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Fenofibrate a Treatment for Diabetic Retinopathy

Multiple studies show possible benefit of using fenofibrate in diabetic retinopathy….

The Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) and Action to Control Cardiovascular Risks in Diabetes (ACCORD) are two major studies that have produced positive evidence for fenofibrate. Both studies determined that taking fenofibrate daily can reduce the progression of DR, the need for laser treatment, and also lower renal and neurological outcomes.

When looking at progression, the FIELD study observed fundus photographs taken over 5 years which showed that taking fenofibrate decreased 2-step progression by 79% in patients with existing DR prior to the study. The ACCORD trial found that the fundus photographs of type 2 diabetics over 4 years had a decrease in outcome by 36% with fenofibrate compared to the placebo. In patients with strict glycemic control, fenofibrate lowered outcomes by 25%. In patients with regular control, fenofibrate lowered outcomes by 43% which suggests that its benefit increases with worsening control.

Laser treatment is used when all else fails at treating DR. The laser helps to stop the progression, but often damages peripheral vision. The FIELD study found that 5 years of fenofibrate decreased the need for a first laser treatment for any retinopathy by 31%. The number needed to treat was 17 to prevent 1 patient with pre-existing DR needing laser treatment. A FIELD sub-study found a 79% reduction in the number of people needing laser. The ACCORD trial found that 1.6% of participants on fenofibrate needed laser treatment for proliferative diabetic retinopathy compared to 2.7% with the placebo.

Neither study showed significant improvement in visual acuity. Fenofibrate preserved GFR in both trials. In the FIELD trial, non-traumatic amputations were lowered by 37% and minor amputations without large vessel disease were decreased by 47%.

Retinal benefits are not related to lipid improvements caused by fenofibrate. There are a few proposed mechanisms as to how fenofibrate works for this condition, but it is not completely understood. Continued evidence shows that fenofibrate protects against certain macrovascular complications but in the end more trials are needed. The authors advise that "incorporation into practice should be revised as more information becomes available."

Practice Pearls:

  • Fenofibrate is a fibric acid derivative that is currently used to treat high triglycerides and low HDL or as adjunct to statin therapy. It regulates the expression of many genes that work against lipids, inflammation, angiogenesis, and cell apoptosis.
  • Diabetic retinopathy is damage to the blood vessels in the retina that can result in loss of vision over time. The longer someone has diabetes, the more risk they have.
  • Fenofibrate is more effective in patients with pre-existing diabetic retinopathy at baseline.

Noonan, J. et al. An Update on the Molecular Actions of Fenofibrate and Its Clinical Effects on Diabetic Retinopathy and Other Microvascular End Points in Patients with Diabetes. Diabetes December 2013 62(12): 3968-3975