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Lipid modification - primary and secondary CVD prevention - Management
When should fibrates be prescribed?

  • For primary and secondary prevention of cardiovascular disease, fibrates should only be used when a statin is not tolerated.
  • Fibrates should only be considered as first-line therapy in people with isolated severe hypertriglyceridaemia.
  • Combination therapy with a statin and a fibrate should be only initiated under specialist advice.
Basis for recommendation
  • These recommendations are based on guidance issued by the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Primary Care, 2008a; NICE, 2008a] and jointly by the Medicines and Healthcare products Regulatory Agency (MHRA) and Commission on Human Medicines (CHM) [MHRA, 2007].
  • In a Drug Safety Update, issued jointly by the MHRA and CHM, the review considered published and unpublished data and relevant clinical guidelines and concluded that [MHRA, 2007]:
    • There is limited evidence to support the long-term clinical benefit of fibrate treatment in the primary or secondary prevention of cardiovascular disease (CVD). Given the robust evidence for statins in these indications, the use of fibrates as a first-line treatment is no longer justified.
    • However, the effects of fibrates (mainly on triglycerides, and to a smaller extent on other lipid parameters) suggest that some subgroups of people may still benefit from a fibrate. In these subgroups, the overall benefit-risk balance of fibrates for specific indications remains positive.
    • Combination therapy with a statin should only be used with caution due to a lack of robust evidence for their long-term clinical benefit, and the increased risk of myopathy and rhabdomyolysis. CKS recommends that combination therapy should only be initiated by specialists.
  • The recommendation to use fibrates in people who can not tolerate a statin is supported by NICE. The Guidance Development Group did not find sufficient evidence to recommend the use of fibrates as a first-line treatment for primary or secondary prevention of CVD [National Collaborating Centre for Primary Care, 2008a; NICE, 2008a].

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