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Year : 2004  |  Volume : 5  |  Issue : 3  |  Page : 47-53 Table of Contents     

Ciprofibrate Therapy in Patients with Hypertriglyceridemia and Low High Density Lipoprotein (HDL)-Cholesterol: Greater Reduction of Non-HDL Cholesterol in Subjects with Excess Body Weight (The Ciproamlat Study)

1 Departamento de Endocrinologia y Metabolismo, Instituto Nacional de la Nutrición, México City, Mexico
2 Hospital Socor. Department de Aterosclerose, Rua Tupis, 1540 - 1° andar - Barro Preto - Belo Horizonte/MG-30190-062, Brazil
3 Universidad De La Frontera, Departamento Medicina Interna, Av. Francisco Salazar 01145 Temuco-Chile
4 Centro Médico del Pacífico, Departamento de Endocrinología, Calle 5B No. 42-16, Cali - Colombia
5 CINDI - Centro de Investigações Diagnósticas Ltda. Dept° de Cardiologia, Rua Rei Alberto, 196 - Centro - Juiz de Fora/MG - 36016-300, Brazil
6 Hospital São Salvador, Dept° de Cardiologia. Avenida A, 333 - Setor Oeste - Goiânia/GO - 74110-020, Brazil
7 Fundação Baiana de Cardiologia, Dept° de Lípides, Rua Augusto Viana, S/N° - Canela - Salvador/BA - 40140-060, Brazil
8 Prócardio, Dept° de Aterosclerose, Avenida Nascimento de Castro, 1930 - Lagoa Nova - Natal/RN - 59056-450, Brazil
9 Hospital Universitário Clementino Fraga Filho, Dept° de Diabetes/Nutrição, Avenida Brigadeiro Trompowiski, S/N° - Ilha do Fundão - Rio de Janeiro/RJ - 21941-590, Brazil
10 Centro de Referência de Hipertensão Arterial Diabetes e Apoio à Saúde do Idoso Dept° de Centro de Referência em Dislipidemia Rua Doutor Clementino, 200 - Belém - São Paulo/SP - 03059-030, Brazil
11 Hospital Dipreca, Unidad de Asistencia Nutricional Intensiva, División Medicina Interna Vital Apoquindo 1200, Las Condes.Santiago, Chile
12 Consulta Privada, Guardia Vieja 181 of 405, Providencia, Santiago, Chile
13 Hospital Del Salvador, Sección Cardiología, Av. Salvador 364, Providencia, Santiago, Chile
14 Hospital Fuerza Aérea De Chile, Unidad De Cardiología.Av, Las Condes 8631, Las Condes Santiago, Chile
15 Hospital de Cardiología del Centro Médico Nacional Siglo XXI (IMSS),Depto. de Estudios Metabólicos y Clínica de Lípidos.Av, Cuauhtemoc No. 330 Col Doctores.México, D. F.
16 Hospital Juárez de México (SSA).Unidad Coronaria.Av. Instituto Politécnico Nacional 5160 Col Magdalena de las Salinas.México, D. F
17 Hospital General Regional No. 72 (IMSS).Terapia Intensiva.Filiberto Gómez S/N y Vía Gustavo Baz.Tlalnepantla, Edo. de México, Mexico
18 Centro Médico Nacional de Occidente (IMSS).Departamento de Cardiología.Belisario Domínguez sin número Col. Centro.Guadalajara, Jal, Mexico
19 Hospital Dr. Santiago Ramón y Cajal (ISSSTE). Departamento de Cardiología Predio Canoa S/N Col. Los Angeles. Durango, Dgo, Mexico
20 Asociación De Diabéticos De Chile, Quebec 496, Santiago, Chile

Date of Web Publication22-Jun-2010

Correspondence Address:
Carlos A Aguilar-Salinas
Departamento de Endocrinologia y Metabolismo, Instituto Nacional de la Nutrición, México City, Mexico

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Source of Support: None, Conflict of Interest: None

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Background: Hypertriglyceridemia, in combination with low HDL cholesterol levels, is a risk factor for cardiovascular disease. Our objective was to evaluate the efficacy of ciprofibrate for the treatment of this form of dyslipidemia and to identify factors associated with better treatment response.
Methods: Multicenter, international, open-label study. Four hundred and thirty seven patients were included. The plasma lipid levels at inclusion were fasting triglyceride concentrations between 1.6 - 3.9 mM/L and HDL cholesterol ?1.05 mM/L for women and ?0.9 mM/L for men. The LDL cholesterol was below 4.2 mM/L. All patients received ciprofibrate 100 mg/d. Efficacy and safety parameters were assessed at baseline and at the end of the treatment. The primary efficacy parameter of the study was percentage change in triglycerides from baseline.
Results: After 4 months, plasma triglyceride concentrations were decreased by 44% (p <0.001). HDL cholesterol concentrations were increased by 10% (p < 0.001). Non-HDL cholesterol was decreased by 19%. A greater HDL cholesterol response was observed in lean patients (body mass index <25 kg/m2) compared to the rest of the population (8.2 vs 19.7%, p <0.001). In contrast, cases with excess body weight had a larger decrease in non-HDL cholesterol levels (-20.8 vs -10.8%, p <0.001). There were no significant complications resulting from treatment with ciprofibrate.
Conclusions: Ciprofibrate is efficacious for the correction of hypertriglyceridemia/low HDL cholesterol. A greater decrease in non-HDL cholesterol was found among cases with excess body weight. The mechanism of action of ciprofibrate may be influenced by the pathophysiology of the disorder being treated.

Keywords: ciprofibrate, obesity, HDL , cholesterol, triglycerides, and fibrates

How to cite this article:
Aguilar-Salinas CA, Assis-Luores-Vale A, Stockins B, Rengifo HM, Filho JD, Neto AA, Rabelo LM, Torres KP, Paulo de Oliveira JE, Machado CA, Reyes E, Saavedra V, Florenzano F, Hernandez MV, Jimenez SH, Ramirez E, Vazquez C, Salinas S, Hernandez I, Medel O, Moreno R, Lugo P, Alvarado R, Mehta R, Gutierrez V, Gomez Perez FJ. Ciprofibrate Therapy in Patients with Hypertriglyceridemia and Low High Density Lipoprotein (HDL)-Cholesterol: Greater Reduction of Non-HDL Cholesterol in Subjects with Excess Body Weight (The Ciproamlat Study). Heart Views 2004;5:47-53

How to cite this URL:
Aguilar-Salinas CA, Assis-Luores-Vale A, Stockins B, Rengifo HM, Filho JD, Neto AA, Rabelo LM, Torres KP, Paulo de Oliveira JE, Machado CA, Reyes E, Saavedra V, Florenzano F, Hernandez MV, Jimenez SH, Ramirez E, Vazquez C, Salinas S, Hernandez I, Medel O, Moreno R, Lugo P, Alvarado R, Mehta R, Gutierrez V, Gomez Perez FJ. Ciprofibrate Therapy in Patients with Hypertriglyceridemia and Low High Density Lipoprotein (HDL)-Cholesterol: Greater Reduction of Non-HDL Cholesterol in Subjects with Excess Body Weight (The Ciproamlat Study). Heart Views [serial online] 2004 [cited 2023 Mar 26];5:47-53. Available from: https://www.heartviews.org/text.asp?2004/5/3/47/64557

   Background Top

Hypertriglyceridemia in combination with abnormally low concentrations of HDL cholesterol (High Density Lipoprotein Cholesterol) is one of the most common and atherogenic profiles of lipid metabolism [1] . In the PROCAM study [2] , the 6-year incidence of coronary events in men aged between 40 and 60 years, was twelve times higher than in the control group. The prevalence of this abnormality varies among ethnic groups [3] . It is found in 13% of the Mexican adults living in urban areas [4] . It is more common in men than in women (20.9% vs 7.2%) and in some age groups (i.e. men aged 30 to 39 years) this prevalence is as high as 30%. This lipid profile is the most frequent form of dyslipidemia in the metabolic syndrome [5] . However, it is also found in subjects affected by primary dyslipidemias (e.g familial combined hyperlipidemia).

In the Veteran Affairs HDL Intervention Trial (VAHIT), the use of a fibrate (gemfibrozil) resulted in a 22% reduction in the incidence of cardiovascular events in subjects with low HDL cholesterol and a broad range of triglyceride values [6] . The positive effects obtained in cases with insulin resistance accounted for the benefit [7] . In spite of these positive results, there are few studies assessing the efficacy of other fibrates in the treatment of this form of dyslipidemia [8] , Relevant data such as the percentage of cases that achieve treatment goals are not described in the majority of these reports. Also, variables predicting a greater likelihood of achieving treatment goals remain to be identified.

Our objective was to assess the efficacy and safety of ciprofibrate (100 mg/day) for the treatment of cases with hypertriglyceridemia/ hypoalphalipoproteinemia in an open label, multicenter, international study. A clinically oriented approach is used for the description of the results.

   Materials and Methods Top

The trial included men and post-menopausal or non-pregnant women aged between 30 and 70 years who had hypertriglyceridemia (fasting concentrations between 1.68-3.9 mM/L (150 - 350 mg/dl) and hypoalphalipoproteinemia (HDL cholesterol ≤ 1.05 mM/L (40 mg/dl) for women and ≤ 0.92 mM/L (35 mg/dL) for men).

The LDL cholesterol had to be lower than 4.2 mM/L (160 mg/dL). Patients were excluded if they had an acute coronary event during the three months preceding the study, type 1 diabetes, uncontrolled hypertension, severe renal dysfunction, nephrotic syndrome or aspartate aminotransferase (AST) or alanine aminotransferase (ALT) levels >1.5 x the upper limit of normal (ULN), or if their creatine phosphokinase (CPK) levels were >3 x ULN. Consumption of any lipid- altering drug within the previous 4 weeks (6 months for probucol) prevented entry into the study. Patients could be receiving other concomitant medication as long as the dosage was not modified during the study.

The Ethics Committee in each institution approved the protocol and every patient provided witnessed, written informed consent prior to entering the study.

This was a multicenter, international, open-label study. Patients were recruited from 25 lipid clinics from Mιxico (n = 152), Brazil (n = 129), Chile (n = 78) and Colombia (n = 78). Cases fulfilling the inclusion criteria were invited to participate.

The initial visit included a medical evaluation, a physical examination and the prescription of an isocaloric diet consisting of 50% carbohydrate, 30% fat, 20% protein with a cholesterol content of 200 mg [9] . Blood samples were obtained after a 9-12 h fasting period. All patients were assigned to receive ciprofibrate 100 mg at bedtime. The second and final visit was scheduled 4 months later. During this visit drug compliance and safety profile were assessed and body weight as well as laboratory parameters were measured. Drug compliance was measured by counting the returned pills. Adherence to the diet was not assessed during the study.

The primary efficacy parameter was the percentage change in triglycerides from baseline. Secondary efficacy parameters included the percentage change in total cholesterol, HDL cholesterol and non-HDL cholesterol from baseline. Non-HDL cholesterol was calculated by subtracting the HDL cholesterol from the total cholesterol levels. In a post hoc analysis, the percentage of cases that achieved the treatment goals proposed by the ATP-III recommendations [10] on the final visit was also estimated.

At each visit, AST, ALT, fasting plasma glucose and CPK levels were measured. Clinically relevant complications were defined as either CPK >5 x ULN accompanied by muscle pain, tenderness or weakness or ALT or AST >3 x ULN. Patients were excluded from the study if they developed severe hyperglycemia or any other significant complication to treatment. Other reasons for premature withdrawal were lack of compliance to the medication. Cases were instructed to contact their physician in case of any side effect.

All samples were analyzed in a central laboratory (Quest laboratories). In Brazil, the local laboratory of every center was used instead. Blood samples were taken after an overnight fast (≥ 9 hours). Measurements were performed during the first 24 hours after the blood was drawn; blood samples were kept at 4°C until the analysis. All laboratory analyses were performed with commercially available standardized methods. Glucose was measured using the glucose oxidase method. Total serum cholesterol and triglycerides levels were measured using an enzymatic method. HDL cholesterol levels were assessed using phosphotungstic acid and Mg2+.

Statistical analysis was performed using SPSS for Windows version 10. An intention to treat analysis was used. Two sided ANOVA tests were used for assessing differences between groups for continuous variables. All categorical variables were analyzed using the chi squared test. Multiple logistic regression models were constructed for the identification of variables associated with the achievement of treatment goals.

   Results Top

Four hundred thirty seven patients were included. The clinical characteristics of the study subjects are shown in [Table 1]. Almost half of the population had a body mass index between 25 and 30 kg/m 2 (n = 221); an additional 32.5% were obese (n = 142). Diabetes was present in 125 subjects (28.7%).

Both evaluations were completed in every case. The medication was stopped before the trial was completed by 117 subjects (26.7%). In the majority of cases, this was not related to side effects (see below). In addition, 46 cases (10.5%) had poor compliance to the medication. The body weight remained constant in all patients. The alcohol and tobacco consumption was not modified during the study.

Ciprofibrate treatment and diet had a significant beneficial effect on the lipid profile, as shown in [Table 2]. After 4 months of treatment, plasma triglyceride concentrations were decreased by 44% (p<0.001). HDL cholesterol concentrations were increased by 10.1% (p<0.001). Non-HDL cholesterol was decreased by 19.2% (p<0.001). Total cholesterol was also favorably modified (-14.9%, p<0.001). In contrast, LDL cholesterol had a minor modification (-5.4%, p<0.001). A significant decrease in fasting glycemia was observed in both obese and diabetic cases. This change was not found in lean subjects.

The achievement of treatment goals is the ultimate aim of lipid- lowering therapy. Almost half of the cases had reduced their triglyceride concentrations below 1.68 mM/L (150 mg/dL) (n=191(43.7%). HDL cholesterol levels above 1.05 mM/L (40 mg/dL) were found in 51% of the cases (n=223). Also, a significant proportion of the subjects (63.15%, n=276) achieved the non-HDL cholesterol goal 4.2 mM/L (<160 mg/dL). The LDL cholesterol goal < 3.4 mM/L (<130 mg/dL) was attained by 56.2% (n=246). A full correction of the hypertrigliceridemia / low HDL cholesterol occurred in 129 subjects (29.5%). Many of them also had a non-HDL cholesterol level below 4.2 mM/L (160 mg/dL) (n=101, 23.1%).

The lipid response during treatment differed between cases with a body mass index above or below 25 kg/m 2 . As is shown in [Figure 1], the percentage change in HDL cholesterol was higher in lean subjects. In contrast, the non-HDL cholesterol concentration had a significantly greater reduction among subjects with excess body weight. Both differences remained significant even after adjusting for age and gender. The lipid profile did not differ between these groups during the initial visit.

Patients with diabetes had moderate hyperglycemia during the study. Their fasting glycemia was 7.7 ± 2.6 mM/L (139 ± 47 mg/dL) at baseline. A small but statistically significant decrease in glucose concentration was observed at the end of the trial (5.7 ± 3 mM/L, 104 ± 54 mg/dL p<0.001). At baseline, their lipid profile differed, from the non-diabetic subjects, only with regards to higher triglyceride concentrations (3.13 ± 0.97 vs 2.95 ± 0.66 mM/L, p< 0.001). The lipid response to ciprofibrate and dietary treatment did not differ from that observed in the whole group. Individuals with a family history of dyslipidemia (n=171) had higher cholesterol, triglycerides and LDL cholesterol at baseline compared to the rest of the population. The lipid response to treatment was similar to that reported in the whole group.

Multiple regression models were constructed to identify variables associated with the achievement of the treatment goals. For every target value, the main determinants were the baseline value and the percentage change after treatment. No other parameter provided additional information in any of the models. Thus, we analyzed the variables associated with the percentage change during treatment. The non-HDL cholesterol model provided more information compared to models derived from the other lipid parameters. In the non-HDL cholesterol model, a body mass index greater than 25 kg/m 2 , the triglyceride response and the coexistence of cholesterol above 5.2 mM/L (200 mg/dL) (mixed hyperlipidemia) were predictors for a greater non-HDL cholesterol response [Table 3]. For both, the HDL cholesterol and the triglycerides models, the inclusion of a body mass index <25 kg/m 2 added little information and had only borderline statistical significance. No other clinically relevant variable was associated with the percentage change of any other lipid parameter.

Liver function tests were not modified by the treatment. No patient had a significant alteration of any of the laboratory tests. There were no incidents of either myopathy or liver dysfunction. No persistent elevations in ALT, AST or CPK, defined as clinically relevant, were reported during the course of the study.

   Discussion Top

The combination of hypertriglyceridemia/low HDL cholesterol is a common abnormality of lipoprotein metabolism and is associated with increased cardiovascular risk. Our data show that ciprofibrate and an isocaloric diet are an effective treatment for this dyslipidemia. However, there was significant variation in response to treatment between individuals. Excess body weight may be an important determinant of the lipid response. It is associated with a greater degree of non-HDL cholesterol reduction and a relatively smaller elevation in HDL cholesterol.

A significant improvement in plasma triglycerides/HDL cholesterol concentrations resulted from the administration of ciprofibrate and dietary modifications. Our results are in agreement with previous studies [11],[12],[13],[14],[15] . This study differs from previous reports due to its design. We wanted to assess the lipid response to ciprofibrate in a real life environment. Hence, the highly controlled conditions of a randomized, double blind study were avoided. Also, we limited our inclusion criteria to subjects with hypertriglyceridemia/low HDL cholesterol, instead of including subjects with a wide variety of lipid profiles. The results are in accordance with the uncontrolled design of the study. By the use of ciprofibrate and isocaloric diet, almost half of the cases achieved the triglyceride goal (1.68 mM/L, 150 mg/dL). HDL cholesterol levels above 40 mg/dL were found in 51% of the cases. The full correction of the combination of hypertriglyceridemia/ low HDL cholesterol occurred in a third of the population. This rate is similar to that reported for the LDL cholesterol goals achieved by the use of statins. Thus, our results reflect the strengths and limitations of treating this lipid abnormality in an uncontrolled setting.

A large range of lipid responses was observed between individuals. There are few reports designed to analyse the determinants of the lipid response to fibrates. Robins reported a lower HDL cholesterol elevation with a fibrate when insulin resistance is present [7] . In this report, a lower HDL cholesterol response was observed in patients with excess body weight (body mass index above 25 kg/m 2 ) in comparison to that found in lean individuals. Since excess body weight is strongly associated with insulin resistance [16],[17] , our observations may be in agreement with the findings of Robins.

Interestingly, the presence of insulin resistance was associated with the lowest incidence of coronary events in the VAHIT study. In our report, obese individual had a larger decrease in non-HDL cholesterol levels. The greater response in non-HDL cholesterol observed in our obese (and possibly insulin resistant) subjects may be one possible explanation for the greater benefit found in insulin resistant subjects during the VAHIT study. Our data suggest that the mechanism of action of ciprofibrate may be altered by the pathophysiology of the disorder being treated. The same phenomenon has been observed with the use of statins [18],[19] .

The greater reduction in non-HDL cholesterol in subjects with excess body weight could be explained by an increased clearance of remnants, IDL and VLDL particles. Ciprofibrate may enhance their clearance either by decreasing the concentration of the apolipoprotein CIII (an inhibitor of the lipolytic activity of the lipoprotein lipase) [20],[21],[22] or by increasing the mass and activity of lipoprotein lipase [23] . Genes encoding apolipoprotein CIII and lipoprotein lipase contain a PPAR-alpha response element; hence their expression may be modified during treatment with a fibrate [24] . Additional studies are needed to identify other possible determinants of the lipid response to treatment with a fibrate.

Several limitations of the study must be recognized. The uncontrolled design resulted in a relatively high rate of drug discontinuation. However, this phenomenon is a common finding in studies done in open populations assessing the adherence to different lipid-lowering medications [25] . To overcome this limitation, an intention to treat analysis was used. Also, the lack of a run-in period in which the effect of diet could be measured and the absence of information about the adherence to the diet prevented us from discerning to what extent the observed result was due to fibrate alone. Finally, some of the conclusions, like the identification of the determinants of the lipid response, came from a post hoc analysis.

In conclusion, ciprofibrate is effective in the treatment of patients with hypertriglyceridemia / low HDL cholesterol. Significant reductions in triglycerides and non-HDL cholesterol resulted from ciprofibrate therapy. In addition, higher HDL cholesterol levels were found at the end of the treatment. Excess body weight alters the lipid response to ciprofibrate. A greater non-HDL cholesterol lowering is achieved in subjects with excess body weight compared to that found in lean individuals. Controlled trials are needed to compare the lipid-lowering effects of ciprofibrate in groups of subjects defined by their adiposity or other markers of insulin resistance.

   Acknowledgments Top

This study was supported by an unrestricted grant from SANOFI-Synthelabo

   References Top

1.Jeppesen J, Hein HO, Suadicani P, Gyntelberg F: High triglycerides/low high density lipoprotein cholesterol, ischemic electrocardiogram changes, and risk of ischemic heart disease. Am Heart J 2002; 145:103 -108.  Back to cited text no. 1      
2.Assmann G, Schulte H, Cullen P: New and classical risk factors - The Munster heart study (PROCAM). Eur J Med Res 19972:237-242.   Back to cited text no. 2      
3.Stong K, Bonita R, the SuRF Report1: Surveillance of risk factors related to non-communicable diseases: Current status of global data.Geneva, World Health Organization 2003.  Back to cited text no. 3      
4.Aguilar-Salinas CA, Olaiz G, Valles V, Rνos JM, Gσmez Pιrez FJ, Rull JA, Rojas R, Franco A, Sepϊlveda J: High prevalence of low HDL cholesterol concentrations and mixed hyperlipidemia in a Mexican nation wide survey. J Lipid Res 2001;42:1298-1307.  Back to cited text no. 4      
5.Groop L, Orho-Melander M: The dysmetabolic syndrome. J Intern Med 2001;250:105-120.  Back to cited text no. 5      
6.Bloomfield Rubins H, Robins SJ, Collins D, Fye CL, Anderson JW, Elam MB, Faas F, Linares E, Schaefer EJ, Schectman G, Wilt T, Wittes J, for the Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial Study Group: Gemfibrozil for the secondary prevention of coronary heart disease in men with low levels of high density lipoprotein cholesterol. Veterans Affairs High - Density Lipoprotein Cholesterol Intervention Trial Study Group. N Engl J Med 1999; 341:410-418.  Back to cited text no. 6      
7.Robins S, Bloomfield Rubins H, Faas F, Schaefer E, Elam M, Anderson J, Collin D, on behalf of the VA-HIT Study Group: Insulin resistance and cardiovascular events with low HDL cholesterol. Diabetes Care 2003;26:1513-1517.  Back to cited text no. 7      
8.Faergeman O: Hypertriglyceridemia and the fibrate trials. Curr Opin Lipidol 2000;11:609-614.  Back to cited text no. 8      
9.Betteridge DJ, Khan M: Review of the guidelines for management of dislipidemia. Baillieres Clin Endocrinol Metab 1995; 9:867-890.  Back to cited text no. 9      
10.Expert panel on detection, evaluation and treatment of high blood cholesterol in adults: Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert panel on detection, evaluation and treatment of high cholesterol in adults (adult treatment panel III). JAMA 2001;285:2486-2497.  Back to cited text no. 10      
11.Cattin L, Da Col PG, Feruglio FS, Finazzo L, Rimondi S, Descovich G, Manzato E, Zambon S, Crepaldi G, Siepi D: Efficacy of ciprofibrate in primary type II and IV hyperlipidemia: the Italian Multicenter Study. Clin Ther 1990, 12:482-488.  Back to cited text no. 11      
12.Bruckert E, Dejager S, Chapman MJ: Ciprofibrate therapy normalizes the atherogenic low density lipoprotein subspecies profile in combined hyperlipidemia. Atherosclerosis 1993;100:91-102.  Back to cited text no. 12      
13.Goa K, Barradell L, Plosker G: Bezafibrate. Drugs 1996;52:725-753  Back to cited text no. 13      
14.Betteridge DJ: Ciprofibrate: a profile. Postgrad Med J 1993;69:S42-S47.  Back to cited text no. 14      
15.Knipscheer H, de Valois C, van den Ende B, Wouter J, Kastelin J: Ciprofibrate versus gemfibrozil in the treatment of primary hyperlipidemia. Atherosclerosis 1996;124(Suppl):S75-S81.  Back to cited text no. 15      
16.Ferrannini E, Natali A, Bell P, Cavallo-Perin P, Lalic N, Mingrone G: Insulin resistance and hypersecretion in obesity. J Clin Invest 1997; 100:1166-1173.  Back to cited text no. 16      
17.Schmidt MI, Duncan BB, Watson RL, Sharrett AR, Brancati FL, Heiss G: A metabolic syndrome in whites and African-Americans: the Atherosclerosis Risk in Communities baseline study. Diabetes Care 1996;19:414-418.  Back to cited text no. 17      
18.Aguilar Salinas CA, Barrett H, Schonfeld G: Metabolic modes of action of statins in hyperlipoproteinemias. Atherosclerosis 1998;141:203-207.  Back to cited text no. 18      
19.Hugh P, Barrett R, Watts GF: Kinetic studies of lipoprotein metabolism in the metabolic syndrome including effects of nutritional interventions. Curr Opin Lipidol 2003; 14:61-68.  Back to cited text no. 19      
20.Shachter N: Apolipoproteins C-I and C-III as important modulators of lipoprotein metabolism. Curr Opin Lipidol 2001; 12:297-304.  Back to cited text no. 20      
21.Fu T, Mukhopadhyay D, Davidson NO, Borensztajn J: The PPAR alpha agonist ciprofibrate inhibits apolipoprotein B mRNA editing in LDL receptor-deficient mice: Effects on plasma lipoproteins and the development of atherosclerotic lesions. J Biol Chem, in press. 2004;Apr 27.  Back to cited text no. 21      
22.Guerin M, Le Goff W, Frisdal E, Schneider S, Milosavljevic D, Bruckert E, Chapman MJ: Action of ciprofibrate in type IIb hyperlipoproteinemia: modulation of the atherogenic lipoprotein phenotype and stimulation of high-density lipoprotein-mediated cellular cholesterol efflux. J Clin Endocrinol Metab 2003;88:3738-3746.  Back to cited text no. 22      
23.Gaw A: Evidence based approach for the management of mixed hyperlipidemia. Atherosclerosis 1998;137(Suppl):S97-S100.  Back to cited text no. 23      
24.Barbier O, Torra IP, Duguay Y, Blanquart C, Fruchart JC, Glineur C, Staels B: Pleiotropic actions of peroxisome proliferator-activated receptors in lipid metabolism and atherosclerosis. Arterioscler Thromb Vasc Biol 2002;22:717-726.  Back to cited text no. 24      
25.Tsuyuki RT, Bungard TJ: Poor adherence with hypolipidemic drugs: a lost opportunity. Pharmacotherapy 2001; 21:576-582.  Back to cited text no. 25      


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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