From the Guidelines
No, Atorvastatin does not need to be stopped before adding Fenofibrate in a patient with hypertriglyceridemia, as Fenofibrate may be considered concomitantly with a low- or moderate-intensity statin only if the benefits from ASCVD risk reduction or triglyceride lowering when triglycerides are 500 mg/dL are judged to outweigh the potential risk for adverse effects 1. When considering the addition of Fenofibrate to Atorvastatin, it is essential to evaluate the potential benefits and risks, particularly the increased risk of muscle-related side effects.
- Key considerations include:
- Baseline renal status should be evaluated before Fenofibrate initiation, within 3 months after initiation, and every 6 months thereafter, with assessment of both serum creatinine level and eGFR based on creatinine 1.
- Fenofibrate should not be used if moderate or severe renal impairment, defined as eGFR <30 mL/min per 1.73 m2, is present 1.
- The dose of Fenofibrate should not exceed 54 mg/day if eGFR is between 30 and 59 mL/min per 1.73 m2 1.
- Patients should be monitored for signs of muscle toxicity, such as unexplained muscle pain, tenderness, or weakness, and educated to report these symptoms immediately. The combination of Atorvastatin and Fenofibrate can be useful in patients with diabetes or metabolic syndrome who often have both elevated LDL cholesterol and triglycerides, but requires careful monitoring and consideration of the potential risks and benefits 1.
From the Research
Patient with Hypertriglyceridemia on Atorvastatin
- The patient is currently taking Atorvastatin for hypertriglyceridemia, but the question arises whether Atorvastatin should be stopped before adding Fenofibrate to the treatment regimen.
- According to the study 2, Atorvastatin has been shown to significantly lower levels of triglyceride-rich remnant lipoproteins and favorably change LDL particle size in patients with hypertriglyceridemia.
- However, the study 3 suggests that for patients with severe hypertriglyceridemia, the addition of fibrates or omega-3 fatty acids may be necessary to further reduce residual ASCVD risk.
Addition of Fenofibrate
- The study 4 demonstrates the effectiveness and safety of Fenofibrate in routine treatment of patients with hypertriglyceridemia and metabolic syndrome, with significant reductions in TG, LDL-C, and non-HDL-C levels.
- Another study 5 recommends the addition of fibrates, such as Fenofibrate, if elevated triglyceride or non-high-density lipoprotein cholesterol levels persist despite the use of high-intensity statin therapy.
- The study 6 examines the effect of Atorvastatin on lipid and apolipoprotein levels and distribution in patients with hypertriglyceridemia, but does not provide direct evidence on the interaction between Atorvastatin and Fenofibrate.
Stopping Atorvastatin before Adding Fenofibrate
- There is no direct evidence from the provided studies to suggest that Atorvastatin should be stopped before adding Fenofibrate to the treatment regimen.
- However, the studies 3 and 5 imply that the addition of Fenofibrate may be necessary to further reduce residual ASCVD risk in patients with hypertriglyceridemia, and that Atorvastatin can be continued while adding Fenofibrate, as there is no mention of stopping Atorvastatin before adding Fenofibrate.