Fibrate Use in the United States and Canada—Reply

In Reply: The letters from Drs Tenenbaum and Fisman and Drs Lim and Wong address 2 common arguments for the use of fibrates. In the United States, most of the fibrate sales are for formulations of fenofibrate. There are 2 large trials that have failed to show that fenofibrate reduces risk and none that show benefit. In ACCORD, the prespecified subgroup analysis to evaluate the tertile of the highest triglyceride concentration (≥204 mg/dL)/lowest high-density lipoprotein level (≤34 mg/dL) failed to show that fenofibrate was statistically significantly different from the comparison group.¹ The meta-analysis by Sacks et al cited by Tenenbaum and Fisman performed a post hoc analysis of 5 fibrate trials that used different fibrates, employed different lipid profile cutoffs (triglyceride, >180 to ≥204 mg/dL; high-density lipoprotein, ≤34 to <50 mg/dL), and were conducted in different prevention eras.² These analyses should be viewed as hypothesis generating. Our analysis of the evidence is consistent with the recent American Heart Association scientific statement that says that the effect of fibrates on patient risk is debatable and recommends lifestyle modification with diet and exercise as initial management in these types of patients, with fibrate therapy only recommended in those with triglyceride concentrations of 500 mg/dL or greater.³