Nicotinic acid: clinical considerations

Introduction: Nicotinic acid (NA), the oldest hypolipidemic drug, possesses unique broad-spectrum beneficial effects on lipid profiles. Specifically, NA reduces both triglycerides and low-density lipoprotein cholesterol levels, while significantly increasing high-density lipoprotein cholesterol levels. However, NA is often avoided in the clinical setting, or prematurely discontinued by the provider or patient, due to side effects that could possibly be prevented (flushing, gastrointestinal disorders) or that are feared out of proportion to their true incidence rate (hyperglycemia, hyperuricemia). Areas covered: This article reviews NA's side effects, along with a number of old and new strategies to reduce their incidence, especially flushing. The aim of this paper is to provide a useful clinical guide to the administration of NA in dyslipidemic patients. Expert opinion: An important number of side effects affects compliance and restricts NA's clinical use. NA-induced flushing is the most restricting side effect, accounting for the majority of NA therapy discontinuations. In addition, gastrointestinal side effects, hyperuricemia, deterioration of glycemic profile, or even new-onset diabetes discourage therapy consecution. Aspirin pretreatment, considered selection and proper counseling of patients, and regular monitoring of liver aminotransferases, creatine kinase, serum uric acid levels, and glycemic profiles can reduce NA's side effect rate and improve compliance.