Multiple mechanisms of hypocholesterolemic action of pactimibe, a novel acyl-coenzyme A:cholesterol acyltransferase inhibitor

Acyl-Coenzyme A: Cholesterol Acyltransferase (ACAT) in Cholesterol Metabolism: From Its Discovery to Clinical Trials and the Genomics Era

The purification and cloning of the acyl-coenzyme A: cholesterol acyltransferase (ACAT) enzymes and the sterol O-acyltransferase (SOAT) genes has opened new areas of interest in cholesterol metabolism given their profound effects on foam cell biology and intestinal lipid absorption. The generation of mouse models deficient in Soat1 or Soat2 confirmed the importance of their gene products on cholesterol esterification and lipoprotein physiology. Although these studies supported clinical trials which used non-selective ACAT inhibitors, these trials did not report benefits, and one showed an increased risk. Early genetic studies have implicated common variants in both genes with human traits, including lipoprotein levels, coronary artery disease, and Alzheimer’s disease; however, modern genome-wide association studies have not replicated these associations. In contrast, the common SOAT1 variants are most reproducibly associated with testosterone levels.

Isoform-specific inhibitors of ACATs: recent advances and promising developments

Acyl-CoA:cholesterol acyltransferase (ACAT) is a promising therapeutic target for cardiovascular diseases. Although a number of synthetic ACAT inhibitors have been developed, they have failed to show efficacy in clinical trials. Now, the presence of two ACAT isoforms with distinct functions, ACAT1 and ACAT2, has been discovered. Thus, the selectivity of ACAT inhibitors toward the two isoforms is important for their development as novel anti-atherosclerotic agents. The selectivity study indicated that fungal pyripyropene A (PPPA) is only an ACAT2-specific inhibitor. Furthermore, PPPA proved orally active in atherogenic mouse models, indicating it possessed cholesterol-lowering and atheroprotective activities. Certain PPPA derivatives, semi-synthetically prepared, possessed more potent and selective in vitro activity than PPPA against ACAT2. This review covers these studies and describes the future prospects of ACAT2-specific inhibitors.

Current and emerging strategies for treating dyslipidemia and macrovascular disease

Statins, inhibitors of hydroxymethylglutaryl CoA (HMG-CoA) reductase, have been in clinical use for over 20 years. The widespread use of these agents has left doubt of the efficacy of cholesterol-lowering therapy to prevent cardiovascular disease. In spite of the widespread use of these agents and the successful lowering of circulating cholesterol together with reduction of cardiovascular-related deaths, there is consensus that further improvements in therapy are needed. Cardiovascular disease remains a major cause of premature death and continues to exert an extensive drain on the health-care costs. This chapter outlines some of the emerging strategies for discovering and developing novel treatments of dyslipidemia and macrovascular disease. Mechanisms considered include alternate ways to lower total cholesterol through inhibition of synthesis, limitation of absorption, or recycling. Other approaches include the modification of circulating forms of cholesterol and changes in gene expression at the key sites of storage, utilization, and pathology. The next successful strategy will likely be one that works well in concert with existing statins.

Synthesis and biological evaluation of unprecedented classes of spiro-beta-lactams and azido-beta-lactams as acyl-CoA:cholesterol acyltransferase inhibitors

Unprecedented classes of four- and five-membered hydroxyl-spiro-beta-lactams and hydroxyl-azido-beta-lactams were prepared via regioselective ring opening of hydroxyl-epoxides. The potential of these particular beta-lactams as biologically active compounds has been confirmed by the results obtained in ACAT inhibition assays.

The return of two old targets?

Once the physiological function of an enzyme is understood, a rationale for therapeutic intervention often becomes apparent. It is much harder to find synthetic inhibitors with the required specificity and safety. Preclinical biological data packages are not always predictive of the response in humans. Rational targets, therefore, go in and out of fashion according to the status of candidate drugs. Acyl-CoA:cholesterol acyltransferase and squalene synthase inhibitors have been studied for many years, but safety and early clinical data did not support progression. In recent months, data have become available on new compounds for each target which suggest a way forward. This editorial reviews the difficulties and potential for each target in the light of recent reports.

Discontinued drugs in 2005: cardiovascular drugs

This perspective describes cardiovascular compounds dropped from clinical development in 2005 and is the first in a series of papers to be published in Expert Opinion on Investigational Drugs, discussing discontinued drugs from that year. Discontinued candidates are described by the phase of development they reached, based on the information available from the Pharmaprojects database. Discontinued drugs in the atherosclerosis/dyslipidaemia area are discussed in more detail.