Recently, Dr. Joseph M. Keenan, researcher and professor emeritus in the Department of Family Medicine and Community Health, University of Minnesota and Kathleen M. Dunn, MPH, registered dietitian and medical writer published “The Niacin Breakthrough, the Keenan Protocol for Heart Health and Healthy Aging.”

In it, Dr. Keenan, one of the world’s foremost experts on niacin therapy, explains the history, faulty and exemplary research, and innovations of this oral agent since it’s discovery over 70 years ago.

It’s written to help you better understand niacin and prepare you to talk with your doctor about its cardiovascular and overall health merits.

Below, Dr. Keenan and Dunn answer questions about niacin therapy and explain why it’s crucial to work with a health care provider experienced with it.

About Niacin – What You and Your Dr Need to Know

How is niacin different from other options people use to help maintain healthy cholesterol levels?

"Unlike other oral agents, niacin (as nicotinic acid) delivers a broad range of cardioprotective actions. Many people know niacin may help maintain healthy blood levels of cholesterol and triglycerides in the normal range. What’s less known is niacin also has beneficial actions on key lipoproteins associated with heart health and supports health of the endothelium – the  thin layer of cells lines the inside of blood vessels.

Niacin in the form of nicotinic acid is the only agent that can improve all forms of dyslipidemia. It promotes healthy total cholesterol, “good” cholesterol (HDL), helps balance “bad” cholesterol (LDL), and is one of the best agents for lowering triglycerides. It’s the only oral treatment that can promote healthy lipoprotein (a) which is a hereditary lipid risk factor as concerning as LDL.

Nicotinic acid also has many non-lipid benefits including reducing levels of chemo attractive protein 1, a molecule that attaches to the lining of a blood vessel and causes plaque or clot formation. That’s especially important for nerve and brain health and helps prevent dementia and reduce strokes. It also produces nicotinamide adenine dinucleotide (NAD+), which is critical for the health of every cell in the body."

If niacin treatment has been around for over 70 years, why haven't I heard about it before?

“The famous original niacin study called the Coronary Drug Project (CDP. 1966-1975) showed improvements in all blood lipids, especially HDL and triglycerides, as well as a reduction in heart attacks, strokes, and deaths from vascular disease.

But the researchers used immediate-release nicotinic acid (IRNA) and were experts at gradually increasing dosing so patients could develop a tolerance and adding aspirin if needed to control flushing. Unfortunately, many doctors impressed with the study results started their patients on high doses without instructions to prevent of side effects like flushing. So, the intolerance and dropout rates that were 9% in the CDP soared to 40-60%, which led many physicians to stop using IRNA. However, this led to the development of controlled-release formulations of nicotinic acid.

During this time statins were discovered and became the preferred choice of dyslipidemia treatment for most physicians, especially because they were the best agent to reduce LDL (even though statins had some very bad side effects and a dropout rate of 20%). Other negative reports on specific brands of nicotinic acid – some later revealed as flawed research – caused most doctors to stop using it altogether.”

Why is individualized niacin dosing so important?

“Individualized dosing with nicotinic acid for dyslipidemia is important because each person has a unique response to niacin, both in therapeutic benefits and sensitivity to potential side effects and toxicity.

We want to help people reach the desired level of lipid benefits without the undesirable side effects of flushing or gastric upset. That’s why we typically start with a low dose and gradually increase the dose over several weeks. I also recommend people take extended-release niacin to reduce flushing and take it with meals.

We also need to monitor for liver toxicity, gout, and elevated levels of homocysteine. In my research, I found about 10% of persons are extremely sensitive to niacin yet they often see the best results when the dose is increased gradually. That’s why it’s important to work with a provider experienced with niacin treatment. Eating green leafy vegetables and fruits regularly and avoiding excessive alcohol consumption also helps prevent toxicity."

You say the delivery form of niacin is also significant, why?

"The immediate-release form of niacin requires a 2 to 3-times higher dose and has a very high rate of undesirable side effects, especially flushing and sometimes upset stomach.  Also, immediate-release niacin may not provide as good a reduction in LDL as controlled-release formulations do. 

The ideal time release for niacin is 6-8 hours which greatly reduces side effects and promotes healthy LDL balancing results. A caution is advised, however, to avoid dosing multiple times a day with controlled-release formulations, because associated with an increased risk of liver toxicity. Optimal dozing should be administered and monitored by a clinician. Also, avoid the popular "no flush" niacin form (generic name inositol hexanicotinate) which doesn't contain nicotinic acid at all. No flush, but no benefit!”

What is the niacin flush?

“Skin flushing, or the niacin flush, is the most common side effect of supplementing with higher amounts of nicotinic acid. It’s harmless and temporary, typically subsiding within 30 minutes as the body metabolizes nicotinic acid. For sensitive people, however, it can be a nuisance. The good news is there are simple ways to help avoid the niacin flush, including taking it with a meal and a full glass of water, avoiding hot liquids, and choosing extended-release nicotinic acid which is specifically formulated to help reduce skin flushing.”

What if my doctor won’t talk to me about supplements? What kind of doctor will?

“Few medical doctors (MDs) were trained to use supplements, although many have come to recognize their many excellent benefits. By their training, naturopathic doctors (NDs) are more likely to discuss supplements than MDs. They study supplements’ unique benefits and the best formulation and dosage for optimal benefits with minimal side effects.”

Can I benefit from niacin if heart health isn’t an issue for me?

“Even if your current cholesterol levels are okay, niacin can help improve them and promote healthy arteries, so it cleans your pipes.

Also, niacin as either nicotinic acid or niacinamide is a building block for nicotinamide adenine dinucleotide (NAD+), which is essential for the healthy intracellular chemistry of every cell in the body. As we age, we need more NAD+ but our bodies produce less.”

Still have questions?