March 23rd, 2011
Fibrate Prescriptions: A Tale Of Two Countries
During the past decade, fibrate use more than doubled in the U.S. but remained relatively stable in Canada, according to a study just published in JAMA.
In January 2002, fibrate use was similar in the two countries: 336 prescriptions per 100,000 population in the U.S. versus 402 per 100,000 in Canada. By December 2009, the number in the U.S. had skyrocketed to 730 per 100,000, while the number in Canada hit only 474 per 100,000 . Most of the change in the U.S. was attributed to an increase in the use of branded fenofibrate, whereas in Canada, fibrate use shifted from branded drugs to generic ones.
The study investigators (including senior author Harlan Krumholz, who is editor-in-chief of CardioExchange) concluded that “at a time when a less-is-more approach is being embraced by the medical community, this ever-increasing pattern of prescribing brand-name medications without evidence of clinical benefit warrants attention and close scrutiny to ensure that such medication use is optimized for clinical benefit, while avoiding unwarranted costs.” Here, lead author Cynthia Jackevicius answers questions about the study from CardioExchange editor Susan Cheng.
Q: Accumulating evidence suggests that fibrates have limited clinical utility, yet this study shows that fibrate use is increasing in the U.S. What do you think are some of the main reasons behind that observation?
CJ: We did not specifically study the reasons for the increase in fibrate prescriptions, but prescribing changes are usually a result of changes in evidence, policy, or marketing. During the past decade, there was not any new evidence — or any widespread policy changes — to support fibrate use, so the most likely influential factor was marketing.
Q: Is your group likely to pursue an analysis of outcomes associated with the observed prescribing patterns?
CJ: Whether the increasing use of fibrates in the U.S. over the last decade translates into improved patient outcomes is uncertain, so we would definitely like to explore this more. The main evidence to support clinical outcomes benefit is from placebo-controlled trials with the older fibrates gemfibrozil and clofibrate. These trials exert substantial influence in the meta-analyses that show that fibrates in aggregate significantly reduce cardiac events but not overall mortality. The relevance of this older evidence to contemporary practice is uncertain, particularly given the negative results of the ACCORD study, which is the only trial that has assessed fibrates in a population taking statins.
Q: How would you recommend that clinicians apply the main findings from this study? What about practice groups, health plans, and policy makers?
CJ: Our results should give clinicians pause about what is being accomplished with the increased use of fibrates. From a mechanistic perspective, lowering triglycerides should lower the risk for cardiac events and mortality, but the recent fenofibrate trials do not support this relationship. The increased use of fenofibrate that we observed indicates that the negative clinical outcomes results of these trials have been ignored. Continued caution is warranted in guideline and formulary recommendations for fibrates, particularly fenofibrate, as we await evidence of clinical outcomes benefits.