1
|
Karp A, Jacobs M, Barris B, Labkowsky A, Frishman WH. Lipoprotein(a): A Review of Risk Factors, Measurements, and Novel Treatment Modalities. Cardiol Rev 2024:00045415-990000000-00218. [PMID: 38415744 DOI: 10.1097/crd.0000000000000667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
The study of lipoprotein(a) [Lp(a)] has long been a source of interest as a possible independent risk factor for atherosclerotic cardiovascular disease (ASCVD). The results of large sample observational studies, genome-wide association studies, and Mendelian randomization studies have been strong indicators supporting the link between ASCVD and Lp(a) despite early studies, with less sensitive assays, failing to show a connection. The recommendations for the indications and frequency of testing Lp(a) levels vary between US, Canadian, and European organizations due to the uncertain role of Lp(a) in ASCVD. The innovation of recent therapies, such as antisense oligonucleotides and small interfering RNA, designed to specifically target and reduce Lp(a) levels by targeting mRNA translation have once more thrust LP(a) into the spotlight of inquiry. These emerging modalities serve the dual purpose of definitively elucidating the connection between elevated Lp(a) levels and atherosclerotic cardiovascular risk, as well as the possibility of providing clinicians with the tools necessary to manage elevated Lp(a) levels in vulnerable populations. This review seeks to examine the mechanisms of atherogenicity of Lp(a) and explore the most current pharmacologic therapies currently in development.
Collapse
Affiliation(s)
- Avrohom Karp
- From the Department of Medicine, New York Medical College/Westchester Medical Center, Valhalla, NY
| | - Menachem Jacobs
- Department of Medicine, State University of New York Downstate Health Sciences University, Brooklyn, NY
| | - Ben Barris
- From the Department of Medicine, New York Medical College/Westchester Medical Center, Valhalla, NY
| | - Alexander Labkowsky
- From the Department of Medicine, New York Medical College/Westchester Medical Center, Valhalla, NY
| | - William H Frishman
- From the Department of Medicine, New York Medical College/Westchester Medical Center, Valhalla, NY
| |
Collapse
|
2
|
Fogacci F, Yerlitaş Sİ, Giovannini M, Zararsız G, Lido P, Borghi C, Cicero AFG. Sex X Time Interactions in Lp(a) and LDL-C Response to Evolocumab. Biomedicines 2023; 11:3271. [PMID: 38137492 PMCID: PMC10741148 DOI: 10.3390/biomedicines11123271] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 12/05/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
The aim of this study was to evaluate whether there were significant sex x time interactions in lipoprotein(a) (Lp(a)) and low-density lipoprotein cholesterol (LDL-C) response to treatment with the Proprotein Convertase Subtilisin/Kexin type 9 inhibitor (PCSK9i) Evolocumab, in a real-life clinical setting. For this purpose, we pooled data from 176 outpatients (Men: 93; Women: 83) clinically evaluated at baseline and every six months after starting Evolocumab. Individuals who had been on PCSK9i for less than 30 months and nonadherent patients were excluded from the analysis. Over time, absolute values of Lp(a) plasma concentrations significantly decreased in the entire cohort (p-value < 0.001) and by sex (p-value < 0.001 in men and p-value = 0.002 in and women). However, there were no sex-related significant differences. Absolute plasma concentrations of LDL-C significantly decreased over time in the entire cohort and by sex (p-value < 0.001 always), with greater improvements in men compared to women. The sex x time interaction was statistically significant in LDL-C (all p-values < 0.05), while absolute changes in Lp(a) were not influenced by either sex or time (all p-value > 0.05). Our data partially reinforce the presence of differences in response to treatment to PCSK9i between men and women and are essential to gain a better understanding of the relationship between LDL-C and Lp(a) lowering in response to PCSK9i. Further research will clarify whether these sex-related significant differences translate into a meaningful difference in the long-term risk of ASCVD.
Collapse
Affiliation(s)
- Federica Fogacci
- Hypertension and Cardiovascular Risk Research Center, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40100 Bologna, Italy; (F.F.); (M.G.); (C.B.)
| | - Serra İlayda Yerlitaş
- Department of Biostatistics, Erciyes University School of Medicine, 38039 Kayseri, Turkey; (S.İ.Y.); (G.Z.)
- Drug Application and Research Center (ERFARMA), Erciyes University, 38280 Kayseri, Turkey
| | - Marina Giovannini
- Hypertension and Cardiovascular Risk Research Center, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40100 Bologna, Italy; (F.F.); (M.G.); (C.B.)
| | - Gökmen Zararsız
- Department of Biostatistics, Erciyes University School of Medicine, 38039 Kayseri, Turkey; (S.İ.Y.); (G.Z.)
- Drug Application and Research Center (ERFARMA), Erciyes University, 38280 Kayseri, Turkey
| | - Paolo Lido
- Italian Medicines Agency (AIFA), 00187 Rome, Italy;
| | - Claudio Borghi
- Hypertension and Cardiovascular Risk Research Center, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40100 Bologna, Italy; (F.F.); (M.G.); (C.B.)
- Unit of Cardiovascular Internal Medicine, Department of Cardiac, Thoracic, Vascular Pathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40100 Bologna, Italy
| | - Arrigo F. G. Cicero
- Hypertension and Cardiovascular Risk Research Center, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40100 Bologna, Italy; (F.F.); (M.G.); (C.B.)
- Unit of Cardiovascular Internal Medicine, Department of Cardiac, Thoracic, Vascular Pathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40100 Bologna, Italy
| |
Collapse
|
3
|
Alieva R, Shek A, Abdullaev A, Fozilov K, Khoshimov S, Abdullaeva G, Zakirova D, Kurbanova R, Kan L, Kim A. E670G PCSK9 polymorphism in HeFH & CAD with diabetes: is the bridge to personalized therapy within reach? FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2023; 4:1277288. [PMID: 38028979 PMCID: PMC10646404 DOI: 10.3389/fcdhc.2023.1277288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/11/2023] [Indexed: 12/01/2023]
Abstract
Objective To assess the distribution of PCSK9 E670G genetic polymorphism and PCSK9 levels in patients with Coronary Artery Disease (CAD) and Heterozygous Familial Hypercholesterolemia (HeFH), based on the presence of type 2 Diabetes Mellitus (T2DM). Methods The study included 201 patients with chronic CAD, including those with HeFH (n=57, group I) and without it (n=144, group II). DLCN was used to diagnose HeFH. The PCSK9 E670G (rs505151) polymorphism was genetically typed using the PCR-RFLP procedure. In both the patient and control groups, the genotype frequency matched the Hardy-Weinberg equilibrium distribution (P>0.05). Results There were twice more G alleles in group I (13, 11.4%) than in group II (17, 6.0%), and thrice more (1, 3.0%) than in the healthy control group; nevertheless, these differences weren't statistically significant. Simultaneously, PCSK9 levels were higher in HeFH patients (P<0.05) compared to non-HeFH patients not taking statins (n=63). T2DM was equally represented in groups I and II (31.6% vs. 33.3%). But carriers of AG+GG genotypes in group I had a higher chance of having a history of T2DM (RR 4.18; 95%CI 2.19-8.0; P<0.001), myocardial infarction (RR 1.79; 95%CI 1.18-2.73; P<0.05), and revascularization (RR 12.6; 95%CI 4.06-38.8; P<0.01), than AA carriers. T2DM was also more common among G allele carriers (RR 1.85; 95% CI 1.11-3.06; P<0.05) in patients with non-HeFH. Conclusion T2DM in patients with CAD, both with HeFH and non-HeFH, in the Uzbek population was significantly more often associated with the presence of the "gain-of-function" G allele of the PCSK9 E670G genetic polymorphism.
Collapse
Affiliation(s)
- Rano Alieva
- CAD & Atherosclerosis Department, Republican Specialized Center of Cardiology, Tashkent, Uzbekistan
| | - Aleksandr Shek
- CAD & Atherosclerosis Department, Republican Specialized Center of Cardiology, Tashkent, Uzbekistan
| | - Alisher Abdullaev
- Center for Advanced Technologies, Ministry of Innovative Development of Uzbekistan, Tashkent, Uzbekistan
| | - Khurshid Fozilov
- CAD & Atherosclerosis Department, Republican Specialized Center of Cardiology, Tashkent, Uzbekistan
| | - Shovkat Khoshimov
- CAD & Atherosclerosis Department, Republican Specialized Center of Cardiology, Tashkent, Uzbekistan
| | - Guzal Abdullaeva
- CAD & Atherosclerosis Department, Republican Specialized Center of Cardiology, Tashkent, Uzbekistan
| | - Dariya Zakirova
- Center for Advanced Technologies, Ministry of Innovative Development of Uzbekistan, Tashkent, Uzbekistan
| | - Rano Kurbanova
- CAD & Atherosclerosis Department, Republican Specialized Center of Cardiology, Tashkent, Uzbekistan
| | - Lilia Kan
- CAD & Atherosclerosis Department, Republican Specialized Center of Cardiology, Tashkent, Uzbekistan
| | - Andrey Kim
- CAD & Atherosclerosis Department, Republican Specialized Center of Cardiology, Tashkent, Uzbekistan
| |
Collapse
|
4
|
Milosavljevic MN, Stefanovic SM, Pejcic AV. Potential Novel RNA-Targeting Agents for Effective Lipoprotein(a) Lowering: A Systematic Assessment of the Evidence From Completed and Ongoing Developmental Clinical Trials. J Cardiovasc Pharmacol 2023; 82:1-12. [PMID: 37070852 DOI: 10.1097/fjc.0000000000001429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 03/25/2023] [Indexed: 04/19/2023]
Abstract
ABSTRACT An increase in blood lipoprotein (a) [Lp(a)] levels, mostly genetically determined, has been identified as an independent risk factor of atherosclerotic cardiovascular disease. No drug has yet been approved that markedly lowers Lp(a) and thereby reduces residual cardiovascular risk. The aim of this article was to critically review the evidence from clinical development studies to date on the efficacy and safety of new RNA-based therapeutics for targeted lowering of Lp(a). PubMed/MEDLINE, Scopus, Web of Science, and ClinicalTrials.gov were searched without any language or date restriction up to November 5, 2022, and a total of 12 publications and 22 trial records were included. Several drugs were found that are currently in various stages of clinical development, such as the antisense oligonucleotide pelacarsen and the small interfering RNA molecule olpasiran and drugs coded as SLN360 and LY3819469. Among them, pelacarsen has progressed the most, currently reaching phase 3. All these drugs have so far shown satisfactory pharmacokinetic properties, consistently high and stable, dose-dependent efficacy in lowering Lp(a) even by more than 90%, with an acceptable safety profile in subjects with highly elevated Lp(a). In addition, reports of early clinical trials with pelacarsen imply a promising suppressive effect on key mechanisms of atherogenesis. Future research should focus on confirming these beneficial clinical effects in patients with lower average Lp(a) levels and clearly demonstrating the association between lowering Lp(a) and reducing adverse cardiovascular outcomes.
Collapse
Affiliation(s)
- Milos N Milosavljevic
- Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Srdjan M Stefanovic
- Department of Pharmacy, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia; and
- Department of Clinical Pharmacology, University Clinical Center Kragujevac, Kragujevac, Serbia
| | - Ana V Pejcic
- Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| |
Collapse
|
5
|
Ouyang M, Li C, Hu D, Peng D, Yu B. Mechanisms of unusual response to lipid-lowering therapy: PCSK9 inhibition. Clin Chim Acta 2023; 538:113-123. [PMID: 36403664 DOI: 10.1016/j.cca.2022.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/13/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022]
Abstract
The efficacy of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition has broadened lipid-lowering therapy thus providing decreased risk in atherosclerotic cardiovascular disease. Unfortunately, the widespread use of PCSK9 inhibitors (PCSK9i), ie, monoclonal antibodies, has led to the findings of unusual responsiveness, ie, a phenomenon defined as an LDL-C reduction of <30% vs the average LDL-C reduction efficacy of 50-60%. This unusual responsiveness to PCSK9i is attributable to several factors, ie, lack of adherence, impaired absorption, poor distribution or early elimination as well as abnormal effects of PCSK9i in the presence of anti-antibodies or mutations in PCSK9 and LDLR. Unexpectedly increased lipoprotein (Lp)(a) also appear to contribute to the unusual responsiveness scenario. Identification of these responses and mechanisms underlying them are essential for effective management of LDL-C and cardiovascular risk. In this review, we describe plausible reasons underlying this phenomenon supported by findings of clinical trials. We also elaborate on the need for education and regular follow-up to improve adherence. Collectively, the review provides a summary of the past, present, and future of mechanisms and countermeasures revolving around unusual responses to PCSK9i therapy.
Collapse
Affiliation(s)
- Mingqi Ouyang
- Department of Cardiovascular Medicine, the Second Xiangya Hospital, Research Institute of Blood Lipid and Atherosclerosis, Central South University, NO.139 Middle Renmin Road, Changsha 410011, Hunan, China
| | - Chenyu Li
- Department of Cardiovascular Medicine, the Second Xiangya Hospital, Research Institute of Blood Lipid and Atherosclerosis, Central South University, NO.139 Middle Renmin Road, Changsha 410011, Hunan, China
| | - Die Hu
- Department of Cardiovascular Medicine, the Second Xiangya Hospital, Research Institute of Blood Lipid and Atherosclerosis, Central South University, NO.139 Middle Renmin Road, Changsha 410011, Hunan, China
| | - Daoquan Peng
- Department of Cardiovascular Medicine, the Second Xiangya Hospital, Research Institute of Blood Lipid and Atherosclerosis, Central South University, NO.139 Middle Renmin Road, Changsha 410011, Hunan, China
| | - Bilian Yu
- Department of Cardiovascular Medicine, the Second Xiangya Hospital, Research Institute of Blood Lipid and Atherosclerosis, Central South University, NO.139 Middle Renmin Road, Changsha 410011, Hunan, China.
| |
Collapse
|
6
|
Sex differences in LDL-C response to PCSK9 inhibitors: A real world experience. J Clin Lipidol 2023; 17:142-149. [PMID: 36641299 DOI: 10.1016/j.jacl.2022.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/22/2022] [Accepted: 12/01/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Previous studies have shown the efficacy of PCSK9 inhibitors (PCSK9i) in lowering LDL-C. One clinical trial with alirocumab suggested that the LDL-C reduction effect is larger in men than women. In contrast, none of the studies with evolocumab have observed a difference in the treatment effect between men and women. However, sex differences data from real life experience is lacking. In addition, the difference in LDL-C response to PCSK9i between pre- and post-menopausal women has not been investigated so far. OBJECTIVES To compare the relative change in LDL-C following the introduction of a PCSK9i in a real-life clinical setting according to sex and menopausal status. METHODS All patients were recruited at the IRCM lipid clinic. Lipid profiles before and after the introduction of PCSK9i were available in the medical file for 259 patients (160 men and 99 women (72 post-menopausal, 20 pre-menopausal and 7 unknown menopausal status). RESULTS We observed a significant difference in relative LDL-C change between men (-70%) and women (-59%), p<0.0001. However, no difference was observed between pre-menopausal (-58%) and post-menopausal (-58%) women. In a linear regression model, sex remains a significant predictor of the response to PCSK9i after correction for confounding factors such as statin intensity (beta coefficient=-0.245, p<0.0001). CONCLUSION We observed a greater relative LDL-C response to PCSK9i in men than in women in a real-life clinical context. However, it is still unknown whether this difference in LDL-C change between men and women translates into a meaningful difference on long-term cardiovascular risk.
Collapse
|
7
|
Patnaik S, Pollevick ME, Lara-Breitinger KM, Stone NJ, Patnaik S, Pollevick ME, Lara-Breitinger KM, Stone NJ. Inter-Individual Variability in Lipid Response: A Narrative Review. Am J Med 2022; 135:1427-1433.e7. [PMID: 35878687 DOI: 10.1016/j.amjmed.2022.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 11/15/2022]
Abstract
Lipid-lowering guidelines emphasize shared decision-making between clinicians and patients, resulting in patients anticipating the degree of response from diet or drug therapy. Challenging for physicians is understanding the sources of variability complicating their management decisions, which include non-adherence, genetic considerations, additional lipid parameters including lipoprotein (a) levels, and rare systemic responses limiting benefits that result in non-responsiveness to monoclonal antibody injection. In this narrative review, we focus on the variability of low-density lipoprotein cholesterol (LDL-C) response to guideline-directed interventions such as statins, ezetimibe, bile acid sequestrants, fibrates, proprotein/convertase subtilisin-kexin type 9 inhibitors, and LDL-C-lowering diets. We hypothesize that the variability in individual lipid responses is multifactorial. We provide an illustrative model with a check list that can be used to identify factors that may be present in the individual patient.
Collapse
Affiliation(s)
- Swagata Patnaik
- Northwestern University Feinberg School of Medicine, Chicago, Ill
| | | | | | - Neil J Stone
- Northwestern University Feinberg School of Medicine, Chicago, Ill; Department of Medicine (Cardiology) and Preventive Medicine, Vascular Center of the Bluhm Cardiovascular Institute of Northwestern Memorial Hospital, Chicago, Ill.
| | - Swagata Patnaik
- Northwestern University Feinberg School of Medicine, Chicago IL
| | | | | | - Neil J Stone
- Northwestern University Feinberg School of Medicine, Chicago IL; Department of Medicine (Cardiology) and Preventive Medicine, Vascular Center of the Bluhm Cardiovascular Institute of Northwestern Memorial Hospital, Chicago, Illinois.
| |
Collapse
|
8
|
Yang L, Xiao YY, Shao L, Ouyang CS, Hu Y, Li B, Lei LF, Wang H. Proprotein convertase subtilisin/kexin type 9 inhibitor non responses in an adult with a history of coronary revascularization: A case report. World J Clin Cases 2022; 10:6728-6735. [PMID: 35979295 PMCID: PMC9294880 DOI: 10.12998/wjcc.v10.i19.6728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 04/07/2022] [Accepted: 04/30/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Familial hypercholesterolemia (FH) is an autosomal dominant disorder that is characterized by severely increased low-density lipoprotein (LDL) cholesterol levels. At the same time, elevated LDL levels accelerated the development of coronary heart disease. Several classes of drugs are currently in use to treat FH. Proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) is novel one of these.
CASE SUMMARY This manuscript reports a case of FH that responded modestly after treatment with PCSK9i and statin drugs. Of even more concern is that the patient frequently admitted to the hospital during a 12-year follow-up period. Subsequently, we identified a heterozygous mutation, 1448G>A (W483X) of the LDL receptor (LDLR) in this patient. The serum levels of PCSK9 (proprotein convertase subtilisin/kexin type 9) in the patient was 71.30 ± 26.66 ng/mL, which is close the average level reported in the literature. This LDLR mutation affects LDLR metabolism or structure, which may make it unsuitable for use of PCSK9i.
CONCLUSION Our outcome demonstrates that LDLR-W483X represents a partial loss-of-function LDLR and may contribute to PCSK9i ineffective. In the meanwhile, additional measures are therefore required (particularly with gene sequencing or change the treatment plan) must be initiated as early as possible. Genetic testing for clinically challenging cases who do not respond to PCSK9i therapy is very helpful.
Collapse
Affiliation(s)
- Liu Yang
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang 330006, Jiangxi Province, China
| | - Yan-Yan Xiao
- Postgraduate School of Jiangxi University of Traditional Chinese Medicine, Jiangxi University of Traditional Chinese Medicine, Nanchang 330008, Jiangxi Province, China
| | - Liang Shao
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang 330006, Jiangxi Province, China
| | - Chang-Sheng Ouyang
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang 330006, Jiangxi Province, China
| | - Yao Hu
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang 330006, Jiangxi Province, China
| | - Bin Li
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang 330006, Jiangxi Province, China
| | - Li-Feng Lei
- Department of Internal Medicine, Tonggu People's Hospital, Yichun 336299, Jiangxi Province, China
| | - Hong Wang
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang 330006, Jiangxi Province, China
| |
Collapse
|
9
|
Arnold N, Koenig W. PCSK9 Inhibitor Wars: How Does Inclisiran Fit in with Current Monoclonal Antibody Inhibitor Therapy? Considerations for Patient Selection. Curr Cardiol Rep 2022; 24:1657-1667. [PMID: 36087240 PMCID: PMC9729136 DOI: 10.1007/s11886-022-01782-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Treatment of dyslipidemia represents one of the most crucial strategies to reduce risk of atherosclerotic cardiovascular (CV) disease (ASCVD). In this review, we critically summarize our knowledge on emerging cholesterol-lowering therapy, targeting PCSK9, paying particular attention on treatment allocation of two drug groups, currently available for clinical use, namely, anti-PCSK9 monoclonal antibodies (mAbs) and inclisiran, a first-in-class small interfering RNA against PCSK9. RECENT FINDINGS Although both drug classes show a pronounced, but fairly similar reduction in LDL-cholesterol, their long-term safety is still unknown. Compared to mAbs, inclisiran has a more favorable dosing regimen with biannual application that might improve therapeutic adherence significantly. However, a CV outcome trial (CVOT) for inclisiran is still missing. If inclisiran will be safe and effective in ongoing/future CVOTs, it has a huge potential to overcome medication non-compliance, thereby providing a powerful therapeutic option to decrease the burden of ASCVD.
Collapse
Affiliation(s)
- Natalie Arnold
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Wolfgang Koenig
- German Heart Center, Munich, Technical University of Munich, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| |
Collapse
|
10
|
McIntosh CS, Watts GF, Wilton SD, Aung-Htut MT. Splice correction therapies for familial hypercholesterolemic patients with low-density lipoprotein receptor mutations. Curr Opin Lipidol 2021; 32:355-362. [PMID: 34653074 PMCID: PMC8631153 DOI: 10.1097/mol.0000000000000793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Antisense oligomers (ASOs) have been available for decades: however, only recently have these molecules been applied clinically. This review aims to discuss the possible development of antisense-mediated splice correction therapies as precision medicines for familial hypercholesterolemic patients carrying mutations that compromise normal splicing of the low-density lipoprotein receptor (LDLR) gene transcript. RECENT FINDINGS Three antisense drugs are currently being assessed in ongoing clinical trials for dyslipidemias, aiming to lower the plasma concentrations of lipoproteins that lead to end-organ damage, principally coronary artery disease. Although a handful of drugs may be applicable to many patients with familial hypercholesterolemia (FH), mutation-specific personalised antisense drugs may be even more effective in selected patients. Currently, there is no therapy that effectively addresses mutations in the LDLR, the major cause of FH. Many mutations in the LDLR that disrupt normal pre-mRNA processing could be applicable to splice correction therapy to restore receptor activity. SUMMARY Precision medicine could provide long-term economic and social benefits if they can be implemented effectively and sustainably. Many mutations found in the LDLR gene could be amendable to therapeutic splice correction and we should consider developing a therapeutic ASO platform for these mutations.
Collapse
Affiliation(s)
- Craig S. McIntosh
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia
- Centre for Molecular Medicine and Innovative Therapeutics, Health Futures Institute, Murdoch University, Murdoch, Western Australia, Australia
| | - Gerald F. Watts
- School of Medicine, University of Western Australia
- Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Steve D. Wilton
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia
- Centre for Molecular Medicine and Innovative Therapeutics, Health Futures Institute, Murdoch University, Murdoch, Western Australia, Australia
| | - May T. Aung-Htut
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia
- Centre for Molecular Medicine and Innovative Therapeutics, Health Futures Institute, Murdoch University, Murdoch, Western Australia, Australia
| |
Collapse
|
11
|
Krittanawong C, Khawaja M, Rosenson RS, Amos CI, Nambi V, Lavie CJ, Virani SS. Association of PCSK9 Variants With the Risk of Atherosclerotic Cardiovascular Disease and Variable Responses to PCSK9 Inhibitor Therapy. Curr Probl Cardiol 2021; 47:101043. [PMID: 34780866 DOI: 10.1016/j.cpcardiol.2021.101043] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/05/2021] [Indexed: 12/29/2022]
Abstract
Genetic polymorphisms or variations, randomly distributed in a population, may cause drug-gene response variations. Investigation into these polymorphisms may identify novel mechanisms contributing to a specific disease process. Such investigation necessitates the use of Mendelian randomization, an analytical method that uses genetic variants as instrumental variables for modifiable risk factors that affect population health.1 In the past decade, advances in our understanding of genetic polymorphisms have enabled the identification of genetic variants in candidate genes that impact low-density lipoprotein cholesterol (LDL-C) regulating pathways and cardiovascular disease (CVD) outcomes. A specific candidate gene of interest is that of the LDL receptor degrading protein, PCSK9. In fact, loss-of-function genetic variants for the PCSK9 gene are what first highlighted this pathway as a candidate for pharmacologic inhibition. PCSK9 inhibitors (PCSK9i) are a class of cholesterol-lowering medications that provide significant reductions in LDL by inhibiting the degradation of LDL receptors (LDLR). These inhibitors have also been found to reduce production and enhance clearance of lipoprotein A (Lp[a]), an LDL-like particle currently under study as a separate risk factor for atherosclerotic CVD. Here, we discuss the promise of personalized medicine in developing a more efficacious and individualized pharmacogenomics-based approach for the use of PCSK9i that considers genetic variation and targets different patient populations. This review explores the pharmacogenomics of PCSK9i in the context of PCSK9 allele variants related to drug-metabolizing enzymes and responses since more studies are demonstrating that some patients are hyporesponsive or non-responsive to PCSK9i.2 In summary, the pharmacogenomics of PCSK9 are a promising therapeutic target and genetic information from prospective randomized clinical trials is warranted to gain a full understanding of the efficacy and cost-effectiveness of such allele and/or gene-guided PCSK9i therapy.
Collapse
Affiliation(s)
- Chayakrit Krittanawong
- The Michael E. DeBakey VA Medical Center, Houston, TX; Section of Cardiology, Baylor College of Medicine, Houston, TX.
| | - Muzamil Khawaja
- The Michael E. DeBakey VA Medical Center, Houston, TX; Section of Cardiology, Baylor College of Medicine, Houston, TX
| | - Robert S Rosenson
- Director, Cardiometabolics Unit, Mount Sinai Hospital, Mount Sinai Heart, NY, NY
| | - Christopher I Amos
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, TX
| | - Vijay Nambi
- The Michael E. DeBakey VA Medical Center, Houston, TX; Section of Cardiology, Baylor College of Medicine, Houston, TX
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA
| | - Salim S Virani
- The Michael E. DeBakey VA Medical Center, Houston, TX; Section of Cardiology, Baylor College of Medicine, Houston, TX
| |
Collapse
|
12
|
Korneva VA, Kuznetsova TY, Julius U. Modern Approaches to Lower Lipoprotein(a) Concentrations and Consequences for Cardiovascular Diseases. Biomedicines 2021; 9:biomedicines9091271. [PMID: 34572458 PMCID: PMC8469722 DOI: 10.3390/biomedicines9091271] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/09/2021] [Accepted: 09/15/2021] [Indexed: 12/11/2022] Open
Abstract
Lipoprotein(a) (Lp(a)) is a low density lipoprotein particle that is associated with poor cardiovascular prognosis due to pro-atherogenic, pro-thrombotic, pro-inflammatory and pro-oxidative properties. Traditional lipid-lowering therapy does not provide a sufficient Lp(a) reduction. For PCSK9 inhibitors a small reduction of Lp(a) levels could be shown, which was associated with a reduction in cardiovascular events, independently of the effect on LDL cholesterol. Another option is inclisiran, for which no outcome data are available yet. Lipoprotein apheresis acutely and in the long run decreases Lp(a) levels and effectively improves cardiovascular prognosis in high-risk patients who cannot be satisfactorily treated with drugs. New drugs inhibiting the synthesis of apolipoprotein(a) (an antisense oligonucleotide (Pelacarsen) and two siRNA drugs) are studied. Unlike LDL-cholesterol, for Lp(a) no target value has been defined up to now. This overview presents data of modern capabilities of cardiovascular risk reduction by lowering Lp(a) level.
Collapse
Affiliation(s)
- Victoria A. Korneva
- Department of Faculty Therapy, Petrozavodsk State University, Lenin Ave. 33, 185000 Petrozavodsk, Russia;
- Correspondence:
| | | | - Ulrich Julius
- Lipidology and Lipoprotein Apheresis Center, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany;
| |
Collapse
|