Niacin + statin

Combination drug therapy is an effective means to achieve greater reductions in LDL cholesterol (statin + ezetimibe or bile acid resin, bile acid resin + ezetimibe, or three-drug combinations) as well as raising HDL cholesterol and lowering serum triglycerides (statin + niacin or fibrate). 

Reducing LDL cholesterol while substantially raising HDL cholesterol (statin + niacin) appears to reduce the risk of atherosclerotic disease progression to a greater degree than statin monotherapy. 

Primary hypercholesterolemia (familial hypercholesterolemia, familial combined hyperlipidemia, type Ila hyperlipoproteinemia) is treated with BARs, statins, niacin, or ezetimibe. 

Figure 111-7-2. Site of Action of Statins, Niacin, and Gemfibrozi on the Sythesis of Lipids...

Figure 111-7-2 summarizes the effects of statins, niacin, and gemfibrozil on the synthesis of lipids. ... 

Another treatment for cholesterol is niacin. The use of niacin predates the statins. Niacin is also known as nicotinic acid or vitamin B3. The name, niacin comes from nicotinic ac id and vitamin and was coined to avoid confusion and so that people would not think that the vitamin contained nicotine or that tobacco products contained vitamins. Niacin inhibits lipoprotein synthesis by preventing the secretion of very low density lipoprotein from the liver. Very low density lipoprotein is a precursor of low density lipoproteins (LDL). However there are several adverse side effects with niacin including flushing, warm skin, itching rash, constipation, nausea, hearthum, and problems with liver function. Because of these side effects, niacin is often used in a controlled release form [17] and even in this form is unsuitable for many patients. 

In general, niacin reduces LDL cholesterol from 5% to 25%, reduces triglycerides by 20% to 50%, and increases HDL cholesterol by 15% to 35% (Table 9-8). Niacin has been shown to reduce CHD events and total mortality31 as well as the progression of atherosclerosis when combined with a statin.31... 

Some patients, in particular those with genetic forms of hypercholesterolemia (Table 9-2), will require three or more drugs to manage their disorder. Regimens using a statin, resin, and niacin were found to reduce LDL cholesterol up to 75%.42 These early studies were conducted with lovastatin, so larger reductions would be expected with the more potent statins available today. 

In general, a statin plus a BAR or niacin plus a BAR provide the greatest reduction in total and LDL cholesterol. 

Regimens intended to increase HDL levels should include either gemfibrozil or niacin, bearing in mind that statins combined with either of these drugs may result in a greater incidence of hepatotoxicity or myositis. 

Dosingof selected agents by class fibrate (gemfibrozil 600 mg twice a day) niacin (1.5-3 g/day of immediate-release product) statin (simvastatin 10-40 mg/day if glomerular filtration rate [GFR] <30 mL/min, 20-80 mg/day if GFR >30 mL/min) bile acid sequestrant (cholestyramine 4-16 g/day). 

Niacin (11) is the most potent HDL-raising drug (20-30%) on the market, and also provides some reduction in TG and LDL-C levels. Clinical studies with niacin as monotherapy or in combination with statins have yielded marked reductions in... 

Crestor Astra-Zeneca) and lovastatin + niacin (Advicor Kos Pharmaceutical) — that can also cause rhabdomyolysis remain on the market. Although scientists agree that the other statins "seem to have essentially identical safety profiles and benefif-risk rafios," FDA said the ADRs associated with Baycol "have been reported significantly more frequently than for other approved statins." ... 

Action HMG-CoA reductase inhibitor Dose 5-40 mg PO daily max 5 mg/d w/cyclosporine, 10 mg/d w/gemfibrozil or CrCl <30 mL/min (avoid Al-/Mg-based antacids for 2 h after) Caution [X, /-] Contra Active Uvct Dz, unej lained t LFT Disp Tabs SE Myalgia, constipation, asthenia, abd pain, N, myopathy, rarely rhabdomyolysis Interactions t Effects OF warfarin t risk of myopathy W/ cyclosporine, fibrates, niacin, statins EMS t Effects of warfarin concurrent EtOH use can t risk of liver tox Asian pts have an t risk of advise effects OD Unlikely to cause life-threatening Sxs... 

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