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Try out PMC Labs and tell us what you think. Learn More. Niacin is a form of vitamin B3 which is used for the medical treatment of hyperlipidemia and niacin deficiency. However, within the last few years, it is being advertised on the Internet as a quick way to detoxify the human body in an attempt to evade urine drug tests. This claim is without any medical or scientific evidence and as a result, many cases have been reported where young adults have ended up with niacin toxicity. In this case report, we discuss a rare presentation of niacin toxicity and the effects Internet has had on the healthcare being practised by both the physicians and the patients themselves.
Niacin, a water-soluble vitamin, is used by physicians for treating dyslipidemias and pellagra caused by niacin deficiency. These medical conditions are clear indications for niacin use as indicated by a variety of medical literature and data.
The dose of niacin being used for this purpose is also variable leading to multiple incidents of overdose. To our knowledge, 12 cases of niacin toxicity discussed in Table 1. In this report, we discuss a similar case of niacin use but with a different presentation. A year-old gentleman with no medical history presented to our Emergency department with complaints of vomiting, diarrhoea, facial flushing, myalgias and palpitations.
He gave a history of using tetrahydrocannabinol THC on a weekly basis and had an upcoming pre-employment urine drug test. In order to pass the drug test, he had searched the Internet to quickly detoxify his body where he had found that niacin can be used for this purpose. Without discussing this information with any physician, he had ingested mg of extended-release niacin within 12 h after which he started experiencing the stated symptoms. His skin appeared flushed but the rest of the examination was unremarkable. APTT was normal but prothrombin time was elevated to Acetaminophen, salicylate and alcohol levels were negative.
Surprisingly, his urine drug test was also negative for any drugs including cannabinoids. He was started on dextrose-saline infusion for hypoglycemia and transferred to ICU for monitoring. By day 2, his symptoms improved while lactic acidosis and hypoglycemia resolved. On the other hand, liver enzymes and prothrombin time worsened although he continued to remain stable demonstrating no s of liver failure or coagulopathy.
By day 3, he was asymptomatic and did not require any IV fluids. Meanwhile, prothrombin time and liver enzymes started to improve and thus he was downgraded to medical floor. Serial lab values are discussed in Table 2. He made a full recovery and was discharged on the 4th day with advice to follow as an outpatient. Niacin, also known as Nicotinic acid or Vitamin B3, is a water-soluble vitamin which is FDA approved for the treatment of dyslipidemia and niacin deficiency. Niacin works by inhibiting hepatic lipogenesis and triglycerides production [ 1 ].
It is available by prescription either as an immediate-release, sustained-release or extended-release formulation Table 3.
However, there are many over-the-counter OTC formulations of immediate-release and sustained-release niacin [ 2 ]. In addition, it can be found in a variety of energy drinks. Some drinks are documented to have as much as 10 mg of niacin per gm Niacin pills to pass a drug test. All these preparations, thus, make niacin readily available for unregulated and dangerous use. This is particularly concerning in an era of advanced technology where unreliable medical information is readily available on Internet.
This is supported by various studies and systemic reviews done in the recent years. Quality is a major issue in consumer health information available on World Wide Web as found in a systemic review [ 3 ]. Another study estimated that more than half of the patients use Internet for advice on health issues without discussing it with their physicians [ 4 ].
This behaviour has been found more prevalent in younger adults. Our patient reported to have ingested large doses of niacin in attempt to evade a urine marijuana test. Various illicit drugs such as cannabinoids and cocaine are stored in body fat and slowly released thus making them detectable in blood and urine for a long duration.
A single search on Google can lead one to various forums and blogs where this claim is being highly touted and openly supported. Another case review by Ellsworth et al. However, nowhere in medical literature, is Niacin pills to pass a drug test claim supported nor is there any recommendation about a safe dose of niacin for such use. Therefore, cases have been reported where young adults have presented with a variety of niacin adverse effects ranging from mild to life threatening.
These calls were identified in five US states within 9-month duration. Most common adverse effects reported were tachycardia, flushing, skin rash and vomiting. Thirteen were referred for medical treatment and no deaths were reported. Our patient presented with hypotension and lactic acidosis. This can be explained by volume depletion secondary to persistent vomiting. However, quite interestingly, niacin has been documented to cause acute hypotension primarily due to prostaglandin-induced systemic vasodilation. Bays et al. Wide anion gap metabolic acidosis secondary to niacin overdose is an uncommon finding.
A review of clinical literature showed ten case reports Niacin pills to pass a drug test 8 — 13 ] of metabolic acidosis due to niacin overdose — intentional or unintentional — out of whom five patients were documented to have elevated lactic acid levels. In our patient, dehydration and hypotension could have contributed towards the lactic acidosis.
Although niacin induced hepatotoxicity can lead to decreased clearance of lactic acid and subsequent lactic acidosis, our patient only had mildly elevated liver enzymes and prothrombin time with no s of liver failure or coagulopathy. Niacin is also documented to cause insulin resistance leading to hyperglycemia.
However, our patient presented with hypoglycemia requiring IV dextrose infusion. Niacin causes hypoglycemia by inhibition of lipolysis and decreased production of free fatty acids which cannot be used as substrate for gluconeogenesis during prolonged fasting and starvation.
Similar clinical scenarios were reported by Mittal et al. Niacin overdose has been classically associated with flushing and hepatotoxicity but in recent years, we have seen various other cases of niacin toxicity such as hypoglycemia and lactic acidosis. These rare cases are likely to become more prevalent due to unregulated Internet-based health practices.
As healthcare providers, we need to be more cautious while treating our patients. This case, while being a unique presentation of niacin toxicity also invites us to consider other ificant aspects. First, this case is a perfect example of the extensive role Internet nowadays plays in self-practiced healthcare especially by young adult population due to its uninhibited use. Second, lack of FDA regulations on nutritional and herbal supplements is quite concerning.
As healthcare providers, we should be aware of the fact that our patients may be exposed to unreliable medical information leading to use of unrestricted drug paraphernalia resulting in increased incidence of various overdoses such as niacin with a myriad of clinical presentations. We should, therefore, maintain a high degree of suspicion and should strive to keep ourselves updated about recent Internet-based health trends which are not scientifically proven but might be widely practiced by our patients.
National Center for Biotechnology InformationU. Published online Apr Beenish Fayyaza Hafiz J. Rehmanb and Sunita Upreti b. Hafiz J. Author information Article notes Copyright and information Disclaimer.
Received Dec 19; Accepted Feb 6. Introduction Niacin, a water-soluble vitamin, is used by physicians for treating dyslipidemias and pellagra caused by niacin deficiency. Table 1. Reported cases of niacin overdose in attempts to pass drug tests. Source Clinical features Ingested dose Outcome Paopairochanakorn et al. Metabolic acidosis, hepatotoxicity Not reported Recovered Metabolic acidosis, hepatotoxicity, coagulopathy Not reported Recovered Mittal et al. Diabetic ketoacidosis, hepatotoxicity, prolonged QT interval.
Metabolic acidosis, hypoglycemia, myopathy. Acute renal failure, haemolytic anaemia, thrombocytopenia. Acute Liver Failure. Not reported Recovered Sheila et al. Open in a separate window. Table 2. Serial laboratory findings of the patient. Table 3. Formulations and dosage of niacin. Formulation Initial dose Maximum dose OTC availability Immediate release mg once daily 6 g daily in 3 divided doses Yes Sustained release mg once daily mg once daily Yes Extended release mg once daily 2 g once daily No.
Case description A year-old gentleman with no medical history presented to our Emergency department with complaints of vomiting, diarrhoea, facial flushing, myalgias and palpitations.
Discussion Niacin, also known as Nicotinic acid or Vitamin B3, is a water-soluble vitamin which is FDA approved for the treatment of dyslipidemia and niacin deficiency. Conclusion This case, while being a unique presentation of niacin toxicity also invites us to consider other ificant aspects. Disclosure statement No potential conflict of interest was reported by the authors. Recent advances in niacin and lipid metabolism. Curr Opin Lipidol.
Evaluation and treatment of hypertriglyceridemia: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. Empirical studies assessing the quality of health information for consumers on the World Wide Web: a systemic review. J Gen Intern Med. Acute liver failure secondary to niacin toxicity. Case Rep Pediatr. Morb Mortal Wkly Rep. Does nicotinic acid niacin lower blood pressure?Niacin pills to pass a drug test
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Toxicity from the use of niacin to beat urine drug screening