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A Clinical Trial of Oat Bran and Niacin in the Treatment of Hyperlipidemia Joseph M

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A Clinical Trial of Oat Bran and Niacin in the Treatment of Hyperlipidemia Joseph M A Clinical Trial of Oat Bran and Niacin in the Treatment of Hyperlipidemia Joseph M. Keenan, MD, Joyce B. Wenz, RD, MS, Cynthia M. Ripsin, MS, MPH, Zhiquan Huang, MD, and David J. McCaffrey Minneapolis, Minnesota Background. Previous studies have demonstrated the showed greater than expected lipid improvement on lipid-lowering potential of wax-matrix controlled-rc- combination therapy. From baseline to the end of the leasc forms of nicotinic acid, but questions have been final phase, significant reductions (P < .05) occurred raised about the risks associated with long-term use. for total cholesterol (—10%) and low-density lipopro­ This report describes a 38-week trial that was designed tein cholesterol (—16%). High-density lipoprotein cho­ as a follow-up to a shorter 16-wcek clinical trial of lesterol rose significantly at the end of the oat bran wax-matrix controlled-rclcasc niacin. The present study plus niacin phase, but returned to near baseline by the also tested the hypothesis that niacin (1500 mg/d) and end of the study. The liver enzymes alkaline phos­ oat bran (56 g/d [2 oz/day]) may have a synergistic ef­ phatase, lactate dehydrogenase, and aspartate ami­ fect on improving scrum lipid levels. notransferase all showed a tendency to rise throughout Methods. Ninety-eight subjects began the following the study. protocol: oat bran alone (6 weeks), oat bran plus nia­ Conclusions. The results of this 38-week trial suggest cin (6 weeks), and niacin alone (32 weeks). Blood lip­ that the relatively inexpensive wax-matrix form of nia­ ids, blood chemistries, nutritional variables, and side- cin is effective and reasonably well tolerated. Approxi­ effect profiles were monitored throughout the study. mately 8% of subjects were unable to continue taking Sixty-nine (70%) subjects completed the trial taking niacin because of side effects, and 4% discontinued tak­ the full dose of niacin (1500 mg/d); 8 subjects com­ ing niacin because of liver enzyme elevations. A small pleted the trial taking a reduced dose of niacin (average group of subjects (10%) experienced greater than ex­ 906 mg/d); 11 discontinued taking anv niacin because pected lipid improvements (synergism) on combined of either intolerable side effects (n = 7) or liver en­ oat-bran and niacin therapy. Liver function monitoring zyme abnormalities (n = 4). with long-term use of niacin is warranted. Results. Generally, oat bran—niacin synergism was not Key words. Cholesterol; niacin; clinical trials; cereals. found. Only 10% of subjects who completed the study / Fam Pract 1992; 34:313-319. Recent studies using a wax-matrix form of controllcd- tcin | LDL] cholesterol as a result of taking 1500 to 2000 relcase nicotinic acid (CNA) (Endur-acin) have sug­ mg/d) with a low incidence of intolerance (3.7%).2 Trials gested improved clinical potential for this particular for­ using other (non—wax-matrix) CNA products have typ­ mulation of nicotinic acid, and invite a reexamination of ically reported drug intolerance due to side effects in the the risks vs the benefits of CNA.1-2 Wax-matrix CNA has range of 16% to 40% of subjects.4-5 bioavailability comparable to unmodified nicotinic acid.3 The above studies suggest that wax-matrix CNA Recently, we reported a randomized controlled clinical may offer desirable clinical advantages over unmodified trial of wax-matrix CNA (201 subjects) demonstrating nicotinic acid and other forms of CNA. These studies efficacy (—19% to —26% change in low-density lipopro- have not resolved the issue of drug safety with the use of wax-matrix CNA, however, especially with respect to the potential for hcpatotoxicity. In the clinical trial cited Submitted, revised, November 14, 1991. above, the reduction in LDL cholesterol was associated From the Department o f Family Practice and Community Health, University of with a modest but significant rise for the highest dose Minnesota, Minneapolis. Requests far repnnts should be addressed to Joseph M . Keenan, AID , Department o f Family Practice, 825 Washington Avc SE, Bax 25, Minneapolis, group (2000 mg) in baseline levels o f liver enzymes.2 The M N 55414. study was relatively short in duration, only 8 weeks at full © 1992 Appleton & Lange ISSN 0094-3509 The Journal of Family Practice, Vol. 34, No. 3, 1992 313 Oat Bran and Niacin for Hyperlipidemia Keenan, VVenz, Ripsin, et al close. It raised but did not answer the question of using a standardized protocol for phlebotomy technique whether the liver enzyme changes observed (though gen­ and specimen handling. Plasma specimens were used for erally within the normal range for those blood chemis­ all lipid analysis. The methods used for specimen han­ tries) were evidence of therapeutic effect or incipient liver dling and analysis have been detailed previously.2 toxicity. To answer that and related longer term efficacy and tolerance questions, a 38-week sequel study at a stable Study Protocol dosing level (1500 mg) with repeated interval blood lipid and chemistry determinations was undertaken. A total daily The study design was a sequential trial of all subjects dose of 1500 mg of wax-matrix CNA was determined from consuming oat bran alone, followed by oat bran with the previous clinical trial to be optimal for most persons. wax-matrix CNA, and finally wax-matrix CNA alone. In addition, wax-matrix CNA had been reported The study was conducted in three phases: Phase 1 was a anecdotally to be more effective for cholesterol manage­ 6-week treatment period using the American Heart As­ ment when used in conjunction with a fat-modified diet sociation Step I (AHA-1) diet supplemented with 28 g and oat bran supplement. The sequel study was de­ (1 oz) twice daily of instant hot oat bran cereal. Phase 2 signed to also evaluate this potential synergistic effect of was also 6 weeks in length, with the treatment consisting oat-bran supplement with wax-matrix CNA. of 1500 mg/d of wax-matrix CNA added to the initial treatment of AHA-1 diet and oat bran (56 g [2 oz]). Phase 3 was a 32-wcek period (with lipid and chemistry' Methods monitoring at midpoint, ic, week 16) consisting of the AHA-1 diet and wax-matrix CNA (1500 mg) without Study Subjects the oat-bran supplement. Subjects were given a choice of Of the 158 subjects completing the initial clinical trial of taking either 500-mg or 750-mg tablets to enhance over­ wax-matrix CNA, 98 agreed to participate in the sequel all compliance with taking pills during the sequel study. study. There was a 4-month interval between the com­ Lipid profiles were obtained at baseline and at the pletion of the clinical trial and the beginning of the end of each phase. Three different fasting morning sam­ sequel study, effectively accomplishing a washout of ni­ ples were collected on separate (usually consecutive) acin effects between the studies. Originally, subjects had days, and the average of the three samples was used in been recruited from community cholesterol screening data analysis. Blood chemistry testing was also done on programs, newspaper notices, and chart reviews of pa­ fasting samples obtained at baseline, at the end of phase tients from two family practice training clinics. Men and 2, and at the midpoint and end of phase 3. The Innovitc women between 20 and 70 years of age with LDL Corporation (Tigard, Ore) supplied the 750-mg and cholesterol levels in the 75th to 95th percentile level for 500-mg wax matrix CNA tablets in prelabeled bottles, age and sex were included in the study. Individuals were and Quaker Oats Company (Barrington, 111) supplied the excluded if they had a fasting triglyceride level >4.5 instant hot oat bran cereal in premeasured 28-g (1-oz) mmol/L(400 mg/dL), fasting glucose level >7.8 mmol/L packets. (140 mg/dL), hyperuricemia, active liver disease, were presently using drugs that affect lipids, were pregnant or had a reasonable chance of becoming pregnant, had a Monitoring for Dietary and Drug Adherence history of gout, peptic ulcer disease, drug or alcohol abuse, or had surgical treatment to lower lipids. Baseline dietary' behavior was assessed by a self-adminis­ Comparison of characteristics between the group of tered, semiquantitative food frequency questionnaire.6 sequel study subjects and those in the original study To assess dietary adherence during the study, 4-day food revealed no apparent selection bias in the sequel study. records were completed during each phase. Subjects were Age was the only variable in which the two groups requested to keep their diet adjustments isocaloric as differed significantly (sequel study, 52 years, vs original much as possible for the study' period and not to inten­ study, 46 years, P < .05). tionally change lifestyle or physical activity in a manner that might independently affect their weight and lipids. Laboratory Methods Compliance with drug regimens was estimated with pill counts. Actual pill counts were compared with expected All blood samples for lipid determinations in both the counts to determine the percentage of compliance with initial clinical trial and the sequel study were obtained doses. 314 The Journal of Family Practice, Vol. 34, No. 3, 1992 Oat Bran and Niacin for Hyperlipidemia Keenan, Wen/, Ripsin, et al Initially Enrolled: data, two-tailed paired t tests w ere used to assess changes 98 subjects Drop-outs: by phase. n 8 for intolerable side effects (8%) T----- 4 for elevated blood chemistries (4%) Completed the Trial: 9 for personal reasons (9%) 77 subjects (79% completion rate) Results Full Dose Reduced Dose 49 subjects: 750 mg BID ^ (average dose 906 mg) 20 subjects: 500 mg TID Total: 69 subjects Total: 8 subjects Subjects Figure 1 shows the various dispositions of the 98 sub­ Figure 1.
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