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Klevmoen M, Mulder JWCM, Roeters van Lennep JE, Holven KB. Sex Differences in Familial Hypercholesterolemia. Curr Atheroscler Rep 2023; 25:861-868. [PMID: 37815650 PMCID: PMC10618303 DOI: 10.1007/s11883-023-01155-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 10/11/2023]
Abstract
PURPOSE OF REVIEW This review aims to summarize the existing research on sex differences in familial hypercholesterolemia (FH) across the lifespan. RECENT FINDINGS From childhood onward, total- and low-density lipoprotein cholesterol (LDL-C) levels in girls are higher than those in boys with FH. By the age of 30 years, women with FH have a higher LDL-C burden than men. In adulthood, women are diagnosed later than men, receive less lipid-lowering treatment, and consequently have higher LDL-C levels. An excessive atherosclerotic cardiovascular disease risk is reported in young female compared to male FH patients. The periods of pregnancy and breastfeeding contribute to treatment loss and increased cholesterol burden. Earlier initiation of treatment, especially in girls with FH, and lifelong treatment during all life stages are important. Future research should aim to recruit both women and men, report sex-specific data, and investigate the impact of the female life course on cardiovascular outcomes. Future guidelines should include sex-specific aspects.
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Affiliation(s)
- Marianne Klevmoen
- Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Norwegian National Advisory Unit on Familial Hypercholesterolemia, Oslo University Hospital, Oslo, Norway
| | - Janneke W C M Mulder
- Department of Internal Medicine, Cardiovascular Institute, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jeanine E Roeters van Lennep
- Department of Internal Medicine, Cardiovascular Institute, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Kirsten B Holven
- Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.
- Norwegian National Advisory Unit on Familial Hypercholesterolemia, Oslo University Hospital, Oslo, Norway.
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Cuchel M, Raal FJ, Hegele RA, Al-Rasadi K, Arca M, Averna M, Bruckert E, Freiberger T, Gaudet D, Harada-Shiba M, Hudgins LC, Kayikcioglu M, Masana L, Parhofer KG, Roeters van Lennep JE, Santos RD, Stroes ESG, Watts GF, Wiegman A, Stock JK, Tokgözoğlu LS, Catapano AL, Ray KK. 2023 Update on European Atherosclerosis Society Consensus Statement on Homozygous Familial Hypercholesterolaemia: new treatments and clinical guidance. Eur Heart J 2023:7148157. [PMID: 37130090 DOI: 10.1093/eurheartj/ehad197] [Citation(s) in RCA: 68] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 12/22/2022] [Accepted: 03/16/2023] [Indexed: 05/03/2023] Open
Abstract
This 2023 statement updates clinical guidance for homozygous familial hypercholesterolaemia (HoFH), explains the genetic complexity, and provides pragmatic recommendations to address inequities in HoFH care worldwide. Key strengths include updated criteria for the clinical diagnosis of HoFH and the recommendation to prioritize phenotypic features over genotype. Thus, a low-density lipoprotein cholesterol (LDL-C) >10 mmol/L (>400 mg/dL) is suggestive of HoFH and warrants further evaluation. The statement also provides state-of-the art discussion and guidance to clinicians for interpreting the results of genetic testing and for family planning and pregnancy. Therapeutic decisions are based on the LDL-C level. Combination LDL-C-lowering therapy-both pharmacologic intervention and lipoprotein apheresis (LA)-is foundational. Addition of novel, efficacious therapies (i.e. inhibitors of proprotein convertase subtilisin/kexin type 9, followed by evinacumab and/or lomitapide) offers potential to attain LDL-C goal or reduce the need for LA. To improve HoFH care around the world, the statement recommends the creation of national screening programmes, education to improve awareness, and management guidelines that account for the local realities of care, including access to specialist centres, treatments, and cost. This updated statement provides guidance that is crucial to early diagnosis, better care, and improved cardiovascular health for patients with HoFH worldwide.
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Affiliation(s)
- Marina Cuchel
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 9017 Maloney Building, 3600 Spruce Street, Philadelphia, PA 19104, USA
| | - Frederick J Raal
- Carbohydrate and Lipid Metabolism Research Unit, Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand Parktown, Johannesburg, South Africa
| | - Robert A Hegele
- Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Khalid Al-Rasadi
- Department of Biochemistry, College of Medicine & Health Sciences, Medical Research Center, Sultan Qaboos University, Muscat, Oman
| | - Marcello Arca
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Maurizio Averna
- Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialities, University of Palermo, Palermo, Italy
- Istituto di Biofisica, Consiglio Nazionale delle Ricerche, Genova, Italy
| | - Eric Bruckert
- Pitié-Salpêtrière Hospital and Sorbonne University, Cardio metabolic Institute, Paris, France
| | - Tomas Freiberger
- Centre for Cardiovascular Surgery and Transplantation, and Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Daniel Gaudet
- Clinical Lipidology and Rare Lipid Disorders Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal, ECOGENE, Clinical and Translational Research Center, and Lipid Clinic, Chicoutimi Hospital, Chicoutimi, Québec, Canada
| | - Mariko Harada-Shiba
- Cardiovascular Center, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Lisa C Hudgins
- Rogosin Institute, Weill Cornell Medical College, New York, NY, USA
| | - Meral Kayikcioglu
- Department of Cardiology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Luis Masana
- Vascular Medicine and Metabolism Unit, Research Unit on Lipids and Atherosclerosis, Sant Joan University Hospital, Universitat Rovira i Virgili, IISPV CIBERDEM, Reus, Spain
| | - Klaus G Parhofer
- Medizinische Klinik und Poliklinik IV, Ludwigs-Maximilians University Klinikum, Munich, Germany
| | | | - Raul D Santos
- Lipid Clinic, Heart Institute (InCor), University of São Paulo Medical School Hospital, São Paulo, Brazil
- Academic Research Organization Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Gerald F Watts
- Medical School, University of Western Australia, and Department of Cardiology, Lipid Disorders Clinic, Royal Perth Hospital, Perth, Australia
| | - Albert Wiegman
- Department of Pediatrics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Jane K Stock
- European Atherosclerosis Society, Gothenburg, Sweden
| | - Lale S Tokgözoğlu
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Alberico L Catapano
- IRCCS MultiMedica, and Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Milan, Italy
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
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Mulder JW, Kranenburg LW, Treling WJ, Hovingh GK, Rutten JH, Busschbach JJ, Roeters van Lennep JE. Quality of life and coping in Dutch homozygous familial hypercholesterolemia patients: A qualitative study. Atherosclerosis 2022; 348:75-81. [DOI: 10.1016/j.atherosclerosis.2022.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 03/05/2022] [Accepted: 03/10/2022] [Indexed: 11/02/2022]
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Alothman L, Bélanger AM, Ruel I, Brunham LR, Hales L, Genest J, Akioyamen LE. Health-related quality of life in homozygous familial hypercholesterolemia: A systematic review and meta-analysis. J Clin Lipidol 2021; 16:52-65. [PMID: 35027327 DOI: 10.1016/j.jacl.2021.11.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/04/2021] [Accepted: 11/30/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Homozygous familial hypercholesterolemia (HoFH) is a rare genetic disease characterized by extreme elevations of low-density lipoprotein cholesterol (LDL-C) and extremely premature atherosclerotic cardiovascular disease. To date, impacts of HoFH and its treatment on the psychosocial wellbeing of patients have been poorly characterized. OBJECTIVES We performed a systematic review of the association between HoFH and health-related quality of life (HRQL). METHODS This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) consensus guidelines. We searched MEDLINE, Embase, The Cochrane Controlled Register of Trials (CENTRAL), Pubmed, Scopus, AfricaWide (via EBSCO), and six trial registries and grey-literature databases from inception to May 2021 for published English-language literature examining HRQL and its determinants in HoFH. Studies were eligible if they included patients with confirmed HoFH and evaluated HRQL using validated tools. We performed a narrative synthesis of qualitative findings from included studies and, where data permitted, random-effects meta-analysis reporting standardized mean differences (SMD) and 95% confidence intervals (CIs). RESULTS Our review identified seven eligible studies examining HRQL in HoFH participants. Pooling data from two included studies, we found that relative to the general population, HoFH patients demonstrated significantly poorer HRQL in multiple dimensions of the 36-item Short-Form Health Survey (SF-36) with lower scores in physical functioning (SMD -0.37; 95% CI: -0.60, -0.15), role limitations due to physical health (SMD -0.63; 95% CI: -1.24, -0.02), social functioning (SMD -0.61; 95% CI: -1.19, -0.03), bodily pain (SMD -0.24; 95% CI: -0.46, -0.01), and general health (SMD -1.55; 95% CI: -1.80, -1.31). No differences were observed in domains of energy and vitality, mental health and emotional well-being, or role limitations due to emotional problems. Patients suffered high treatment burdens related to lipoprotein apheresis that compromised educational attainment and employment. However, few patients received psychological support in navigating their treatment challenges. No studies evaluated the association of HoFH with incident anxiety, depression, or other psychopathology. CONCLUSIONS Limited data are available on quality of life for patients with HoFH. The available data suggest that these patients may suffer disease-related impairments in quality of life. Future work should aim to elucidate relationships between HoFH and mental health outcomes and develop interventions to improve quality of life in this population.
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Affiliation(s)
- Latifah Alothman
- Research Institute of the McGill University Health Centre, Montreal QC H4A 3J1, Canada
| | - Alexandre M Bélanger
- Research Institute of the McGill University Health Centre, Montreal QC H4A 3J1, Canada
| | - Isabelle Ruel
- Research Institute of the McGill University Health Centre, Montreal QC H4A 3J1, Canada
| | - Liam R Brunham
- Department of Medicine, University of British Columbia, Vancouver, V5Z 1M9, Canada; Centre for Heart Lung Innovation, University of British Columbia, Vancouver, V6Z 1Y6, Canada
| | - Lindsay Hales
- McGill University Health Center Medical Libraries, Montreal QC, H3G 1A4, Canada
| | - Jacques Genest
- Research Institute of the McGill University Health Centre, Montreal QC H4A 3J1, Canada
| | - Leo E Akioyamen
- Department of Medicine, University of Toronto, Toronto ON, M5S 1A8, Canada.
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Omer L, Hudson EA, Hudgins LC, Boyd NL. Cohort Generation and Characterization of Patient-Specific Familial Hypercholesterolemia Induced Pluripotent Stem Cells. Stem Cells Dev 2021; 30:632-640. [PMID: 34029164 DOI: 10.1089/scd.2021.0004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Homozygous familial hypercholesterolemia (hoFH) is a rare disorder caused primarily by pathological mutations in the low-density lipoprotein receptor (LDLR), which disrupts LDL-cholesterol (LDL-C) metabolism homeostasis. hoFH patients are at extremely high risk for cardiovascular disease and are resistant to standard therapies. LDLR knockout animals and in vitro cell models overexpressing different mutations have proved useful, but may not fully recapitulate human LDLR mutation biology. We and others have generated induced pluripotent stem cells (iPSC) from hoFH patient's fibroblasts and T cells and demonstrated their ability to recapitulate hoFH biology. In this study, we present the generation and characterization of a cohort of seven hoFH-iPSC lines derived from peripheral blood mononuclear cells (PBMC) collected from four homozygous and three compound heterozygous patients. The hoFH-iPSC cohort demonstrated a wide range of LDLR expression and LDL-C internalization in response to rosuvastatin that correlated with the predicted pathogenicity of the mutation. We were able to confirm that hoFH-iPSC cohort were pluripotent by differentiation toward all three germ layers and specifically to hepatocyte-like cells (HLC), the cell with primary LDL-C metabolic regulatory control, by expression of hepatocyte markers. hoFH patient PBMC-derived iPSC recapitulate the LDLR dysfunction of their specific mutation. They were capable of differentiating to HLC and could be useful for early developmental studies, pharmacology/toxicology, and potentially autologous cell therapy.
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Affiliation(s)
- Linda Omer
- Department of Biochemistry and Molecular Genetics and University of Louisville School of Medicine, Louisville, Kentucky, USA.,Cardiovascular Innovation Institute, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Elizabeth A Hudson
- Department of Biochemistry and Molecular Genetics and University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Lisa C Hudgins
- Rogosin Institute, Weill Cornell Medical College, New York, New York, USA
| | - Nolan L Boyd
- Department of Biochemistry and Molecular Genetics and University of Louisville School of Medicine, Louisville, Kentucky, USA.,Department of Physiology, University of Louisville School of Medicine, Louisville, Kentucky, USA
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Mahzari M, Zarif H. Homozygous Familial Hypercholesterolemia (HoFH) in Saudi Arabia and Two Cases of Lomitapide Use in a Real-World Setting. Adv Ther 2021; 38:2159-2169. [PMID: 33829367 PMCID: PMC8107066 DOI: 10.1007/s12325-021-01720-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 03/18/2021] [Indexed: 12/19/2022]
Abstract
Introduction Homozygous familial hypercholesterolemia (HoFH) is a rare, genetic condition in which mutations in key peptides involved in the low-density lipoprotein receptor (LDL-R) pathway result in markedly elevated levels of circulating LDL-cholesterol (LDL-C). Patients are at high risk of developing early-onset atherosclerotic cardiovascular disease with associated mortality risks. Treatment options are extremely limited, and aspects of society and medical care in Saudi Arabia have the potential to increase incidence and limit treatment pathways in HoFH. Methods Along with a brief review of the evidence available on HoFH we describe the treatment of two Saudi Arabian patients with HoFH diagnosed and treated in accordance with local clinical practices and with the microsomal triglyceride transferase protein inhibitor lomitapide. Results HoFH in Saudi Arabia is characterized by problems associated with consanguinity, a lack of access to lipoprotein apheresis, and pressures to proceed to liver transplant. Among the case histories, the first patient was commenced on lomitapide therapy, and underwent a dramatic decrease in LDL-C levels from 16.5 to 2.2 mmol/L (87% decrease). This patient had problems with access to lomitapide and cessation of the drug resulted in rebound in LDL-C to 22 mmol/L. The second patient experienced delayed commencement of lomitapide therapy. Despite a 45% decrease in LDL-C levels from 15.3 to 6.9 mmol/L, the patient died the following year at age 26 years from complications subsequent to cardiovascular surgery. Lomitapide was well tolerated in both patients Discussion The experience of these two cases highlights the need for prompt, effective, and sustained intervention in HoFH to prevent cardiovascular morbidity and mortality. Lomitapide is an effective therapy for HoFH, and we look forward to improved access to this drug in Saudi Arabia, where there is a chronic unmet medical need in HoFH.
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Affiliation(s)
- Moeber Mahzari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
- Department of Medicine, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
| | - Hawazen Zarif
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- Department of Medicine, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
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Katsi V, Georgiopoulos G, Mitropoulou P, Kontoangelos K, Kollia Z, Tzavara C, Soulis D, Toutouzas K, Oikonomou D, Aimo A, Tsioufis K. Exercise tolerance and quality of life in patients with known or suspected coronary artery disease. Qual Life Res 2021; 30:2541-2550. [PMID: 33893931 DOI: 10.1007/s11136-021-02844-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Coronary artery disease (CAD) is known to impact on patients' physical and mental health. The relationship between performance on treadmill exercise tolerance test (ETT) and health-related quality of life (HRQL)has never been specifically investigated in the setting of CAD. METHODS Consecutive patients undergoing an ETT with the Bruce protocol during a diagnostic workup for CAD (n = 1,631, age 55 ± 12 years) were evaluated. Exercise-related indices were recorded. Detailed information on cardiovascular risk factors and past medical history were obtained. HRQLwas assessed with the use of the validated 36-Item Short Form Survey (SF-36) questionnaire. RESULTS Increasing age and the presence of cardiovascular risk factors and comorbidities correlated with lower scores on the physical and mental health component of SF-36(all P < 0.05). Subjects with arrhythmias during exercise and slow recovery of systolic blood pressure had lower scores on the physical health indices or the Social Role Functioning component (P < 0.05). Achieved target heart rate and good exercise tolerance were independently associated with better scores of the physical and mental health domains of SF-36 and overall HRQLscores (β = 0.05 for target HR and PCS-36, β = 1.86 and β = 1.66 per increasing stage of exercise tolerance and PCS-36 and MCS-36, respectively, P < 0.001 for all associations). Ischemic ECG changes were associated with worse scores on Physical Functioning (β = - 3.2, P = 0.02) and Bodily Pain (β = - 4.55, P = 0.026). CONCLUSION ETT parameters are associated with HRQL indices in patients evaluated for possible CAD. Physical conditioning may increase patient well-being and could serve as a complementary target in conjunction with cardiovascular drug therapy.
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Affiliation(s)
- Vasiliki Katsi
- First Department of Cardiology, Hippocration Hospital, Athens, Greece
| | - Georgios Georgiopoulos
- First Department of Cardiology, Hippocration Hospital, Athens, Greece.
- Cardiovascular Imaging Department, School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas Hospital, Westminster Bridge Road, London, SE1 7EH, UK.
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece.
| | - Panagiota Mitropoulou
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Konstantinos Kontoangelos
- 1st Department of Psychiatry, Eginition Hospital, Medical School National and Kapodistrian University of Athens, Athens, Greece
| | - Zoi Kollia
- Emergency Department, Amalia Fleming' General Hospital, Athens, Greece
| | - Chara Tzavara
- Emergency Department, Amalia Fleming' General Hospital, Athens, Greece
| | - Dimitrios Soulis
- Emergency Department, Amalia Fleming' General Hospital, Athens, Greece
| | | | | | - Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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Abstract
PURPOSE OF REVIEW Lipoprotein apheresis is the most effective means of lipid-lowering therapy. However, it's a semi-invasive, time consuming, and chronic therapy with variable adherence. There are still no specific guideline recommendations for the management of patients on lipid apheresis. The purpose of this review is to discuss the clinical indications and major drawbacks of lipid apheresis in the light of recent evidence. RECENT FINDINGS Lipoprotein apheresis should be initiated at early ages and performed frequently to receive the expected cardiovascular benefits. However, in clinical practice, most patients experience ineffective apheresis and fail to reach lipid targets. This real-world failure is due to several factors including late diagnosis, delayed referral, and improper frequency of procedures. All these denote that awareness is still low among physicians. Another important factor is the semi-invasive, time consuming nature of the apheresis, leading to high refusal and low adherence rates. Moreover, apheresis decreases quality of life and increases the risk of depression. Mental status is also deteriorated in patients with familial hypercholesterolemia on lipid apheresis. New effective lipid lowering agents are underway with promising cardiovascular results. To overcome the drawbacks, a structured approach, including standardized protocols for lipoprotein apheresis with regular cardiovascular follow-up is warranted. New effective lipid lowering agents with documented cardiovascular benefit, should be integrated into the treatment algorithms of patients on lipoprotein apheresis.
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Affiliation(s)
- Meral Kayikcioglu
- Department of Cardiology, Faculty of Medicine, Ege University, İzmir, Turkey.
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Stefanutti C. Lomitapide-a Microsomal Triglyceride Transfer Protein Inhibitor for Homozygous Familial Hypercholesterolemia. Curr Atheroscler Rep 2020; 22:38. [PMID: 32557261 PMCID: PMC7303073 DOI: 10.1007/s11883-020-00858-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Homozygous familial hypercholesterolemia (HoFH) is a rare, genetic condition characterized by high levels of Low density lipoprotein cholesterol (LDL-C); overt, early-onset atherosclerotic cardiovascular disease (ASCVD); and premature cardiovascular events and mortality. Lomitapide is a first-in-class microsomal triglyceride transfer protein inhibitor for the treatment of HoFH. This review provides an update on data emerging from real-world studies of lomitapide following on from its pivotal phase 3 clinical trial in HoFH. RECENT FINDINGS Recent registry data have confirmed that HoFH is characterized by delayed diagnosis, with many patients not receiving effective therapy until they are approaching the age when major adverse cardiovascular events may occur. Data from case series of varying sizes, and from a 163-patient registry of HoFH patients receiving lomitapide, have demonstrated that lomitapide doses are lower and adverse events less severe than in the phase 3 study. Lomitapide enables many patients to reach European Atherosclerosis Society LDL-C targets. Some patients are able to reduce frequency of lipoprotein apheresis or, in some cases, stop the procedure altogether-unless there is significant elevation of lipoprotein (a). Modelling analyses based on historical and clinical trial data indicate that lomitapide has the potential to improve cardiovascular outcomes and survival in HoFH. Real-world clinical experience with lomitapide has shown the drug to be effective with manageable, less marked adverse events than in formal clinical studies. Event modelling data suggest a survival benefit with lomitapide in HoFH.
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Affiliation(s)
- Claudia Stefanutti
- Extracorporeal Therapeutic Techniques Unit, Lipid Clinic and Atherosclerosis Prevention Centre, Regional Centre (Lazio) for Rare Diseases, Immunohematology and Transfusion Medicine, Department of Molecular Medicine, "Sapienza" University of Rome, "Umberto I" Hospital, Rome, Italy.
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Ben-Omran T, Masana L, Kolovou G, Ariceta G, Nóvoa FJ, Lund AM, Bogsrud MP, Araujo M, Hussein O, Ibarretxe D, Sanchez-Hernández RM, Santos RD. Real-World Outcomes with Lomitapide Use in Paediatric Patients with Homozygous Familial Hypercholesterolaemia. Adv Ther 2019; 36:1786-1811. [PMID: 31102204 PMCID: PMC6824397 DOI: 10.1007/s12325-019-00985-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Homozygous familial hypercholesterolaemia (HoFH) is a rare, autosomal disease affecting the clearance of low-density lipoprotein cholesterol (LDL-C) from circulation, and leading to early-onset atherosclerotic cardiovascular disease (ASCVD). Treatment consists mainly of statins, lipoprotein apheresis (LA) and, more recently, the microsomal triglyceride transfer protein inhibitor lomitapide. Lomitapide is not licensed for use in children, but has been made available through an expanded access programme or on a named patient basis. METHODS This case series includes 11 HoFH patients in 10 different centres in eight countries, less than 18 years of age (mean 11.6 ± 1.1 years, 64% male), with signs of ASCVD, and who have received treatment with lomitapide (mean dose 24.5 ± 4.3 mg/day; mean exposure 20.0 ± 2.9 months). Background lipid-lowering therapy was given according to local protocols. Lomitapide was commenced with a stepwise dose escalation from 2.5 mg or 5 mg/day; dietary advice and vitamin supplements were provided as per the product label for adults. Laboratory analysis was conducted as part of regular clinical care. RESULTS In the 11 cases, mean baseline LDL-C was 419 ± 74.6 mg/dL and was markedly reduced by lomitapide to a nadir of 176.7 ± 46.3 mg/dL (58.4 ± 6.8% decrease). Six patients achieved recommended target levels for children below 135 mg/dL, five of whom had LA frequency reduced. In one case, LDL-C levels were close to target when lomitapide was started but remained stable despite 75% reduction in LA frequency (from twice weekly to biweekly). Adverse events were mainly gastrointestinal in nature, occurred early in the treatment course and were well managed. Three patients with excursions in liver function tests were managed chiefly without intervention; two patients had decreases in lomitapide dose. CONCLUSIONS Lomitapide demonstrated promising effectiveness in paediatric HoFH patients. Adverse events were manageable, and the clinical profile of the drug is apparently similar to that in adult patients. FUNDING Amryt Pharma.
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Affiliation(s)
- Tawfeg Ben-Omran
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, Hamad Medical Corporation and Sidra Medicine, Doha, Qatar
| | - Luis Masana
- Vascular Medicine and Metabolism Unit, Universitat Rovira i Virgili, IISPV, CIBERDEM, Reus, Spain
| | | | - Gema Ariceta
- Pediatric Kidney Diseases, University Hospital Vall d' Hebron, Barcelona, Spain
| | - F Javier Nóvoa
- Endocrinology Department, University Hospital Insular de Gran Canaria, University Institute of Biomedical and Health Research of the University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Allan M Lund
- Center for Inherited Metabolic Diseases, Departments of Paediatrics and Clinical Genetics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Martin P Bogsrud
- National Advisory Unit for Familial Hypercholesterolemia, Oslo University Hospital, Oslo, Norway
| | - María Araujo
- Nutrition Service, Hospital Nacional de Pediatría 'Dr Juan P. Garrahan', Buenos Aires, Argentina
| | - Osamah Hussein
- Internal Medicine Department 'A, Ziv Medical Centre, Azreili Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Daiana Ibarretxe
- Vascular Medicine and Metabolism Unit, Universitat Rovira i Virgili, IISPV, CIBERDEM, Reus, Spain
| | - Rosa M Sanchez-Hernández
- Endocrinology Department, University Hospital Insular de Gran Canaria, University Institute of Biomedical and Health Research of the University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Raul D Santos
- Lipid Clinic, Heart Institute (InCor), University of Sao Paulo and Hospital Israelita Albert Einstein, São Paulo, Brazil.
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Kayikcioglu M, Kuman-Tunçel O, Pirildar S, Yílmaz M, Kaynar L, Aktan M, Durmuş RB, Gökçe C, Temizhan A, Özcebe OI, Akyol TK, Okutan H, Sağ S, Oz Gul O, Salcioglu Z, Yenercag M, Altunkeser BB, Kuku I, Yasar HY, Kurtoğlu E, Demir M, Demircioğlu S, Pekkolay Z, Ílhan O, Tokgozoglu L. Clinical management, psychosocial characteristics, and quality of life in patients with homozygous familial hypercholesterolemia undergoing LDL-apheresis in Turkey: Results of a nationwide survey (A-HIT1 registry). J Clin Lipidol 2019; 13:455-467. [DOI: 10.1016/j.jacl.2019.02.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 01/24/2019] [Accepted: 02/01/2019] [Indexed: 01/18/2023]
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PATIENT PRIORITIES FOR TREATMENT ATTRIBUTES IN ADJUNCTIVE DRUG THERAPY OF SEVERE HYPERCHOLESTEROLEMIA IN GERMANY: AN ANALYTIC HIERARCHY PROCESS. Int J Technol Assess Health Care 2018; 34:267-275. [PMID: 29987994 DOI: 10.1017/s0266462318000247] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Severe hypercholesterolemia is a major cause of death in coronary heart disease. New adjunctive drug therapies have passed authorization processes and been launched recently. So far it is not known which properties of the new treatment options generate the highest benefit for patients. The aim was to evaluate patient priorities in the field of adjunctive drug therapy with apheresis. Therapy characteristics were examined as to their relevance to hypercholesterolemia patients. METHODS To identify all potential patient-relevant treatment characteristics, a systematic literature review and ten interviews with patients were conducted. Seven key characteristics were identified from the patient perspective. Patients' priorities were elicited using an analytic hierarchy process (AHP). RESULTS In total, N = 61 patients diagnosed with severe hypercholesterolemia and undergoing apheresis participated in the study. The analysis showed predominance for the attribute "reduction of LDL-C level in blood" (Wglobal:0.362). The "risk of myopathy" (Wglobal:0.164), "risk of neurocognitive impairment" (Wglobal:0.161) and "frequency of apheresis" (Wglobal:0.119) were ranked second, third and fourth. Subgroup analyses revealed that "frequency of apheresis" is of greater importance to younger patients, men and/or patients who indicated a reduction in quality of life due to apheresis. CONCLUSIONS The essential decision criteria for optimal therapy from the patients' perspective were obtained. "Reduction of lipoprotein in blood" was ranked highest compared with the "mode of administration" and "side effects" characteristics. The study offers a transparent approach for the identification of patient priorities for adjunctive PCSK9-inhibitor therapy in apheresis-treated hypercholesterolemia. The project can be used by healthcare decision makers to understand the importance of each patient-relevant endpoint.
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Mühlbacher AC, Sadler A, Dippel FW, Juhnke C. Treatment Preferences in Germany Differ Among Apheresis Patients with Severe Hypercholesterolemia. PHARMACOECONOMICS 2018; 36:477-493. [PMID: 29388056 DOI: 10.1007/s40273-018-0614-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Severe hypercholesterolemia is a major risk factor of death in patients with coronary heart disease. New adjunctive drug therapies (proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitors) have gained approval in Europe and the USA. OBJECTIVE In this empirical study, we documented preferences regarding adjuvant drug therapy in apheresis-treated patients with severe familial hypercholesterolemia. METHODS We conducted a systematic literature search to identify patient-relevant outcomes in patients with severe hypercholesterolemia currently undergoing apheresis. Data were used to generate a semi-structured qualitative interview that enabled seven patient-relevant characteristics with three levels each to be identified. For the discrete choice experiment, an experimental design (7 × 3) was generated using NGene Software that consisted of 96 choices divided into eight blocks. The survey was conducted between November 2015 and April 2016 using computer-assisted personal interviews. RESULTS The survey was completed by 348 patients (64.9% male). The random parameter logit estimation showed predominance for the attribute 'reduction of LDL-C (low-density lipoprotein cholesterol) level'. 'Risk of myopathy' and 'frequency of apheresis' dominated next. Within the random parameter logit estimation, all coefficients were significant (P ≤ 0.01). The latent class analysis identified three patient groups. The first group (126 patients) found 'reduction of LDL-C level in blood' to be most important. This group focused solely on this treatment outcome independently of apheresis frequency or additional injections. The second group (106 patients) focused on three attributes: 'frequency of apheresis', 'risk of myopathy', and 'reduction of LDL-C level in blood'. Respondents clearly considered a high frequency of apheresis to have a negative impact. The third group (116 patients) demonstrated the highest preference for apheresis. These patients have adjusted to apheresis for > 10 years. CONCLUSION Regarding patient preference, clinical efficacy seems to dominate. Hence, 'reduction of LDC-C in blood' was ranked highest above patient-relevant modes of administration and adverse effects. In the patient groups identified, reduction of apheresis was important for only a subsegment (30%) of patients. Another 30% wanted effective LDL-C reduction by whatever means necessary. Most strikingly, another 30% preferred higher frequencies of apheresis.
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Affiliation(s)
- Axel C Mühlbacher
- Professur Gesundheitsökonomie und Medizinmanagement, Hochschule Neubrandenburg, Brodaer Straße 2, 17033, Neubrandenburg, Germany.
- Gesellschaft für empirische Beratung GmbH (GEB), Denzlingen, Germany.
| | - Andrew Sadler
- Professur Gesundheitsökonomie und Medizinmanagement, Hochschule Neubrandenburg, Brodaer Straße 2, 17033, Neubrandenburg, Germany
- Gesellschaft für empirische Beratung GmbH (GEB), Denzlingen, Germany
| | | | - Christin Juhnke
- Professur Gesundheitsökonomie und Medizinmanagement, Hochschule Neubrandenburg, Brodaer Straße 2, 17033, Neubrandenburg, Germany
- Gesellschaft für empirische Beratung GmbH (GEB), Denzlingen, Germany
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Real J, Arbona C, Goterris R, Ascaso JF. Management of homozygous familial hypercholesterolaemia in two brothers. BMJ Case Rep 2018; 2018:bcr-2017-222155. [PMID: 29306853 PMCID: PMC5775811 DOI: 10.1136/bcr-2017-222155] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Homozygous familial hypercholesterolaemia (HoFH) is a rare, genetic disorder of abnormally high levels of low-density lipoprotein cholesterol (LDL-C) requiring aggressive interventions to retard the evolution of atherosclerotic cardiovascular disease. We treated two brothers (ages 46 years and 47 years) with HoFH with statins, lipoproteinapheresis (LA) and the microsomal triglyceride transfer protein inhibitor lomitapide. Both brothers carried the p.Thr434Arg homozygous LDLR mutation and had childhood total cholesterol levels >700 mg/dL. Inter-LA LDL-C levels remained high; therefore, they were given escalating doses of oral lomitapide (5–10 mg/day). One brother was able to maintain LDL-C levels <70 mg/dL and stop LA. Lomitapide was well tolerated, with only an episode of headache requiring dose reduction from 40 mg/day to 20 mg/day in one patient. In two HoFH cases, lomitapide was an effective and well-tolerated adjunct therapy. Lomitapide doses required to maintain LDL-C goal levels appear to be lower in clinical practice than in clinical trials.
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Affiliation(s)
- José Real
- Department of Medicine, University of Valencia, Valencia, Spain
| | - Cristina Arbona
- Apheresis Unit, Haematology Service, University of Valencia, Valencia, Spain
| | - Rosa Goterris
- Apheresis Unit, Haematology Service, University of Valencia, Valencia, Spain
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Bruckert E, Gallo A. Is lomitapide a life-saving drug in homozygous familial hypercholesterolemia. Eur J Prev Cardiol 2017; 24:1841-1842. [PMID: 28952803 DOI: 10.1177/2047487317734387] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Eric Bruckert
- Department of Endocrinology and Cardiovascular Disease Prevention, Hôpital Pitié-Salpêtrière, France
| | - Antonio Gallo
- Department of Endocrinology and Cardiovascular Disease Prevention, Hôpital Pitié-Salpêtrière, France
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Toward an international consensus—Integrating lipoprotein apheresis and new lipid-lowering drugs. J Clin Lipidol 2017; 11:858-871.e3. [DOI: 10.1016/j.jacl.2017.04.114] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 03/30/2017] [Accepted: 04/15/2017] [Indexed: 12/11/2022]
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Mehta R, Zubirán R, Martagón AJ, Vazquez-Cárdenas A, Segura-Kato Y, Tusié-Luna MT, Aguilar-Salinas CA. The panorama of familial hypercholesterolemia in Latin America: a systematic review. J Lipid Res 2016; 57:2115-2129. [PMID: 27777316 PMCID: PMC5321217 DOI: 10.1194/jlr.r072231] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 10/23/2016] [Indexed: 11/20/2022] Open
Abstract
The burden caused by familial hypercholesterolemia (FH) varies among countries and ethnic groups. The prevalence and characteristics of FH in Latin American (LA) countries is largely unknown. We present a systematic review (following the PRISMA statement) of FH in LA countries. The epidemiology, genetics, screening, management, and unique challenges encountered in these countries are discussed. Published reports discussing FH in Hispanic or LA groups was considered for analysis. Thirty studies were included representing 10 countries. The bulk of the data was generated in Brazil and Mexico. Few countries have registries and there was little commonality in FH mutations between LA countries. LDL receptor mutations predominate; APOB and PCSK9 mutations are rare. No mutation was found in an FH gene in nearly 50% of cases. In addition, some country-specific mutations have been reported. Scant information exists regarding models of care, cascade screening, cost, treatment effectiveness, morbidity, and mortality. In conclusion, FH is largely underdiagnosed and undertreated in the LA region. The genetic admixture with indigenous populations, producing mestizo's groups, may influence the mutational findings in Latin America. Potential opportunities to close gaps in knowledge and health care are identified.
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Affiliation(s)
- Roopa Mehta
- Departamento de Endocrinologia y Metabolismo, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Rafael Zubirán
- Departamento de Endocrinologia y Metabolismo, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | | | | | - Yayoi Segura-Kato
- Departamento de Endocrinologia y Metabolismo, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico; Unidad de Biología Molecular y Medicina Genómica Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - María Teresa Tusié-Luna
- Departamento de Endocrinologia y Metabolismo, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico; Unidad de Biología Molecular y Medicina Genómica Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Carlos A Aguilar-Salinas
- Departamento de Endocrinologia y Metabolismo, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico.
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Averna M, Cefalù AB, Stefanutti C, Di Giacomo S, Sirtori CR, Vigna G. Individual analysis of patients with HoFH participating in a phase 3 trial with lomitapide: The Italian cohort. Nutr Metab Cardiovasc Dis 2016; 26:36-44. [PMID: 26723464 DOI: 10.1016/j.numecd.2015.11.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 09/30/2015] [Accepted: 11/03/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIMS The efficacy and safety of lomitapide as adjunct treatment for adults with homozygous familial hypercholesterolaemia (HoFH) have been confirmed in a phase 3 trial. Given the small number of patients (N = 29), and variations in patient characteristics, examining individual cases provides additional details regarding patient management with lomitapide. Here, we examine the details of the Italian patient cohort in the phase 3 trial. METHODS AND RESULTS The methodology of the multinational, single-arm, open-label, 78-week, dose-escalation, phase 3 trial has been previously reported. The current report details the Italian cohort of six patients (three males, three females) based on individual patient data, individual patient histories and narratives, and by mean data ± SD. Lomitapide was administered according to the dose-escalation protocol. At Week 78, concentrations of low-density lipoprotein-cholesterol were decreased by a mean of 42.6 ± 21.8% compared with baseline. Lomitapide was similarly well tolerated in the Italian cohort as in the entire study population. The most common adverse events were gastrointestinal symptoms. One patient showed an increase in liver transaminases >5× upper limit of normal that resolved after lomitapide treatment was reduced and maintained at a lower dose. CONCLUSION The efficacy, safety and tolerability of lomitapide demonstrated in the Italian subgroup of patients are consistent with findings in the entire study population, and illustrate the broad applicability of lomitapide therapy across genotypes and clinical phenotypes. These data also provide an insight into the management of lomitapide use in a cohort of patients within a clinical trial protocol. Clinicaltrials.gov Identifier: NCT00730236.
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Affiliation(s)
| | | | | | | | - C R Sirtori
- Università di Milano, Center for Dyslipidemias, Niguarda Hospital, Milano, Italy
| | - G Vigna
- Università di Ferrara, Ferrara, Italy
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Cuchel M, Blom DJ, Averna MR. Clinical experience of lomitapide therapy in patients with homozygous familial hypercholesterolaemia. ATHEROSCLEROSIS SUPP 2015; 15:33-45. [PMID: 25257075 DOI: 10.1016/j.atherosclerosissup.2014.07.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The microsomal triglyceride transfer protein (MTP) inhibitor lomitapide is a licenced adjunct to a low-fat diet and other lipid-lowering medication, with or without low-density lipoprotein apheresis, for the treatment of adults with homozygous familial hypercholesterolaemia (HoFH). In a recently published phase 3 study, patients with HoFH received lomitapide in addition to maximally tolerated lipid-lowering therapy. Treatment with lomitapide resulted in a mean approximate 50% reduction in LDL-C levels after 26 weeks compared with baseline levels (p < 0.0001). This decrease in LDL-C was maintained at Weeks 56 and 78 (44% [p < 0.0001] and 38% [p = 0.0001], respectively). This paper offers clinical perspectives based on selected case histories of patients participating in the phase 3 lomitapide study. These cases provide illustrative examples of the efficacy of lomitapide, with or without apheresis, and show that the effective management of adverse effects can enable patients to remain on effective treatment.
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Affiliation(s)
- Marina Cuchel
- Institute for Translational Medicine and Therapeutics, and Department of Medicine, University of Pennsylvania, 8039 Maloney Building, 3600 Spruce Street, Philadelphia, PA 19104, USA.
| | - Dirk J Blom
- University of Cape Town, Cape Town, South Africa; Medical Research Council of South Africa, Cape Heart Group, Cape Town, South Africa
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Santos RD. What are we able to achieve today for our patients with homozygous familial hypercholesterolaemia, and what are the unmet needs? ATHEROSCLEROSIS SUPP 2014; 15:19-25. [DOI: 10.1016/j.atherosclerosissup.2014.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bruckert E. Recommendations for the management of patients with homozygous familial hypercholesterolaemia: Overview of a new European Atherosclerosis Society consensus statement. ATHEROSCLEROSIS SUPP 2014; 15:26-32. [DOI: 10.1016/j.atherosclerosissup.2014.07.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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