What does the future hold for niacin as a treatment for hyperlipidaemia and cardiovascular disease?

Statin therapy is widely used in treatment and prevention of cardiovascular disease (CVD). It is well established that statin therapy is not associated with significant increase in high-density lipoprotein cholesterol (HDL-c) or significant decrease in triglyceride level. Importantly, emerging evidence has suggested that low HDL-c and high triglyceride are strong risk factors associated with CVD. Niacin is a unique lipid-lowering medication with a capacity to lower low-density lipoprotein cholesterol (LDL-c), triglyceride and increase HDL-c. In this context, there is considerable interest in trials involving niacin as monotherapy and in association with statins. Recent trials showed that the combination of statin and niacin is an effective treatment not only for dyslipidaemia (high LDL-c, high triglyceride and low HDL-c) but also for carotid intima-media thickness, one of the important features of atherosclerosis. Furthermore, niacin is distinguished by its unique capacity to effectively lower lipoprotein (a) [Lp(a)] levels. Flushing is the only factor that limits the wide use of niacin. The combination of statin and niacin has potential as a future treatment of atherogenic dyslipidemias; however, further evidence is needed. Importantly, the impact of niacin and statin on insulin sensitivity is not yet known. This article projects the potential benefits of current and possible future niacin clinical trials.