid, pioglitazone, pravastatin, repaglinide, rosuvastatin, roxithromycin, simvastatin, statins, warfarin... 

Type Ha Familial hypercholesterolemia (1LDL receptors) tUjL Increased LDL colestipol, cholestyramine, lovastatin, nicotinic acid... 

Type IV Endogenous hyperlipemia (T VLDL production -l removal) Increased VLDL Nicotinic acid, gemfibrozil, lovastatin... 

Although these cases are isolated, some caution is certainly warranted. The US manufacturers of lovastatin recommend a maximum dose of 20 mg in patients taking nicotinic acid in doses of 1 g or more daily. Similarly the UK manufacturers of simvastatin recommend a maximum dose of 10 mg in patients taking nicotinic acid in doses of 1 g or more daily." To be on the safe side, if the decision is made to use nicotinic acid with any statin the outcome should be very well monitored. Patients should be told to report otherwise unexplained muscle pain, tenderness or weakness or dark coloured urine). See also muscle toxicity , (p.l086), for further guidance on monitoring, and risk factors for muscle toxieity. 

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