User talk:Midgley/DfL

Adrian, I have some nodding agreement from John on civility going forward, but I need your help in several areas.
 * 1. May I get a technical/clinical list and brief description of what areas you know, or think, you disagree with John as "complete bullocks", "unfounded speculation", "poorly founded", "well maybeeee..." as proposed categories as well as anything you think you both agree on (alt & med). Pls leave out the interpersonal parts alone for the moment.
 * 2. What background, reading or investigation have you had with naturopathic or orthomolecular literature, popular or original medical publications, more detail is better. (any article / book / experiment names?).
 * If you like we can take this over to my Talk page (to be cont'd)--66.58.130.26 11:08, 28 April 2006 (UTC)


 * Medicine. As far as the naturopathic or orthomolecular literature goes, there is only medicine which works, and medicine which doesn't.  Since the 17th century we have developed ways of dividing it up.  Midgley 17:31, 28 April 2006 (UTC)


 * Yes. "... and medicine which doesn't" So then the survivors, "patience(sic?)", wind up at the naturopaths and orthomeds in the US ;> . These questions persist in every generation of doctors, but the answers, er, medicines, er products, change ~17 yrs (the old US patent expiry), or more frequently, even if the survival rates may not.  And I can then safely assume that well over half of your hyper-, dyslipidema patients are cheaply using 0.75g - 6 grams per day of niacins, in combination or monotherapy, to cheaply drive their small dense LDL, Lp(a) (VERY bad LDL related fractions), apo(B), excess fibrinogen, and triglycerides through the floor, over 40%, and jack HDL2b 100+% (*very* good cholesterol fraction) rather than just the junk HDL, HDL3. Even though many "cholesterol" articles in the journals read like a detail man's wet dream, many patients in the U$ are, for over 40 yr, getting more additive benefit out of $2-$5/mo of plain old niacin and/or ~$9/mo generic intermediate release niacin than $100-$250/mo of the non-niacin containing "advanced" formulas and combos. Your *costs* may differ.  --66.58.130.26 23:13, 28 April 2006 (UTC)


 * Very much so. Niacin m/r is expensive and not very effective.  One of my pateints has been taking it for a while having found a couple of statins unsatisfactory.  I think you'd need an account to access the www.bbnf.org on line, but it may be in a library. 23:25, 28 April 2006 (UTC)


 * m/r? "...expensive and not very effective" Different world or you might review source and dosing protocols. Often niacin is underprescribed (favorite of comparison tests), at ~2g/day plain, vs 3g -6g/day for full effect or partially in combination with intermediate release forms for maximum effect.  If you have some kind of niacin tolerant or nician dependent personage, which according to Hoffer (niacin concepts originator) occurs more often with certain mental features, it's easy to spot and measure - they don't flush at reasonably high levels (say > 1 - 3g plain, instant release niacin in a first, single sitting), they do not respond as much upon treatment either. It may be more specific for the Lp(a) and sm, dense LDL variety - don't know. A lucky few will approach -50% LDL at ~3 g/d (plain + time release) as well as a big HDL spike upwards, e.g. 30 -> 50+. Cheap($), best($$) or convenient($$$), choose one.


 * M/r is modified release IE not all at once the latter causing flushing. I'll take your word for it that it is cheaper than statins, as all I have to go on is the price of the two drugs from the national UK pricing authority, the drug budget cost shown, and the approx wholesale cost indicated in the British National Formulary, and it has been made clear to me that such mere printed numeric facts have an inferior stnading to assertions based on how things ought to be to conform with theory.  THe all at once is not currently available, but as I remarked, produced flushing, whcih is noted in the sumamry of prdct characteristics, and as one would expect considering its nature.  It isn't that interesting, until you get into blinded randomised controlled trials reported in peer-reviewed journals ...  care to point me at some of those?  Midgley 00:59, 29 April 2006 (UTC)

Thanks, the US niacin product mkt is more much varied on the "m/r" niacin forms, originally segmented as just "time release niacin (nicotinic acid)" TRNA, defined as dissolved in water in more than 1 hour, vs. "plain", "pure", "crystalline", "unmodified" niacin, dissolved in as quickly as few minutes depending on manufacture. Time release niacin went through many quirky forms over 30+ years with a number of application difficulties, but plain niacin is cheap and very effective for many people. Over the last 10-15 years the manufacturers have zeroed in on good, time release formulas (Enduracin, Slo-Niacin, Niaspan in the US). More recently the niacin mkt has segmented into "sustained release" (SR > 1hr), "extended/intermediate release" (ER ~50 min ), "immediate release" (IR ~3- 20 minutes for plain niacin). Cheap: as low as $2/mo Ann Int Med 2002 by Veterans administration, $3-5/mo (3-6g/d) at a popular US mkt (Rugby, $15 for 500 tab x 500mg plain niacin, over the counter). Flushing is considered good or even pleasant by some. First RCT was 1955, drug companies have been trying deseparately to catch up ever since, statins only excelled in one of 7 interesting parameters, overall LDL. Yet too many have thought fibrates are wonderful for decades, usually a pale flower next to niacin. Ditto statins with all their quirks - e.g. myopathies, CoQ10 depletion etc. Even with an underdose, at 2g/day in the 1969-1975 Coronary Drug Project, patients showed substantial improvements in longevity. More recent papers show competitors' tests designed to make niacin look secondary or inferior, still show fair results; much more for skillful administration and titration by a skillful doctor. Typically the dble RCT are in the 1g - 3g/day range, and skilled MDs typically are applying 3g-4.5g/day, up to 6 g/day, on a plain niacin basis for strong results. However intermediate release niacins products are now generally considered superior in many ways.

I would recommend the book "Cholesterol Control without Diet! The Niacin Solution" by Wm Parsons, MD, the original investigator for the Mayo Clinic, as a hands-on guide for clinicians. He refers to a number of the papers.
 * Varying Cost and Free Nicotinic Acid Content in Over-the-Counter Niacin Preparations for Dyslipidemia 16 Dec 2003
 * Effect of Niacin on Lipid and Lipoprotein Levels and Glycemic Control in Patients With Diabetes and Peripheral Arterial Disease, The ADMIT Study: A Randomized Trial (Niacor - prescription, plain niacin tests with 3g/day OR LESS)

ADMIT looks worth looking at, this is the sort of thing we tend to look at:-
 * http://www.tripdatabase.com/spider.html?itemid=229903
 * http://www.clinicalevidence.com/ceweb/conditions/cvd/0206/0206_I30.jsp secondary prevention
 * http://www.clinicalevidence.com/ceweb/conditions/cvd/0215/0215_keymessages.jsp "We found no RCTs examining the effects of niacin for lowering cholesterol in ... primary prevention"
 * http://ganfyd.org/index.php?title=Nicotinic_acid "has a low therapeutic index in this indication" ... "but use ... has a poor evidence base"
 * And NICE of course, and the other thing is that the purchaser - the NHS - pays for statins and for people being put on statins.
 * THis isn't very encyclopaedic. Midgley 16:33, 29 April 2006 (UTC)


 * It is a conversational introduction to the diffrences between "mainstream" and biologically based alternative medicine. Niacin exists right at a juncture between conventional and orthomolecular medicine, with lots of historical research, niacin has clear, biologically based claims as a primary therapeutic.  Its impressive benefits, when properly administered on ~2/3 up to 80+% of dyslipidemas, is now easy to verify on the individual with the advanced lipid-cholesterol panels.  These tests are becoming widely available in the US, as low as ~$50 at wholesale or up to $200 depending on specific test and ongoing competition. see Berkeley HeartLab, Burlingame, California; Atherotech of Birmingham, Alabama with the VAP test (for vertical auto profile); and NMR Lipoprofile by LipoScience of Raleigh, N.C. The US is going broke on issues like this.--66.58.130.26 22:37, 29 April 2006 (UTC)


 * Niacin is a drug. Medicine, and pharmacology, are biologically based - they couldn't be based on anything else.  Those lipid tests sound remarkably expensive.  I'm reasonably confident that 4S and subsequent studies indicating that reducing cholesterol reduces morbidity from certain CVS causes are reliable, I'm less confident in the demonstration of more complicated lipid effects because this is a complex system. It still isn't building an encysclopaediaMidgley 05:12, 30 April 2006 (UTC)