Q: I recently had a
cholesterol profile blood test and learned that I may be at risk
of heart disease because my levels of beneficial HDL
(high-density lipoprotein) are too low. I read that niacin could
help increase my HDL, but my doctor said niacin is dangerous.
Whom should I believe?
A: Your doctor would be
right—if we were still living in 1985. Since then, however, we
have learned how to use niacin (vitamin B3) safely and
effectively. Unfortunately, many physicians have not yet
caught up, or are still trapped by the idea that
cholesterol-lowering statin drugs are the only way to decrease
cardiovascular disease risk. I have personally prescribed
niacin for thousands of patients as part of our program to
reverse coronary disease. In fact, niacin is the closest thing
we have available to a perfect treatment that corrects most of
the causes of coronary heart disease.
Niacin, also known as “nicotinic acid,” is found in red meat,
chicken, turkey, beans, and grains. It is a required
nutrient and a member of the B vitamin family. Have you
ever taken a B-complex vitamin pill that triggered a strange
burning sensation of the skin? If so, that was the niacin
you experienced. Niacin plays a crucial role in
energy production, gene expression, and hormone synthesis.
Humans cannot exist without it.
The recommended dietary allowance (RDA) of niacin to prevent
pellagra (a disease caused by vitamin B3 deficiency and
characterized by diarrhea, dermatitis, dementia, and possible
death) is 16 mg a day for males and 14 mg for females.
Pellagra induced by niacin deficiency was widespread in the
United States during the nineteenth century, but is now long
forgotten and rarely seen.
When taken at doses greater than the RDA, niacin confers an
array of health benefits.
- Increases high-density lipoprotein (HDL) by 20-35%. No
other available over-the-counter treatments, and very few
drugs, are as effective.
- Decreases small low-density lipoprotein (small LDL)
particles. Small LDL is an important yet under-appreciated
cause of heart disease. Niacin is the most effective agent
known for correcting this abnormal pattern.
- Decreases triglycerides by 30%. Niacin is especially
effective when taken with fish oil (at doses of 4000 mg a
day, providing 1200 mg of EPA/DHA).
- Decreases very low-density lipoprotein (VLDL) particles.
- Decreases lipoprotein(a), or Lp(a). No other treatment
approaches the power of niacin to reduce the genetically
determined pattern of high Lp(a), which is among the most
serious risk factors for heart disease.
- Decreases low-density lipoprotein (LDL), usually by
20-40 mg/dL, or 5-25%.
Niacin blocks the release of fatty acids from fat cells.
Fewer fatty acids are passed through to the liver, resulting in
fewer VLDL particles. Less VLDL leads to less small LDL
and higher HDL.1
Niacin also improves endothelial function and nitric oxide
Niacin’s benefits are not limited to its influence on blood
markers of cardiovascular disease risk. It also reduces heart
attack risk dramatically. The Coronary Drug Project was
the first to establish that niacin is a powerful agent in
lowering heart attack risk. When more than 1,000 heart
attack survivors were given 3000 mg of
(immediate-release/crystalline) niacin daily for six years, the
incidence of recurrent non-fatal heart attacks was reduced by
27%, and the number of strokes was reduced by 26%.2
In the well-known HDL-Atherosclerosis Treatment Study (HATS),
160 participants were given niacin and simvastatin (Zocor®) or a
placebo. Compared to the placebo group, the group
receiving niacin and simvastatin experienced a 90% reduction in
death and myocardial infarction over three years.3
In other words, coronary events were nearly eliminated.
Although the study sample was small, its results are striking.
By comparison, statin drugs alone typically reduce heart attack
risk by 25-35%. The 90% reduction achieved in the HATS
trial thus is truly remarkable.
Despite niacin’s track record, many physicians have never
learned how to use it effectively. Statin drugs have
caused many physicians to forget how effective niacin can be.
This is a shame, because niacin can be a powerful agent in
combating heart disease, when used alone or in combination with
other treatments (especially fish oil).
Niacin’s safety record is equally impressive. However,
a brief foray into the use of very-slow-release niacin
preparations in the 1980s taught us an important lesson ...
niacin is very safe, if the liver is exposed to it for only a
few hours at a time. Niacin is, after all, just vitamin
B3. However, 24-hour, day-after-day exposure to
niacin over an extended period can be toxic to the liver.
Thus, the very-slow-release niacin preparations that yielded
sustained, high blood levels of niacin caused liver toxicity in
10-20% of people who used these preparations in the 1980s.
Unfortunately, this learning experience left some physicians
fearful of recommending niacin to their patients. For this
reason, very-slow-release niacin should be avoided.
There are two safe forms of niacin:
- Immediate-release/crystalline niacin is
available as a nutritional supplement and is inexpensive and
effective. The niacin in each table is released immediately
and usually provokes a “hot flush,” a warm, itchy feeling of
the skin. For this reason, starting at small doses, such as
250 mg, can be helpful. The dose can be increased gradually
(by 250 mg every four weeks) to achieve the desired amount.
Doses greater than 500 mg per day should be used only under
medical supervision. Some people take their niacin in small
doses, three or four times daily, to spread out the dose.
This could be unsafe, and I recommend that patients never
take immediate-release niacin more than twice a day.
- Extended-release niacin is a
time-release preparation, but does not act as slowly as
slow-release niacin. This makes it safer than the
slow-release preparations that can cause liver side
effects. Extended-release niacin also provokes fewer hot
flushes than immediate-release niacin. An example is
Slo-Niacin®, which is sold over the counter. Niaspan® is an
extended-release niacin preparation sold as a prescription
By contrast, slow-release niacin preparations reduce the
hot-flush effect by releasing niacin over an extended period of
12 hours or longer. Most of these preparations are unsafe
and I do not recommend them. “No-flush” niacin
preparations, such as inositol hexaniacinate and nicotinamide,
are widely sold as niacin alternatives that do not cause hot
flushes. In my experience, however, they simply do not
work. In other words, no flush, no effect.
The correct dose of niacin depends on what abnormality you
and your doctor are trying to correct. To raise HDL and
correct small LDL, a dose of 750-1000 mg a day usually provides
full benefit. Increasing this dose to 1500 mg a day may
provide slightly greater benefit. To reduce LDL or Lp(a),
higher doses (from 1000 mg up to 4000-5000 mg per day) are often
used, with higher doses providing greater effects.
However, doses this high should be taken only with a physician’s
supervision. Keep in mind that it may take three months or
longer to realize the full lipid-optimizing benefits of niacin.
As previously noted, the one common though generally harmless
side effect of taking niacin use is hot flushes. Some
people find them bothersome enough that they want to flush the
niacin down the toilet!
The flush, which feels like blushing when one is embarrassed,
is usually accompanied by a prickly sensation over the face,
neck, and chest. Some women say it feels like the hot
flashes of menopause. These flushes are usually
short-lived, lasting no more than 20 minutes. Tolerance to
this effect occurs with continued niacin use, usually after a
few weeks or months. You may experience flushing at the
start of your niacin program as well as when you increase your
dose. In rare cases, a more marked flushing reaction may
occur, resembling a rash or hives. If this occurs, speak
to your doctor about whether you should continue using niacin.
You can employ several strategies to greatly minimize or even
eliminate niacin-induced hot flushes:
- Drink plenty of water. This is very
important and especially helpful when you experience a hot
flush: drink two 8- to 12-ounce glasses of water
immediately, and the hot flush will almost always disappear
within a few minutes. If you need to drink water to block
hot flushes but find yourself getting up several times a
night to urinate, take your niacin with dinner or
breakfast. If you are restricting your fluid intake because
of kidney disease, heart disease, water retention, or
diuretic use, talk with your doctor before increasing your
Take niacin after consuming a small handful of nuts,
such as 5-10 raw almonds, walnuts, or pecans.
This will slow niacin’s absorption in the body. You may
want to skip this if you are limiting your calorie intake in
order to lose weight. While some people recommend taking
niacin with a low-fat snack, I discourage this approach, as
low-fat snacks like crackers contribute to increased levels
of dangerous small LDL.
- Take niacin with an aspirin. When you
start niacin and whenever you increase the dose, taking an
adult (325-mg) uncoated aspirin tablet can block the niacin
flush. After a few weeks or months, when flushing
dissipates, changing to a low-dose (81-mg) enteric-coated
aspirin can minimize stomach upset and the long-term risk of
stomach ulcers and bleeding. Always discuss aspirin use
with your doctor, and only use aspirin on a long-term basis
with your doctor’s recommendation.
- Avoid alcohol and spicy foods when taking
niacin. This strategy is not crucial for everyone,
as only some people are sensitive to this phenomenon. You
can consume alcohol and spicy foods apart from your use of
niacin—for example, having a glass of wine at 7 p.m. and
then taking niacin at 9 p.m. Only a few people will have
more flushing due to the combination.
Niacin may raise blood sugar by about 4-5 mg/dL at the
beginning of therapy. This increase usually dissipates
over a few months, and is rarely clinically important.
However, increases in blood sugar may be greater if you already
have high blood sugar or diabetes. For this reason, niacin
should be taken under medical supervision, with gradual
increases in dosage, if you have high blood sugar. Having
diabetes or pre-diabetes is not necessarily a contraindication
to niacin use. In fact, people with these conditions are
most likely to benefit from niacin, since diabetes and
pre-diabetes are strongly associated with small LDL, low HDL,
increased triglycerides, and other abnormalities that are
corrected by niacin.4 (Individuals with extremely high
triglyceride levels of greater than 1000 mg/dL may require a
combination of therapies to achieve effective lipid level
control.) Type I (childhood-onset) diabetes, however, is
often a contraindication to niacin use, as blood sugar is
significantly elevated in this condition.
Niacin therapy should be initiated in patients with low HDL
levels (less than 40 mg/dL for men and less than 50 mg/dL for
women), particularly if other risk factors are present.
Niacin is among the most effective agents known for correcting
the multiple causes of heart and vascular disease, and has been
shown to greatly diminish the risk of heart attack. Niacin
is very safe and easy to use, if used properly. In my
experience, over 95% of people who follow these guidelines are
able to take niacin with only minimal hot flushes.
Potentially serious side effects are almost never seen.
People with liver disease, unexplained elevation of liver
enzymes, active peptic ulcer disease, or a history of abnormal
bleeding should consult their physician before beginning niacin
treatment. Those with a past history of liver disease,
jaundice, peptic ulcer disease, gastritis, or alcoholism should
exercise caution with niacin. Gout may flare up when
niacin is used, so talk to your doctor if you have a history of
Dr. William Davis is an author and cardiologist
practicing in Milwaukee, Wisconsin. He is author of the book,
Track Your Plaque: The only heart disease prevention
program that shows you how to use the new heart scans to detect,
track, and control coronary plaque. He can be contacted at