Expert: William J. Walker, Pharm.D. - 1/6/2004

Question
I have been taking Niaspan 1500MG for lipid modification, with good results.  I'm going to try immediate-release niacin instead, in hopes of reducing my pharmacy expenses.  The prescribing literature for Niaspan indicates that it would be dangerous to go directly from immediate-release niacin to an equivalent dose of Niaspan.  Would it also be dangerous to go directly from Niapan to an equivalent dose of immediate-release niacin?  If so, at what rate should I increase the immediate-release niacin to the 1500MG level?  Thanks for sharing your expertise.

Answer
Niacin is vastly underutilized in todays market place as a lipid lowering agent and that is unfortunate.   The HMG-CoA reductase inhibitors (statins) have taken the limelight instead.   Niacin is not only much less costly than most of the other available pharmaceuticals for this indication but it also happens to be perhaps the overall most efficacious agent.    The problems with using it have given it a bad reputation but in truth the other agents are no less offensive.

Niaspan as a product is the most superior form of Niacin available I am sorry to report.    Sorry only because I empathize over the relative costs.     Other slow release niacin products have been quite prone to causing liver damage at higher doses and higher doses are what is required to do the job right.    Niaspan seems to be much more friendly to the liver.

The "danger" in converting a niacin dose directly over to Niaspan is not a reverse problem.    Taking a dose of niacin abruptly as the same dose of Niaspan is risky in terms of the hepatic response.    A slow titration upwards allows the liver to adjust to the task of metabolizing it.    However the conversion directly in the opposite direction does not pose this problem.    Although it is not "dangerous" in the same manner such an abrupt conversion will still present problems.    That is because of the notorious niacin rush.    Immediate release niacin is very inexpensive and for that reason alone it is very attractive as a product to use.    But the catch 22 is that you need about 2000 mg daily to be effective and almost everybody will experience an uncomfortable facial flushing and burning rash at doses larger than 500 mg daily.    This does not occur with the sustained release forms such as Niaspan.     And therefore the cost is worth every penny.

But give it a try and see for yourself.    It won't harm you.    See how well your body handles it first.    I would start by taking a once daily dosage of 500 mg.    Then the next day try 1000 mg.     Increase by 500 mg daily until you are taking 1500 to 2000 mg daily.    You will know quite soon whether or not you will want to continue or not.

My bet is that you will return to taking the Niaspan.