Assessment of the impact of fibrates and diet on survival and their cost-effectiveness: evidence from randomized, controlled trials in coronary heart disease and health economic evaluations.

The fibrates are one of several classes of lipid-reducing agents commonly prescribed to reduce hypercholesterolemia and prevent coronary heart disease. In today's evidence-based, cost-conscious health care environment, interventions promoted by policymakers must provide clear clinical benefits and economic value. We assessed the evidence regarding the impact of fibrates and diet on survival and the cost-effectiveness of these interventions. A literature search was conducted for randomized, controlled trials of diet, fibrates, and heart disease that were published after 1971; both primary and secondary prevention clinical trials were reviewed, and recent literature reviews and meta-analyses were searched. The evidence that diet alone improves survival is poor, although specifically increasing intake of polyunsaturated fatty acid (including n-3 fatty acids) relative to saturated fatty acid intake may provide some clinical benefit in the secondary prevention of coronary heart disease. The cost-effectiveness of dietary intervention is also questionable because compliance is extremely poor. There is no consistent evidence from primary or secondary prevention trials that fibrates improve survival; in fact, fibrates may increase the risk of death from noncoronary causes. No consistent data suggest that fibrates are a cost-effective therapy. Because diet and fibrates do not appear to improve survival or provide value, policymakers should promote the use of alternative drug interventions that have consistently been proved to reduce mortality and are cost-effective.