Class: Fibric Acid Derivatives
VA Class: CV350
Chemical Name: 5-(2,5-Dimethylphenoxy)-2,2-dimethylpentanoic acid
Molecular Formula: C15H22O3
CAS Number: 25812-30-0
Antilipemic agent; fibric acid derivative.2
Uses for Gemfibrozil
Prevention of Cardiovascular Events
Adjunct to dietary therapy to reduce the risk of developing CHD in patients with type IIb hyperlipoproteinemia without clinical evidence of CHD (primary prevention) who have an inadequate response to dietary management, weight loss, exercise, and drugs known to reduce LDL-cholesterol and increase HDL-cholesterol (e.g., bile acid sequestrants, niacin) and who have low HDL-cholesterol concentrations in addition to elevated LDL-cholesterol and triglycerides.1 67 68 104 105 110 127
Potential benefit unlikely to outweigh potential risks in patients with type IIa hyperlipoproteinemia and elevations of LDL-cholesterol only (because of toxicity, including malignancy, gallbladder disease, abdominal pain leading to appendectomy and other abdominal surgeries, and increased incidence of noncardiovascular and all-cause mortality, associated with the chemically and pharmacologically similar drug clofibrate [no longer commercially available in US]).1
Manufacturer states that gemfibrozil is not indicated for use in the management of patients with low HDL-cholesterol as their only lipid abnormality (isolated low HDL-cholesterol).1
Reduction of recurrent coronary events†, including death from coronary causes, MI, and stroke in men with clinical evidence of CHD who have low HDL-cholesterol and moderately elevated LDL-cholesterol concentrations.137
ACC/AHA cholesterol management guideline states that nonstatin drugs (e.g., fibric acid derivatives) do not provide acceptable atherosclerotic cardiovascular disease (ASCVD) risk reduction benefits compared to their potential for adverse effects in the routine prevention of ASCVD.350 May be useful as adjuncts to statin therapy in certain high-risk patients (e.g., patients with ASCVD, LDL-cholesterol concentrations ≥190 mg/dL, or diabetes mellitus) who have a less-than-anticipated response to statins, are unable to tolerate even a less-than-recommended intensity of a statin, or are completely intolerant to statin therapy.350 However, do not use gemfibrozil with statins because of increased risk of adverse muscle effects and rhabdomyolysis.350 When combined statin and fibric acid derivative therapy is required, fenofibrate is considered drug of choice;350 however, addition of fenofibrate to simvastatin therapy in patients with diabetes mellitus not shown to substantially reduce major adverse cardiovascular events compared with statin monotherapy.353
Current ACC/AHA recommendations regarding prevention of ASCVD and lifestyle modifications to reduce cardiovascular risk are available at or ).350 352
Adjunct to dietary therapy in the management of severe hypertriglyceridemia in patients at risk of developing pancreatitis (typically those with serum triglyceride concentrations >2000 mg/dL and elevated concentrations of VLDL-cholesterol and fasting chylomicrons) who do not respond adequately to dietary management.1
Also may be used in patients with triglyceride concentrations of 1000–2000 mg/dL who have a history of pancreatitis or of recurrent abdominal pain typical of pancreatitis;1 however, efficacy in patients with type IV hyperlipoproteinemia and triglyceride concentrations >1000 mg/dL who exhibit type V patterns subsequent to dietary or alcoholic indiscretion has not been adequately studied.1
Manufacturer states that gemfibrozil is not indicated for use in patients with type I hyperlipoproteinemia who have elevated triglyceride and chylomicron concentrations but normal VLDL-cholesterol concentrations.1
Effective in a very limited number of patients with type III hyperlipoproteinemia†17 18 37 38 43 45 49 to decrease elevated triglyceride and cholesterol concentrations associated with this disorder.
Gemfibrozil Dosage and Administration
Patients should be placed on a standard lipid-lowering diet before initiation of gemfibrozil therapy and should remain on this diet during treatment with the drug.1
Administer orally twice daily, 30 minutes before the morning and evening meals.1
Prevention of Cardiovascular Events
600 mg twice daily.1 16 17 18 21 22 24 25 26 27 30 31 91 104 106
Monitor lipoprotein concentrations periodically.1 Discontinue therapy in patients who fail to achieve an adequate response after 3 months of therapy.1
600 mg twice daily.1 16 17 18 21 22 24 25 26 27 30 31 91 104 106
Monitor lipoprotein concentrations periodically.1 Discontinue therapy in patients who fail to achieve an adequate response after 3 months of therapy.1
Cautions for Gemfibrozil
Hepatic impairment, including primary biliary cirrhosis; severe renal impairment; or preexisting gallbladder disease.1
Known hypersensitivity to gemfibrozil or any ingredient in the formulation.1
May increase cholesterol excretion in bile,1 34 61 resulting in cholelithiasis.1 26 34 Cholecystitis and cholelithiasis reported.1 Discontinue therapy if gallbladder studies indicate the presence of gallstones.1
Use may be associated with myositis.1 Myalgia, myopathy, myasthenia, painful extremities, arthralgia, synovitis, and rhabdomyolysis reported.1 Myopathy, rhabdomyolysis, and other complications also reported in patients receiving gemfibrozil concomitantly with certain other antilipemic agents.1
Monitor creatine kinase (CK, creatine phosphokinase, CPK) concentrations in patients reporting adverse musculoskeletal effects.1 108 116 Discontinue therapy if myositis is suspected or diagnosed.1
Effect on Morbidity and Mortality
Effect on cardiovascular mortality not established.1 Because gemfibrozil is chemically, pharmacologically, and clinically similar to other fibric acid derivatives, some adverse effects of clofibrate (no longer commercially available in the US) such as increased incidence of cholelithiasis, cholecystitis requiring surgery, postcholecystectomy complications, malignancy, pancreatitis, appendectomy, gallbladder disease, and increased overall mortality may also apply to gemfibrozil,1 and the usual precautions associated with fibrate therapy should be observed.1
Possible subcapsular bilateral and unilateral cataracts.1
Angioedema, laryngeal edema, urticaria, rash, dermatitis, and pruritus reported.1
Mild decreases in hemoglobin,1 2 hematocrit,1 2 38 and leukocyte counts1 2 reported; these counts usually normalize during long-term therapy.1 Severe anemia, leukopenia, thrombocytopenia, and bone marrow hypoplasia have occurred rarely; eosinophilia also reported.1
Monitor blood cell counts periodically during the first 12 months of therapy.1
Possible elevations in serum concentrations of aminotransferase (i.e., AST, ALT),1 2 24 25 47 LDH,1 2 bilirubin,1 and alkaline phosphatase.1 2 15 25 47 Serum aminotransferase concentrations usually return slowly to pretreatment values following discontinuance of gemfibrozil.1 Cholestatic jaundice reported.1
Perform liver function tests periodically.1 Discontinue therapy if abnormalities persist.1
Carcinogenicity (e.g., hepatic, Leydig cell tumors) demonstrated in animals.1
Not known if gemfibrozil is distributed into milk.1 102 Discontinue nursing or the drug.1
Safety and efficacy not established.1
Possible exacerbation of renal insufficiency in patients with baseline Scr >2 mg/dL.1 Consider use of alternative antilipemic therapy against the risks and benefits of a lower dose of gemfibrozil.1
Common Adverse Effects
GI disturbances (e.g., dyspepsia, abdominal pain, diarrhea, nausea, vomiting, constipation, acute appendicitis, gallbladder surgery), adverse CNS effects (headache, hypesthesia, paresthesias, dizziness, somnolence, peripheral neuritis, depression), fatigue, eczema, vertigo, taste perversion, blurred vision, decreased libido, impotence.1
Interactions for Gemfibrozil
β-Adrenergic blocking agents
Possible increase in serum triglyceride and decreases in HDL-cholesterol concentrations30 74
Anticoagulants, oral (e.g., warfarin)
Potentiation of anticoagulant effects1 102 124
Use with caution;1 reduce anticoagulant dosage to maintain PT at desired level to prevent bleeding complications; monitor PT frequently until stabilized1
Potential increase in serum triglyceride concentrations73
HMG-CoA reductase inhibitors (statins)
Increased risk of adverse musculoskeletal effects (e.g., myopathy, rhabdomyolysis)1
Avoid concomitant use350
Possible decrease in HDL- and LDL-cholesterol concentrations74
Increased repaglinide concentrations and half-life, resulting in enhanced and prolonged blood glucose-lowering effects;138 139 potential for severe hypoglycemia138
Do not initiate repaglinide in patients receiving gemfibrozil, and vice versa138 139
Monitor blood glucose and reduce repaglinide dosage as required if drugs already used concomitantly138
Patients receiving gemfibrozil concomitantly with repaglinide should not receive itraconazole138
Possible increase in total cholesterol and triglyceride concentrations74
Rapidly and completely absorbed from the GI tract.1 2 7 76
Peak plasma concentrations occur within 1–2 hours.1 2 7 9 Plasma concentrations do not appear to correlate with therapeutic response.29 102
Rate and extent of absorption increased when administered 30 minutes before meals.1
Highest tissue concentrations observed in the liver and kidneys in animals.2
Gemfibrozil crosses the placenta;2 not known if it is distributed into milk.1 102
Plasma Protein Binding
Appears to be metabolized in the liver to 4 major metabolites produced via 3 metabolic pathways.2 7 102 A phenol derivative (metabolite I)2 7 is pharmacologically active.102
Excreted in urine (70%) in the form of metabolites and in feces (approximately 6%).1
1.3–1.5 hours.1 7 9 10
20–25°C.1 Protect from light and humidity.1
Actions and Spectrum
Decreases serum concentrations of triglycerides,1 15 16 17 18 19 21 22 23 24 26 27 28 29 30 32 33 37 38 45 48 76 91 104 VLDL-cholesterol,1 15 17 18 19 25 33 37 38 45 48 76 and, to a lesser extent, LDL-cholesterol.1 15 33 37 38 45 76 Increases HDL-cholesterol.1 15 16 19 21 22 24 25 26 31 32 33 36 38 45 88 91 Causes a variable reduction in serum total cholesterol,1 15 16 17 18 19 21 24 25 26 27 28 29 30 31 32 33 37 38 48 68 105 106 because the decrease in serum cholesterol is a net result of a decrease in VLDL-cholesterol,18 19 21 25 26 28 32 33 38 45 an increase in HDL-cholesterol,37 68 and an increase15 21 30 33 37 45 91 or decrease in LDL-cholesterol.21 24 26 32 37 38 45
Generally increases LDL-cholesterol in patients with type IV or V hyperlipoproteinemia and decreases LDL-cholesterol in type IIa or IIb disorder.21 25 28 45 91
Inhibits lipolysis of fat in adipose tissue1 54 56 75 76 91 and decreases hepatic uptake of plasma free fatty acids1 54 75 76 (i.e., free fatty acid turnover is decreased),51 54 75 thereby reducing hepatic triglyceride production1 54 75 76 (triglyceride turnover rate is decreased).51 75 Also inhibits production1 15 54 75 91 and increases clearance1 75 102 of VLDL carrier apolipoprotein B (VLDL-apo B), leading to a decrease in VLDL production,1 15 45 54 75 enhanced clearance of VLDL,15 and, subsequently, a decrease in serum triglyceride concentrations.2 54 91
Advice to Patients
Importance of patients informing clinicians of any unexplained muscle pain, tenderness, or weakness.1
Importance of adhering to nondrug therapies and measures, including dietary management, weight control, physical activity, and management of potentially contributory disease (e.g., diabetes mellitus).1 64 67 70 133 136
Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1
Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as concomitant illnesses.1
Importance of informing patients of other important precautionary information.1 (See Cautions.)
Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.
Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.
* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name
AHFS DI Essentials. © Copyright 2017, Selected Revisions November 10, 2014. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.
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