Niacin is currently a favored drug for increasing high-density lipoprotein, especially in patients with ischemic heart disease or at high risk of developing it. In addition, niacin further decreases low-density lipoprotein in statin-treated patients and has been shown to reduce morbidity and mortality. Among the available niacin preparations, crystalline, immediate-release niacin is the most effective for increasing high-density lipoprotein and is relatively free of hepatic toxicity. We present the case of a patient who had an excellent clinical and laboratory response to 3 g daily of immediate-release niacin, but who later developed clinical hepatitis when he inadvertently switched to the same dose of slow-release niacin. We encourage the use of niacin in general, immediate-release niacin in particular, and caution that niacin is a drug and not a dietary supplement. We also present practical steps for starting niacin, including close patient contact and support, and beginning with a therapeutic dose of 2 g per day right from the start.
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