Cochrane for Clinicians

Putting Evidence into Practice

Use of Niacin for Primary or Secondary Prevention of Cardiovascular or Cerebrovascular Events


Am Fam Physician. 2018 Apr 1;97(7):436-437.

  Related letter: Does Niacin Have Cardiovascular Benefits in Patients with Dyslipidemia?

Author disclosure: No relevant financial affiliations.

Clinical Question

Is niacin effective for primary or secondary prevention of cardiovascular or cerebrovascular events?

Evidence-Based Answer

Prescription niacin (nicotinic acid, vitamin B3) does not reduce myocardial infarctions, strokes, or overall mortality when used for primary or secondary prevention.1 (Strength of Recommendation: A, based on consistent, good-quality patient-oriented evidence.)

Practice Pointers

Prescription niacin is one of the most effective agents in increasing serum levels of high-density lipoprotein (HDL) cholesterol.2 Previous research has shown that lower levels of HDL cholesterol are independently associated with an increased risk of cardiovascular disease (CVD), and that use of prescription niacin could raise HDL cholesterol levels and may reduce cardiovascular events.3,4 The objective of this review was to assess the effectiveness of niacin therapy (monotherapy or in addition to statin therapy) vs. placebo in terms of overall mortality, cardiovascular events, cerebrovascular events, and adverse effects.

This Cochrane review included 23 randomized controlled trials (published between 1968 and 2015) involving 39,195 participants.1 The authors looked for studies including patients who were considered at risk of CVD as well as those with known CVD. The primary outcome examined was overall mortality, as discussed in 12 high-quality studies. Niacin did not appear to lower overall mortality. Concurrent statin use, comorbidities, and duration of niacin treatment did not change the impact on the primary outcome. Niacin also had no apparent impact on the secondary outcomes of myocardial infarctions, strokes, or need for revascularization procedures.

Niacin did appear to increase the risk of several adverse effects, including flushing (relative risk [RR] = 7.69; 95% confidence interval [CI], 4.14 to 14.28; number needed to harm [NNH] = 3.5), pruritus (RR = 5.26; 95% CI, 2.68 to 10.32; NNH = 4.8), rash (RR = 3.15; 95% CI, 1.94 to 5.13; NNH = 77), and gastrointestinal symptoms (RR = 1.69; 95% CI, 1.37 to 2.07; NNH = 125). Niacin users were at risk of discontinuing the medication because of these adverse effects (RR = 2.17; 95% CI, 1.70 to 2.77; NNH = 8 [95% CI, 5 to 14]). Alarmingly, there was also an apparent increased risk of developing diabetes mellitus in patients who used niacin (RR = 1.32; 95% CI, 1.16 to 1.51; NNH = 143).

Although current guidelines mention that niacin is used to potentially lower the risk of CVD, it is only discussed insofar as to caution physicians regarding the adverse effects associated with its use.5 Based on this review, niacin should not be used for primary or secondary prevention of cardiovascular or cerebrovascular events.

Author disclosure: No relevant financial affiliations.

The practice recommendations in this activity are available at

The views expressed reflect the opinions of the authors alone and do not reflect the opinion of the Department of the Army, Air Force, Defense Health Agency, Department of Defense, or the U.S. government.

Editor's Note: The numbers needed to harm reported in this Cochrane for Clinicians were calculated by AFP medical editors based on raw data provided in the original Cochrane review.


show all references

1. Schandelmaier S, Briel M, Saccilotto R, et al. Niacin for primary and secondary prevention of cardiovascular events. Cochrane Database Syst Rev. 2017;(6):CD009744....

2. Kamanna VS, Kashyap ML. Mechanism of action of niacin. Am J Cardiol. 2008;101(8A):20B–26B.

3. Pekkanen J, Linn S, Heiss G, et al. Ten-year mortality from cardiovascular disease in relation to cholesterol level among men with and without preexisting cardiovascular disease. N Engl J Med. 1990;322(24):1700–1707.

4. The Coronary Drug Project Research Group. Clofibrate and niacin in coronary heart disease. JAMA. 1975;231(4):360–381.

5. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published corrections appear in J Am Coll Cardiol. 2015; 66(24):2812 and J Am Coll Cardiol 2014;63(25 pt B):3024–3025]. J Am Coll Cardiol. . 2014;63(25 pt B):2889–2934.

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, Assistant Medical Editor.

A collection of Cochrane for Clinicians published in AFP is available at



Copyright © 2018 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

More in Pubmed


Jan 2022

Access the latest issue of American Family Physician

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article