From Wikipedia, the free encyclopedia
Niacin, also known as
nicotinic acid, is an
organic compound and a form of
vitamin B3, an
essential human nutrient. It has the
formula C
6H
5NO
2 and belongs to the group of the
pyridinecarboxylic acid.
Niacin is obtained in the diet from a variety of
whole and
processed foods, with highest contents in
fortified packaged foods, tuna, some vegetable and other animal sources. Some countries require its addition to
grains. Medication and
supplemental niacin are primarily used to treat
high blood cholesterol and
pellagra
(niacin deficiency). Insufficient niacin in the diet can cause nausea,
skin and mouth lesions, anemia, headaches, and tiredness. The lack of
niacin may also be observed in
pandemic deficiency diseases, which are caused by a lack of five crucial vitamins (niacin,
vitamin C,
thiamin,
vitamin D, and
vitamin A) and are usually found in areas of widespread poverty and malnutrition.
This colorless, water-soluble solid is a derivative of
pyridine, with a
carboxyl group (COOH) at the 3-position. Other forms of vitamin B
3 include the corresponding
amide nicotinamide (niacinamide), where the carboxyl group has been replaced by a
carboxamide group (
CONH
2), as well as more complex amides and a variety of
esters.
Niacin and nicotinamide are both
precursors of the
coenzymes nicotinamide adenine dinucleotide (NAD) and
nicotinamide adenine dinucleotide phosphate (NADP)
in vivo. NAD converts to NADP by phosphorylation in the presence of the enzyme
NAD+ kinase. NADP and NAD are coenzymes for many
dehydrogenases, participating in many hydrogen transfer processes.
NAD is important in catabolism of fat, carbohydrate, protein, and
alcohol, as well as cell signaling and DNA repair, and NADP mostly in
anabolism reactions such as fatty acid and cholesterol synthesis. High energy requirements (brain) or high turnover rate (gut, skin) organs are usually the most susceptible to their deficiency.
Niacin supplementation has not been found useful for decreasing the risk of
cardiovascular disease in those already on a
statin, but appears to be effective in those not taking a statin.
Although niacin and nicotinamide are identical in their vitamin
activity, nicotinamide does not have the same pharmacological effects (
lipid-modifying effects) as niacin. Nicotinamide does not reduce cholesterol or cause
flushing. As the
precursor for NAD and NADP, niacin is also involved in DNA repair.
Medical uses
Treatment of deficiency
Niacin and niacinamide are used for prevention and treatment of
pellagra.
Abnormal lipids
Niacin has sometimes been used in addition to other
lipid-lowering medications. Systematic reviews found no effect of niacin on
cardiovascular disease or death, in spite of raising
HDL cholesterol, and reported side effects including an increased risk of
diabetes.
Contraindications
Niacin is
contraindicated with active
liver disease, persistent elevated serum
transaminases, active
peptic ulcer disease, or
arterial bleeding.
Side effects
The
most common adverse effects are flushing (e.g., warmth, redness,
itching or tingling), headache, pain, abdominal pain, diarrhea,
dyspepsia, nausea, vomiting,
rhinitis,
pruritus
and rash. These can be minimized by initiating therapy at low dosages,
increasing dosage gradually, and avoiding administration on an empty
stomach. High doses of niacin often temporarily reduce blood pressure as a result of acute
vasodilation. In the longer term, high-dose niacin use may persistently lower blood pressure in individuals with
hypertension, but more research is needed to determine the extent of this effect.
Facial flushing
Flushing
usually lasts for about 15 to 30 minutes, though it can sometimes last
up to two hours. It is sometimes accompanied by a prickly or
itching sensation, in particular, in areas covered by clothing. Flushing can be blocked by taking 300 mg of
aspirin half an hour before taking niacin, by taking one tablet of
ibuprofen per day or by co-administering the
prostaglandin receptor antagonist laropiprant.
Taking niacin with meals also helps reduce this side effect. Acquired
tolerance will also help reduce flushing; after several weeks of a
consistent dose, most patients no longer experience flushing. Reduction of flushing focuses on altering or blocking the prostaglandin-mediated pathway. Slow- or "sustained"-release forms of niacin have been developed to lessen these side effects. One study showed the incidence of flushing was significantly lower with a
sustained-release formulation, though doses above 2 g per day have been associated with
liver damage, in particular, with slow-release formulations.
Prostaglandin (
PGD2) is the primary cause of the flushing reaction, with
serotonin appearing to have a secondary role in this reaction. The effect is mediated by prostaglandin E2 and D2 due to GPR109A activation of epidermal
Langerhans cells and keratinocytes.
Langerhans cells use cyclooxygenase type 1 (COX-1) for PGE2 production
and are more responsible for acute flushing, while keratinocytes are
COX-2 dependent and are in active continued vasodilation. Flushing was often thought to involve histamine, but histamine has been shown not to be involved in the reaction.
Gastrointestinal and hepatic
Gastrointestinal complaints, such as
indigestion, nausea and
liver failure, have also been reported.
Hepatotoxicity is possibly related to metabolism via amidation resulting in NAD production. The
time-release form has a lower
therapeutic index for lowering serum lipids relative to this form of toxicity.
Diabetes
The high doses of niacin used to improve the lipid profile have been shown to elevate
blood sugar by 5-10%, thereby worsening existing
diabetes mellitus.
In a meta-analysis of 11 trials with non-diabetic participants, niacin
therapy increased the relative risk of new-onset diabetes by 34%.
Other
Side effects of
heart arrhythmias have also been reported. Increased
prothrombin time
and decreased platelet count have been reported; therefore, these
should be monitored closely in patients who are also taking
anticoagulants.
Particularly the
time-release variety, at extremely high doses, can cause
acute toxic reactions. Extremely high doses of niacin can also cause niacin
maculopathy, a thickening of the
macula and
retina, which leads to blurred vision and blindness. This maculopathy is reversible after niacin intake ceases.
Pregnancy
Niacin in doses used to lower cholesterol levels has been associated with
birth defects in laboratory animals, with possible consequences for infant development in
pregnant women.
Deficiency
A man with
pellagra, which is caused by a chronic lack of vitamin B
3 in the diet
Between 1906 and 1940 more than 3 million Americans were affected by pellagra, with more than 100,000 deaths.
Joseph Goldberger
was assigned to study pellagra by the Surgeon General of the United
States and produced good results. In the late 1930s, studies by
Tom Spies,
Marion Blankenhorn, and Clark Cooper established that niacin cured
pellagra in humans. The disease was greatly reduced as a result.
At present, niacin deficiency is sometimes seen in developed
countries, and it is usually apparent in conditions of poverty,
malnutrition, and chronic alcoholism. It also tends to occur in less developed areas where people eat
maize (corn) as a staple food, as maize is the only grain low in digestible niacin. A cooking technique called
nixtamalization
i.e., pretreating with alkali ingredients, increases the
bioavailability of niacin during maize meal/flour production. For this
reason, people who consume corn as tortillas or
hominy are not at risk of niacin deficiency.
Mild niacin deficiency has been shown to slow metabolism, causing decreased tolerance to cold.
Severe deficiency of niacin in the diet causes the disease
pellagra, which is characterized by diarrhea, dermatitis, and dementia, as well as
Casal's necklace
lesions on the lower neck, hyperpigmentation, thickening of the skin,
inflammation of the mouth and tongue, digestive disturbances, amnesia,
delirium, and eventually death, if left untreated.
Common psychiatric symptoms of niacin deficiency include irritability,
poor concentration, anxiety, fatigue, restlessness, apathy, and
depression.
Studies have indicated that, in patients with alcoholic pellagra,
niacin deficiency may be an important factor influencing both the onset
and severity of this condition. Patients with alcoholism typically
experience increased
intestinal permeability, leading to negative health outcomes.
Hartnup disease is a
hereditary nutritional disorder resulting in niacin deficiency.
This condition was first identified in the 1950s by the Hartnup family
in London. It is due to a deficit in the intestines and kidneys,
making it difficult for the body to break down and absorb dietary
tryptophan
(an essential amino acid that is utilized to synthesize niacin). The
resulting condition is similar to pellagra, including symptoms of red,
scaly rash, and sensitivity to sunlight. Oral niacin is given as a
treatment for this condition in doses ranging from 40–200 mg, with a
good prognosis if identified and treated early. Niacin synthesis is also deficient in
carcinoid syndrome, because of metabolic diversion of its
precursor tryptophan to form
serotonin.
Dietary recommendations
The U.S.
National Academy of Medicine
(then the Institute of Medicine [IOM]) updated Estimated Average
Requirements (EARs) and Recommended Dietary Allowances (RDAs) for B
vitamins in 1998.
The
European Food Safety Authority
(EFSA) refers to the collective set of information as Dietary Reference
Values (DRV), with Population Reference Intake (PRI) instead of RDA,
and Average Requirement instead of EAR. AI and UL defined the same as in
United States. For women (including those pregnant or lactating), men
and children the PRI is 1.6 mg niacin per megajoule (MJ) of energy
consumed. As the conversion is 1 MJ = 238.8 kcal, an adult consuming
2388 calories should be consuming 16 mg niacin. This is comparable to
U.S. RDAs.
The niacin UL is set at 10 mg/day, which is much less than the U.S.
value. The UL applies to niacin as a supplement consumed as one dose,
and in intended to avoid the skin flush reaction. This explains why the
PRI can be higher than the UL.
Both the DRI and DRV describe amounts needed as niacin
equivalents (NE), calculated as 1 mg NE = 1 mg niacin or 60 mg of the
essential amino acid tryptophan. This is because the amino acid is
utilized to synthesize the vitamin.
For U.S. food and dietary supplement labeling purposes the amount in a serving is expressed as a percent of
Daily Value
(%DV). For niacin labeling purposes 100% of the Daily Value was 20 mg,
but as of May 27, 2016 it was revised to 16 mg to bring it into
agreement with the RDA. A table of the old and new adult Daily Values is provided at
Reference Daily Intake.
The original deadline to be in compliance was July 28, 2018, but on
September 29, 2017 the FDA released a proposed rule that extended the
deadline to January 1, 2020 for large companies and January 1, 2021 for
small companies.
Food sources
Niacin is found in a variety of
whole and
processed foods, including
fortified packaged foods,
meat from various animal sources,
seafoods, and
spices.
Among whole food sources with the highest niacin content per 100 grams:
Meats
Plant foods and
spices
Fortified
breakfast cereals have among the highest niacin contents (more than 20 mg per 100 grams).
Whole grain flours, such as from wheat, rice, barley or corn, and
pasta have niacin contents in a range of 3–10 mg per 100 grams.
Pharmacology
Pharmacodynamics
The therapeutic effects of niacin are partly mediated through the activation of
G protein-coupled receptors, including
niacin receptor 1 (NIACR1) and
niacin receptor 2 (NIACR2) which are highly expressed in
adipose tissue,
spleen,
immune cells, and
keratinocytes, but not in other expected organs such as
liver,
kidney,
heart or
intestine. NIACR1 and NIACR2 inhibit
cyclic adenosine monophosphate (cAMP) production and thus fat breakdown in
adipose tissue and free
fatty acids available for liver to produce
triglycerides and
very-low-density lipoproteins (VLDL) and consequently
low-density lipoprotein (LDL). A decrease in free fatty acids also suppresses liver expression of
apolipoprotein C3 and
PPARg coactivator-1b, thus increasing VLDL turnover and reducing its production.
The mechanism behind niacin increasing HDL is not totally understood, but seems to occur in various ways. Niacin increases
apolipoprotein A1 levels due to
anticatabolic
effects resulting in higher reverse cholesterol transport. It also
inhibits HDL hepatic uptake, down-regulating production of the
cholesterol ester transfer protein (CETP) gene. Finally, it stimulates the
ABCA1 transporter in monocytes and macrophages and
upregulates peroxisome proliferator-activated receptor gamma, resulting in reverse cholesterol transport.
Niacin reduces secondary outcomes associated with
atherosclerosis,
such as low-density lipoprotein cholesterol (LDL), very low-density
lipoprotein cholesterol (VLDL-C), and triglycerides (TG), but increases
high-density lipoprotein cholesterol (HDL).
[48]
Despite the importance of other cardiovascular risk factors, high HDL
was associated with fewer cardiovascular events independent of LDL
reduction. Other effects include anti-
thrombotic and vascular inflammation, improving
endothelial function, and
plaque stability. As mediators produced from
adipocytes,
adipokines, such as
tumor necrosis factor (TNF)-a,
interleukins and
chemokines, have pro-inflammatory effects, while others, such as
adiponectin, have anti-inflammatory effects that influence the onset of atherosclerosis. Niacin also appears to upregulate
brain-derived neurotrophic factor and
tropomyosin receptor kinase B (TrkB) expression.
Research has been able to show the function of niacin in the
pathway lipid metabolism. It is seen that this vitamin can decrease the
synthesis of apoB-containing lipoproteins such as VLDL, LDL, IDL and
lipoprotein (a) via several mechanisms: (1) directly inhibiting the
action of DGAT2, a key enzyme for triglyceride synthesis; (2)
influencing binding to the receptor HCAR2 thereby decreasing lipolysis
and FFA flux to the liver for triglyceride synthesis; and (3) increasing
apoB catabolism. HDL cholesterol levels are increased by niacin through direct and indirect pathways, such as by decreasing
cholesterylester transfer protein activity and triglyceride levels, while increasing HDL cholesterol levels.
Pharmacokinetics
Biosynthesis
The
liver can synthesize niacin from the essential
amino acid tryptophan, requiring 60
mg of tryptophan to make 1
mg of niacin.
Riboflavin,
vitamin B6 and
iron are required for the process.
Physical and chemical properties
Laboratory synthesis
Several thousand tons of niacin are manufactured each year, starting from
3-methylpyridine.
Preparations
Niacin is available as a prescription product, and in the United States as a
dietary supplement. Prescription products can be immediate release (Niacor, 500 mg tablets) or
extended release
(Niaspan, 500 and 1000 mg tablets). Dietary supplement products can be
immediate or slow release, the latter including inositol hexanicotinate. The last has questionable clinical efficacy in reducing cholesterol levels.
Nicotinamide
Nicotinamide
may be obtained from the diet where it is present primarily as NAD+ and
NADP+. These are hydrolysed in the intestine and the resulting
nicotinamide is absorbed either as such, or following its hydrolysis to
nicotinic acid. Nicotinamide is present in nature in only small amounts,
however it is the main form of vitamin B3 in plasma. In unprepared
foods, niacin is present mainly in the form of the cellular pyridine
nucleotides NAD and NADP. Enzymatic hydrolysis of the co-enzymes can
occur during the course of food preparation. Boiling releases most of
the total niacin present in sweet corn as nicotinamide (up to 55 mg/kg).
Nicotinamide may be toxic to the liver at doses exceeding 3 g/day for adults.
Extended release
A prescription
extended release
niacin, Niaspan, has a film coating that delays release of the niacin,
resulting in an absorption over a period of 8–12 hours. The extended
release formulations generally reduce
vasodilation and
flushing side effects, but increase the risk of
hepatotoxicity compared to the immediate release forms.
A formulation of
laropiprant
(Merck & Co., Inc.) and niacin had previously been approved for use
in Europe and marketed as Tredaptive. Laropiprant is a prostaglandin D2
binding drug shown to reduce vasodilatation and flushing up to 73%. The HPS2-THRIVE study,
a study sponsored by Merck, showed no additional efficacy of
Tredaptive in lowering cholesterol when used together with other statin
drugs, but did show an increase in other side effects. The study
resulted in the complete withdrawal of Tredaptive from the international
market.
Inositol hexanicotinate
One form of dietary supplement is
inositol hexanicotinate (IHN), which is
inositol that has been
esterified with niacin on all six of inositol's alcohol groups.
IHN is usually sold as "flush-free" or "no-flush" niacin in units of
250, 500, or 1000 mg/tablets or capsules. It is sold as an
over-the-counter formulation, and often is marketed and labeled as
niacin, thus misleading consumers into thinking they are getting the
active form of the medication. While this form of niacin does not cause
the flushing associated with the immediate-release products, the
evidence that it has lipid-modifying functions is disputed. As the
clinical trials date from the early 1960s (Dorner, Welsh) or the late
1970s (Ziliotto, Kruse, Agusti), it is difficult to assess them by
today's standards.
One of the last of those studies affirmed the superiority of inositol
and xantinol esters of nicotinic acid for reducing serum free fatty
acid, but other studies conducted during the same period found no benefit. Studies explain that this is primarily because "flush-free"
preparations do not contain any free nicotinic acid. A more recent
placebo-controlled trial was small (n=11/group), but results after three
months at 1500 mg/day showed no trend for improvements in total
cholesterol, LDL-C, HDL-C or triglycerides. Thus, so far there is not enough evidence to recommend IHN to treat
dyslipidemia.
Rename
In 1942, when flour
enrichment
with nicotinic acid began, a headline in the popular press said
"Tobacco in Your Bread." So the Council on Foods and Nutrition of the
American Medical Association approved of the
Food and Nutrition Board's new names
niacin and
niacin amide for use primarily by non-scientists. It was thought appropriate to choose a name to dissociate it from
nicotine, to avoid the perception that vitamins or niacin-rich food contains nicotine, or that cigarettes contain vitamins. The resulting name
niacin was derived from
nicotinic acid +
vitamin.
History
Niacin was first described by chemist
Hugo Weidel in 1873 in his studies of
nicotine. The original preparation remains useful: the oxidation of
nicotine using
nitric acid. For the first time, niacin was extracted by
Casimir Funk, but he thought that it was
thiamine and due to the discovered
amine group he coined the term "vitamine". Niacin was extracted from livers by biochemist
Conrad Elvehjem
in 1937, who later identified the active ingredient, then referred to
as the "pellagra-preventing factor" and the "anti-blacktongue factor." Soon after, in studies conducted in Alabama and Cincinnati, Dr.
Tom Spies found that nicotinic acid cured the sufferers of pellagra.
Niacin is referred to as vitamin B
3 because it was the third of the
B vitamins
to be discovered. It has historically been referred to as "vitamin PP",
"vitamin P-P" and "PP-factor", that are derived from the term
"pellagra-preventive factor". Carpenter found in 1951 that niacin in corn is biologically unavailable, and can be released only in very alkaline
lime water of
pH 11. In 1955, Altschul and colleagues described niacin as having a lipid-lowering property. As such, niacin is the oldest lipid-lowering drug.
Research
In
animal models and
in vitro,
niacin produces marked anti-inflammatory effects in a variety of
tissues – including the brain, gastrointestinal tract, skin, and
vascular tissue – through the activation of
NIACR1. Niacin has been shown to attenuate
neuroinflammation and may have efficacy in treating
neuroimmune disorders such as
multiple sclerosis and
Parkinson's disease. Unlike niacin, nicotinamide does not activate NIACR1; however, both niacin and nicotinamide activate the
G protein-coupled estrogen receptor (GPER)
in vitro.
In 2014, concurring with earlier work in 2001 by
Arizona State University, researchers from
Pennsylvania State University working with
NASA found niacin, pyridine carboxylic acids and pyridine dicarboxylic acids inside
meteorites.