Fenofibrate

Fenofibrate, sold under the brand name Tricor among others, is a medication of the fibrate class used to treat abnormal blood lipid levels.[2] It is less preferred to statin medications as it does not appear to reduce the risk of heart disease or death.[2][3] Its use is recommended together with dietary changes.[2] It is taken by mouth.[2]

Fenofibrate
Clinical data
Trade namesFenoglide, Lipofen, others
AHFS/Drugs.comMonograph
MedlinePlusa601052
License data
Pregnancy
category
  • AU: B3
  • US: N (Not classified yet)
    Routes of
    administration    		By mouth
    ATC code
    Legal status
    Legal status
    • UK: POM (Prescription only) [1]
    • US: ℞-only
    • In general: ℞ (Prescription only)
    Pharmacokinetic data
    Protein binding99%
    Metabolismglucuronidation
    Elimination half-life20 h
    Excretionurine (60%), feces (25%)
    Identifiers
    CAS Number
    PubChem CID
    IUPHAR/BPS
    DrugBank
    ChemSpider
    UNII
    KEGG
    ChEBI
    ChEMBL
    CompTox Dashboard (EPA)
    ECHA InfoCard100.051.234
    Chemical and physical data
    FormulaC20H21ClO4
    Molar mass360.83 g·mol−1
    3D model (JSmol)
    Melting point80 to 81 °C (176 to 178 °F)
      (verify)

    Common side effects include liver problems, breathing problems, abdominal pain, muscle problems, and nausea.[2] Serious side effects may include toxic epidermal necrolysis, rhabdomyolysis, gallstones, blood clots, and pancreatitis.[2] Use in pregnancy and breastfeeding is not recommended.[3][4] It works by a number of mechanisms.[2]

    It was patented in 1969, and came into medical use in 1975.[5] It is available as a generic medication.[3] In 2017, it was the 70th most commonly prescribed medication in the United States with more than eleven million prescriptions.[6][7]

    Medical uses

    Fenofibrate is mainly used for primary hypercholesterolemia or mixed dyslipidemia. Fenofibrate appears to decrease the risk of cardiovascular disease and possibly diabetic retinopathy in those with diabetes mellitus,[8][9] and firstly indicated for the reduction in the progression of diabetic retinopathy in patients with type 2 diabetes and existing diabetic retinopathy in Australia.[10] It also appears to be helpful in decreasing amputations of the lower legs in this same group of people.[11] Fenofibrate also has an off-label use as an added therapy of high blood uric acid levels in people who have gout.[12]

    It is used in addition to diet to reduce elevated low-density lipoprotein cholesterol (LDL), total cholesterol, triglycerides (TG), and apolipoprotein B (apo B), and to increase high-density lipoprotein cholesterol (HDL) in adults with primary hypercholesterolemia or mixed dyslipidemia.[13]

    It is used in addition to diet for treatment of adults with severe hypertriglyceridemia. Improving glycemic control in diabetics showing fasting chylomicronemia will usually decrease the need for pharmacologic intervention.[13]

    Statins remain the first line for treatment of blood cholesterol. AHA guidelines from 2013 did not find evidence for routine use of additional medications.[14]

    Additionally, in 2016, the FDA filed "Withdrawal of Approval of Indications Related to the Coadministration With Statins in Applications for Niacin Extended-Release Tablets and Fenofibric Acid Delayed Release Capsules" noting "the Agency has concluded that the totality of the scientific evidence no longer supports the conclusion that a drug-induced reduction in triglyceride levels and/or increase in HDL cholesterol levels in statin-treated patients results in a reduction in the risk of cardiovascular events. Consistent with this conclusion, FDA has determined that the benefits of niacin ER tablets and fenofibric acid DR capsules for coadministration with statins no longer outweigh the risks, and the approvals for this indication should be withdrawn."[15]

    Contraindications

    Fenofibrate is contraindicated in:[13]

    • Patients with severe renal impairment, including those receiving dialysis (2.7-fold increase in exposure, and increased accumulation during chronic dosing in patients with estimated glomerular filtration rate < 30 mL/min)
    • Patients with active liver disease, including those with primary biliary cirrhosis and unexplained persistent liver function test abnormalities
    • Patients with preexisting gallbladder disease
    • Nursing mothers
    • Patients with known hypersensitivity to fenofibrate or fenofibric acid

    Adverse effects

    The most common adverse events (>3% of patients with coadministered statins) are[16]

    Precautions

    When fenofibrate and a statin are given as combination therapy, it is recommended that fenofibrate be given in the morning and the statin at night, so that the peak dosages do not overlap.[17]

    Musculoskeletal

    Hepatotoxicity

    Nephrotoxicity

    Biliary

    Coagulation/Bleeding

    • Exercise caution in concomitant treatment with oral Coumadin anticoagulants (e.g. warfarin). Adjust the dosage of Coumadin to maintain the prothrombin time/INR at desired level to prevent bleeding complications.[16]

    Overdose

    "There is no specific treatment for overdose with fenofibric acid delayed-release capsules. General supportive care is indicated, including monitoring of vital signs and observation of clinical status". Additionally, hemodialysis should not be considered as an overdose treatment option because fenofibrate heavily binds to plasma proteins and does not dialyze well.[16]

    Interactions

    These drug interactions with fenofibrate are considered major and may need therapy modifications:

    • Bile acid sequestrants (e.g. cholestyramine, colestipol, etc.): If taken together, bile acid resins may bind to fenofibrate, resulting in a decrease in fenofibrate absorption. To maximize absorption, patients need to separate administration by at least 1 h before or 4 h to 6 h after taking the bile acid sequestrant.[16][18]
    • Immunosuppressants (e.g. ciclosporin or tacrolimus): An increased risk of renal dysfunction exists with concomitant use of immunosuppressants and fenofibrate. Approach with caution when coadministering additional medications that decrease renal function.[19]
    • Vitamin K antagonists (e.g. warfarin): As previously mentioned, fenofibrate interacts with coumadin anticoagulants to increase the risk of bleeding. Dosage adjustment of vitamin K antagonist may be necessary.[16]
    • Statins: Combination of statins and fenofibrate may increase the risk of rhabdomyolysis or myopathy.[20]

    Mechanism of action

    "In summary, enhanced catabolism of triglyceride-rich particles and reduced secretion of VLDL underlie the hypotriglyceridemic effect of fibrates, whereas their effect on HDL metabolism is associated with changes in HDL apolipoprotein expression."[21]

    Fenofibrate is a fibric acid derivative, a prodrug comprising fenofibric acid linked to an isopropyl ester. It lowers lipid levels by activating peroxisome proliferator-activated receptor alpha (PPARα). PPARα activates lipoprotein lipase and reduces apoprotein CIII, which increases lipolysis and elimination of triglyceride-rich particles from plasma.[21]

    PPARα also increases apoproteins AI and AII, reduces VLDL- and LDL-containing apoprotein B, and increases HDL-containing apoprotein AI and AII.

    Formulations

    Fenofibrate is available in several formulations and is sold under several brand names, including Tricor by AbbVie, Lipofen by Kowa Pharmaceuticals America Inc, Lofibra by Teva, Lipanthyl, Lipidil, Lipantil micro and Supralip by Abbott Laboratories, Fenocor-67 by Ordain Health Care, Fibractiv 105/35 by Cogentrix Pharma( India), Fenogal by SMB Laboratories, Antara by Oscient Pharmaceuticals, Tricheck by Zydus (CND), Atorva TG by Zydus Medica, Golip by GolgiUSA and Stanlip by Ranbaxy (India). Different formulations may differ in terms of pharmacokinetic properties, particularly bioavailability; some must be taken with meals, whereas others may be taken without regard to food.[22]

    The active form of fenofibrate, fenofibric acid, is also available in the United States, sold as Trilipix. Fenofibric acid may be taken without regard to the timing of meals.[16][23]

    Controversy

    In the United States, Tricor was reformulated in 2005. This reformulation is controversial, as it is seen as an attempt to stifle competition from generic equivalents of the drug,[24] and is the subject of antitrust litigation by generic drug manufacturer Teva.[24] Also available in the United States, Lofibra is available in 54 and 160 mg tablets, as well as 67, 134, and 200;mg micronized capsules.[25] Generic equivalents of Lofibra capsules are currently available in all three strengths in the United States. In Europe, it is available in either coated tablet or capsule; the strength range includes 67, 145, 160 and 200 mg. The differences among strengths are a result of altered bioavailability (the fraction absorbed by the body) due to particle size. For example, 200 mg can be replaced by 160 mg micronized fenofibrate. The 145 mg strength is a new strength that appeared in 2005-2006 which also replaces 200 or 160 mg as the fenofibrate is nanonised (i.e. the particle size is below 400 nm).

    History

    Fenofibrate was first synthesized in 1974, as a derivative of clofibrate, and was launched on the French market shortly thereafter. It was initially known as procetofen, and was later renamed fenofibrate' to comply with World Health Organization International Nonproprietary Name guidelines.[26]

    Fenofibrate was developed by Groupe Fournier SA of France, which was acquired in 2005 by Solvay Pharmaceuticals, a business unit of the Belgian corporation Solvay S.A.. In 2009, Solvay was, in turn, acquired by Abbott Laboratories (now AbbVie in the US and Mylan in Europe, Canada, Australia, New Zealand and Japan).

    Research

    COVID-19

    In July 2020, researchers from Israel and the U.S. suggested that fenofibrate might significantly slow down the replication of the SARS-CoV-2 virus in lung cells.[27] This hypothesis awaits testing in clinical trials.

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    References
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    3. British national formulary : BNF 76 (76 ed.). Pharmaceutical Press. 2018. p. 198. ISBN 9780857113382.
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    • "Fenofibrate". Drug Information Portal. U.S. National Library of Medicine.
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