Fenofibrate Dosing in Dyslipidemia with Renal Impairment
For patients with dyslipidemia and impaired renal function, fenofibrate dosing should be adjusted based on renal function: 96 mg daily for normal/mild CKD, 48-54 mg daily for moderate CKD (eGFR 30-59 mL/min), and avoid use in severe CKD (eGFR <30 mL/min). 1, 2
Dosing Recommendations Based on Renal Function
Fenofibrate dosing must be carefully adjusted according to renal function:
| Renal Function | Recommended Dose |
|---|---|
| Normal or mild CKD (eGFR ≥60 mL/min) | 96-160 mg daily |
| Moderate CKD (eGFR 30-59 mL/min) | 48-54 mg daily |
| Severe CKD (eGFR <30 mL/min) | Avoid use |
For patients with severe hypertriglyceridemia, the initial dose can range from 54-160 mg daily, with individualization based on patient response and renal function 2.
Indications for Fenofibrate
Fenofibrate is indicated for:
- Primary hypercholesterolemia or mixed dyslipidemia (adjunctive to diet)
- Severe hypertriglyceridemia (TG ≥500 mg/dL) 2
The FDA label specifies that fenofibrate should be given with meals to optimize bioavailability 2.
Monitoring Requirements
When initiating fenofibrate therapy, especially in patients with impaired renal function, the following monitoring is essential:
- Baseline assessment: Renal function, liver function tests, lipid profile, and CPK levels
- Follow-up monitoring: Renal function should be assessed periodically, particularly in patients with moderate renal impairment
- Lipid levels: Should be monitored every 4-8 weeks initially to assess response and guide dose adjustments 1, 2
Special Considerations for Renal Impairment
- Fenofibrate clearance is significantly reduced in renal impairment, necessitating dose adjustment
- Treatment should be initiated at lower doses (54 mg daily) in patients with mild to moderate renal impairment
- Dose increases should only occur after careful evaluation of effects on renal function and lipid levels 2
- Fenofibrate is contraindicated in patients with severe renal impairment, including those receiving dialysis 2
Adverse Effects and Precautions
Fenofibrate may cause several adverse effects that require monitoring:
- Renal effects: Fenofibrate can cause transient increases in serum creatinine levels, particularly when combined with ACE inhibitors or ARBs 3
- Liver effects: Monitor liver function tests; discontinue if persistent elevations occur
- Myopathy risk: Increased risk when combined with statins, particularly in patients with renal impairment 1
- Drug interactions: May potentiate effects of coumarin anticoagulants, requiring INR monitoring 1
Clinical Pearls
- Fenofibrate-associated increases in serum creatinine are often transient and reversible, even without treatment discontinuation 3
- Consider discontinuing treatment if serum creatinine increases ≥30% from baseline 3
- The combination of fenofibrate with a statin is preferred over gemfibrozil-statin combinations due to lower risk of myopathy 1
- Elderly patients should receive dosing based on renal function rather than age alone 1, 2
Contraindications
Fenofibrate is contraindicated in:
- Severe renal impairment (eGFR <30 mL/min)
- Active liver disease
- Preexisting gallbladder disease
- Nursing mothers
- Known hypersensitivity to fenofibrate or fenofibric acid 2
By following these dosing guidelines and monitoring recommendations, fenofibrate can be safely and effectively used in patients with dyslipidemia and renal impairment, while minimizing the risk of adverse effects.