Keep HDL High with Exercise

Q:  I'm 64 years old and have diabetes and very low HDL cholesterol, 28mg/dL. I can't exercise because of knee trouble, so my doctor started me on Niaspan 500mg once daily. I am having terrible flushing from it, and it has only raised my HDL cholesterol to 30mg/dL.

Is there anything else that I can do to improve my HDL cholesterol?

A:  The optimal lipid levels for adults are as follows:

• Total cholesterol: Less than 200 mg/dL
  
• Low Density Lipoprotein (LDL) cholesterol ("bad" cholesterol): Less than 100 mg/dL
  
• High Density Lipoprotein (HDL) cholesterol ("good" cholesterol): 40 mg/dL or higher
  
• Triglycerides: Less than 150 mg/dL

Doctors usually want the HDL (high-density lipoproteins, or "good cholesterol"), to be as high as possible. An HDL lower than 40 in a male or 45 in a female increases your risk for cardiovascular disease.

An HDL of 28, especially in a diabetic, is concerning. Even small increases in the HDL cholesterol can significantly reduce your risk for cardiovascular events. Your doctor suggested the appropriate therapy - exercise and Niaspan. There are some things you can do to make the treatments more tolerable and there are other therapies that may also help.

While you indicated you are unable to exercise because of knee pain, exercise is a key component in raising HDL cholesterol. In your case, it would also help control your blood sugars.

I would recommend a trial of non-weight bearing exercise. Try swimming, water aerobics or stationary biking. In order to raise the HDL cholesterol, exercise needs to be regular and vigorous. Prior to starting an exercise regimen, you should check with your doctor to make sure that this is safe as you already have numerous risk factors for heart disease.

Niaspan is an extended-release version of niacin and is usually effective in raising HDL cholesterol. However, in many people niacin causes the flushing (redness, usually of the face and neck) that you mention. Taking the extended-release formulation should help reduce this common side effect.

To improve tolerability, try taking an aspirin 30 minutes prior to taking the medication, which usually reduces flushing. Also avoid spicy foods, warm drinks, alcohol and exercise after taking the medication. Once you are tolerating the Niaspan using these measures, then your dose should be increased, ideally to 2,000 mg daily, or to the highest dose you can tolerate without severe side effects. During the titration of Niaspan, your diabetes will need to be monitored as it can also affect your blood sugars.

Statin medications are usually used to lower LDL cholesterol, (low-density lipoproteins, or "bad cholesterol"), but they do have the benefit of also raising HDL cholesterol slightly. When used with Niaspan, there can be a higher rate of side effects. Patients on both medications may require more monitoring.

Diabetics often have elevated triglycerides along with low HDL cholesterol. You did not mention your triglyceride level, however, if you do have elevated triglycerides along with your low HDL, you may benefit from adding a medicine called gemfibrozil to Niaspan. Gemfibrozil alone raises HDL only slightly, but using gemfibrozil in combo with Niaspan can provide dramatic increases in HDL.

Other interventions that can raise your HDL cholesterol include dark chocolate and alcohol. Studies looking at dark chocolate, cocoa and alcohol have found substances in them that increase HDL cholesterol. Prior to adding these to your diet, discuss them with your doctor because it can also change your diabetic control.

Deidre L. Faust, MD, is a Staff Physician (Internal Medicine) at the Medical College of Wisconsin's Plank Road Clinic. Her column appears in the Milwaukee Journal-Sentinel.