Nicotinic acid

How it works

It inhibits hepatic synthesis and secretion of very-low-density lipoprotein, reducing circulating LDL-cholesterol and triglycerides while increasing HDL-cholesterol, in part through effects on adipose tissue lipolysis.

Prescribing in practice

• Cutaneous flushing is very common and dose-limiting, and large outcome trials have not shown that adding nicotinic acid to statin therapy reduces cardiovascular events while it may increase certain adverse effects, so its routine use is limited.
• It can worsen glycaemic control, raise uric acid and precipitate gout, and may cause hepatotoxicity, particularly with modified-release formulations.
• Caution is needed in active peptic ulcer disease and hepatic impairment; consult the SPC for full cautions.

Monitoring

Monitor lipid profile, liver function, blood glucose and uric acid during treatment.

Counselling the patient

• Warn the patient that flushing, warmth and itching of the skin are common, often shortly after a dose.
• Explain that taking it with food and avoiding alcohol and hot drinks around dosing can reduce flushing.

Evidence & guidelines

Outcome trials (including AIM-HIGH and HPS2-THRIVE) did not show added cardiovascular benefit of nicotinic acid on top of statin therapy; refer to current prescribing references.