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Xu M, Zhang P, Lv W, Chen Y, Chen M, Leng Y, Hu T, Wang K, Zhao Y, Shen J, You X, Gu D, Zhao W, Tan S. A bifunctional anti-PCSK9 scFv/Exendin-4 fusion protein exhibits enhanced lipid-lowering effects via targeting multiple signaling pathways in HFD-fed mice. Int J Biol Macromol 2023; 253:127003. [PMID: 37739280 DOI: 10.1016/j.ijbiomac.2023.127003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 05/14/2023] [Accepted: 09/17/2023] [Indexed: 09/24/2023]
Abstract
Fusion protein which encompasses more than one functional component, has become one of the most important representatives of macromolecular drugs for disease treatment since that monotherapy itself might not be effective enough to eradicate the disease. In this study, we sought to construct a bifunctional antibody fusion protein by fusing anti-PCSK9 scFv with Exendin-4 for simultaneously lowering both LDL-C and TG. Firstly, three Ex4-anti-PCSK9 scFv fusion proteins were constructed by genetically connecting the C-terminal of Exendin-4 to the N-terminal of anti-PCSK9 scFv through various flexible linker peptides (G4S)n (n = 2, 3, 4). After soluble expression in E. coli, the most potent Ex4-(G4S)4-anti-PCSK9 scFv fusion protein was selected based on in vitro activity assays. Then, we investigated the in vivo therapeutic effects of Ex4-(G4S)4-anti-PCSK9 scFv on the serum lipid profile and bodyweight changes as well as underlying molecular mechanism in HFD-fed C57BL/6 mice. The data showed that Ex4-(G4S)4-anti-PCSK9 scFv exhibits enhanced effects of lowering both LDL-C and TG in serum, reducing food intake and body weight via blocking PCSK9/LDLR, activating AMPK/SREBP-1 pathways, and up-regulating sirt6. Conclusively, Ex4-(G4S)4-anti-PCSK9 has the potential to serve as a promising therapeutic agent for effectively treating dyslipidemia with high levels of both LDL-C and TG.
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Affiliation(s)
- Menglong Xu
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing 210009, PR China
| | - Panpan Zhang
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing 210009, PR China
| | - Wenxiu Lv
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing 210009, PR China
| | - Yuting Chen
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing 210009, PR China
| | - Manman Chen
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing 210009, PR China
| | - Yeqing Leng
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing 210009, PR China
| | - Tuo Hu
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing 210009, PR China
| | - Ke Wang
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing 210009, PR China
| | - Yaqiang Zhao
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing 210009, PR China
| | - Jiaqi Shen
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing 210009, PR China
| | - Xiangyan You
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing 210009, PR China
| | - Dian Gu
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing 210009, PR China
| | - Wenfeng Zhao
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing 210009, PR China
| | - Shuhua Tan
- Department of Cell and Molecular Biology, School of Life Science and Technology, State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, China Pharmaceutical University, Nanjing 210009, PR China.
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Krishnamurthy A, Bradley C, Ascunce R, Kim SM. SAMSON and the Nocebo Effect: Management of Statin Intolerance. Curr Cardiol Rep 2022; 24:1101-1108. [PMID: 35759168 DOI: 10.1007/s11886-022-01729-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Statins are essential medications in the treatment of atherosclerotic cardiovascular disease; however, remain widely underutilized in large part due to concerns regarding adverse side effects. We describe the role of the nocebo effect in the perception of statin intolerance and provide management recommendations utilizing both statin and non-statin lipid-lowering therapies. RECENT FINDINGS The recent Self-Assessment Method for Statin side-effects Or Nocebo (SAMSON) trial demonstrated that 90% of adverse symptoms related to statins were also elicited by placebo, a powerful demonstration of the nocebo effect. Importantly, 50% of the study patients were able to successfully reinitiate statin therapy. Statin intolerance is common and can often be managed with expectation setting and adjustment of doses and/or dosing regimens. In those who remain unable to tolerate statins, numerous alternative lipid-lowering therapies exist with strong safety and efficacy profiles.
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Affiliation(s)
- Amrita Krishnamurthy
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Avenue, 8th Floor, New York, NY, 10021, USA
| | - Corey Bradley
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Rebecca Ascunce
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Avenue, 8th Floor, New York, NY, 10021, USA
| | - Samuel M Kim
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Avenue, 8th Floor, New York, NY, 10021, USA.
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Laufs U, Filipiak KJ, Gouni-Berthold I, Catapano AL. Practical aspects in the management of statin-associated muscle symptoms (SAMS). ATHEROSCLEROSIS SUPP 2018; 26:45-55. [PMID: 28434484 DOI: 10.1016/s1567-5688(17)30024-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIMS Statin-associated muscle symptoms (SAMS) frequently cause statin non-adherence, switching and discontinuation, contributing to adverse cardiovascular (CV) outcomes. Therefore, the management of SAMS is key in the effective treatment of patients with cardiovascular disease (CVD), through achievement of maximum-tolerated statin dosing and other practical aspects. The aim of this article is to provide practical, focused advice for healthcare professionals on the management of patients with SAMS. METHODS An expert working group combined current evidence, published guidelines and experiences surrounding a number of topics concerning SAMS to provide recommendations on how to best assess and manage this condition and reach the highest tolerated dose of statin for each individual patient. RESULTS The group collaborated to provide guidance on definitions in the SAMS field, psychological issues, re-challenging and switching treatments, as well as interpretation of current guidelines and optimal treatment of SAMS in different patient populations. An algorithm was developed to guide the management of patients with SAMS. In addition, the expert working group considered some of the more complex scenarios in a series of frequently asked questions and suggested answers. CONCLUSIONS The expert working group gave recommendations for healthcare professionals on the management of SAMS but highlighted the importance of tailoring the treatment approach to each individual patient. Evidence supporting the role of nutraceuticals and complementary therapies, such as vitamin D, was lacking, however the majority of the group favoured combination therapy with ezetimibe and the addition of PCSK9 inhibitors in high-risk patients.
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Affiliation(s)
- Ulrich Laufs
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, Saarland University Medical Center, Homburg, Germany.
| | - Krysztof J Filipiak
- First Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Ioanna Gouni-Berthold
- Polyclinic for Endocrinology, Diabetes and Preventive Medicine, University of Cologne, Cologne, Germany
| | - Alberico L Catapano
- Department of Pharmacological and Biomolecular Sciences, University of Milan, and IRCCS Multimedica, Milan, Italy
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K Siddiqui M, Maroteau C, Veluchamy A, Tornio A, Tavendale R, Carr F, Abelega NU, Carr D, Bloch K, Hallberg P, Yue QY, Pearson ER, Colhoun HM, Morris AD, Dow E, George J, Pirmohamed M, Ridker PM, Doney ASF, Alfirevic A, Wadelius M, Maitland-van der Zee AH, Chasman DI, Palmer CNA. A common missense variant of LILRB5 is associated with statin intolerance and myalgia. Eur Heart J 2017; 38:3569-3575. [PMID: 29020356 PMCID: PMC5837247 DOI: 10.1093/eurheartj/ehx467] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/26/2017] [Accepted: 07/24/2017] [Indexed: 12/11/2022] Open
Abstract
Aims A genetic variant in LILRB5 (leukocyte immunoglobulin-like receptor subfamily-B) (rs12975366: T > C: Asp247Gly) has been reported to be associated with lower creatine phosphokinase (CK) and lactate dehydrogenase (LDH) levels. Both biomarkers are released from injured muscle tissue, making this variant a potential candidate for susceptibility to muscle-related symptoms. We examined the association of this variant with statin intolerance ascertained from electronic medical records in the GoDARTS study. Methods and results In the GoDARTS cohort, the LILRB5 Asp247 variant was associated with statin intolerance (SI) phenotypes; one defined as having raised CK and being non-adherent to therapy [odds ratio (OR) 1.81; 95% confidence interval (CI): 1.34-2.45] and the other as being intolerant to the lowest approved dose of a statin before being switched to two or more other statins (OR 1.36; 95% CI: 1.07-1.73). Those homozygous for Asp247 had increased odds of developing both definitions of intolerance. Importantly the second definition did not rely on CK elevations. These results were replicated in adjudicated cases of statin-induced myopathy in the PREDICTION-ADR consortium (OR1.48; 95% CI: 1.05-2.10) and for the development of myalgia in the JUPITER randomized clinical trial of rosuvastatin (OR1.35, 95% CI: 1.10-1.68). A meta-analysis across the studies showed a consistent association between Asp247Gly and outcomes associated with SI (OR1.34; 95% CI: 1.16-1.54). Conclusion This study presents a novel immunogenetic factor associated with statin intolerance, an important risk factor for cardiovascular outcomes. The results suggest that true statin-induced myalgia and non-specific myalgia are distinct, with a potential role for the immune system in their development. We identify a genetic group that is more likely to be intolerant to their statins.
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Affiliation(s)
- Moneeza K Siddiqui
- Pat McPherson Centre for Pharmacogenetics & Pharmacogenomics, Division of Molecular & Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee DD19SY, UK
| | - Cyrielle Maroteau
- Pat McPherson Centre for Pharmacogenetics & Pharmacogenomics, Division of Molecular & Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee DD19SY, UK
| | - Abirami Veluchamy
- Pat McPherson Centre for Pharmacogenetics & Pharmacogenomics, Division of Molecular & Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee DD19SY, UK
| | - Aleksi Tornio
- Pat McPherson Centre for Pharmacogenetics & Pharmacogenomics, Division of Molecular & Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee DD19SY, UK
| | - Roger Tavendale
- Pat McPherson Centre for Pharmacogenetics & Pharmacogenomics, Division of Molecular & Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee DD19SY, UK
| | - Fiona Carr
- Pat McPherson Centre for Pharmacogenetics & Pharmacogenomics, Division of Molecular & Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee DD19SY, UK
| | - Ngu-Uma Abelega
- Pat McPherson Centre for Pharmacogenetics & Pharmacogenomics, Division of Molecular & Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee DD19SY, UK
| | - Dan Carr
- Institute of Translation Medicine, University of Liverpool, Liverpool L69 3BX, UK
| | - Katyrzyna Bloch
- Institute of Translation Medicine, University of Liverpool, Liverpool L69 3BX, UK
| | - Par Hallberg
- Department of Medical Sciences, Clinical Pharmacology and Science of Life Laboratory, Uppsala University, 751 85 Uppsala, Sweden
| | - Qun-Ying Yue
- Medical Products Agency, Dag Hammarskjölds väg 42, 75237 Uppsala, Sweden
| | - Ewan R Pearson
- Pat McPherson Centre for Pharmacogenetics & Pharmacogenomics, Division of Molecular & Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee DD19SY, UK
| | - Helen M Colhoun
- Pat McPherson Centre for Pharmacogenetics & Pharmacogenomics, Division of Molecular & Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee DD19SY, UK
- Institute of Genetics & Molecular Medicine, University of Edinburgh, Edinburgh EH4 2XU, UK
| | - Andrew D Morris
- Pat McPherson Centre for Pharmacogenetics & Pharmacogenomics, Division of Molecular & Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee DD19SY, UK
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh EH4 2XU, UK
| | - Eleanor Dow
- Ninewells Hospital and Medical School, Dundee DD19SY, UK
| | - Jacob George
- Ninewells Hospital and Medical School, Dundee DD19SY, UK
| | - Munir Pirmohamed
- Institute of Translation Medicine, University of Liverpool, Liverpool L69 3BX, UK
| | - Paul M Ridker
- Brigham and Women's Hospital, Department of Medicine, Preventive Medicine, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Alex S F Doney
- Ninewells Hospital and Medical School, Dundee DD19SY, UK
| | - Ana Alfirevic
- Institute of Translation Medicine, University of Liverpool, Liverpool L69 3BX, UK
| | - Mia Wadelius
- Department of Medical Sciences, Clinical Pharmacology and Science of Life Laboratory, Uppsala University, 751 85 Uppsala, Sweden
| | - Anke-Hilse Maitland-van der Zee
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, 3508 TB Utrecht, The Netherlands
- Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Daniel I Chasman
- Brigham and Women's Hospital, Department of Medicine, Preventive Medicine, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Colin N A Palmer
- Pat McPherson Centre for Pharmacogenetics & Pharmacogenomics, Division of Molecular & Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee DD19SY, UK
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Hohenstein B, Tselmin S, Bornstein SR, Julius U. How effectively will PCSK9 inhibitors allow retrieval of freedom from apheresis in cardiovascular high risk patients? – Estimates form a large single center. ATHEROSCLEROSIS SUPP 2017; 30:28-32. [DOI: 10.1016/j.atherosclerosissup.2017.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
PURPOSE Recent evidence suggests that statin intolerance may be more common than reported in randomized trials. However, the statin-intolerant population is not well characterized. The goal of this report is to characterize the population enrolled in the phase 3 Goal Achievement after Utilizing an anti-PCSK9 antibody in Statin Intolerant Subjects Study (GAUSS-2; NCT 01763905). METHODS GAUSS-2 compared evolocumab, a fully human monoclonal antibody to proprotein convertase subtilisin/kexin type 9 (PCSK9) to ezetimibe in hypercholesterolemic patients who discontinued statin therapy due to statin-associated muscle symptoms (SAMS). GAUSS-2 was a 12-week, double-blind, placebo-controlled, randomized study that enrolled patients with elevated LDL-C who were either not on a statin or able to tolerate only a low-dose due to SAMS. Patients had received ≥2 statins and were unable to tolerate any statin dose or increase in dose above a specified weekly dose due to SAMS. RESULTS Three hundred seven patients (mean [SD] age, 62 [10] years; 54 % males) were randomized 2:1 (evolocumab:ezetimibe). Mean (SD) LDL-C was 4.99 (1.51) mmol/L. Patients had used ≥2 (100 %), ≥3 (55 %), or ≥4 (21 %) statins. Coronary artery disease was present in 29 % of patients. Statin-intolerant symptoms were myalgia in 80 % of patients, weakness in 39 %, and more serious complications in 20 %. In 98 % of patients, SAMS interfered with normal daily activity; in 52 %, symptoms precluded moderate exertion. CONCLUSION Evaluation of the GAUSS-2 trial population of statin-intolerant patients demonstrates that most patients were high risk with severely elevated LDL-C and many had statin-associated muscle symptoms that interfered with their quality of life.
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Jacobson TA, Edelman SV, Galipeau N, Shields AL, Mallya UG, Koren A, Davidson MH. Development and Content Validity of the Statin Experience Assessment Questionnaire (SEAQ)©. THE PATIENT 2017; 10:321-334. [PMID: 27981439 PMCID: PMC5422451 DOI: 10.1007/s40271-016-0211-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
INTRODUCTION The National Lipid Association Statin Intolerance (SI) Panel recognized the need for better understanding of the patient SI experience. OBJECTIVE The objective of this research was to develop a patient-reported outcome (PRO) questionnaire to assess a patient's experience with SI. METHODS Questionnaire development was informed via a series of research activities: literature review, concept elicitation, item generation, and content evaluation. Following the literature review and concept elicitation, a draft questionnaire was constructed and subsequently modified based on feedback from therapeutic area experts and patients via cognitive debriefing interviews. RESULTS Muscle-related symptoms were the most commonly reported symptoms associated with SI in the literature review (35 of 41 articles reviewed [85%]) and in semi-structured interviews with experts (n = 5 [100%]) and patients (n = 17 of 20 [85.0%]). Physical and other impacts of SI symptoms on daily activities were also frequently reported. A 17-item draft questionnaire was created, and cognitive debriefing with experts (n = 5) and patients (n = 15) was conducted. Overall, the items, response options, and instructions were comprehensible and positively reviewed; minor changes resulted in the 15-item Statin Experience Assessment Questionnaire (SEAQ)©. Using a 30-day recall period, the SEAQ© assesses the severity and impact of six SI symptoms (muscle ache, muscle pain, muscle cramps, muscle weakness, tiredness, and joint pain) on an 11-point numeric scale. Statin discontinuation and likelihood of discontinuation due to symptoms are assessed and scored on a yes/no and five-point verbal response scale, respectively. CONCLUSION The SEAQ
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Affiliation(s)
- Terry A Jacobson
- Emory University School of Medicine, Lipid Clinic and Cardiovascular Risk Reduction Program, Department of Medicine, 49 Jesse Hill Jr Drive SE, Atlanta, GA, 30303, USA.
| | - Steven V Edelman
- University of California San Diego School of Medicine, Veterans Affairs Medical Center, 3350 La Jolla Village Drive (111G), San Diego, CA, 92161, USA
| | - Nina Galipeau
- Adelphi Values, 290 Congress Street, 7th Floor, Boston, MA, 02210, USA
| | - Alan L Shields
- Adelphi Values, 290 Congress Street, 7th Floor, Boston, MA, 02210, USA
| | - Usha G Mallya
- Sanofi US, 55 Corporate Drive, Bridgewater, NJ, 08807, USA
| | - Andrew Koren
- Sanofi US, 55 Corporate Drive, Bridgewater, NJ, 08807, USA
| | - Michael H Davidson
- University of Chicago Pritzker School of Medicine, 150 E. Huron, Suite 900, Chicago, IL, 60611, USA
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Abstract
Reducing plasma levels of low-density lipoprotein cholesterol (LDL-C) remains the cornerstone in the primary and secondary prevention of cardiovascular disease. However, lack of efficacy and adverse effects mean that a substantial proportion of patients fail to achieve acceptable LDL-C levels with currently available lipid-lowering drugs. Over the last decade, inhibition of proprotein convertase subtilisin/kexin type 9 (PCSK9) has emerged as a promising therapeutic strategy to reduce residual cardiovascular disease risk. Binding of PCSK9 to the LDL receptor targets the receptor for lysosomal degradation. The recognition that inhibition of PCSK9 increases LDL receptor activity has led to the development of a number of approaches to directly target PCSK9. Numerous monoclonal antibodies against PCSK9 are currently being evaluated in phase 3 trials, involving various patient categories on different background lipid-lowering therapies. Current evidence shows reductions in LDL-C levels of up to 70 % may be achieved with PCSK9 inhibition, independent of background statin therapy. This review examines the most recent evidence and future prospects for the use of PCSK9 inhibitors in the prevention of cardiovascular disease.
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Affiliation(s)
- James Latimer
- Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, M3.131, 3rd Floor William Leech Building, Newcastle upon Tyne, NE2 4HH, UK
| | - Jonathan A Batty
- Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, M3.131, 3rd Floor William Leech Building, Newcastle upon Tyne, NE2 4HH, UK
- Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - R Dermot G Neely
- Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, M3.131, 3rd Floor William Leech Building, Newcastle upon Tyne, NE2 4HH, UK
- Royal Victoria Infirmary, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Vijay Kunadian
- Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, M3.131, 3rd Floor William Leech Building, Newcastle upon Tyne, NE2 4HH, UK.
- Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK.
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Drakopoulou M, Toutouzas K, Stathogiannis K, Synetos A, Trantalis G, Tousoulis D. Managing the lipid profile of coronary heart disease patients. Expert Rev Cardiovasc Ther 2016; 14:1263-1271. [PMID: 27552726 DOI: 10.1080/14779072.2016.1221341] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Lipid profile management is even more critical in patients treated for secondary prevention, since patients with established coronary heart disease are at higher risk of developing events. Current guidelines encourage lifestyle modification and patient engagement in disease prevention. However, the American College of Cardiology/American Heart Association guidelines seem to differ considerably from their predecessors, having an impact on clinical practice of lipid management. Area covered: This review article discusses and provides a summary of the current recommendations for lipid profile management in patients with coronary heart disease, with a view to present lifestyle modification and novel treatment strategies, and to indicate areas of dispute among recent guidelines. Expert commentary: Existing controversies between current guidelines concerning treatment goals and therapeutic decisions may have potential implications on the clinical management of patients. In the meantime, we eagerly wait for the results of randomized controlled trials evaluating promising, potent, safe and prolonged drugs that are in progress.
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Affiliation(s)
- Maria Drakopoulou
- a First Department of Cardiology , Medical School of Athens University, Hippokration Hospital , Athens , Greece
| | - Konstantinos Toutouzas
- a First Department of Cardiology , Medical School of Athens University, Hippokration Hospital , Athens , Greece
| | - Konstantinos Stathogiannis
- a First Department of Cardiology , Medical School of Athens University, Hippokration Hospital , Athens , Greece
| | - Andreas Synetos
- a First Department of Cardiology , Medical School of Athens University, Hippokration Hospital , Athens , Greece
| | - George Trantalis
- a First Department of Cardiology , Medical School of Athens University, Hippokration Hospital , Athens , Greece
| | - Dimitrios Tousoulis
- a First Department of Cardiology , Medical School of Athens University, Hippokration Hospital , Athens , Greece
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Abstract
The 2 or 4‑week subcutaneous therapy with the recently approved antibodies alirocumab and evolocumab for inhibition of proprotein convertase subtilisin-kexin type 9 (PCSK9) reduces low-density lipoprotein cholesterol (LDL-C) in addition to statins and ezetimibe by 50-60 %. The therapy is well-tolerated. The safety profile in the published studies is comparable to placebo. Outcome data and information on long-term safety and the influence on cardiovascular events are not yet available but the results of several large trials are expected in 2016-2018. At present (spring 2016) PCSK9 inhibitors represent an option for selected patients with a high cardiovascular risk and high LDL-C despite treatment with the maximum tolerated oral lipid-lowering therapy. This group includes selected patients with familial hypercholesterolemia and high-risk individuals with statin-associated muscle symptoms (SAMS).
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Affiliation(s)
- U Laufs
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, IMED Geb. 41.1, Universitätsklinikum des Saarlandes, 66421, Homburg/Saar, Deutschland.
| | - F Custodis
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, IMED Geb. 41.1, Universitätsklinikum des Saarlandes, 66421, Homburg/Saar, Deutschland
| | - C Werner
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, IMED Geb. 41.1, Universitätsklinikum des Saarlandes, 66421, Homburg/Saar, Deutschland
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Abstract
Since their introduction, statin (HMG-CoA reductase inhibitor) drugs have advanced the practice of cardiology to unparalleled levels. Even so, coronary heart disease (CHD) still remains the leading cause of death in developed countries, and is predicted to soon dominate the causes of global mortality and disability as well. The currently available non-statin drugs have had limited success in reversing the burden of heart disease, but new information suggests they have roles in sizeable subpopulations of those affected. In this review, the status of approved non-statin drugs and the significant potential of newer drugs are discussed. Several different ways to raise plasma high-density lipoprotein (HDL) cholesterol (HDL-C) levels have been proposed, but disappointments are now in large part attributed to a preoccupation with HDL quantity, rather than quality, which is more important in cardiovascular (CV) protection. Niacin, an old drug with many antiatherogenic properties, was re-evaluated in two imperfect randomized controlled trials (RCTs), and failed to demonstrate clear effectiveness or safety. Fibrates, also with an attractive antiatherosclerotic profile and classically used for hypertriglyceridemia, lacks evidence-based proof of efficacy, save for a subgroup of diabetic patients with atherogenic dyslipidemia. Omega-3 fatty acids fall into this category as well, even with an impressive epidemiological evidence base. Omega-3 research has been plagued with methodological difficulties yielding tepid, uncertain, and conflicting results; well-designed studies over longer periods of time are needed. Addition of ezetimibe to statin therapy has now been shown to decrease levels of low-density lipoprotein (LDL) cholesterol (LDL-C), accompanied by a modest decrease in the number of CV events, though without any improvement in CV mortality. Importantly, the latest data provide crucial evidence that LDL lowering is central to the management of CV disease. Of drugs that inhibit cholesteryl ester transfer protein (CETP) tested thus far, two have failed and two remain under investigation and may yet prove to be valuable therapeutic agents. Monoclonal antibodies to proprotein convertase subtilisin/kexin type 9, now in phase III trials, lower LDL-C by over 50 % and are most promising. These drugs offer new ability to lower LDL-C in patients in whom statin drug use is, for one reason or another, limited or insufficient. Mipomersen and lomitapide have been approved for use in patients with familial hypercholesterolemia, a more common disease than appreciated. Anti-inflammatory drugs are finally receiving due attention in trials to elucidate potential clinical usefulness. All told, even though statins remain the standard of care, non-statin drugs are poised to assume a new, vital role in managing dyslipidemia.
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Dahagam C, Goud A, Abdelqader A, Hendrani A, Feinstein MJ, Qamar A, Joshi PH, Swiger KJ, Byrne K, Quispe R, Jones SR, Blumenthal RS, Martin SS. PCSK9 inhibitors and their role in high-risk patients in reducing LDL cholesterol levels: evolocumab. Future Cardiol 2016; 12:139-48. [DOI: 10.2217/fca.15.89] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Patients with familial hypercholesterolemia or statin intolerance are especially challenging to manage since LDL cholesterol levels often remain considerably elevated despite clinicians’ best efforts. With statins regarded as first-line pharmacologic therapy by the current American College of Cardiology/American Heart Association guidelines to reduce LDL cholesterol and cardiovascular risk, there is now a critical need to determine when other agents will play a role beyond maximally tolerated statin therapy and lifestyle changes. In this review, we take a closer look at evolocumab (Repatha®), one of the new injectable human monoclonal antibodies to PCSK9 and its efficacy and safety properties from the results of various trials.
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Affiliation(s)
- Chanukya Dahagam
- MedStar Franklin Square Medical Center, Department of Medicine, Baltimore, MD, USA
| | - Aditya Goud
- MedStar Franklin Square Medical Center, Department of Medicine, Baltimore, MD, USA
| | - Abdelhai Abdelqader
- MedStar Franklin Square Medical Center, Department of Medicine, Baltimore, MD, USA
| | - Aditya Hendrani
- MedStar Good Samaritan/Union Memorial Hospital, Department of Medicine, Baltimore, MD, USA
| | - Matthew J Feinstein
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Arman Qamar
- Cardiovascular Division, Brigham & Womens Hospital, Boston, MA, USA
| | - Parag H Joshi
- Cardiovascular Division, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kristopher J Swiger
- Cardiovascular Division, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kathleen Byrne
- Pediatric Cardiology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Renato Quispe
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Carnegie 591, Baltimore, MD 21287, USA
| | - Steven R Jones
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Carnegie 591, Baltimore, MD 21287, USA
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Carnegie 591, Baltimore, MD 21287, USA
| | - Seth S Martin
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Carnegie 591, Baltimore, MD 21287, USA
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Abstract
PURPOSE OF REVIEW Adherence to hydroxymethylglutaryl-CoA reductase reductase inhibitor (statin) therapy correlates with cardiovascular mortality. Muscle symptoms are the most significant side-effects of statin therapy. This review article summarizes the current concepts of the diagnosis and clinical work-up of patients with statin-associated muscle symptoms (SAMS). RECENT FINDINGS SAMS represent a major barrier to maintain long-term persistence to statin treatment. SAMS reduce the quality of life and rare complications may extend to rhabdomyolysis. The molecular pathology of SAMS is heterogeneous. After exclusion of other causes of muscle symptoms the main principle of treatment is re-exposure to very low dose of statin and slow uptitration until the maximally tolerated dose is established. Using this approach the vast majority of patients can be treated with statins long term. For patients with SAMS that are not at low-density lipoproteins (LDL) goal with their maximally tolerated dose of statin combination therapy with ezetimibe and proprotein convertase subtilisin/kexin-9 inhibitors are available. SUMMARY Time and care is needed to address SAMS because they impair drug adherence. For most patients it is possible to continue the statin therapy. However, combination therapy is wanted if the maximally tolerated statin dose is not sufficient to reach LDL targets.
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Affiliation(s)
- Ulrich Laufs
- aKlinik Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universitätsklinikum des Saarlandes, Homburg, GermanybClinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, AustriacMedical Clinic V (Nephrology, Hypertensiology, Rheumatology, Endocrinology, Diabetology), Medical Faculty Mannheim, University of Heidelberg, HeidelbergdSynlab Academy, Synlab Services GmbH, Mannheim and Augsburg, Germany
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14
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Orho-Melander M. Genetics of coronary heart disease: towards causal mechanisms, novel drug targets and more personalized prevention. J Intern Med 2015; 278:433-46. [PMID: 26477595 DOI: 10.1111/joim.12407] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Coronary heart disease (CHD) is an archetypical multifactorial disorder that is influenced by genetic susceptibility as well as both modifiable and nonmodifiable risk factors, and their interactions. Advances during recent years in the field of multifactorial genetics, in particular genomewide association studies (GWASs) and their meta-analyses, have provided the statistical power to identify and replicate genetic variants in more than 50 risk loci for CHD and in several hundreds of loci for cardiometabolic risk factors for CHD such as blood lipids and lipoproteins. Although for a great majority of these loci both the causal variants and mechanisms remain unknown, progress in identifying the causal variants and underlying mechanisms has already been made for several genetic loci. Furthermore, identification of rare loss-of-function variants in genes such as PCSK9, NPC1L1, APOC3 and APOA5, which cause a markedly decreased risk of CHD and no adverse side effects, illustrates the power of translating genetic findings into novel mechanistic information and provides some optimism for the future of developing novel drugs, given the many genes associated with CHD in GWASs. Finally, Mendelian randomization can be used to reveal or exclude causal relationships between heritable biomarkers and CHD, and such approaches have already provided evidence of causal relationships between CHD and LDL cholesterol, triglycerides/remnant particles and lipoprotein(a), and indicated a lack of causality for HDL cholesterol, C-reactive protein and lipoprotein-associated phospholipase A2. Together, these genetic findings are beginning to lead to promising new drug targets and novel interventional strategies and thus have great potential to improve prevention, prediction and therapy of CHD.
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Affiliation(s)
- M Orho-Melander
- Department of Clinical Sciences in Malmö, Lund University Diabetes Centre, Lund University, Malmö, Sweden
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15
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Thomopoulos C, Skalis G, Michalopoulou H, Tsioufis C, Makris T. Effect of Low-Density Lipoprotein Cholesterol Lowering by Ezetimibe/Simvastatin on Outcome Incidence: Overview, Meta-Analyses, and Meta-Regression Analyses of Randomized Trials. Clin Cardiol 2015; 38:763-9. [PMID: 26282344 DOI: 10.1002/clc.22441] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 07/06/2015] [Accepted: 07/09/2015] [Indexed: 01/11/2023] Open
Abstract
This analysis investigated the extent of different outcome reductions from low-density lipoprotein cholesterol (LDL-C) lowering following ezetimibe/simvastatin treatment and the proportionality of outcome to LDL-C reductions. The authors searched PubMed between 1997 and mid-June 2015 (any language) and the Cochrane Library to identify all randomized controlled trials comparing ezetimibe/simvastatin with placebo or less intensive LDL-C lowering. Risk ratios (RR) and 95% confidence intervals (CIs), standardized to 20 mg/dL LDL-C reduction, were calculated for 5 primary outcomes (fatal and nonfatal) and 4 secondary outcomes (non-cardiovascular [CV] death, cancer, myopathy, and hepatopathy). Five ezetimibe/simvastatin RCTs (30 051 individuals) were eligible, 2 comparing ezetimibe/simvastatin vs placebo and 3 vs less intensive treatment. Outcomes reduced almost to the same extent were stroke (RR: -13%, 95% CI: -21% to -3%), coronary heart disease (CHD; RR: -12%, 95% CI: -19% to -5%), and composite of stroke and CHD (RR: -14%, 95% CI: -20% to -8%). Absolute risk reductions: 5 strokes, 10 CHD events, and 16 stroke and CHD events prevented for every 1000 patients treated for 5 years. Residual risk was almost 7× higher than absolute risk reduction for all the above outcomes. All death outcomes were not reduced, and secondary outcomes did not differ between groups. Logarithmic risk ratios were not associated with LDL-C lowering. Our meta-analysis provides evidence that, in patients with different CV disease burden, major CV events are safely reduced by LDL-C lowering with ezetimibe/simvastatin, while raising the hypothesis that the extent of LDL-C lowering might not be accompanied by incremental clinical-event reduction.
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Affiliation(s)
| | - George Skalis
- Department of Cardiology, Helena Venizelou Hospital, Athens, Greece
| | | | - Costas Tsioufis
- First Cardiology Clinic, Hippokration Hospital, Athens University, Athens, Greece
| | - Thomas Makris
- Department of Cardiology, Helena Venizelou Hospital, Athens, Greece
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17
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Page MM, Watts GF. Emerging PCSK9 inhibitors for treating dyslipidaemia: buttressing the gaps in coronary prevention. Expert Opin Emerg Drugs 2015; 20:299-312. [DOI: 10.1517/14728214.2015.1035709] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Rodriguez F, Knowles JW. PCSK9 Inhibition: Current Concepts and Lessons from Human Genetics. Curr Atheroscler Rep 2015; 17:487. [DOI: 10.1007/s11883-015-0487-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Schulz R, Schlüter KD, Laufs U. Molecular and cellular function of the proprotein convertase subtilisin/kexin type 9 (PCSK9). Basic Res Cardiol 2015; 110:4. [PMID: 25600226 PMCID: PMC4298671 DOI: 10.1007/s00395-015-0463-z] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 01/04/2015] [Accepted: 01/07/2015] [Indexed: 12/16/2022]
Abstract
The proprotein convertase subtilisin/kexin type 9 (PCSK9) has emerged as a promising treatment target to lower serum cholesterol, a major risk factor of cardiovascular diseases. Gain-of-function mutations of PCSK9 are associated with hypercholesterolemia and increased risk of cardiovascular events. Conversely, loss-of-function mutations cause low-plasma LDL-C levels and a reduction of cardiovascular risk without known unwanted effects on individual health. Experimental studies have revealed that PCSK9 reduces the hepatic uptake of LDL-C by increasing the endosomal and lysosomal degradation of LDL receptors (LDLR). A number of clinical studies have demonstrated that inhibition of PCSK9 alone and in addition to statins potently reduces serum LDL-C concentrations. This review summarizes the current data on the regulation of PCSK9, its molecular function in lipid homeostasis and the emerging evidence on the extra-hepatic effects of PCSK9.
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Affiliation(s)
- Rainer Schulz
- Physiologisches Institut, Justus-Liebig Universität Giessen, Aulweg 129, 35392, Giessen, Germany,
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20
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PCSK9 antibodies for the treatment of hypercholesterolemia. Nutrients 2014; 6:5517-33. [PMID: 25470376 PMCID: PMC4276981 DOI: 10.3390/nu6125517] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Revised: 10/24/2014] [Accepted: 11/04/2014] [Indexed: 12/12/2022] Open
Abstract
The serine protease proprotein convertase subtilisin/kexin type 9 (PCSK9) binds to the low-density lipoprotein (LDL) receptor (LDLR) and directs it to lysosomes for intracellular degradation. This results in decreased numbers of LDLR available on the hepatic cell surface to bind LDL particles and remove them from the circulation and therefore to a subsequent increase in circulating LDL-cholesterol (LDL-C) plasma levels. Since 2003, when the role of PCSK9 in LDL-C metabolism was discovered, there have been major efforts to develop efficient and safe methods to inhibit it. Amongst those, monoclonal antibodies against PCSK9 are the furthest in development, with multiple phase 3 trials already published and with cardiovascular endpoint trials currently underway. Two fully human monoclonal antibodies, evolocumab (AMG 145) and alirocumab (REGN727/SAR236553), have been extensively studied in a wide range of subjects, such as those with statin intolerance, as an add-on to statin therapy, as a monotherapy and in patients with familial hypercholesterolemia. PCSK9 antibodies result in a consistent and robust decrease in LDL-C plasma levels ranging from 40% to 70%, either on top of statins or as a monotherapy. If the safety data from the on-going phase 3 trials remain as reassuring as the data available till now, PCSK9 antibodies will offer a novel, powerful therapeutic option to decrease LDL-C plasma levels and, hopefully, cardiovascular risk.
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Prakash A. 63rd Annual Scientific Sessions of the American College of Cardiology: 29-31 March 2014; Washington, DC, USA. Am J Cardiovasc Drugs 2014; 14:327-31. [PMID: 25056279 DOI: 10.1007/s40256-014-0086-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Dragan S, Serban MC, Banach M. Proprotein convertase subtilisin/kexin 9 inhibitors: an emerging lipid-lowering therapy? J Cardiovasc Pharmacol Ther 2014; 20:157-68. [PMID: 24938457 DOI: 10.1177/1074248414539562] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Proprotein convertase subtilisin/kexin 9 (PCSK9) is part of the proteinase K subfamily of subtilases and plays a key role in lipid metabolism. It increases degradation of the low-density lipoprotein receptor (LDL-R), modulates cholesterol metabolism and transport, and contributes to the production of apolipoprotein B (apoB) in intestinal cells. Exogenous PCSK9 modifies the activity of 3-hydroxy-3-methylglutaryl-coenzyme A reductase and acyl coenzyme A:cholesterol acyltransferase and enhances secretion of chylomicrons by modulating production of lipids and apoB-48. Statins increase PCSK9 messenger RNA expression and attenuate the capacity to increase LDL-R levels. Therefore, the inhibition of PCSK9 in combination with statins provides a promising approach for lowering low-density lipoprotein cholesterol (LDL-C) concentrations. This review will address new therapeutic strategies targeting PCSK9, including monoclonal antibodies, antisense oligonucleotides, small interfering RNAs, and other small molecule inhibitors. Further studies are still needed to determine the efficacy and safety of the PCSK9 inhibitors not only to decrease LDL-C but also to investigate the potential underlying mechanisms involved and to test whether these compounds actually reduce cardiovascular end points and mortality.
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Affiliation(s)
- Simona Dragan
- Department of Cardiology, University of Medicine and Pharmacy "Victor Babes" Timisoara, Timisoara, Romania Center for Interdisciplinary Research, University of Medicine and Pharmacy "Victor Babes" Timisoara, Timisoara, Romania
| | - Maria-Corina Serban
- Center for Interdisciplinary Research, University of Medicine and Pharmacy "Victor Babes" Timisoara, Timisoara, Romania Department of Functional Sciences, Chair of Pathophysiology, University of Medicine and Pharmacy "Victor Babes" Timisoara, Timisoara, Romania
| | - Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Poland
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23
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Abstract
The American College of Cardiology (ACC) Scientific Session was held at the Walter E. Washington Convention Center in Washington, DC from March 29-31, 2014. The ACC Scientific Session is one of 3 major scientific cardiology meetings in the world, with over 20,000 attendees from 109 countries. There were over 2,200 oral and poster abstracts, and 22 late-breaking clinical trials (LBCTs), which are the focus of this report. Interestingly, in the CoreValve trials, transcatheter aortic valve replacement with a self-expanding transcatheter aortic-valve bioprosthesis was associated with a higher survival rate at 1 year than surgical aortic valve replacement. Long-term results in a further study are needed. I hope the present report will encourage others to attend the ACC Scientific Session 2015 to be held in San Diego on March 14-16, 2015.
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Affiliation(s)
- Kenya Kusunose
- Department of Cardiovascular Medicine, Tokushima University Hospital
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24
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Stroes E, Colquhoun D, Sullivan D, Civeira F, Rosenson RS, Watts GF, Bruckert E, Cho L, Dent R, Knusel B, Xue A, Scott R, Wasserman SM, Rocco M. Anti-PCSK9 antibody effectively lowers cholesterol in patients with statin intolerance: the GAUSS-2 randomized, placebo-controlled phase 3 clinical trial of evolocumab. J Am Coll Cardiol 2014; 63:2541-2548. [PMID: 24694531 DOI: 10.1016/j.jacc.2014.03.019] [Citation(s) in RCA: 399] [Impact Index Per Article: 39.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 03/18/2014] [Accepted: 03/19/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This study sought to evaluate the efficacy and safety of subcutaneous evolocumab compared with oral ezetimibe in hypercholesterolemic patients who are unable to tolerate effective statin doses. BACKGROUND Statin intolerance, which is predominantly due to muscle-related side effects, is reported in up to 10% to 20% of patients. Evolocumab, a fully human monoclonal antibody to proprotein convertase subtilisin/kexin type 9 (PCSK9), demonstrated marked reductions in plasma low-density lipoprotein cholesterol (LDL-C) in a phase 2 study in statin-intolerant patients. METHODS The GAUSS-2 (Goal Achievement after Utilizing an Anti-PCSK9 Antibody in Statin Intolerant Subjects) trial was a 12-week, double-blind study of randomized patients (2:2:1:1) to evolocumab 140 mg every two weeks (Q2W) or evolocumab 420 mg once monthly (QM) both with daily oral placebo or subcutaneous placebo Q2W or QM both with daily oral ezetimibe 10 mg. Co-primary endpoints were percent change from baseline in LDL-C at the mean of weeks 10 and 12, and at week 12. RESULTS Three hundred seven patients (age 62 ± 10 years; LDL-C 193 ± 59 mg/dl) were randomized. Evolocumab reduced LDL-C from baseline by 53% to 56%, corresponding to treatment differences versus ezetimibe of 37% to 39% (p <0.001). Muscle adverse events occurred in 12% of evolocumab-treated patients and 23% of ezetimibe-treated patients. Treatment-emergent adverse events and laboratory abnormalities were comparable across treatment groups. CONCLUSIONS Robust efficacy combined with favorable tolerability makes evolocumab a promising therapy for addressing the largely unmet clinical need in high-risk patients with elevated cholesterol who are statin intolerant. (Goal Achievement After Utilizing an Anti-PCSK9 Antibody in Statin Intolerant Subjects-2; NCT01763905).
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Affiliation(s)
- Erik Stroes
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands.
| | | | - David Sullivan
- Department of Clinical Biochemistry, Royal Prince Alfred Hospital, Camperdown, Australia
| | | | - Robert S Rosenson
- Cardiometabolic Disorders Department, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gerald F Watts
- Lipid Disorders Clinic, Royal Perth Hospital, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
| | | | - Leslie Cho
- Preventive Cardiology and Rehabilitation, Cleveland Clinic, Cleveland, Ohio
| | | | | | | | | | | | - Michael Rocco
- Cardiovascular Medicine Department, Cleveland Clinic, Cleveland, Ohio
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