Targeting Cardiovascular Risk Associated with Both Low Density and High Density Lipoproteins Using Statin–niacin Combination Therapy

Background Cardiovascular risk might be reduced by targeted changes in both low density and high density lipoprotein cholesterol (LDL-C and HDL-C). This dual strategy will require a well tolerated, effective regimen, as well as a better understanding of how HDL-C may be targeted.

Design An open-label, uncontrolled, retrospective cohort study of combined statin–niacin therapy.

Methods We reviewed all patients (n = 132) started on this combination in a referral lipid clinic over a 6.5-year period for tolerability, safety and effectiveness.

Results Combined therapy was tolerated by 77% of patients. No serious adverse events attributable to medication were encountered. In drug-naive patients (n = 37), moderate doses of statin and niacin (mean 1180 mg/day) reduced LDL-C 31% and increased HDL-C 29% (P < 0.002, both comparisons). At niacin doses ≥ 1000 mg/day (mean 1480) added to a constant statin regimen (n = 29), HDL-C increased 20% (P < 0.001). Even at niacin doses < 1000 mg/day (mean 580, n = 23), HDL-C increased 13% (P < 0.05). Although mean HDL-C increased, the initial and final HDL-C distributions were broad and largely overlapping. Any chosen cutpoint for HDL-C goal would apply to only a minority of patients. The total/HDL cholesterol ratio had narrower distributions, as the percentage of patients with ratio < 5.0 increased from 17% to 67%.

Conclusion Combined statin–niacin therapy lowers LDL-C and raises HDL-C with acceptable tolerance and safety. If treating LDL-C is the primary goal, consistent with current guidelines, then a strategy of targeting the total/HDL cholesterol ratio as a secondary goal is applicable to more patients than targeting HDL-C itself.