Interpreting clinical trials of diabetic dyslipidaemia: new insights

High residual cardiovascular risk after lipid-lowering: prime time for Predictive, Preventive, Personalized, Participatory, and Psycho-cognitive medicine

As time has come to translate trial results into individualized medical diagnosis and therapy, we analyzed how to minimize residual risk of cardiovascular disease (CVD) by reviewing papers on "residual cardiovascular disease risk". During this review process we found 989 papers that started off with residual CVD risk after initiating statin therapy, continued with papers on residual CVD risk after initiating therapy to increase high-density lipoprotein-cholesterol (HDL-C), followed by papers on residual CVD risk after initiating therapy to decrease triglyceride (TG) levels. Later on, papers dealing with elevated levels of lipoprotein remnants and lipoprotein(a) [Lp(a)] reported new risk factors of residual CVD risk. And as new risk factors are being discovered and new therapies are being tested, residual CVD risk will be reduced further. As we move from CVD risk reduction to improvement of patient management, a paradigm shift from a reductionistic approach towards a holistic approach is required. To that purpose, a personalized treatment dependent on the individual's CVD risk factors including lipid profile abnormalities should be configured, along the line of P5 medicine for each individual patient, i.e., with Predictive, Preventive, Personalized, Participatory, and Psycho-cognitive approaches.

Fenofibric acid for hyperlipidemia

INTRODUCTION

3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (i.e., statins) are the mainstay of therapy for hyperlipidemia, as per the current National Cholesterol Education Program (NCEP) recommendation. However, the role of other agents, such as the fibrates, is continually being debated in the context of incremental risk reduction, especially in the setting of mixed dyslipidemia. Results from the ACCORD Trial have further added to the confusion. Fibrates also have a role to play in familial hyperlipidemias and in hypertriglyceridemia. Fenofibric acid is one of the newly approved forms of fenofibrate with enhanced bioavailability and was recently approved by the Food and Drug Administation (FDA) for the treatment of various types of hyperlipidemia, in conjunction with statins.

AREAS COVERED

This article reviews the role of fenofibric acid in the context of results from recent randomized trials on fenofibrate, including the ACCORD Trial. It discusses the current status of fenofibric acid in the management of dyslipidemia, especially in combination with statins, and also addresses the comparative efficacy and safety profile of this new molecule against other agents in its class.

EXPERT OPINION

Fenofibric acid in combination with low- to moderate-dose statins is an effective and safe option in the treatment of mixed dyslipidemia, although the long-term effects on cardiovascular risk reduction need to be explored further.

Fibrates in the treatment of cardiovascular risk and atherogenic dyslipidaemia

PURPOSE

New data have emerged over the last few years about the role of fibrates in treatment of microvascular and macrovascular disease.

RECENT FINDINGS

Endpoint studies have been conducted with fibrates in coronary heart disease (CHD) since 1971 and initial results were contradictory. Fibrates later showed benefits in patients with low HDL-C and low LDL-C. The prominence ascribed to the lipid triad of the metabolic syndrome and the increasing prevalence of diabetes has increased the topicality of fibrates given their main action of converting small dense to light buoyant LDL. The Fenofibrate Intervention in Endpoint Lowering in Diabetes (FIELD) study has carried on the tradition. Fenofibrate therapy in 9795 patients comprising a mixed low-risk primary and a medium-risk secondary prevention cohort resulted in an 11% reduction in coronary events (P = 0.16), a similar but significant reduction in cardiovascular events (P = 0.04; number-needed-to-treat = 70). The benefits were concentrated in primary prevention and on nonfatal myocardial events, and post-hoc greater effects were seen in patients with moderate hypertriglyceridaemia (>2.3 mmol/l) and low HDL-C, as had previously been noted in a trial with bezafibrate. Safety was generally good, including in combination with statins, but old concerns about sudden death, pancreatitis and venous thrombosis returned. Unexpected benefits were seen with fenofibrate for microvascular endpoints including microalbuminuria and retinopathy.

SUMMARY

Fenofibrate and bezafibrate are reasonable second-line therapies for dyslipidaemia and in diabetes, and well tolerated in combination therapy. The benefits of fenofibrate for microvascular disease and its potential role in combination therapy require further confirmation.

Fibrate therapy in the management of dyslipidemias, alone and in combination with statins: role of delayed-release fenofibric acid

IMPORTANCE OF THE FIELD

Optimization of lipid management is a crucial aspect in the treatment of cardiovascular disease. Currently, HMG-CO reductase inhibitors (statins) are a mainstay of therapy. While this class of drugs has proven efficacy at lowering low-density lipoprotein cholesterol (LDL-C), their effects on other important lipid parameters, such as high-density lipoprotein cholesterol (HDL-C) and triglycerides, are less robust.

AREAS COVERED IN THIS REVIEW

The current paper will address the significance of these secondary targets and review currently available therapies, including a new formulation of delayed-release fenofibric acid. A comprehensive MEDLINE search (1966 to September 2009) was performed.

WHAT THE READER WILL GAIN

The reader will gain a comprehensive review of the importance of secondary cholesterol targets, as well as the effectiveness of currently available therapies to address non-LDL-C. The role of the newly released fenofibric acid will also be addressed, as well as its potential use in combination therapy with a statin.

TAKE HOME MESSAGE

Adequate treatment of lipid parameters beyond LDL-C is an essential component in the treatment of dyslipidemia. The fibrate class of drugs has proven efficacy in improving secondary targets; however, concerns regarding severe myopathy and rhabdomyolysis have limited their combination with statins. Recently, a new fibrate derivative, fenofibric acid, has become available. Studies to date reflect a positive safety and tolerability profile when combined with statins. This may offer a new tool to address the important secondary cholesterol targets that are becoming increasingly recognized as important contributors to cardiovascular outcomes.