Review of extended-release niacin/laropiprant fixed combination in the treatment of mixed dyslipidemia and primary hypercholesterolemia

Figures & data

Table 1 Low-density lipoprotein (LDL) goals in different patient groups⁵

Risk group	LDL cholesterol goal	Threshold for drug therapy
High risk (CAD or CAD equivalent: peripheral vascular disease, abdominal aortic aneurysm, cerebrovascular disease, diabetes) 10-year risk >20%	<100 mg/dL (2.6 mmol/L) optional: <70 mg/dL (1.8 mmol/L)	≥100 mg/dL (2.6 mmol/L)
Moderately high risk: ≥2 risk factors 10-year risk 10%–20%	<130 mg/dL (3.4 mmol/L)	≥130 mg/dL (3.4 mmol/L)
Moderate risk ≥2 risk factors 10 year risk <10%	<130 mg/dL (3.4 mmol/L)	≥160 mg/dL (4.1 mmol/L)
Lower risk ≤1 risk factor	<160 mg/dL (4.1 mmol/L)	≥190 mg/dL (4.9 mmol/L)

Notes: Risk factors: smoking, hypertension, low HDL-cholesterol (<40 mg/dL), positive family history for premature CAD (men < 55 years, women < 65 years), age (men ≥ 45 years, women ≥ 55 years).

Abbreviations: CAD, coronary artery disease; HDL, high-density lipoprotein; LDL, low-density lipoprotein.

Table 2 Effect of lipid-modifying drugs

	Lipid effect	Effect on morbidity/mortality
Statins	LDL ↓↓↓, TG ↓	++++/−
Fibrates	TG ↓↓↓, HDL ↑, LDL ↓	+/−
Nicotinic acid/niacin	LDL ↓↓, TG ↓↓, HDL ↑↑	+
Cholesterol adsorption inhibitors	LDL ↓↓	0
Bile acid binding resins	LDL ↓↓, TG ↑	+
Omega-3-fatty acids	TG ↓↓, HDL ↑	0/(+)

Abbreviations: HDL, high-density lipoprotein; LDL, low-density lipoprotein; TG, total triglycerides.

Table 3 Effect of nicotinic acid on lipids, lipoprotein and apoproteins

Lipoprotein class	Effects
Apo B-containing lipoproteins	VLDL ↓
	IDL ↓
	LDL ↓
	Apo B ↓
	Small-dense LDL ↓
	LP(a) ↓
Apo A-containing lipoproteins	HDL ↑
	HDL2 ↑
	HDL3 ∼
	Apo A-I ↑
Important ratios	Total cholesterol/HDL cholesterol ↓
	LDL-cholesterol/HDL cholesterol ↓
	Apo B/Apo A-I ↓
	HDL2/HDL3↑
	Lp A-I/Lp A-I +
	A-II ↑

Abbreviations: Apo, apoprotein; HDL, high-density lipoprotein; LDL, low-density lipoprotein; Lp, lipoprotein; VLDL, very low-density lipoprotein.

Table 4 Selected randomized controlled trials of nicotinic acid^12,22–26

Study	Intervention	Patients receiving treatment/total	Change in lipids %	Duration years	Outcome
CDP (1975)	Nicotinic acid	1119/8341	Chol −10	6	Decreased nonfatal MI
			TG −26
			HDL NR
			LDL NR
CDP follow up (1986)	Nicotinic acid	1119/8341	See above	15	Decreased total mortality
CLAS (1987)	Nicotinic acid + colestipol	80/162	HDL +37	2	Decreased coronary atherosclerosis on angiography (P = 0.002)
			LDL −43
			TG −22
HATS (2001)	Nicotinic acid + simvastatin	38/160	HDL +26	3	Decreased MACE (first event: death, MI, stroke, revascularization)
			LDL −42
			TG −36
ARBITER 2 (2004)	Nicotinic acid + statin	87/167	HDL +21	1	Decreased progression of carotid IMT (P = 0.08); significant in patients with insulin resistance
			LDL −3
			TG −13

Abbreviations: HDL, high-density lipoprotein; IMT, intima-media thickness; LDL, low-density lipoprotein; MACE, major adverse cardiovascular events; MI, myocardial infarction; NR, no result; TG, total triglycerides.

Figure 1 The figure describes a possible algorithm for treating patients with different forms of dyslipidemia.

Notes: ^aIn patients with established cardiovascular disease lifestyle modification and drug therapy will usually be implemented simultaneously; ^bisolated hypertriglyceridemia refers to a LDL-cholesterol < 100 mg/dL and elevated triglycerides; fibrates, omega-3 fatty acids or ERN/LRPT may be used if lifestyle modification is not sufficient; in selected patients combination therapy may be necessary; ^cif LDL-cholesterol goal is not achieved the statin dose may be increased or switched to a more potent statin; ^dstatin/fibrate combination is associated with significant side effects and should therefore be only used in selected patients.
Abbreviations: ω-3-FA, omega-3 fatty acids; ERN/LRPT, extended release niacin/laropiprant.

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