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Adding niacin to statins is 'better than ezetimibe'

By Mark Pownall

Adding extended-release niacin to a statin in patients with – or at risk of - coronary heart disease results in significantly fewer major cardiovascular events than adding ezetimibe, a new US study has found.

The study found that one per cent of those taking statins and niacin had a major event in the following 14 months compared to five per cent of those on ezetimibe.

A major event was defined as an MI, myocardial revascularisation, admission to hospital with an acute coronary syndrome or death from CHD.

The study also found that adding niacin boosted HDL levels by 19% and significantly reduced the thickness of the carotid intima-media, an established marker of atherosclerosis. Adding ezetimibe reduced LDL levels by 18%, but had virtually no effect on the intima-media thickness.

Lead researcher Dr Allen Taylor director of the lipid clinic at Washington Hospital Center in Washington DC said: ‘These findings for ezetimibe challenge the use of LDL reduction as a guaranteed surrogate for clinical performance.

‘They are counter to the prevailing understanding of LDL cholesterol – that lowering LDL cholesterol results in slowing of the atherosclerotic process as has been convincingly shown for other classes of lipid-modifying drugs such as statins and bile acid resins.'

But Dr Peter Kim, president of Merck Research Laboratories, defended the use of ezetimibe.

'The results of [the study] were widely predicted because the study design favoured niacin as the patient population selected had well-controlled LDL cholesterol and relatively low HDL cholesterol,' he said.

'Also, it is important to remember that [this] is not an outcomes study and does not have the rigour or size to provide meaningful insight into the effect of either niacin or ezetimibe on clinical outcomes. Both niacin and ezetimibe have established effects on lipids, as noted in the prescribing information for these medicines.'

N Engl J Med 2009; 361. Published online November 15

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