From the Guidelines
For patients with chronic kidney disease stage 3 (CKD 3), fenofibrate is the preferred fibrate option, requiring dose adjustment to 48 mg daily, while gemfibrozil may be used at 600 mg twice daily with caution. The use of fibrates in CKD 3 patients is supported by the 2012 KDOQI clinical practice guideline for diabetes and CKD, which recommends dose adjustments for lipid-lowering medications in CKD patients 1. According to the guideline, fenofibrate should be initiated at a lower dose of 48 mg daily in CKD 3 patients, while gemfibrozil may be used at 600 mg twice daily.
The 2015 KDOQI US commentary on the 2013 KDIGO clinical practice guideline for lipid management in CKD also supports the use of fibrates in CKD patients, but with caution, due to the increased risk of myopathy and further kidney function deterioration, especially when combined with statins 1. The commentary recommends that fibrates be reserved for cases of severe hypertriglyceridemia (>500 mg/dL) where the risk of pancreatitis outweighs potential adverse effects.
Key considerations for the use of fibrates in CKD 3 patients include:
- Regular monitoring of kidney function, creatinine, and muscle enzymes
- Assessments recommended at baseline, 3 months after initiation, and periodically thereafter
- Discontinuation of the fibrate if creatinine increases by more than 30% or GFR declines significantly
- Activation of peroxisome proliferator-activated receptors (PPARs) to regulate lipid metabolism and reduce triglycerides and increase HDL cholesterol
- Uncertain cardiovascular benefit of fibrates in CKD patients, making them suitable only for severe hypertriglyceridemia cases.
Overall, the use of fibrates in CKD 3 patients requires careful consideration of the potential benefits and risks, and close monitoring of kidney function and lipid profiles 1.
From the FDA Drug Label
Treatment with fenofibrate tablets should be initiated at a dose of 54 mg per day in patients having mild to moderately impaired renal function and increased only after evaluation of the effects on renal function and lipid levels at this dose. The use of fenofibrate tablets should be avoided in patients with severe renal impairment [see Use in Specific Populations (8. 6) and Clinical Pharmacology (12.3)].
For patients with Chronic Kidney Disease (CKD) stage 3, the recommended initial dose of fenofibrate is 54 mg per day. The dose may be increased after evaluating the effects on renal function and lipid levels. Fenofibrate is a suitable option for these patients. 2 2 2
From the Research
Fibrate Options for CKD 3
- Fibrate therapy is a class of lipid-lowering medications that can be used in patients with chronic kidney disease (CKD) 3.
- The use of fibrates in CKD patients has been associated with a reduction in cardiovascular risk, including a lower risk of major adverse cardiac and cerebrovascular events 4, 5, 6.
- Fenofibrate, in particular, has been shown to delay the need for dialysis and reduce cardiovascular risk in patients with advanced CKD 4.
- However, fibrate therapy can also increase serum creatinine levels, which may not necessarily represent a true deterioration in renal function 3, 7.
- The effects of fibrates on kidney function are still not fully understood, and further studies are needed to determine their safety and efficacy in CKD patients 5, 7.
- Pemafibrate, a newer fibrate, has been shown to be associated with a decreased risk of major adverse cardiovascular events in CKD patients, and may have a superior effect compared to other fibrates 6.
- The decision to use fibrates in CKD patients should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 3, 5.