What is the interaction between Nicotinamide (Niacinamide) and statin (HMG-CoA reductase inhibitor) medications?

From the Guidelines

Nicotinamide and statin medications can be taken together, but patients should consult their healthcare provider before combining them, as the combination may carry an increased risk of myositis, particularly when using gemfibrozil or fenofibrate with statins 1.

Key Considerations

• The primary concern with this combination is the potential for additive side effects, particularly myopathy (muscle pain or weakness) 1.
• Patients should report any unusual muscle pain, weakness, or brown-colored urine to their doctor immediately.
• Statins work by inhibiting HMG-CoA reductase to reduce cholesterol production, while nicotinamide can help improve lipid profiles through different mechanisms.
• Regular liver function tests and monitoring of creatine kinase levels may be recommended when taking these medications together.
• Patients with pre-existing liver or kidney disease should be particularly cautious with this combination.

Medication Details

• Common statins include atorvastatin (Lipitor), rosuvastatin (Crestor), and simvastatin (Zocor), which are typically taken once daily at doses ranging from 5-80mg depending on the specific medication and patient needs 1.
• Nicotinamide is often taken at doses of 500-1000mg daily when used as a supplement.
• The combination of statins with nicotinic acid and especially with gemfibrozil or fenofibrate may carry an increased risk of myositis, although the risk of clinical myositis appears to be low 1.

Patient Monitoring

• Patients should be monitored closely for signs of myopathy, such as muscle pain or weakness, and liver function tests should be performed regularly.
• Creatine kinase levels should also be monitored, particularly when using the combination of statins with nicotinic acid or fibrates.
• Patients with diabetes should be cautious when using nicotinic acid, as it may worsen hyperglycemia, and glucose levels should be monitored frequently 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Statin-Related Myopathies

• Statin-induced myalgia is relatively common but often mild and does not limit treatment for most people 2
• Statin-induced rhabdomyolysis affects only a tiny proportion of statin users, but is an important clinical problem due to widespread prescribing of statins 2
• Statin-induced immune-mediated necrotising myopathy represents a novel disease mechanism and clinically mimics forms of myositis, requiring immunosuppressant drug treatment and statin withdrawal 2

Mechanism of Muscle Injury

• The mechanism of muscle injury combines statin accumulation within muscles, muscle fragility, abnormalities in statin transport or liver metabolism, drug-drug interactions, and genetic susceptibility 3
• HMG-CoA reductase inhibition in muscles by statins exerts pleiotropic effects, affecting energy metabolism, inducing mitochondrial dysfunction, modifying lipid oxidation, promoting apoptosis and cell membrane lysis, altering muscle protein synthesis, or triggering an autoimmune process 3

Comparison of Statins

• Rosuvastatin is associated with mild myotoxic effects in rats, especially when compared to atorvastatin 4
• Rosuvastatin-induced myopathy has been reported in case series, with patients developing bilateral lower limb pain and weakness after starting the medication 5

Safety Profile in Older Adults

• There is no evidence to suggest an increased risk of myopathy in older adults receiving statin therapy 6
• Statins are relatively safe, even in older people, with no increased risk of rhabdomyolysis or mortality due to muscle-related events 6
• Discontinuations due to adverse effects were reduced in the treatment group compared to placebo 6

Nicotinamide and Statin Medications

• There is no direct evidence in the provided studies regarding the interaction between nicotinamide and statin medications.