There are many encounters with my attending professors, from renowned internationally recognized researchers to an aging kindly small town doctor, that easily come to mind as medicine adds gray to my own hair. Dr. George Bosworth, a pediatrician in Rome, Georgia holds more than a few memories.
He was a skilled B-52 bomber pilot in Vietnam who left the war to pursue a career in medicine, specifically pediatrics, possibly to quiet the memories of dropping bombs and death on people he never knew. Later on he began teaching residents in training. Once he pummeled me with one of the worst professional chewing-outs I have ever had (well deserved as my talented colleague Paul Schriever and I were a bit unprepared for morning report) and then paid me one of the greatest compliments of my medical career less than a week later. He was an attending physician I always wanted to have the correct answer for.
He stormed into the Kid's Care Clinic we had one afternoon where I was working with a loud flourish, looking angrier and redder in the face than I could ever remember. We all knew he had heart disease and a temper, and that when he was really angry the one hair on top of his balding head would curl to the right.
He looked at me and said, "Why am I red?.......What PILL did I just take, Littleton?" and from the depths of a distant memory I answered "Niacin".
"Right," he said. "How'd you know that? I hate this drug, but I'm supposed to take it to increase my HDL."
That was nearly twenty years ago and I remember it every time I discuss or prescribe niacin, or the long acting Niaspan, for a patient. It is a ruggedly tough drug to take because of the side effects of "flushing", not to mention the long known concerns for the liver. I have told my male patients it is as close to menopause as they will ever get.
Well, I won't have to worry about that anymore.
Niacin, a vitamin, was given its pharmaceutical eulogy in the New England Journal of Medicine last week after showing no ability to reduce cardiovascular events (heart attacks), causing "toxicity" (their word, not mine) and the unfortunate ability to increase the risk of diabetes.
Niacin generated over one billion dollars in sales in 2013.
And, ironically, niacin did exactly what it was supposed to do: Increase the "good" cholesterol (HDL).
Increasing the HDL, without the nasty side effects of niacin, has been a long sought after goal of the pharmaceutical industry. From over 50 years of research in Framingham, Massachusetts, we have learned that people with high HDL levels have much less risk of heart attacks and strokes. So, the reasoning went, if niacin is known to increase HDLs, then we must use it to reduce cardiovascular disease.
The two studies cited in the New England Journal noted that niacin increased HDL levels, but made no significant reduction in cardiovascular events of stroke and heart attack.
It is sort of like seeing an NBA team with a lot of well paid, high scoring, big play stars and yet they can't win anymore games than a mediocre team.
It is rare to see a drug given such a stunning blow from a leading medical journal. Yet, even as we in the medical community focussed on treating the lab (the HDL), we failed to make a difference in the life. The commentaries have discussed this at length, mostly settling on one uniform point: emphasize a healthy lifestyle.
Treating a lab has a value in many instances, but so does controlling the treats. Wanting a lab number goal may be good, but so can setting a goal of numbers - numbers of minutes walking, exercising, or numbers of calories limited in the diet.
One remaining use of niacin may continue in New Orleans, though. Shared with me by someone who knows, a resident was utterly frustrated with a patient in the city hospital in New Orleans who was utterly convinced she was possessed by a demon (apparently this is a very common belief by some there) and said so on every office visit. The resident (name withheld) had the idea to give her a 500 mg tablet of niacin and told her to take it when she got home. He told her she would feel the demons coming out of her within two hours. It worked, and she remained a loyal patient convinced the demons had left her for good thereafter.
Niacin will rapidly fall from its pinnacle of notoriety as a prescribed medicine, or vitamin, recommended to reduce heart attacks, but its lessons will remain. There is something more to treating a patient that just treating a number on a lab. That all be a tough pill for some academics to swallow.
Eric J. Littleton, M.D. is a Family Physician in Sevierville, TN. His new office is located at 958 Dolly Parton Parkway. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician. Send questions to askdrlittleton@gmail.com.
