Use of fibrates in the metabolic syndrome: A review

Abstract

The use of fibrates in the treatment of dyslipidaemia has changed significantly over recent years. Their role appeared clear at the start of this century. The Helsinki Heart Study and Veterans Affairs High-Density Cholesterol Intervention Trial suggested significant benefit, especially in patients with atherogenic dyslipidaemia. However, this clarity disintegrated following the negative outcomes reported by the Bezafibrate Infarction Prevention, Fenofibrate Intervention and Event Lowering in Diabetes and Action to Control Cardiovascular Risk in Diabetes randomised controlled trials. In this review we discuss these and other relevant trials and consider patient subgroups such as those with the metabolic syndrome and those needing treatment to prevent the microvascular complications associated with diabetes in whom fibrates may be useful. We also discuss observations from our group that may provide some explanation for the varying outcomes reported in large trials. The actions of fibrates in patients who are also on statins are interesting and appear to differ from those in patients not on statins. Understanding this is key as statins are the primary lipid lowering agents and likely to occupy that position for the foreseeable future. We also present other features of fibrate treatment we have observed in our clinical practice; changes in creatinine, liver function tests and the paradoxical high density lipoprotein reduction. Our purpose is to provide enough data for the reader to make objective decisions in their own clinical practice regarding fibrate use.

Keywords: Fibrates, Metabolic syndrome, Paradoxical high density lipoprotein cholesterol decrease, High density lipoprotein cholesterol, Cardiovascular disease, Peroxisome proliferator-activated receptor, Randomised control trial, Triglycerides

Core tip: Atherogenic dyslipidaemia is characterised by low high density lipoprotein cholesterol (HDL-C) and raised triglycerides, this pattern being associated with adverse cardiovascular risk. The fibrate class of drugs has been shown to both elevate HDL-C and reduce triglyceride concentrations. Despite several randomised control trials the data remain conflicting in regards to the use of fibrates in cardiovascular disease management. Our objective is to consolidate and summarise the literature to clarify the current evidence base.