DEAR DR. ROACH: I have been taking niacin for many years. What side effects should I be looking for? My cardiologist recently added Lipitor to my medications, which tells me that the niacin was not doing the best job. — A.H.

ANSWER: Niacin has been used for decades as a treatment for high cholesterol levels when a good trial of diet and exercise has been ineffective. However, despite the fact that niacin lowers the unhealthy LDL levels and increases the healthy HDL levels somewhat, the several most recent studies have been unable to show that niacin reduces the risk of heart attack beyond what a statin can do. For that reason, most experts have stopped using niacin, and opted for statins alone. Niacin can cause an unpleasant flushing sensation, especially when it is first started or at higher doses, and it can raise liver enzyme levels. It generally is considered safe but is no longer considered very effective. I haven’t prescribed it for some time, but there might still be some people in whom it is beneficial.

DEAR DR. ROACH: If you, as a doctor, examine a patient and see that this patient needs medications for high fasting glucose levels, high total cholesterol and high blood pressure, what would you do if the patient said he or she will not be compliant and plans on taking nothing? Can you force this patient to take the drugs that you suggest? Will you worry about getting sued if your patient dies? Would you continue working with him or her in the future on his or her terms? — R.I.

ANSWER: This isn’t a hypothetical question at all — it comes up not uncommonly in daily practice. While the best thing to do isn’t always clear, it is certainly clear that doctors can’t force their patients to take medication. Patients have the right to autonomy; that is, they decide what is right for themselves. I see it as my role, as their doctor, to explain why they would benefit from the medication and what is likely to happen if they don’t take it. In the case of blood pressure and cholesterol medicine, we use these to prevent heart disease and stroke. In the case of diabetes, we use medication to prevent symptoms and to reduce the likelihood of end-organ disease, particularly of the kidney, eyes and nerves. If patients can understand the risks they face by not taking medication, then I have to respect those wishes. I certainly would try to use other methods to reduce risk, including dietary modification, salt restriction and possibly supplements. If patients aren’t willing to make any changes, then I ask them whether they want to continue seeing me. I also request that they bring in a family member to hear the discussion. As far as getting sued, it’s prudent to carefully document patients’ wishes and their exact words why they don’t want particular treatments.

DEAR DR. ROACH: I am confused about your article on the elimination of prostate screening. How can one be proactive in lowering the probability of dying of prostate cancer? — D.C.

ANSWER: I believe that screening does save lives, but it comes at a high cost in terms of the numbers of surgeries and complications that are required to prevent one death from prostate cancer. However, there are ways to prevent prostate cancer in the first place without these risks. These include smoking cessation and weight management, since both smoking and obesity are risk factors. A healthy diet including fruits and vegetables probably reduces prostate cancer risk, and soy protein may have a modest benefit.

DEAR READERS: The booklet on the prostate gland discusses enlargement and cancer. Readers can obtain a copy by writing: Dr. Roach — No. 1001, 628 Virginia Dr., Orlando, FL 32803. Enclose a check or money order (no cash) for $4.75 U.S./$6 Can. with the recipient’s printed name and address. Please allow four weeks for delivery.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or request an order form of available health newsletters at 628 Virginia Dr., Orlando, FL 32803. Health newsletters may be ordered from www.rbmamall.com.

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