Lipitor (atorvastatin) vs. niacin (nicotinic acid, vitamin B3)

Lipitor vs. Niacin: What’s the difference?

• Lipitor (atorvastatin) and niacin (nicotinic acid, vitamin B3) are used to lowers cholesterol levels in the blood.
• Lipitor and niacin belong to different drug classes. Lipitor is an HMG-CoA reductase inhibitor (a “statin” drug) and niacin is a nutrient.
• Brand names for niacin include Niacor, Niaspan, Slo-Niacin, and Nicolar.
• Side effects of Lipitor and niacin that are similar include diarrhea and headache.
• Side effects of Lipitor that are different from niacin include constipation, fatigue, gas, heartburn, common cold, joint pain, pain in the extremities, and urinary tract infection (UTI).
• Side effects of niacin that are different from Lipitor include stomach upset, flushing, dizziness on standing, vomiting, itching, and tingling sensations of the extremities.

What is Lipitor? What is niacin?

Lipitor (atorvastatin) is an HMG-CoA reductase inhibitor (a “statin”) used to lower cholesterol levels in the blood. Lipitor reduces total cholesterol as well as LDL (“bad”) cholesterol, which is largely responsible for the development of coronary artery disease. Reducing LDL cholesterol can slow the progression and may even reverse coronary artery disease. Lipitor also increases HDL ("good") cholesterol, which protects against coronary artery disease and reduces the concentration of triglycerides (fats) in the blood. High blood concentrations of triglycerides are also associated with coronary artery disease. In people with coronary artery disease, Lipitor prevents angina, stroke, heart attack, hospitalization for congestive heart failure, and revascularization procedures.

Niacin (nicotinic acid, vitamin B3) is a nutrient that is part of a normal diet and is essential to various chemical reactions in the body. It is used medically to treat individuals with deficiency of niacin. Niacin also is used to reduce cholesterol and triglyceride levels in the blood. Nicain reduces LDL (“bad”) cholesterol and increases HDL (“good”) cholesterol. Niacin is thought to work by reducing the production of proteins that transport cholesterol and triglycerides in the blood. Niacin is available in immediate and slow-release forms (Niaspan, Slo-Niacin). Natural sources of niacin include meat, poultry, liver, fish, nuts, green vegetables, whole grains, and potatoes.

What are the side effects of Lipitor and niacin?

Lipitor

Lipitor is generally well tolerated. Minor side effects include:

• Constipation
• Diarrhea
• Fatigue
• Gas
• Heartburn
• Headache

Other commonly reported side effects include:

• Common cold (nasopharyngitis)
• Joint pain (arthralgia)
• Pain in the extremities
• Urinary tract infection

Lipitor may cause liver and muscle damage. Serious liver damage caused by statins is rare. Liver tests should be performed at the beginning of treatment then as needed thereafter.

Inflammation of the muscles caused by statins can lead to serious breakdown of muscle cells called rhabdomyolysis. Rhabdomyolysis causes the release of muscle protein (myoglobin) into the blood, and myoglobin can cause kidney failure and even death. When used alone, statins cause rhabdomyolysis in less than one percent of patients. To prevent the development of serious rhabdomyolysis, patients taking atorvastatin should contact their health-care professional immediately if they develop unexplained muscle pain, weakness, or muscle tenderness.

Statins have been associated with increases in HbA1c and fasting serum glucose levels as seen in diabetes.

Post-marketing reports for atorvastatin of adverse events include:

• Memory loss
• Forgetfulness
• Amnesia
• Confusion
• Memory impairment

Symptoms may start one day to years after starting treatment and resolve within a median of three weeks after stopping the statin.

Niacin

The most common side effects of niacin are:

• stomach upset,
• flushing,
• headache,
• reduced blood pressure upon standing (orthostatic hypotension),
• vomiting,
• diarrhea,
• itching and
• tingling sensations of the extremities.

Flushing may be reduced by taking 325 mg of aspirin 30 minutes before the niacin and by increasing the dose of niacin slowly. Drinking hot liquids or alcohol shortly before or after niacin is taken may increase the occurrence of flushing. Extended release formulations of niacin may cause flushing less frequently than immediate release formulations.

Rare cases of liver failure or muscle injury have occurred from the use of niacin. Blood tests to monitor for liver injury should be performed before niacin therapy begins, every 6-12 weeks for the first year, and then occasionally thereafter. Niacin should be discontinued if liver tests are greater than three times the upper limit of normal, are persistently elevated, or are accompanied by nausea, vomiting, or weakness.

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What is the dosage of Lipitor vs. niacin?

Lipitor

• Lipitor is prescribed once daily.
• The usual starting dose for adults is 10-20 mg per day, and the maximum dose is 80 mg per day. Adults who need more than a 45% reduction in LDL cholesterol may be started at 40 mg daily.
• Pediatric patients should receive 10 mg once daily up to a maximum dose of 20 mg daily.
• Lipitor may be taken with or without food and at any time of day.

Niacin

The recommended oral dose of immediate release niacin for treating high cholesterol levels in adults is 1-2 g two to three times daily. The maximum recommended dose is 6 g daily. When using extended release tablets, the maximum recommended dose is 2 g per day. Niacin should be started at low doses and increased slowly over several weeks. To avoid stomach upset, niacin should be taken with meals.

Extended release tablets should be swallowed whole and should not be crushed or chewed. Extended release formulations should not be substituted with equivalent doses of immediate release niacin since this leads to an overdose of niacin that may cause liver failure.

Pellagra may be treated with up to 500 mg per day of oral niacin.

What is cholesterol?
See Answer

What drugs interact with Lipitor and niacin?

Lipitor

Decreased elimination of Lipitor could increase levels of Lipitor in the body and increase the risk of muscle toxicity from Lipitor. Therefore, Lipitor should not be combined with drugs that decrease its elimination. Examples of such drugs includes:

• erythromycin (E-Mycin),
• ketoconazole (Nizoral),
• itraconazole (Sporanox),
• clarithromycin (Biaxin),
• telithromycin (Ketek),
• cyclosporine (Sandimmune),
• nefazodone (Serzone), and
• HIV protease inhibitors such as indinavir (Crixivan) and ritonavir (Norvir).

Large quantities of grape fruit juice (>1.2 liters daily) also will increase blood levels of Lipitor and should not be taken.

The following drugs also may increase the risk of muscle toxicity when combined with Lipitor.

• amiodarone (Cordarone)
• verapamil (Calan Verelan, Isoptin)
• cyclosporine (Sandimmune)
• niacin (Niacor, Niaspan, Slo-Niacin)
• gemfibrozil (Lopid)
• fenofibrate (Tricor)

Lipitor increases the effect of warfarin (Coumadin) and the concentration in blood of digoxin (Lanoxin). Patients taking Lipitor and warfarin or digoxin should be monitored carefully. Cholestyramine (Questran) decreases the absorption of Lipitor. Lipitor should be given at least two hours before and at least four hours after cholestyramine.
Rifampin increases breakdown of Lipitor. To reduce the likelihood of this interaction both drugs should be given at the same time. Lipitor should not be given after rifampin.

Niacin

Use of niacin with drugs that cause liver or muscle injury, for example, lovastatin (Mevacor) or simvastatin (Zocor) may increase the occurrence of liver or muscle injury.
Niacin may increase blood glucose levels in individuals with diabetes. Therefore, medications for controlling blood glucose may need to be adjusted when niacin is taken by those with diabetes.

Bile acid sequestrants (for example, cholestyramine [Questran]) bind and prevent absorption of niacin. Administration of bile acid sequestrants and niacin should be separated by 4-6 hours.

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Are Lipitor and niacin safe to use while pregnant or breastfeeding?

Lipitor

• Lipitor should not be taken during pregnancy because the developing fetus requires cholesterol for development, and Lipitor reduces the production of cholesterol. Lipitor should only be administered to women of childbearing age if they are not likely to become pregnant.
• It is not known if Lipitor is secreted in breast milk. Because of the potential risk of adverse events, breastfeeding mothers should not use Lipitor.

Niacin

• It is not known whether the high doses of niacin used in treating elevated cholesterol levels are harmful to the fetus during pregnancy.
• Niacin is actively secreted in breast milk. Therefore, nursing mothers taking niacin should avoid breastfeeding or discontinue niacin in order to prevent the newborn from ingesting large amounts of niacin.