From the Guidelines
Daily use of statins and fibrates together is possible but should only be done under close medical supervision due to increased risk of side effects, particularly muscle problems. When considering the combination of these two drugs, it's essential to weigh the benefits against the potential risks. The primary concern with this combination is the increased risk of myopathy and rhabdomyolysis, as noted in studies such as 1. To minimize this risk, it's recommended to use the lowest effective doses of both medications and to monitor patients closely for signs of muscle damage.
Key Considerations
- Statins, such as atorvastatin or simvastatin, are typically taken once daily in the evening, with doses ranging from 10 to 80 mg depending on the specific drug and patient needs.
- Fibrates, such as gemfibrozil or fenofibrate, are usually taken once or twice daily, often with meals.
- A common regimen might be atorvastatin 20 mg at bedtime and fenofibrate 145 mg once daily with breakfast.
- Regular monitoring of liver enzymes and muscle symptoms is crucial when using this combination.
Mechanism of Action
- Statins primarily lower LDL cholesterol by inhibiting its production in the liver.
- Fibrates mainly reduce triglycerides and increase HDL cholesterol by activating certain genes involved in lipid metabolism, as discussed in 1 and 1.
Patient Selection
- This combination is generally reserved for patients with very high triglycerides and LDL cholesterol who haven't responded adequately to single-drug therapy.
- Patients with diabetes or established cardiovascular disease may benefit from this combination, but close monitoring is necessary to minimize the risk of adverse effects.
Monitoring and Safety
- Patients should be instructed to report any warning symptoms, such as myalgia, to their healthcare provider promptly.
- Regular monitoring of liver enzymes, creatinine, and muscle symptoms is essential to minimize the risk of adverse effects.
- The combination of statins with fibrates, especially gemfibrozil, may carry an increased risk of myositis, as noted in 1.
From the Research
Effects of Daily Use of Statin and Fibrate
The daily use of statin (HMG-CoA reductase inhibitor) and fibrate (fibrinic acid derivative) has several effects on the body. Some of the key effects include:
- Reduction in cardiovascular risk: Combination therapy with statins and fibrates can improve lipid and lipoprotein profiles, reducing the risk of cardiovascular events 2, 3, 4.
- Increased risk of myopathy: The combination of statins and fibrates can increase the risk of myopathy, including rhabdomyolysis, due to elevated levels of statins in the blood 2, 3, 5.
- Improvement in lipid profiles: Statins and fibrates can reduce levels of low-density lipoprotein (LDL) cholesterol, triglycerides, and increase levels of high-density lipoprotein (HDL) cholesterol 3, 6.
- Potential for adverse effects on skeletal muscle: The combination of statins and fibrates can have adverse effects on skeletal muscle, including myopathy, which can be increased by factors such as high doses, combination with certain fibrates, and underlying medical conditions 2, 5.
Factors Influencing the Risk of Myopathy
Several factors can influence the risk of myopathy associated with the combination of statins and fibrates, including:
- Type of fibrate used: Fenofibrate is associated with a lower risk of myopathy compared to gemfibrozil 2, 3.
- Dose of statin and fibrate: Higher doses of statins and fibrates can increase the risk of myopathy 5.
- Underlying medical conditions: Conditions such as hypothyroidism, renal insufficiency, and intake of cytochrome P450 inhibitors can increase the risk of myopathy 5.
- Monitoring and management: Regular monitoring of clinical and laboratory alterations can help identify potential myopathy, and prompt withdrawal of lipid-lowering drugs can prevent further complications 5.