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Keep in mind cholesterol can be a lithogenic substance. The fibrate (gemfibrozil and fenofibrate) and fibric acid (fenofibric acid) package lists cholelithiasis as a contraindication to their use. Interestingly it also states fibrates cane be associated with pancreatitis (although the etiology of fibrate-induced pancreatitis is not known it may be related to tiny biliary stones). The biliary lithiasis is thought to be both cholesterol and bile acid related. Fibrates by upregulating scavenger receptors increase liver delipidation of cholesterol from mature HDLs. Hepatic cholesterol can be used for many functions buts any excess is exported into the bile using upregulated ATP binding cassette transporters ABCG5 and ABCG8 which are found at the hepatobiliary interface. Fibrates through an effect on nuclear transcription factors are also involved with regulation of bile acid synthesis. It is conceivable that by changing the bile acid/cholesterol ratio may set up a trend towards lithogenic bile. 

Usually the bile acid/cholesterol  bile is stored in the gall bladder where stones form. However without the gall bladder, stones can still form throughout the biliary ducts. Tiny stones if they get into pancreatic duct might cause pancreatitis. Therefore, even without a gall bladder susceptible patients theoretically can get biliary stones or perhaps pancreatitis. The chance of a fibrate causing biliary or pancreatic lithiasis although theoretically possible ,would have to be very, very unusual.

Despite all of this and the current package insert warnings the only fibrate that has ever been associated with gall stones in clinical trials is clofibrate (Atromid S). In none of the gemfibrozil trials (Helsinki, VA-HIT) or the fenofibrate trial FIELD, (5000 patients using the drug) was there an increase of gallstones. Indeed in FIELD they actually let several patients with gallstones enter the trial and take fenofibrate without consequence. There was a tiny increase incidence of pancreatitis in FIELD.

Thus the package insert warning on cholelithiasis is considered a class effect even though it is based solely on clofibrate data. Using fenofibrate or fenofibric acid is a clinical decision that one would make balancing risk vs benefit. Since it is listed as a contraindication, one should inform any patient using current fibrates or fibric acid and document such a patient discussion on this topic. As with all meds, the clinician has to decide if the benefit outweighs any potential adversity.