How Can We Improve the Management of Vascular Risk in Type 2 Diabetes: Insights from FIELD

Intensive multifactorial risk factor intervention, targeting blood glucose, blood pressure and low-density lipoprotein cholesterol, is central to therapeutic management of type 2 diabetes. This strategy reduces, but does not eliminate the risk for cardiovascular complications, and microvascular complications such as diabetic retinopathy and nephropathy still continue to develop or progress. Fibrates have been shown to be effective in managing mixed dyslipidemia characterized by elevated triglycerides and low high-density lipoprotein cholesterol (HDL-C), typically associated with type 2 diabetes.

Data were reviewed from the largest fibrate study to date, the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study which evaluated the effect of fenofibrate treatment in 9,795 patients with type 2 diabetes (about 80% without prior cardiovascular disease or microvascular complications).

Although FIELD did not show a significant benefit with fenofibrate for major coronary events (the primary outcome), there was significant reduction in total cardiovascular events (relative risk reduction [RRR] 11%, p = 0.035 vs. placebo). The clinical benefits of fenofibrate treatment were greater in patients with marked mixed dyslipidemia (elevated triglycerides ≥200 mg/dL and low plasma levels of HDL-C), features of the metabolic syndrome commonly observed in patients with type 2 diabetes, with a RRR of 27%, p = 0.005. These data are consistent with evidence from other fibrate trials showing increased treatment benefits in patients with metabolic syndrome or type 2 diabetes and mixed dyslipidemia. The FIELD study also provided promising data for microvascular benefits with fenofibrate, specifically on the need for laser treatment for diabetic retinopathy, progression of albuminuria, and prevention of diabetes-related lower-limb amputation.

Adding fenofibrate to primary statin therapy might be a useful strategy to address residual macrovascular and microvascular risk in type 2 diabetes.