Add-on-Statin Extended Release Nicotinic Acid/Laropiprant but Not the Switch to High-Dose Rosuvastatin Lowers Blood Pressure: An Open-Label Randomized Study

Nicotinic acid/laropiprant reduces platelet count but increases mean platelet volume in patients with primary dyslipidemia

INTRODUCTION

Nicotinic acid (NA) has been associated with reduced cardiovascular morbidity and mortality. Of note, beyond its lipid-modifying actions, NA possesses a number of not yet thoroughly defined pleiotropic actions including anti-inflammatory and antithrombotic effects. As a growing body of evidence points towards mean platelet volume (MPV) and platelet distribution width (PDW) as independent risk factors for cardiovascular disease, it would be interesting to evaluate the effect of NA on these platelet indices.

MATERIAL AND METHODS

We recruited 50 consecutive patients with dyslipidemia who were treated with a conventional statin dose (10-40 mg simvastatin or 10-20 mg atorvastatin or 5-20 mg rosuvastatin) and had not achieved the low-density lipoprotein cholesterol (LDL-C) or non-high-density lipoprotein cholesterol (non-HDL-C) goal. Add-on-statin treatment with extended release (ER) NA/laropiprant (1,000/20 mg/day for the first 4 weeks followed by 2,000/40 mg/day for the next 8 weeks) was given to all patients for 3 months.

RESULTS

The ER-NA/laropiprant resulted in a 20% reduction in platelet count (from 277,150/µl (min: 163,000/µl - max: 223,400/µl) to 220,480/µl (min: 141,000/µl - max: 319,000/µl), p < 0.001), while it increased MPV by 3.5% (from 11.4 fl (min: 9.2 fl - max: 13.6 fl) to 11.8 fl (min: 9.5 fl - max: 14.1 fl), p = 0.01), without affecting PDW significantly (from 14.6 fl (min: 10.5 fl - max: 19.3 fl) to 14.5 fl (min: 11 fl - max: 21.1 fl), p = NS).

CONCLUSIONS

The NA is associated with reduced platelet count but with increased MPV, thereby raising questions regarding NA's antithrombotic and vasculoprotective properties.

Comparison of switch to the highest dose of rosuvastatin vs. add-on nicotinic acid vs. add-on fenofibrate for mixed dyslipidaemia

BACKGROUND

Use of a statin at a standard dose may be insufficient for the treatment of mixed dyslipidaemia. Whether switch to the highest dose of rosuvastatin (40 mg) or add-on nicotinic acid (NA) or fenofibrate is more efficacious remains unknown.

PATIENTS AND METHODS

This was a prospective, randomised, open-label, blinded end-point (PROBE) study. We recruited 100 patients with mixed dyslipidaemia who were treated with a statin at a standard dose but had not achieved lipid targets. Patients were randomised to switch to the highest approved dose of rosuvastatin (40 mg), add-on extended release nicotinic acid (ER-NA)/l-aropiprant (LRPT) or to add-on micronised fenofibrate for 3 months. The primary end-point was the change in non-high-density lipoprotein cholesterol (non-HDL-C) levels.

RESULTS

Ninety patients completed the study. Non-HDL-C decreased in all groups (by 23, 24 and 7% in the rosuvastatin, ER-NA/LRPT and fenofibrate group, respectively, p < 0.01 for all compared with baseline and p < 0.01 for all compared with fenofibrate group). Low-density lipoprotein cholesterol (LDL-C) decreased by 23 and 19% in the rosuvastatin and ER-NA/LRPT group, respectively (p < 0.01 compared with baseline), but not in the add-on fenofibrate group. Add-on ER-NA/LRPT was associated with the greatest HDL-C increase, while add-on ER-NA/LRPT and add-on fenofibrate were associated with the greatest triglyceride decrease. Twenty-four per cent of patients initially randomised to add-on ER-NA/LRPT dropped out because of side effects.

CONCLUSIONS

In conclusion, switch to the highest dose of rosuvastatin and add-on ER-NA/LRPT may be better options compared with add-on fenofibrate for the management of patients with mixed dyslipidaemia not on treatment goals with a statin at a standard dose.

Nicotinic acid: Do we know how it works after 55 years of clinical experience

Nicotinic acid (NA) comprises the oldest hypolipidemic drug, in use since 1955. Despite its established broad spectrum effect on lipid profile and the associated reduction in cardiovascular morbidity and mortality, the mechanisms by which NA achieves its beneficial effects remain elusive. Regarding the NA-associated reduction in triglyceride and low density lipoprotein cholesterol levels, data are controversial. The prevailing view which suggested that NA inhibits lipolysis and decreases free fatty acid (FFA) release both via activation of adipose tissue G-protein receptor-109A (GPR109A) and via inhibition of hepatic triglyceride synthesis is currently debated by the observation that the initially decreased FFA levels rebound during long-term NA treatment even though the beneficial NA effects on lipid metabolism are preserved, while other mechanisms involving modulation of transcription and translation pathways are emerging. In addition, NA has been demonstrated to affect high density lipoprotein (HDL) particles remodeling in a number of ways, including reducing cholesterol ester transfer protein levels and activity, increasing apolipoprotein A-I levels, eliminating HDL hepatic uptake, increasing cholesterol efflux via ATP-binding cassette A1, inhibiting hepatic lipase, thereby overall increasing the plasma residence time of HDL and apoA-I with retention of cholesterol esters in HDL. Focus of this article is to present the mechanisms by which NA exerts its broad spectrum hypolipidemic actions.