Niacin HALTS progression of carotid thickness in imaging trial

Due to the residual risk that remains with statin monotherapy, cholesterol treatment can be intensified with the use of a secondary agent such a ezetimibe or nicotinic acid.  Whist ezetimibe has potent LDL-lowering capabilities, nicotinic acid is also capable of raising HDL-cholesterol and lowering triglyceride levels.
The ARBITER6-HALTS (Arterial Biology for the Investigation of the Treatment Effects of Reducing Cholesterol 6 – HDL and LDL treatment strategies) trial compared the effects of either niacin or ezetimibe added to long-term statin therapy on carotid intima media thickness (CIMT).  Patients either with or at risk of coronary heart disease with LDL cholesterol levels <2.6 mmol per liter and HDL cholesterol levels < 1.4 mmol per liter were randomly assigned to receive either extended-release niacin (target dose of 2000mg per day) or ezetimibe (10mg per day).    The primary end point was the between-group difference in the change from baseline in the mean common carotid intima-media thickness after 14 months.  Niacin therapy was noted to significantly reduce LDL and triglyceride levels, whereas ezetimibe therapy reduced HDL cholesterol and triglyceride levels.  When compared with ezetimibe, nicotinic acid therapy led to a greater efficacy regarding the change  in mean carotid intima-media thickness over 14 months (p=0.003).

Conclusions:
In this comparative-effectiveness trial, extended release niacin (when combined with statin therapy) led to a significant regression of carotid intima-media thickness when compared to the use of ezetimibe with a statin.  However, the population studied already had low levels of LDL cholesterol, which would minimise any potential benefit from ezetimibe.  Furthermore, it is not clear whether the benefit seem with niacin is due to the HDL-raising effect of niacin or any of its other pleiotropic effects.

•    Taylor AJ, Villines TC, Stanck EJ et al.  Extended-release niacin or ezetimibe and carotid intima-media thickness. N Engl J Med 2009; 361: 2113-2122.
•    Blumental RS, Michos ED.  The HALTS trial – Halting Atherosclerosis or Halted Too Early?  N Engl J Med 2009; 361: 2178-2180.
•    Kastelein JJP, Bots ML.  Statin Therapy with Ezetimibe or Niacin in High-Risk Patients.  N Engl J Med 2009; 361: 2180-2183.

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