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Cholesterol Medications: Statins vs. Fibrates

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It may surprise you to learn that approximately 100 million, or one-third of Americans, have unhealthy cholesterol levels and are at risk of major vascular events. Diet and exercise can help bring cholesterol numbers down naturally in some people. But if these lifestyle changes don’t work for you, your doctor may recommend lipid-lowering drugs as the next step in reducing your cardiovascular risk factors. Two common types of medications used to treat high cholesterol are statins and fibrates. Please continue reading to learn more about the differences between the two.

What are lipid-lowering drugs?

Lipid-lowering drugs bring down your cholesterol levels and reduce your risk of cardiovascular disease. These medications are effective for primary prevention in high-risk patients, i.e., reducing cardiovascular risk in people who have not yet had any major cardiovascular events. They are also effective for secondary prevention of subsequent events, i.e., improving cardiovascular outcomes in patients who have had previous events. 

There are mainly two types of medications used as cholesterol-lowering drugs - statins and fibrates. 

Statin Therapy

Statins can lower your cholesterol by blocking a substance that the body needs to make cholesterol. By reducing cholesterol levels, statin therapy can significantly reduce your risk of heart disease and stroke. Statin treatment also helps stabilize plaques in blood vessels and reduces the risk of blood clots. 

Examples of statins available in the US are simvastatin (Zocor), atorvastatin (Lipitor), rosuvastatin (Crestor), pravastatin (Pravachol), lovastatin (Mevacor, Altoprev), and pitavastatin (Zypitamag, Livalo). Statin medications are also available in combination with other medications, for example, Caduet (atorvastatin and amlodipine) and Vytorin (ezetimibe and simvastatin).

Fibrate Therapy

Fibrates are the other group of medicines that are prescribed to lower high blood cholesterol. They are particularly effective in lowering serum triglyceride levels. Fibrates also help raise the levels of high-density lipoprotein cholesterol (HDL-C) or “good” cholesterol. High triglyceride and low HDL cholesterol levels are associated with an increased risk of heart disease, myocardial infarction (heart attack), and stroke. 

Examples of fibrate medications include gemfibrozil (Lopid), fenofibrate (Fenoglide, Antara, Tricor, Lipofen, and Triglide), and fenofibric acid (Trilipix).

Are statins better than fibrates?

Statin treatment can be very effective in lowering low-density lipoprotein (LDL) cholesterol levels, also called “bad” cholesterol, by 20%-60%. This can significantly reduce your risk of coronary artery disease and cardiovascular events like stroke. Most physicians choose statin therapy as a first-line treatment for high cholesterol because these drugs are popular and have been studied extensively for safety and efficacy.

Nonetheless, randomized controlled trials have shown that fibrates are effective in treating atherogenic dyslipidemia. This group of medications can help to reduce triglyceride levels and raise high-density lipoprotein cholesterol (HDL-C), also called “good cholesterol.” Fibrates are especially useful in reducing cardiovascular risk factors in people with metabolic syndrome, which is a cluster of conditions including high blood pressure, high blood sugar levels, high cholesterol, and triglyceride levels. However, fibrates are less effective in lowering LDL cholesterol levels (low-density lipoprotein cholesterol or bad cholesterol).

In general, doctors try statin therapy first and prescribe fibrates to patients who cannot tolerate statin treatment. 

Which is better, statin or fenofibrate, in reducing the risk of coronary heart disease?

Hyperlipidemia or mixed dyslipidemia are present with elevated LDL cholesterol and triglycerides levels with low HDL cholesterol levels. This condition is associated with an increased risk of cardiovascular disease. 

As mentioned above, statins are effective in reducing LDL cholesterol, and fibrates are effective in reducing serum triglycerides while raising HDL cholesterol. Therefore, there is no one-size-fits-all cholesterol-lowering therapy. Physicians generally will evaluate the risks vs. the benefits of each type of therapy for each patient. 

Randomized controlled trials and subgroup analysis have shown that fenofibrate treatment or other fibrate drug therapy is more useful in patients with obesity (body mass index of 30 or higher), metabolic syndrome, and diabetes mellitus, especially if LDL cholesterol levels are under 130 mg/dL and triglyceride and HDL levels are only moderately high.

Also, fibrates are good options for a small number of people who don’t do well on statin therapy. For instance, statin treatment simply does not work in some people, and others discontinue statin therapy due to intolerable side effects.

Can you take a statin and a fibrate?

Combining statins and fibrates should only be undertaken under strict medical supervision. This is because while the risk for muscle damage with either a statin or a fibrate alone is not very significant, combination therapy with both a statin and a fibrate can increase this risk by more than six times. 

What is the best cholesterol medication with the least side effects?

It is difficult to directly compare the effects of statins and fibrates on cardiovascular morbidity and mortality. In general, statins tend to be associated with lower adverse effects than fibrates. Among the different statins, simvastatin (Zocor) and pravastatin (Pravachol) have been found to cause the fewest side effects. 

However, fibrates do have the edge over statins in other ways. They are significantly better at boosting HDL levels and reducing triglyceride levels. Fibrates are particularly effective in diabetic patients with high triglycerides and low HDL cholesterol levels. 

The Takeaway

The most important thing is to keep an eye on your average cholesterol levels. The National Cholesterol Education Program (NCEP) recommends that all adults aged 20 years and older should have their blood cholesterol measured. High blood cholesterol is linked to serious diseases like high blood pressure, coronary artery disease, stroke, diabetes, and peripheral vascular disease. 

If you have multiple risk factors for coronary heart disease events, and if lifestyle changes like diet, exercise, and weight control have not been effective at lowering your cholesterol, then cholesterol-lowering drugs, either statins or fibrates, are worth considering. Patients treated with these medications experience a substantial reduction in the risk of major cardiovascular events such as heart attacks and strokes. You should work with your doctor to decide which is better for you, statins vs fibrates, to improve your overall cardiovascular outcomes.
 

References

  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2980504/
  2. https://www.mayoclinic.org/diseases-conditions/high-blood-cholesterol/in-depth/statins/art-20045772
  3. https://medlineplus.gov/ency/patientinstructions/000789.htm
  4. https://www.health.harvard.edu/newsletter_article/help-for-your-cholesterol-when-the-statins-wont-do
  5. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0246480