An Update on Statin Alternatives and Adjuncts

Matthew J Sorrentino


Clin Lipidology. 2012;7(6):721-730. 

In This Article


Niacin in high doses can lower total cholesterol and LDL-C, and has the greatest potential for raising HDL cholesterol. An early lipid-lowering study with immediate-release niacin showed a cardiovascular benefit. The Coronary Drug Project conducted between 1966 and 1975 evaluated the long-term efficacy of 3 g of niacin daily in a group of men who had a previous myocardial infarction.[46] After 6 years the patients taking niacin had a lower incidence of nonfatal myocardial infarction. After 15 years of follow-up, the patients assigned to niacin had an 11% lower mortality than the placebo group, even though these subjects had stopped taking niacin 9 years earlier.[47]

Studies combining niacin with a statin, however, have not been able to show additional risk reduction. The AIM-HIGH trial evaluated whether the addition of extended-release niacin added to statin therapy titrated to reduce the LDL-C to <70 mg/dl could bring about a further cardiovascular risk reduction.[48] The study was stopped early because no additional benefit was observed. Of note, the niacin therapy in this study was added to raise HDL cholesterol since the LDL-C was already treated to very low levels. The addition of niacin to a statin may be useful to further lower LDL-C in individuals that cannot tolerate high-dose statins because of side effects or cannot achieve the desired LDL-C goal with a statin alone.