A meta-analysis of 18 RCTs and 45 058 patients showed that fibrates, agonists of peroxisome proliferator-activated receptor-alfa, could reduce major cardiovascular events predominantly by preventing coronary events but had no impact on mortality rates [187]. However, in recent studies, no additional benefit of treatment with fibrate on top of statin therapy has been demonstrated [188]. Bile acid sequestrants (cholestyramine, colestipol and colesevelam) reduce LDL-C by 18–25% and may be used in combination with statins [20]. However, gastrointestinal adverse events and drug interactions limit their use.
