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Since niacin is known to be one of the best agents for fighting hyperlipidemia, why is it so rarely prescribed? Some of the reported side effects can be refuted: (1) Flushing can be minimized by starting with a minimal dose (50 mg) that is increased gradually and by taking an aspirin a day. (2) USP-labeled immediate-release niacin will avoid the liver damage caused by the binding of slow-release niacin to liver cells. (3) Some studies suggest that niacin has positive effects on cognition, while statins have negative effects sometimes interpreted as mini-strokes. On a related matter, other studies suggest that fiber (e.g., oat bran and psyllium husk [Metamucil]) is as effective for interfering with cholesterol absorption as ezetimibe. Your comments, please.
—Chagai Dubrawsky, MD, Houston

Niacin is a good hyperlipidemic agent, and its side effects can be minimized—although not eliminated—by the measures Dr. Dubrawsky describes. I do question the implication that statins cause mini-strokes or reduced cognitive ability. Studies in these areas actually indicate the statins’ usefulness in doing just the opposite (see the excellent article by Peter Jones, MD, in Cardiology Review. 2005;22:25-30). As far as reductions in cholesterol levels seen with fiber, they are usually in the 5% range, not nearly as much as is seen with ezetimibe (Circulation. 2005;112:3184-3209).
—Peter F. Cohn, MD (107-5)

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