Which medications in the drug class Lipid-Lowering Agents, Other are used in the treatment of Hypertriglyceridemia?

Updated: Jul 23, 2021
  • Author: Mary Ellen T Sweeney, MD; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Lipid-Lowering Agents, Other

Niacin (vitamin B-3) inhibits the hepatic secretion of VLDL cholesterol. This agent is effective in most categories of hyperlipidemia. Niacin has been demonstrated to lower LDL cholesterol by 32% (generally, 15-25% decrease), lower triglycerides by 20-50% (≥1.5 g/d decreases triglycerides by as much as 50%), and raise HDL cholesterol by 43%, particularly at higher doses. Niacin lowers lipoprotein (a) levels, which may be of some clinical importance, because lipoprotein (a) levels have been associated with coronary heart disease in numerous epidemiologic studies. The clinical benefit of lowering lipoprotein (a) levels has not been determined.

Whether purchased by prescription or not, niacin costs less than any other lipid-lowering medication. For reasons not clearly understood, changing brands during treatment is more likely to cause hepatotoxicity, occurring more so with time-release than immediate-release niacin. Insulin resistance may increase; nevertheless, niacin is a useful medication in patients with type 2 diabetes. [70]

Niacin (Slo-Niacin, Niaspan, Niacor)

Niacin, or water-soluble vitamin B-3, functions in the body after conversion to nicotinamide adenine dinucleotide (NAD) in the NAD coenzyme system. In gram doses, niacin reduces levels of total cholesterol, VLDL, IDL, LDL, and triglycerides but increases HDL. The magnitude of individual lipid and lipoprotein responses may be influenced by the severity and type of underlying lipid abnormality. Thus, although niacin may increase insulin resistance and worsen glucose control, it is useful for the dyslipidemias common in patients with diabetes. This agent should be taken at bedtime after a low-fat snack and individualized according to patient response.

The slow-release formulation is more hepatotoxic than immediate-release niacin; carefully monitor aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels indefinitely in these patients. Patients strongly advised against switching formulations or brands during treatment. Both prescription and nonprescription formulas are available. Nonprescription brands cost less, but only reliable manufacturers should be recommended. Slo-Niacin is a nonprescription formulation that is available in 250-, 500-, and 750-mg tablets. Prescription extended-release (ER) niacin (Niaspan) is available by prescription in 500-, 750-, and 1000-mg tabs.

At high doses (4-6 g/d), the immediate-release formulation of niacin is less hepatotoxic than the sustained-release (SR) formulation, but it is also less well tolerated by patients due to prostaglandin-mediated flushing, itching, and rash. Therapy is best started at a low dose, such as 100 mg tid pc, and increased gradually (titrated) over several weeks, allowing some patients to accommodate adverse effects. Changing formulation at high doses may increase risk of hepatotoxicity.

Niacor and Nicolar are prescription formulations that, although more expensive than nonprescription brands, may have an advantage in making it less likely that the patient switches brands.

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