Fibrates and niacin: is there a place for them in clinical practice?

Niacin and fibrates are lipid-lowering drugs with actions to raise high density lipoprotein cholesterol (HDL-C), reduce triglycerides and non-HDL-C but with modest (if any) effect in reducing low density lipoprotein cholesterol (LDL-C). Niacin and fibrates have an evidence base from monotherapy trials starting from the Coronary Drug Project and more recently in combination therapy with statins.

This article reviews their place as lipid-lowering drugs in the light of recent trials adding them to baseline statin therapy. Literature searches were conducted using the terms 'cardiovascular disease (CVD)' and either 'niacin' or 'fibrate' (including individual compounds), concentrating on evidence from randomised controlled trials, meta-analyses and recent guideline statements.

Statins are the first choice for treating increased CVD risk due to raised non-HDL-C. Though raised triglycerides and reduced HDL-C, contribute to risk statins, are effective in reducing CVD events in all patients. Extra therapies add little in current trials. Niacin will have little role in the treatment of hyperlipidaemia. Other options in development to lower LDL-C further, raise HDL-C or reduce lipoprotein(a), may have the potential to replace niacin in particular. In contrast, fibrates may continue to have a role in the treatment of extreme hypertriglyceridaemia and in mixed hyperlipidaemia as they reduce CVD events and have additional benefits in improving diabetes and microvascular outcomes.