How Long Does Niacin Flush Last

In a previous articles I covered the tremendous health benefits of niacin supplementation, mediated via both lipid (cholesterol and claret fat) and non-lipid mechanisms, and what y'all demand to know nearly niacin products:

Here I volition explain what the notorious niacin affluent is all about, and give you easily-on practical tips on how to beat it.

Niacin flush – what'south the fuss about?

Despite niacin'south tremendous health benefits, the infamous flushing has been a major impediment to the clinical employ of niacin, and is the main reason for discontinuation of niacin supplementation.[1-iii] Most people who get-go taking a niacin supplement volition initially experience the flushing.[1-four] The niacin affluent is not unsafe, just can be uncomfortable. The flush manifests equally a "prickly heat" or a sense of warmth in the confront, neck, ears, trunk, and, less often arms and legs.[5] This is often accompanied by itching, tingling and a reddening of the skin, usually in patches (known as erythema).

Symptoms typically get-go 15-30 minutes after ingesting immediate-release niacin on empty stomach, and 30-120 minutes afterwards ingesting extended-release niacin. Due to inconsistencies in time-release niacin products, their onset of flush occurs at more unpredictable and variable times.[two, iii] The exception is wax-matrix niacin, which is the most reliable time-release conception.

The flush usually lasts for less than 1 hour to two.5 hours.[ii, iii] For somebody who has never taken a niacin supplement before, as niggling as 50 mg can result in the characteristic flush.[5] This is why doses should exist escalated progressively. Taking an effective dose of 1000 mg (1g) the first time will crusade very intense flush reaction over the whole body.[5]

The niacin flush is caused past the release of prostaglandin D2 (and possibly other eicosanoids) from cells in the skin.[6] Information technology was recently demonstrated that niacin also activates the capsaicin receptor - which also mediates the heat sensation caused past consumption of spicy food - and that this activation of the capsaicin receptor contributes to the niacin flush.[7, 8]

Importance of informing people near the flush and how to bargain with it

Flushing symptom severity is a strong predictor of niacin discontinuation.[9] One study reported that 27% of niacin users stopped taking niacin afterward four months, and those were the ones who were most bothered by the flush.[ix] In contrast, discontinuation rates due to flushing in niacin studies are as low equally v%.[10] A study that specifically evaluate niacin compliance in a "existent-world" primary care setting reported discontinuation due to flushing to exist 10%.[11]

A shared characteristic amid niacin studies reporting low discontinuation rates is the patient education procedures employed prior to study initiation.[10] This suggests that patient instruction may be a critical factor in niacin supplementation adherence. Back up for this comes from a survey of patients in routine clinical practice who were prescribed niacin and reported a high rate of discontinuation; less than half of niacin users reported being advised by their doctor to accept aspirin to avoid flushing.[ix] This underscores the importance of informing people nearly ways to mitigate the flush.

How to crush the affluent?

The onset and intensity of the affluent is directly related to the niacin absorption rate and the consequent rate of peak of blood niacin levels; one time a abiding claret niacin level is reached the flush starts to abate.[12] Therefore, fast niacin absorption, as seen with immediate-release niacin, causes a greater initial flush intensity than does extended-release niacin, which is absorbed slower.[13-xv] Nonetheless, fifty-fifty extended-release niacin may initially causes a flush reaction. The good news is that there are several means to reduce the initial intensity of the flush:

Gradually increment daily niacin doses in a "start depression go slow" mode and dissever the daily dose

Immediate-release niacin should be administered in divided doses, later on meals, and doses should be gradually increased.[xvi] A dose-escalation guideline is to first taking fifty-100 mg twice daily for the first

calendar week, then double the daily dose each week until the target dose is reached, ideally 1.5 to 3 chiliad per day.[17] 750 mg taken 2-three times per day for a total daily dose of i,500 to 2,250 mg seems to work well for well-nigh people.

If you lot are using time-release niacin – make certain information technology is was-matrix niacin. I explained why you should chose the was-matrix version of time-release niacin in a previous article "Niacin Supplements - what y'all need to know near niacin products". Showtime taking 250 mg 3 times per day, and build up the dose to 750 mg 2-3 times per day. Always take information technology after meals.

Extended-release niacin is recommended to be taken at bedtime, later the final daily meal.[eighteen, nineteen] The prescribing information for extended-release niacin (known every bit Niaspan) suggests a starting dose of 500 mg for iv weeks, which is increased in 500-mg increments every 4 weeks to i g (two 500-mg tablets) during weeks v to 8, 1.five one thousand (ii 750-mg tablets) during weeks nine to 12, and 2 g (2 1-g tablets) for the final 4 weeks.[20]

Accept aspirin thirty min before taking niacin

Several studies shows that aspirin attenuates niacin flushing.[21-27] one study found that 325 mg of aspirin significantly attenuated flushing symptoms when administered 30 to 60 min, but not 15 or 120 min, earlier ingestion of 500 mg immediate-release niacin.[21] Notably, a higher aspirin dose of 650 mg was non improve than 325 mg.[21] Even so, 325 mg of aspirin is superior to 80 mg in mitigating flushing with 500 mg of immediate-release niacin.[22] 325 mg of aspirin xxx min earlier niacin ingestion is besides significantly superior to 200 mg of ibuprofen in blunting flushing and itching.[23] Taking 325 mg of aspirin 30 min before extended-release niacin (500 to 2000 mg) is also effective, and improves niacin adherence.[25] For greatest reduction in flush intensity, take aspiring earlier meals and niacin after meals.

Take niacin after meals

Take firsthand-release niacin after meals, especially a high-fat meal, every bit that will irksome down its absorption and thus reduce the flush intensity.

Prescription extended-released niacin (Niaspan), which is ingested once daily, should be taken after the last daily meal.

If y'all take any time-release niacin that is non wax-matrix – such as Slo-Niacin or Niaspan - is it all-time to take if some xl min after meals. The reason is that the release mechanism of Slo-Niacin is degraded by peristaltic activity in the gut. Waiting a petty bit after a meal volition let the gut settle and allow for the fourth dimension-release circuitous to work as it is supped to.

Develop tolerance to the flush

Most people don't know that continued niacin supplementation leads to development of tolerance to the flush.[28] This means that the intensity of the flush decreases or even completely vanishes with time, often within the first week or two, as long equally niacin is taken regularly on a daily basis.[18, nineteen, 28, 29] Knowing this is critical, as most discontinuations take place during the outset calendar week of niacin supplementation, before tolerance has adult.[29]

Flush tolerance is due in office to smaller increases of prostaglandin D2 production after long-term regular niacin ingestion.[28] However, if niacin supplementation is interrupted, one has to start from scratch and re-develop tolerance, equally tolerance only exists every bit long niacin is taken. Hence, with niacin supplementation 1 has to stick to it!

Niacin sensitivity

Several studies have shown that many of the people who appear to be intolerant of niacin, primarily because of the affluent, are often merely more sensitive to niacin and practise well on a reduced dose.[30-32] It appears likely that much of what has been presumed to exist niacin intolerance may simply be overdosing of niacin in sensitive individuals.[32]

The possibility that some people may have higher niacin sensitivity was demonstrated in an 11 month study with a dose reduction protocol, where niacin sensitive subjects who completed the study on less than 1000 mg/solar day actually had comparable lipid results to subjects on the full dose of 2000 mg/d.[xxx] Another study institute that taking 435 mg immediate-release niacin per 24-hour interval for ane year elevates HDL levels by 20% while reducing triglyceride levels by ix%.[33] I study showed that an fifty-fifty lower dose of niacin (50 mg twice daily) increased HDL past half-dozen% in statin treated patients.[34]

Thus, if yous cannot tolerate a full dose of immediate-release niacin or time-release niacin, don't fret. You lot may withal derive substantial health benefits with a lower dose.

BOX: Practical advice on how to take niacin supplements

With immediate-release niacin, get-go taking 100 mg twice daily for the first week, then double the daily dose each week until the target dose is reached, ideally 1500 to 3000 mg per day.

With time-release niacin – ideally wax-matrix niacin – first taking 250 mg three times per twenty-four hour period, and build up the dose to 750 mg ii-3 times per twenty-four hours.

Spread out intake over the twenty-four hour period and take some 40 min subsequently meals to dampen the niacin flush.

If the flush makes you uncomfortable, taking 325 mg aspirin about thirty minutes prior to niacin reduces the flushing intensity. Try taking the aspiring before meals, and then the niacin afterwards meals.

Stick to it! With regular daily niacin supplementation, tolerance develops to the affluent. Over time, the flush sensation can disappear completely in people who diligently continue taking niacin every day.

Summary

Niacin – a.ka. vitamin B3 - is a unique broad spectrum cholesterol "drug". The reason information technology has non been getting the attention it deserves in the medical community and amid health conscious people, is the flush.

While the niacin affluent may be uncomfortable, information technology is not unsafe; it is a natural reaction to high-dose niacin. Every bit outlined here, there are several simple ways to mitigate this flush. This will help you lot stick with the niacin supplementation and develop tolerance to the flush, and ultimately reap its wide array of health benefits.

References:

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2. Guyton, J.R. and P.D. Simmons, Flushing and other dermatologic adverse events associated with extended-release niacin therapy. J Clin Lipidol, 2009. 3(2): p. 101-8.

3. Davidson, One thousand.H., Niacin use and cutaneous flushing: mechanisms and strategies for prevention. Am J Cardiol, 2008. 101(8A): p. 14B-19B.

four. Kamanna, V.S., Due south.H. Ganji, and G.L. Kashyap, The mechanism and mitigation of niacin-induced flushing. Int J Clin Pract, 2009. 63(9): p. 1369-77.

5. Carlson, L.A., Nicotinic acrid: the broad-spectrum lipid drug. A 50th anniversary review. J Intern Med, 2005. 258(2): p. 94-114.

6. Morrow, J.D., et al., Identification of peel as a major site of prostaglandin D2 release post-obit oral administration of niacin in humans. J Invest Dermatol, 1992. 98(5): p. 812-five.

7. Clifton, H.L., et al., TRPV1 channels are involved in niacin-induced cutaneous vasodilation in mice. J Cardiovasc Pharmacol, 2015. 65(ii): p. 184-91.

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12. Svedmyr, N., L. Harthon, and L. Lundholm, The relationship betwixt the plasma concentration of free nicotinic acid and some of its pharmacologic furnishings in man. Clin Pharmacol Ther, 1969. 10(iv): p. 559-70.

thirteen. Pieper, J.A., Agreement niacin formulations. Am J Manag Intendance, 2002. 8(12 Suppl): p. S308-fourteen.

14. Piepho, R.W., The pharmacokinetics and pharmacodynamics of agents proven to heighten high-density lipoprotein cholesterol. Am J Cardiol, 2000. 86(12A): p. 35L-40L.

15. McKenney, J., New perspectives on the use of niacin in the treatment of lipid disorders. Arch Intern Med, 2004. 164(7): p. 697-705.

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17. ASHP Therapeutic Position Argument on the safe employ of niacin in the management of dyslipidemias. American Club of Health-System Pharmacists. Am J Health Syst Pharm, 1997. 54(24): p. 2815-9.

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19. Guyton, J.R., et al., Effectiveness of once-nightly dosing of extended-release niacin alone and in combination for hypercholesterolemia. Am J Cardiol, 1998. 82(6): p. 737-43.

20. Abbott Laboratories NIASPAN™ (niacin extended-release tablets) US prescribing information. Available at: http://www.niaspan.com2005.

21. Jungnickel, P.W., et al., Effect of two aspirin pretreatment regimens on niacin-induced cutaneous reactions. J Gen Intern Med, 1997. 12(ten): p. 591-6.

22. Whelan, A.Grand., et al., The outcome of aspirin on niacin-induced cutaneous reactions. J Fam Pract, 1992. 34(2): p. 165-8.

23. Dunn, R.T., et al., Depression-Dose Aspirin and Ibuprofen Reduce the Cutaneous Reactions Following Niacin Administration. Am J Ther, 1995. ii(7): p. 478-480.

24. Cefali, E.A., et al., Aspirin reduces cutaneous flushing afterwards administration of an optimized extended-release niacin formulation. Int J Clin Pharmacol Ther, 2007. 45(2): p. 78-88.

25. Thakkar, R.B., et al., Acetylsalicylic acid reduces niacin extended-release-induced flushing in patients with dyslipidemia. Am J Cardiovasc Drugs, 2009. 9(ii): p. 69-79.

26. Alves, J.D., et al., Influence of the timing of depression-dose aspirin on tolerability of prolonged-release nicotinic acrid in patients at elevated cardiovascular risk. Curr Med Res Opin, 2008. 24(10): p. 2815-20.

27. Oberwittler, H. and Grand. Baccara-Dinet, Clinical evidence for use of acetyl salicylic acrid in control of flushing related to nicotinic acid handling. Int J Clin Pract, 2006. threescore(6): p. 707-fifteen.

28. Stern, R.H., et al., Tolerance to nicotinic acid flushing. Clin Pharmacol Ther, 1991. l(1): p. 66-70.

29. Paolini, J.F., et al., Measuring flushing symptoms with extended-release niacin using the flushing symptom questionnaire: results from a randomised placebo-controlled clinical trial. Int J Clin Pract, 2008. 62(6): p. 896-904.

30. Alderman, J.D., et al., Effect of a modified, well-tolerated niacin regimen on serum total cholesterol, loftier density lipoprotein cholesterol and the cholesterol to high density lipoprotein ratio. Am J Cardiol, 1989. 64(12): p. 725-ix.

31. Keenan, J.M., et al., Niacin revisited. A randomized, controlled trial of wax-matrix sustained-release niacin in hypercholesterolemia. Arch Intern Med, 1991. 151(seven): p. 1424-32.

32. Keenan, J.G., Wax-matrix extended-release niacin vs inositol hexanicotinate: a comparison of wax-matrix, extended-release niacin to inositol hexanicotinate "no-affluent" niacin in persons with mild to moderate dyslipidemia. J Clin Lipidol, 2013. 7(1): p. 14-23.

33. Luria, M.H. and D. Sapoznikov, Raising HDL cholesterol with low-dose nicotinic acid and bezafibrate: preliminary experience. Postgrad Med J, 1993. 69(810): p. 296-9.

34. Wink, J., G. Giacoppe, and J. Male monarch, Effect of very-depression-dose niacin on high-density lipoprotein in patients undergoing long-term statin therapy. Am Heart J, 2002. 143(3): p. 514-8.