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Abdalla MA, Zakhary CM, Rushdi H, Hamdan JA, Youssef KN, Khan A, Khan S. The Effectiveness of Statins as Potential Therapy for Multiple Sclerosis: A Systematic Review of Randomized Controlled trials. Cureus 2021; 13:e18092. [PMID: 34692306 PMCID: PMC8525664 DOI: 10.7759/cureus.18092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/19/2021] [Indexed: 01/04/2023] Open
Abstract
Evidence of the effectiveness of statins, the lipid-lowering agents in retarding the progression of Multiple Sclerosis (MS), a disabling neurological disease with autoimmune etiology, have been highlighted in animal studies and observational studies. The proposed immune-modulatory actions and neuroprotective effects of statins make them a promising treatment option for MS that needs to be explored further. In this systematic review, we aim to investigate the role of different statins as monotherapy or in combination with the established MS medications in improving the clinical and radiological course of MS variants, including optic neuritis, using randomized controlled trials (RCTs). We systematically searched PubMed, PubMed Central (PMC), MEDLINE, Cochrane library, and Scopus databases using regular keywords and medical subject headings terms. Randomized controlled trials of any statin used in any variants of MS, including studies on statins used in optic neuritis published up to April 2021, were included in the review. Data on the effects on the relapse rate, the Expanded Disability Status Scale (EDSS) alterations, and the changes in Magnetic Resonance Imaging (MRI) lesions were collected from the included studies. Seven studies with a total of 831 patients and an average duration of follow-up of six to 36 months were included in our review. Five trials were of statins add-on to interferon therapy in relapsing-remitting multiple sclerosis (RRMS), of which four studies were assessed to be of good quality while the remaining study featured a high risk of bias. One trial of simvastatin monotherapy in Secondary Progressive Multiple Sclerosis (SPMS) was included, which was assessed to be of good methodological quality with low risk of bias and adequate patient number. A trial of simvastatin monotherapy on patients with optic neuritis was included, which was evaluated as a good quality study. Still, it had a low number of participants and a short duration of follow-up. We used the changes in disease relapse rate and EDSS as primary outcome variables and the MRI lesions changes as a secondary outcome variable. Studies in RRMS showed no significant effects on primary and secondary outcomes. The study on SPMS featured a significant improvement in EDSS in simvastatin-treated patients with no effect on relapse rate or MRI changes. Simvastatin use in optic neuritis enhances clinical visual outcomes with no significant effect on MRI changes or the rate of progression to definite MS. In contrast to animal studies and observational studies, randomized controlled trials do not replicate the positive effects of statins used as monotherapy or combined with interferon beta in patients with RRMS and optic neuritis in relapse rate EDSS or MRI changes. However, trials of statins on SPMS showed a promising effect on disability progression (EDSS score), which might support the proposed immune-modulatory and neuroprotective role of statins and serve as a baseline for further RCTs applying statins as monotherapy or combination with other established MS therapies.
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Affiliation(s)
- Mohammed A Abdalla
- Department of Clinical Pathology, Faculty of Medicine, Al-Neelain University, Khartoum, SDN
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Christine M Zakhary
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Hiam Rushdi
- Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Jaafar A Hamdan
- Medicine, American University of Antigua, St. John, ATG
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Kerolos N Youssef
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Aafreen Khan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Lanzillo R, Moccia M, Russo CV, Carotenuto A, Nozzolillo A, Petruzzo M, Palladino R, Chataway J, Brescia Morra V. Therapeutic lag in reducing disability progression in relapsing-remitting multiple sclerosis: 8-year follow-up of two randomized add-on trials with atorvastatin. Mult Scler Relat Disord 2019; 28:193-196. [DOI: 10.1016/j.msard.2018.12.042] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 12/20/2018] [Accepted: 12/31/2018] [Indexed: 11/16/2022]
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Lanzillo R, Quarantelli M, Pozzilli C, Trojano M, Amato MP, Marrosu MG, Francia A, Florio C, Orefice G, Tedeschi G, Bellantonio P, Annunziata P, Grimaldi LM, Comerci M, Brunetti A, Bonavita V, Alfano B, Marini S, Brescia Morra V. No evidence for an effect on brain atrophy rate of atorvastatin add-on to interferon β1b therapy in relapsing-remitting multiple sclerosis (the ARIANNA study). Mult Scler 2015; 22:1163-73. [PMID: 26466947 DOI: 10.1177/1352458515611222] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 09/17/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND A previous phase 2 trial has suggested that statins might delay brain atrophy in secondary progressive multiple sclerosis. OBJECTIVES The objective of this study was to evaluate the effect of atorvastatin add-on therapy on cerebral atrophy in relapsing-remitting multiple sclerosis. METHODS This randomised, placebo-controlled study compared atorvastatin 40 mg or placebo add-on therapy to interferon β1b for 24 months. Brain magnetic resonance imaging, multiple sclerosis functional composite score, Rao neuropsychological battery and expanded disability status scale were evaluated over 24 months. RESULTS A total of 154 patients were randomly assigned, 75 in the atorvastatin and 79 in the placebo arms, with a comparable drop-out rate (overall 23.4%). Brain atrophy over 2 years was not different in the two arms (-0.38% and -0.32% for the atorvastatin and placebo groups, respectively). Relapse rate, expanded disability status scale, multiple sclerosis functional composite score or cognitive changes were not different in the two arms. Patients withdrawing from the study had a higher number of relapses in the previous 2 years (P=0.04) and a greater probability of relapsing within 12 months. CONCLUSIONS Our results suggest that the combination of atorvastatin and interferon β1b is not justified in early relapsing-remitting multiple sclerosis and adds to the body of evidence indicating an absence of significant radiological and clinical benefit of statins in relapsing-remitting multiple sclerosis.
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Affiliation(s)
- Roberta Lanzillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University of Naples, Italy
| | - Mario Quarantelli
- National Research Council (CNR) Biostructure and Bioimaging Institute (IBB), Naples Multiple Sclerosis Centre, Italy
| | - Carlo Pozzilli
- Department of Neurology and Psychiatry, Sapienza University, Italy
| | - Maria Trojano
- Department of Neurosciences and Organs of Senses, University of Bari, Italy
| | | | - Maria G Marrosu
- Department of Public Health and Clinical and Molecular Medicine, University of Cagliari, Italy
| | - Ada Francia
- Department of Neurology and Psychiatry, Sapienza University, Italy
| | - Ciro Florio
- Multiple Sclerosis Regional Center, Azienda Ospedaliera "Antonio Cardarelli", Italy
| | - Giuseppe Orefice
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University of Naples, Italy
| | - Gioacchino Tedeschi
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, Second University of Naples, Italy
| | | | - Pasquale Annunziata
- Department of Neurological, Neurosurgical and Behavioural Sciences, University of Siena, Italy
| | - Luigi M Grimaldi
- Neurology Unit, Fondazione Istituto San Raffaele "G. Giglio", Italy
| | - Marco Comerci
- National Research Council (CNR) Biostructure and Bioimaging Institute (IBB), Naples Multiple Sclerosis Centre, Italy
| | - Arturo Brunetti
- Department of Biomedical Advanced Sciences, Federico II University, Italy
| | | | - Bruno Alfano
- National Research Council (CNR) Biostructure and Bioimaging Institute (IBB), Naples Multiple Sclerosis Centre, Italy
| | | | - Vincenzo Brescia Morra
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University of Naples, Italy
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Atar S, Ye Y, Lin Y, Freeberg SY, Nishi SP, Rosanio S, Huang MH, Uretsky BF, Perez-Polo JR, Birnbaum Y. Atorvastatin-induced cardioprotection is mediated by increasing inducible nitric oxide synthase and consequent S-nitrosylation of cyclooxygenase-2. Am J Physiol Heart Circ Physiol 2006; 290:H1960-8. [PMID: 16339820 DOI: 10.1152/ajpheart.01137.2005] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We determined the effects of cyclooxygenase-1 (COX-1; SC-560), COX-2 (SC-58125), and inducible nitric oxide synthase (iNOS; 1400W) inhibitors on atorvastatin (ATV)-induced myocardial protection and whether iNOS mediates the ATV-induced increases in COX-2. Sprague-Dawley rats received 10 mg ATV·kg−1·day−1 added to drinking water or water alone for 3 days and received intravenous SC-58125, SC-560, 1400W, or vehicle alone. Anesthesia was induced with ketamine and xylazine and maintained with isoflurane. Fifteen minutes after intravenous injection rats underwent 30-min myocardial ischemia followed by 4-h reperfusion [infarct size (IS) protocol], or the hearts were explanted for biochemical analysis and immunoblotting. Left ventricular weight and area at risk (AR) were comparable among groups. ATV reduced IS to 12.7% (SD 3.1) of AR, a reduction of 64% vs. 35.1% (SD 7.6) in the sham-treated group ( P < 0.001). SC-58125 and 1400W attenuated the protective effect without affecting IS in the non-ATV-treated rats. ATV increased calcium-independent NOS (iNOS) [11.9 (SD 0.8) vs. 3.9 (SD 0.1) × 1,000 counts/min; P < 0.001] and COX-2 [46.7 (SD 1.1) vs. 6.5 (SD 1.4) pg/ml of 6-keto-PGF1α; P < 0.001] activity. Both SC-58125 and 1400W attenuated this increase. SC-58125 did not affect iNOS activity, whereas 1400W blocked iNOS activity. COX-2 was S-nitrosylated in ATV-treated but not sham-treated rats or rats pretreated with 1400W. COX-2 immunoprecipitated with iNOS but not with endothelial nitric oxide synthase. We conclude that ATV reduced IS by increasing the activity of iNOS and COX-2, iNOS is upstream to COX-2, and iNOS activates COX-2 by S-nitrosylation. These results are consistent with the hypothesis that preconditioning effects are mediated via PG.
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Affiliation(s)
- Shaul Atar
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX 77555-0553, USA
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Ye Y, Lin Y, Atar S, Huang MH, Perez-Polo JR, Uretsky BF, Birnbaum Y. Myocardial protection by pioglitazone, atorvastatin, and their combination: mechanisms and possible interactions. Am J Physiol Heart Circ Physiol 2006; 291:H1158-69. [PMID: 16603698 DOI: 10.1152/ajpheart.00096.2006] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
We assessed 1) whether pretreatment before ischemia with pioglitazone (Pio) limits infarct size (IS) and whether this protective effect is due to nitric oxide synthase (NOS) and/or prostaglandin production, as has been shown for atorvastatin (ATV); and 2) whether Pio and ATV have synergistic effects on myocardial protection. Sprague-Dawley rats received oral ATV (10 mg.kg-1.day-1), Pio (10 mg.kg-1.day-1), their combination (Pio+ATV), or water alone for 3 days. Additional rats received Pio (10 mg.kg-1.day-1) for 3 days and intravenous SC-58125 [a cyclooxygenase-2 (COX-2) inhibitor] or SC-560 (a COX-1 inhibitor) 15 min before ischemia. Rats underwent 30 min of myocardial ischemia and 4 h of reperfusion, or hearts were harvested for analysis. IS in the Pio and in the ATV groups was significantly smaller than in the sham-treated group. IS in the Pio+ATV group was smaller than in all other groups (P<0.001 vs. each group). The protective effect of Pio was abrogated by SC-58125 but not by SC-560. Pio, ATV, and Pio + ATV increased the expression and activity of cytosolic phospholipase A2 (cPLA2) and COX-2. ATV increased phosphorylated-Akt, phosphorylated-endothelial NOS (P-eNOS), inducible NOS, and COX-2 levels. In contrast, Pio caused an insignificant increase in myocardial levels of phosphorylated-Akt but did not change P-eNOS and iNOS expression. In conclusion, the IS-limiting effects of Pio and ATV involve COX-2. However, the upstream steps differ. ATV induced eNOS phosphorylation and iNOS, cPLA2, and COX-2 expression, whereas Pio induced mainly the expression and activity of cPLA2. The effects of Pio and ATV were additive.
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Affiliation(s)
- Yumei Ye
- Division of Cardiology, Department of Biochemistry and Molecular Genetics, University of Texas Medical Branch, 5.106 John Sealy Annex, 301 Univ. Blvd., Galveston, Texas 77555-0553, USA
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Shafiq N, Malhotra S, Pandhi P, Grover A. The "Statinth" wonder of the world: a panacea for all illnesses or a bubble about to burst. J Negat Results Biomed 2005; 4:3. [PMID: 15788096 PMCID: PMC1079931 DOI: 10.1186/1477-5751-4-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2005] [Accepted: 03/23/2005] [Indexed: 12/20/2022] Open
Abstract
After the introduction of statins in the market as effective lipid lowering agents, they were shown to have effects other than lipid lowering. These actions were collectively referred to as 'pleiotropic actions of statins.' Pleiotropism of statins formed the basis for evaluating statins for several indications other than lipid lowering. Evidence both in favour and against is available for several of these indications. The current review attempts to critically summarise the available data for each of these indications.
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Affiliation(s)
- Nusrat Shafiq
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Samir Malhotra
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Promila Pandhi
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Anil Grover
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
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Sönmez Uydeş-Doğan B, Topal G, Takir S, Ilkay Alp F, Kaleli D, Ozdemir O. Relaxant effects of pravastatin, atorvastatin and cerivastatin on isolated rat aortic rings. Life Sci 2005; 76:1771-86. [PMID: 15698855 DOI: 10.1016/j.lfs.2004.11.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2004] [Accepted: 11/22/2004] [Indexed: 12/14/2022]
Abstract
Increasing evidence suggests that statins may have pleiotropic effects on vascular wall independent of their cholesterol lowering properties. In the present study, we investigated the acute vascular effects of pravastatin, atorvastatin and cerivastatin on rat isolated aortic rings. Statins effectively and comparably relaxed the aortic rings precontracted submaximally with noradrenaline, in a concentration-dependent manner, in which a high potency was observed with cerivastatin. Endothelium removal or incubation of the aortic rings with nitric oxide synthase inhibitor L-NOARG (10(-4) M) and/or cyclooxygenase inhibitor indomethacin (10(-5) M) significantly attenuated the acute vasorelaxation induced by either of statin. Additionally, different from the other two statins, a significant reduction was observed in response to cerivastatin in the presence of KATP channel inhibitor, glibenclamide (10(-5) M) and Na+- K+ ATPase inhibitor, ouabain (10(-4) M). Furthermore, pretreatment of the rings with the cholesterol precursor mevalonate (10(-3) M) significantly inhibited the endothelium-mediated relaxant effects of the statins. Our findings suggest that statins could acutely modulate vascular tone importantly by endothelium-dependent and mevalonate-related pathways.
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Affiliation(s)
- B Sönmez Uydeş-Doğan
- Istanbul University Faculty of Pharmacy, Department of Pharmacology, 34116, Beyazit, Istanbul, Turkey.
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