Atorvastatin
Severe
Textbook-cited
Increased risk of myopathy and rhabdomyolysis
Use with caution; monitor for muscle symptoms and CK levels
Source: KDT 7e · p949
Drug reference
Nicotinic acid
Lipid-modifying agent (niacin / vitamin B3) · Antihyperlipidemic
START
IR 250 mg/day (or ER 500 mg nocte), titrate slowly
TYPICAL MAX
6 g/day IR; 2 g/day extended-release
STOP IF
Transaminases >3× ULN, myopathy, or severe hyperglycaemia
WATCH
LFTs, glucose, uric acid, CK if on a statin; flushing
CDSCO approvedATC C10AD02
KDIGO 2024 + manufacturer label
- ONSET
- 15min · absorption
- PEAK
- 45min · Tmax
- t½
- 30min · t½ (saturable)
- DURATION
- 7h · IR dosing
EXCRETION
Renal — unchanged plus metabolites
route + CYP
INTERACTIONS
12 major
SEVERE in our sources
PREGNANCY
Vitamin doses safe; pharmacologic lipid doses only if clearly needed.
FDA category + note
Top interactionssee all 12 →
- AtorvastatinSevereTextbook-citedKDT 7e · p949
- LovastatinSevereTextbook-citedKDT 7e · p949
- PravastatinSevereTextbook-citedKDT 7e · p949
- RosuvastatinSevereTextbook-citedKDT 7e · p949
Available in India
2 branded formulations. Look up specific brands in the Drugs workspace.
Mechanism
At pharmacologic doses inhibits hepatic VLDL/triglyceride synthesis and lipolysis (GPR109A), lowering LDL-C and triglycerides and raising HDL-C; at physiologic doses a vitamin (NAD/NADP precursor).
Indications
Dyslipidaemia (adjunct — raising HDL, lowering TG/LDL)Pellagra (niacin deficiency)Hypertriglyceridaemia
Dosing
- Adult
- Lipid: immediate-release 250 mg/day, titrate slowly to 1–2 g 2–3 times daily; extended-release 500 mg at bedtime up to 2 g. Pellagra: 50–100 mg several times daily.
- Pediatric
- Pellagra/deficiency by age; lipid use not established.
- Renal adjustment
- Caution in renal impairment (hyperuricaemia); no fixed adjustment.
- Hepatic adjustment
- Contraindicated in active liver disease; monitor LFTs.
- Geriatric
- Start low; flushing/hepatic risk.
- Max dose
- 6 g/day (immediate-release); 2 g/day (extended-release)
Pharmacokinetics
Onset
Lipid effects over days–weeks
Peak effect
~30–60 min plasma; lipid effect weeks
Duration
~5–8 h (IR)
Half-life
~20–45 min (dose-dependent saturable)
Bioavailability
Well absorbed (saturable first-pass)
Protein binding
Low
Metabolism
Hepatic (two pathways: amidation vs conjugation)
Excretion
Renal (unchanged + metabolites)
Contraindications
- Active liver disease / unexplained transaminase elevation
- Active peptic ulcer disease
- Arterial bleeding
- Hypersensitivity
Side effects
Common
Cutaneous flushingPruritusGI upsetHeadacheHyperglycaemia
Serious
- Hepatotoxicity (esp. sustained-release)
- Hyperuricaemia/gout
- Severe hyperglycaemia
- Myopathy (with statins)
- Worsened glucose control
Pregnancy & lactation
Pregnancy
Vitamin doses safe; pharmacologic lipid doses only if clearly needed.
Lactation
Vitamin doses compatible; high lipid doses not recommended.
Drug interactions
Lovastatin
Severe
Textbook-cited
Increased risk of myopathy and rhabdomyolysis
Use with caution; monitor for muscle symptoms and CK levels
Source: KDT 7e · p949
Pravastatin
Severe
Textbook-cited
Increased risk of myopathy and rhabdomyolysis
Use with caution; monitor for muscle symptoms and CK levels
Source: KDT 7e · p949
Rosuvastatin
Severe
Textbook-cited
Increased risk of myopathy and rhabdomyolysis
Use with caution; monitor for muscle symptoms and CK levels
Source: KDT 7e · p949
Simvastatin
Severe
Textbook-cited
Increased risk of myopathy and rhabdomyolysis
Use with caution; monitor for muscle symptoms and CK levels
Source: KDT 7e · p949
Alirocumab
Severe
Textbook
Increased risk of myopathy and rhabdomyolysis.
A lower dose of statin is advisable when nicotinic acid is given concurrently. Close monitoring for muscle symptoms is essential.
Source: KDT 7e · p637, p640
Amiodarone
Severe
Textbook
Increased plasma concentrations of statins and their active metabolites, leading to an increased risk of myopathy and rhabdomyolysis.
Consider using pravastatin, fluvastatin, or rosuvastatin, as they are not extensively metabolized by CYP3A4. Carefully weigh the benefits against the risk of myopathy.
Source: G&G 14e · p736
Atorvastatin + Aspirin
Severe
Textbook
Increased risk of myopathy and rhabdomyolysis.
A lower dose of statin is advisable when nicotinic acid is given concurrently. Close monitoring for muscle symptoms is essential.
Source: KDT 7e · p637, p640
Azole Antifungals
Severe
Textbook
Increased plasma concentrations of statins and their active metabolites, leading to an increased risk of myopathy and rhabdomyolysis.
Consider using pravastatin, fluvastatin, or rosuvastatin, as they are not extensively metabolized by CYP3A4. Carefully weigh the benefits against the risk of myopathy.
Source: G&G 14e · p736
Cyclosporine
Severe
Textbook
Increased risk of myopathy and rhabdomyolysis.
Consider using pravastatin, fluvastatin, or rosuvastatin, as they are not extensively metabolized by CYP3A4. Carefully weigh the benefits against the risk of myopathy. For simvastatin, coadministration is contraindicated.
Source: G&G 14e · p736
Erythromycin
Severe
Textbook
Increased risk of myopathy and rhabdomyolysis.
Concomitant use should be avoided or used with extreme caution, especially for statins metabolized by CYP3A4. Dose reduction of the statin and vigilant monitoring for muscle symptoms are necessary.
Source: KDT 7e · p637
Evolocumab
Severe
Textbook
Increased risk of myopathy and rhabdomyolysis.
A lower dose of statin is advisable when nicotinic acid is given concurrently. Close monitoring for muscle symptoms is essential.
Source: KDT 7e · p637, p640
Related guidelines
Ask House about Nicotinic acid
Continue into a citation-backed clinical answer with the drug context already attached.
Sources: KD Tripathi 7e, Katzung, BNF, Nelson·Verified: 2026-05-20 · House clinical team·Cockpit curated: 2026-05-20