Scientists are humans, and humans make a lot of mistakes. A lot of mistakes are
being made right now with niacin, and I'm not gonna say which side is. But I will
name the side that I'm on the debate that I'm on... I use nice. Actually, niacin
was used for decades for cardiovascular prevention, a mainstay. It's the only
thing that increases HDL and decreases LDL and most importantly also decreases
Lp(a) as well as some other things. But everybody agreed and all the meta
analyses showed that niacin helped until 2 studies came along. The two studies
were HPS2 THRIVE, which used laropiprant to get rid of that niacin
flush. Laropiprant not only gets rid of niacin flush. It gets rid of the positive
aspects, the positive treatment effects of niacin. The other study was AIM HIGH.
Now, this video is about AIM HIGH because it's very interesting. Even the principal
investigator of the AIM HIGH trials said this. I'm afraid people are going to
interpret this study results as meaning that we shouldn't use niacin and that
would be a big mistake. So we're gonna cover the video where he says that and
the New England Journal article where they describe it. This video has an
interviewer plus Dr. Boden on the left here with his arm on the table and
recognized international expert Dr. David Chapman,
the director of the atherosclerosis program at the NIH for France in Paris.
So again, these two studies HPS2 THRIVE and AIM HIGH were the one-two punch that
took out niacin therapy for most Americans. Again, as I mentioned, even
scientists, as dispassionate as we're supposed to be, are humans. As a result of
those two studies, now, meta-analysis (you know a meta-analysis is something that
covers all of the science) even the meta analyses...
despite the preponderance of indicating a positive impact by niacin,
over half of whom now are saying, oh it doesn't work, how can you look at almost
the same science and come up with different conclusions like that? No
further comment. I've already stated my case. Meta-analysis still says, look
it still helps, and I would obviously agree with that. Now, let's go into the
details of the AIM HIGH trial. This is the New England Journal title page and
that's the clip and image from the video and we'll show some clips of the video
itself, seeing it's kind of grainy. You know these guys that obviously used
to feel like I did, and that was if content is king then video quality and
editing may not matter. Well, I think we all learned our lessons the hard way on
that one. Here's the title page Here's the link to the video itself on YouTube.
The AIM HIGH study design was a secondary prevention trial. Basically
what that meant was we already knew these people had cardiovascular disease.
We're just trying to prevent it getting worse. These patients were treated
already, and they were treated in a big way. This is the issue. I'll give you a
spoiler at this point. These patients, according to my beliefs and a lot of
beliefs these days I'm not alone, these patients were over medicated and under
managed in terms of lifestyle, already on simvastatin 40 to 80 milligrams
every day high-dose simvastatin. Then they added his ezetimibe. Their goal was to
get LDL down to 80 or below a target level of 40 to 80 to those people
then they added a gram and a half to two grams of niacin, also significant healthy
doses. Now you can see it on the video timestamp 1:00 to 2:30
will show some of that here. Now just to repeat, LDL was targeted
at 40 to 80 milligrams per deciliter, an aggressive target,
aggressive high-dose statins 40 to 80. Obvious simvastatin
quite a bit but never those doses. I've taken it myself and didn't take those
doses, and I haven't used it with my patients either. In the study, they then
took ezetimibe to reach goal for LDL. And again,
that LDL goal was at this point at minimum debatable. Video timestamp for
this was 2:59 to 3:36. As I mentioned, I don't have anybody on that and don't
agree with that over-treating and under- managing lifestyle. How did they deal
with the niacin flush? Here's another issue which again Dr. Boden
admitted well. We didn't think that was a problem then but now it's interesting
and it's a video time-stamped 2:30 to 2:59. What does this mean? What's this thing
about the masking the placebo effect? So as you know, niacin causes a flush. So how
do you do a placebo in the study AIM HIGH? They don't figure it out if I get a
flush. I know I was in the study of if. I don't get a flush. I know I was taking
placebo. So to get around that, they gave niacin for just in smaller doses, 50
milligrams instead of a gram and a half. Again, you can see Dr. Boden's own
reaction to that in retrospect. Endpoints on this study where what they usually
are in this face heart attack, stroke, cardiovascular hospitalization, or death.
They stopped the study early. The original intent was to study 4,000
people for probably about 7 years. A real goal was an event-driven trial.
They wanted to accrue 800 events. They stopped in 36 months. And actually, in the
group that took the niacin, there appeared to be a potential for a
little bit more strokes. So they clearly showed at least in that group that
niacin was not helpful. High-dose nice then was not, and you know what, I don't
disagree with the results of that study at all. As I've said, if I've mentioned
too many medications too high in doses and not enough lifestyle, yes, I guess
I've mentioned that, maybe I beat that to death. You know, one of the things that
would that caused all of this was this murky issue around statins and HDL.
Many people have thought about it. And if you look it up on Google and read it in
different articles, you'll see many articles saying that statins will
increase HDL. At best, you get maybe a 5 to 12 percent elevation of HDL But with
many patients you get especially the ones that get a major decrease in LDL,
they'll often get a decrease in HDL as well. So the statins and HDL issue is a
murky issue. And when you go back to the original study design, that was the whole
point, giving people a lot of statins, giving them ezetimibe still having very
low HDL levels. So can we give them iesson instead? That was the real study
question. Why don't we just use lifestyle Harvard Health Publishing has noticed
this for years, and they wrote it up. They said, look, smoking will cause low HDL,
eating a high carb diet causes low HDL. So why don't you stop the smoking and
stop the carbs? And that's what I recommend. Very simple. So again, as I
pointed out, even Dr. Boden said it's premature to abandon niacin. I'm very
concerned that many will say as a result of this study that we no longer need
niacin. That would be a mistake again. My credits to Dr. Boden in terms of
being very open and honest about the challenges he worked through in this
study. And obviously, I don't hold with a major portion of it for the Europeans. It's
mostly Americans. The Europeans are still using niacin, and I am at too. So at the end
of the day, patients will say to me, Doc, all that science is right but just tell
me what you do and tell me what you think I should do. Well, first of all and
most importantly, if you've got a low HDL, you need to look at your lifestyle,
restrict carbs. And of course, if you're smoking, you need to stop. Restrict carbs,
stop smoking, and yes, I take niacin. I take Enduracin. There's
some technical reasons why I do and we'll save that for other videos. Thank
you very much for your interest.
So I'd like to talk with you a minute about the webinar. People don't
understand what the webinar is. It's actually a great way to get some access
to health care that you're just not going to get any other way. You actually
get the lab tests yourself for at a local lab, a Quest lab near you for the
inflammation panel and the OGTT and the insulin survey. These are things -
inflammation and prediabetes - that your doctor just does not know about. And
here's the thing. Harvard Health and many others have said, look, sudden death is
not always so sudden. The Hollywood picture that it's a bolt out of the blue
is not realistic. It's more like real lightning preceded by clouds, wind, and
rain. Stop that metabolic storm before the lightning strikes. And here's where
that metabolic storm comes from. It's inflammation, and it has to do usually
with prediabetes. So again, we actually get labs, we go over
them in the webinar, and then you can start finding out how you can prevent
that heart attack Others said that you couldn't even predict. We can show you
how. Thanks.