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Time to review fibrate prescribing?
  1. Christopher Nicholas Floyd12
  1. 1 Department of Clinical Pharmacology, King’s College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, London, UK
  2. 2 Biomedical Research Centre, Clinical Research Facility, Guy's and St Thomas' NHS Foundation Trust, London, UK
  1. Correspondence to Dr Christopher Nicholas Floyd,King’s College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London, London, London, UK; christopher.floyd{at}kcl.ac.uk

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  • The evidence for fibrates in primary and secondary prevention of cardiovascular disease is limited and substantially weaker than the extensive evidence for statins. Consequently, national and international guidelines do not recommend the routine use of fibrates for the management of hypercholesterolaemia.

  • Fibrates may have utility as an add-on to statins for the management of hypertriglyceridaemia or familial hypercholesterolaemia, but should only be initiated following specialist advice.

  • Clinicians should review patients prescribed fibrates and consider alternative treatment with a statin if this has not been attempted in the past. Where older statins were stopped due to myalgia, infrequent dosing of a modern statin (such as rosuvastatin) may be tolerated and result in reduced cardiovascular risk.

Introduction

Cardiovascular disease (CVD) is the leading causes of morbidity and mortality worldwide.1 Dyslipidaemia is integral to the pathogenesis of atherosclerosis, and prospective observational studies have shown an independent association between plasma cholesterol concentration and vascular morbidity and mortality.2 3 Subsequent randomised control trials (RCTs) have established cholesterol-lowering therapies as a key pillar of cardiovascular risk reduction strategies along with blood pressure control, smoking cessation and glycaemic control.4

The relationship between plasma triglyceride concentration and cardiovascular risk is more complex as hypertriglyceridaemia appears not represent a single disease but rather a heterogeneous collection of disorders.5 Cardiovascular risk appears to depend on the type of particles carrying the triglyceride rather than the plasma concentration per se. Consequently, RCTs have not provided robust evidence that plasma triglyceride concentration is an independent causal factor in promoting cardiovascular disease but rather acts as a biomarker of risk when combined with elevated low-density lipoprotein cholesterol (LDL-C) and reduced high-density lipoprotein cholesterol (HDL-C) as part of the atherogenic dyslipidaemic triad.6 However as hypertriglyceridaemia is associated with an increased risk of acute pancreatitis, treatment must also be considered outside …

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