Statement 7

From the Clinical Practice Guidelines for the Management of Dyslipidemia by the Philippine Heart Association
This guideline starts below.

Statement 7

Fibrates may be recommended as an alternative to statins in diabetic patients with HDL less than 35 mg/dl AND LDL less than 90 mg/dl.

Summary of Evidence

Sound evidence for the use of fibrates in the primary prevention of CV events among diabetic patients was provided by the Diabetes Atherosclerosis Intervention Study (DAIS) and the St. Mary's Ealing, Northwick Park Diabetes Cardiovascular Disease Prevention (SEND-CAP) study. Although primarily intended for patients with diabetes, these trials were not powered for hard clinical outcomes but only for mechanistic or surrogate outcomes.

The pooled estimate for the composite endpoint of CV events indicated a significant 33% risk reduction. Data for other outcomes are not available, and adverse events from treatment are minimal and similar to placebo. Hence, fibrate use has a net benefit in the primary prevention of diabetic dyslipidemia. Cost analysis of three-year therapy using bezafibrate 400 mg OD or fenofibrate 200 mg OD on 32 patients to prevent one adverse CV event showed respective costs of PHP 0.88 and 0.1 million.

The recommendation for fibrates was "probably do it," as fibrates are probably more beneficial for patients with low HDL, considering its mechanism. The preference for statins over fibrates is indicated by inherent limitations of evidence for fibrates. As mentioned, DAIS and SENDCAP primarily evaluated mechanistic or surrogate outcomes rather than clinical ones, and were not powerful enough to evaluate clinical outcomes. Treatment thresholds were primarily based on DAIS, although cut-offs from the two studies approximate each other.