On 2015 Dec 02, David Keller commented:

Extended-release niacin reduced Lp(a) but not CV risk, when added to statin therapy

The AIM-HIGH trial yielded a 21% reduction in Lp(a) levels when high dose niacin was added to statin therapy, but without the expected additional reduction in cardiovascular (CV) events. This is puzzling because it is known that CV risk is correlated to Lp(a) level. Niacin is known to lower Lp(a) levels, which was again demonstrated in this study.

The Coronary Drug Project, conducted in the pre-statin era, demonstrated that monotherapy with high-dose niacin reduced recurrent nonfatal myocardial infarctions, cerebrovascular events, and overall mortality at 15 years compared with placebo [1]. However, more recent studies of patients taking appropriate baseline statin therapy did not demonstrate additional reduced CV risk due to the improvement in lipids caused by the addition of niacin.

All of the patients in this study were on appropriate statin therapy at baseline. Again, we see that adding niacin to baseline statin therapy somehow fails to yield the additional outcome benefits expected from niacin's improvements in cholesterol and Lp(a) levels.

Given the evidence of outcome benefits with niacin monotherapy, but not with niacin added to a statin, it may be that statins somehow negate niacin's outcome benefits, despite preserving its improvement of the lipid profile. If so, then statin-intolerant patients remain candidates for niacin therapy, unless and until future clinical trials fail to reproduce the outcome benefits niacin demonstrated in the Coronary Drug Project.

Reference

1: Canner PL, Berge KG, Wenger NK, Stamler J, Friedman L, Prineas RJ, Friedewald W. Fifteen year mortality in Coronary Drug Project patients: long-term benefit with niacin. J Am Coll Cardiol. 1986 Dec;8(6):1245-55. PubMed PMID: 3782631.

On 2015 Dec 02, David Keller commented:

Extended-release niacin reduced Lp(a) but not CV risk, when added to statin therapy

The AIM-HIGH trial yielded a 21% reduction in Lp(a) levels when high dose niacin was added to statin therapy, but without the expected additional reduction in cardiovascular (CV) events. This is puzzling because it is known that CV risk is correlated to Lp(a) level. Niacin is known to lower Lp(a) levels, which was again demonstrated in this study.

The Coronary Drug Project, conducted in the pre-statin era, demonstrated that monotherapy with high-dose niacin reduced recurrent nonfatal myocardial infarctions, cerebrovascular events, and overall mortality at 15 years compared with placebo [1]. However, more recent studies of patients taking appropriate baseline statin therapy did not demonstrate additional reduced CV risk due to the improvement in lipids caused by the addition of niacin.

All of the patients in this study were on appropriate statin therapy at baseline. Again, we see that adding niacin to baseline statin therapy somehow fails to yield the additional outcome benefits expected from niacin's improvements in cholesterol and Lp(a) levels.

Given the evidence of outcome benefits with niacin monotherapy, but not with niacin added to a statin, it may be that statins somehow negate niacin's outcome benefits, despite preserving its improvement of the lipid profile. If so, then statin-intolerant patients remain candidates for niacin therapy, unless and until future clinical trials fail to reproduce the outcome benefits niacin demonstrated in the Coronary Drug Project.

Reference

1: Canner PL, Berge KG, Wenger NK, Stamler J, Friedman L, Prineas RJ, Friedewald W. Fifteen year mortality in Coronary Drug Project patients: long-term benefit with niacin. J Am Coll Cardiol. 1986 Dec;8(6):1245-55. PubMed PMID: 3782631.