A: To begin with, the regular use of niacin can be preceded by either diphenhydramine (Benadryl) or aspirin that will prevent the flushing aspect that is so difficult for patients to deal with. However, I strongly urge you to speak with your primary care physician before putting this into play because of an anti-coagulant issue that could present problems for some individuals.

Inositol hexanicotinate is used for a variety of conditions to include hypertension, insomnia, atherosclerosis, restless legs syndrome, poor circulation, Raynaud’s disease, high cholesterol levels, and more. It is a compound of niacin (vitamin B3) and inositol. This form of niacin is purported to reduce or prevent flushing, simply because it breaks down at a slower rate. Inositol hexanicotinate appears safe for most individuals, works to reduce cholesterol levels in some people but the results of tests are contradictory. It does not release the active form of niacin and can cause unwanted side effects in others, to include nausea, stomach upset, headache, hiccups, and indigestion. There appears to be some reports of possible liver damage in some patients and questions remain if it actually helps lower cholesterol levels.

Some patients are warned not to take the product if they have a history of kidney disorders, angina, diabetes, allergies, gout, hypotension, gallbladder disorders and more. The chronic use of inositol hexanicotinate might increase blood sugar levels and thus, decrease the effectiveness of diabetic medications. Therefore, individuals who choose to take it should have their sugar levels closely monitored. Further, it may also slow blood clotting so taking it with prescription medications to slow the clotting process could result in easy bruising and bleeding.

Because the product works to lower cholesterol levels in some individuals and not in others, I might opt for other methods to lower your readings such as a trial of the prescription Niaspan which is regulated and considered both safe and effective. Consider avoiding saturated fats in your daily diet. Substitute what you are using with olive or canola oil. Reduce your consumption of marbled or fatty beef and fill in with broiled fish or chicken. Fish is an excellent means of lowering cholesterol levels because of the omega 3 oils. Increase your dietary fiber by eating more whole grains, fresh fruits and vegetables. Sprinkle flax seed on your toast or cereal in the morning and nibble on walnuts or almonds when you get hungry. If these methods fail to work after a period of time, ask your physician what he or she would recommend as a natural remedy first prior to getting into a prescription medication.

Readers who would like related information can order Dr. Gott’s Health Report “Cholesterol” by sending a self-addressed, stamped number 10 envelope and a $2 US check or money order to Dr. Gott’s Health Report, PO Box 433, Lakeville, CT 06039. Be sure to mention thew title or print an order form from www.AskDrGottMD.com.

I am assuming that the value of niacin in its blood vessel dilating properties which could tend to move the free cholesterol out of the blood stream. If that is true, then I question the value of either the extended-release or flush-free niacin.

My reason for asking is that the plain niacin seems to be disappearing from store shelves. CVS cannot order it for me any more and directed me to Whole Foods. I have looked elsewhere (but not the internet). If this is a stupid question, please disregard it.

DEAR READER: Your question certainly isn’t stupid. In fact, I’m sure many of my readers have had questions about the various forms of niacin at one point or another. As to why CVS no longer carries it or why it is becoming harder to find, I cannot provide an answer. Perhaps one of my readers can shed some light on this situation.

As to the three forms of niacin and their differences, that I can answer.

Niacin, also known as B3, is a water soluble vitamin that the body requires in order to create certain co-enzymes. Most individuals can get adequate amounts through a proper diet.

Nicotinic acid (the most common form of niacin) is known to reduce serum cholesterol and triglyceride levels and improve cardiovascular health. When used in doses needed to produce these effects, it is considered a drug. It has been found to work best when combined with other lipid-lowering drugs. It also enables the user to take lower doses of each to reduce the risk of side effects, the most common of which are itching, flushing and gastrointestinal disturbances.

Extended-release niacin is essentially the same as regular niacin, except that the pills that deliver the medication to the blood stream are coated with a substance that limits the release. After the pill is swallowed, the digestive juices begin to break down the pill. This coating prevents that from occurring quickly, which then allows small amounts to be released over a longer period of time. This is done to reduce side effects.

Flush-free niacin is also known as inositol niacin. The added inositol is what prevents the flushing side effects. For some, this also appears to block the cholesterol/triglyceride lowering effects of the niacin.

Anyone interested in using niacin should first speak with his or her physician, as the product can interact with some medication, may not be appropriate for some with certain medical conditions, and some people may experience allergic reactions.

Readers who are interested in learning more can order my Health Report “Vitamins and Minerals”by sending a self-addressed, stamped number 10 envelope and a $2 US check or money order to Dr. Peter Gott, PO Box 433, Lakeville, CT 06039. Be sure to mention the title when writing or print an order form from my website, www.AskDrGottMD.com.

This seems to nullify any value the niacin has, so why does the Food and Drug Administration allow OTC niacin with the antiflushing additive to be sold when it obviously does no good?

DEAR READER: High-density lipoprotein cholesterol (HDL) is often identified as the “good” cholesterol because it helps to keep low-density lipoproteins (LDL) from building in the arteries. High levels of HDL appear to help protect people from coronary artery disease.

If your HDL levels were low, the natural place to begin was with appropriate diet and exercise. That is not to imply you are or were overweight. Rather, it refers to eating foods low in cholesterol and avoiding luncheon meats, fried foods, ice cream, cheese and a host of other items.

If that failed to produce results, over-the-counter supplements such as niacin, a water-soluble vitamin B3 supplement, might be appropriate. OTCs include regular and nonflushing forms. I cannot confirm that the nonflushing type is less effective for everyone in lowering cholesterol levels and raising HDLs than regular niacin, but this often appears to be the case.

Now, on to the FDA. In most instances, manufacturers are responsible for the safety of a product but are not required to register or obtain approval before producing or selling dietary supplements. OTC supplements don’t even require documentation of efficacy or proof that they will be effective.

The contents of OTC preparations of niacin are not federally regulated in the United States. Those marketed as nonflushing may not contain nicotinic acid and, as such, are likely ineffective. SOME formulations of sustained-release niacin such as Slo-Niacin and perhaps Endur-acin appear to be relatively safe, while other OTC sustained-release niacin formulations have been associated with an increased risk of hepatotoxicity. OTC immediate-release niacin preparations are inexpensive, contain a full amount of free nicotinic acid, and are safer than most sustained-release preparations. Sustained-release Niaspan (which you may have been prescribed) is more expensive but appears to be safe, effective and should not cause flushing. Your physician should have informed you that the nonflushing formulations don’t work for everyone. When a patient experiences flushing, he or she may be helped by taking one antihistamine or aspirin 15 to 30 minutes before taking niacin. I typically recommend the antihistamine because aspirin is more likely to interact with some medications, and cause bruising, excessive bleeding and other unwanted side effects.

To provide related information, I am sending you a copy of my Health Report “Understanding Cholesterol.” Other readers who would like a copy should send a self-addressed stamped No. 10 envelope and a $2 check or money order to Newsletter, P.O. Box 167, Wickliffe, OH 440902-0167. Be sure to mention the title or print an order form off my website at www.AskDrGottMD.com.

I took simvastatin for four years. After about two years, I started having a slight weakness and muscle pain in my left leg. I talked to my doctor about whether the statin was to blame and he said no. The pain got worse and I started having restless legs syndrome and cramps at night in my left leg. The weakness progressed to the point that I had to hold on to a railing to climb stairs. When it got to the point that I couldn’t depress the clutch pedal in my stick shift truck I stopped the simvastatin without my doctor’s approval. One month later the weakness, pain, cramps and restless legs syndrome were gone.

DEAR READER:
Restless legs syndrome is not a side effect of simvastatin; however, all of your other symptoms were.

I have received several letters about side effects from statin drugs and doctors claiming that the statin was not blame. I find this astonishing, especially considering all the publicity and manufacturer’s warnings about these potentially serious side effects.

I am glad that you discovered the source of your pain but urge you to return to your physician to discuss other cholesterol lowering options. A low fat diet combined with flax seed oil, omega 3, or niacin may be an appropriate option. Adequate exercise can also aid you in this aspect.

To give you related information, I am sending you a copy of my Health Report “Understanding Cholesterol”. Other readers who would like a copy should send a self-addressed, stamped number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

After doing another internet search, this time on TGA episodes, he found that some people (including a retired NASA physician) think that there may be a connection between these episodes and statins. (He also discovered that red yeast rice is a statin.) He also found, after talking to one of his sisters who takes statins, that she has had as many eight TGA episodes. On several occasions she had to be taken to the ER but the connection with the statins was never brought up and she was never told to stop them.

My husband has since decided it best to avoid all statins, despite a family history of cholesterol problems. Given his past experience and that of his sister I cannot blame him so we are working together to modify his diet. We have read your cholesterol newsletter and while he isn’t totally inline with it, he is close and eats oatmeal, grapefruit and bananas on a daily basis. He will have his cholesterol tested in a few weeks to see if it is working. Oh, and he is lactose intolerant so high fat diary products are very easily avoided.

DEAR READER:
Transient Global Amnesia is a sudden and temporary episode of memory loss. It is not associated with any neurological condition. During an “attack”, the sufferer’s ability to recall recent events disappears. They do not know where they are or how they got there and in some cases the individual cannot recall events from a day, month or even a year ago, yet they remember who they are and recognize family and long-time friends.

During an episode it is important to get the individual to the hospital to rule out other causes of amnesia, such as epilepsy, stroke, or transient ischemic attack (TIA or mini-stroke). Transient Global Amnesia doesn’t appear to have any lasting complications but can cause plenty of emotional distress so after an episode it is important to relax.

Nearly half of all TGA episodes occur immediately after physical or emotional stress such as sudden immersion in hot or cold water, medical procedures (such as angiography), strenuous physical activity and more. Individuals who suffer chronic migraines and are between the ages of 56 and 75 appear to be at a higher risk.

That being said, both you and your sister appear to have had similar effects of TGA episodes after taking statin drugs. While medical science may have no answer for this, it is likely that there simply are not have enough reports from consumers to warrant further testing. The medical community can only know as much as drug manufacturers and scientists tell us and if they have failed to research properly these complaints or have simply not informed consumers of this possible side effect, then shame on them.

In my opinion your husband is taking appropriate steps. If diet alone does not work (which is likely because there seems to be a genetic predisposition) I recommend he try omega 3 oil, flax seed oil, or niacin. He still needs to have his cholesterol tested regularly to determine if his modifications are working. Niacin can have the uncomfortable side effect of flushing and can raise liver enzymes (rarely) but can be used in lower quantities (to reduce side effects) in conjunction with either or both of the oils. Be sure to inform your husband’s doctors of any and all changes and medication (even over-the-counters) he is taking to ensure he has proper testing and follow-up.

To give you related information, I am sending you a copy of my Health Report “Understanding Cholesterol”. Other readers who would like a copy should send a self-addressed, stamped number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

You have repeatedly recommended niacin instead of statins for lowering cholesterol. I will be going to my doctor soon for my routine physical and plan on asking if this is an appropriate option for me as I realize every case and body is different.

My concern, however, is that many people have told me that some vitamins and supplements can cause anal leakage. I would like to know what you think of this and, if it is true, to what vitamins it applies.

DEAR READER:
To the best of my knowledge, vitamins and supplements do not cause anal leakage (also known as bowel or fecal incontinence). This is not to say that there is no possibility for problems from the medication, just that it is highly unlikely because most vitamins and supplements are naturally occurring in foods and are necessary for normal body functions and metabolism.

The body only needs a small amount of niacin which is used in the formation of certain coenzymes. When used in higher doses is can lower cholesterol in some individuals. It is also a vasodilator, meaning it opens blood vessels, which causes the more notorious (and annoying) side effect, flushing. This is an appropriate option for lowering cholesterol when diet and exercise alone do not produce adequate results.

Bowel incontinence can be caused by many things but always occurs when there is a malfunction of the nerves or muscles or when there is decreased sensation. Women and the elderly are most often affected. The reason for this is simple; women who give birth can damage the muscles and nerves of the rectum and the elderly often have decreased sensation within the colon and weakened muscle control.

Any surgery on the intestine, prostate or rectum has the possibility of nerve damage. Emotional problems and stress can also cause problems. Chronic constipation, diarrhea or laxative use (because of irritable bowel syndrome, eating disorders, or other bowel disorders) often lead to muscle weakness or stiffness. Even lactose intolerance and certain other food allergies can play a role.

Certain medications, including sedatives, antacids, laxatives, narcotics, and more can cause leakage or incontinence. Orlistat (better known as Alli), Olean and sugar substitutes can also cause problems in many people.

Luckily, for people with chronic bowel incontinence or leakage, there are several treatment options. Based on the cause of the problem, treatment can include diet modifications, bowel retraining, medication, surgery, implants or transplants.

As you can see there are many factors that come into play and perhaps everyone who claims to have problems with vitamins and other supplements is really suffering from something else. Perhaps even one of the inactive ingredients is causing the problems; is there a sugar substitute, such as sorbitol, to make the pill more palatable?

Anyone suffering from bowel incontinence should be seen by a gastroenterologist who can determine the cause and provide appropriate treatment.

To give you related information, I am sending you copies of my Health Reports “Dr. Gott’s Compelling Home Remedies”, “Vitamins and Minerals” and “Irritable Bowel Syndrome”. Other readers who would like copies should send a self-addressed, stamped number 10 envelope and $2 (per report) to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure mention the title(s).

DEAR READER:
Niacin is an excellent alternative choice for lowering cholesterol levels. I often recommend patients to start with a relatively low-dose of 250-500 mg daily and then slowly work up to 1000-1500 mg daily, usually in increments of 250 mg. This is primarily to allow the body to become accustomed to the vitamin and reduce the chance of side effects, namely, flushing.

It is important also to have your cholesterol level checked every few months, as well as liver function, to ensure that the medication is working and not causing any damage.

Some individuals are very sensitive to the medication and cannot tolerate it well. For these individuals, I recommend omega-3 oils or flaxseed oil. These do not, to my knowledge, have any side effects but cholesterol testing is still important to determine if the medication is working. If that fails, try combining therapy such as niacin and flaxseed oil daily. This can also reduce the dosage of the niacin leading to a smaller incidence of side effects.

As for red yeast rice, I do not recommend it because it is basically a natural form of the drug Mevacor which is a statin. It is more likely to cause side effects similar to those of other statins, such as muscle/joint pain and liver damage.

To give you related information, I am sending you copies of my Health Reports “Understanding Cholesterol” and “Dr. Gott’s Compelling Home Remedies”. Other readers who would like a copy should send a self-addressed, stamped number 10 envelope and $2 (per report) to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure mention the title.

DEAR READER:
Lipitor will work the same regardless of what time of day it is taken or even if it is taken with or without food. In my experience most physicians recommend some medications be taken in the morning and others at night simply to reduce the number of pills taken simultaneously and to reduce the chance of drug interactions. If your physician has said you can safely take the Lipitor in the morning, I recommend you take his advice. If that fails to stop the sleeplessness, perhaps you could successfully be switched to another cholesterol lowering medication. You may also choose to try other treatments such as omega 3’s, niacin or flaxseed oil. Ask your doctor about this.

To give you related information, I am sending you a copy of my Health Report “Understanding Cholesterol”. Other readers who would like a copy should send a self-addressed, stamped number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092.

The only niacin a person can buy without a prescription is the non-flushing kind that does nothing for high density lipoprotein (HDL) levels. The one that helps is Niaspan that requires a prescription and can definitely cause flushing — to the degree that some people cannot take it at all.

Can you please clear this up?

DEAR READER:
Non-flushing niacin contains an ingredient called inositol which does nothing for reducing cholesterol levels and may prevent the niacin from working correctly. Straight niacin or sustained-release niacin is available over-the-counter and does work toward reducing high counts. Flushing and itching are common side effects. However, taking an antihistamine or 81 mg aspirin 10 or 15 minutes prior to the niacin or splitting the daily intake between morning and evening may reduce or eliminate the unpleasant side effects. Another option is to work up to a higher level slowly.

Many readers have successfully used omega 3 fish oil, flax seed oil or a combination (niacin and one of the oils or both oils).

A low fat, low or no salt diet is a must for individuals with high cholesterol levels. See your physician for his or her recommendations. Prescription medications might be necessary to achieve lower readings. Periodic testing of cholesterol levels (and liver enzymes if on medication) should be done to be sure you are on the right track.

To give you related information, I am sending you a copy of my Health Report “Understanding Cholesterol”. Other readers who would like a copy should send a self-addressed, stamped, number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

Does this mean I will not ever be able to take niacin again? Are there other forms that might work better? I had renewed energy and really felt great while taking it.

DEAR READER: Niacin (vitamin B3) has many beneficial properties. It is used to treat dizziness, headaches, circulatory problems, ringing in the ears, Raynaud’s syndrome, and depression. In addition, it may increase energy, stimulate circulation, maintain normal blood pressure, raise HDL (good) cholesterol levels, and lower LDL (bad) cholesterol levels. Other uses are for acne, age-related macular degeneration, arthritis, combating hardening of the arteries, migraines, psoriasis, the prevention of cataracts, and more. It’s no wonder you felt good and had renewed energy while taking this supplement.

The prickly sensation that you experienced is a common side effect. Others include flushing of the face, neck and ears, palpitations, liver irritation, and abnormal heart rhythms. Flushing and a prickling can occur when the daily dosage is 50 mg or higher. While the feelings are often annoying, they are essentially harmless. To combat flushing, an aspirin or non-steroidal anti-inflammatory (NSAID) can be taken for the first week or two with any form of niacin, or an antihistamine can be taken about 15 minutes prior to usage. This supplement should always be taken with food to prevent stomach upset. The U.S. Department of Agriculture does not strictly regulate herbs and other supplements. Therefore, different forms or brands of niacin might be more appropriate for you.

A low dose of flush free niacin can be used as a start for your hypertension and feeling of well-being. Unfortunately, perhaps because of the inclusion of the ingredient inositol hexanicotinate, the flush free form appears to block any cholesterol benefits that might otherwise be realized. Follow the recommended dosage to maintain your nervous and digestive systems, skin health and to support cell growth.

Extended release niacin may cause less flushing but can have a higher risk of stomach upset or liver irritation. Clotting problems, headache and decreased thyroid function have also been reported by some users. If the ultimate goal is for better cholesterol readings, this is the preferred form.

Of note is the use of niacin for certain conditions associated with Type II diabetes. Its use has been controversial because of the possibility of worsening glycemic control. Therefore, patients with diabetes should check with their physician or pharmacist before taking niacin (or any other supplement).

Niacin deficiency is known as pellagra. It affects all body cells, especially those of the skin, nervous system and GI tract where there is rapid turnover. Symptoms include indigestion, skin irregularities, weakness, fatigue, halitosis, anorexia and they can progress to include canker sores, nausea, vomiting and diarrhea.

Foods rich in niacin include lamb, poultry, tuna, eggs, peanut butter, avocados, peanuts, figs, and wheat germ. The consumption of these foods will work toward lowering total cholesterol levels naturally, can relieve the pain of arthritis, and may rival prescription drugs or over-the-counter supplements. Remember, the benefits of this vitamin (and many others as well) can be lost through vigorous food processing, when taking sleeping pills, or with alcohol consumption.

Vegetarians, vegans or individuals who drink alcohol in excess should consider taking a niacin supplement, as diets that lack protein are probably niacin deficient, and alcohol inhibits absorption of the vitamin.

To be on the safe side, check with your primary care physician before making the decision to resume your niacin. A simple blood test is all that is necessary to determine the possibility of B3 deficiency. When it comes to your health, it’s always better to have an outside professional opinion.

To give you related information, I am sending you a copy of my Health Report “Vitamins and Minerals”. Other readers who would like a copy should send a self-addressed, stamped number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.