Familial hypercholesterolemia: current treatment options and patient selection for low-density lipoprotein apheresis

Attenuation of Hyperlipidemia by Medicinal Formulations of Emblica officinalis Synergized with Nanotechnological Approaches

The ayurvedic herb Emblica officinalis (E. officinalis) is a gift to mankind to acquire a healthy lifestyle. It has great therapeutic and nutritional importance. Emblica officinalis, also known as Indian gooseberry or Amla, is a member of the Euphorbiaceae family. Amla is beneficial for treating illnesses in all its forms. The most crucial component is a fruit, which is also the most common. It is used frequently in Indian medicine as a restorative, diuretic, liver tonic, refrigerant, stomachic, laxative, antipyretic, hair tonic, ulcer preventive, and for the common cold and fever. Hyperlipidemia is also known as high cholesterol or an increase in one or more lipid-containing blood proteins. Various phytocompounds, including polyphenols, vitamins, amino acids, fixed oils, and flavonoids, are present in the various parts of E. officinalis. E. officinalis has been linked to a variety of pharmacological effects in earlier studies, including hepatoprotective, immunomodulatory, antimicrobial, radioprotective, and hyperlipidemic effects. The amla-derived active ingredients and food products nevertheless encounter challenges such as instability and interactions with other food matrices. Considering the issue from this perspective, food component nanoencapsulation is a young and cutting-edge field for controlled and targeted delivery with a range of preventative activities. The nanoformulation of E. officinalis facilitates the release of active components or food ingredients, increased bioaccessibility, enhanced therapeutic activities, and digestion in the human body. Accordingly, the current review provides a summary of the phytoconstituents of E. officinalis, pharmacological actions detailing the plant E. officinalis's traditional uses, and especially hyperlipidemic activity. Correspondingly, the article describes the uses of nanotechnology in amla therapeutics and functional ingredients.

Low-density lipoprotein cholesterol lowering therapy for the secondary prevention of atherosclerotic cardiovascular disease

Atherosclerotic cardiovascular disease (ASCVD) is highly prevalent and a major contributor to morbidity and mortality worldwide. Elevated blood cholesterol is a key driver of risk for atherosclerotic events, and patients with established ASCVD comprise a specific high-risk population in which low-density lipoprotein cholesterol (LDL-C) lowering therapy is strongly endorsed by multiple guidelines. An increasing number of medications across several pharmacologic classes are available today in clinical practice. Therefore, guidance on the appropriate use of these interventions is necessary for cost-effective solutions to managing residual atherothrombotic risk. In this review we summarize the key evidence supporting LDL-C lowering as described in the most recent 2018 multi-society Blood Cholesterol Guidelines, and provide a framework for optimizing LDL-C lowering therapy in secondary prevention populations.

Sleeping Beauty Transposon Vectors in Liver-directed Gene Delivery of LDLR and VLDLR for Gene Therapy of Familial Hypercholesterolemia

Plasmid-based Sleeping Beauty (SB) transposon vectors were developed and used to deliver genes for low-density lipoprotein and very-low-density lipoprotein receptors (LDLR and VLDLR, respectively) or lacZ reporter into liver of an LDLR-deficient mouse model of familial hypercholesterolemia (FH). SB transposase, SB100x, was used to integrate the therapeutic transposons into mice livers for evaluating the feasibility of the vectors in reducing high blood cholesterol and the progression of atherosclerosis. Hydrodynamic gene delivery of transposon-VLDLR into the livers of the mice resulted in initial 17-19% reductions in plasma cholesterol, and at the later time points, in a significant stabilization of the cholesterol level for the 6.5-month duration of the study compared to the control mice. Transposon-LDLR-treated animals also demonstrated a trend of stabilization in the cholesterol levels in the long term. Vector-treated mice had slightly less lipid accumulation in the liver and reduced aortic atherosclerosis. Clinical chemistry and histological analyses revealed normal liver function and morphology comparable to that of the controls during the follow-up with no safety issues regarding the vector type, transgenes, or the gene transfer method. The study demonstrates the safety and potential benefits of the SB transposon vectors in the treatment of FH.

Recent developments in modulating atherogenic lipoproteins

PURPOSE OF REVIEW

Randomized clinical trials have assessed the effects of several classes of drugs on plasma cholesterol levels in patients with coronary artery disease. Agents including niacin, fibrates and statins significantly lower LDL-cholesterol, but tolerance issues and undesirable side-effects are common. Residual risk may also be present in patients with persistently low HDL-cholesterol despite a reduction in LDL-cholesterol. Recent trials of drugs that increase circulating HDL-cholesterol have also been disappointing.

RECENT FINDINGS

Ongoing efforts target the development of new pharmacotherapies to reduce circulating levels of atherogenic lipoproteins. The goal of this review is to discuss recent advances in the treatment of coronary artery disease and other vascular diseases characterized by an increase in circulating atherogenic lipoproteins. These include the development of inhibitors of ATP citrate lyase and proprotein convertase subtilisin/kexin type 9. We also discuss recent developments in HDL therapy, including the clinical assessment of cholesteryl ester transfer protein inhibitors and apolipoprotein E mimetic peptides.

SUMMARY

Several new classes of drug are undergoing clinical evaluation that show promise for atherogenic lipoprotein reduction in patients who are statin intolerant.

Anti-inflammatory and cholesterol-reducing properties of apolipoprotein mimetics: a review

Reduced levels of HDL cholesterol (HDL-C) are a strong independent predictor of coronary artery disease (CAD) risk. The major anti-atherogenic function of HDL is to mediate reverse cholesterol transport. This response is highly dependent on apoA-I and apoE, protein components of HDL. Randomized clinical trials have assessed effects of several classes of drugs on plasma cholesterol levels in CAD patients. Agents including cholestyramine, fibrates, niacin, and statins significantly lower LDL cholesterol (LDL-C) and induce modest increases in HDL-C, but tolerance issues and undesirable side effects are common. Additionally, residual risk may be present in patients with persistently low HDL-C and other complications despite a reduction in LDL-C. These observations have fueled interest in the development of new pharmacotherapies that positively impact circulating lipoproteins. The goal of this review is to discuss the therapeutic potential of synthetic apolipoprotein mimetic peptides. These include apoA-I mimetic peptides that have undergone initial clinical assessment. We also discuss newer apoE mimetics that mediate the clearance of atherogenic lipids from the circulation and possess anti-inflammatory properties. One of these (AEM-28) has recently been given orphan drug status and is undergoing clinical trials.

Familial hypercholesterolemia: developments in diagnosis and treatment

BACKGROUND

Familial hypercholesterolemia (FH) is a congenital disorder of lipid metabolism characterized by a marked elevation of the plasma concentration of LDL (low-density lipoprotein) cholesterol beginning in childhood and by the early onset of coronary heart disease. It is among the commonest genetic disorders, with an estimated prevalence in Germany of at least 1 per 500 persons.

METHOD

Review of pertinent literature retrieved by a selective search.

RESULTS

FH is underdiagnosed and undertreated in Germany. It is clinically diagnosed on the basis of an elevated LDL cholesterol concentration (>190 mg/dL [4.9 mmol/L]), a family history of hypercholesterolemia, and early coronary heart disease, or the demonstration of xanthomas. The gold standard of diagnosis is the identification of the underlying genetic defect, which is possible in 80% of cases and enables the identification of affected relatives of the index patient. The recommended goals of treatment, based on the results of observational studies, are to lower the LDL cholesterol concentration by at least 50% or to less than 100 mg/dL (2.6 mmol/L) (for children: <135 mg/dL [3.5 mmol/L]). The target value is lower for patients with clinically overt atherosclerosis (<70 mg/dL [1.8 mmol/L]). Statins, combined with a health-promoting lifestyle, are the treatment of choice. Lipoprotein apheresis is used in very severe cases; its therapeutic effects on clinical endpoints and its side effect profile have not yet been documented in randomized controlled trials.

CONCLUSION

Familial hypercholesterolemia is a common disease that can be diagnosed simply and reliably on clinical grounds and by molecular genetic testing. Timely diagnosis and appropriate treatment can lower the risk of atherosclerosis in heterozygous patients to that of the general population.

HELP LDL apheresis reduces plasma pentraxin 3 in familial hypercholesterolemia

BACKGROUND

Pentraxin 3 (PTX3), a key component of the humoral arm of innate immunity, is secreted by vascular cells in response to injury, possibly aiming at tuning arterial activation associated with vascular damage. Severe hypercholesterolemia as in familial hypercholesterolemia (FH) promotes vascular inflammation and atherosclerosis; low-density lipoprotein (LDL) apheresis is currently the treatment of choice to reduce plasma lipids in FH. HELP LDL apheresis affects pro- and antiinflammatory biomarkers, however its effects on PTX3 levels are unknown. We assessed the impact of FH and of LDL removal by HELP apheresis on PTX3.

METHODS

Plasma lipids, PTX3, and CRP were measured in 19 patients with FH undergoing chronic HELP LDL apheresis before and after treatment and in 20 control subjects. In the patients assessment of inflammation and oxidative stress markers included also plasma TNFα, fibrinogen and TBARS.

RESULTS

At baseline, FH patients had higher (p = 0.0002) plasma PTX3 than matched control subjects. In FH PTX3 correlated positively (p≤0.05) with age, gender and CRP and negatively (p = 0.01) with HELP LDL apheresis vintage. The latter association was confirmed after correction for age, gender and CRP. HELP LDL apheresis acutely reduced (p≤0.04) plasma PTX3, CRP, fibrinogen, TBARS and lipids, but not TNFα. No association was observed between mean decrease in PTX3 and in LDL cholesterol. PTX3 paralleled lipids, oxidative stress and inflammation markers in time-course study.

CONCLUSION

FH is associated with increased plasma PTX3, which is acutely reduced by HELP LDL apheresis independently of LDL cholesterol, as reflected by the lack of association between change in PTX3 and in LDL levels. These results, together with the finding of a negative relationship between PTX3 and duration of treatment suggest that HELP LDL apheresis may influence both acutely and chronically cardiovascular outcomes in FH by modulating PTX3.

Preventing Early Cardiovascular Death in Patients With Familial Hypercholesterolemia

Familial hypercholesterolemia (FH) is an autosomal dominant disorder resulting in severe elevation of total and low-density lipoprotein cholesterol levels. There are more than 600,000 individuals in the United States with FH. Individuals with FH tend to experience premature cardiovascular disease and often die from sudden cardiac death at a young age. Statins alone or in combination with other lipid-lowering medications are effective in managing FH and preventing cardiovascular events. For patients who do not respond to or are intolerant of pharmacotherapy, low-density lipoprotein apheresis is available as a nonpharmacologic treatment option. Despite the prevalence of FH, it is undiagnosed and untreated in the majority of patients. Screening, combined with appropriate drug therapy, can save lives. The authors review the screening, diagnosis, and management of FH.

Bioinspired multiple-interaction model revealed in adsorption of low-density lipoprotein to surface containing saccharide and alkanesulfonate

A new "multiple-interaction model" for low-density lipoprotein (LDL) adsorption to a specific surface containing saccharide and alkanesulfonate ligands is proposed. The model suggests that there are interactions of the saccharide component beyond electrostatic interactions of the alkanesulfonate component that both influence the LDL adsorption process. This concept of multiple interactions between saccharide and LDL was inspired by the similarity in structures of LDL receptors (LDLR), heparin, and heparans used in LDL-apheresis. The model was confirmed by SPR analysis by the adsorption maxima on SAM surfaces with different compositions of saccharide and alkanesulfonate and additionally by CD detection of the conformation of LDL when in contact with saccharide.

Italian multicenter study on low-density lipoprotein apheresis Working Group 2009 survey

We present results of the second survey of the Italian Multicenter Study on Low-Density Lipoprotein Apheresis (IMSLDLa-WG/2). The study involved 18 centers in 2009, treating 66 males and 35 females, mean age 47 ± 18 years. Mean age for initiation of drug treatment before low-density lipoprotein apheresis (LDLa) was 31 ± 18 years, mean age to the first LDLa was 37 ± 20 years and average duration of treatment was 9 ± 6 years. The techniques used included direct adsorption of lipids, dextran sulfate cellulose adsorption, heparin-mediated low-density lipoprotein (LDL) precipitation, cascade filtration, and plasma exchange. The mean treated plasma/blood volumes/session were 3127 ± 518 mL and 8666 ± 1384 mL, respectively. The average plasma volume substituted was 3500 ± 300 mL. Lipid therapy before LDLa included ezetimibe, statins, ω-3 fatty acids and fenofibrate. Baseline mean LDL cholesterol (LDLC) levels were 386 ± 223 mg/dL. The mean before/after apheresis LDLC level decreased by 67% from 250 ± 108 mg/dL (P = 0.05 vs. baseline) to 83 ± 37 mg/dL (P = 0.001 vs. before). Baseline mean Lipoprotein(a) [Lp(a)] level was 179 ± 136 mg/dL. Mean before/after apheresis Lp(a) level decreased by 71% from 133 ± 120 mg/dL (P = 0.05 vs. baseline) to 39 ± 44 mg/dL (P = 0.001 vs. before). Major and minor side effects occurred in 27 and 62 patients, respectively. Among patients with coronary artery disease (CAD), 62.3% had coronary angiography and 50.4% coronary revascularization before LDLa. Single vessel, double vessel and triple vessel CAD occurred in 19 (30.1%), 15 (23.8%) and 29 (46%) patients, respectively. Both CAD and extra-CAD occurred in 41.5%, 39% had hypertension, 9.9% were smokers, 9.9% consumed alcohol and 42% were physically active. Ischemic cardiovascular events were not observed in any patient over 9 ± 6 years of treatment. Two centers have also treated 34 patients (females: 17/males 17; no. sessions: 36; average plasma volume treated: 3000 mL) for sudden hearing loss (SHL). Relief of symptoms was obtained, independently of the system used (HELP; cascade-filtration).

Hyperlipidemia as a risk factor for cardiovascular disease

Elevated levels of blood lipids are well-documented risk factors for cardiovascular disease. Current classification schemes and treatment levels for hyperlipidemia are based on the National Cholesterol Education Panel's Adult Treatment Program-3 (ATP-III) guidelines. Extensive research over the past decade has raised the question whether or not ATP-III guidelines are sufficiently aggressive. New guidelines from ATP-IV are expected to be released in the near future, but in the meantime physicians are faced with uncertainty about how low to target low-density lipoprotein cholesterol, whether to pharmacologically treat high-density lipoprotein cholesterol and triglyceride levels, and how best to achieve target goals.

Apheresis-inducible cytokine pattern change in severe, genetic dyslipidemias

OBJECTIVE

The effects of direct adsorption of lipids LDL-apheresis (DALILDL-a) on plasma cytokines in two Homozygous and heterozygous familial hypercholesterolemic (HozFH, HtzFH) and in four HyperLp(a)lipoproteinemic [HyperLp(a)] patients, were evaluated.

METHODS

Plasma, macrophage inflammatory proteins 1α (MIP-1α), macrophage inflammatory proteins 1β (MIP-1β), monocyte chemoattractant protein-1 (MCP-1), RANTES (Regulated upon Activation, Normal T-cell Expressed, and Secreted), granulocyte-colony stimulating factor (GCSF), granulocyte macrophage-colony stimulating factor (GM-CSF), interleukin-1α (IL-1α), interleukin-1β (IL-1β), interleukin-2 (IL-2), interleukin-6 (IL-6), interferon-γ (IFN-γ), concentrations, were measured before and after LDL-a on three consecutive sessions for each patient.

RESULTS

MIP-1α was significantly reduced (P=0.05), while MIP-1β was significantly increased (P=0.05). Plasma MCP-1 was reduced, although not significantly, while RANTES was significantly increased (P=0.05). GCSF and GM-CSF were both significantly reduced (GM-CSF: P=0.05, GCSF: P=0.05, respectively). IL-1α level was significantly reduced (P=0.001). IL-1β, IL-6, and IFN-γ levels were significantly reduced in plasma after apheresis (IL-1β: P=0.001, IL-6: T1 P=0.001; T2 P=0.05, respectively, IFN-γ: P=0.001). IL-2 level in plasma was significantly reduced at T0, and T2, (P=0.001). However, IL-2 level showed a statistically significant increase at T1 (P=0.001). A significant correlation between IL-1α and IFN-γ was found: r=0.882 (P=0.001).

CONCLUSIONS

In this study LDL-a induced profound changes in several circulating cytokines and promoted anti-inflammatory and anti-atherogenic cytokine profile in plasma of patients with severe dyslipidemia, with pre-existing angiographically demonstrated Coronary heart disease (CHD), and aortic valvular disease (#=1) (AVD).

Lipid and low-density-lipoprotein apheresis. Effects on plasma inflammatory profile and on cytokine pattern in patients with severe dyslipidemia

Available evidence on the effects of therapeutic plasmapheresis (TP) techniques and in particular lipid- and LDL-apheresis (LDL-a) on plasmatic inflammatory mediators including cytokines were reviewed. Studies on this issue are not numerous. However, the review of existing evidence clearly suggests an active role of apheresis on the profile of inflammatory molecules and on cytokine pattern in plasma. These non-lipid-lowering effects can be defined to some extent pleiotropic or pleiotropic-equivalent. Although further studies are desirable, the data reported in this review confirm that lipid- and LDL-a not only show acute lipid-lowering and cholesterol-lowering effects, but also efficacy in reducing several proinflammatory peptides, including cytokines. This effect was not related apparently to lipids and lipoproteins reduction. Thus, TP (lipid- and LDL-a), commonly utilized in the treatment of severe genetically determined lipid disorders, unresponsive to hypolipidemic drugs, offers new possibilities of interpretation of its role in the mechanisms leading to the blockade of atherosclerotic lesion development and progression. The ability of TP on short-term to induce such a profound change in the plasmatic metabolic and inflammatory profiles must be kept in mind in the treatment of acute coronary syndromes, before and after interventions of coronary revascularization, and in the acute phase of cerebrovascular ischemia, at least in patients with severe dyslipidemia. Further studies are needed, in particular aimed at assessing if circulating cytokines may be downregulated by TP not only by direct removal, but through indirect effects on both gene translation and transcription perhaps via the cytokine receptor function.