What is the role of niacin, fibrates and statins in the treatment of low HDL cholesterol (hypoalphalipoproteinemia)?

Updated: May 21, 2021
  • Author: Vibhuti N Singh, MD, MPH, FACC, FSCAI; Chief Editor: George T Griffing, MD  more...
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Multiple studies have shown that niacin, fibrates, and statins can decrease the risk of cardiovascular disease and atherosclerosis progression by affecting multiple lipid parameters. In a study by AIM-HIGH Investigators et al, the addition of niacin to statin therapy did not provide any clear benefit to patients with cardiovascular disease and low HDL levels. [37] The much larger HPS2-THRIVE study (N=25,673) confirmed these findings. Additionally, adding niacin to statins increased risk for serious adverse events. [38]

Overall, fibrates reduce the risk for major coronary events by 25%, whereas currently available data for niacin suggest about a 27% reduction. Statins do have modest affects on HDL, increasing concentrations by 5% to 10%, providing a secondary benefit to this therapy beyond LDL reduction.

Completion of trials with clinical endpoints (eg, AIM-HIGH and HPS2-THRIVE clinical trials) have shown that the addition of niacin that decreased TGs and/or increased HDL-C levels in statin-treated patients does not cause further reduction in risk of CV events. Consistent with this conclusion, the FDA has determined that the benefits of niacin ER tablets for coadministration with statins no longer outweigh the risks, and the approval for this indication should be withdrawn. Additionally, the combination products that include simvastatin or lovastatin plus long-acting niacin (ie, Advicor, Simcor) were withdrawn from the U.S. market at the beginning of 2016 and are no longer available. [39]

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