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We read the letter of Olukoga1 (in response to our earlier paper2) with interest and feel that it covers the area of fibrate induced hypoalphalipoproteinaemia excellently. Unfortunately, we are not aware of a clear and unifying explanation as to why some patients exhibit a paradoxical decrease in serum high density lipoprotein (HDL)-cholesterol concentrations upon initiation of a fibrate drug. However, we accept that further studies are important to unravel this apparent paradoxical situation, particularly because a decline in HDL-cholesterol concentration would be expected to put the patient at increased cardiovascular risk. It would of course be useful to be able to predict those who might be susceptible to this phenomenon because they may benefit from alternative lipid modifying treatment, but as yet the extent and the cause of the problem are not known. This is particularly relevant because there are controversies in the literature regarding the benefit of fibrates in reducing cardiovascular disease—for example, the VAHIT and BIP studies.3,4
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