Omega-3 carboxylic acids in patients with severe hypertriglyceridemia: EVOLVE II, a randomized, placebo-controlled trial

Flash'O real-world evidence programme - Attitude and practices toward the use of omega-3 FA by physicians from Middle East Countries

The Flash'O project was designed to provide insights into the current use of prescription omega-3 and their perceived benefits by physicians in real-world clinical practice, in Russia, Saudi Arabia, Thailand, and Gulf countries, and to determine the adherence of physicians to dyslipidemia management guidelines. The present study focuses on Flash'O's process and results in Middle East countries. A total of 338 physicians and specialists completed the online questionnaire. Most responding physicians were male (91.7%), general practitioners (42.6%) with more than 5 years of seniority (80.4%) and saw more than 50 patients a week (71.5%). Most surveyed physicians (64.2%) reported using guidelines in their daily practice for the management of their patients with dyslipidemia. They mostly followed national guidelines (68.6%). American or European ones were less commonly used. Responding physicians thought that omega-3 supplementation could be more beneficial in all types of dyslipidemia, except high non- hight density lipoproteins, and for patients suffering from obesity, type 2 diabetes mellitus, acute coronary syndrome with ST-segment elevation myocardial infarction and high cardiovascular diseases risk (score ≥ 5% and < 10%), but less beneficial in chronic kidney disease. Respondents recommended omega-3 to their patients mainly after statin treatment in patients with dyslipidemia and for the treatment of dyslipidemia. This survey confirmed that omega-3 fatty acids are at the heart of the cardiovascular medical strategy.

Association Between Omega-3 Fatty Acid Intake and Dyslipidemia: A Continuous Dose-Response Meta-Analysis of Randomized Controlled Trials

Background Previous results provide supportive but not conclusive evidence for the use of omega-3 fatty acids to reduce blood lipids and prevent events of atherosclerotic cardiovascular disease, but the strength and shape of dose-response relationships remain elusive. Methods and Results This study included 90 randomized controlled trials, reported an overall sample size of 72 598 participants, and examined the association between omega-3 fatty acid (docosahexaenoic acid, eicosapentaenoic acid, or both) intake and blood lipid changes. Random-effects 1-stage cubic spline regression models were used to study the mean dose-response association between daily omega-3 fatty acid intake and changes in blood lipids. Nonlinear associations were found in general and in most subgroups, depicted as J-shaped dose-response curves for low-/high-density lipoprotein cholesterol. However, we found evidence of an approximately linear dose-response relationship for triglyceride and non-high-density lipoprotein cholesterol among the general population and more evidently in populations with hyperlipidemia and overweight/obesity who were given medium to high doses (>2 g/d). Conclusions This dose-response meta-analysis demonstrates that combined intake of omega-3 fatty acids near linearly lowers triglyceride and non-high-density lipoprotein cholesterol. Triglyceride-lowering effects might provide supportive evidence for omega-3 fatty acid intake to prevent cardiovascular events.

A Multi-Center, Prospective Observational Study to Investigate the Safety, Compliance, and Efficacy of Omethyl QTlet Soft Capsule

Omega-3 fatty acids have been shown to be effective in lowering triglyceride (TG) levels; however, tolerability issues arise due to the large size of the pills. The purpose of this study was to examine the safety, compliance, and efficacy of Omethyl QTlet soft capsules (OQCs). This multi-center, prospective, observational study evaluated the safety, compliance, and efficacy of OQCs. Patients with hypertriglyceridemia with a history of omega-3 fatty acid intake were enrolled in this study and were prescribed OQCs (2 g−4 g/day) for eight weeks. All adverse events (AEs), adverse drug reactions (ADRs), and serious adverse events (SAEs) were recorded for safety evaluation. Adherence to treatment was assessed using questionnaires, and efficacy was assessed by changes in lipid and lipoprotein levels after eight weeks from baseline. The convenience of taking medication was analyzed for 580 patients, and the efficacy test was performed for 563 patients. The AE and ADR rates were 8.2% and 5.7%, respectively. There were only two SAEs. Of the patients, 55.8% responded that the OQC improved medication convenience, and mean changes in TG, total cholesterol, LDL-C, and non-HDL-C from baseline to eight weeks were −37.88 mg/dL, −11.56 mg/dL, −5.55 mg/dL, and −10.87 mg/dL, respectively (p-values < 0.001). In patients who had previously taken omega-3 fatty acids, OQCs showed safety and efficacy in lowering TG, and it was confirmed that compliance with medicine also improved compared to omega-3 fatty acids.

Saroglitazar is non-inferior to fenofibrate in reducing triglyceride levels in hypertriglyceridemic patients in a randomized clinical trial

Saroglitazar, being a dual PPAR-α/γ agonist, has shown beneficial effect in diabetic dyslipidemia and hypertriglyceridemia. Fibrates are commonly used to treat severe hypertriglyceridemia. However, the effect of saroglitazar in patients with moderate to severe hypertriglyceridemia was not evaluated. We conducted a study to compare the efficacy and safety of saroglitazar (4 mg) with fenofibrate (160 mg) in patients with moderate to severe hypertriglyceridemia. This was a multicenter, randomized, double-blinded, double-dummy, active-control, and noninferiority trial in adult patients with fasting triglyceride (TG) levels of 500–1,500 mg/dl. The patients were randomized in a 1:1 ratio to receive daily dose of saroglitazar or fenofibrate for 12 weeks. The primary efficacy end point was the percent change in TG levels at week 12 relative to baseline. The study comprised of 41 patients in the saroglitazar group and 41 patients in the fenofibrate group. We found that the percent reduction from baseline in TG levels at week 12 was significantly higher in the saroglitazar group (least square mean = −55.3%; SE = 4.9) compared with the fenofibrate group (least square mean = −41.1%; SE = 4.9; P = 0.048). Overall, 37 treatment-emergent adverse events (AEs) were reported in 24 patients (saroglitazar: 13; fenofibrate: 11). No serious AEs were reported, and no patient discontinued the study because of AEs. We conclude that saroglitazar (4 mg) is noninferior to fenofibrate (160 mg) in reducing TG levels after 12 weeks of treatment, was safe, and well tolerated.

The Effect of Dietary Interventions on Hypertriglyceridemia: From Public Health to Molecular Nutrition Evidence

Approximately 25–50% of the population worldwide exhibits serum triglycerides (TG) (≥150 mg/dL) which are associated with an increased level of highly atherogenic remnant-like particles, non-alcoholic fatty liver disease, and pancreatitis risk. High serum TG levels could be related to cardiovascular disease, which is the most prevalent cause of mortality in Western countries. The etiology of hypertriglyceridemia (HTG) is multifactorial and can be classified as primary and secondary causes. Among the primary causes are genetic disorders. On the other hand, secondary causes of HTG comprise lifestyle factors, medical conditions, and drugs. Among lifestyle changes, adequate diets and nutrition are the initial steps to treat and prevent serum lipid alterations. Dietary intervention for HTG is recommended in order to modify the amount of macronutrients. Macronutrient distribution changes such as fat or protein, low-carbohydrate diets, and caloric restriction seem to be effective strategies in reducing TG levels. Particularly, the Mediterranean diet is the dietary pattern with the most consistent evidence for efficacy in HTG while the use of omega-3 supplements consumption is the dietary component with the highest number of randomized clinical trials (RCT) carried out with effective results on reducing TG. The aim of this review was to provide a better comprehension between human nutrition and lipid metabolism.

Beneficial effects of dietary supplementation with olive oil, oleic acid, or hydroxytyrosol in metabolic syndrome: Systematic review and meta-analysis

BACKGROUND AND AIMS

Olive oil and components might have a beneficial effect on Metabolic Syndrome (MetS). The aim of this review and meta-analysis was to assess whether those effects are related to hydroxytyrosol or oleic acid contents, or the combination of them as olive oil, and how powerful is this effect.

METHODS

A systematic literature search was performed in MEDLINE via Pubmed, Web of Science (WOS) core collection, and Virtual Health Library (VHL) via LILACS and IBECS (Spain). MeSH terms used were "obesity", "body weight", "body mass index", "adipose tissue", "lipid metabolism", "LDL", "HDL", "VLDL", "insulin resistance", "glucose", "insulin", "hypertension", "arterial pressure", "olive oil", "oleic acid", and other (non-MeSH) terms: "total antioxidant capacity", "total antioxidant status", "hydroxytyrosol" (PROSPERO ID: CRD42021247614). Results of the included studies were meta-analyzed with the RevMan 5.3 program, assuming a random effects model.

RESULTS

76 articles (67 different trials) were identified. Hydroxytyrosol had no effect on MetS [combined standardized mean differences (SMD) = 0.01 (CI 95%: [-0.23, 0.25], I² = 83%; p = 0.920)]. Oleic acid had no significant beneficial effect on MetS [SMD = 0.03 (CI 95%: [-0.01, 0.07], I² = 0%); p = 0.150], but it improved lipid profile [SMD = 0.06 (CI 95%: [-0.00, 0.12], I² = 0%); p = 0. 050]. Olive oil had no effect on MetS [SMD = -0.01 (CI 95%: [-0.05, 0.03]), I² = 55%; p = 0.550)]. The supplementation with hydroxytyrosol, oleic acid or olive oil showed a beneficial effect on antioxidant capacity related to components of MetS [SMD = 0.31 (CI 95%: [-0.34, 0.95], I² = 81%)]; p = 0.35).

CONCLUSION

Most articles compared olive oil and oleic acid with other strategies specially designed for MetS management. Our findings suggest that olive oil or oleic acid consumption are as good as the other strategies to manage MetS.

[Omega-3 Polyunsaturated Fatty Acids in Patients with Hypertriglyceridemias and Atherosclerosis]

Along with increased levels of low-density cholesterol, lipid factors of the risk of cardiovascular complications (CVC) include hypertriglyceridemia, particularly increased plasma levels of remnant particles. Omega-3 polyunsaturated fatty acids (ω-3 PUFA) are essential for normal functioning of cell membranes, retina, nerve tissue, skeletal muscles, etc. Among the large family of fatty acids (FA), eicosapentaenoic (EPC) and docosahexaenoic (DHX) FA are most studied. The beneficial effect of ω-3 PUFA consumption on the cardiovascular system is related with improvement of blood rheology, antiarrhythmic and anti-inflammatory effects, and a decrease in triglycerides. Large randomized studies of ω-3 PUFA (mixed EPC and DHX or only EPC) have demonstrated their efficiency and safety and a capability for reducing the incidence of CVC and sudden death as well as improvement of the prognosis in various patient populations. In the STRENGTH study (combination of omega-3 and statins), no significant decrease in the risk of CVC was achieved in patients with high triglycerides and low high-density lipoproteins. The ω-3 PUFA treatment is regulated by current international Guidelines and Consensuses as a part of combination therapy with statins for reduction of the risk of CVC and correction of pronounced hypertriglyceridemia.

Epidemiology of hypertriglyceridaemia

Based on the most recent scientific evidence, in this chapter we describe the relation of levels of triglycerides and risk of cardiovascular diseases. Particularly, we describe the prevalence of hypertriglyceridemia based on studies published at national and international reports; the relation between hypertriglyceridemia and cardiovascular diseases according to results of cohort studies; and finally, we describe the most recent evidence from clinical trials, meta-analysis and systematic reviews that have shown data on the efficacy of lowering triglyceride levels and reducing cardiovascular diseases.

Treatment of mild-to-moderate hypertriglyceridemia

The atherogenic role of triglycerides (TG) as an independent cardiovascular risk factor has been discussed for many years, largely because hypertriglyceridaemia (HTG) is a complex metabolic entity of multiple aetiology involving processes of diverse nature. In this chapter, a discussion will be presented on the current recommendations for the management of mild-moderate hypertriglyceridaemia (150-880mg/dL). The aim of the interventions used is to decrease the LDL-cholesterol (c-LDL) and control the HTG. This entails reducing apoprotein B (ApoB) levels, the number of remaining TG-rich lipoproteins (LRP), non-HDL-cholesterol (c-non-HDL), and increasing HDL-cholesterol (c-HDL). The management strategy includes healthy lifestyle recommendations, and subsequent use of lipid-lowering drugs, including statins, fibrates, n-3 fatty acids and PCSK9 inhibitors.

Comparative efficacy of pharmacological agents on reducing the risk of major adverse cardiovascular events in the hypertriglyceridemia population: a network meta-analysis

BACKGROUND

Hypertriglyceridemia (HTG) is considered an independent risk factor for major adverse cardiovascular events (MACE).

METHODS

This study analyzed the effects of various agents on MACE risk reduction in HTG (serum triglyceride ≥ 150 mg/dl) populations by performing a network meta-analysis. We performed a frequentist network meta-analysis to conduct direct and indirect comparisons of interventions. PubMed, EMBASE, and the Cochrane library were searched for trials until Jul 6, 2020. Randomized controlled trials that reported MACE associated with agents in entire HTG populations or in subgroups were included. The primary outcome was MACE.

RESULTS

Of the 2005 articles screened, 21 trials including 56,471 patients were included in the analysis. The network meta-analysis results for MACE risk based on frequency data showed that eicosapentaenoic acid (EPA) (OR: 1.32; 95% CI 1.19-1.46), gemfibrozil (OR: 1.53; 95% CI 1.20-1.95), niacin plus clofibrate (OR: 2.00; 95% CI 1.23-3.25), pravastatin (OR: 1.32; 95% CI 1.15-1.52), simvastatin (OR: 2.38; 95% CI 1.55-3.66), and atorvastatin (OR: 0.55; 95% CI 0.37-0.82) significantly reduced the risk of MACE compared to the control conditions. In the subgroup analysis of HTG patients with triglycerides ≥ 200 mg/dL, bezafibrate (OR: 0.56; 95% CI 0.33-0.94), EPA (OR: 0.72; 95% CI 0.62-0.82), and pravastatin (OR: 1.33; 95% CI 1.01-1.75) significantly reduced the MACE risk.

CONCLUSIONS

Simvastatin had a clear advantage in reducing the risk of MACE in the entire HTG population analyzed in this meta-analysis. EPA, but not omega-3 fatty acid, was considered an effective HTG intervention. Among fibrates, gemfibrozil was most effective, though bezafibrate may significantly reduce the risk of MACE in populations with triglyceride levels of 200-300 mg/dL. Trial registration retrospectively registered in PROSPERO (CRD42020213705).

Lipid lowering therapy in cardiovascular disease: From myth to molecular reality

Lipid-lowering therapy is one major cornerstone of medical treatment of cardiovascular disease in order to modulate atherosclerosis. Statins, ezetimibe and novel PCSK9-inhibitors are already recommended in current guidelines and were shown to improve lipid profiles and have positive effects on the rate of ischemic events and cardiovascular mortality. Recent studies suggest that the concept of "The lower the better" might be valid at least regarding low density lipoproteins. In addition, lowering lipoprotein (a) still displays a major challenge in lipid therapy. Furthermore, also lowering triglycerides seems to improve cardiovascular outcome. Regarding triglycerides, icosapent ethyl, a polyunsaturated fatty acid recently attracted attention showing cardiovascular risk reduction due to triglyceride lowering. Therefore, new therapeutic strategies and drug classes are eagerly awaited. Targeting LDL, bempedoic acid and the siRNA inclisiran provide promising results. Moreover, regarding TG a monoclonal antibody called evinacumab and an antisense-oligonucleotide against ANGPTL3 showed effective TG-lowering. At least, using antisense-oligonucleotides against ApoC-III and Lp(a) resulted in promising outcomes. In this review, current and future options for lipid management are presented depending on different drug classes.

Recent developments in pharmacotherapy for hypertriglyceridemia: what's the current state of the art?

Introduction: Hypertriglyceridemia is associated with both the development of cardiovascular disease (CVD) when mild-to-moderate and high risk of pancreatitis when more severe. The residual CVD risk after low-density lipoprotein cholesterol (LDL-C) lowering is, in part, attributed to high triglyceride (TG) levels. Therefore, there appears to be a need for effective TG-lowering agents.Areas covered: This review presents the most recent advances in hypertriglyceridemia treatment; specifically, it discusses the results of clinical trials and critically comments on apolipoprotein C-III inhibitors, angiopoietin-like 3 inhibitors, alipogene tiparvovec, pradigastat, pemafibrate and novel formulations of omega-3 fatty acids.Expert opinion: In the era of extreme lowering of LDL-C levels with several agents, there seems to be space for novel therapeutic options to combat parameters responsible for residual CVD risk, among which are elevated TGs. Furthermore, a significant number of individuals have very high TG levels and encounter the risk of acute pancreatitis. The most recently developed TG-lowering drugs appear to have a role in both conditions; the choice is mainly based on baseline TG levels. Dyslipidemia guidelines are likely to change in the near future to include some of these agents. Of course, long-term data regarding their safety and efficacy in terms of CVD outcomes and pancreatitis are warranted.

Investigational drugs in development for hypertriglyceridemia: a coming-of-age story

Introduction: Elevated triglyceride (TG) level is a prevalent condition in the general population and in patients with cardiovascular (CV) risk even under statin therapy. Severe hypertriglyceridemia (HTG) puts patients at risk for acute pancreatitis. Several TG-lowering drugs failed in clinical trials, but subgroup analyses suggest that high-risk patients, such as those with atherogenic dyslipidemia or diabetes, benefit from TG lowering.Areas covered: We review advances for TG-lowering drugs in clinical development. These include selective PPARα modulators, omega-3 fatty acid formulations that have been approved for severe HTG, and inhibitors of apolipoprotein C-III, angiopoietin-like-3 or microsomal transfer protein. Lessons learned from the success of the phase 3 trial REDUCE-IT with high-dose icosapent ethyl are also reviewed.Expert opinion: We believe that TG-lowering therapies are coming of age as they will allow to treat patients with high CV risk and moderate HTG, including T2D subjects, as well as patients with severe HTG or even homozygous familial hypercholesterolemia, all of which being 'optimally' treated with a statin. More studies on the impact of therapy on quality of life in patients with severe HTG should be conducted with the help of patient registries.

Hypertriglyceridemia-Related Pancreatitis In Patients With Type 2 Diabetes: Links And Risks

Disturbances in glucose and lipid homeostasis are cardinal features of the metabolic syndrome that affect millions of people worldwide. These conditions have multi-organ impact, and while cardiovascular effects are usually the core for studies and preventive measures, other systems may also be affected, including the pancreas. Acute pancreatitis related to severe hypertriglyceridemia is an under-recognized condition that could lead to significant morbidity and mortality. Therefore, when suspected, prompt diagnosis and treatment should be initiated to cover the various aspects of this disorder. Though commonly known to be associated with excess of alcohol use, hypertriglyceridemia-related pancreatitis is particularly observed in diabetics, especially when uncontrolled. Here, we portray the possible mechanisms and clinical features that link type 2 diabetes, hypertriglyceridemia and pancreatitis, and discuss their health-related outcomes and the current and novel treatment options for this unique disease.

Hypertriglyceridaemia-associated acute pancreatitis: diagnosis and impact on severity

BACKGROUND

The level of hypertriglyceridaemia (HTG) at which the risk of acute pancreatitis (AP) increases and the impact of HTG on AP attributable to other aetiologies remains unclear.

METHODS

We compared clinical outcomes of patients admitted within 48 h of the onset of abdominal pain from a first episode of AP and admission serum triglyceride levels of either <5.65 mmol/l (<500 mg/dl) or ≥5.65 to <11.3 mmol/l (moderate HTG) or ≥11.3 mmol/l (≥1000 mg/dl, severe HTG).

RESULTS

Among a cohort of 1,233 patients with AP there were significant progressive increases in all major deleterious clinical outcomes including mortality (all P_trend < 0.05) that were directly dependent on admission triglyceride levels. Outcomes were improved by earlier presentation (<24 h compared to 24-48 h from abdominal pain onset). Patients with severe HTG and a concomitant aetiology (n = 68) had significantly more persistent organ failure, pancreatic necrosis and longer hospital stays (P < 0.05) than those with severe HTG alone (n = 206).

CONCLUSIONS

There appears to be an association between HTG grade and the severity of AP. Severe HTG significantly increased the severity of AP, over AP attributable to other aetiologies. Moderate as well as severe HTG can be used as a criterion for the diagnosis of HTG-associated AP.

Diabetic Ketoacidosis Revealing a Severe Hypertriglyceridemia and Acute Pancreatitis in Type 1 Diabetes Mellitus

Diabetic ketoacidosis (DKA) is a life-threatening acute metabolic complication occurring in patients with diabetes, especially in patients with type 1 diabetes (T1D), due to an insulin deficiency. Moderate hypertriglyceridemia is commonly observed in DKA but severe hypertriglyceridemia with a triglyceride level exceeding 10g/L is very rarely reported. We report a case of a 14-year-old boy who had type 1 diabetes for 4 years treated with insulin therapy, also having adrenal insufficiency treated with hydrocortisone who presented with ketoacidosis and excruciating abdominal pain. Investigations revealed hypertriglyceridemia at 64g/L, lipasemia at 1000 U/L, and stage E pancreatitis on abdominal CT. The patient was treated with intravenous insulin, rehydration, and fenofibrate with good clinical and biological evolution. Severe hypertriglyceridemia causing pancreatitis in type 1 diabetes mellitus is a rare but very serious complication of DKA in children.

Clinical effects of early lipid-lowering therapy in patients with hyperlipidemic acute pancreatitis

AIM

To evaluate the clinical effects of early lipid-lowering therapy in patients with hyperlipidemic acute pancreatitis (HLAP) to provide a basis for the clinical use of various lipid-lowering therapies in patients with HLP.

METHODS

Two hundred and ninety patients with HLAP randomly selected between January 2014 and July 2016 were divided into a control group and a study group. Both groups were given conventional treatment, and the study group additionally underwent secondary membrane separation plasmapheresis. All patients were treated for one month. The rating scores [Ramson, acute physiology and chronic health evaluation Ⅱ (APACHEⅡ), and modified computed tomography severity index (MCTSI )], blood rheology parameters (high cut whole blood viscosity, low cut whole blood viscosity, specific plasma viscosity, fibrinogen, hematocrit, platelet aggregation rate, and erythrocyte sedimentation rate), and specific indicators [serum amylase, urine amylase, serum calcium, interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α)] were compared between the two groups of patients.

RESULTS

After treatment, correlation analysis showed that serum triglycerides were significantly correlated with Ramson score, APACHE Ⅱ score, MCTSI score, whole blood viscosity, high shear whole blood viscosity, blood plasma viscosity, fibrinogen, hematocrit, platelet aggregation rate, erythrocyte sedimentation rate, serum amylase, urinary amylase, blood calcium, IL-6, and TNF-α in HLP patients (P < 0.05). Ranson score, APACHE Ⅱ score, Balthazar CT score, whole blood viscosity, high shear whole blood viscosity, plasma viscosity, fibrinogen, hematocrit, platelet aggregation rate, erythrocyte sedimentation rate, serum amylase, urinary amylase, blood calcium, IL-6, and TNF-α differed significantly between before and after treatment in both groups (P < 0.05). After treatment, Ranson score, APACHE Ⅱ score, Balthazar CT score, whole blood viscosity, high shear whole blood viscosity, hematocrit, serum amylase, urinary amylase, IL-6, and TNF-α were significantly better in the study group than in the control group (P < 0.05). Serum triacylglycerol levels were significantly decreased in both groups after treatment. Serum triacylglycerol level in the study group (0.31 mmol/L ± 0.14 mmol/L) was significantly higher than that in the control group (0.62 mmol/L ± 0.11 mmol/L; P < 0.05).

CONCLUSION

Early lipid-lowering therapy is more effective than conventional treatment in patients with HLAP and worthy of clinical application.

PPAR Agonists and Metabolic Syndrome: An Established Role?

Therapeutic approaches to metabolic syndrome (MetS) are numerous and may target lipoproteins, blood pressure or anthropometric indices. Peroxisome proliferator-activated receptors (PPARs) are involved in the metabolic regulation of lipid and lipoprotein levels, i.e., triglycerides (TGs), blood glucose, and abdominal adiposity. PPARs may be classified into the α, β/δ and γ subtypes. The PPAR-α agonists, mainly fibrates (including newer molecules such as pemafibrate) and omega-3 fatty acids, are powerful TG-lowering agents. They mainly affect TG catabolism and, particularly with fibrates, raise the levels of high-density lipoprotein cholesterol (HDL-C). PPAR-γ agonists, mainly glitazones, show a smaller activity on TGs but are powerful glucose-lowering agents. Newer PPAR-α/δ agonists, e.g., elafibranor, have been designed to achieve single drugs with TG-lowering and HDL-C-raising effects, in addition to the insulin-sensitizing and antihyperglycemic effects of glitazones. They also hold promise for the treatment of non-alcoholic fatty liver disease (NAFLD) which is closely associated with the MetS. The PPAR system thus offers an important hope in the management of atherogenic dyslipidemias, although concerns regarding potential adverse events such as the rise of plasma creatinine, gallstone formation, drug-drug interactions (i.e., gemfibrozil) and myopathy should also be acknowledged.