The B vitamin niacin has a special quality setting it apart from the other members of the B vitamin complex family.  That quality is the ability to increase high-density lipoprotein (HDL) cholesterol – the ‘good’ cholesterol that helps remove low-density lipoprotein (LDL) the ‘bad’ cholesterol from the bloodstream.

Niacin also has the distinction of being the first treatment for high cholesterol when its beneficial effects were discovered in 1955.  Over the years, statin medications were formulated to help lower cholesterol and thus became more popular in being prescribed by physicians for the intended use. 

Why use niacin?

Most people with high cholesterol levels who are unable to improve their numbers sufficiently with diet and exercise are often prescribed statin drugs.  However, some individuals would rather not take a prescription drug or cannot tolerate a statin medication.  This is when they may be willing to give high-dose niacin a try to possibly improving cholesterol levels and reducing heart attacks.    

Another reason for using niacin is that even though statins do a better job of lowering LDL cholesterol, niacin appears to have an advantage by raising HDL cholesterol much more than statins do.  It may also lower triglycerides which are fats in the blood increasing the risk of heart disease.

However, over the years, research studies have questioned niacin’s efficacy in boosting HDL cholesterol.  Many physicians are not totally convinced of niacin’s ability to do this.  A 2014 study in the New England Journal of Medicine found that the combination of niacin and the antiflushing agent laropiprant was no better than a placebo at reducing cardiovascular disease. 

This is where any patient considering using niacin to control blood lipid levels, should thoroughly discuss this with their doctor. 

Using niacin as a treatment for cholesterol

Even though classified as a dietary supplement, in large doses it does act as a drug, whether it is bought over-the-counter or by prescription.  High-dose niacin can be in the prescriptions forms of Niaspan (extended release) and Niacor (immediate release) in addition to generic and intermediate forms of the vitamin.  The intended forms are designed to raise HDL cholesterol and lower LDL cholesterol helping to reduce the risk of cardiovascular disease. 

When niacin is combined with a cholesterol-lowering statin drug, it can be even more effective for lowering cholesterol. 

Depending on the dose of niacin prescribed by a physician, will determine the effect it has on blood lipids. To see the biggest increases in HDL and reduction in triglycerides, niacin needs to be prescribed at 1200-1500 mg per day while the greatest effects on LDL occur at doses of 2000-3000 mg per day.  No one should take these doses on their own as they should be taken only under a doctor’s supervision because of possible damaging effects on the liver.

What are the risks of high-dose niacin?

The main side effect of using high-dose or prescription niacin is flushing of the skin (mostly on the face and upper body) which can worsen with alcohol intake.  This side effect is not harmful or long-lasting and generally will subside over time.  The nicotinamide form does not usually cause flushing and is better tolerated than the nicotinic acid form. 

Some people may experience an allergic reaction to prescription doses of niacin, including symptoms of a rash, itching, swelling (face, throat, and tongue), severe dizziness, and trouble breathing. 

In rare cases, high-dose niacin may cause liver damage.  Used in amounts of up to 3 grams or more has been found, in some cases, to cause liver damage though doses as low as 750 mg a day for three months have resulted in elevated liver enzymes. 

Be careful not to confuse niacin or nicotinamide with niacinamide, inositol niacinamide, or nicotinate.  None of these have been shown to lower cholesterol levels. 

Anyone using other prescription medications needs to be aware of the possibility of an interaction with niacin and know that bile acid sequestrants, such as cholestyramine, colestipol and colesevelam can reduce the absorption of niacin. 

Bottom line

The first-line of defense in treating elevated blood lipid levels are statins along with lifestyle improvements that include dietary and exercise interventions.  Statins are still considered to be the most effective at lowering LDL, and shown to prevent heart attacks and have few side effects. 

Anyone wanting to try niacin for improving blood lipid levels needs to discuss this with their physician or pharmacist about the different forms and to take it only under medical supervision.