Fibrates: What Have We Learned in the Past 40 Years?

James M. Backes, Pharm.D.; Cheryl A. Gibson, Ph.D.; Janelle F. Ruisinger, Pharm.D.; Patrick M. Moriarty, M.D.

Disclosures

Pharmacotherapy. 2007;27(3):412-424. 

In This Article

Current Role of Fibrates

Hypertriglyceridemia

Despite a lack of consistent and robust results in major trials, fibric acid derivatives do maintain a role in treating certain types of dyslipidemia. This is especially true for hypertriglyceridemia. According to NCEP ATP-III, reducing concen-trations of very high plasma triglyceride concentrations (> 500 mg/dl) is top priority to prevent acute pancreatitis.[6] In this clinical scenario, many practitioners prefer fibrates to niacin because of less need for dosage titration, lower rate of adverse effects, and greater efficacy.[48] Statins also have the ability to lower plasma triglyceride concentrations; however, these agents are generally less effective when triglyceride concentrations are very high.[6]

Mixed Dyslipidemia

Fibrates have clinical benefit in patients with mixed dyslipidemia and/or impaired glucose homeostasis. Post hoc analyses of data from major trials indicate fibrates produce dramatic reductions in clinical events among patients with elevated plasma triglyceride concentrations and low HDL concentrations. However, primary study results regarding this are lacking. Further, because statins have demonstrated impressive results in reducing cardiovascular events among persons with diabetes, fibrates have been delegated as second-line agents in this population. Use of fibrates in combination with LDL-lowering agents (e.g., statins) for individuals with multiple lipid abnormalities is increasing. For high-risk patients receiving an LDL-lowering drug, adding niacin or fibrates to further improve elevated plasma triglyceride concentrations or low HDL levels is an option.[75]

Isolated Low Levels of High Density Lipoprotein Cholesterol

The primary effect on lipid profiles provided by fibrates is a reduction in plasma triglyceride concentrations; however, moderate increases in HDL level are also noted. The use of fibrates for patients with isolated low levels of HDL is another niche for this drug class. The first priority for this population is achieving the LDL goal; once this is accomplished, further emphasis should be placed on therapeutic lifestyle changes. However, if HDL levels remain low, the addition of an HDL-raising agent (i.e., fibrate or niacin) can be considered.[75] The treatment of isolated low HDL levels is generally limited to high-risk patients (CHD or CHD risk equivalent).

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