What is the role of niacin in the treatment of pediatric lipid disorders?

Updated: Jun 27, 2019
  • Author: Henry J Rohrs, III, MD; Chief Editor: Stuart Berger, MD  more...
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Answer

Niacin was the second-line drug recommended by the 1991 NCEP panel for treatment of elevated LDL-C concentrations. [16] Niacin is also effective in patients with combined hyperlipidemia (eg, FCH or type IIB HLP) and in patients with isolated hypertriglyceridemia due to elevated VLDL levels. Niacin (ie, nicotinic acid) has been shown to be effective in adults for treating HLP types IIA, IIB, IV, and V. Niacin decreases lipoprotein production and increases lipoprotein clearance. Decrements in LDL-C levels up to 17% have been reported.

Niacin has been associated with toxicities, including liver disease, GI tract upset (abdominal pain, nausea), and facial flushing. In adults, glucose intolerance and hyperuricemia have been reported. Flushing may be minimized by taking aspirin, although this is not an option in prepubertal children because of the risk of Reye syndrome.

In the authors' experience, many children (or their parents) have been unable to endure the facial flushing and GI tract upset produced by niacin. These complications severely limit its use. [25] Although they produce less flushing, extended-release preparations are more likely to produce liver toxicity than immediate-release preparations because higher niacin levels are sustained for longer periods of time. In children, the extended-release agents should only be used with great care and should be used only in exceptional circumstances (eg, homozygous FH).

Few guidelines for niacin dosing in children are available. An effective dose must be balanced against the toxicities. Niacin should be started at a dose of 50 mg/d and very gradually increased (eg, every 4 wk or less often) until the LDL-C level is less than 160 mg/dL when treating HLP type IIA or HLP type IIB, until the TG level is less than 300 mg/dL when treating type IV HLP, or until a dose of 1500-3000 mg/m2 is reached without liver toxicity. Splitting the dose (ie, administering the dose divided twice daily or three times daily) should be attempted as soon as a dose of 100 mg/d of niacin is reached. ALT levels should be measured every 3 months.

With a decline in LDL-C to less than 160 mg/dL or TG levels to less than 300 mg/dL, the dose does not need to be further increased. If the LDL-C level declines to less than 130 mg/dL (in HLP type IIA or IIB) or if the TG level decreases to less than 125 mg/dL (in type IV HLP), the niacin dose can be reduced or a trial period without the medication can be attempted.


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