A Defense of Niacin with Dr. Howard Elkin: Rational Wellness Podcast 362

Dr. Howard Elkin and Dr. Ben Weitz defend the Therapeutic Use of Niacin.

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Podcast Highlights

0:39  Niacin.  Niacin is vitamin B3 and it is found in many foods and most multivitamins and we know that not having enough niacin can lead to a life-threatening condition–Pellagra. Today we want to comment about a new study in Nature by Dr. Stanley Hazen and colleagues that questions whether the therapeutic use of niacin is safe or effective because a downstream metabolite of niacin–4PY–promotes vascular inflammation and contributes to cardiovascular disease risk.  The paper, which was published in February 19, 2024 is called A Terminal Metabolite of Niacin Promotes Vascular Inflammation and Contributes of Cardiovascular Disease Risk.

2:12  Niacin has been a very effective therapeutic tool to reduce cardiovascular disease risk and it has many unique properties, including that it reduces small, dense LDL, increases LDL particle size, reduces triglycerides, increases HDL, improves HDL functionality, and is pretty much the only effective therapy to reduce Lp(a).

4:14  Statins. Niacin was a very popular treatment for high cholesterol until statins came out and then everything changed and statins became the go to drugs for reducing cholesterol.  Statins do a good job of lowering LDL but they don’t increase the size of the LDL particles and particle size is more important than LDL, which is why you should do advanced lipid testing. Small, dense LDL is more dangerous than large buoyant LDL.  In fact, LDL is less of a culprit than oxidized LDL and small, dense LDL particles are more likely to be oxidized. Lp(a) is a fragment of LDL that sticky and inflammatory. Niacin can help in both of these situations where statins do not.

7:23  A large number of studies over the years that have shown significant benefit with using niacin.  Dr. Hazen points out in this paper that because patients who are taking very strong medications like PSK9 inhibitors to reduce cardiovascular risk still have have heart attacks, so there must be some additional markers to screen for this risk.  This is why he searched for new biomarkers and found this downstream metabolite of niacin–4PY that appears to be associated with inflammation. He points out that 4PY is associated with vascular adhesion molecule one, VCAM1.  This is quite ironic, since a study in 2010 found that niacin reduces VCAM1 (Wu BJ, Yan L, Charlton F, et al. Evidence that niacin inhibits acute vascular inflammation and improves endothelial dysfunction independent of changes in plasma lipids. Arteriosclerosis, Thrombosis, and Vascular Biology. 2010;30:968-975.).  But if Dr. Hazen wanted additional biomarkers outside of a basic lipid profile, he does not need to look any further than the markers in an advanced lipid profile, such as the one developed by Cleveland Clinic, where Dr. Hazen works.

10:48  If Dr. Hazen is saying that niacin is unsafe because it leads to 4PY, since none of these patients were taking therapeutic niacin, then we should all stop eating salmon, sardines, nuts, and avocados, and a bunch of other healthy foods that naturally contain niacin. 


Dr. Howard Elkin is an Integrative Cardiologist with offices in Whittier and in Santa Monica, California and he has been in practice since 1986.  While Dr. Elkin does utilize medications and he performs angioplasty and stent placement and other surgical procedures, his focus in his practice is employing natural strategies for helping patients, including recommendations for diet, lifestyle changes, and targeted nutritional supplements to improve their condition.  Dr. Elkin has written an excellent new book, From Both Sides of the Table: When Doctor Becomes Patient.  His website is Heartwise.com and his office number is 562-945-3753.

Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure.  Dr. Weitz has also successfully helped many patients with managing their weight and improving their athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.



Podcast Transcript

Dr. Weitz:  Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates. And to learn more, check out my website, drweitz.com.  Thanks for joining me and let’s jump into the podcast. Hello, Rational Wellness Podcasters.

I’m very excited to be speaking with one of my favorite guests, Integrative Cardiologist, Dr. Howard Elkin again. And today the topic is niacin. Niacin is vitamin B3. It is found in many foods.  It’s found in most multivitamins.  We know that not having significant amounts of niacin in the diet leads to pellagra, which is a life threatening disease.  And so we have known about the benefits of niacin, but today we really want to talk about the Therapeutic use of niacin in higher dosages, which has been used by cardiologists and now very commonly by integrative and functional cardiologists to decrease cardiovascular risk.  And it has been used safely, has a lot of unique properties and benefits, and It seems to be periodically under attack and now it seems to be under attack again. And the Dr. Elkin and I thought it was important to comment about a new study which was published in Nature by Dr. Stanley Hazen of Cleveland Clinic and colleagues.  The name of the paper is A Terminal Metabolite of Niacin Promotes Vascular Inflammation and Contributes to Cardiovascular Disease risk.  Dr. Hazen argues that a metabolite of niacin, or PY, is associated with increased risk of major cardiovascular events.

But we also know that niacin has proven to be a very effective tool for decades in reducing cardiovascular disease risk.  And it’s unique in many of its properties, and I’m just going to mention a couple, and Dr. Elkin and, and I will go into more details, but it’s pretty much the only substance we know that can reduce small dense LDL and increase LDL particle size. It reduces triglycerides. It’s, it’s pretty much the only effective tool for increasing HDL and improving HDL functionality.  And it’s really, at this time, the only effective therapy for reducing LP little a.

Dr. Howard Elkin is an integrative cardiologist with offices in Whittier and in Santa Monica, and he’s been in practice since 1986. While Dr. Elkin does utilize medications and performs angioplasty and stent placement and other surgical procedures, his focus is really On employing natural strategies for helping patients, including recommendations for diet lifestyle and targeted nutritional supplements like niacin to improve their condition.  Dr. Elkin has also written an excellent book From Both Sides of the Table: When doctor becomes patient that’s available on Amazon, Dr. Elkin, Thanks for joining me again.

Dr. Elkin: Thank you, thank you Ben so much, and I appreciate being here. This is a topic that’s very dear to my heart because, pun intended, because it’s like every so often, like every few years, they come up with another say that disses or throws niacin under the bus and my [00:04:00] niacin, if you look historically, has been around, first of all, it doesn’t bite, like you say, it’s vitamin B3, it’s been around forever.  I mean, in the 60s and 70s, that was one of the few things we had to even lower cholesterol. And it did it pretty, you know, pretty okay, did a good job of it. And then everything kind of changed when statins came about, and I was actually a fellow at Northwestern when the first one, Mevacor, came out. I remember that Time magazine with the, with the cover was like, you know, fried egg with, I think it was bacon for eyes or a mouth or something.  And really, statins became very popular because they do something very well. They lower LDL, and they lower it quite nicely, and more potently than niacin. Well, but you’ve already mentioned what niacin does, but that, I mean, I could give someone 80 milligrams of Lipitor and it’s not going to increase the size of the LDL particle.  So, why do I care about that?  Because particle size is really more important than the LDL by itself, and you have to do really advanced lipid testing to test for that. So, small dense is less preferred than large fluffy or large buoyant, and because of the fact that small dense is like, you know, almost 30 percent more likely to get oxidized.  So LDL isn’t so much the culprit, it’s oxidized LDL. And we know that small dense particles have a predilection for that. Same thing with LP little A. LP little A is a fragment of LDL. It’s sticky. It’s inflammatory. We don’t like it. And so it’s, and it promotes inflammation. It does oxidation of LDL, so those, those are two components right there where niacin comes in in handy.

It will decrease triglycerides, it can increase HDL, it can increase HDL functionality, which is important because you can have a high HDL number yet it’s dysfunctional, and you don’t know that unless you test for it, and Cleveland Heart Lab does that. Um, so, I mean, definitely in accordance with you, this article did not talk about any benefits of niacin.  It just said, well, if you happen to have one of these horrible toxic metabolites, you know, you’re more likely to have toxic effects in a way called MACE, which is, you know, major Adverse cardiovascular events, that’s the term we use, and they looked at mace over three years. But there’s a lot of, you know, fallacies of the study.

First of all, you have to have a certain polymorphism or single nuclear polymorphism to even have the, this, this, these, to break down to these toxic metabolites. So probably at the most, one out of four, I mean, we don’t even know the number of people that are affected by this, but I can promise you in 37, almost 38 years of practice, I’ve never had a problem with niacin such as this–someone developing a heart attack or stroke. So I think it’s been taken way out of context.  I’m not saying there’s no validity in toxic metabolites. I mean, every drug, or every substance will break down. It’s how it breaks down.  And so we found these, the 2PY and 4PY, but you have to have the SNP in order to break it down. So it’s, it’s really taken out of context because I think most people really are not affected by this. And therefore the study is really not nearly, it’s important. It’s, I mean, they call it the Niacin paradox.  It’s supposed to help, but it doesn’t. Why? I beg to differ with that.

Dr. Weitz:  Right.  And there’s been a large number of studies over the years that have shown significant benefit with using niacin, including reducing blockages in the arteries, including reducing cardiovascular risk. And one of the things that Dr. Hazen points out in this article at the beginning is that patients who were taking these PSK9 inhibitors, which are the most potent drugs we have to reduce LDL, that some of the patients still have heart attacks. So his conclusion is if LDL is not enough to understand why people are having heart attacks, let’s see what else we can find.  And so he’s searching through the blood of patients who have cardiovascular disease, none of whom, by the way, were being prescribed niacin. So none of the patients in this study were prescribed therapeutic niacin. So there’s nothing that can be said on the basis of this study that applies to the therapeutic use of niacin.  And he found that a certain percentage of patients had these Toxic metabolites.  And the one that was the most significant is the 4PY. And he also found that that 4PY was associated with with inflammation.  And he correlated in some in-vivo studies that it’s associated with vascular adhesion molecule one, VCAM1.

First of all, I want to point out that I think the main message I would like everybody to get from this discussion is that if Dr. Hazen realized that patients who were taking effective lipid lowering drugs were still having heart attacks. Instead of searching for some obscure downstream metabolite that only occurs in a percentage of patients with a certain genetic SNP, all he needed to do was look at an advanced lipid profile to get information about what other factors are important in lowering cardiovascular risk. And unfortunately, statins and PSK9 inhibitors, don’t do anything about addressing LDL particle size. They don’t increase particle size. They don’t increase HDL functionality.  They don’t significantly lower Lp(a).  PSK9 inhibitors do a little bit, but actually not as effectively as niacin does.  And so I think the answer is look at an advanced lipid profile. Look at homocysteine, look at metabolic factors. When you put that whole picture together, I think we do have a much better assessment of understanding cardiovascular risk because LDL C alone is not enough.  And I think he’s absolutely right about that. He, we just don’t need to look for this obscure, downstream metabolite of niacin. And so if what Dr. Hazen is saying that niacin is unsafe because it leads to 4PY and none of these patients were taking therapeutic niacin. Then what he’s saying is, is that we should all stop eating salmon, sardines, nuts, and avocados, and a bunch of other healthy foods that naturally contain niacin.  As well as avoiding niacin supplements and taking multivitamins. And I think that goes against everything we know about nutrition and… 

Dr. Elkin:   Interesting. I think the real paradox, the niacin paradox, the real paradox is that this guy is from the Cleveland Clinic. Cleveland Clinic has premier, I mean, Boston and Cleveland Clinic have the best advanced lipid testing out there. 

Dr. Weitz:  Exactly.

Dr. Elkin:   It’s right available at their fingertips.

Dr. Weitz:  Look at your own testing, dude!

Dr. Elkin:   Look at your own testing, because you’re going to find answers there. And potentially all my patients that have elevated cholesterol, which is, as you can imagine, a hell of a lot, I always do advance the testing. If the baseline is abnormal, I’m going to go test it.  To, [00:12:00] and most, in many cases, I go straight to advanced testing, but that’s where I’m going to get answers. That’s where I’m going to find out about risk factors and inflammation and metabolic aberrations, not by l, not by this study. It doesn’t help me at all.

Dr. Weitz:  By the way, interestingly, I looked into some of the literature and this association, the reason why I mentioned this technical name, vascular adhesion molecule one, VCAM one is because there’s a study in 2010, (Wu BJ, Yan L, Charlton F, et al. Evidence that niacin inhibits acute vascular inflammation and improves endothelial dysfunction independent of changes in plasma lipids. Arteriosclerosis, Thrombosis, and Vascular Biology. 2010;30:968-975.), that shows that one of the benefits of niacin is that it reduces inflammation by reducing VCAM one. So interestingly, therapeutic higher dosages of niacin reduced VCAM1.  However, patients who are found to have 4PY were patients who, as far as we know, had probably relatively lower levels of niacin because none of them were taking niacin. So we don’t know this, but maybe, maybe there is a J shaped curve and he’s measuring people with low levels of niacin, and maybe people who had higher levels actually have lower level of vascular adhesion molecule and lower levels of inflammation and atherogenesis.

Dr. Elkin: And I think one of the reasons why we’re doing this is that the day after the study came out, I kid you not, I got four phone calls from my patients. Should I be should I be taking the shot to stop my niacin?  I’m, really worried about this study. It went viral in a matter of hours, of course

Dr. Weitz:  And that’s what happens with the press, unfortunately so now um this paper in order to bolster their findings also Mention two previous other trials That have been used.  In fact, 10 years ago they were used and it was all over the news. Um, that niacin’s not good to take. And these were the HPS Two Thrive study and the AIM High trial. [00:14:00] So why don’t we take a quick look at these two trials and why don’t we start with the HPS two Thrive trial that gave patients who had a history of heart disease 40 milligrams of simvastatin, along with high dose extended release niacin, along with an investigational drug from Merck called lariparipant, which decreased the flushing effect of niacin.  And this study did not show a reduction in cardiovascular benefits after approximately four years.

Dr. Elkin:  You know, first of all, it was a non flushed, right? That was the compound they used.

Dr. Weitz:  Well, they used this additional drug to reduce the flushing. So they used extended release niacin, which does flush, along with this other investigational drug.

Dr. Elkin: First of all, my problem with that is that you’re not talking apples and apples anymore. You’re not just talking about niacin. Pure niacin, which is the only thing that I recommend. I use supplemental form. I don’t use the pharmaceutical brand because you take it once at night with your evening meal and then you wake up at 2 am with flushing.  The flushing is extended and it also has liver abnormalities. I use regular supplemental niacin. There’s several good companies out there that make it. But it’s the non flushed, first of all, It, it doesn’t, it’s not the same thing and it doesn’t work. It simply doesn’t work.

Dr. Weitz: So the reality is this additional drug, lariparipirant, which is not on the market, is associated with a lot of the side effects that they attributed to niacin.

Dr. Elkin: Exactly, exactly. So, again, this is another example. You know, this study was, that’s 2014, if I’m not correct. Correct, right? 2014, 10 years ago. And, by that time, statins had their main, I mean, statins were, it was right before PSK9 inhibitors came out. PSK, PSK9 inhibitors came out, I believe, about 8 years ago.  And that changed things a bit, but and there’s another argument they had about niacin, if I’m not mistaken, right? 

Dr. Weitz: Yeah. So there was, there was there was also the aim high trial and this used a time release niacin added to statin therapy. And, you know, another problem with both of these studies is.  Niacin, a lot of its benefits will be most profound with patients, um, who have higher levels of, of cholesterol and triglycerides, et cetera. So when you already start out by pre treating the patient for a while, um, with, um, statins, you’re going to [00:17:00] decrease some of the benefits. Even this aim high trial, which found that there was no additional reduction in heart attacks.  Um, uh, it, it, it actually did show significant improvements in several cardiovascular disease risk factors, including increased HDL from 35 to 42. Lowering of triglycerides from 1 64 to 1 22.  Further lowering LDL cholesterol and lowering LP little a.  And so I, I think both of these trials are  flawed and really don’t refute the benefits of niacin.

Dr. Elkin: I think one benefit, you already mentioned it, when you increase HDL and decrease triglycerides, you are affecting the metabolic milieu, because almost 95 percent of the population in this country is metabolically unhealthy, and that’s a major culprit in coronary disease and heart disease in general.  And these parameters are not affected by statins or even PCS can inhibitors to a certain extent. So there is benefit to niacin, which was never mentioned in these studies. Um, yeah, it’s like, it’s easy to do something. And, and, but I certainly, I was a physician treating lots of patients with lipid disorders for over, really, I worked with Robert Sperko in Berkeley Heart Lab 25 years ago.  That’s when I learned about particle size. No one was even talking about that back then, and that’s when I started using, but niacin, it’s, you know, and I still use it and I have not stopped it in any of my patients, despite all the phone calls I got. And so I just think it, this study was just really.  It was taken out of context, and [00:19:00] our job is to teach the public that, you know, you have to know both sides of the story.

Dr. Weitz: Yeah, it was a basic science study. It was not a study that tested therapeutic use of niacin. And then, further, part of a message from doctors like you and myself who practice integrative functional approaches are that when you treat the whole patient and you address their diet, their exercise, their stress component, and then you layer in some of these additional therapies like niacin and possibly statins or other medications.  The overall therapeutic benefit you’re going to get from these patients improving their metabolic profile, reducing overall levels of inflammation is going to be far superior than just taking people following the standard American diet, leading a sedentary lifestyle, and just throwing in some pharmaceuticals.

Dr. Elkin: Exactly, exactly. So as Ross said, so I mean this is a great, there’s a lot of other studies that we can talk about, but I think the niacin issue is a big one and I think not stopping a niacin just because of this one study is uncalled for.

Dr. Weitz: And niacin has these unique benefits that we’ve mentioned, like, for example, improving HDL functionality.  Interestingly HDL has sort of been the forgotten cardiovascular risk marker. And, and, and unfortunately, a lot of the data around some, some medicine has to do with whether or not we have a pharmaceutical to treat it. So most doctors are, they, they’re waiting, conventional medical doctors, primary care doctors, cardiologists, They don’t measure these other things.  They don’t measure HDL functionality. They don’t measure LpA. Why? There’s no drug to treat it. In a couple of years, there’s going to be one or several drugs that are on the market that effectively lower HP, LpA, and you’re going to see everybody testing LpA. But right now, they don’t care because They don’t have any means to reduce it, but we know that niacin can produce, uh, a 30 to 70 percent reduction in Lp(a).

Dr. Elkin: exactly.  I think, yeah, once the medic, the pharmaceuticals come out, it’ll be, it’ll go viral, you know, they may be treating it.

Dr. Weitz: Right. And the same thing about HDL is they’ve tried to come out with several drugs to raise HDL and they haven’t been effective in reducing risk. Right. And so, you know, one of the [00:22:00] morals of the story is there is different ways to accomplish the same thing.  And we see this also with trying to control metabolic syndrome and controlling blood sugar and insulin. And if you do it with very aggressive drug therapy And and you just keep increasing the medications to lower Hemoglobin A1C.  We actually have negative effects on people’s health and and and some Some doctors have concluded, well, you shouldn’t try to reduce your blood sugar and your hemoglobin A1c too aggressively.  Well, no, that’s not the answer. The answer is if you do it naturally, if you get people to change your diet, stop eating ultra processed foods, start eating a lower glycemic diet, start exercising appropriately, manage your stress, get proper sleep. [00:23:00] You’re going to find that. They’re going to significantly lower their risk of death and, and all cause mortality and everything else.  But if you just do it with drugs, that’s not the answer.

Dr. Elkin: I concur a hundred percent. And that’s it.

Dr. Weitz: That’s it. So I there’s another study that just came out, but I know we’re short on time. So you and I are going to get together in a few weeks and discuss this other trial that seemed to show that LDL is completely irrelevant.  Right. Exactly. Okay. So, so Howard, how can our listeners, get ahold of you and contact you if they want you to help them?

Dr. Elkin: Okay. Very good. So my website is Heartwise.com. That’s one word Heartwise. And I also, my book is Be Your Own Medical Advocate. com, but you can see me on Instagram under DocHElkin. or Facebook, uh, Heart Wise Fitness and Longevity Center.  But I’m pretty connected to social media, so I’m glad you had to answer your questions and so forth. But, uh, you know, I love doing this, not that I’m into much dissecting studies, but doctors, so they just look at a study at face value and then the pharmaceutical reps come in there and push meds. And, you know, and I understand because we’re really limited in time, but there’s no substitute for interpreting a study and diving into it like we just did.

Dr. Weitz: I just want to point out again that we’re not trying to bash medications. Medications can be very beneficial, but if they’re integrated into a full care program where you’re helping patients to improve their diet, improve their lifestyle, exercise regularly, get proper sleep, manage their stress, and then you add in the proper nutritional supplements to meet all their nutritional needs and then add in the proper medications to top it off.  That’s a completely different picture than taking a metabolically unhealthy a sedentary American eating the standard American diet, eating ultra processed foods and try to lower their risk just with medications.

Dr. Elkin: 100 percent agreed. You know, that’s why in integrative medicine, we integrate lifestyle.  Lifestyle was always number one in my book. Yeah, I use a lot of medicines. I have sick cardiac patients, but I always vouch for that. I did a YouTube live on hypertension and may it’s also blood pressure awareness month. And you know, with With weight loss and exercise in that order, we could probably wipe out stage one, you know, mild hypertension.  But by the time people are diagnosed, they’re stage two already. They’re, you know, they have advanced disease because no one’s talked about lifestyle.

Dr. Weitz:  Diet and exercise for weight loss?  I thought weight gain was caused by a deficiency of Ozembic.  Thank you, Howard.



Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast. I would appreciate it if you could go to Apple Podcasts or Spotify and give us a five star ratings and review. If you would like to work with me personally to help you improve your health, I do accept a limited number of new patients per month for a functional medicine consultation.  Some of the areas I specialize in include helping patients with specific health issues like gut problems. neurodegenerative conditions, autoimmune diseases, cardiometabolic conditions, or for an executive health screen. And to help you promote longevity. And take a deeper dive into some of those factors that can lead to chronic diseases along the way.  Please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111. And we’ll set you up for a new consultation for functional medicine. And I look forward to speaking to everybody next week.

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