This patient is exhibiting flushing and warmth due to administration of a non-statin lipid-lowering medication. This is a classic side effect of niacin (nicotinic acid). Aspirin is commonly given as a pretreatment to alleviate niacin-induced flushing.
This flushing is thought to be mediated by prostaglandin release. When aspirin is administered 30-60 minutes prior to niacin administration, its anti-prostaglandin effects can prevent or minimize niacin-induced flushing. Other techniques commonly used to decrease niacin side effects include eating food while taking the medication and administration of a controlled-release form of niacin (Niaspan).
Last et al. describe the approach to lipid-lowering in a patient who with previous myocardial infarction (MI). The first-line medication is a statin. The goal LDL cholesterol value is <100 mg/dL or, in some cases, <70 mg/dL. In patients in whom a sufficiently low LDL-C level cannot be achieved through the use of statins alone, an additional class of lipid-lowering medication is sometimes prescribed. Niacin lowers LDL-C and increases HDL-C by decreasing hepatic VLDL synthesis and secretion into circulation, and by decreasing lipolysis in peripheral adipose tissue. It increases HDL-C and decreases LDL-C substantially, and also decreases triglyceride levels somewhat.
Boden et al. showed that, despite its favorable effect on lipid profile, there is no evidence that niacin reduces cardiovascular events or mortality. In this large-scale randomized controlled trial, AIM-HIGH, the authors found no decrease in cardiovascular-induced death or major adverse cardiovascular events in patients with pre-existing cardiovascular disease treated with niacin, despite a markedly improved lipid profile (increased HDL-C, decreased LDL-C, and decreased triglycerides).
Illustration A illustrates the flushing side effect of niacin.
Answer 1: Diphenhydramine (Benadryl) is a first-generation histamine antagonist used for the treatment of non-life-threatening allergic reactions. However, niacin-induced flushing is not mediated by histamine, so diphenhydramine is not the best answer.
Answer 3: Coenzyme Q10 is sometimes prescribed to treat statin-induced muscle pain. It is not used to alleviate niacin-induced flushing.
Answer 4: Hydroxyzine is another first-generation histamine antagonist used to treat allergic reactions. It is not prescribed to prevent niacin-induced flushing.
Answer 5: Acetaminophen is an analgesic that is not used to alleviate niacin-induced flushing.
Last AR, Ference JD, Falleroni J. Pharmacologic treatment of hyperlipidemia. Am Fam Physician. 2011 Sep 1;84(5):551-8. Review.
PMID:21888306 (Link to Abstract)
1: AIM-HIGH Investigators, Boden WE, Probstfield JL, Anderson T, Chaitman BR, Desvignes-Nickens P, Koprowicz K, McBride R, Teo K, Weintraub W. Niacin in patients with low HDL cholesterol levels receiving intensive statin therapy. N Engl J Med. 2011 Dec 15;365(24):2255-67. doi: 10.1056/NEJMoa1107579. Epub 2011 Nov 15. Erratum in: N Engl J Med. 2012 Jul 12;367(2):189.
PMID:22085343 (Link to Abstract)
USMLE World Step 1 QBank Question #160. Copyright © USMLEWorld, LLC 2012