SUN-071 Unexpected Paradoxical Extremely Low of HDL-Cholesterol Level in a Non-Diabetes, Non-CKD Patient after Treatment with Specific Fibrate and Statin and Specific Fibrate Alone

Background: Fibrates are the class of the lipid-modifying agents to treat hypertriglyceridemia with usually increasing HDL that generally reflected by increased plasma levels of apoA-I and apoA-II. Paradoxical decrease in serum HDL level has been rarely reported. This presents a specific use of fibrates and statins therapy lead to markedly low of serum HDL level, in a non-diabetes and non-kidney disease patient. Clinical case: A 50-year-old man, underlying NAFLD, hypertension and dyslipidemia, has been followed up for 11 years. He was a non-smoker, non-drinker and denied to use any herbal supplement. His BMI and renal function were normal. He had a family history of cardiovascular death, including his grandmother (at 63 years old), his father (at 59 years old) and his mother (at 65 years old). Eleven years ago, he was started with simvastatin 10 mg when his presentation fasting serum lipids values were LDL 130 mg/dL, triglyceride 137 mg/dL and HDL 34 mg/dL. Three years later, his lipids showed severe hypertriglyceridemia; 795 mg/dL, LDL 75 mg/dL and HDL 28 mg/dL, he was added gemfibrozil 600 mg and up titrate dose to 900 mg during next two years of follow-up without any adverse event. After that, FDA warning drugs interaction between statins and gemfibrozil, simvastatin 10 mg was changed to ezetimibe 10 mg when his serum lipids were LDL 85 mg/dL, triglyceride 339 mg/dL and HDL 41 mg/dL for the next 3 years. Because his lipids values showed increase LDL to 150 mg/dL, he was changed his medications to ezetimibe/ simvastatin 10/20 with lifestyle modification to maintain normal triglyceride level. One year following, he complained myalgia with mildly elevated of CPK (298 U/L; < 190) together with ALT (86 U/L; < 41). At that time, his serum lipids were LDL 67 mg/dL, triglyceride 318 mg/dL and HDL 32 mg/dL. Ezetimibe/ simvastatin 10/20 was stopped and changed to pravastatin 40 mg due to the lesser side effects on the muscles and liver. In the next six months, his CPK level turned to normal however triglyceride level elevated to 533 mg/dL then fenofibrate 300 mg was added. Four months later, his serum lipids revealed triglyceride 190 mg/dL, LDL 86 mg/dL and HDL 3 mg/dL which pravastatin was stopped alone. During next several visits, serum HDL slightly elevated from 3 to 9 to 11 mg/dL every two months until fenofibrate was decided to stop as the serum HDL level was 8 mg/dL, LDL 126 mg/dL and triglyceride 241 mg/dL. Four months later, his serum HDL returned to 31 mg/dL with ezetimibe 10 mg alone. Concussion: This case presents the paradoxical severe decrease in serum HDL-cholesterol after treatment with specific combination of pravastatin and fenofibrate and fenofibrate alone which did not happen in the longer period use of simvastatin and gemfibrozil or gemfibrozil alone without abnormal renal function or diabetes. Awareness of decline in HDL during treatment with fenofibrate alone or combination with statins should be considered.