The Great Debate: Niacin vs. Fibrate Part 1

Which is better for treating lipids in combination with statins, niacin or fibrates?

Two presenters attempted to prove the case for each therapy in a debate at the 2010 Cardiometablic Health Congress.

Although the title of the session was “Debate on Niacin Versus Fibrates,” the session was much less of a debate and more of a friendly discourse. Henry Ginsberg, MD, and Allen Taylor, MD, each presented information for one of the two therapies and a rebuttal afterwards.

Ginsburg began his talk on fibrate, by mentioning that he believes niacin is a fine alternative as well, but prefers to use fibrate. Ginsberg presented a case report of a patient with the following characteristics: age 60, post MI 3 years, hypertension treated, LDL 140, BMI 29, triglycerides 250, HDL 35, and non-HDL 190.

He then provided an overview of the mechanisms related to insulin resistance and dyslipidemia. Ginsberg said it is always important to pay special attention to adipose tissue in evaluating insulin resistance. To provide an understanding of the role of niacin, Ginsberg highlighted the processes that contribute to insulin resistance. The liver oxidizes a great amount of fatty acids and turns them into triglycerides, he said, which triggers the pancreas to create more insulin. CETP then drives the lipid fluid to increase and HDL goes down while vLDL rises, he said. This approach relates to energy, he said. There is an energy balance distortion involving food intake and exercise, he explained. With many patients, more food is being taken in than necessary.

Most patients are first treated with statins to treat LDLs, but the next target should be HDL, he said. Fibrates help lower apoCIII (apolipoprotein CIII) production in humans. LPL and ApoA-1 both also increase, which effects HDL positively. There is a dramatic reduction in triglycerides in people with high LDL and low HDL, he said.

According to the ACCORD trial, treatment with fenofibrate was associated with a 40% reduction in retinopathy. In the same trial, the fenofibrate group experienced a sharp increase in HDL cholesterol within the first few months, but then the group’s improvement in HDL eventually progressed at a similar rate as the placebo group.

His recommendations were that every diabetic patient should be placed on statins first; then, if his or her LDL cholesterol is not reduced to below 90, a second statin should be used. If the HDL level is below 45 he would then add a fibrate.