"Dr. Andrew B. Chung, MD/PhD" > wrote in message news:<1100529306.ghI4DRtNXozHfRGslYVoIA@teranews>. ..
> David Rind wrote:
>
> > Ed Mathes wrote:
> > > So, Dr. Harris, what do you propose then for patients who don't tolerate
> > > statins? Remember, although primarily triglyceride drugs, fibrates also
> > > have effects on other cholesterol parameters.
> > >
> > > Ed
> >
> > Dr. Harris can give his own answer, but my take on this is that in
> > patients who don't tolerate statins we're in the same situation we were
> > before the statins were available: there is no evidence that any of the
> > other cholesterol-lowering medications are of benefit in primary
> > prevention, and several studies suggest these drugs cause harm.
> >
> > In secondary prevention, using a fibrate or niacin is a reasonable
> > option (though one that doesn't get you enormous benefits). In primary
> > prevention, you mostly need to accept that we don't have any medications
> > other than statins that have been show to work.
> >
> > --
> > David Rind
> >
>
> Yes, David, you are correct that the story concerning the benefit of using
> non-statin lipid lowering medications for primary prevention is not complete.
>
> However, fenofibrate either singly or in combination with statins will likely
> to have a role in primary prevention of atherosclerosis in folks with
> Metabolic Syndrome (MetS) who have insulin resistance and secondary prevention
> of atherosclerosis in folks with Type 2 Diabetes.
>
> This is suggested by DAIS as cited by Ed Mathes.


COMMENT:

It is not. At best the DAIS findings "suggest" a role for fibrates in
diabetics, but even that's not proven. By the time you get to people
with metabolic syndrome, you're way down on the evidence curve. It's
hard enough even to show that statins save lives when you're doing
primary prevention in people who merely have metabolic syndrome, but
not yet frank diabetes. For fibrates, you're in even worse trouble.




There is a case to be made
> for being proactive here and not wait for "definitive" trials because these
> folks are at high risk for cardiovascular events. I would commend Ed for his
> position which is one of concern for his patients.


COMMENT:

His concern for his patients has nothing to do with it. Part of
concern in medicine is "first, do no harm." Gemfibrozil has had at
least 20,000 patient-years of placebo controlled trial to show that it
prevents heart attack death or death in people with "metabolic
syndrome." It has failed. Do you know how much 20,000 patient years of
gembribrozil costs, Andrew? Something on the high side of $10
million. Any "definitive trials" showing it saves lives will
certainly show it costs more than $10 million per life to do it, if at
all. And will be lucky if they don't show it (on net) kills people,
like clofibrate.

There are opportunity costs in medical care. $10 million you spend
here is $10 million you don't get to spend there. Even if Ed is very
lucky and gemfibrozile does save lives and it's only $10 million per
life, there are better ways to spend the money in medicine. I can
think of many, many areas of preventive medicine in which you can save
certainly more than one life for $10 million.


SBH