It’s striking how niacin’s reputation has swung from darling to dubious in the lipid world. I agree that the lack of outcome benefits in the statin era really put the brakes on its broad use, but I wouldn’t throw it out entirely. For folks who genuinely can’t tolerate statins, or for distinct phenotypes-like elevated Lp(a) or familial combined hyperlipidemia-it still might be worth a careful look, especially when triglycerides are truly out of control and other agents aren’t accessible or tolerated.
But honestly, if we’re being skeptical, the risk-benefit balance is tilting the wrong way for most people. Titrating slowly and regular liver and glucose monitoring are a must, and I’ve seen more than a few cases of consistent elevated liver enzymes and significant insulin resistance. The claims about niacin for detoxes or mental health are based mostly on shaky ground-a lot more marketing than medicine.
If I had to pin down a “niche” alternative use, maybe some refractory lipid cases or specific psychiatric protocols supervised by someone experienced, but for most, we’re better focusing on lifestyle, proven therapies, and, frankly, not chasing numbers just because we can.