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Niacin Tops Zetia in Cutting Artery Plaque

Study Shows an Older Drug Works Better Than a Newer Cholesterol-Lowering Drug
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WebMD Health News

Nov. 16, 2009 (Orlando, Fla.) -- A prescription version of niacin beat out a blockbuster cholesterol-lowering drug in slowing the buildup of plaque in artery walls, researchers report.

The study pitted extended-release niacin, sold as Niaspan, which works by boosting levels of HDL "good" cholesterol, against ezetimibe. Ezetimibe, sold as Zetia, lowers levels of LDL "bad" cholesterol.

The findings are the second recent setback for Zetia. Last year, another study showed that Vytorin, a combination of Zetia and Zocor, worked no better than Zocor alone.

"The question is whether ezetimibe works at all," says researcher Allen Taylor, MD, of the Washington Hospital Center in Washington, D.C. "Niacin has been around for 50 years. It's a well-understood drug, and in this trial it was clearly superior."

Peter Kim, president of Merck Research Laboratories, which makes Zetia, says the new study was limited due to its small size and short length. "It would be very unfortunate if a flawed analysis led patients to discontinue their cholesterol treatment."

The new findings were released at the annual American Heart Association (AHA) meeting and published online by TheNew England Journal of Medicine.

Niacin Slows Plaque Buildup

The new study, funded by Abbott, the maker of Niaspan, involved 363 people who had heart disease or were at high risk of heart disease. All the patients were on statin drugs that had brought their LDL cholesterol below 100 mg/dL. However, they all had suboptimal HDL levels.

About half of the patients were given Niaspan and the other half were given Zetia, in addition to their usual statin drugs.

The study was halted in July, about four months early, when investigators concluded that one group was clearly doing better than the other -- although they did not say which group was doing better at the time; 208 patients completed the trial.

At a news conference at the AHA meeting Sunday night, Taylor reported that the "winner" was Niaspan.

Ultrasound images of neck arteries showed that Niaspan reduced artery plaque by about 2%. Zetia did not slow plaque buildup, although it did lower cholesterol.

Patients taking niacin also suffered fewer heart attacks and other heart problems than those in the Zetia group, but that finding could have been due to chance, Taylor says.

Second Opinion

"This trial doesn't quite put the nail in the coffin for ezetimibe, but it pushes it way down on the list of medications for cholesterol-lowering therapy," Anthony DeMaria, MD, editor-in-chief of the Journal of the American College of Cardiology, says in a statement.

Two editorials accompanying the findings in The New England Journal of Medicine raised questions about the findings.

"Unfortunately, the premature termination of the trial, the small number of patients studied and the limited duration of follow-up preclude us from conclusively declaring niacin the adjunctive agent of choice," write Roger Blumenthal, MD, and Erin Michos, MD, both of Johns Hopkins.

Still, Vytorin and Zetia should probably be reserved for patients whose cholesterol isn’t controlled with statins and niacin, Blumenthal tells WebMD.

That said, some patients have trouble tolerating niacin, whose main side effects are itching and flushing, he says. Thirty-six percent of patients taking niacin in the trial reported flushing.

Blumenthal adds that several large clinical trials of niacin and Zetia that are in progress should offer more guidance.

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Your total cholesterol level is Borderline High, but fortunately your level of "bad" LDL cholesterol is near optimal. This could mean you have a high level of high-density lipoprotein, or "good" HDL cholesterol, which protects against heart disease. Or you could have other non-measured increases in LDL-like particles that can increase heart disease. Your LDL level also could be optimal if you are taking a statin medication. Please check with your doctor to get your complete lipid profile and see if you may need additional treatment. In the meantime, find more information on WebMD's Cholesterol Health Center.

Your total cholesterol level is Borderline High. Your level of "bad" LDL cholesterol is Borderline High, too. Working to bring down your total cholesterol decreases your LDL cholesterol level. You can do this by exercising more and eating less food with saturated fats. Check food labels!

Your total cholesterol level is Borderline High. Your level of "bad" LDL cholesterol is High. Working to bring down your total cholesterol decreases your LDL cholesterol level. You can do this by exercising more and eating less food with saturated fats. Check food labels!

Your total cholesterol level is Borderline High. But your level of "bad" LDL cholesterol is Very High. Working to bring down your total cholesterol decreases your LDL cholesterol level. You can do this by exercising more and eating less food with saturated fats. Check food labels!

Your total cholesterol is High, but your level of "bad" LDL cholesterol is optimal. This could mean you have a high level of high-density lipoprotein, or "good" HDL cholesterol, which protects against heart disease. Or you could have elevated secondary lipids, such as non-HDL particles that increase the risk of heart disease. Your LDL level also could be optimal if you are taking a statin medication. Please check with your doctor to get your complete lipid profile and see if you may need additional treatment. In the meantime, find more information on WebMD's Cholesterol Health Center.

Your total cholesterol is High, but your level of "bad" LDL cholesterol is near optimal. This could mean you have a high level of high-density lipoprotein, or "good" HDL cholesterol, which protects against heart disease. Or you could have elevated secondary lipids, such as non-HDL particles that increase the risk of heart disease. Your LDL level also could be optimal if you are taking a statin medication. Please check with your doctor to get your complete lipid profile and see if you may need additional treatment. In the meantime, find more information on WebMD's Cholesterol Health Center.

Your total cholesterol level is High. Your level of "bad" LDL cholesterol is Borderline High. Working to bring down your total cholesterol decreases your LDL cholesterol level. You can do this by exercising more and eating less food with saturated fats. Check food labels!

Your total cholesterol level is High. Your level of "bad" LDL cholesterol is High, too. Working to bring down your total cholesterol decreases your LDL cholesterol level. You can do this by exercising more and eating less food with saturated fats. Check food labels! If you are struggling to bring down your total cholesterol and LDL cholesterol levels, your doctor may prescribe medication, such as statins. Following medication, dietary, and exercise instructions should result in improvements.

Your total cholesterol level is High, and your level of "bad" LDL cholesterol is Very High. Working to bring down your total cholesterol decreases your LDL cholesterol level. You can do this by exercising more and eating less food with saturated fats. Check food labels! If you are struggling to bring down your total cholesterol and LDL cholesterol levels, your doctor may prescribe statins or other cholesterol-lowering medications.

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