Abstract:
The present invention relates to pharmacological interventions with pemafibrate for cardiovascular diseases and adverse cardiovascular events. In addition, the invention relates to the use of pemafibrate to treat dyslipidemia and type 2 diabetes mellitus and thereby reduce the risk of cardiovascular disease and adverse cardiovascular events.

Description:
PRIOR APPLICATIONS 
       [0001]    This application claims priority to U.S. Provisional Patent Application Nos. 62/368,245 (filed Jul. 29, 2016) and 62/462,574 (filed Feb. 23, 2017). The contents of these applications is hereby incorporated by reference. 
     
    
     FIELD OF THE INVENTION 
       [0002]    The present invention relates to pharmacological interventions with pemafibrate for cardiovascular diseases and adverse cardiovascular events. In addition, the invention relates to the use of pemafibrate to treat dyslipidemia and type 2 diabetes mellitus and thereby reduce the risk of cardiovascular disease and adverse cardiovascular events. 
       BACKGROUND OF THE INVENTION 
       [0003]    Cardiovascular diseases (CVDs) are a group of disorders of the heart and circulatory system that include coronary heart disease, cerebrovascular disease, peripheral arterial disease, rheumatic heart disease, congenital heart disease, deep vein thrombosis and pulmonary embolism. Despite significant advances in medical treatments, CVDs remain the number 1 cause of death globally. An estimated 17.5 million people died from CVDs in 2012, representing 31% of all global deaths. Dyslipidemia is one of the primary risk factors for CVDs. 
         [0004]    Dyslipidemia is an imbalance in a person&#39;s lipid metabolism, such that one or more of the person&#39;s lipid values are associated with an increased risk of CVDs. Dyslipidemia is particularly prevalent in type 2 diabetes patients and other patients at high risk for CVDs. Dyslipidemia is typically characterized by one or a combination of elevated levels of low-density lipoprotein cholesterol (LDL-C), elevated triglyceride (TG) levels, or low levels of high-density lipoprotein cholesterol (HDL-C), the so-called “good cholesterol.” Pharmacological therapies aimed at treating dyslipidemia are one of the principal tools employed by physicians to reduce the risk of CVDs. 
         [0005]    The Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) discloses cut-points for initiating treatment for dyslipidemia, which can be used to evaluate cardiovascular risk. Under these standards, a person having an LDL-C concentration greater than 100 mg/dL (2.59 mmol/L) is at risk for a cardiovascular event. A person having a total cholesterol concentration greater than 200 mg/dL (5.18 mmol/L) is at risk for a cardiovascular event. A person having an HDL-C concentration less than 40 mg/dL (1.0 mmol/L) for men and less than 50 mg/dL (1.3 mmol/L) for women is at risk for a cardiovascular event. A person having a fasting triglyceride concentration greater than 150 mg/dL (1.70 mmol/L) is at risk for cardiovascular events. A person having a non-HDL-C concentration greater than 130 mg/dL (3.37 mmol/L) is also at risk for a cardiovascular event. 
         [0006]    Statins, also known as HMG-CoA reductase inhibitors, are one of the first classes of drugs approved by the United States Food and Drug Administration for the treatment of dyslipidemia. This class of drugs is particularly effective at reducing LDL-C levels in at-risk individuals, and has been credited with significantly decreasing the prevalence of CVDs in the United States and around the world. However, statins are typically less effective at modifying concentrations of other lipids that contribute to cardiovascular risk, such as elevated TGs, elevated total cholesterol other than HDL (non-HDL-C), elevated apolipoprotein CIII (Apo CIII), elevated remnant cholesterol, and low HDL-C. 
         [0007]    Other drug classes, particularly the fibrates, have also been developed to correct lipid imbalances. Fibrates activate peroxisome proliferator-activated receptor alpha (PPARα) and are particularly effective at reducing extremely high levels of cholesterol or triglycerides. As a consequence, fibrates are commonly used alone or in combination with other lipid-modifying therapies to treat hypercholesterolemia and hypertriglyceridemia, although their utility for reducing the risk of CVDs has been called into question in several large randomized clinical trials. This is particularly true in patients already taking statins for their dyslipidemia, or type 2 diabetes mellitus patients. 
         [0008]    The FIELD (Fenofibrate Intervention and Event Lowering in Diabetes) (L ANCET  2005; 366:1849-1861) and ACCORD (Action to Control Cardiovascular Risk in Diabetes) (N E NGL  J M ED  2010; 362:1563-1574) trials are frequently cited long-term placebo-controlled trials evaluating the ability of fenofibrate to reduce cardiovascular risk in patients with type 2 diabetes mellitus. The FIELD study enrolled 9795 people aged 50-75 years with type 2 diabetes mellitus and not taking statin therapy at study entry, and treated them for five years with placebo or fenofibrate. Patients were eligible to participate in the trial if they had a total-cholesterol concentration ranging from 3.0 to 6.5 mmol/L; a total-cholesterol/HDL-cholesterol ratio of 4.0 or more; and serum triglycerides ranging from 1.0 to 5.0 mmol/L. The study did not show a benefit in its primary endpoint of major coronary events, although secondary endpoints such as nonfatal myocardial infarction (MI) and coronary revascularization showed some potential benefit. 
         [0009]    The ACCORD study investigated whether fenofibrate in combination with a statin, as compared with statin monotherapy, would reduce the risk of cardiovascular disease in patients with type 2 diabetes mellitus (glycated hemoglobin level of 7.5% or more). Patients were eligible to participate in the trial if they had an LDL-C level of 60 to 180 mg per deciliter (1.55 to 4.65 mmol per liter), an HDL-C level below 55 or 50 mg per deciliter (1.42 or 1.29 mmol per liter), and a TG level below 750 mg per deciliter (8.5 mmol per liter) if not receiving lipid therapy or below 400 mg per deciliter (4.5 mmol per liter) if receiving lipid therapy. The primary outcome was the first occurrence of nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes. The mean follow-up was 4.7 years. The study did not detect a significant treatment effect in its primary endpoint or in any of its secondary endpoints. 
         [0010]    Pemafibrate, whose chemical name is (2R)-2-[3-({1,3-benzoxazol-2-yl[3-(4-methoxyphenoxy)propyl]amino}methyl)phenoxy]butanoic acid, is a PPARα activator like fenofibrate, although it has proven much more potent at affecting lipid metabolism and is more specific for the PPARα receptor than fenofibrate. Thus, pemafibrate is also described as a selective PPARα modulator (SPPARMα). The drug is under development by Kowa Company, Ltd. for the treatment of dyslipidemia and cardiovascular disease. 
         [0011]    A poster by Ishibashi et al. in EAS 2012 reports an evaluation of the efficacy of pemafibrate in comparison to placebo and fenofibrate in atherogenic dyslipidemia patients. The major inclusion criteria were fasting TG ≧200 mg/dL (2.26 mmol/L) and HDL-C ≦50 mg/dL (1.29 mmol/L) for males or ≦55 mg/dL (1.42 mmol/L) for females. The primary endpoints were percent change in fasting TG and the incidence of adverse events. The poster reports that while placebo increased fasting plasma TG levels by 28.5%, pemafibrate reduced fasting plasma TG levels dose-dependently and by 42.7% with 0.2 mg BID, which was significantly lower than the 29.7% reduction achieved by 100 mg/day of fenofibrate. 
         [0012]    A poster by Araki et al. in EASD 2014 reports an integrated analysis of two Phase 2 trials (one pemafibrate monotherapy trial and one add-on therapy to a stable 2 mg/day dose of pitavastatin) and one Phase 2/3 trial (monotherapy). All subjects reportedly had hypertriglyceridemia and low HDL-C and/or high non-HDL-C. The poster does not disclose actual levels of TGs in the study population, or break out the results based on whether the patient had low HDL-C or high non-HDL-C. The efficacy and safety of pemafibrate 0.05, 0.1, 0.2 and 0.4 mg/day (twice daily) were examined in all trials. The poster reports a significant reduction in TG dose-dependently and an increase in HDL-C in all pemafibrate groups. The poster also reports dose-dependent favorable effects on insulin sensitivity. 
         [0013]    Despite these advances in lipid therapies, the clinical benefits of fibrate-based lipid altering therapies remain unknown with large randomized clinical trials yielding equivocal results. Pemafibrate is a promising drug, but it has not been shown to reduce cardiovascular risk. 
         [0014]    Pharmacological therapies are needed that can alter lipid parameters in a beneficial way, particularly in patients with type 2 diabetes, or those presenting with residual risk of cardiovascular events in spite of statin treatment, to lower the risk of adverse cardiovascular events. Better definitions of populations likely to benefit from such therapies are also needed, based on lipid profiles and cardiovascular risk. 
         [0015]    It is therefore an object of the present invention to provide pemafibrate therapies that can reduce cardiovascular risk in patients with one or more risk factors for cardiovascular events, particularly in patients on concurrent statin treatment. 
         [0016]    Another object of the present invention is to reduce cardiovascular risk in populations at risk for adverse cardiovascular events due to an imbalanced lipid metabolism, particularly in patients with type 2 diabetes mellitus. 
         [0017]    Other objects of the present invention are to identify at-risk patients likely to benefit from pemafibrate treatment and to define specific subjects for such treatment. 
       SUMMARY OF THE INVENTION 
       [0018]    In a first aspect, the invention relates to the surprising ability of pemafibrate to reduce cardiovascular risk, in spite of equivocal results reported for known fibrates in the clinical literature. Thus, in a first embodiment, the invention provides a method of preventing the occurrence of cardiovascular events in a patient with one or more risk factors for cardiovascular diseases, comprising administering to the patient an effective amount of pemafibrate or a pharmaceutically acceptable salt thereof. 
         [0019]    In a second embodiment, the invention provides a method of treating dyslipidemia in a patient with type 2 diabetes mellitus comprising administering to the patient a therapeutically effective amount of pemafibrate or a pharmaceutically acceptable salt thereof, wherein the patient has (a) a fasting TG concentration ≧175 mg/dL (2.26 mmol/L) and ≦500 mg/dL (5.64 mmol/L); and (b) an HDL-C concentration 50 mg/dL if male or ≦55 mg/dL if female. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0020]    The accompanying drawings, which are incorporated in and constitute a part of this specification, illustrate several embodiments of the invention and together with the description serve to explain the invention. 
           [0021]      FIGS. 1A-1D  report changes from baseline to Week 12 in TG [A], non-HDL-C [B], Apo CIII [C] and remnant-C [D] with pemafibrate versus placebo in dyslipidemia patients receiving statin treatment, as described in Example 1. Each graph reports left to right 0.05 mg BID, 0.1 mg BID, 0.2 mg BID, 0.1 mg QD, 0.2 mg QD, and 0.4 mg QD pemafibrate. 
           [0022]      FIGS. 2A-2D  report changes from baseline to Week 12 in TG [A], non-HDL-C [B], Apo CIII [C] and remnant-C [D] with pemafibrate versus placebo in dyslipidemia patients with type 2 diabetes mellitus receiving statin treatment, as described in Example 2. Each graph reports left to right 0.05 mg BID, 0.1 mg BID, 0.2 mg BID, 0.1 mg QD, 0.2 mg QD, and 0.4 mg QD pemafibrate. 
           [0023]      FIGS. 3A-3D  report changes from baseline to Week 12 in TG [A], VLDL-C, RemL-C, Apo CIII, non-HDL-C, LDL-C and Apo B [B], HDL-C, Apo AI and Apo AII [C], and fasting plasma glucose and HOMA-IR [D], with pemafibrate versus placebo in dyslipidemia patients receiving a stable dose of pitavastatin, as reported in Example 3. Each graph reports left to right placebo, 0.1 mg BID, 0.2 mg BID, and 0.4 mg BID pemafibrate. 
       
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
       [0024]    The present invention provides the following:
   1) A method of preventing the occurrence of cardiovascular events in a patient with one or more risk factors, comprising administering to the patient a therapeutically effective amount of pemafibrate or a pharmaceutically acceptable salt thereof.   2) The method according to 1), wherein the patient has type 2 diabetes mellitus.   3) The method according to 1), wherein the patient has an age greater than or equal to 50 years if male or 55 years if female, or systemic atherosclerosis.   4) The method according to 1), wherein the patient is taking concurrent statins.   5) The method according to 1), wherein the patient has a fasting TG concentration ≧200 mg/dL and &lt;500 mg/dL.   6) The method according to 1), wherein the patient has an HDL-C concentration ≦40 mg/dL.   7) The method according to 1), wherein the patient has:
       a) type 2 diabetes mellitus;   b) a fasting TG concentration ≧200 mg/dL and &lt;500 mg/dL; and   c) an HDL-C concentration ≦40 mg/dL.   
       8) The method according to 7) wherein:
       a) the patient has an age greater than or equal to 50 years if male or 55 years if female, or systemic atherosclerosis;   b) the therapeutically effective amount of pemafibrate or pharmaceutically acceptable salt thereof is 0.4 mg, administered orally per day; and   c) the cardiovascular events are selected from nonfatal myocardial infarction, nonfatal ischemic stroke, hospitalization for unstable angina requiring unplanned coronary revascularization, cardiovascular death, or a combination thereof.   
       9) The method according to 1), wherein the patient is:
       a) on concomitant moderate to high intensity statin therapy;   b) on concomitant lipid-lowering therapy other than the concomitant moderate to high intensity statin therapy and has an LDL-C concentration ≦70 mg/dL; or   c) statin-intolerant and has an LDL-C concentration ≦100 mg/dL.   
       10) The method according to 1), wherein the therapeutically effective amount of pemafibrate or pharmaceutically acceptable salt thereof is from 0.2 to 1.0 mg, administered orally per day.   11) The method according to 1), wherein the therapeutically effective amount of pemafibrate or pharmaceutically acceptable salt thereof is 0.4 mg, administered orally per day.   12) The method according to 1), wherein the therapeutically effective amount of pemafibrate or pharmaceutically acceptable salt thereof is 0.2 mg, administered orally twice daily.   13) The method according to 1), wherein the cardiovascular events are selected from nonfatal myocardial infarction, nonfatal ischemic stroke, hospitalization for unstable angina requiring unplanned coronary revascularization, cardiovascular death, or a combination thereof.   14) The method according to 1), wherein the patient has type 2 diabetes mellitus as defined by:
       a) a hemoglobin A1c level of 6.5% or greater; and   b) a plasma glucose level selected from:
           i) greater than or equal to 126 mg/dL when fasting;   ii) greater than or equal to 200 mg/dL at 2 hours during oral glucose tolerance testing; or   iii) greater than or equal to 200 mg/dL with classic type 2 diabetes mellitus symptoms.   
           
       15) The method according to 1), wherein the patient has cardiovascular disease.   16) A method of treating dyslipidemia in a patient with type 2 diabetes mellitus comprising administering to the patient a therapeutically effective amount of pemafibrate or a pharmaceutically acceptable salt thereof, wherein the patient has:
       a) a fasting TG concentration ≧175 mg/dL and ≦500 mg/dL; and   b) an HDL-C concentration ≦50 mg/dL if male or ≦55 mg/dL if female.   
       17) The method according to 16), wherein the patient has:
       a) a fasting TG concentration ≧200 mg/dL and &lt;500 mg/dL; and   b) an HDL-C concentration ≦40 mg/dL.   
       18) The method according to 16), wherein the therapeutically effective amount of pemafibrate or pharmaceutically acceptable salt thereof is from 0.1 to 1.0 mg, administered orally per day.   19) The method according to 16), wherein the therapeutically effective amount of pemafibrate or pharmaceutically acceptable salt thereof is 0.4 mg, administered orally per day.   20) The method according to 16), wherein the therapeutically effective amount of pemafibrate or pharmaceutically acceptable salt thereof is 0.2 mg, administered orally twice daily.   21) The method according to 16), wherein the patient has type 2 diabetes mellitus as defined by:
       a) hemoglobin A1c level of 6.5% or greater; and   b) plasma glucose level is selected from:
           i) greater than or equal to 126 mg/dL when fasting;   ii) greater than or equal to 200 mg/dL at 2 hours during oral glucose tolerance testing; or   iii) greater than or equal to 200 mg/dL with classic type 2 diabetes mellitus symptoms.   
           
       22) The method according to 16), wherein:
       a) the patient has an age greater than or equal to 50 years if male or 55 years if female, or systemic atherosclerosis;   b) the therapeutically effective amount of pemafibrate or pharmaceutically acceptable salt thereof is 0.4 mg, administered orally per day; and   c) the method is effective to prevent the occurrence of a cardiovascular event selected from nonfatal myocardial infarction, nonfatal ischemic stroke, hospitalization for unstable angina requiring unplanned coronary revascularization, cardiovascular death, or a combination thereof   
       23) The method according to 16) or 17), wherein the patient has an LDL-C concentration ≦100 mg/dL.   24) The method according to 16) or 17), wherein the patient is:
       a) on concomitant moderate to high intensity statin therapy;   b) on concomitant lipid-lowering therapy other than the concomitant moderate to high intensity statin therapy and has an LDL-C concentration ≦70 mg/dL; or   c) statin-intolerant and has an LDL-C concentration ≦100 mg/dL.   
       25) The method according to 16), wherein the patient has cardiovascular disease.   26) A method of treating type 2 diabetes mellitus in a patient in need thereof comprising administering to the patient a therapeutically effective amount of pemafibrate or a pharmaceutically acceptable salt thereof, wherein the patient has:
       a) a fasting TG concentration ≧200 mg/dL and &lt;500 mg/dL;   b) an HDL-C concentration ≦40 mg/dL; and   c) controlled LDL-C levels.   
       27) A method of treating cardiovascular disease or preventing adverse cardiovascular events in a patient with type 2 diabetes mellitus, comprising administering to the patient a therapeutically effective amount of pemafibrate or a pharmaceutically acceptable salt thereof, wherein the patient has:
       a) a fasting TG concentration ≧200 mg/dL and &lt;500 mg/dL;   b) an HDL-C concentration ≦40 mg/dL; and   c) controlled LDL-C levels.   
       28) The method according to 27) for preventing adverse cardiovascular events wherein the cardiovascular event is selected from nonfatal myocardial infarction, nonfatal ischemic stroke, hospitalization for unstable angina requiring unplanned coronary revascularization, cardiovascular death, or a combination thereof.   29) A method of prolonging the time to first occurrence of:
       a) any component of the primary endpoint in a subgroup of subjects defined at baseline by: sex; presence or absence of established CVD; and baseline lipid lowering therapy as defined hierarchically by:
           i) receiving treatment with a stable dose (i.e. for at least 12 weeks) of a qualifying moderate-to high intensity statin; or   ii) statin intolerant and having evidence of LDL &lt;100 mg/dl (2.59 mmol/L) by a local laboratory determination within the previous 12 months; or   iii) having evidence of LDL-C &lt;70 mg/dl (1.81 mmol/L) by a local laboratory determination within the previous 12 months if untreated or on stable dosing (i.e. for at least 12 weeks) of another lipid-lowering regimen including a PCSK9 inhibitor.   
           b) any component of nonfatal MI, nonfatal ischemic stroke, hospitalization of for unstable angina requiring unplanned coronary revascularization, CV death, or any coronary revascularization;   c) any component of nonfatal MI, nonfatal ischemic stroke, hospitalization for unstable angina requiring unplanned coronary revascularization, or all-cause mortality;   d) any component of nonfatal MI, nonfatal ischemic stroke, CV death, any coronary revascularization, or hospitalization for heart failure;   e) any component of nonfatal MI, nonfatal stroke (any), CV death, or hospitalization for unstable angina requiring unplanned coronary revascularization;   f) individual components of the primary endpoint, nonfatal stroke (any), all cause mortality, and hospitalization for heart failure;   g) diabetic retinopathy, as assessed by use of retinal laser treatment, anti-vascular endothelial growth factor therapy, or vitrectomy due to development of and/or deterioration in diabetic retinopathy;   h) diabetic nephropathy, as assessed by an increase in microalbumin/creatinine ratio to &gt;30 mg/g among those without microalbuminuria at baseline, and categorical change from baseline albuminuria (normo-, micro-, or macroalbuminuria), doubling of creatinine from baseline, creatinine level &gt;6.0 mg/dl, glomerular filtration rate (GFR) &lt;15 ml/ml, or initiation of renal replacement therapy (dialysis or transplant), among all subjects; and   i) peripheral artery disease, defined as incidence of lower-extremity revascularization, intermittent claudication, rest pain, lower-extremity ischemic ulceration, or amputation with either ankle brachial index ≦0.9 or other diagnostic testing (e.g., angiogram, toe-brachial index, or imaging study),   wherein the method comprises administering to a subject in need thereof a therapeutically effective amount of pemafibrate or a pharmaceutically acceptable salt thereof.   
       30) A method of prolonging the time to first occurrence of:
       a) any component of the 3-component composite endpoint of non-fatal MI, non-fatal stroke, or cardiovascular death;   b) any component of the primary endpoint or hospitalization for heart failure;   c) any component of the primary endpoint or all-cause mortality;   d) any component of the primary endpoint, any coronary revascularization, or hospitalization for heart failure; or   e) any new or worsening peripheral artery disease, defined as incidence of lower extremity revascularization, intermittent claudication, rest pain, lower extremity ischemic ulceration, or major amputation with either ankle-brachial index ≦0.9 or other diagnostic testing (eg, toe-brachial index, angiogram, or other imaging study).   
       31) The method according to 3), wherein systemic atherosclerosis is defined by:
       a) prior myocardial infarction or ischemic (non-hemorrhagic) stroke;   b) coronary angiographic lesion of ≧60% stenosis in a major epicardial vessel or ≧50% left main stenosis;   c) asymptomatic carotid disease with ≧70% carotid artery stenosis;   d) symptomatic carotid disease with ≧50% carotid artery stenosis;   e) symptomatic lower extremity peripheral artery disease selected from intermittent claudication, rest pain, or lower extremity ischemic ulceration with an ankle-brachial index ≦0.9; or   f) prior arterial revascularization procedure selected from coronary, carotid or peripheral angioplast, stenting, bypass, atherectomy, or endarterectomy.   
       32) The method according to 1), wherein the patient does not have systemic atherosclerosis.   
 
         [0116]    As used in the specification and claims, the singular forms “a,” “an,” and “the” include plural references unless the context clearly dictates otherwise. For example, the term “a pharmaceutical excipient” refers to one or more pharmaceutical excipients for use in the presently disclosed formulations and methods. 
         [0117]    The use of numerical values in the various quantitative values specified in this application, unless expressly indicated otherwise, are stated as approximations as though the minimum and maximum values within the stated ranges were both preceded by the word “about”. Also, the disclosure of ranges is intended as a continuous range including every value between the minimum and maximum values recited as well as any ranges that can be formed by such values. Also disclosed herein are any and all ratios (and ranges of any such ratios) that can be formed by dividing a disclosed numeric value into any other disclosed numeric value. Accordingly, the skilled person will appreciate that many such ratios, ranges, and ranges of ratios can be unambiguously derived from the numerical values presented herein and in all instances such ratios, ranges, and ranges of ratios represent various embodiments of the present invention. 
         [0118]    As used herein, “cardiovascular events” includes cardiovascular death; nonfatal myocardial infarction; nonfatal ischemic stroke; unstable angina (e.g., unstable angina determined to be caused by myocardial ischemia by, for example, invasive or non-invasive testing, and requiring hospitalization); cardiac arrest; peripheral cardiovascular disease requiring intervention, angioplasty, bypass surgery or aneurysm repair; and onset of new congestive heart failure. 
         [0119]    As used herein, “preventing the occurrence of cardiovascular events” includes delaying the incidence of cardiovascular events as well as minimizing the severity of cardiovascular events. It also refers a time interval beginning at (a) an initial administration of a therapeutically effective amount of pemafibrate or a pharmaceutically acceptable salt thereof as disclosed herein to the patient to (b) a cardiovascular event in the patient greater than or substantially greater than a control time interval beginning at (a′) initial administration of a placebo to control subjects to (b′) a cardiovascular event in the control subjects. In some embodiments, the cardiovascular event of the patient is selected from those noted above. In some embodiments, the cardiovascular event of the control subjects is selected from those noted above. 
         [0120]    As used herein, “therapeutically effective amount” refers to an amount sufficient to elicit the desired biological response in a patient. The therapeutically effective amount or dose depends on the age, sex and weight of the patient, and the current medical condition of the patient. The skilled artisan can determine appropriate amount or dose depending on the above factors based on his or her knowledge and the teachings contained herein. 
         [0121]    “Pharmaceutically acceptable” means that which is useful in preparing a pharmaceutical composition that is generally safe, non-toxic and neither biologically nor otherwise undesirable and includes that which is acceptable for veterinary use as well as human pharmaceutical use. “Pharmaceutically acceptable salts” means salts that are pharmaceutically acceptable, as defined above, and which possess the desired pharmacological activity. 
         [0122]    The terms “treating” and “treatment,” when used herein, refer to the medical management of a patient with the intent to cure, ameliorate, stabilize, or prevent a disease, pathological condition, or disorder (collectively “disorder”). These terms include active treatment, that is, treatment directed specifically toward the improvement of a disorder, and also include causal treatment, that is, treatment directed toward removal of the cause of the associated disorder. In addition, this term includes palliative treatment, that is, treatment designed for the relief of symptoms rather than the curing of the disorder; preventative treatment, that is, treatment directed to minimizing or partially or completely inhibiting or delaying the development of the disorder; and supportive treatment, that is, treatment employed to supplement another specific therapy directed toward the improvement of the disorder. 
         [0123]    “Treatment of dyslipidemia” includes the correction of one or more lipid imbalances in the human body, even if the concentration of other lipids remains in an unhealthy state. 
         [0124]    All analyte measurements recited herein, when used to define a patient described herein, are measured at the beginning of pemafibrate treatment. 
         [0125]    Unless stated herein to the contrary, all analyte measurements are taken in the fasting state, and are based on the concentration of the analyte in plasma or serum. The fasting state means that the patient has not eaten anything in from 8 to 12 hours, except for water. Standard methods of measuring analytes can be found in Lab Protocols for NHANES 2003-2004 data published by the United States Centers for Disease Control. 
         [0126]    Unless stated herein to the contrary, all methods described herein are performed in all ages, preferably adults, more preferably greater than 50 years if male and greater than 55 years if female. 
         [0127]    As used herein, the term “significantly” refers to a level of statistical significance. The level of statistical significant can be, for example, of at least p&lt;0.05, of at least p&lt;0.01, of at least p&lt;0.005, or of at least p&lt;0.001. 
         [0128]    Statins, also known as HMG-CoA reductase inhibitors, include atorvastatin, simvastatin, fluvastatin, pitavastatin, rosuvastatin, pravastatin, and lovastatin and their pharmaceutically acceptable salts. 
         [0129]    Dyslipidemia is an elevation of plasma cholesterol, triglycerides (TGs), or both, or a low high-density lipoprotein level that contributes to the development of atherosclerosis. Causes may be primary (genetic) or secondary. Diagnosis is performed by measuring plasma levels of total cholesterol, TGs, and individual lipoproteins. Treatment involves dietary changes, exercise, and lipid-lowering drugs. 
         [0130]    In a first embodiment, the invention provides a method of preventing the occurrence of cardiovascular events in a patient with one or more risk factors, comprising administering to the patient an effective amount of pemafibrate or a pharmaceutically acceptable salt thereof. 
         [0131]    In a preferred first embodiment, the invention provides a method of preventing the occurrence of cardiovascular events in a patient with one or more of multiple risk factors, comprising administering to the patient an effective amount of pemafibrate or a pharmaceutically acceptable salt thereof. 
         [0132]    According to this embodiment, the occurrence of cardiovascular events can be prevented. That is, the occurrence of the following events can be prevented: cardiovascular death; nonfatal myocardial infarction; nonfatal ischemic stroke; coronary revascularization; unstable angina (e.g., unstable angina determined to be caused by myocardial ischemia by, for example, invasive or non-invasive testing, and requiring hospitalization); cardiac arrest; peripheral cardiovascular disease requiring intervention, angioplasty, bypass surgery or aneurysm repair; and onset of new congestive heart failure. 
         [0133]    In a preferred first embodiment, the occurrence of: (a) nonfatal myocardial infarction, (b) nonfatal ischemic stroke, (c) hospitalization for unstable angina requiring unplanned coronary revascularization, (d) cardiovascular death; or a combination thereof can be prevented. 
         [0134]    In another preferred first embodiment, the risk of a cardiovascular event, for example (a) nonfatal myocardial infarction, (b) nonfatal ischemic stroke, (c) hospitalization for unstable angina requiring unplanned coronary revascularization, (d) cardiovascular death; or a combination thereof can be reduced. 
         [0135]    In another preferred first embodiment, the method can be performed in patients along with statin treatment, or who have controlled LDL-C levels (i.e. LDL-C levels less than or equal to 70 or 100 mg/dL). If the patient is on concomitant moderate to high intensity statin therapy, it can be assumed that the patient has low or controlled LDL-C levels. In this embodiment, statins can be selected from rosuvastatin, pitavastatin, atorvastatin, fluvastatin, simvastatin, pravastatin and lovastatin, preferably selected from atorvastatin ≧40 mg/d, rosuvastatin ≧20 mg/d, simvastatin ≧40 mg/d, or pitavastatin 4 mg/d. In addition, if the patient is on concomitant lipid-lowering therapy, the patient can be presumed to have low or controlled LDC levels if the patient has a LDL-C concentration less than or equal to 70 mg/dL. If the patient is statin-intolerant, the patient can be presumed to have low or controlled LDL levels if the patient has a LDL-C concentration less than or equal to 100 mg/dL. In this embodiment, “lipid-lowering therapy” includes therapy in which the patient is treated by a lipid-lowering drug such as a statin e.g. rosuvastatin, pitavastatin, atorvastatin, fluvastatin, simvastatin, pravastatin and lovastatin; an inhibitor of cholesterol absorption in the small intestine e.g. ezetimibe; probucol; niacin; bile acid sequestrants, e.g. cholestyramine; omega-3 fatty acids, e.g. eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). 
         [0136]    Thus, in one preferred first embodiment the method is performed in patients: a) on concomitant moderate to high intensity statin therapy; b) on concomitant lipid-lowering therapy other than the concomitant moderate to high intensity statin therapy and having an LDL-C concentration ≦70 mg/dL; or c) who are statin-intolerant and have an LDL-C concentration ≦100 mg/dL. 
         [0137]    This first embodiment is preferably practiced in patients with one or more risk factors for cardiovascular events selected from: (i) elevated fasting triglyceride levels; (ii) low HDL-C; (iii) type 2 diabetes mellitus; (iv) age (male ≧50 or female ≧55); (v) atherosclerosis; (vi) hypertension; (vii) smoking; and (viii) family history of early coronary heart disease. It is known that a habit of smoking and/or a family history of early coronary heart disease raise the risk for cardiovascular events. As used herein, the risk factors for cardiovascular disease are also referred as “multiple risk factors”. 
         [0138]    Elevated fasting triglyceride levels refers to a fasting triglyceride level greater than 150, 160, 170, 175, 180, 190, 200, or 210 mg/dL triglycerides, with 200 mg/dL (2.26 mmol/L) defining a preferred cutoff value. The upper limit of the patient&#39;s fasting triglyceride is not particularly limited, but less than 500 mg/dL is a preferred cutoff value. 
         [0139]    Low HDL-C levels refers to an HDL-C level at which the patient is at risk for a cardiovascular event, and can be different depending on the patient&#39;s sex. In preferred embodiments, the patient can be said to have a low HDL-C level if the patient has an HDL-C concentration less than 55, 50, 45, 40 or 35 mg/dL, preferably ≦50 mg/dL if male or ≦55 mg/dL if female. More preferably, 40 mg/dL (1.034 mmol/L) HDL-C will define the cutoff value. 
         [0140]    Other lipid values and their cutoff values can also be used to define the patients treated by this first embodiment, including elevated non-HDL-C, elevated Apo CIII, and elevated remnant cholesterol. In one embodiment, the patient&#39;s non-HDL-C concentration is greater than 130, 160, or 190 mg/dL. In another embodiment, the patient&#39;s remnant cholesterol level is greater than 5.0, 5.3, 5.6, or 5.9 mg/dL. In yet another embodiment, the patient&#39;s Apo CIII concentration is 5 to 20 mg/dL, for example, 5.8 to 10 mg/dL for male and 5.4 to 9.0 mg/dL for female. 
         [0141]    In another preferred first embodiment, the patient being treated has type 2 diabetes mellitus, defined as a patient with: elevated glycated hemoglobin A1c levels and elevated plasma glucose levels. A patient having a glycated hemoglobin A1c concentration of 6.5% (48 mmol/mol) or greater, on two consecutive tests may typically be considered to have type 2 diabetes mellitus, particularly when combined with an elevated plasma glucose level. An elevated plasma glucose level can be defined by one of three tests: (i) greater than or equal to 126 mg/dL (7.0 mmol/L) fasting plasma glucose level; (ii) greater than or equal to 200 mg/dL (11.1 mmol/L) plasma glucose level at 2 hours during oral glucose tolerance testing; (iii) a random plasma glucose level greater than or equal to 200 mg/dL with classic type 2 diabetes mellitus symptoms (i.e. frequent urination and extreme thirst); or (iv) currently taking medication for treatment of diabetes. For oral glucose tolerance testing, the patient fasts overnight, and fasting blood sugar level is measured. The patient then drinks a sugary liquid, and blood sugar levels are tested periodically for the next two hours. 
         [0142]    Insulin resistance, as measured by HOMA-IR (homeostasis model assessment-estimated insulin resistance), may also be used to diagnose type 2 diabetes mellitus. As used herein, HOMA-IR refers to the Homeostasis Model Assessment for Insulin Resistance or “insulin resistance score,” as reported by Matthews et al. Diabetologia 1985; 28:412-419. HOMA-IR can be computed with the formula: fasting plasma glucose (mmol/l) times fasting serum insulin (mU/l) divided by 22.5. Low HOMA-IR values indicate high insulin sensitivity, whereas high HOMA-IR values indicate low insulin sensitivity (i.e. insulin resistance). 
         [0143]    Age is known as one of the multiple risk factors for cardiovascular disease, especially greater than 50 years of age if male and greater than 55 years of age if female. 
         [0144]    A patient with atherosclerosis includes any patient with (i) prior myocardial infarction or ischemic (non-hemorrhagic) stroke; (ii) coronary angiographic lesion of ≧60% stenosis in a major epicardial vessel or ≧50% left main stenosis; (iii) asymptomatic carotid disease with ≧70% carotid artery stenosis; (iv) symptomatic carotid disease with ≧50% carotid artery stenosis; (v) symptomatic lower extremity peripheral artery disease selected from intermittent claudication, rest pain, lower extremity ischemic ulceration, or major amputation with an ankle-brachial index ≦0.9 or other diagnostic testing (e.g, toe-brachial index, angiogram, or other imaging study); (vi) prior arterial revascularization procedure selected from coronary, carotid or peripheral angioplasty, stenting, bypass, atherectomy, or endarterectomy; or (vii) a combination thereof. 
         [0145]    Hypertension can be defined as having a systolic blood pressure of greater than 120, 130, 140, or 160 mmHg and a diastolic blood pressure greater than 80, 90, or 100 mmHg. 
         [0146]    The therapeutically effective amount of pemafibrate can be defined as a range of suitable doses on a daily basis. Thus, in one embodiment, the therapeutically effective amount is from 0.1 to 1.0 mg of pemafibrate or a pharmaceutically acceptable salt thereof, administered orally per day. In another embodiment the therapeutically effective amount is from 0.2 to 0.8 mg of pemafibrate or a pharmaceutically acceptable salt thereof, administered orally per day. In still another embodiment the therapeutically effective amount is 0.4 mg of pemafibrate or a pharmaceutically acceptable salt thereof, administered orally per day. These doses are preferably based on the weight of the free base of pemafibrate. 
         [0147]    In a second embodiment, the invention provides a method of treating dyslipidemia in a patient with type 2 diabetes mellitus comprising administering to the patient a therapeutically effective amount of pemafibrate or a pharmaceutically acceptable salt thereof for a therapeutically effective period of time, wherein the patient has (a) an elevated fasting triglyceride level; (b) a low HDL-C concentration; and (c) controlled LDL-C levels. 
         [0148]    In this second embodiment, elevated fasting triglyceride levels preferably refers to a fasting triglyceride level greater than 150, 160, 170, 175, 180, 190, 200, or 210 mg/dL triglycerides, with 175 or 200 mg/dL defining a particularly preferred cutoff value. The upper limit of the patient&#39;s fasting triglyceride levels is not particularly limited, but a cutoff value not greater than 500 mg/dL is preferred. 
         [0149]    In this second embodiment, a low HDL-C level preferably refers to an HDL-C level at which the patient is at risk for an adverse cardiovascular event, and can be different depending on the patient&#39;s sex. In preferred embodiments the patient can be said to have a low HDL-C level if the patient has an HDL-C concentration less than 55, 50, 45, 40 or 35 mg/dL. A preferred cutoff value is ≦50 mg/dL if male or ≦55 mg/dL if female. A particularly preferred cutoff value is ≦40 mg/dL without regard to sex. 
         [0150]    In this second embodiment, a patient with controlled LDL-C levels can refer to a patient having an LDL-C concentration ≦100 or 70 mg/dL, but preferably refers to a patient who is on concurrent statin therapy. A particularly preferred patient is: a) on concomitant moderate to high intensity statin therapy; b) on concomitant lipid-lowering therapy other than the concomitant moderate to high intensity statin therapy and has an LDL-C concentration ≦70 mg/dL; or c) statin-intolerant and has LDL-C concentration ≦100 mg/dL. 
         [0151]    In this second embodiment, a patient with type 2 diabetes mellitus can be defined as a patient with: elevated glycated hemoglobin A1c levels and elevated plasma glucose levels. A patient having a glycated hemoglobin A1c concentration of 6.5% (48 mmol/mol) or greater, on two consecutive tests may typically be considered to have type 2 diabetes mellitus, particularly when combined with an elevated plasma glucose level. The elevated plasma glucose level can be defined by one of three tests: (i) greater than or equal to 126 mg/dL (7.0 mmol/L) fasting plasma glucose level; (ii) greater than or equal to 200 mg/dL (11.1 mmol/L) plasma glucose level at 2 hours during oral glucose tolerance testing; (iii) a random plasma glucose level greater than or equal to 200 mg/dL with classic type 2 diabetes mellitus symptoms; or (iv) currently taking medication for treatment of diabetes. 
         [0152]    The therapeutically effective amount of pemafibrate for this second embodiment can be defined as a range of suitable doses on a daily basis. Thus, in one embodiment, the therapeutically effective amount is from 0.1 to 1.0 mg of pemafibrate or a pharmaceutically acceptable salt thereof, administered orally per day. In another embodiment the therapeutically effective amount is from 0.2 to 0.8 mg of pemafibrate or a pharmaceutically acceptable salt thereof, administered orally per day. In still another embodiment the therapeutically effective amount is 0.4 mg of pemafibrate or a pharmaceutically acceptable salt thereof, administered orally per day. These doses are preferably based on the weight of the free base of pemafibrate. 
         [0153]    Other lipid values and their cutoff values can also be used to define the patients treated by this second embodiment, including elevated non-HDL-C, elevated Apo CIII, and elevated remnant cholesterol. In one embodiment, the patient&#39;s non-HDL-C concentration is greater than 130, 160, or 190 mg/dL. In another embodiment, the patient&#39;s remnant cholesterol level is greater than 5.0, 5.3, 5.6, or 5.9 mg/dL. In yet another embodiment, the patient&#39;s Apo CIII concentration is 5 to 20 mg/dL, for example, 5.8 to 10 mg/dL for male and 5.4 to 9.0 mg/dL for female. 
         [0154]    Thus, in this second embodiment, the invention preferably provides a method of treating dyslipidemia in a patient with type 2 diabetes mellitus comprising administering to the patient a therapeutically effective amount of pemafibrate or a pharmaceutically acceptable salt thereof for a therapeutically effective period of time, wherein the patient has (a) a fasting TG concentration 175 mg/dL (2.26 mmol/L) and &lt;500 mg/dL (5.64 mmol/L); (b) a HDL-C concentration 50 mg/dL if a male and 55 mg/dL if a female; and controlled LDL-C levels. 
         [0155]    In this second embodiment, the invention most preferably provides a method of treating dyslipidemia in a patient with type 2 diabetes mellitus comprising administering to the patient a therapeutically effective amount of pemafibrate or a pharmaceutically acceptable salt thereof for a therapeutically effective period of time, wherein the patient has (a) a fasting TG concentration ≧200 mg/dL (2.26 mmol/L) and &lt;500 mg/dL (5.64 mmol/L); (b) an HDL-C concentration ≦40 mg/dL (1.034 mmol/L); and LDL-C levels ≦100 mg/dL. 
         [0156]    In a third embodiment, the invention provides a method of treating type 2 diabetes mellitus in a patient in need thereof comprising administering to the patient a therapeutically effective amount of pemafibrate or a pharmaceutically acceptable salt thereof for a therapeutically effective period of time, wherein the patient has (a) an elevated fasting triglyceride level; (b) a low HDL-C concentration; and (c) controlled LDL-C levels. 
         [0157]    In this third embodiment, elevated fasting triglyceride levels preferably refers to a fasting triglyceride level greater than 150, 160, 170, 175, 180, 190, 200, or 210 mg/dL triglycerides, with 175 or 200 mg/dL defining a particularly preferred cutoff value. The upper limit of the patient&#39;s fasting triglyceride levels is not particularly limited, but a cutoff value not greater than 500 mg/dL is preferred. 
         [0158]    In this third embodiment, a low HDL-C level preferably refers to an HDL-C level at which the patient is at risk for an adverse cardiovascular event, and can be different depending on the patient&#39;s sex. In preferred embodiments the patient can be said to have a low HDL-C level if the patient has an HDL-C concentration less than 55, 50, 45, 40 or 35 mg/dL. A preferred cutoff value is ≦50 mg/dL if male or ≦55 mg/dL if female. A particularly preferred cutoff value is ≦40 mg/dL without regard to sex. 
         [0159]    In this third embodiment, a patient with controlled LDL-C levels can refer to a patient having an LDL-C concentration ≦100 or 70 mg/dL, but preferably refers to a patient who is on concurrent statin therapy. A particularly preferred patient is: a) on concomitant moderate to high intensity statin therapy; b) on concomitant lipid-lowering therapy other than the concomitant moderate to high intensity statin therapy and has an LDL-C concentration ≦70 mg/dL; or c) statin-intolerant and has LDL-C concentration ≦100 mg/dL. 
         [0160]    In this third embodiment, a patient with type 2 diabetes mellitus can be defined as a patient with: elevated glycated hemoglobin A1c levels and elevated plasma glucose levels. A patient having a glycated hemoglobin A1c concentration of 6.5% (48 mmol/mol) or greater, on two consecutive tests may typically be considered to have type 2 diabetes mellitus, particularly when combined with an elevated plasma glucose level. The elevated plasma glucose level can be defined by one of three tests: (i) greater than or equal to 126 mg/dL (7.0 mmol/L) fasting plasma glucose level; (ii) greater than or equal to 200 mg/dL (11.1 mmol/L) plasma glucose level at 2 hours during oral glucose tolerance testing; (iii) a random plasma glucose level greater than or equal to 200 mg/dL with classic type 2 diabetes mellitus symptoms; or (iv) currently taking medication for treatment of diabetes. 
         [0161]    The therapeutically effective amount of pemafibrate for this third embodiment can be defined as a range of suitable doses on a daily basis. Thus, in one embodiment, the therapeutically effective amount is from 0.1 to 1.0 mg of pemafibrate or a pharmaceutically acceptable salt thereof, administered orally per day. In another embodiment the therapeutically effective amount is from 0.2 to 0.8 mg of pemafibrate or a pharmaceutically acceptable salt thereof, administered orally per day. In still another embodiment the therapeutically effective amount is 0.4 mg of pemafibrate or a pharmaceutically acceptable salt thereof, administered orally per day. These doses are preferably based on the weight of the free base of pemafibrate. 
         [0162]    Other lipid values and their cutoff values can also be used to define the patients treated by this third embodiment, including elevated non-HDL-C, elevated Apo CIII, and elevated remnant cholesterol. In one embodiment, the patient&#39;s non-HDL-C concentration is greater than 130, 160, or 190 mg/dL. In another embodiment, the patient&#39;s remnant cholesterol level is greater than 5.0, 5.3, 5.6, or 5.9 mg/dL. In yet another embodiment, the patient&#39;s Apo CIII concentration is 5 to 20 mg/dL, for example, 5.8 to 10 mg/dL for male and 5.4 to 9.0 mg/dL for female. 
         [0163]    Thus, in this third embodiment, the invention preferably provides a method of treating dyslipidemia in a patient with type 2 diabetes mellitus comprising administering to the patient a therapeutically effective amount of pemafibrate or a pharmaceutically acceptable salt thereof for a therapeutically effective period of time, wherein the patient has (a) a fasting TG concentration ≧175 mg/dL (2.26 mmol/L) and &lt;500 mg/dL (5.64 mmol/L); (b) a HDL-C concentration ≦50 mg/dL if a male and ≦55 mg/dL if a female; and controlled LDL-C levels. 
         [0164]    In this third embodiment, the invention most preferably provides a method of treating dyslipidemia in a patient with type 2 diabetes mellitus comprising administering to the patient a therapeutically effective amount of pemafibrate or a pharmaceutically acceptable salt thereof for a therapeutically effective period of time, wherein the patient has (a) a fasting TG concentration ≧200 mg/dL (2.26 mmol/L) and &lt;500 mg/dL (5.64 mmol/L); (b) a HDL-C concentration ≦40 mg/dL (1.034 mmol/L); and LDL-C levels ≦100 mg/dL. 
         [0165]    In a fourth embodiment, the invention provides a method of treating cardiovascular disease or preventing cardiovascular events in a patient with type 2 diabetes mellitus comprising administering to the patient a therapeutically effective amount of pemafibrate or a pharmaceutically acceptable salt thereof for a therapeutically effective period of time, wherein the patient has (a) an elevated fasting triglyceride level; (b) a low HDL-C concentration; and (c) controlled LDL-C levels. 
         [0166]    In this fourth embodiment, elevated fasting triglyceride levels preferably refers to a fasting triglyceride level greater than 150, 160, 170, 175, 180, 190, 200, or 210 mg/dL triglycerides, with 175 or 200 mg/dL defining a particularly preferred cutoff value. The upper limit of the patient&#39;s fasting triglyceride levels is not particularly limited, but a cutoff value not greater than 500 mg/dL is preferred. 
         [0167]    In this fourth embodiment, a low HDL-C level preferably refers to an HDL-C level at which the patient is at risk for an adverse cardiovascular event, and can be different depending on the patient&#39;s sex. In preferred embodiments the patient can be said to have a low HDL-C level if the patient has an HDL-C concentration less than 55, 50, 45, 40 or 35 mg/dL. A preferred cutoff value is ≦50 mg/dL if male or ≦55 mg/dL if female. A particularly preferred cutoff value is ≦40 mg/dL without regard to sex. 
         [0168]    In this fourth embodiment, a patient with controlled LDL-C levels can refer to a patient having an LDL-C concentration ≦100 or 70 mg/dL, but preferably refers to a patient who is on concurrent statin therapy. A particularly preferred patient is: a) on concomitant moderate to high intensity statin therapy; b) on concomitant lipid-lowering therapy other than the concomitant moderate to high intensity statin therapy and has an LDL-C concentration ≦70 mg/dL; or c) statin-intolerant and has LDL-C concentration ≦100 mg/dL. 
         [0169]    In this fourth embodiment, a patient with type 2 diabetes mellitus can be defined as a patient with: elevated glycated hemoglobin A1c levels and elevated plasma glucose levels. A patient having a glycated hemoglobin A1c concentration of 6.5% (48 mmol/mol) or greater, on two consecutive tests may typically be considered to have type 2 diabetes mellitus, particularly when combined with an elevated plasma glucose level. The elevated plasma glucose level can be defined by one of three tests: (i) greater than or equal to 126 mg/dL (7.0 mmol/L) fasting plasma glucose level; (ii) greater than or equal to 200 mg/dL (11.1 mmol/L) plasma glucose level at 2 hours during oral glucose tolerance testing; (iii) a random plasma glucose level greater than or equal to 200 mg/dL with classic type 2 diabetes mellitus symptoms; or (iv) currently taking medication for treatment of diabetes. 
         [0170]    The therapeutically effective amount of pemafibrate for this fourth embodiment can be defined as a range of suitable doses on a daily basis. Thus, in one embodiment, the therapeutically effective amount is from 0.1 to 1.0 mg of pemafibrate or a pharmaceutically acceptable salt thereof, administered orally per day. In another embodiment the therapeutically effective amount is from 0.2 to 0.8 mg of pemafibrate or a pharmaceutically acceptable salt thereof, administered orally per day. In still another embodiment the therapeutically effective amount is 0.4 mg of pemafibrate or a pharmaceutically acceptable salt thereof, administered orally per day. These doses are preferably based on the weight of the free base of pemafibrate. 
         [0171]    Other lipid values and their cutoff values can also be used to define the patients treated by this fourth embodiment, including elevated non-HDL-C, elevated Apo CIII, and elevated remnant cholesterol. In one embodiment, the patient&#39;s non-HDL-C concentration is greater than 130, 160, or 190 mg/dL. In another embodiment, the patient&#39;s remnant cholesterol level is greater than 5.0, 5.3, 5.6, or 5.9 mg/dL. In yet another embodiment, the patient&#39;s Apo CIII concentration is 5 to 20 mg/dL, for example, 5.8 to 10 mg/dL for male and 5.4 to 9.0 mg/dL for female. 
         [0172]    Thus, in this fourth embodiment, the invention preferably provides a method of treating dyslipidemia in a patient with type 2 diabetes mellitus comprising administering to the patient a therapeutically effective amount of pemafibrate or a pharmaceutically acceptable salt thereof for a therapeutically effective period of time, wherein the patient has (a) a fasting TG concentration ≧175 mg/dL (2.26 mmol/L) and &lt;500 mg/dL (5.64 mmol/L); (b) a HDL-C concentration ≦50 mg/dL if a male and ≦55 mg/dL if a female; and controlled LDL-C levels. 
         [0173]    In this fourth embodiment, the invention most preferably provides a method of treating dyslipidemia in a patient with type 2 diabetes mellitus comprising administering to the patient a therapeutically effective amount of pemafibrate or a pharmaceutically acceptable salt thereof for a therapeutically effective period of time, wherein the patient has (a) a fasting TG concentration ≧200 mg/dL (2.26 mmol/L) and &lt;500 mg/dL (5.64 mmol/L); (b) a HDL-C concentration ≦40 mg/dL (1.034 mmol/L); and LDL-C levels ≦100 mg/dL. 
         [0174]    In a fifth embodiment, the invention provides a method of prolonging the time to first occurrence of: 
         [0175]    a) any component of the primary endpoint in subgroups of subjects defined at baseline by: sex; presence or absence of established CVD; and baseline lipid lowering therapy as defined hierarchically by:
       i) receiving treatment with a stable dose (i.e. for at least 12 weeks) of a qualifying moderate-to high intensity statin; or   ii) statin intolerant and have evidence of LDL &lt;100 mg/dl (2.59 mmol/L) by local laboratory determination within the previous 12 months; or   iii) have evidence of LDL-C &lt;70 mg/dl (1.81 mmol/L) by local laboratory determination within the previous 12 months if untreated or on stable dosing (i.e. for at least 12 weeks) of another lipid-lowering regimen including a PCSK9 inhibitor.       
 
         [0179]    b) any component of nonfatal MI, nonfatal ischemic stroke, hospitalization of for unstable angina requiring unplanned coronary revascularization, CV death, or any coronary revascularization; 
         [0180]    c) any component of nonfatal MI, nonfatal ischemic stroke, hospitalization for unstable angina requiring unplanned coronary revascularization, or all-cause mortality; 
         [0181]    d) any component of nonfatal MI, nonfatal ischemic stroke, CV death, any coronary revascularization, or hospitalization for heart failure; 
         [0182]    e) any component of nonfatal MI, nonfatal stroke (any), CV death, or hospitalization for unstable angina requiring unplanned coronary revascularization; 
         [0183]    f) individual components of the primary endpoint, nonfatal stroke (any), all cause mortality, and hospitalization for heart failure; 
         [0184]    g) diabetic retinopathy, as assessed by use of retinal laser treatment, anti-vascular endothelial growth factor therapy, or vitrectomy due to development of and/or deterioration in diabetic retinopathy; 
         [0185]    h) diabetic nephropathy, as assessed by an increase in microalbumin/creatinine ratio to &gt;30 mg/g among those without microalbuminuria at baseline, and categorical change from baseline albuminuria (normo-, micro-, or macroalbuminuria), doubling of creatinine from baseline, creatinine level &gt;6.0 mg/dl, glomerular filtration rate (GFR) &lt;15 ml/ml, or initiation of renal replacement therapy (dialysis or transplant), among all subjects; and 
         [0186]    i) peripheral artery disease, defined as incidence of lower-extremity revascularization, intermittent claudication, rest pain, lower-extremity ischemic ulceration, or amputation with either ankle brachial index &lt;0.9 or other diagnostic testing (e.g., angiogram, toe-brachial index, or imaging study), 
         [0000]    wherein the method comprises administering to the subjects a therapeutically effective amount of pemafibrate or a pharmaceutically acceptable salt thereof. 
         [0187]    The sixth embodiment, the invention provides a method of prolonging the time to first occurrence of:
       a) any component of the 3-component composite endpoint of non-fatal MI, non-fatal stroke, or cardiovascular death;   b) any component of the primary endpoint or hospitalization for heart failure;   c) any component of the primary endpoint or all-cause mortality;   d) any component of the primary endpoint, any coronary revascularization, or hospitalization for heart failure; or   e) any new or worsening peripheral artery disease, defined as incidence of lower extremity revascularization, intermittent claudication, rest pain, lower extremity ischemic ulceration, or major amputation with either ankle-brachial index ≦0.9 or other diagnostic testing (eg, toe-brachial index, angiogram, or other imaging study).       
 
         [0193]    Pemafibrate achieves these benefits without any significant safety concerns, even when co-administered with a statin. 
         [0194]    The dosing of the pemafibrate is preferably defined based on route of administration, dose, and length of treatment. The preferred route of administration is oral. Pemafibrate can be administered to a patient in the fed or fasting state. 
         [0195]    The therapeutically effective amount of pemafibrate can be defined as a range of suitable doses on a daily basis. Thus, in one embodiment the therapeutically effective amount is from 0.1 to 1.0 mg of pemafibrate or a pharmaceutically acceptable salt thereof, administered orally per day. In another embodiment the therapeutically effective amount is from 0.2 to 0.8 mg of pemafibrate or a pharmaceutically acceptable salt thereof, administered orally per day. In still another embodiment the therapeutically effective amount is 0.4 mg of pemafibrate or a pharmaceutically acceptable salt thereof, administered orally per day. These doses are preferably based on the weight of the free base of pemafibrate. 
         [0196]    The dose of pemafibrate can be administered as one dose per day or in two, three or four evenly divided doses per day. 
         [0197]    In some embodiment, pemafibrate can be administered for a therapeutically effective period of time. The therapeutically effective period of time refers to the period of time necessary to prevent the occurrence of cardiovascular events, and varies depending on the conditions of a patient being treated, extent and severity of risk factors, and other factors such as the patient&#39;s age. The therapeutically effective period of time generally equates to three or more months of treatment, six or more months, one or more years, two or more years, three or more years, or four or more years. 
         [0198]    In some embodiments, lipid values and these risk factors can be combined in any manner to define patient populations treatable by the methods of the present invention, and that any of the cutoff value provided for a particular parameter can be applied to define the patient. Thus, in one embodiment, the patient can have high TG and/or low HDL-C. In another embodiment, the patient can have high TG and/or low HDL-C, and one or more selected from the group consisting of controlled LDL-C, atherosclerosis, age (male ≧50 or female ≧55), type 2 diabetes mellitus, elevated non-HDL-C, elevated Apo CIII, elevated remnant cholesterol and atherosclerosis. 
         [0199]    Additional advantages of the invention are set forth in part in the description that follows, and in part will be obvious from the description, or may be learned by practice of the invention. The advantages of the invention will be realized and attained by means of the elements and combinations particularly pointed out in the appended claims. It is to be understood that both the foregoing general description and the following detailed description are exemplary and explanatory only and are not restrictive of the invention, as claimed. 
         [0200]    Other embodiments of the invention may be apparent to those skilled in the art from consideration of the specification and practice of the invention disclosed herein. It is intended that the specification and examples be considered as exemplary only, with a true scope and spirit of the invention being indicated by the following claims. 
       EXAMPLES 
       [0201]    In the following examples, efforts have been made to ensure accuracy with respect to numbers (e.g., amounts, temperature, etc.) but some errors and deviations should be accounted for. The following examples are put forth so as to provide those of ordinary skill in the art with a complete disclosure and description of how the methods claimed herein are made and evaluated, and are intended to be purely exemplary of the invention and are not intended to limit the scope of what the inventors regard as their invention. 
       Example 1 Treatment of Dyslipidemia with Pemafibrate as Add-On to Statin Therapy 
       [0202]    A placebo-controlled, randomized, double-blind parallel-group study was performed to evaluate the treatment effect of pemafibrate in dyslipidemia patients on concurrent statin therapy. Dyslipidemia patients on a stable dose of statin therapy (atorvastatin, rosuvastatin or simvastatin) were randomized to one (1) of seven (7) treatment groups: once daily [QD] pemafibrate 0.1 mg, 0.2 mg, or 0.4 mg; twice daily [BID] pemafibrate 0.05 mg, 0.1 mg, or 0.2 mg; or placebo, for 12 weeks of pemafibrate treatment, and were followed for an additional 2 weeks thereafter. 
         [0203]    Patients were required to have statin controlled LDL-C (≦10 mg/dl above the NCEP ATP III target) or on a maximum tolerated dose of statin, but residual dyslipidemia (TG ≧175 and ≦500 mg/dl; HDL-C ≦50 mg/dl for male and ≦55 mg/dl for female). Differences in changes of TG, non-HDL-C, Apo CIII, and remnant-C between treatment groups were evaluated for significance. Overall, 408 patients were randomized to treatment, and 375 patients (91.9%) completed the study. There were no significant differences between the 7 treatment groups at baseline. 99% of patients were white Caucasian, 31.9% had a history of coronary heart disease, 37.8% had type 2 diabetes mellitus; intensity of statin treatment was high in 46.3% of patients, moderate in 48.1%. The results of the study are depicted in  FIGS. 1A-1D . 
         [0204]    The following observations also were made:
       Pemafibrate significantly reduced TG levels in all treatment groups after 12 weeks ( FIG. 1A ).   Non-HDL-C levels were significantly reduced at 0.2 mg BID and 0.2 mg QD doses ( FIG. 1B ).   LDL-C levels were significantly increased at 0.1 mg BID (22.46% vs. placebo), 0.2 mg BID (24.25%), and 0.4 mg QD (18.74%), with no significant change in total Apo B at any dose.   Significant increases in HDL-C (7.35% to 10.95% vs. placebo) were observed at all doses except the 0.1 mg QD dose.   There were dose-dependent reductions with BID dosing for TG, non-HDL-C, Apo CIII ( FIG. 1C ), remnant-C ( FIG. 1D ), and Apo B48 (−40.8% to −63.4%) that reached statistical significance for both TG and non-HDL-C at 0.2 mg BID; the effects of QD dosing were more variable across doses.   Adverse events occurred in 56.7% of patients on placebo vs. 46.4% of those on pemafibrate, with no relationship to dose. No other safety concerns were observed.       
 
       Example 2 Retrospective Analysis of Type 2 Diabetes Patients 
       [0211]    A post-hoc analysis of patients with type 2 diabetes mellitus (HbA1c ≦10%) who participated in the study described in Example 1, was undertaken to determine the treatment effect of pemafibrate in diabetes patients. Overall, 161 type 2 diabetes mellitus patients were randomized and 154 patients completed treatment. 99.4% were white Caucasian, and 35.7% had a history of CHD; intensity of statin therapy was high in 45.5% of patients, moderate in 49.4%. The results of the analysis are reported in  FIGS. 2A-2D . 
         [0212]    Tables 1-4 also report the results of the analyses, and compare the results to the results obtained for the general residual dyslipidemia population studied in Example 1. 
         [0000]    
       
         
               
             
               
               
               
             
               
               
               
             
           
               
                 TABLE 1 
               
             
             
               
                   
               
               
                 (TG Reduction Relative to Placebo) 
               
             
          
           
               
                   
                 Residual  
                 Diabetic  
               
               
                 Dose 
                 Dyslipidemia Population 
                 Sub-Population 
               
               
                   
               
             
          
           
               
                 0.05 mg BID 
                 −36.1 
                 −47.0 
               
               
                  0.1 mg BID 
                 −45.8 
                 −67.4 
               
               
                  0.2 mg BID 
                 −54.4 
                 −56.1 
               
               
                  0.1 mg QD 
                 −34.0 
                 −44.7 
               
               
                  0.2 mg QD 
                 −37.7 
                 −48.1 
               
               
                  0.4 mg QD 
                 −42.7 
                 −47.9 
               
               
                   
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
               
             
               
               
               
             
           
               
                 TABLE 2 
               
             
             
               
                   
               
               
                 (Non HDL-C Reduction Relative to Placebo) 
               
             
          
           
               
                   
                 Residual  
                 Diabetic  
               
               
                 Dose 
                 Dyslipidemia Population 
                 Sub-Population 
               
               
                   
               
             
          
           
               
                 0.05 mg BID 
                 −6.8 
                 −14.2 
               
               
                  0.1 mg BID 
                 −7.4 
                 −17.3 
               
               
                  0.2 mg BID 
                 −8.9 
                 −10.9 
               
               
                  0.1 mg QD 
                 −5.2 
                 −5.5 
               
               
                  0.2 mg QD 
                 −9.1 
                 −15.3 
               
               
                  0.4 mg QD 
                 −7.8 
                 −10.3 
               
               
                   
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
               
             
               
               
               
             
           
               
                 TABLE 3 
               
             
             
               
                   
               
               
                 (Apo CIII Reduction Relative to Placebo) 
               
             
          
           
               
                   
                 Residual  
                 Diabetic  
               
               
                 Dose 
                 Dyslipidemia Population 
                 Sub-Population 
               
               
                   
               
             
          
           
               
                 0.05 mg BID 
                 −15.5 
                 −26.1 
               
               
                  0.1 mg BID 
                 −28.7 
                 −37.3 
               
               
                  0.2 mg BID 
                 −36.0 
                 −39.7 
               
               
                  0.1 mg QD 
                 −17.1 
                 −23.8 
               
               
                  0.2 mg QD 
                 −24.3 
                 −35.4 
               
               
                  0.4 mg QD 
                 −23.8 
                 −32.4 
               
               
                   
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
               
             
               
               
               
             
           
               
                 TABLE 4 
               
             
             
               
                   
               
               
                 (Remnant-C Reduction Relative to Placebo) 
               
             
          
           
               
                   
                 Residual  
                 Diabetic  
               
               
                 Dose 
                 Dyslipidemia Population 
                 Sub-Population 
               
               
                   
               
             
          
           
               
                 0.05 mg BID 
                 −35.6 
                 −55.6 
               
               
                  0.1 mg BID 
                 −48.8 
                 −81.8 
               
               
                  0.2 mg BID 
                 −58.0 
                 −70.7 
               
               
                  0.1 mg QD 
                 −39.9 
                 −62.1 
               
               
                  0.2 mg QD 
                 −45.9 
                 −66.3 
               
               
                  0.4 mg QD 
                 −45.5 
                 −58.7 
               
               
                   
               
             
          
         
       
     
         [0213]    As can be seen, pemafibrate consistently reduced TG, non-HDL-C, Apo CIII, and remnant cholesterol values more in type 2 diabetes patients than in the general dyslipidemia population treated in Example 1. 
         [0214]    The following observations also were made:
       Pemafibrate significantly reduced TG levels across all doses ( FIG. 2A ).   Decreases in non-HDL-C were less consistent across treatment groups ( FIG. 2B ); pemafibrate significantly increased BQ LDL-C at 0.2 mg BID (1.8%) and 0.1 mg QD (6.7%), with no significant change in total Apo B at any dose.   Pemafibrate significantly reduced Apo CIII ( FIG. 2C ), remnant-C ( FIG. 2D ), and Apo B48 levels at all doses.   Significant increases were seen for HDL-C at doses of 0.05 mg BID (11.39%), 0.1 mg BID (11.94%), and 0.2 mg QD (9.48%).   With the exception of Apo CIII and BQ LDL-C levels, changes in lipid parameters were not further increased at doses higher than 0.1 mg BID.   57.7% of placebo patients reported an adverse event compared with 25.0% to 71.4% of pemafibrate-treated patients, with no relationship to dose.       
 
       Example 3 Effectiveness of Pemafibrate as Add-On to Pitavastatin Therapy 
       [0221]    A double-blind parallel-group study was undertaken to determine the effectiveness of pemafibrate when added to an existing statin regimen. A total of 188 patients with fasting high TG (≧200, &lt;1000 mg/dL) and non-HDL-C (≧150 mg/dL), treated with pitavastatin (once daily, 2 mg/day) were randomized to 12-week treatment groups; placebo (n=46), twice-daily pemafibrate 0.1 (n=45), 0.2 (n=49) and 0.4 mg/day (n=48). The primary endpoint was the percentage change in TG from baseline and incidence of adverse drug reactions (ADRs) and adverse events (AEs). 
         [0222]    The results of the study are reported in  FIGS. 3A-3D  and summarized as follows. Fasting TG reduction was as follows; placebo: −6.9%, pemafibrate 0.1, 0.2 and 0.4 mg: −46.1%, −53.4% and −52.0%. All pemafibrate groups had significant reductions compared with placebo (P&lt;0.001). Fasting non-HDL-C reductions were −5.9% with placebo and −11.3, −14.1 and −13.3% with pemafibrate 0.1, 0.2 and 0.4 mg, respectively. Significant increase in HDL-C, and reductions in VLDL-C, remnant lipoprotein cholesterol and Apo CIII compared to placebo were found in all pemafibrate groups (P&lt;0.01). Although pemafibrate had a neutral effect on total LDL-C, HPLC analysis revealed a significant reduction of very small LDL-C with pemafibrate compared to the placebo group (P&lt;0.05). Moreover, the highest dose of pemafibrate (0.4 mg/day) showed significant reductions in fasting plasma glucose and HOMA-IR compared to placebo (P=0.003 and 0.019, respectively). 
       REFERENCES CITED 
       [0223]    Throughout this application, various publications are referenced. The disclosures of these publications in their entireties are hereby incorporated by reference into this application in order to more fully describe the state of the art to which this invention pertains. The references disclosed are also individually and specifically incorporated by reference herein for the material contained in them that is discussed in the sentence in which the reference is relied upon.
   The FIELD study investigators.  Effects of long - term fenofibrate therapy on cardiovascular events in  9795  people with type  2  diabetes mellitus  ( the FIELD study ):  randomised controlled trial , L ANCET  2005; 366:1849-1861.   The ACCORD Study Group.  Effects of Combination Lipid Therapy in Type  2  Diabetes Mellitus , N E NGL  J M ED  2010; 362:1563-1574.   Matthews D R, Hosker J P, Rudenski A S, Naylor B A, Treacher D F, Turner R C:  Homeostasis model assessment: insulin resistance and beta - cell function from fasting plasma glucose and insulin concentrations in man . D IABETOLOGIA  1985; 28:412-419.   Ishibashi S, Arai H, Yamashita S, Araki E, Yamada N,  Beneficial effects of K -877 , a highly potent and selective PPARα agonist, on plasma lipoprotein profile in patients with atherogenic dyslipidemia  (80 th  European Atherosclerosis Society (EAS) Congress 2012; M4.5).   Araki E, Ishibashi S, Yamashita S, Arai H, Yokote K, Suganami H and Kodama T:  A highly potent and specific PPAR alpha agonist, K -877 , improves lipid profiles and insulin sensitivity in dyslipidemia patient; an integrated analysis of  3  phase  2/3  trials  (50 th  European Association for the Study of Diabetes (EASD) 2014; 663).