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Chen T, Liu N. How safe are proprotein convertase subtilisinekexin type 9 inhibitors in diabetes? Curr Opin Lipidol 2024; 35:187-194. [PMID: 38527426 DOI: 10.1097/mol.0000000000000934] [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] [Indexed: 03/27/2024]
Abstract
PURPOSE OF REVIEW To examine the safety of proprotein convertase subtilisinekexin type 9 (PCSK9) inhibitors in patients with diabetes, specifically focusing on their impact on glucose metabolism. RECENT FINDINGS Patients with diabetes often require intensified lipid-lowering therapy. PCSK9 inhibitors can reduce low-density lipoprotein cholesterol (LDL-C) concentrations by approximately 60%, and significantly reduce cardiovascular risk when added to statin therapy. Some studies have suggested an association between low LDL-C levels and an increased risk of new-onset diabetes, and genetics has almost consistently shown an increased glucose concentration and risk of diabetes. Most clinical trials have not demonstrated a deterioration in glycaemic control in patients with diabetes after the use of PCSK9 inhibitors, and they do not lead to other significant treatment-emergent adverse events. SUMMARY Although the majority of patients with diabetes are undergoing background statin therapy, which may mask potential adverse effects of PCSK9 inhibitors on glycaemic control, current data suggest that the benefits outweigh the risks for diabetic patients using PCSK9 inhibitors. Considering the different nature of genetic studies and of clinical trials, close monitoring of glucose parameters is necessary, especially in individuals with prediabetes.
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Affiliation(s)
- Tian Chen
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
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Goodman SG, Steg PG, Szarek M, Bhatt DL, Bittner VA, Diaz R, Harrington RA, Jukema JW, White HD, Zeiher AM, Manvelian G, Pordy R, Poulouin Y, Stipek W, Garon G, Schwartz GG. Safety of the PCSK9 inhibitor alirocumab: insights from 47 296 patient-years of observation. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:342-352. [PMID: 38658193 PMCID: PMC11249957 DOI: 10.1093/ehjcvp/pvae025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/25/2024] [Accepted: 04/23/2024] [Indexed: 04/26/2024]
Abstract
The ODYSSEY OUTCOMES trial, comprising over 47 000 patient-years of placebo-controlled observation, demonstrated important reductions in the risk of recurrent ischaemic cardiovascular events with the monoclonal antibody to proprotein convertase subtilisin/kexin type 9 alirocumab, as well as lower all-cause death. These benefits were observed in the context of substantial and persistent lowering of low-density lipoprotein cholesterol with alirocumab compared with that achieved with placebo. The safety profile of alirocumab was indistinguishable from matching placebo except for a ∼1.7% absolute increase in local injection site reactions. Further, the safety of alirocumab compared with placebo was evident in vulnerable groups identified before randomization, such as the elderly and those with diabetes mellitus, previous ischaemic stroke, or chronic kidney disease. The frequency of adverse events and laboratory-based abnormalities was generally similar to that in placebo-treated patients. Thus, alirocumab appears to be a safe and effective lipid-modifying treatment over a duration of at least 5 years.
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Affiliation(s)
- Shaun G Goodman
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Philippe Gabriel Steg
- Université Paris-Cité, Institut Universitaire de France, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, FACT (French Alliance for Cardiovascular Trials), and INSERM U1148, F-75018 Paris, France
| | - Michael Szarek
- CPC Clinical Research and Division of Cardiology, University of Colorado School of Medicine, Aurora, 80045 CO, USA
- State University of New York, Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Vera A Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Rafael Diaz
- Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, S2000 Rosario, Argentina
| | | | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands
| | - Harvey D White
- Green Lane Cardiovascular Research Unit, Te Whatu Ora—Health New Zealand, Te Toka Tumai, and University of Auckland, Auckland 1030, New Zealand
| | - Andreas M Zeiher
- Department of Medicine III, Goethe University, 60596 Frankfurt am Main, Germany
| | | | - Robert Pordy
- Regeneron Pharmaceuticals Inc., Tarrytown, NY 10591, USA
| | | | - Wanda Stipek
- Regeneron Pharmaceuticals Inc., Tarrytown, NY 10591, USA
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Park D, Bea S, Bae JH, Lee H, Choe YJ, Shin JY, Kim H. PCSK9 Inhibitors and Infection-Related Adverse Events: A Pharmacovigilance Study Using the World Health Organization VigiBase. Drugs Real World Outcomes 2024:10.1007/s40801-024-00430-5. [PMID: 38954190 DOI: 10.1007/s40801-024-00430-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2024] [Indexed: 07/04/2024] Open
Abstract
AIMS Protein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) are novel lipid-lowering agents used in patients with cardiovascular disease. Despite reassuring safety data from pivotal trials, increasing evidence from real-world studies suggests that PCSK9i increase the risk of bacterial and viral infections. Therefore, this study aimed to identify signals of infection-related adverse events (AEs) associated with PCSK9i. METHODS We performed an observational pharmacovigilance study using the World Health Organization's VigiBase, recorded up to December 2022. We included individual case safety reports (ICSRs) of PCSK9 inhibitors, alirocumab and evolocumab, and compared them with those of other drugs. Infection-related ICSRs were retrieved from the Medical Dictionary for Regulatory Activities System Organ Class 'infections and infestations.' RESULTS Among 114,293 reports (258,099 drug-AE pairs) related to PCSK9 inhibitors, 54% included female patients, 41% included patients aged ≥65 years, and 82% included patients who received evolocumab. Additionally, beyond AEs recognized by regulatory authorities, organ infections such as influenza (reporting odds ratio [ROR] 2.89, 95% confidence interval [CI] 2.74-3.05), gastric infections (ROR 2.47, 95% CI 1.63-3.75), and kidney infections (ROR 1.36, 95% CI 1.06-1.73) were observed. Sensitivity analysis indicated a heightened risk of infection-related AEs associated with PCSK9i regardless of the specific drug type. CONCLUSIONS In addition to the labelled respiratory infections, six infection-related symptoms in the gastrointestinal, urinary, and renal organs were identified. Our findings support the need for systematic surveillance of infections among PCSK9i users.
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Affiliation(s)
- Dahyun Park
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
| | - Sungho Bea
- School of Pharmacy, Sungkyunkwan University, 2066, Seobu-ro, Jangan-gu, Suwon, Gyeonggi-do, South Korea
| | - Ji-Hwan Bae
- School of Pharmacy, Sungkyunkwan University, 2066, Seobu-ro, Jangan-gu, Suwon, Gyeonggi-do, South Korea
| | - Hyesung Lee
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
- School of Pharmacy, Sungkyunkwan University, 2066, Seobu-ro, Jangan-gu, Suwon, Gyeonggi-do, South Korea
| | - Young June Choe
- Department of Paediatrics, Korea University Anam Hospital, Seoul, South Korea
| | - Ju-Young Shin
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea.
- School of Pharmacy, Sungkyunkwan University, 2066, Seobu-ro, Jangan-gu, Suwon, Gyeonggi-do, South Korea.
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea.
| | - Hoon Kim
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea.
- School of Pharmacy, Sungkyunkwan University, 2066, Seobu-ro, Jangan-gu, Suwon, Gyeonggi-do, South Korea.
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Rivera FB, Cha SW, Magalong JV, Bantayan NRB, Cruz LLA, Arias-Aguirre E, Aguirre Z, Varona MC, Co EMF, Lumbang GNO, Enkhmaa B. Safety profile of proprotein convertase subtilisin/kexin type 9 inhibitors alirocumab and evolocumab: an updated meta-analysis and meta-regression. Curr Med Res Opin 2024; 40:1103-1121. [PMID: 38836510 DOI: 10.1080/03007995.2024.2363971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 05/31/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND The use of alirocumab and evolocumab is generally safe and well-tolerated. However, concerns remain about their long-term safety, especially with regard to new-onset or worsening diabetes mellitus (DM). We aim to assess the safety profile of alirocumab and evolocumab compared to comparator. METHODS Studies were retrieved comparing the safety of PCSK9i vs. comparator (placebo or statin with or without ezetimibe). The primary outcome was adverse events leading to death. Secondary outcomes included serious adverse events, new onset diabetes mellitus (DM), worsening of DM, neurocognitive dysfunction, creatine kinase (CK) elevation, elevation of liver enzymes and local injection site reaction. Factors associated with the treatment effect were determined by meta-regression analysis. Subgroup analyses were done to explore potential treatment effect differences based on PCSK9i type and treatment duration. RESULTS We identified 56 studies with 85,123 adults (29.14% females). PCSK9i was not associated with adverse events that lead to death (OR 0.94, 95% CI 0.84 to 1.04, p = 0.22). Between the two PCSK9i, alirocumab decreased adverse events leading to death (OR 0.79, 95% CI, 0.67 to 0.94, p = 0.008). PCSK9i was associated with less serious events compared to the comparator (OR 0.93, 95% CI 0.89 to 0.98, p < 0.001). This reduction was driven mainly by alirocumab (OR 0.89, 95% CI, 0.85 to 0.93, p < 0.001). Evolocumab worsened DM (OR 2.3, 95% CI 1.26 to 4.2, p = 0.041). Subgroup analysis showed worsening of DM in the first 24 weeks of treatment with odds being highest in the first 12 weeks of treatment (<12 weeks: OR 3.82, 95% CI 1.13 to 12.99, p = 0.03; 12-24 weeks OR 2.12, 95% CI 1.20 to 3.73, p = 0.01. On the other hand, therapy >24 weeks reduced the odds of worsening DM (OR 0.89, 95% CI 0.79 to 0.99, p = 0.04). PCSK9i did not increase cognitive dysfunction, (OR 1.02, 95% CI 0.88 to 1.18, p = 0.76), or cause elevations in liver enzyme (OR 0.91, 95% CI 0.81 to 1.03, p = 0.14), or CK (OR 0.82, 95% CI 0.65 to 1.04, p = 0.10). However, PCSK9i was associated with local injection site reaction (OR 1.54, 95% CI 1.37 to 1.73, p < 0.01). CONCLUSION Alirocumab decreased adverse events leading to death. Alirocumab and Evolocumab both decreased serious adverse events. PCSK9i did not increase new onset DM however evolocumab worsened DM in the first 24 weeks of treatment. PCSK9i did not increase neurologic dysfunction, and did not elevate liver enzymes and CK, however it was associated with local injection site reaction.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Byambaa Enkhmaa
- Division of Endocrinology, Diabetes & Metabolism, UC Davis Health, Davis, CA, USA
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Rajabian A, McCloskey AP, Jamialahmadi T, Moallem SA, Sahebkar A. A review on the efficacy and safety of lipid-lowering drugs in neurodegenerative disease. Rev Neurosci 2023; 34:801-824. [PMID: 37036894 DOI: 10.1515/revneuro-2023-0005] [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: 01/14/2023] [Accepted: 03/10/2023] [Indexed: 04/11/2023]
Abstract
There is a train of thought that lipid therapies may delay or limit the impact of neuronal loss and poor patient outcomes of neurodegenerative diseases (NDDs). A variety of medicines including lipid lowering modifiers (LLMs) are prescribed in NDDs. This paper summarizes the findings of clinical and observational trials including systematic reviews and meta-analyses relating to LLM use in NDDs published in the last 15 years thus providing an up-to-date evidence pool. Three databases were searched PubMed, CINAHL, and Web of Science using key terms relating to the review question. The findings confirm the benefit of LLMs in hyperlipidemic patients with or without cardiovascular risk factors due to their pleotropic effects. In NDDs LLMs are proposed to delay disease onset and slow the rate of progression. Clinical observations show that LLMs protect neurons from α-synuclein, tau, and Aβ toxicity, activation of inflammatory processes, and ultimately oxidative injury. Moreover, current meta-analyses and clinical trials indicated low rates of adverse events with LLMs when used as monotherapy. LLMs appear to have favorable safety and tolerability profiles with few patients stopping treatment due to severe adverse effects. Our collated evidence thus concludes that LLMs have a role in NDDs but further work is needed to understand the exact mechanism of action and reach more robust conclusions on where and when it is appropriate to use LLMs in NDDs in the clinic.
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Affiliation(s)
- Arezoo Rajabian
- Department of Internal Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Alice P McCloskey
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool L3 3AF, UK
| | - Tannaz Jamialahmadi
- Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Adel Moallem
- Department of Pharmacology and Toxicology, College of Pharmacy, Al-Zahraa University for Women, Karbala, Iraq
- Department of Pharmacodynamics and Toxicology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amirhossein Sahebkar
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
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Raschi E, Casula M, Cicero AFG, Corsini A, Borghi C, Catapano A. Beyond statins: New pharmacological targets to decrease LDL-cholesterol and cardiovascular events. Pharmacol Ther 2023; 250:108507. [PMID: 37567512 DOI: 10.1016/j.pharmthera.2023.108507] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 08/13/2023]
Abstract
The pharmacological treatment of dyslipidemia, a major modifiable risk factor for developing atherosclerotic cardiovascular disease (ASCVD), remains a debated and controversial issue, not only in terms of the most appropriate therapeutic range for lipid levels, but also with regard to the optimal strategy and sequence approach (stepwise vs upstream therapy). Current treatment guidelines for the management of dyslipidemia focus on the intensity of low-density lipoprotein cholesterol (LDL-C) reduction, stratified according to risk for developing ASCVD. Beyond statins and ezetimibe, different medications targeting LDL-C have been recently approved by regulatory agencies with potential innovative mechanisms of action, including proprotein convertase subtilisin/kexin type 9 modulators (monoclonal antibodies such as evolocumab and alirocumab; small interfering RNA molecules such as inclisiran), ATP-citrate lyase inhibitors (bempedoic acid), angiopoietin-like 3 inhibitors (evinacumab), and microsomal triglyceride transfer protein inhibitors (lomitapide). An understanding of their pharmacological aspects, benefit-risk profile, including impact on hard cardiovascular endpoints beyond LDL-C reduction, and potential advantages from the patient perspective (e.g., adherence) - the focus of this evidence-based review - is crucial for practitioners across medical specialties to minimize therapeutic inertia and support clinical practice.
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Affiliation(s)
- Emanuel Raschi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy.
| | - Manuela Casula
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy
| | - Arrigo F G Cicero
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy; IRCCS AOU S. Orsola-Malpighi, Bologna, Italy
| | - Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Claudio Borghi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy; IRCCS AOU S. Orsola-Malpighi, Bologna, Italy
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7
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Basiak M, Hachula M, Kosowski M, Machnik G, Maliglowka M, Dziubinska-Basiak M, Krysiak R, Okopien B. The Effect of PCSK9 Inhibition on the Stabilization of Atherosclerotic Plaque Determined by Biochemical and Diagnostic Imaging Methods. Molecules 2023; 28:5928. [PMID: 37570897 PMCID: PMC10421011 DOI: 10.3390/molecules28155928] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/21/2023] [Accepted: 07/31/2023] [Indexed: 08/13/2023] Open
Abstract
Atherosclerosis is a multifactorial, progressive, chronic inflammatory disease. Ultrasound and magnetic resonance imaging are the most accurate predictors of atherosclerotic plaque instability (MRI). Cytokines such as osteopontin, osteoprotegerin, and metalloproteinase 9 could be used as the most recent markers to identify and track the efficacy of anti-atherosclerotic therapy. Patients with USG and MRI-verified unstable atherosclerotic plaque were included in the study. Biomarker concentrations were measured and compared before and after PCSK9 inhibitor therapy. Additionally, concentrations prior to treatment were correlated with MRI images of the carotid artery. After treatment with alirocumab, the concentrations of MMP-9 (p < 0.01) and OPN, OPG (p < 0.05) decreased significantly. Furthermore, the results of OPN, OPG, and MMP 9 varied significantly depending on the type of atherosclerotic plaque in the MRI assay. In stable atherosclerotic plaques, the concentrations of OPN and OPG were greater (p < 0.01), whereas the concentration of MMP9 correlated with the instability of the plaque (p < 0.05). We demonstrated, probably for the first time, that alirocumab therapy significantly decreased the serum concentration of atherosclerotic plaque markers. In addition, we demonstrated the relationship between the type of atherosclerotic plaque as determined by carotid MRI and the concentration of these markers.
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Affiliation(s)
- Marcin Basiak
- Department of Internal Medicine and Clinical Pharmacology, Medical University of Silesia, Medyków 18, 40-752 Katowice, Poland
| | - Marcin Hachula
- Department of Internal Medicine and Clinical Pharmacology, Medical University of Silesia, Medyków 18, 40-752 Katowice, Poland
| | - Michal Kosowski
- Department of Internal Medicine and Clinical Pharmacology, Medical University of Silesia, Medyków 18, 40-752 Katowice, Poland
| | - Grzegorz Machnik
- Department of Internal Medicine and Clinical Pharmacology, Medical University of Silesia, Medyków 18, 40-752 Katowice, Poland
| | - Mateusz Maliglowka
- Department of Internal Medicine and Clinical Pharmacology, Medical University of Silesia, Medyków 18, 40-752 Katowice, Poland
| | | | - Robert Krysiak
- Department of Internal Medicine and Clinical Pharmacology, Medical University of Silesia, Medyków 18, 40-752 Katowice, Poland
| | - Boguslaw Okopien
- Department of Internal Medicine and Clinical Pharmacology, Medical University of Silesia, Medyków 18, 40-752 Katowice, Poland
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Zhang R, Wang Y, Peng Y, Zhao J, Zhang Z. Advanced progress of the relationship between PCSK9 monoclonal antibodies and hyperglycemic adverse events. Front Cardiovasc Med 2023; 10:1117143. [PMID: 37435056 PMCID: PMC10330718 DOI: 10.3389/fcvm.2023.1117143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 06/06/2023] [Indexed: 07/13/2023] Open
Abstract
Purpose of Review Long-term use of statins had been confirmed to cause an increase in hyperglycemic adverse events (HAEs), whose mechanism has been well understood. Proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibodies (PCSK9-mAbs), a kind of new lipid-lowering drug, can effectively reduce plasma low-density lipoprotein cholesterol levels in patients with CHD and have been widely used. However, animal experiments, Mendelian randomization studies, clinical researches and Meta-analyses which focused on the relationship between PCSK9-mAbs and HAEs had reached different conclusions, which has attracted great attention from clinicians. Recent Findings The newest FOURIER-OLE randomized controlled trial followed PCSK9-mAbs users for over 8 years, whose results suggested that long-term use of PCSK9-mAbs did not increase the incidence of HAEs. Newest Meta-analyses also indicated that there was no relationship between PCSK9-mAbs and NOD. Meanwhile, genetic polymorphisms and variants related to PCSK9 might have effects on HAEs. Conclusion According to the results of current studies, there is no significant relationship between PCSK9-mAbs and HAEs. However, longer-term follow-up studies are still needed to confirm it. Although PCSK9 genetic polymorphisms and variants may affect the possible occurrence of HAEs, there is no need to perform relevant genetic testing before applying PCSK9-mAbs.
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Affiliation(s)
- Ruixing Zhang
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
- Department of Heart Center, The First Hospital of Lanzhou University, Lanzhou, China
- Key Laboratory for Cardiovascular Diseases of Gansu Province, The First Hospital of Lanzhou University, Lanzhou, China
| | - Yongxiang Wang
- Department of Heart Center, The First Hospital of Lanzhou University, Lanzhou, China
- Key Laboratory for Cardiovascular Diseases of Gansu Province, The First Hospital of Lanzhou University, Lanzhou, China
| | - Yu Peng
- Department of Heart Center, The First Hospital of Lanzhou University, Lanzhou, China
- Key Laboratory for Cardiovascular Diseases of Gansu Province, The First Hospital of Lanzhou University, Lanzhou, China
| | - Jing Zhao
- Department of Heart Center, The First Hospital of Lanzhou University, Lanzhou, China
- Key Laboratory for Cardiovascular Diseases of Gansu Province, The First Hospital of Lanzhou University, Lanzhou, China
| | - Zheng Zhang
- Department of Heart Center, The First Hospital of Lanzhou University, Lanzhou, China
- Key Laboratory for Cardiovascular Diseases of Gansu Province, The First Hospital of Lanzhou University, Lanzhou, China
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9
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Oza PP, Kashfi K. The evolving landscape of PCSK9 inhibition in cancer. Eur J Pharmacol 2023; 949:175721. [PMID: 37059376 PMCID: PMC10229316 DOI: 10.1016/j.ejphar.2023.175721] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/23/2023] [Accepted: 04/11/2023] [Indexed: 04/16/2023]
Abstract
Cancer is a disease with a significant global burden in terms of premature mortality, loss of productivity, healthcare expenditures, and impact on mental health. Recent decades have seen numerous advances in cancer research and treatment options. Recently, a new role of cholesterol-lowering PCSK9 inhibitor therapy has come to light in the context of cancer. PCSK9 is an enzyme that induces the degradation of low-density lipoprotein receptors (LDLRs), which are responsible for clearing cholesterol from the serum. Thus, PCSK9 inhibition is currently used to treat hypercholesterolemia, as it can upregulate LDLRs and enable cholesterol reduction through these receptors. The cholesterol-lowering effects of PCSK9 inhibitors have been suggested as a potential mechanism to combat cancer, as cancer cells have been found to increasingly rely on cholesterol for their growth needs. Additionally, PCSK9 inhibition has demonstrated the potential to induce cancer cell apoptosis through several pathways, increase the efficacy of a class of existing anticancer therapies, and boost the host immune response to cancer. A role in managing cancer- or cancer treatment-related development of dyslipidemia and life-threatening sepsis has also been suggested. This review examines the current evidence regarding the effects of PCSK9 inhibition in the context of different cancers and cancer-associated complications.
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Affiliation(s)
- Palak P Oza
- Department of Molecular, Cellular and Biomedical Sciences, Sophie Davis School of Biomedical Education, City University of New York School of Medicine, New York, NY, 10031, USA
| | - Khosrow Kashfi
- Department of Molecular, Cellular and Biomedical Sciences, Sophie Davis School of Biomedical Education, City University of New York School of Medicine, New York, NY, 10031, USA; Graduate Program in Biology, City University of New York Graduate Center, New York, 10091, USA.
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10
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Li RT, Li Y, Wang BW, Gao XQ, Zhang JX, Li F, Zhang XY, Fang ZZ. Relationship between plasma glutamate and cardiovascular disease risk in Chinese patients with type 2 diabetes mellitus by gender. Front Endocrinol (Lausanne) 2023; 14:1095550. [PMID: 37124739 PMCID: PMC10130405 DOI: 10.3389/fendo.2023.1095550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 03/10/2023] [Indexed: 05/02/2023] Open
Abstract
Objectives This study aimed to assess the association between plasma glutamate (Glu) and the risk of cardiovascular disease (CVD) in patients with type 2 diabetes mellitus (T2DM) and whether this association differs by gender. Material and methods We retrieved clinical information on 1032 consecutive patients with T2DM from a same tertiary care center from May 2015 to August 2016. Glu was quantified by liquid chromatography-tandem mass spectrometry analysis. Glu was converted into a categorical variable based on the median concentration in the whole population, while logistic regression was used to obtain the odds ratio (OR) and 95% confidence interval (CI), and the correlation between Glu and various biochemical indices was analyzed. Results We found that Glu was positively associated with the risk of CVD in patients with T2DM. This correlation was more significant in women. In T2DM patients, the higher the age, body mass index (BMI), weight and systolic blood pressure (SBP), the lower the glycosylated hemoglobin (HbA1C) concentration and the higher the Glu. In female patients, the correlation between age, weight, BMI, SBP, and plasma Triglycerides (TG), and Glu was also statistically significant. Conclusion In conclusion, female T2DM patients with high levels of Glu have a higher risk of developing CVD.
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Affiliation(s)
- Ru-Tao Li
- School and Hospital of Stomatology, Tianjin Medical University, Tianjin, China
| | - Yang Li
- Department of Toxicology and Sanitary Chemistry, School of Public Health, Tianjin Medical University, Tianjin, China
| | - Bo-Wen Wang
- Department of Toxicology and Sanitary Chemistry, School of Public Health, Tianjin Medical University, Tianjin, China
| | - Xiao-Qian Gao
- Department of Toxicology and Sanitary Chemistry, School of Public Health, Tianjin Medical University, Tianjin, China
| | - Jing-Xi Zhang
- School and Hospital of Stomatology, Tianjin Medical University, Tianjin, China
| | - Fan Li
- School and Hospital of Stomatology, Tianjin Medical University, Tianjin, China
| | - Xiang-Yu Zhang
- School and Hospital of Stomatology, Tianjin Medical University, Tianjin, China
- *Correspondence: Zhong-Ze Fang, ; Xiang-Yu Zhang,
| | - Zhong-Ze Fang
- Department of Toxicology and Sanitary Chemistry, School of Public Health, Tianjin Medical University, Tianjin, China
- *Correspondence: Zhong-Ze Fang, ; Xiang-Yu Zhang,
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Feng Z, Li X, Tong WK, He Q, Zhu X, Xiang X, Tang Z. Real-world safety of PCSK9 inhibitors: A pharmacovigilance study based on spontaneous reports in FAERS. Front Pharmacol 2022; 13:894685. [PMID: 36506552 PMCID: PMC9729267 DOI: 10.3389/fphar.2022.894685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 11/15/2022] [Indexed: 11/25/2022] Open
Abstract
Objective: We aimed to evaluate alirocumab- and evolocumab-related adverse events (AEs) in real-world compared with all other drugs, overall and by gender and age subgroups; we also aimed to compare their risks of cognitive impairment, musculoskeletal disorders and diabetes with various statins and ezetimibe. Methods: We retrospectively extracted AE reports from the FDA Adverse Event Reporting System (FAERS) database during July 2015-June 2021. Disproportionality analyses were performed using reporting odds ratios (RORs) to detect AE signals of alirocumab and evolocumab in the overall population and in different age and gender subgroups, respectively. Results: Compared with all other drugs, both alirocumab and evolocumab had a significant signal in "musculoskeletal and connective tissue disorders" (ROR1 = 2.626, 95% CI 2.552-2.702; ROR2 = 2.575, 95% CI 2.538-2.613). The highest ROR value of 2.311 (95% CI 2.272-2.351) was for "injury, poisoning and procedural complications" and was found in patients aged ≥65 years on evolocumab. The most frequent AEs were "general disorders and administration site conditions" and "musculoskeletal and connective tissue disorders" for all subpopulations. At the preferred term level, the most frequent AE signal was myalgia for alirocumab and injection site pain for evolocumab, overall and by subgroups. Compared with statins/ezetimibe, PCSK9 inhibitors exhibited lower ROR values for adverse events associated with SOC "nervous system disorders", "psychiatric disorders" and "metabolism and nutrition disorders" (all RORs < 1), but mixed results for musculoskeletal disorders. Compared with all other drugs, undocumented AEs, such as acute cardiac event (ROR = 30.0, 95% CI 9.4-95.3) and xanthoma (ROR = 9.3, 95% CI 3.4-25.5), were also reported. Conclusion: Real-world evidence showed that PCSK9 inhibitors were associated with an increased risk of musculoskeletal and connective tissue disorders and general disorders and administration site conditions, overall and by subgroups. Muscle toxicity, injection site reactions, and influenza-like illness were significant AE signals. Compared with various statins and ezetimibe, PCSK9 inhibitors have shown a favorable safety profile in muscle-related events, cognitive impairment and diabetes. Some undocumented AE signals were also reported. Due to the limitations of spontaneous reporting databases, further studies are still needed to establish causality and validate our results.
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Affiliation(s)
- Zhen Feng
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai, China
| | - Xiaoye Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wai Kei Tong
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai, China
| | - Qingfeng He
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai, China
| | - Xiao Zhu
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai, China
| | - Xiaoqiang Xiang
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai, China
| | - Zhijia Tang
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai, China,*Correspondence: Zhijia Tang,
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Cefalù AB, Garbelotto R, Mombelli G, Pirro M, Rubba P, Arca M, Borghi C, Bonomo K, Gonnelli S, Massaroni K, Tirone G, Averna M. A subgroup analysis of the ODYSSEY APPRISE study: Safety and efficacy of alirocumab in the Italian cohort. Nutr Metab Cardiovasc Dis 2022; 32:2638-2646. [PMID: 36064689 DOI: 10.1016/j.numecd.2022.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 06/30/2022] [Accepted: 07/21/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND AND AIMS ODYSSEY APPRISE trial evaluated efficacy and safety of alirocumab in 994 patients with hypercholesterolemia and high CV risk in a real-life setting. The aim of the present report is to detail on the Italian cohort enrolled and treated in the trial. METHODS AND RESULTS The methodology of the of the multinational, single-arm, Phase 3b open-label ODYSSEY APPRISE (Clinicaltrials.gov: NCT02476006) has been previously reported. 255 Italian patients were enrolled and treated according to the trial protocol. Overall mean exposure to alirocumab was 83.3 ± 27.7 weeks. At week 12, LDL-C decreased by 51.3 ± 23.1% and this reduction was overall maintained for the duration of the study. A similar reduction was observed in patients with and without heterozygous familial hypercholesterolemia (HeFH 50.7% ± 23.9 vs. non-FH, 53.6% ± 19.6). LDL-C was reduced below 1.8 mmol/L and/or by ≥ 50% reduction from baseline in 62% of patients overall (61% in HeFH and 67% in non-FH). Alirocumab was similarly well tolerated in the Italian cohort as in the entire study population and the more common treatment emergent adverse events (TEAEs) were influenza, myalgia and nasopharyngitis. The incidence LDL-C levels <25 mg/dl and <15 mg/dl, was 8.2% and 2.9% respectively. CONCLUSION The efficacy and safety of alirocumab in a real-life setting, in the Italian subgroup of patients are consistent with findings in the entire study population and confirm that alirocumab is a beneficial approach to further reduce LDL-C levels in patients at high CV risk on maximally tolerated conventional lipid lowering treatment. GOV IDENTIFIER NCT02476006.
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Affiliation(s)
- Angelo B Cefalù
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy.
| | - Raffaella Garbelotto
- Unit of General Medicine, Presidio Ospedaliero di Vittorio Veneto, Vittorio Veneto, Italy
| | - Giuliana Mombelli
- Centro Dislipidemie, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Matteo Pirro
- Unit of Internal Medicine, Angiology and Arteriosclerosis Diseases Department of Medicine and Surgery University of Perugia Perugia Italy
| | - Paolo Rubba
- Dipartimento di Medicina Clinica e Chirurgia, Università "Federico II" di Napoli, Italy
| | - Marcello Arca
- Department of Translational and Precision Medicine "Sapienza" University of Rome Rome Italy
| | - Claudio Borghi
- Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Katia Bonomo
- Department of Clinical and Biological Sciences, University of Turin, Orbassano, Italy
| | - Stefano Gonnelli
- Department of Medicine, Surgery and Neuroscience, Policlinico Le Scotte, University of Siena, Siena, Italy
| | | | | | - Maurizio Averna
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy.
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Li J, Du H, Wang Y, Aertgeerts B, Guyatt G, Hao Q, Shen Y, Li L, Su N, Delvaux N, Bekkering G, Khan SU, Riaz IB, Vandvik PO, Su B, Tian H, Li S. Safety of proprotein convertase subtilisin/kexin 9 inhibitors: a systematic review and meta-analysis. BRITISH HEART JOURNAL 2022; 108:1296-1302. [PMID: 35508401 DOI: 10.1136/heartjnl-2021-320556] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/10/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To determine the harms of proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors in people who need lipid-lowering therapy. METHODS This systematic review included randomised controlled trials that compared PCSK9 inhibitors with placebo, standard care or active lipid-lowering comparators in people who need lipid-lowering therapy with the follow-up duration of at least 24 weeks. We summarised the relative effects for potential harms from PCSK9 inhibitors using random-effect pairwise meta-analyses and assessed the certainty of evidence using GRADE (Grading of Recommendation Assessment, Development and Evaluation) for each outcome. RESULTS We included 32 trials with 65 861 participants (with the median follow-up duration of 40 weeks, ranging from 24 to 146 weeks). The meta-analysis showed an incidence of injection-site reaction leading to discontinuation (absolute incidence of 15 events (95% CI 11 to 20) per 1000 persons in a 5-year time frame, high certainty evidence). PCSK9 inhibitors do not increase the risk of new-onset diabetes mellitus, neurocognitive events, cataracts or gastrointestinal haemorrhage with high certainty evidence. PCSK9 inhibitors probably do not increase the risks of myalgia or muscular pain leading to discontinuation or any adverse events leading to discontinuation with moderate evidence certainty. Given very limited evidence, PCSK9 inhibitors might not increase influenza-like symptoms leading to discontinuation (risk ratio 1.5; 95% CI 0.06 to 36.58). We did not identify credible subgroup analyses results, including shorter versus longer follow-up duration of trials. CONCLUSIONS PCSK9 inhibitors slightly increase the risk of severe injection-site reaction but not cataracts, gastrointestinal haemorrhage, neurocognitive events, new-onset diabetes or severe myalgia or muscular pain.
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Affiliation(s)
- Jing Li
- Department of Endocrinology and Metabolism, Chinese Evidence-Based Medicine Center, Cochrane China Center and MAGIC China Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Heyue Du
- Department of Endocrinology and Metabolism, Chinese Evidence-Based Medicine Center, Cochrane China Center and MAGIC China Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yang Wang
- Department of Endocrinology and Metabolism, Chinese Evidence-Based Medicine Center, Cochrane China Center and MAGIC China Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Gordon Guyatt
- Department of Clinical Epidemiology and Biostatistics, and Department of Medicine, and School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Qiukui Hao
- Department of Clinical Epidemiology and Biostatistics, and Department of Medicine, and School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada.,Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yanjiao Shen
- Department of Endocrinology and Metabolism, Chinese Evidence-Based Medicine Center, Cochrane China Center and MAGIC China Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ling Li
- Department of Endocrinology and Metabolism, Chinese Evidence-Based Medicine Center, Cochrane China Center and MAGIC China Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Na Su
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Nicolas Delvaux
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | | | - Safi U Khan
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Pennsylvania, USA
| | - Irbaz B Riaz
- Mayo Clinic Arizona and Brigham and Women hospital, Harvard Medical School, Boston, New York, USA
| | - Per Olav Vandvik
- Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Baihai Su
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Haoming Tian
- Department of Endocrinology and Metabolism, Chinese Evidence-Based Medicine Center, Cochrane China Center and MAGIC China Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Sheyu Li
- Department of Endocrinology and Metabolism, Chinese Evidence-Based Medicine Center, Cochrane China Center and MAGIC China Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Verdickt S, Van der Schueren B, Vangoitsenhoven R, Descamps OS, Mertens A. Belgian data of ODYSSEY APPRISE: stringent LDL-c targets are in reach when using all available tools. Int J Clin Pract 2021; 75:e14916. [PMID: 34551183 DOI: 10.1111/ijcp.14916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 09/20/2021] [Accepted: 09/21/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND As lipid targets became more stringent in the latest ESC/EAS guidelines, many patients on statin monotherapy are left above their risk-based target, increasing the need for lipid-lowering therapies. The results of the ODYSSEY APPRISE study were recently published by Gaudet et al In this trial, alirocumab (a PCSK9 inhibitor) was investigated in high cardiovascular risk patients in a real-life setting. OBJECTIVE We aim at analysing the characteristics, safety and efficacy of alirocumab in the Belgian population of the ODYSSEY APPRISE trial and, based on literature research, we aim to evaluate the importance and the need for the add-on, non-statin lipid-lowering therapy in clinical practice. METHODS AND RESULTS ODYSSEY APPRISE is a multicentric, prospective, single-arm, Phase 3b open-label trial. A total of 68 Belgian patients were enrolled, 63 patients had heterozygous familial hypercholesterolaemia (HeFH). Baseline mean LDL-c was 188.7 mg/dL (SD ± 51.8). At week 12, 65 patients had an evaluable efficacy end point with a mean LDL-c reduction of 59.9% from baseline. The overall incidence of treatment-emergent adverse events (TEAEs) was 75.0%. The most frequent TEAE was back pain (10.3%), nasopharyngitis (10.3%) and injection site erythema (8.8%). Based on the literature, a majority of patients do not reach their risk-based lipid target despite statin therapy alone. CONCLUSION In a real-life setting, alirocumab is both well-tolerated, safe and very effective in reducing LDL-c in this Belgian cohort. In clinical practice, more patients should be initiated on the add-on, non-statin lipid-lowering therapy in order to reach their risk-based lipid target.
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Affiliation(s)
- Sébastien Verdickt
- Department of Diabetes and Endocrinology, University Hospitals of Leuven, Leuven, Belgium
| | - Bart Van der Schueren
- Department of Diabetes and Endocrinology, University Hospitals of Leuven, Leuven, Belgium
- Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
| | - Roman Vangoitsenhoven
- Department of Diabetes and Endocrinology, University Hospitals of Leuven, Leuven, Belgium
- Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
| | - Olivier S Descamps
- Department of Internal Medicine, Centres Hospitaliers Jolimont, Haine-Saint-Paul, Belgium
- Department of Cardiology, UCL Cliniques Universitaires Saint-Luc, Bruxelles, Belgium
| | - Ann Mertens
- Department of Diabetes and Endocrinology, University Hospitals of Leuven, Leuven, Belgium
- Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
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Alirocumab treatment and neurocognitive function according to the CANTAB scale in patients at increased cardiovascular risk: A prospective, randomized, placebo-controlled study. Atherosclerosis 2021; 331:20-27. [PMID: 34303265 DOI: 10.1016/j.atherosclerosis.2021.06.913] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/21/2021] [Accepted: 06/24/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND AIMS Trials of the fully human monoclonal antibody proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9) alirocumab in hypercholesterolemia demonstrated substantial low-density lipoprotein cholesterol (LDL-C) lowering, reduction in cardiovascular (CV) events and outcomes, and a generally acceptable safety and tolerability profile. The impact of maintaining low LDL-C levels on higher order brain function is unclear, with reports of neurocognitive disorders with other lipid-lowering therapies. METHODS Patients (n = 2176) with heterozygous familial hypercholesterolemia (HeFH) or non-FH, at high or very-high CV risk despite maximally tolerated statin therapy, randomly received subcutaneous alirocumab 75/150 mg or placebo every 2 weeks in this double-blind, placebo-controlled trial. The primary outcome was prospectively evaluated every 24 weeks over 96 weeks by Cambridge Neuropsychological Test Automated Battery (CANTAB). RESULTS Among 2086 patients with CANTAB cognitive domain Spatial Working Memory Strategy (SWMS) assessments, change from baseline to Week 96 in SWMS z-score (primary outcome) achieved noninferiority between alirocumab and placebo (least squares [LS] mean change at Week 96, -0.180 vs -0.200; LS mean difference vs placebo [95% confidence interval]: -0.020 [-0.094 to 0.055], p = 0.6055). Exploratory outcome measures, which further assessed neurocognitive function in the CANTAB domains, did not differ significantly over 96 weeks and achieved nominal noninferiority between treatment groups. Alirocumab resulted in nominally significant reductions in LDL-C and other lipid parameters, and was generally well tolerated. CONCLUSIONS Confirming previous PCSK9 inhibitor data, alirocumab showed no effect on neurocognitive function over 96 weeks' treatment, substantially reduced LDL-C and was generally well tolerated in patients with HeFH or non-FH at high or very-high CV risk.
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16
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PCSK9 Inhibitors in a German Single-Center Clinical Practice: Real-World Treatment of Patients at High Cardiovascular Risk Over 68 Weeks. Am J Cardiovasc Drugs 2021; 21:83-92. [PMID: 32514867 PMCID: PMC7838077 DOI: 10.1007/s40256-020-00411-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Aims Several the use of proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) for patients at high/very high cardiovascular risk who are inadequately treated with maximally tolerated lipid-lowering therapies (LLTs). Objectives We assessed the effectiveness and safety of the PCSK9i alirocumab and evolocumab in a single-center clinical practice for up to 68 weeks. Methods In this prospective, open-label study conducted in Germany, 635 enrolled patients were treated with alirocumab [75 or 150 mg every 2 weeks (Q2W)] or evolocumab (140 mg Q2W) according to European Society of Cardiology/European Atherosclerosis Society guidelines (low-density lipoprotein cholesterol [LDL-C] > 1.81/2.59 mmol/L (70/100 mg/dL), depending on cardiovascular risk]. Investigators were able to adjust LLTs, including PCSK9i, according to their own clinical judgment. The primary effectiveness endpoint was LDL-C reduction from baseline to week 68. Results At baseline, approximately 50% of patients were statin intolerant, and approximately 90% reported a history of cardiovascular disease. LDL-C reductions remained generally unchanged from weeks 4 to 68 in each treatment group. At week 68, LDL-C mean percentage changes from baseline were − 41.7% (alirocumab 75 mg Q2W), − 53.7% (alirocumab 150 mg Q2W), and − 54.1% (evolocumab 140 mg Q2W). LDL-C reduction was 7.1% greater in patients receiving statins than in those not receiving statins because of statin intolerance (P < 0.0001). PCSK9i consistently improved levels of other lipoproteins throughout. Overall, 47.1% of patients reported adverse events at week 68. Conclusions Consistent with clinical trial findings, alirocumab and evolocumab improved lipid levels in a real-world setting in patients with high baseline LDL-C levels despite receiving maximally tolerated LLTs. PCSK9i were generally well-tolerated. Electronic supplementary material The online version of this article (10.1007/s40256-020-00411-3) contains supplementary material, which is available to authorized users.
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Gaudet D, López-Sendón JL, Averna M, Bigot G, Banach M, Letierce A, Loy M, Samuel R, Manvelian G, Batsu I, Henry P. Safety and efficacy of alirocumab in a real-life setting: the ODYSSEY APPRISE study. Eur J Prev Cardiol 2020; 28:1864-1872. [DOI: 10.1093/eurjpc/zwaa097] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/07/2020] [Accepted: 09/24/2020] [Indexed: 01/20/2023]
Abstract
Abstract
Aims
To obtain safety and efficacy data of alirocumab, a proprotein convertase subtilisin/kexin type 9 inhibitor, in a real-life setting in high cardiovascular (CV) risk patients with heterozygous familial hypercholesterolaemia (HeFH) or very-high low-density lipoprotein cholesterol (LDL-C) levels despite maximally tolerated dose of statin ± other lipid-lowering therapies (MTD ± LLTs). ODYSSEY APPRISE was a prospective, single-arm, Phase 3b open-label (≥12 weeks to ≤ 30 months) European/Canadian study with alirocumab.
Methods and results
Patients received alirocumab 75 or 150 mg every 2 weeks, with dose adjustment based on physician’s judgment. In total, 994 patients were enrolled and treated. The mean [standard deviation (SD)] duration of alirocumab exposure was 72.4 (42.5) weeks. Patients with HeFH were younger [mean (SD) age of 53.8 (11.6) vs. 61.6 (10.1) years], more likely to be female (41.7% vs. 29.1%) and had higher baseline LDL-C compared with non-familial hypercholesterolaemia (non-FH) patients [mean (SD) of 5.1 (1.7) vs. 4.1 (1.1) mmol/L]. The overall incidence of treatment-emergent adverse events (TEAEs) was 71.6%; common TEAEs included nasopharyngitis (7.8%), myalgia (7.1%), and headache (6.2%). At Week 12, mean (SD) LDL-C was reduced by 54.8 (20.1)% from baseline [2.6 (1.2) mmol/L], maintained for the trial duration. LDL-C was reduced below 1.8 mmol/L and/or by ≥50% reduction from baseline in 69.1% of patients overall, and for 64.7 and 77.4% of the HeFH and non-FH subgroups, respectively.
Conclusion
In a real-life setting in patients with hypercholesterolaemia and high CV risk, alirocumab was generally well tolerated and resulted in clinically significant LDL-C reductions.
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Affiliation(s)
- Daniel Gaudet
- ECOGENE-21 and Clinical Lipidology Unit, Community Gene Medicine Center, Department of Medicine, Université de Montréal, Chicoutimi, QC G7H 7K9, Canada
| | | | - Maurizio Averna
- Department of Health Promotion Sciences, Maternal and Infantile Care, Internal Medicine and Medical Specialties—PROMISE, School of Medicine, University of Palermo, Palermo 90133, Italy
| | - Grégory Bigot
- IviData Life Sciences, Levallois-Perret 92300, France
| | - Maciej Banach
- Department of Hypertension, Medical University of Lodz, Lodz 90-419, Poland
| | | | | | - Rita Samuel
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY 10591, USA
| | | | | | - Patrick Henry
- Hôpital Lariboisière, Service de Cardiologie, Paris 75010, France
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Duprez DA, Handelsman Y, Koren M. Cardiovascular Outcomes and Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors: Current Data and Future Prospects. Vasc Health Risk Manag 2020; 16:403-418. [PMID: 33116551 PMCID: PMC7548340 DOI: 10.2147/vhrm.s261719] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/11/2020] [Indexed: 12/12/2022] Open
Abstract
Cardiovascular (CV) disease remains the leading cause of morbidity and mortality worldwide and poses an ongoing challenge with the aging population. Elevated low-density lipoprotein cholesterol (LDL-C) is an established risk factor for atherosclerotic cardiovascular disease (ASCVD), and the expert consensus is the use of statin therapy (if tolerated) as first line for LDL-C reduction. However, patients with ASCVD may experience recurrent ischemic events despite receiving maximally tolerated statin therapy, including those whose on-treatment LDL-C remains ≥70 mg/dL, patients with familial hypercholesterolemia, high-risk subgroups with comorbidities such as diabetes mellitus, and those who have an intolerance to statin therapy. Optimal therapeutic strategies for this unmet need should deploy aggressive lipid lowering to minimize the contribution of dyslipidemia to their CV risk, particularly for very high-risk populations with additional risk factors beyond hypercholesterolemia and established ASCVD. To understand the current clinical climate and guidelines regarding ASCVD, we primarily searched PubMed for articles published in English regarding lipid-lowering therapies and CV risk reduction, including emerging therapies, and CV outcomes trials with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. This review discusses the findings of recent clinical trial evidence for CV risk reduction with cholesterol-lowering therapies, with a focus on CV outcomes trials with PCSK9 inhibitors, and considers the impact of the study results for secondary prevention and future strategies in patients with hypercholesterolemia and CV risk despite maximally tolerated statin therapy.
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Affiliation(s)
- Daniel A Duprez
- Cardiovascular Division, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | | | - Michael Koren
- Jacksonville Center for Clinical Research, Jacksonville, FL, USA
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Li H, Wei Y, Yang Z, Zhang S, Xu X, Shuai M, Vitse O, Wu Y, Baccara-Dinet MT, Zhang Y, Li J. Safety, Tolerability, Pharmacokinetics, and Pharmacodynamics of Alirocumab in Healthy Chinese Subjects: A Randomized, Double-Blind, Placebo-Controlled, Ascending Single-Dose Study. Am J Cardiovasc Drugs 2020; 20:489-503. [PMID: 32080823 PMCID: PMC7548281 DOI: 10.1007/s40256-020-00394-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The addition of alirocumab (a fully human monoclonal antibody to proprotein convertase subtilisin/kexin type 9 [PCSK9]) to background statin therapy provides significant incremental low-density lipoprotein cholesterol (LDL-C) lowering and cardiovascular event risk reduction. OBJECTIVES Our objectives were to assess the safety, tolerability, pharmacokinetics, and pharmacodynamics of single ascending doses of alirocumab in healthy Chinese subjects. METHODS In this double-blind, placebo-controlled, phase I study, 35 Chinese subjects (aged 21-45 years) with baseline LDL-C > 100 mg/dL (2.59 mmol/L) were randomized to receive a single 1 mL subcutaneous injection of alirocumab 75, 150, or 300 mg, or placebo, and followed up for ~ 12 weeks. RESULTS Treatment-emergent adverse events, most frequently nasal congestion and dry throat, were reported in three of seven or eight subjects in each alirocumab dose group (two of seven in the placebo group). One patient receiving alirocumab 300 mg had a mild local injection-site reaction. No alirocumab recipients demonstrated antidrug antibodies. Maximum alirocumab serum concentrations (6-34 mg/dL) occurred at a median of 3-7 days across the dose groups. Maximum mean LDL-C reductions from baseline were observed on days 8, 15, and 22 with alirocumab 75 (55.3%), 150 (63.7%), and 300 mg (73.7%), respectively. Mean free PCSK9 levels were reduced to below the lower limit of quantification within 4 h of dosing. Total cholesterol, non-high-density lipoprotein cholesterol, and apolipoprotein B were reduced with alirocumab. CONCLUSIONS In Chinese subjects, alirocumab 75, 150, and 300 mg was safe and well-tolerated. Pharmacokinetic/pharmacodynamic parameters, including clinically meaningful reductions in LDL-C and other lipids/lipoproteins, were consistent with data from Japanese and Western populations. Clinicaltrials.gov identifier: NCT02979015.
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Affiliation(s)
- Haiyan Li
- Department of Cardiology, NHC Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Peking University Third Hospital, 49 North Garden Road, Haidian Distrct, Beijing, 100191, China.
- Drug Clinical Trial Center, Peking University Third Hospital, 49 North Garden Road, Haidian Distrct, Beijing, 100191, China.
| | - Yudong Wei
- Drug Clinical Trial Center, Peking University Third Hospital, 49 North Garden Road, Haidian Distrct, Beijing, 100191, China
| | - Zhenhua Yang
- Drug Clinical Trial Center, Peking University Third Hospital, 49 North Garden Road, Haidian Distrct, Beijing, 100191, China
| | - Shuang Zhang
- Drug Clinical Trial Center, Peking University Third Hospital, 49 North Garden Road, Haidian Distrct, Beijing, 100191, China
| | - Xiuxiu Xu
- Drug Clinical Trial Center, Peking University Third Hospital, 49 North Garden Road, Haidian Distrct, Beijing, 100191, China
| | | | - Olivier Vitse
- Clinical Development R&D, Sanofi, Montpellier, France
| | | | | | - Yi Zhang
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
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Yao H, Hou C, Liu W, Yi J, Su W, Hou Q. Associations of multiple serum biomarkers and the risk of cardiovascular disease in China. BMC Cardiovasc Disord 2020; 20:426. [PMID: 32993518 PMCID: PMC7523396 DOI: 10.1186/s12872-020-01696-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/31/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Previous studies focus on one or several serum biomarkers and the risk of cardiovascular disease (CVD). This study aims to investigate the association of multiple serum biomarkers and the risk of CVD and evaluate the dose-relationship between a single serum metabolite and CVD. METHODS Our case-control study included 161 CVD and 160 non-CVD patients who had a physical examination in the same hospital. We used stratified analysis and cubic restricted analysis to investigate the dose-response relationship of individual serum biomarkers and the CVD incident. Moreover, to investigate serum biomarkers and CVD, we used elastic net regression and logistic regression to build a multi-biomarker model. RESULTS In a single serum biomarker model, we found serum FT4, T4. GLU, CREA, TG and LDL-c were positively associated with CVD. In the male group, serum T4, GLU and LDL-c were positively associated with CVD; and serum TG was positively associated with CVD in the female group. When patients ≤63 years old, serum T4, GLU, CREA and TG were positively associated with CVD, and serum TG and LDL-c were positively associated with CVD when patients > 63 years old. Moreover, serum GLU had nonlinearity relationship with CVD and serum TG and LDL-c had linearity association with CVD. Furthermore, we used elastic regression selecting 5 serum biomarkers (GLU, FT4, TG, HDL-c, LDL-c) which were independently associated with CVD incident and built multi-biomarker model. And the multi-biomarker model had much better sensitivity than single biomarker model. CONCLUSION The multi-biomarker model had much higher sensitivity than a single biomarker model for the prediction of CVD. Serum FT4, TG and LDL-c were positively associated with the risk of CVD in single and multiple serum biomarkers models, and serum TG and LDL-c had linearity relationship with CVD.
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Affiliation(s)
- Huichen Yao
- The third affiliated hospital of Shandong first medical university, Jinan, Shandong, China
| | - Chenyang Hou
- Guangxi Medical University, Nanning, Guangxi, China
| | - Weihua Liu
- Shandong First Medical University (Shandong Academy of Medical Sciences), 169 Great Wall Rd, Taian, 271000, Shandong, China
| | - Jihu Yi
- Shandong First Medical University (Shandong Academy of Medical Sciences), 169 Great Wall Rd, Taian, 271000, Shandong, China
| | - Wencong Su
- Zibo Bashan Wanjie Hospital, Zibo, Shandong, China
| | - Qingzhi Hou
- Shandong First Medical University (Shandong Academy of Medical Sciences), 169 Great Wall Rd, Taian, 271000, Shandong, China.
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21
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Raal FJ, Chilton R, Ranjith N, Rambiritch V, Leisegang RF, Ebrahim IO, Tonder AV, Shunmoogam N, Bouharati C, Musa MG, Karamchand S, Naidoo P, Blom DJ. PCSK9 Inhibitors: From Nature’s Lessons to Clinical Utility. Endocr Metab Immune Disord Drug Targets 2020; 20:840-854. [DOI: 10.2174/1871530320666200213114138] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 10/31/2019] [Accepted: 12/02/2019] [Indexed: 12/21/2022]
Abstract
Background:
Proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors are a novel
class of non-statin lipid lowering therapy that reduce LDL-cholesterol by 50 - 60%. PCSK9 inhibitors
decrease LDL-cholesterol by preventing intracellular degradation of LDL receptors; subsequently, a
greater number of LDL-receptors are available on the cell surface to extract circulating LDL.
Objective:
To describe the origins of PCSK9 inhibitors and their current use in clinical practice.
Methods:
We performed a narrative review of the PCSK9 inhibitor class of drugs.
Results:
Current data indicate that PCSK9 inhibitors effectively reduce LDL-cholesterol and are well
tolerated and safe. PCSK9 inhibitors have also been shown to reduce cardiovascular event rates in
patients with stable atherosclerotic cardiovascular disease and in patients with a recent (up to one year)
acute coronary syndrome. Given the costs, chronicity of the treatment and the potential budget impact,
PCSK9 inhibitors are often limited to patients with the highest absolute risk for major adverse cardiovascular
events despite optimal treatment with high-intensity statin and ezetimibe.
Conclusion:
PCSK9 inhibitors have a favorable safety, efficacy and tolerability profile. Postmarketing
safety surveillance and real-world studies are needed to further support the long-term safety
profile of this class of medicine.
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Affiliation(s)
- Frederick J. Raal
- Department of Medicine, Division of Endocrinology and Metabolism, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Robert Chilton
- Department of Medicine, Faculty of Medicine, Division of Cardiology and Interventional Cardiology, University of Texas Health Science Center at San Antonia, Texas, United States
| | - Naresh Ranjith
- Department of Cardiology, Cardiovascular Research Centre, Durban, South Africa
| | - Virendra Rambiritch
- Department of Pharmacology, Faculty of Health Sciences, Discipline of Pharmaceutical Sciences, University of Kwa-Zulu Natal, Durban, South Africa
| | - Rory F. Leisegang
- Department of Pharmaceutical Biosciences, Faculty of Pharmacy, Uppsala University, Uppsala, Sweden
| | | | - Alet van Tonder
- Department of Diabetes and Cardiovascular Medicine, Medical Affairs, Sanofi, Midrand, South Africa
| | - Nelusha Shunmoogam
- Department of Diabetes and Cardiovascular Medicine, Medical Affairs, Sanofi, Midrand, South Africa
| | - Célia Bouharati
- Department of Clinical Trials, Clinical Study Unit, Sanofi, Midrand, South Africa
| | - Moji G. Musa
- Department of Diabetes and Cardiovascular Medicine, Medical Affairs, Sanofi, Midrand, South Africa
| | - Sumanth Karamchand
- Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Poobalan Naidoo
- Department of Diabetes and Cardiovascular Medicine, Medical Affairs, Sanofi, Midrand, South Africa
| | - Dirk J. Blom
- Department of Medicine, Division of Lipidology and Hatter Institute for Cardiovascular Research in Africa, University of Cape Town, Cape Town, South Africa
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Efficacy and Safety of Alirocumab in Adults With Homozygous Familial Hypercholesterolemia. J Am Coll Cardiol 2020; 76:131-142. [DOI: 10.1016/j.jacc.2020.05.027] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/05/2020] [Accepted: 05/11/2020] [Indexed: 12/16/2022]
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Abstract
BACKGROUND Despite advances in the development of lipid-lowering therapies, clinical trials have shown that a significant residual risk of cardiovascular disease persists. Specifically, new drugs are needed for non-responding or statin-intolerant subjects or patients considered at very high risk for cardiovascular events even though are already on treatment with the best standard of care. RESULTS AND CONCLUSIONS Besides, genetic and epidemiological studies and Mendelian randomization analyses have strengthened the linear correlation between the concentration of low-density lipoprotein cholesterol (LDL-C) and the incidence of cardiovascular events and highlighted various novel therapeutic targets. This review describes the novel strategies to reduce the levels of LDL-C, non-HDL-C, triglyceride, apolipoprotein B, and Lp(a), focusing on those developed using biotechnology-based strategies.
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Abstract
PURPOSE OF REVIEW Proprotein convertase subtilisin kexin 9 (PCSK9) plays a crucial role in regulating circulating levels of LDL-C as a consequence of its ability to inhibit LDL receptor recycling in the liver. Loss of function variants in the PCSK9 gene result in low LDL-C levels and associate with reduced cardiovascular risk, whereas gain of-function variants associate with hypercholesterolemia and increased risk of early cardiovascular events. Thus, PCSK9 inhibition has been established as an additional approach for the treatment of hypercholesterolemia. The aim of this review is to provide a brief overview of current strategies targeting PCSK9 and discuss clinical results of the emerging approaches. RECENT FINDINGS Two monoclonal antibodies targeting circulating PCSK9 (evolocumab and alirocumab) have been approved for the treatment of hypercholesterolemia and cardiovascular disease. Later, a gene silencing approach (inclisiran), which inhibits hepatic PCSK9 synthesis, was shown to be as effective as monoclonal antibodies but with a twice a year injection and is currently under evaluation for approval. Due to the elevated costs of such therapies, several other approaches have been explored, including peptide-based anti PCSK9 vaccination, and small oral PCSK9 inhibitors, which are still in preclinical phase. In the coming years, we will assist to a progressive introduction of novel anti-PCSK9 approaches in the clinical practice for the treatment of patients with hypercholesterolemia as well as patients at high cardiovascular risk.
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Affiliation(s)
- Alberico L Catapano
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy.,IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy
| | - Angela Pirillo
- IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy.,Center for the Study of Atherosclerosis, E. Bassini Hospital, Cinisello Balsamo, Milan, Italy
| | - Giuseppe D Norata
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy. .,Center for the Study of Atherosclerosis, E. Bassini Hospital, Cinisello Balsamo, Milan, Italy.
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25
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PCSK9 inhibition with alirocumab in pediatric patients with heterozygous familial hypercholesterolemia: The ODYSSEY KIDS study. J Clin Lipidol 2020; 14:322-330.e5. [DOI: 10.1016/j.jacl.2020.03.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/10/2020] [Accepted: 03/11/2020] [Indexed: 01/17/2023]
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Seidah NG, Prat A, Pirillo A, Catapano AL, Norata GD. Novel strategies to target proprotein convertase subtilisin kexin 9: beyond monoclonal antibodies. Cardiovasc Res 2020; 115:510-518. [PMID: 30629143 DOI: 10.1093/cvr/cvz003] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/06/2018] [Accepted: 01/05/2019] [Indexed: 12/15/2022] Open
Abstract
Since the discovery of the role of proprotein convertase subtilisin kexin 9 (PCSK9) in the regulation of low-density lipoprotein cholesterol (LDL-C) in 2003, a paradigm shift in the treatment of hypercholesterolaemia has occurred. The PCSK9 secreted into the circulation is a major downregulator of the low-density lipoprotein receptor (LDLR) protein, as it chaperones it to endosomes/lysosomes for degradation. Humans with loss-of-function of PCSK9 exhibit exceedingly low levels of LDL-C and are protected from atherosclerosis. As a consequence, innovative strategies to modulate the levels of PCSK9 have been developed. Since 2015 inhibitory monoclonal antibodies (evolocumab and alirocumab) are commercially available. When subcutaneously injected every 2-4 weeks, they trigger a ∼60% LDL-C lowering and a 15% reduction in the risk of cardiovascular events. Another promising approach consists of a liver-targetable specific PCSK9 siRNA which results in ∼50-60% LDL-C lowering that lasts up to 6 months (Phases II-III clinical trials). Other strategies under consideration include: (i) antibodies targeting the C-terminal domain of PCSK9, thereby inhibiting the trafficking of PCSK9-LDLR to lysosomes; (ii) small molecules that either prevent PCSK9 binding to the LDLR, its trafficking to lysosomes or its secretion from cells; (iii) complete silencing of PCSK9 by CRISPR-Cas9 strategies; (iv) PCSK9 vaccines that inhibit the activity of circulating PCSK9. Time will tell whether other strategies can be as potent and safe as monoclonal antibodies to lower LDL-C levels.
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Affiliation(s)
- Nabil G Seidah
- Laboratory of Biochemical Neuroendocrinology, Montreal Clinical Research Institute (IRCM; Affiliated to the University of Montreal), Montreal, QC H2W1R7, Canada
| | - Annik Prat
- Laboratory of Biochemical Neuroendocrinology, Montreal Clinical Research Institute (IRCM; Affiliated to the University of Montreal), Montreal, QC H2W1R7, Canada
| | - Angela Pirillo
- Center for the Study of Atherosclerosis, E. Bassini Hospital, Cinisello Balsamo, Milan, Italy.,IRCCS MultiMedica, Milan, Italy
| | - Alberico Luigi Catapano
- IRCCS MultiMedica, Milan, Italy.,Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Milan, Italy
| | - Giuseppe Danilo Norata
- Center for the Study of Atherosclerosis, E. Bassini Hospital, Cinisello Balsamo, Milan, Italy.,Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Milan, Italy
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27
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Moriarty PM, Thompson PD, Cannon CP, Guyton JR, Bergeron J, Zieve FJ, Bruckert E, Jacobson TA, Baccara-Dinet MT, Zhao J, Donahue S, Ali S, Manvelian G, Pordy R. Efficacy and safety of alirocumab in statin-intolerant patients over 3 years: open-label treatment period of the ODYSSEY ALTERNATIVE trial. J Clin Lipidol 2020; 14:88-97.e2. [PMID: 32192644 DOI: 10.1016/j.jacl.2020.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/06/2020] [Accepted: 01/06/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The 24-week randomized, double-blind ODYSSEY ALTERNATIVE trial (NCT01709513) demonstrated significant low-density lipoprotein cholesterol (LDL-C) reductions with the PCSK9 inhibitor alirocumab vs ezetimibe in statin-intolerant patients, with significantly fewer skeletal muscle events (SMEs; 32.5%) vs atorvastatin (46.0%; hazard ratio: 0.61, 95% confidence interval: 0.38 to 0.99, P = .042). OBJECTIVE ALTERNATIVE participants could enter an open-label treatment period (OLTP) for assessment of long-term safety. METHODS Two hundred and eighty one patients entered the OLTP; 93.7%, 84.0%, and 92.9% of patients who received atorvastatin, ezetimibe, and alirocumab, respectively, during double-blind treatment, including 216 patients (76.9%) who completed double-blind treatment, as well as patients who either prematurely discontinued treatment due to SME (n = 51 [18.1%]) or other reasons (n = 14 [5.0%]) but completed week 24 assessments. All patients in the OLTP received alirocumab (75 or 150 mg every 2 weeks based on investigator decision) for ∼3 years or until commercial availability, whichever came first. RESULTS SMEs were reported by 38.4% of patients in the OLTP. Safety results from the OLTP were similar to those of the alirocumab group in the double-blind period, except for a lower rate of discontinuations due to SMEs observed with alirocumab in the OLTP (3.2% vs 15.9% in the double-blind period). At OLTP week 8, mean LDL-C reduction from baseline (=week 0 of double-blind period) was 52.0%, with reductions sustained through to the end-of-treatment visits (55.4% and 53.7% reduction at weeks 100 and 148, respectively). CONCLUSIONS In this population of statin-intolerant patients, alirocumab was well tolerated and produced durable LDL-C reductions over 3 years.
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Affiliation(s)
- Patrick M Moriarty
- Division of Clinical Pharmacology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA.
| | | | | | | | - Jean Bergeron
- Lipid Clinic, Centre Hospitalier Universitaire de Quebec, Laval University, Quebec, Canada
| | | | - Eric Bruckert
- Groupe Hospitalier Pitié-Salpêtrière (Assistance Publique-Hôpitaux de Paris), Paris, France
| | | | | | - Jian Zhao
- Regeneron Pharmaceuticals, Inc., Basking Ridge, NJ, USA
| | | | - Shazia Ali
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| | | | - Robert Pordy
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
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28
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Marjot T, Moolla A, Cobbold JF, Hodson L, Tomlinson JW. Nonalcoholic Fatty Liver Disease in Adults: Current Concepts in Etiology, Outcomes, and Management. Endocr Rev 2020; 41:5601173. [PMID: 31629366 DOI: 10.1210/endrev/bnz009] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/14/2019] [Indexed: 02/06/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a spectrum of disease, extending from simple steatosis to inflammation and fibrosis with a significant risk for the development of cirrhosis. It is highly prevalent and is associated with significant adverse outcomes both through liver-specific morbidity and mortality but, perhaps more important, through adverse cardiovascular and metabolic outcomes. It is closely associated with type 2 diabetes and obesity, and both of these conditions drive progressive disease toward the more advanced stages. The mechanisms that govern hepatic lipid accumulation and the predisposition to inflammation and fibrosis are still not fully understood but reflect a complex interplay between metabolic target tissues including adipose and skeletal muscle, and immune and inflammatory cells. The ability to make an accurate assessment of disease stage (that relates to clinical outcome) can also be challenging. While liver biopsy is still regarded as the gold-standard investigative tool, there is an extensive literature on the search for novel noninvasive biomarkers and imaging modalities that aim to accurately reflect the stage of underlying disease. Finally, although no therapies are currently licensed for the treatment of NAFLD, there are interventions that appear to have proven efficacy in randomized controlled trials as well as an extensive emerging therapeutic landscape of new agents that target many of the fundamental pathophysiological processes that drive NAFLD. It is highly likely that over the next few years, new treatments with a specific license for the treatment of NAFLD will become available.
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Affiliation(s)
- Thomas Marjot
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, University of Oxford, John Radcliffe Hospital, Oxford, UK.,Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK
| | - Ahmad Moolla
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK
| | - Jeremy F Cobbold
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Leanne Hodson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK
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Abstract
PURPOSE OF REVIEW To review randomized interventional clinical and imaging trials that support lower targeted atherogenic lipoprotein cholesterol goals in "extreme" and "very high" atherosclerotic cardiovascular disease (ASCVD) risk settings. Major atherosclerotic cardiovascular event (MACE) prevention among the highest risk patients with ASCVD requires aggressive management of global risks, including lowering of the fundamental atherogenic apolipoprotein B-associated lipoprotein cholesterol particles [i.e., triglyceride-rich lipoprotein remnant cholesterol, low-density lipoprotein cholesterol (LDL-C), and lipoprotein(a)]. LDL-C has been the long-time focus of imaging studies and randomized clinical trials (RCTs). The 2004 adult treatment panel (ATP-III) update recognized that the long-standing targeted LDL-C goal of < 100 mg/dL potentially fostered substantial undertreatment of the very highest coronary heart disease (CHD) risk individuals and was lowered to < 70 mg/dL as an "optional" goal for "very high" 10-year CHD [CHD death + myocardial infarction (MI)] risk exceeding 20%. This evidence-based guideline change was supported by the observed benefits demonstrated in the high-risk primary and secondary prevention populations in the Heart Protection Study (HPS), the acute coronary syndrome (ACS) population in the Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction 22 trial (PROVE-IT), and the secondary prevention population in the Reversal of Atherosclerosis with Aggressive Lipid Lowering (REVERSAL) intravascular ultrasound (IVUS) study. Subsequent national and international guidelines maintained a targeted LDL-C goal < 70 mg/dL, or a threshold for management of > 70 mg/dL for patients with CHD, CHD risk equivalency, or ASCVD. RECENT FINDINGS Subgroup or meta-analyses of several RCTs, IVUS imaging studies, and the ACS population in IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) supported the evidence-based 2017 American Association Clinical Endocrinologist (AACE) guideline change establishing a targeted LDL-C goal < 55 mg/dL, non-HDL-C < 80 mg/dl, and apolipoprotein B (apo B) < 70 mg/dL for patients at "Extreme" ASCVD risk, i.e., 10-year 3-point-MACE-composite (CV death, non-fatal MI, or ischemic stroke) risk exceeding 30%. Moreover, with no recognized lower-limit-associated intolerance or safety issues, even more intensive lowering of atherogenic cholesterol levels is supported by the following evidence base: (1) analysis of eight high-intensity statin-based prospective secondary prevention IVUS atheroma volume regression trials; (2) a distribution analysis of on-treatment, ezetimibe and background-statin, of the very low LDL-C levels reached and CVD event risk in the IMPROVE-IT ACS population; (3) the secondary prevention Global Assessment of Pl\aque Regression With a PCSK9 Antibody as Measured by Intravascular Ultrasound (GLAGOV) on background-statin; and (4) the secondary prevention population of Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER). By example, in FOURIER, the population on background-statin at a baseline median 92 mg/dL achieved median LDL-C level of 30 mg/dL and non-HDL-C to < 65 mg/dl, and apo B to < 50 mg/dL, and subgroup and post hoc analyses all demonstrated additional ASCVD event reduction benefits as LDL-C was further reduced. The level of ASCVD risk determines the degree, urgency, and persistence in global risk management, including fundamental atherogenic lipoprotein cholesterol particle lowering. "Extreme" risk patients may require extremely low targeted LDL-C, non-HDL-C and apo B goals; such efforts, implied by more recent interventional trials and analyses, are aimed at maximal atheroma plaque regression, stabilization, and MACE event reduction with the aspiration of improved quality lifespan.
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Affiliation(s)
- Paul D Rosenblit
- Department of Medicine, Division of Endocrinology, Diabetes, & Metabolism, University California, Irvine (UCI), School of Medicine, Irvine, CA, 92697, USA.
- Diabetes Out-Patient Clinic, UCI Medical Center, Orange, CA, 92868, USA.
- Diabetes/Lipid Management & Research Center, 18821 Delaware St., Suite 202, Huntington Beach, CA, 92648, USA.
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30
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Han Y, Chen J, Chopra VK, Zhang S, Su G, Ma C, Huang Z, Ma Y, Yao Z, Yuan Z, Zhao Q, Kuanprasert S, Baccara-Dinet MT, Manvelian G, Li J, Chen R. ODYSSEY EAST: Alirocumab efficacy and safety vs ezetimibe in high cardiovascular risk patients with hypercholesterolemia and on maximally tolerated statin in China, India, and Thailand. J Clin Lipidol 2019; 14:98-108.e8. [PMID: 31882376 DOI: 10.1016/j.jacl.2019.10.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/18/2019] [Accepted: 10/29/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND The proprotein convertase subtilisin/kexin type 9 inhibitor alirocumab significantly reduces low-density lipoprotein cholesterol (LDL-C). OBJECTIVE This study (ODYSSEY EAST) assessed the efficacy and safety of alirocumab vs ezetimibe in high cardiovascular risk patients from Asia. METHODS Patients (n = 615) from China, India, and Thailand with hypercholesterolemia at high cardiovascular risk on maximally tolerated statin were randomized (2:1) to alirocumab (75 mg every 2 weeks [Q2W]; with dose increase to 150 mg Q2W at week 12 if week 8 LDL-C was >1.81 mmol/L [>70 mg/dL]) or ezetimibe (10 mg daily) for 24 weeks. The primary efficacy endpoint was percentage change in calculated LDL-C from baseline to week 24. Safety was assessed throughout. RESULTS Baseline data were similar in both groups. LDL-C levels were reduced from baseline to week 24 by 56.0% and 20.3% in the alirocumab and ezetimibe groups, respectively (P < .0001 vs ezetimibe). Overall, 18.8% of alirocumab-treated patients received a dose increase to 150 mg Q2W. At week 24, 85.1% of alirocumab-treated and 40.5% of ezetimibe-treated patients reached LDL-C <1.81 mmol/L (<70 mg/dL, P < .0001 vs ezetimibe). Treatment-emergent adverse events occurred in 68.5% of alirocumab-treated and 63.1% of ezetimibe-treated patients, with upper respiratory tract infection the most common (alirocumab: 13.3%; ezetimibe: 14.1%). Injection-site reactions occurred more frequently in alirocumab-treated patients (2.7%) than in ezetimibe-treated patients (1.0%). CONCLUSIONS Alirocumab significantly reduced LDL-C vs ezetimibe in high cardiovascular risk patients from Asia and was generally well tolerated. These findings are consistent with previous ODYSSEY studies.
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Affiliation(s)
- Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China.
| | - Jiyan Chen
- Department of Cardiology, Guangdong General Hospital, Guangdong, China
| | | | - Shuyang Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Beijing, China
| | - Guohai Su
- Institute of Translational Medicine, Jinan Central Hospital, Jinan, China
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhouqing Huang
- Division of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yingyan Ma
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Zhuhua Yao
- Department of Cardiology, Tianjin Union Medical Center, Tianjin, China
| | - Zuyi Yuan
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Qiang Zhao
- Department of Cardiac Surgery, Ruijin Hospital of Shanghai, Jiaotong University School of Medicine, Shanghai, China
| | - Srun Kuanprasert
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai Hospital, Chiang Mai, Thailand
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31
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Noto D, Giammanco A, Barbagallo CM, Cefalù AB, Averna MR. Anti-PCSK9 treatment: is ultra-low low-density lipoprotein cholesterol always good? Cardiovasc Res 2019; 114:1595-1604. [PMID: 29931148 DOI: 10.1093/cvr/cvy144] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 06/08/2018] [Indexed: 12/29/2022] Open
Abstract
Anti-PCSK9 (proprotein convertase subtilisin kexin 9) monoclonal antibodies (Mab) are novel, potent lipid-lowering drugs. They demonstrated to improve the lipid profile in high cardiovascular risk patients. Anti-PCSK9 Mab inhibit the targeted low-density lipoprotein (LDL)-receptor degradation induced by PCSK9 protein and are able to reduce LDL cholesterol (LDL-C) levels on top of conventional lipid-lowering therapy. Though these drugs proved to be very safe in the short-term, little is known about the possible long-term effects, due to the short period of their marketing. The genetic low cholesterol syndromes (LCS) represent the natural models of the lipid-lowering anti-PCSK9 therapy, and a valuable opportunity to predict the long-term effects of these drugs. By looking at the clinical features of such models, we could be able to foresee possible drug-induced side effects. In the present review, the correspondences and discordances between the side effects of anti-PCSK9 therapy and the corresponding LCS models will be examined in the attempt to forecast possible long-term consequences of these novel lipid-lowering agents.
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Affiliation(s)
- Davide Noto
- Department of Bioscience Internal Medicine and Specialties, University of Palermo, Palermo, Italy
| | - Antonina Giammanco
- Department of Bioscience Internal Medicine and Specialties, University of Palermo, Palermo, Italy
| | - Carlo M Barbagallo
- Department of Bioscience Internal Medicine and Specialties, University of Palermo, Palermo, Italy
| | - Angelo B Cefalù
- Department of Bioscience Internal Medicine and Specialties, University of Palermo, Palermo, Italy
| | - Maurizio R Averna
- Department of Bioscience Internal Medicine and Specialties, University of Palermo, Palermo, Italy
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Chen B, Shi X, Cui Y, Hou A, Zhao P. A Review of PCSK9 Inhibitors and their Effects on Cardiovascular Diseases. Curr Top Med Chem 2019; 19:1790-1817. [PMID: 31400268 DOI: 10.2174/1568026619666190809094203] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 06/07/2019] [Accepted: 07/25/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cardiovascular diseases remain the leading cause of morbidity and mortality in the world, with elevated Low-Density Lipoprotein-Cholesterol (LDL-C) levels as the major risk factor. Lower levels of LDL-C can effectively reduce the risk of cardiovascular diseases. Proprotein convertase subtilisin/kexin type 9 (PCSK9) plays an important role in regulating the degradation of hepatic LDL receptors that remove LDL-C from the circulation. PCSK9 inhibitors are a new class of agents that are becoming increasingly important in the treatment to reduce LDL-C levels. Two PCSK9 inhibitors, alirocumab and evolocumab, have been approved to treat hypercholesterolemia and are available in the United States and the European Union. Through the inhibition of PCSK9 and increased recycling of LDL receptors, serum LDL-C levels can be significantly reduced. OBJECTIVE This review will describe the chemistry, pharmacokinetics, and pharmacodynamics of PCSK9 inhibitors and their clinical effects.
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Affiliation(s)
- Bo Chen
- Department of Pediatric Cardiology, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 20092, China
| | - Xin Shi
- Department of Pediatric Cardiology, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 20092, China
| | - Yanping Cui
- Department of Pediatric Cardiology, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 20092, China
| | - Aiping Hou
- Department of Pediatric, Shidong Hospital, Shanghai 20092, China
| | - Pengjun Zhao
- Department of Pediatric, Shidong Hospital, Shanghai 20092, China
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Ray KK, Del Prato S, Müller-Wieland D, Cariou B, Colhoun HM, Tinahones FJ, Domenger C, Letierce A, Mandel J, Samuel R, Bujas-Bobanovic M, Leiter LA. Alirocumab therapy in individuals with type 2 diabetes mellitus and atherosclerotic cardiovascular disease: analysis of the ODYSSEY DM-DYSLIPIDEMIA and DM-INSULIN studies. Cardiovasc Diabetol 2019; 18:149. [PMID: 31706300 PMCID: PMC6842201 DOI: 10.1186/s12933-019-0951-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 10/24/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Individuals with diabetes often have high levels of atherogenic lipoproteins and cholesterol reflected by elevated low-density lipoprotein cholesterol (LDL-C), non-high-density lipoprotein cholesterol (non-HDL-C), apolipoprotein B (ApoB), and LDL particle number (LDL-PN). The presence of atherosclerotic cardiovascular disease (ASCVD) increases the risk of future cardiovascular events. We evaluated the efficacy and safety of the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, alirocumab, among individuals with type 2 diabetes (T2DM), high LDL-C or non-HDL-C, and established ASCVD receiving maximally tolerated statin in ODYSSEY DM-DYSLIPIDEMIA (NCT02642159) and DM-INSULIN (NCT02585778). METHODS In DM-DYSLIPIDEMIA, individuals with T2DM and mixed dyslipidemia (non-HDL-C ≥ 100 mg/dL; n = 413) were randomized to open-label alirocumab 75 mg every 2 weeks (Q2W) or usual care (UC) for 24 weeks, with UC options selected before stratified randomization. In DM-INSULIN, insulin-treated individuals with T2DM (LDL-C ≥ 70 mg/dL; n = 441) were randomized in a double-blind fashion to alirocumab 75 mg Q2W or placebo for 24 weeks. Study participants also had a glycated hemoglobin < 9% (DM-DYSLIPIDEMIA) or < 10% (DM-INSULIN). Alirocumab dose was increased to 150 mg Q2W at week 12 if week 8 LDL-C was ≥ 70 mg/dL (DM-INSULIN) or non-HDL-C was ≥ 100 mg/dL (DM-DYSLIPIDEMIA). Lipid reductions and safety were assessed in patients with ASCVD from these studies. RESULTS This analysis included 142 DM-DYSLIPIDEMIA and 177 DM-INSULIN participants with ASCVD, including 95.1% and 86.4% with coronary heart disease, and 32.4% and 49.7% with microvascular diabetes complications, respectively. At week 24, alirocumab significantly reduced LDL-C, non-HDL-C, ApoB, and LDL-PN from baseline versus control. This translated into a greater proportion of individuals achieving non-HDL-C < 100 mg/dL (64.6% alirocumab/23.8% UC [DM-DYSLIPIDEMIA]; 65.4% alirocumab/14.9% placebo [DM-INSULIN]) and ApoB < 80 mg/dL (75.1% alirocumab/35.4% UC and 76.8% alirocumab/24.8% placebo, respectively) versus control at week 24 (all P < 0.0001). In pooling these studies, 66.4% (alirocumab) and 67.0% (control) of individuals reported treatment-emergent adverse events. The adverse event pattern was similar with alirocumab versus controls. CONCLUSIONS Among individuals with T2DM and ASCVD who had high non-HDL-C/LDL-C levels despite maximally tolerated statin, alirocumab significantly reduced atherogenic cholesterol and LDL-PN versus control. Alirocumab was generally well tolerated. Trial registration Clinicaltrials.gov. NCT02642159. Registered 30 December 2015 and Clinicaltrials.gov. NCT02585778. Registered 23 October 2015.
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MESH Headings
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Anticholesteremic Agents/adverse effects
- Anticholesteremic Agents/therapeutic use
- Atherosclerosis/blood
- Atherosclerosis/diagnosis
- Atherosclerosis/drug therapy
- Atherosclerosis/epidemiology
- Biomarkers/blood
- Cholesterol, HDL/blood
- Cholesterol, LDL/blood
- Clinical Trials, Phase III as Topic
- Clinical Trials, Phase IV as Topic
- Coronary Disease/blood
- Coronary Disease/diagnosis
- Coronary Disease/drug therapy
- Coronary Disease/epidemiology
- Diabetes Mellitus, Type 2/blood
- Diabetes Mellitus, Type 2/diagnosis
- Diabetes Mellitus, Type 2/drug therapy
- Diabetes Mellitus, Type 2/epidemiology
- Drug Therapy, Combination
- Dyslipidemias/blood
- Dyslipidemias/diagnosis
- Dyslipidemias/drug therapy
- Dyslipidemias/epidemiology
- Humans
- Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use
- Multicenter Studies as Topic
- PCSK9 Inhibitors
- Randomized Controlled Trials as Topic
- Risk Factors
- Serine Proteinase Inhibitors/adverse effects
- Serine Proteinase Inhibitors/therapeutic use
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, Imperial College, Kensington, London, SW7 2AZ, UK.
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Dirk Müller-Wieland
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany
| | - Bertrand Cariou
- l'institut du thorax, Department of Endocrinology, CHU Nantes, INSERM, 1413, Nantes, France
| | | | - Francisco J Tinahones
- Department of Clinical Endocrinology and Nutrition (IBIMA), Hospital Virgen de la Victoria, University of Málaga, CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Málaga, Spain
| | | | - Alexia Letierce
- Biostatistics and Programming Department, Sanofi, Chilly-Mazarin, France
| | | | - Rita Samuel
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, NY, USA
| | | | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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Stöllberger C, Mertikian G, Stahl D, Finsterer J. Fatal Recurrent Staphylococcus aureus Infection in a Patient With an Aortic Endostent Under Alirocumab. Infect Dis (Lond) 2019; 12:1178633719885387. [PMID: 31695403 PMCID: PMC6822197 DOI: 10.1177/1178633719885387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 10/03/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose: Aortic stent-graft infection (SGI) entails a high mortality. Alirocumab is a monoclonal antibody to proprotein convertase subtilisin/kexin type 9 (PCSK9), approved for treatment of therapy-refractory hypercholesterolemia. Proprotein convertase subtilisin/kexin type 9 might play a role in infections. Case report: A 68-year-old male suffered from fatigue, fever, and back pain. Twelve months previously, a 4-fold-fenestrated aortic endoprosthesis was implanted because of an aortic aneurysm. Four months later, alirocumab 150 mg was initiated. Staphylococcus aureus grew in several blood cultures, and he received cefazolin and fosfomycin. Fludeoxyglucose positron emission tomography computed tomography indicated an infected endoprosthesis. Puncture of the periprosthetic space under antibiotic therapy revealed different strains of Staphylococcus epidermidis. The therapy was changed to dalbavancin. The patient died suddenly 11 days later after complaining about back pain for several days. No autopsy was carried out. Conclusions: The most probable cause of the patient’s recurrent bacteremia with S aureus was an infection of the aortic prosthesis. Although this report is very speculative, it can be concluded that data about infections in patients under PCSK9 inhibitors should be collected systematically and more research is needed about the biological consequences of decreasing cholesterol to extreme low levels.
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Robinson JG, Farnier M, Kastelein JJ, Roth EM, Taskinen MR, Colhoun HM, Brunet A, DiCioccio AT, Lecorps G, Pordy R, Baccara-Dinet MT, Cannon CP. Relationship between alirocumab, PCSK9, and LDL-C levels in four phase 3 ODYSSEY trials using 75 and 150 mg doses. J Clin Lipidol 2019; 13:979-988.e10. [DOI: 10.1016/j.jacl.2019.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/25/2019] [Accepted: 10/03/2019] [Indexed: 11/30/2022]
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Rannikko J, Jacome Sanz D, Ortutay Z, Seiskari T, Aittoniemi J, Huttunen R, Syrjänen J, Pesu M. Reduced plasma PCSK9 response in patients with bacteraemia is associated with mortality. J Intern Med 2019; 286:553-561. [PMID: 31166632 DOI: 10.1111/joim.12946] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The proprotein convertase subtilisin/kexin type 9 (PCSK9) enzyme controls blood cholesterol levels by downregulating the expression of the low-density lipoprotein receptor (LDLR). Pathogenic lipids (e.g. lipopolysaccharide) are removed from the circulation by an LDLR/PCSK9-dependent mechanism; thus, it has been suggested that PCSK9 inhibitors may be beneficial in the treatment of infections. We measured plasma PCSK9 levels in patients with culture-positive bacteraemia and explored pathogen-dependent and infection site-dependent effects as well as correlations between patient characteristics and outcome. METHODS Proprotein convertase subtilisin/kexin type 9 in the plasma was measured with an enzyme-linked immunosorbent assay from 481 patients with blood culture-positive infection on days 0 to 4 after admission to the emergency department. Patient outcome and clinical and laboratory data were gathered retrospectively from patient records. RESULTS The plasma PCSK9 level was elevated equally in patients with Gram-positive or Gram-negative bacterial infections; particularly high levels were seen in patients with a lower respiratory tract infection and Streptococcus pneumoniae bacteraemia. PCSK9 levels showed a significant positive correlation with C-reactive protein (CRP) level. Bacteraemia patients with liver disease or a history of alcohol abuse had significantly lower levels of plasma PCSK9. Reduced PCSK9 plasma responses in patients were significantly associated with mortality at days 7, 28 and 90. CONCLUSION Proprotein convertase subtilisin/kexin type 9 is upregulated in blood culture-positive infections. Plasma PCSK9 resembles acute-phase proteins; its expression is induced during an infection, reduced in liver disease and correlates positively with CRP level. We have shown that PCSK9 levels are lower in patients with a fatal prognosis.
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Affiliation(s)
- J Rannikko
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - D Jacome Sanz
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Z Ortutay
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - T Seiskari
- Department of Clinical Microbiology, Fimlab Laboratories Ltd, Tampere, Finland
| | - J Aittoniemi
- Department of Clinical Microbiology, Fimlab Laboratories Ltd, Tampere, Finland
| | - R Huttunen
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - J Syrjänen
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - M Pesu
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Dermatology, Tampere University Hospital, Tampere, Finland
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Müller-Wieland D, Rader DJ, Moriarty PM, Bergeron J, Langslet G, Ray KK, Manvelian G, Thompson D, Bujas-Bobanovic M, Roth EM. Efficacy and Safety of Alirocumab 300 mg Every 4 Weeks in Individuals With Type 2 Diabetes on Maximally Tolerated Statin. J Clin Endocrinol Metab 2019; 104:5253-5262. [PMID: 31166599 PMCID: PMC6763278 DOI: 10.1210/jc.2018-02703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 05/30/2019] [Indexed: 01/14/2023]
Abstract
CONTEXT In the ODYSSEY CHOICE I trial, alirocumab 300 mg every 4 weeks (Q4W) was assessed in patients with hypercholesterolemia. Alirocumab efficacy and safety were evaluated in a patient subgroup with type 2 diabetes mellitus (T2DM) and who were receiving maximally tolerated statins with or without other lipid-lowering therapies. METHODS Participants received either alirocumab 300 mg Q4W (n = 458, including 96 with T2DM) or placebo (n = 230, including 50 with T2DM) for 48 weeks, with alirocumab dose adjustment to 150 mg every 2 weeks at Week (W) 12 if W8 low-density lipoprotein cholesterol (LDL-C) levels were ≥70 mg/dL or ≥ 100 mg/dL, depending on cardiovascular risk, or if LDL-C reduction was <30% from baseline. Efficacy end points included percentage change from baseline to W24 for lipids, and time-averaged LDL-C over W21 to W24. RESULTS In individuals with T2DM, LDL-C reductions from baseline to W24 and the average of W21 to W24 were significantly greater with alirocumab (-61.6% and -68.8%, respectively) vs placebo. At W24, alirocumab significantly reduced levels of non-high-density lipoprotein cholesterol (HDL-C) and other lipids. At W24, 85.9% and 12.5% of individuals in the alirocumab and placebo groups, respectively, reached both non-HDL-C <100 mg/dL and LDL-C <70 mg/dL. At W12, In total, 18% of alirocumab-treated participants received dose adjustment. The most common treatment-emergent adverse events were upper respiratory tract infection and injection-site reaction. No clinically significant changes in fasting plasma glucose and glycated hemoglobin were observed. CONCLUSION In individuals with T2DM, alirocumab 300 mg Q4W was generally well tolerated and efficacious in reducing atherogenic lipoproteins.
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Affiliation(s)
- Dirk Müller-Wieland
- Department of Medicine I, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Daniel J Rader
- Department of Medicine and Genetics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennysylvania
| | - Patrick M Moriarty
- Department of Internal Medicine, Division of Clinical Pharmacology, University of Kansas Medical Center, Kansas City, Kansas
| | - Jean Bergeron
- Clinique des Maladies Lipidiques, Department of Medicine, Centre Hospitalier Universitaire de Québec – Université Laval, Québec, Canada
| | | | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Imperial College London, London, United Kingdom
| | | | | | | | - Eli M Roth
- The Sterling Research Group and University of Cincinnati, Cincinnati, Ohio
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Steffens D, Bramlage P, Scheeff C, Kasner M, Hassanein A, Friebel J, Rauch-Kröhnert U. PCSK9 inhibitors and cardiovascular outcomes. Expert Opin Biol Ther 2019; 20:35-47. [PMID: 31593483 DOI: 10.1080/14712598.2020.1677604] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Dyslipidemia, particularly elevated low-density lipoprotein cholesterol (LDL-C), is a key risk factor for atherosclerotic cardiovascular disease (ASCVD), and lipid-lowering drugs are beneficial for the primary and secondary prevention of cardiovascular (CV) disease. While statins are clear first-line drugs, new drug developments such as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been shown to improve cardiovascular outcomes when added to statins. Evolocumab reduced the risk of cardiovascular events in patients with ASCVD when added to maximally tolerated statin therapy (± ezetimibe), and recent data from the ODYSSEY OUTCOMES trial indicate that alirocumab added to maximally tolerated statin therapy (± other lipid-lowering drugs) reduces the risk of cardiovascular events in patients with a recent acute coronary syndrome. In this article the authors review the available data on the effect of PCSK9 inhibitors on cardiovascular outcomes.Areas covered: This article reviews the available data on the effect of PCSK9 inhibitors on CV outcomes. Relevant papers were identified from a search of PubMed/Medline and the Cochrane Central Register of Controlled Trials (CENTRAL).Expert opinion: The authors conclude that PCSK9 inhibitors provide substantial and durable reductions in LDL-C levels and improve cardiovascular outcomes.
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Affiliation(s)
- Daniel Steffens
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Céline Scheeff
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Mario Kasner
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Adel Hassanein
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Julian Friebel
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Ursula Rauch-Kröhnert
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
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Parhofer KG, von Stritzky B, Pietschmann N, Dorn C, Paar WD. PEARL: A Non-interventional Study of Real-World Alirocumab Use in German Clinical Practice. Drugs Real World Outcomes 2019; 6:115-123. [PMID: 31280466 PMCID: PMC6702526 DOI: 10.1007/s40801-019-0158-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Several lipid guidelines recommend that proprotein convertase subtilisin/kexin type 9 inhibitors should be considered for patients with atherosclerotic cardiovascular disease who are inadequately treated with maximally tolerated lipid-lowering treatment. OBJECTIVES The PEARL study assessed the efficacy and safety of the proprotein convertase subtilisin/kexin type 9 inhibitor alirocumab in patients with hypercholesterolemia in a real-world setting. METHODS PEARL was an open, prospective, multicenter, non-interventional study conducted in Germany. Patients (n = 619) for whom treating physicians decided to use alirocumab 75 or 150 mg every 2 weeks according to German guidelines (low-density lipoprotein cholesterol > 1.8/2.6 mmol/L [> 70/100 mg/dL], depending on cardiovascular risk, despite maximally tolerated statin therapy with/without other non-alirocumab lipid-lowering therapy) were enrolled and followed for 24 weeks. Physicians could adjust the alirocumab dose based on their clinical judgment. The primary efficacy endpoint was low-density lipoprotein cholesterol reduction from baseline (prior to alirocumab therapy) to week 24. RESULTS Overall, 72.8% of patients reported complete or partial statin intolerance. Mean low-density lipoprotein cholesterol was 4.7 mmol/L (180.5 mg/dL) and 2.3 mmol/L (89.8 mg/dL) at baseline and week 24, respectively. Least-squares mean percentage change from baseline to week 24 in low-density lipoprotein cholesterol was - 48.6%. Initial alirocumab dose was 75 mg in 72.9% of patients and 150 mg in 24.5% of patients; 19.6% of patients received an alirocumab dose increase (75 to 150 mg) and 1.6% of patients received a dose decrease. Adverse events were reported in 10.3% of patients, with myalgia being the most common. CONCLUSIONS In a real-world setting in Germany, alirocumab was used in patients who had high baseline low-density lipoprotein cholesterol levels with/without statin intolerance. Efficacy and safety were consistent with findings observed in the ODYSSEY Phase III program.
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Affiliation(s)
- Klaus G Parhofer
- Medical Department IV-Grosshadern, University of Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | | | | | - Cornelia Dorn
- Medical Department, Sanofi-Aventis Deutschland GmbH, Berlin, Germany
| | - W Dieter Paar
- Medical Department, Sanofi-Aventis Deutschland GmbH, Berlin, Germany
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Hawiger J, Zienkiewicz J. Decoding inflammation, its causes, genomic responses, and emerging countermeasures. Scand J Immunol 2019; 90:e12812. [PMID: 31378956 PMCID: PMC6883124 DOI: 10.1111/sji.12812] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/03/2019] [Accepted: 07/29/2019] [Indexed: 12/11/2022]
Abstract
Inflammation is the mechanism of diseases caused by microbial, autoimmune, allergic, metabolic and physical insults that produce distinct types of inflammatory responses. This aetiologic view of inflammation informs its classification based on a cause‐dependent mechanism as well as a cause‐directed therapy and prevention. The genomic era ushered in a new understanding of inflammation by highlighting the cell's nucleus as the centre of the inflammatory response. Exogenous or endogenous inflammatory insults evoke genomic responses in immune and non‐immune cells. These genomic responses depend on transcription factors, which switch on and off a myriad of inflammatory genes through their regulatory networks. We discuss the transcriptional paradigm of inflammation based on denying transcription factors’ access to the nucleus. We present two approaches that control proinflammatory signalling to the nucleus. The first approach constitutes a novel intracellular protein therapy with bioengineered physiologic suppressors of cytokine signalling. The second approach entails control of proinflammatory transcriptional cascades by targeting nuclear transport with a cell‐penetrating peptide that inhibits the expression of 23 out of the 26 mediators of inflammation along with the nine genes required for metabolic responses. We compare these emerging anti‐inflammatory countermeasures to current therapies. The transcriptional paradigm of inflammation offers nucleocentric strategies for microbial, autoimmune, metabolic, physical and other types of inflammation afflicting millions of people worldwide.
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Affiliation(s)
- Jacek Hawiger
- Immunotherapy Program at Vanderbilt University School of Medicine, Nashville, TN, USA.,Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.,Department of Veterans Affairs, Tennessee Valley Health Care System, Nashville, TN, USA.,Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jozef Zienkiewicz
- Immunotherapy Program at Vanderbilt University School of Medicine, Nashville, TN, USA.,Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.,Department of Veterans Affairs, Tennessee Valley Health Care System, Nashville, TN, USA
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Ako J, Hibi K, Tsujita K, Hiro T, Morino Y, Kozuma K, Shinke T, Otake H, Uno K, Louie MJ, Takagi Y, Miyauchi K. Effect of Alirocumab on Coronary Atheroma Volume in Japanese Patients With Acute Coronary Syndrome - The ODYSSEY J-IVUS Trial. Circ J 2019; 83:2025-2033. [PMID: 31434809 DOI: 10.1253/circj.cj-19-0412] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND In patients with acute coronary syndrome (ACS), alirocumab reduced the risk of recurring ischemic events. ODYSSEY J-IVUS assessed the effect of alirocumab on coronary atheroma volume in Japanese patients recently hospitalized with ACS and hypercholesterolemia, using intravascular ultrasound imaging analysis.Methods and Results:Patients (n=206) who at index ACS diagnosis either had low-density lipoprotein cholesterol (LDL-C) ≥2.59 mmol/L (≥100 mg/dL) despite stable statin therapy, or were not on statins with LDL-C levels above target after statin initiation, were randomized (1:1) to alirocumab (75 mg every 2 weeks [Q2 W]/up to 150 mg Q2 W), or standard of care (SoC; atorvastatin ≥10 mg/day or rosuvastatin ≥5 mg/day) for 36 weeks. The primary efficacy endpoint (week [W] 36 mean [standard error] percent change in normalized total atheroma volume [TAV] from baseline) was -3.1 (1.0)% with SoC vs. -4.8 (1.0)% with alirocumab (between-group difference: -1.6 [1.4]; P=0.23). W36 absolute change from baseline in percent atheroma volume was -1.3 (0.4)% (SoC) and -1.4 (0.4)% (alirocumab; nominal P=0.79). At W36, LDL-C was reduced from baseline by 13.4% (SoC) vs. 63.9% (alirocumab; nominal P<0.0001). In total, 61.8% (SoC) and 75.7% (alirocumab) of patients reported treatment-emergency adverse events. CONCLUSIONS In Japanese patients with ACS and hypercholesterolemia inadequately controlled despite statin therapy, from baseline to W36, a numerically greater percent reduction in normalized TAV was observed with alirocumab vs. SoC, which did not reach statistical significance.
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Affiliation(s)
- Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Kiyoshi Hibi
- Division of Cardiology, Yokohama City University Medical Center
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Takafumi Hiro
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Ken Kozuma
- Division of Cardiology, Teikyo University Hospital
| | - Toshiro Shinke
- Division of Cardiovascular Medicine, Department of Internal Medicine, Showa University School of Medicine
| | - Hiromasa Otake
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | | | | | | | - Katsumi Miyauchi
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
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Bruckert E, Kereiakes DJ, Koren MJ, Louie MJ, Letierce A, Miller K, Cannon CP. PCSK9 inhibition in patients with and without prior myocardial infarction or ischemic stroke: A pooled analysis of nine randomized-controlled studies of alirocumab. J Clin Lipidol 2019; 13:443-454. [PMID: 31076261 DOI: 10.1016/j.jacl.2019.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 03/01/2019] [Accepted: 04/02/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Patients with prior cardiovascular events are at very high risk of recurrent events and may benefit from low-density lipoprotein cholesterol (LDL-C) lowering beyond that achieved with maximally tolerated statins. OBJECTIVE To assess potential differences between the efficacy and safety of the proprotein convertase subtilisin/kexin type 9 inhibitor, alirocumab, in patients with vs without prior myocardial infarction (MI)/ischemic stroke. METHODS Data (n = 4880) were pooled from nine ODYSSEY phase 3 trials of alirocumab 75/150 mg or 150 mg every 2 weeks, mostly on background statins ± other lipid-lowering therapies. Analyses were performed according to statin status, alirocumab dose, and control (placebo or ezetimibe). RESULTS Baseline LDL-C, non-high-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and apolipoprotein B levels were lower and lipoprotein(a) higher in patients with than without prior MI/ischemic stroke. LDL-C levels were reduced from baseline to week 24 in patients with (51.1%-62.9%) and without (43.6%-58.3%) prior MI/ischemic stroke, with no significant interaction between prior MI/ischemic stroke status and LDL-C-lowering efficacy of alirocumab vs controls. Alirocumab significantly reduced other lipid/lipoproteins (including lipoprotein[a]) similarly in patients with/without MI/ischemic stroke. Week 24 LDL-C goal attainment rates for subgroups with/without prior MI/ischemic stroke on background statins were 74.1%-84.8% and 63.7%-74.7%, respectively. The safety profile of alirocumab was generally similar regardless of prior MI/ischemic stroke status. CONCLUSIONS Alirocumab significantly reduced LDL-C and other atherogenic lipids/lipoproteins in patients with prior MI/ischemic stroke, and the majority of this very high cardiovascular risk population achieved LDL-C goals; efficacy and safety results were similar in patients without prior MI/ischemic stroke.
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Affiliation(s)
- Eric Bruckert
- Groupe Hospitalier Pitié-Salpêtrière, Service d'Endocrinologie, Métabolisme et Prévention des Maladies Cardiovasculaires, Paris, France.
| | - Dean J Kereiakes
- The Christ Hospital, Heart and Vascular Center/The Lindner Research Center, Cincinnati, Ohio, USA
| | - Michael J Koren
- Jacksonville Center for Clinical Research, Jacksonville, FL, USA
| | | | - Alexia Letierce
- Biostatistics and Programming, Sanofi, Chilly-Mazarin, France
| | - Kathryn Miller
- Biostatistics and Data Management, Regeneron Pharmaceuticals, Inc, Tarrytown, NY, USA
| | - Christopher P Cannon
- Harvard Clinical Research Institute, Preventive Cardiology Section, Boston, MA, USA
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Casula M, Olmastroni E, Boccalari MT, Tragni E, Pirillo A, Catapano AL. Cardiovascular events with PCSK9 inhibitors: an updated meta-analysis of randomised controlled trials. Pharmacol Res 2019; 143:143-150. [PMID: 30926528 DOI: 10.1016/j.phrs.2019.03.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 02/15/2019] [Accepted: 03/25/2019] [Indexed: 12/15/2022]
Abstract
The therapy with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors efficiently reduces plasma cholesterol levels, which has been recently associated with improvement in cardiovascular outcomes. This meta-analysis aimed at investigating the safety and efficacy of treatment with the clinically available anti-PCSK9 monoclonal antibodies (mAbs) in all published randomized clinical trials (RCTs), updating the available results with the recently published ODYSSEY OUTCOMES trial. Data search was carried out using PubMed/MEDLINE and EMBASE (inception - January 2019). Inclusion criteria were: (1) phase 2 or 3 RCTs; (2) comparing anti-PCSK9 mAbs (specifically evolocumab and alirocumab) with placebo; (3) with effects on outcomes reported; (4) with treatment duration longer than 8 weeks. Odds ratios (ORs) with 95% CIs were used as summary statistics. We pooled the estimates by using both the DerSimonian & Laird method (random-effects model). Between-study heterogeneity was tested by Cochrane's Q test and measured with the I2 statistics. Twenty-eight RCTs comprising 62,281 participants (33,204 in the mAb arm, 29,077 in the placebo arm) were included in the meta-analysis. The treatment follow-up ranged from 8 weeks up to 208 weeks. Overall, no significant difference in all-cause mortality was observed between the two groups (OR 0.93 [95% CI, 0.85-1.03]). The treatment with an anti-PCSK9 mAb was associated with a significant reduction of CV events compared with placebo (OR 0.83 [95% CI, 0.78-0.87]), being the FOURIER and ODYSSEY OUTCOMES studies the major contributors. Both myocardial infarction and stroke were significantly reduced following the treatment with an anti-PCSK9 mAb. No significant difference was observed in cardiovascular mortality (OR 0.94 [95% CI, 0.83-1.07]). The incidence of serious adverse events was similar in the two groups (OR: 0.95, [95% CI, 0.91-0.99]). Thus, the pharmacological approach with anti-PCSK9 mAbs significantly and safely improves cardiovascular outcomes. Despite that, the pooled analysis failed to show a significant cardiovascular mortality benefit with anti-PCSK9 mAb treatment, suggesting that specific longer-term studies are warranted to address this issue. We suggest that the observed delay between the rapid effect on plasma cholesterol levels and the emergence of the clinical benefit, observed both in FOURIER and ODYSSEY OUTCOMES trials, might explain this finding.
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Affiliation(s)
- Manuela Casula
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; Epidemiology and Preventive Pharmacology Centre (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Elena Olmastroni
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; Epidemiology and Preventive Pharmacology Centre (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Mezio T Boccalari
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; Epidemiology and Preventive Pharmacology Centre (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Elena Tragni
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; Epidemiology and Preventive Pharmacology Centre (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Angela Pirillo
- Center for the Study of Atherosclerosis, E. Bassini Hospital, Cinisello Balsamo, Milan, Italy; IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy
| | - Alberico L Catapano
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy.
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Nishikido T, Ray KK. Non-antibody Approaches to Proprotein Convertase Subtilisin Kexin 9 Inhibition: siRNA, Antisense Oligonucleotides, Adnectins, Vaccination, and New Attempts at Small-Molecule Inhibitors Based on New Discoveries. Front Cardiovasc Med 2019; 5:199. [PMID: 30761308 PMCID: PMC6361748 DOI: 10.3389/fcvm.2018.00199] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 12/28/2018] [Indexed: 12/17/2022] Open
Abstract
Low-density lipoprotein (LDL) is one of the principal risk factors for atherosclerosis. Circulating LDL particles can penetrate into the sub-endothelial space of arterial walls. These particles undergo oxidation and promote an inflammatory response, resulting in injury to the vascular endothelial wall. Persistent elevation of LDL-cholesterol (LDL-C) is linked to the progression of fatty streaks to lipid-rich plaque and thus atherosclerosis. LDL-C is a causal factor for atherosclerotic cardiovascular disease and lowering it is beneficial across a range of conditions associated with high risk of cardiovascular events. Therefore, all guidelines-recommended initiations of statin therapy for patients at high cardiovascular risk is irrespective of LDL-C. In addition, intensive LDL-C lowering therapy with statins has been demonstrated to result in a greater reduction of cardiovascular event risk in large clinical trials. However, many high-risk patients receiving statins fail to achieve the guideline-recommended reduction in LDL-C levels in routine clinical practice. Moreover, low levels of adherence and often high rates of discontinuation demand the need for further therapies. Ezetimibe has typically been used as a complement to statins when further LDL-C reduction is required. More recently, proprotein convertase subtilisin kexin 9 (PCSK9) has emerged as a novel therapeutic target for lowering LDL-C levels, with PCSK9 inhibitors offering greater reductions than feasible through the addition of ezetimibe. PCSK9 monoclonal antibodies have been shown to not only considerably lower LDL-C levels but also cardiovascular events. However, PCSK9 monoclonal antibodies require once- or twice-monthly subcutaneous injections. Further, their manufacturing process is expensive, increasing the cost of therapy. Therefore, several non-antibody treatments to inhibit PCSK9 function are being developed as alternative approaches to monoclonal antibodies. These include gene-silencing or editing technologies, such as antisense oligonucleotides, small interfering RNA, and the clustered regularly interspaced short palindromic repeats/Cas9 platform; small-molecule inhibitors; mimetic peptides; adnectins; and vaccination. In this review, we summarize the current knowledge base on the role of PCSK9 in lipid metabolism and an overview of non-antibody approaches for PCSK9 inhibition and their limitations. The subsequent development of alternative approaches to PCSK9 inhibition may give us more affordable and convenient therapeutic options for the management of high-risk patients.
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Affiliation(s)
- Toshiyuki Nishikido
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom.,Department of Cardiovascular medicine, Saga University, Saga, Japan
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
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Bays HE, Rosenson RS, Baccara-Dinet MT, Louie MJ, Thompson D, Hovingh GK. Assessment of the 1% of Patients with Consistent < 15% Reduction in Low-Density Lipoprotein Cholesterol: Pooled Analysis of 10 Phase 3 ODYSSEY Alirocumab Trials. Cardiovasc Drugs Ther 2019; 32:175-180. [PMID: 29627892 PMCID: PMC5958153 DOI: 10.1007/s10557-018-6784-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
PURPOSE Clinical trials of statins and other lipid-lowering therapies (LLTs) often report large inter-individual variations in their effects on low-density lipoprotein cholesterol (LDL-C). We evaluated apparent hyporesponsiveness to the proprotein convertase subtilisin/kexin type 9 inhibitor alirocumab (defined as < 15% LDL-C reduction from baseline at all timepoints) using data from 10 Phase 3 trials (3120 hypercholesterolemic patients). METHODS This report assessed the LDL-C percent reduction from baseline at weeks 4-104 (depending on study), and alirocumab serum levels and antidrug antibodies, in patients with apparent hyporesponsiveness. RESULTS Among the 3120 patients evaluated, 98.9% responded to alirocumab, and 33 (1.1%) had < 15% LDL C reduction at all measured timepoints. Pharmacokinetics data indicated that 13/33 apparent hyporesponders had not received alirocumab; no pharmacokinetics data were available for 14/33, and 6/33 had detectable alirocumab. For the six patients with confirmed alirocumab receipt, the degree of adherence to pre-study concurrent LLTs could not be determined after study start; one of these patients had persistent antidrug antibodies. CONCLUSIONS Apparent hyporesponsiveness to alirocumab appeared to be due to lack of receipt of alirocumab determined by serum alirocumab levels, possible lack of adherence to concurrent LLTs, a theoretical and rare possibility of biological non-responsiveness due to persistent antidrug antibodies, or other causes, as yet unidentified.
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Affiliation(s)
- Harold E Bays
- Departments of Epidemiology & Medicine, Louisville Metabolic and Atherosclerosis Research Center (L-MARC), 3288 Illinois Avenue, Louisville, KY, 40213, USA.
| | - Robert S Rosenson
- Cardiometabolics Unit, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - G Kees Hovingh
- Department of Vascular Medicine - Internal Medicine Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Leiter LA, Tinahones FJ, Karalis DG, Bujas-Bobanovic M, Letierce A, Mandel J, Samuel R, Jones PH. Alirocumab safety in people with and without diabetes mellitus: pooled data from 14 ODYSSEY trials. Diabet Med 2018; 35:1742-1751. [PMID: 30183102 PMCID: PMC6585811 DOI: 10.1111/dme.13817] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2018] [Indexed: 02/06/2023]
Abstract
AIM To evaluate the safety of the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor alirocumab according to diabetes mellitus status. METHODS Safety data from 14 trials (8-104-week durations) were analysed by treatment (alirocumab or placebo/ezetimibe control) and diabetes status (yes/no, defined by medical history). Adverse event data were assessed using descriptive statistics and Cox models. RESULTS Of the 5234 trial participants, 1554 (29.7%) had diabetes. Overall, treatment-emergent adverse events were similar in the alirocumab and control groups, except for more frequent local injection site reactions with alirocumab. Fewer people with diabetes experienced local injection site reactions [alirocumab, 3.5%, control, 2.9%; hazard ratio 1.24 (95% CI 0.68-2.25)] than those without diabetes [alirocumab, 7.5%; control, 4.9%; hazard ratio 1.51 (95% CI 1.13-2.01)]. Those with diabetes reported a greater number of serious adverse events (alirocumab, 19.4%; control, 19.7%) than those without diabetes (alirocumab, 14.5%; control, 13.5%). In people with diabetes, major adverse cardiac events occurred in 2.7% of alirocumab-treated people [control, 3.3%; hazard ratio 0.74 (95% CI 0.41-1.35)]; in those without diabetes, 1.8% of alirocumab-treated people had major adverse cardiac events [control, 1.7%; hazard ratio 0.95 (95% CI 0.56-1.62)]. Overall, no increase in HbA1c or fasting plasma glucose vs control treatment groups was observed, regardless of diabetes status. CONCLUSION This pooled analysis across 14 trials demonstrated similar safety for alirocumab vs control treatment, irrespective of diabetes status, except for more frequent local injection site reactions with alirocumab. People with diabetes reported fewer local injection site reactions than those without diabetes.
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Affiliation(s)
- L A Leiter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - F J Tinahones
- Department of Clinical Endocrinology and Nutrition (IBIMA), Hospital Virgen de la Victoria, University of Málaga, CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Málaga, Spain
| | - D G Karalis
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - A Letierce
- Biostatistics and Programming Department, Sanofi, Chilly-Mazarin, France
| | - J Mandel
- IviData Stats, Levallois Perret, France
- Sanofi, Chilly-Mazarin, France
| | - R Samuel
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| | - P H Jones
- Baylor College of Medicine, Houston, TX, USA
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Wargny M, Ducluzeau PH, Petit JM, Le May C, Smati S, Arnaud L, Pichelin M, Bouillet B, Lannes A, Blanchet O, Lefebvre P, Francque S, Van Gaal L, Staels B, Vergès B, Boursier J, Cariou B. Circulating PCSK9 levels are not associated with the severity of hepatic steatosis and NASH in a high-risk population. Atherosclerosis 2018; 278:82-90. [DOI: 10.1016/j.atherosclerosis.2018.09.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/30/2018] [Accepted: 09/12/2018] [Indexed: 12/24/2022]
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48
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Long-term safety and efficacy of alirocumab in patients with heterozygous familial hypercholesterolemia: An open-label extension of the ODYSSEY program. Atherosclerosis 2018; 278:307-314. [DOI: 10.1016/j.atherosclerosis.2018.08.036] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 08/15/2018] [Accepted: 08/28/2018] [Indexed: 01/22/2023]
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49
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Ganda OP, Plutzky J, Sanganalmath SK, Bujas‐Bobanovic M, Koren A, Mandel J, Letierce A, Leiter LA. Efficacy and safety of alirocumab among individuals with diabetes mellitus and atherosclerotic cardiovascular disease in the ODYSSEY phase 3 trials. Diabetes Obes Metab 2018; 20:2389-2398. [PMID: 29802688 PMCID: PMC6175384 DOI: 10.1111/dom.13384] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 05/14/2018] [Accepted: 05/23/2018] [Indexed: 12/22/2022]
Abstract
AIMS Individuals with both diabetes mellitus (DM) and atherosclerotic cardiovascular disease (ASCVD) are at very high risk of cardiovascular events. This post-hoc analysis evaluated efficacy and safety of the PCSK9 inhibitor alirocumab among 984 individuals with DM and ASCVD pooled from 9 ODYSSEY Phase 3 trials. MATERIALS AND METHODS Changes in low-density lipoprotein cholesterol (LDL-C) and other lipids from baseline to Week 24 were analysed (intention-to-treat) in four pools by alirocumab dosage (150 mg every 2 weeks [150] or 75 mg with possible increase to 150 mg every 2 weeks [75/150]), control (placebo/ezetimibe) and background statin usage (yes/no). RESULTS At Week 24, LDL-C changes from baseline in pools with background statins were -61.5% with alirocumab 150 (vs -1.0% with placebo), -46.4% with alirocumab 75/150 (vs +6.3% with placebo) and -48.7% with alirocumab 75/150 (vs -20.6% with ezetimibe), and -54.9% with alirocumab 75/150 (vs +4.0% with ezetimibe) without background statins. A greater proportion of alirocumab recipients achieved LDL-C < 70 and < 55 mg/dL at Week 24 vs controls. Alirocumab also resulted in significant reductions in non-high-density lipoprotein cholesterol, apolipoprotein B and lipoprotein(a) vs controls. Alirocumab did not appear to affect glycaemia over 78-104 weeks. Overall safety was similar between treatment groups, with a higher injection-site reaction frequency (mostly mild) with alirocumab. CONCLUSION Alirocumab significantly reduced LDL-C and other atherogenic lipid parameters, and was generally well tolerated in individuals with DM and ASCVD.
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Affiliation(s)
- Om P. Ganda
- Clinical Research and Adult Diabetes Sections, Joslin Diabetes Center, Harvard Medical SchoolBostonMassachusetts
| | - Jorge Plutzky
- Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical SchoolBostonMassachusetts
| | | | | | | | - Jonas Mandel
- Biostatistics and Programming, SanofiChilly‐MazarinFrance
- IviData StatsLevallois‐PerretFrance
| | | | - Lawrence A. Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of TorontoToronto, OntarioCanada
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Gürgöze MT, Muller-Hansma AHG, Schreuder MM, Galema-Boers AMH, Boersma E, Roeters van Lennep JE. Adverse Events Associated With PCSK9 Inhibitors: A Real-World Experience. Clin Pharmacol Ther 2018; 105:496-504. [PMID: 30053327 PMCID: PMC6704355 DOI: 10.1002/cpt.1193] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 07/19/2018] [Indexed: 01/02/2023]
Abstract
In randomized clinical trials (RCTs) proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors showed a favorable safety profile, however, “real‐world” data on adverse events (AEs) is scarce. Three datasets, a hospital registry (n = 164), and two Pharmacovigilance databases, Lareb (n = 149) and VigiLyze (n = 15,554), reporting AEs attributed to PCSK9 inhibitors (alirocumab or evolocumab) prescribed in clinical practice were analyzed. In the hospital registry, 41.5% of the patients reported any AE, most often injection‐site reactions (33.8%) and influenza‐like illness (27.9%). Twelve patients (7%) discontinued PCSK9 inhibitor treatment. Most common AE reported in the Lareb and VigiLyze database was myalgia (12.8% and 8.3%, respectively). No clinically relevant differences in gender or between drugs were observed. No specific subgroup of patients could be identified at risk of developing AEs. During follow‐up, AEs resolved in most patients (71.1%). In a real‐world setting, PCSK9 inhibitors are well tolerated with an overall safety profile comparable to RCTs.
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Affiliation(s)
- Muhammed T Gürgöze
- Erasmus MC, University Medical Centre Rotterdam, Department of Cardiology, Rotterdam, The Netherlands
| | | | - Michelle M Schreuder
- Erasmus MC, University Medical Centre Rotterdam, Department of Internal Medicine, Rotterdam, The Netherlands
| | - Annette M H Galema-Boers
- Erasmus MC, University Medical Centre Rotterdam, Department of Internal Medicine, Rotterdam, The Netherlands
| | - Eric Boersma
- Erasmus MC, University Medical Centre Rotterdam, Department of Cardiology, Rotterdam, The Netherlands
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