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Severe decrease in high-density lipoprotein cholesterol with the combination of fibrates and ezetimibe: A case series
Estelle Nobecourt1, Bertrand Cariou2, Gilles Lambert3
1Department of Endocrinology, Metabolic diseases and Nutrition, l'institut du thorax, CHU de Nantes, Nantes, France; CRNH, Human Nutrition Research Center, CHU, Nantes, France; INRA, UMR 1280, Physiologie des Adaptations Nutritionnelles, CHU Hôtel-Dieu, Nantes, France.
Insights
A rare condition, drug-induced low high-density lipoprotein cholesterol (HDL-C) can occur. Combining fibrates and ezetimibe may increase risk, necessitating careful HDL-C monitoring in patients.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Lipidology
Background:
- Familial hypercholesterolemia and mixed dyslipidemia are common lipid disorders.
- Statins and fibrates are frequently used to manage dyslipidemias.
- Drug-induced decreases in high-density lipoprotein cholesterol (HDL-C) are rare.
Observation:
- Two patients with familial hypercholesterolemia on statins and fibrates, and two with mixed dyslipidemia on fibrates, experienced severe HDL-C drops (-44% to -95%).
- Three patients on fibrates experienced a sudden HDL-C decrease after adding ezetimibe.
- HDL-C levels normalized upon discontinuation of the implicated medications.
Findings:
- A combination therapy of fibrates and ezetimibe was associated with a sudden and severe decrease in HDL-C in susceptible patients.
- Reintroducing ezetimibe alone did not impact HDL-C levels in two patients, suggesting a synergistic effect with fibrates.
Implications:
- Identifies a new patient profile at risk for significant HDL-C reduction due to combined fibrate and ezetimibe therapy.
- Recommends close monitoring of plasma HDL-C levels in patients prescribed both fibrates and ezetimibe.
- Highlights the importance of pharmacovigilance for rare but severe adverse drug reactions affecting lipid profiles.
Abstract:
A sudden and severe drug-induced decrease in plasma high-density lipoprotein cholesterol (HDL-C) is a rare condition. We report 2 patients with familial hypercholesterolemia treated with statins and fibrates and 2 others with mixed dyslipidemia treated with fibrates, who presented with a sudden and severe decrease in HDL-C (from -44% to -95%, compared with baseline). Three of the patients were treated with fibrates and had a sudden decrease in HDL-C after the adjunction of ezetimibe. HDL-C returned to normal levels after discontinuation of the offending therapies. In 2 of these patients, the reintroduction of ezetimibe with no fibrates did not affect HDL-C. In conclusion, we report a new profile of patients who are at risk for a sudden drop of HDL-C related to treatment with a combination of fibrates and ezetimibe. Although a sudden drop of HDL-C is a rare event, we recommend to carefully monitor plasma HDL-C in patients submitted to both drugs.