At a time when the
lipid management guidelines give more and more emphasis to the identification and treatment of high-risk patients with the
metabolic syndrome and diabetes, there is an obvious need to balance the known effects of
low-density lipoprotein (
LDL) lowering with the new evidence of clinical efficacy derived from the adjustment of
high-density lipoprotein (HDL) and
triglyceride levels. Whereas the
statins remain the drug of choice for patients who need to reach the
LDL goal,
fibrate therapy may represent the best intervention for subjects with atherogenic
dyslipidemia and an
LDL already close to goal. In addition, the concomitant use of
fibrates may significantly reduce cardiovascular risk in patients whose
LDL is controlled by
statin therapy. In this review, we evaluate the pharmacologic properties of the
fibrate drugs, with particular attention to the effects of
peroxisome proliferator activated receptor a activation in the control of
dyslipidemia as well as in the attenuation of
arterial inflammation. Clinical trials of
fibrates, such as the Helsinki Heart Study, Veterans Affairs
High-density lipoprotein Intervention Trial, Diabetes
Atherosclerosis Intervention Study, and
Bezafibrate Infarction Prevention trial, have conjured up a scenario for the clinical utility of
fibrates and their possible superiority to
statins in the management of obese,
insulin-resistant, and diabetic patients presenting with near-goal
LDL and inappropriate HDL and
triglyceride levels.