Good-by Niaspan. Welcome back Immediate release niacin.

 

One of my clients who has been on Niaspan for 14 years informs me that he has experienced unsolicited advice from many would-be physicians as well as recently trained physicians about the inadvisability of the medication Niaspan. Now this patient had Familial Combined hyperlipidemia with total cholesterols in the 220 range and mildly elevated triglycerides. His ApoB was in the top 5%. For years his total LDL-P has been lowered in the 700 nmol per liter range (bottom 1%) and he has succeeded in reaching the age of 80 without an untoward cardiovascular event. Yet many unsolicited advisors have the chutzpah to make recommendations without benefit of a required medical degree and also physicians with an insufficient experience with this medication. It was noteworthy to hear that at least one of these would-be advisors did recommend particle numbers over the standard lipid panel.

Now the recent generation of physicians who read the flawed and fake AIM-HIGH or HPS Thrive II as if it were Gospel do not have the benefit of the experience nor can they recall the previous trials involving niacin prior to AIM-HIGH or HPS Thrive II, in which the use of niacin had beneficial effects. Now based on AIM-HIGH or HPS Thrive II, how many of you think I should have discontinued niacin in this patient. I know Lipidology lecturers who did exactly that to the point of discontinuing their own Niaspan even though there was not one untoward reaction. After all in reality niacin is nothing but a vitamin. 

It is amazing at National Lipid Association( NLA) meetings to hear the contrast between how old-timers who have had experience with niacin and today’s new generations describe this medication. It is amazing how the pharmaceutical companies with its arm twister, the so-called evidence based medicine trials which apply to very  few in the clinical world, can control the thinking process of the great majority of today’s recently trained physicians and even some old-timers.

Recently the price of Niaspan has shot out of sight reaching up to $700 or more for a 30 day supply of 1000 mg  which is directly an abuse perpetrated by our pharmaceutical corporations and their control of the medical delivery system. On the brighter side with regard to Nisapan, there is a much cheaper alternative i’e. Immediate release niacin costing a little over $8. for #100 500 mg tabs. Because of the gouging by the pharmaceutical industry allowed by our medical delivery system, I am in process of switching the majority of my clients from Niaspan to immediate release niacin and I have no intention to write any further Niaspan prescriptions, or to be a further unwitting or witting accomplice to the pharmaceutical industriy in the fleecing of America. 

I have been successful in minimizing the cost of many of the other anti-cholesterol medications to an affordable level for the vast majority of my clients. Looking into the future, I do not envision, except for the ASO for ApoCIII,  a meditation that should be a clear rival for niacin but if anything this meditation because of the profit motive, similar to PCSK9 inhibitors with its excessive cost, injudicious indications and really unknown future side effects will probably be financially unavailable to many of the US citizens who could benefit. 

For those who now still benefit and will continue to benefit from niacin in the future, I say, Thank God for immediate release niacin.

Does a Desert of Ignorance still Exist for Preventive Cardiovascular Disease?

Greater than 20’s years ago I became aware of a young obese physician who suffered a heart attack and proceeded to perish. Although he selected the group he felt was most experienced in interventional cardiology, the cardiac damage was too extensive to allow his survival even with the then putative most advanced interventional techniques. He left a wife and several teenage children to fend for themselves. Another neurology colleague from Broward county suffered a heart attack within the first 10 years of his practice and although he returned within a few years, his name slipped from the active practitioners in Broward county. Another colleague suffered a heart attack and never worked another day as a physician. Less than 10 years ago at a meeting in Broward county I became re-acquainted with a colleague that I knew well in the first 10 years of my practice, whom I was surprised to ascertain that he had suffered from a acute myocardial infarction and was also on disability. Upon questioning he became interested when I apprised him I was utilizing Advanced Lipid testing and was including the prevention and arrest of atherosclerosis as part of my cardiology practice. However, as with many patients who have undergone interventional cardiology procedures, he had an umbilical cord to his interventional cardiologist and was concerned that it would be severed if he sought the opinions of another cardiologist. All these incidents were well before the year 2000 when we physicians were blinded by the standard lipid panel. Certainly prior to this time there was a desert of ignorance of how to prevent and treat atherosclerosis. The big question is does this desert persist today.

Over the last 20 years, there are still even today, too numerous to count, heart attacks and strokes, which do not exclude physicians. Millions with this same fantasy, despite being sold on today’s highly superior technological advancement, have met their demise or become allocated to the secondary prevention machinery of our medical delivery system. From other similar experiences and my own disastrous start with a hidden metabolic syndrome, I decided that for myself I would prefer to avoid this path and at this time and my age it appears I did. A heart attack or stroke now would not be considered premature. Every year beyond my present age serves to bolster the course that I chose in my 60s. I might be presumptuous enough to claim I will never have a heart attack but gazing upon my history up to age 65, not a stroke.

Over the last 20 years, at times in my career I have intermittently wondered whether cardiovascular disease treatment in United States is a desert of ignorance, as opposed to enlightenment. The latter is claimed by the pharmaceutical industry, vendors and news media, all of whom who are paid or receive benefits for these advertisements,

Recently I was apprised there was a high 40s yo physician cardiologist who suffered a stroke. I wondered if he had any inkling or suspicion and had taken any steps to avert this event. It was said that he was on one of the most powerful LDL-C lowering medications available today. Although this drug for the time it has been released supposedly decreases CVA’s by 21%, do not be that impressed. Four out of five individuals destined to have a CVA off this medication  still suffer a stroke with this medication at a cost of 15-$20,000 per year/treated individual. The question is how many of the population and which physicians are next in line. From previous statistics the numbers will be overwhelming. 

This event made me reminisce about my previous experiences and how I would have and did handle this problem for myself and previous patients. From my experience strokes are caused by hypertension controlled or uncontrolled, various hyper and dyslipidemia’s including LPa insulin resistance, diabetes mellitus  cerebrovascular vascular anomalies, cerebral atherosclerosis, occult thrombotic or platelet  disorders, embolic cerebral vascular disease either vascular or valvular, atrial cardiac arrhythmias, hello hello Afib and the usually neglected latent patent foramen ovale. When I saw predominantly cardiology patients I was aware of each and every risk factor that would predispose my patient to a stroke as well as heart attack. Each of these parameters was addressed with the best treatment of the day; albeit the vast majority as a secondary prevention cardiology patient as they mostly joined my cardiology practice after they had their first event.

Today, in my opinion, cardiovascular medicine is still, despite the rave technological advances, a desert of ignorance possibly spotted with rare or occasional oases of enlightenment, spawned as a result of our profit oriented medical delivery system and the lack of complete well rounded and trained practitioners caught up primarily in the profit motive and the super subspecialties which exist today.