[ed note: Michael Jorrin is longtime medical writer who has been sharing his thoughts with our readers as “Doc Gumshoe” for several years (he’s not a doctor, I gave him the name). He generally covers medical and health news and sometimes health promotions and hype, but he rarely opines about investments or specific stocks. All of his past commentaries can be seen here]
The key word there is “responses” – not answers, but responses. Many of the comments from the Gumshoe Literati are in the form of specific questions – what’s the correct dose of a specific supplement to achieve a particular result? The answer to such a question – coming from Yr Obt Svt at any rate – would be “I haven’t the foggiest.” But I can and will respond. Your questions and comments set my mind to wondering and pondering and exploring, and I’m happy to expose the inner workings of my little grey cells to you all. And, needless to say, to expose my conclusions, tentative as they may be, to your shrewd appraisal.
Niacin as a treatment for elevated cholesterol?
One such comment, which I replied to briefly in the comments thread, was this:
“What did you think about the quote in the N Y Times (about a decade ago?), where the President of the college of cardiology states that the absolutely best drug for cardiovascular disease is Niacin (aka: Nicotinic acid), because it raises “good” HDL, lowers “bad” LDL, & lowers Triglycerides, as no statin can do?”
My reply did not satisfy the reader, particularly my noting that niacin had fallen out of favor as a treatment option for elevated cholesterol. He commented that “fallen out of favor” is not science, and mentioned other potentially beneficial effects of niacin/nicotinic acid which, to be frank, I had never heard of. This prompted some sleuthing.
In previous pieces, I have tried to present a kind of summary of the history of the management of heart disease related to arterial obstruction.
Hardening of the arteries, or arteriosclerosis, had been observed for a really long time – many centuries – but it was only in the early 20th century that it became associated with cardiovascular disease. In the first decade of the 20th century, the stuff that was deposited in the artery walls, and in some cases also clogged the lumen of the arteries, was identified as cholesterol, although some calcium was also deposited in artery walls. The term “arteriosclerosis” was gradually replaced by “atherosclerosis,” which pinned the blame on fat. The emphasis on cholesterol as the culprit is about a century old, but for most of that time, clinicians didn’t have any effective means of dealing with cholesterol or atherosclerosis.
The initial focus, quite reasonably, was to try to manage cholesterol by dietary means – that is, by restricting foods that were highest in cholesterol. Unfortunately, with regard to the population in general, this approach does not work. The principal reason for the failure of this approach is that we, along with most animals, have an excellent capacity for synthesizing cholesterol (cows make it out of grass). That capacity, after all, is necessary for our survival, since cholesterol is an essential component of most body tissues (bones excepted) and is also essential to the synthesis of the hormones on which we depend for body functions. So we make at least 80% of the cholesterol in our systems, and take in perhaps 20% as cholesterol in our food; therefore, lowering dietary cholesterol just doesn’t do the job.
Therefore, the medical community looked around for drugs that might have the effect of lowering cholesterol, and in the mid-1950s niacin was the first one found to have that property. Up to then, niacin, also termed Vitamin B3, had been known as an essential factor in preventing pellagra, a disease caused by deficiency of niacin/ B3 in some people’s diet.
Niacin lowers levels of LDL-cholesterol and VLDL-cholesterol, as well as lowering triglycerides and increasing HDL-cholesterol levels. The principal drawback of niacin as treatment for elevated blood lipids is that many patients find it quite difficult to tolerate niacin at the dosing levels necessary to effect the desirable changes. Many or most patients experience severe flushing, which can be accompanied by severe and persistent itching anywhere in the body. This has greatly affected adherence to treatment with niacin – that’s to say, patients try it, but find that they can’t stick to it.
There are other cholesterol-lowering options other than statins. Fibrates tend to have a beneficial effect on VLDL, and in particular, on triglycerides. Their effects on LDL and HDL are variable. Bile acid sequestrants tend to lower total cholesterol and LDL and produce small increases in HDL. Omega-3 fatty acids may be useful in persons whose lipid imbalance is primarily a matter of elevated triglycerides; these need to be taken in very large doses.
Unfortunately, neither niacin nor these alternatives lower C-reactive protein, which is a marker for systemic inflammation. Inflammation is thought by many to be the key factor in arterial disease, resulting in what’s called