Niacin (Nicotinic Acid)

What it does

Niacin is vitamin B3 as nicotinic acid. At nutritional doses it is unremarkable; at gram doses it becomes a potent lipid drug that raises HDL, lowers triglycerides and LDL, and reduces lipoprotein(a). That drug career, and its ending, is this record.

What the research says

• Moves every lipid number in the 'right' direction at drug doses, powerfully

  Evidence: strong. At 1 to 3 g/day, nicotinic acid lowers triglycerides 20 to 40 percent, raises HDL 15 to 35 percent, lowers LDL, and is one of the few agents that lowers lipoprotein(a), by roughly 20 to 30 percent. On biomarkers, niacin is among the most effective oral lipid drugs ever sold. What follows is why that is not the grade.

• The outcome trials in the statin era found no benefit and net harm

  Evidence: strong. AIM-HIGH (2011) stopped early for futility. HPS2-THRIVE (2014) randomized 25,673 high-risk patients to extended-release niacin plus laropiprant or placebo for about four years: no reduction in major vascular events, and significantly MORE serious adverse events, including infections, bleeding, gastrointestinal and skin problems, new diabetes (about 1.3 percent absolute excess), and worsened diabetic control. In 2016 the FDA withdrew approval for niacin combinations used with statins. The pre-statin Coronary Drug Project (1975) had shown benefit, which is why this record is a story about context, not fraud: niacin worked before statins existed to do its job better.

Niacin is this library's fullest demonstration that biomarkers are not outcomes. Its surrogate effects are strong and real; its two modern outcome mega-trials are null and harmful; its historical benefit belongs to a pre-statin world. What remains is a narrow, specialist-supervised role in selected lipid cases and a standing lesson. C- for genuine pharmacology whose modern clinical verdict has been delivered.

Is it worth it?

Evidence (C-) sits below the leaderboard floor, so the worth-it grade is capped at C+ however inexpensive it is; the derived value lands at C-. About $8 a month at lipid doses. Derived from the October 2026 worth-it model.

Changelog

Last updated 2026-10-23

• 2026-10-23|Graded from the lipid pharmacology and the AIM-HIGH and HPS2-THRIVE outcome trials. This is nicotinic acid, the flushing, lipid-active form of vitamin B3. It is a different compound from niacinamide (nicotinamide), which this library grades separately and which shares neither the lipid effects nor the flush; the two are conflated constantly in the market and are kept apart here.
• 2026-10-23|Not listed under heart: the graded findings are lipid-surrogate effects whose outcome trials are null with net harm, and goal tags follow outcome-grade findings.