Cutaneous manifestations in familial hypercholesterolaemia

Physical signs and atherosclerotic cardiovascular disease in familial hypercholesterolemia: the HELLAS-FH Registry

AIMS

Three physical signs, namely tendon xanthomas, corneal arcus and xanthelasma, have been associated with heterozygous familial hypercholesterolemia (heFH). The prevalence and clinical significance of these signs are not well established among contemporary heFH individuals. This study explored the frequency as well as the association of these physical signs with prevalent atherosclerotic cardiovascular disease (ASCVD) in heFH individuals.

METHODS

Data from the Hellenic Familial Hypercholesterolemia Registry were applied for this analysis. The diagnosis of heFH was based on the Dutch Lipid Clinic Network Score. Multivariate logistic regression analysis was conducted to examine the association of heFH-related physical signs with prevalent ASCVD.

RESULTS

Adult patients ( n  = 2156, mean age 50 ± 15 years, 47.7% women) were included in this analysis. Among them, 14.5% had at least one heFH-related physical sign present. The prevalence of corneal arcus before the age of 45 years was 6.6%, tendon xanthomas 5.3%, and xanthelasmas 5.8%. Among physical signs, only the presence of corneal arcus before the age of 45 years was independently associated with the presence of premature coronary artery disease (CAD). No association of any physical sign with total CAD, stroke or peripheral artery disease was found. Patients with physical signs were more likely to receive higher intensity statin therapy and dual lipid-lowering therapy, but only a minority reached optimal lipid targets.

CONCLUSION

The prevalence of physical signs is relatively low in contemporary heFH patients. The presence of corneal arcus before the age of 45 years is independently associated with premature CAD.

[Laboratory diagnostics of lipid metabolism disorders]

Clinically, disorders of lipid metabolism often remain without symptoms. Typical skin lesions, however, can be indicative. Secondary hyperlipoproteinemias (HLP) are more common than primary hyperlipoproteinemias; they can (partially) be improved by treating the underlying disease. Basic diagnostics consist of the determination of cholesterol, triglycerides, LDL cholesterol and HDL cholesterol. To exclude secondary HLP, glucose, HbA1C, TSH, transaminases, creatinine, urea, protein and protein in the urine are useful. Since virtually all routine methods for LDL-C are biased by high triglycerides, lipoprotein electrophoresis is indicated for triglycerides above 400 mg/dl (4.7 mmol/l). Primary HLPs have known or yet unknown genetic causes. Primary hyperlipidemias should be taken into consideration especially in young patients with an LDL cholesterol concentration are above 190 mg/dl (4.9 mmol/l) and/or triglycerides above 400 mg/dl (10 mmol/l) and secondary HLP (obesity, alcohol, diabetes mellitus, kidney disease) is excluded. The basic diagnostics is meaningfully extended by the measurement of lipoprotein (a) (Lp(a)). It is indicated in moderate and high risk of vascular disease, progression of atherosclerosis in "well-controlled" LDL cholesterol, familial clustering of atherosclerosis or high Lp(a), evidence for elevated Lp(a) coming from lipoprotein electrophoresis, aortic stenosis and in patients in whom statins have a poor effect. Genetic diagnostics needs to be considered if primary HLP is suspected. It is most frequently conducted for suspected familial hypercholesterolemia and has already been recommended in guidelines.

Painful and recurring injection site reaction to alirocumab and evolocumab in a young woman with familial hypercholesterolemia and effective therapeutic alternative based on inclisiran: a case report

A 28-year-old woman with autosomal dominant familial hypercholesterolemia (FH) with a probable coexistent polygenic contribution causing very high low-density lipoprotein-cholesterol (LDL-C) levels, started therapy with the proprotein convertase subtilisin/kexin type 9-inhibitor (PCSK9i) alirocumab, in addition to high-intensity statin plus ezetimibe. Forty-eight hours after the second injection of alirocumab, the patient developed a painful palpable injection site reaction (ISR) that recurred after the third administration of the drug. Treatment was then switched to evolocumab, another PCSK9i, but the patient had an ISR with similar features. The most conceivable cause of the ISR was a cell-mediated hypersensitivity reaction to polysorbate, an excipient contained in both drugs. Although ISR after PCSK9i administration is usually transient and does not compromise the continuation of treatment, in this case the recurrence of such side effect in an exacerbated way led to treatment withdrawal, with a subsequent re-exposure to increased cardiovascular (CV) risk. As soon as it became available in clinical practice, the patient started treatment with inclisiran, a small interfering RNA targeting hepatic PCSK9 synthesis. No adverse events were reported after inclisiran administration and LDL-C levels decreased significantly, confirming the evidence that this innovative approach to hypercholesterolemia is a safe and effective resource in patients at high CV risk who cannot achieve LDL-C goal with conventional lipid-lowering therapies and antibody-based PCSK9i.

Hypercholesterolemia Diagnosis, Treatment Patterns, and 12-Month Target Achievement in Clinical Practice in Germany in Patients with Familial Hypercholesterolemia

Background: Familial hypercholesterolemia (FH) is a highly prevalent disorder and a risk factor for early coronary artery disease. The objective of this registry was to document the clinical characteristics of patients with definite FH in Germany and to document lipid profiles, lipid-lowering therapy, and lipid target achievement during longitudinal follow-up. Methods: HYDRA-FH was a national, prospective, multicenter, non-interventional registry conducted in 35 centers in Germany. Consecutive adult patients with definite FH were included (n = 241). Results: In the cross-sectional analysis (n = 233), lipid-lowering therapy involved statins (82.0%), ezetimibe (31.8%), and PCSK9 antibodies (18.5%); 11.2% of patients were receiving no lipid-lowering drugs. Median lipid levels were: low-density lipoprotein cholesterol (LDL-C) 134 mg/dL (3.5 mmol/L), high-density lipoprotein cholesterol (HDL-C) 48 mg/dL (1.2 mmol/L), triglycerides 160 mg/dL (1.9 mmol/L), total cholesterol 211 mg/dL (5.5 mmol/L). Values were above the normal threshold (150 mg/dL) for LDL-C in 72.9%, total cholesterol in 29.7%, and triglycerides in 45.0% of patients. After the 12-month follow-up (n = 145), only 17.2% had LDL-C < 70 mg/dL, and 20.7% had either LDL-C < 70 mg/dL or a reduction of ≥50% versus baseline. Conclusion: This study provides insight into the clinical characteristics and current treatment status of patients with FH in Germany. Many patients with FH do not achieve recommended lipid levels.