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Movahedan M, Ellis UM, Barry AR. Efficacy of Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors in Patients with Heterozygous Familial Hypercholesterolemia: A Meta-analysis. Am J Cardiovasc Drugs 2024:10.1007/s40256-024-00682-0. [PMID: 39304616 DOI: 10.1007/s40256-024-00682-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Patients with heterozygous familial hypercholesterolemia (HeFH) are at high risk of major adverse cardiovascular events (MACE) and mortality. Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i), including monoclonal antibodies (alirocumab, evolocumab) and small interfering RNA (inclisiran), substantially reduce lipid levels. This meta-analysis aimed to evaluate the efficacy of both types of PCSK9i specifically in patients with HeFH. METHODS A librarian-assisted systematic search of MEDLINE, Embase, CENTRAL, and ClinicalTrials.gov was performed from 2013 to 2023. Randomized controlled trials of PCSK9i versus control in patients with HeFH were included. No language restrictions were applied. Cochrane Risk-of-Bias tool 2 was used to assess quality of evidence. Meta-analyses were performed using Cochrane ReviewManager. Outcomes included change in atherogenic lipids, MACE, and all-cause death. RESULTS Seven trials were included (N = 2196). Overall risk of bias was mostly low or with some concerns. Median follow-up was 24 weeks. PCSK9i had an uncertain effect on MACE (odds ratio [OR] 1.25, 95% confidence interval [CI] 0.69-2.26) and all-cause death (OR 2.47, 95% CI 0.33-18.26) due to the low event rate and short follow-up. However, PCSK9i significantly reduced low-density lipoprotein cholesterol (LDL-C) by 54% (95% CI 49-58), apolipoprotein B by 43% (95% CI 37-49), and lipoprotein(a) by 20% (95% CI 13-28). CONCLUSIONS In patients with HeFH, PCSK9i significantly reduced atherogenic lipids (LDL-C, apolipoprotein B, and lipoprotein[a]). Despite this, the effect on MACE or all-cause death was unclear. Larger-scale randomized controlled trials of longer duration are needed to validate whether this short-term reduction in lipid levels translates into a reduction in clinically meaningful outcomes.
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Affiliation(s)
- Mahsa Movahedan
- St. Paul's Hospital, Lower Mainland Pharmacy Services, Vancouver, BC, Canada
| | - Ursula M Ellis
- Woodward Library, The University of British Columbia, Vancouver, BC, Canada
| | - Arden R Barry
- Faculty of Pharmaceutical Sciences, The University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada.
- Jim Pattison Outpatient Care and Surgery Centre, Lower Mainland Pharmacy Services, Surrey, BC, Canada.
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2
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Jiang H, Li L, Zhang X, He J, Chen C, Sun R, Chen Y, Xia L, Wen L, Chen Y, Liu J, Zhang L, Lv W. Novel insights into the association between genetically proxied inhibition of proprotein convertase subtilisin/kexin type 9 and risk of sarcopenia. J Cachexia Sarcopenia Muscle 2024. [PMID: 39254080 DOI: 10.1002/jcsm.13575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 07/20/2024] [Accepted: 07/29/2024] [Indexed: 09/11/2024] Open
Abstract
BACKGROUND The effects of lipid-lowering drugs [including statins, ezetimibe, and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors] on hyperlipidaemia have been established. Some may have treatment effects beyond their reported properties, offering potential opportunities for drug repurposing. Epidemiological studies have reported conflicting findings on the relationship between lipid-lowering medication use and sarcopenia risk. METHODS We performed a two-sample Mendelian randomization (MR) study to investigate the causal association between the use of genetically proxied lipid-lowering drugs (including statins, ezetimibe, and PCSK9 inhibitors, which use low-density lipoprotein as a biomarker), and sarcopenia risk. The inverse-variance weighting method was used with pleiotropy-robust methods (MR-Egger regression and weighted median) and colocalization as sensitivity analyses. RESULTS According to the positive control analysis, genetically proxied inhibition in lipid-lowering drug targets was associated with a lower risk of coronary heart disease [PCSK9 (OR, 0.67; 95% CI, 0.61 to 0.72; P = 7.7E-21); 3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGCR; OR, 0.68; 95% CI, 0.57 to 0.82; P = 4.6E-05), and Niemann-Pick C1-like 1 (NPC1L1; OR, 0.53; 95% CI, 0.40 to 0.69; P = 3.3E-06)], consistent with drug mechanistic actions and previous trial evidence. Genetically proxied inhibition of PCSK9 (beta, -0.040; 95% CI, -0.068 to -0.012; P = 0.005) and circulating PCSK9 levels (beta, -0.019; 95% CI, -0.033 to -0.005; P = 0.006) were associated with reduced appendicular lean mass (ALM) with concordant estimates in terms of direction and magnitude. Validation analyses using a second instrument for PCSK9 yielded consistent results in terms of direction and magnitude [(PCSK9 to ALM; beta, -0.052; 95% CI, -0.074 to -0.032; P = 7.1E-7); (PCSK9 protein to ALM; beta, -0.060; 95% CI, -0.106 to -0.014; P = 0.010)]. Genetically proxied inhibition of PCSK9 gene expression in the liver may be associated with reduced ALM (beta, -0.013; 95% CI, -0.035 to 0.009; P = 0.25), consistent with the results of PCSK9 drug-target and PCSK9 protein MR analyses, but the magnitude was less precise. No robust association was found between HMGCR inhibition (beta, 0.048; 95% CI, -0.015 to 0.110; P = 0.14) or NPC1L1 (beta, 0.035; 95% CI, -0.074 to 0.144; P = 0.53) inhibition and ALM, and validation and sensitivity MR analyses showed consistent estimates. CONCLUSIONS This MR study suggested that PCSK9 is involved in sarcopenia pathogenesis and that its inhibition is associated with reduced ALM. These findings potentially pave the way for future studies that may allow personalized selection of lipid-lowering drugs for those at risk of sarcopenia.
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Affiliation(s)
- Hongyan Jiang
- Center of Safety Evaluation and Research, Key Laboratory of Drug Safety Evaluation and Research of Zhejiang Province, Hangzhou Medical College, Zhejiang, China
| | - Lulu Li
- Department of Emergency Medicine, The First Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
| | - Xue Zhang
- Department of Emergency Medicine, The First Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
| | - Jia He
- Center of Safety Evaluation and Research, Key Laboratory of Drug Safety Evaluation and Research of Zhejiang Province, Hangzhou Medical College, Zhejiang, China
| | - Chuanhuai Chen
- Center of Safety Evaluation and Research, Key Laboratory of Drug Safety Evaluation and Research of Zhejiang Province, Hangzhou Medical College, Zhejiang, China
| | - Ruimin Sun
- Center of Safety Evaluation and Research, Key Laboratory of Drug Safety Evaluation and Research of Zhejiang Province, Hangzhou Medical College, Zhejiang, China
| | - Ying Chen
- Center of Safety Evaluation and Research, Key Laboratory of Drug Safety Evaluation and Research of Zhejiang Province, Hangzhou Medical College, Zhejiang, China
| | - Lijuan Xia
- Center of Safety Evaluation and Research, Key Laboratory of Drug Safety Evaluation and Research of Zhejiang Province, Hangzhou Medical College, Zhejiang, China
| | - Lei Wen
- Center of Safety Evaluation and Research, Key Laboratory of Drug Safety Evaluation and Research of Zhejiang Province, Hangzhou Medical College, Zhejiang, China
| | - Yunxiang Chen
- Center of Safety Evaluation and Research, Key Laboratory of Drug Safety Evaluation and Research of Zhejiang Province, Hangzhou Medical College, Zhejiang, China
| | - Junxiu Liu
- Center of Safety Evaluation and Research, Key Laboratory of Drug Safety Evaluation and Research of Zhejiang Province, Hangzhou Medical College, Zhejiang, China
| | - Lijiang Zhang
- Center of Safety Evaluation and Research, Key Laboratory of Drug Safety Evaluation and Research of Zhejiang Province, Hangzhou Medical College, Zhejiang, China
| | - Wanqiang Lv
- Center of Safety Evaluation and Research, Key Laboratory of Drug Safety Evaluation and Research of Zhejiang Province, Hangzhou Medical College, Zhejiang, China
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Raschi E, Casula M, Cicero AFG, Corsini A, Borghi C, Catapano A. Beyond statins: New pharmacological targets to decrease LDL-cholesterol and cardiovascular events. Pharmacol Ther 2023; 250:108507. [PMID: 37567512 DOI: 10.1016/j.pharmthera.2023.108507] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 08/13/2023]
Abstract
The pharmacological treatment of dyslipidemia, a major modifiable risk factor for developing atherosclerotic cardiovascular disease (ASCVD), remains a debated and controversial issue, not only in terms of the most appropriate therapeutic range for lipid levels, but also with regard to the optimal strategy and sequence approach (stepwise vs upstream therapy). Current treatment guidelines for the management of dyslipidemia focus on the intensity of low-density lipoprotein cholesterol (LDL-C) reduction, stratified according to risk for developing ASCVD. Beyond statins and ezetimibe, different medications targeting LDL-C have been recently approved by regulatory agencies with potential innovative mechanisms of action, including proprotein convertase subtilisin/kexin type 9 modulators (monoclonal antibodies such as evolocumab and alirocumab; small interfering RNA molecules such as inclisiran), ATP-citrate lyase inhibitors (bempedoic acid), angiopoietin-like 3 inhibitors (evinacumab), and microsomal triglyceride transfer protein inhibitors (lomitapide). An understanding of their pharmacological aspects, benefit-risk profile, including impact on hard cardiovascular endpoints beyond LDL-C reduction, and potential advantages from the patient perspective (e.g., adherence) - the focus of this evidence-based review - is crucial for practitioners across medical specialties to minimize therapeutic inertia and support clinical practice.
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Affiliation(s)
- Emanuel Raschi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy.
| | - Manuela Casula
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy
| | - Arrigo F G Cicero
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy; IRCCS AOU S. Orsola-Malpighi, Bologna, Italy
| | - Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Claudio Borghi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy; IRCCS AOU S. Orsola-Malpighi, Bologna, Italy
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Ferrell MC, Ernst Z, Ferrell SC, Jaiswal DD, Vassar M. Effects of statin therapies on individuals taking antipsychotics: a systematic review. J Cardiovasc Med (Hagerstown) 2023; 24:481-487. [PMID: 37129919 DOI: 10.2459/jcm.0000000000001489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Patients taking antipsychotics to treat severe mental illness may develop adverse effects such as dyslipidaemia. We aimed to provide an update to a previous systematic review showing statin therapy lowering lipid levels in individuals taking antipsychotics, while further identifying any safety concerns or changes in BMI or blood pressure. In August 2022, we searched MEDLINE, Embase, PsycINFO, PubMed and Cochrane Central Register of Controlled Trials for studies on the effects of statins on lipid profile measures for individuals with severe mental illness taking first- or second-generation antipsychotic medications. Data extraction was performed in a masked duplicate fashion. On the basis of article type, the risk of bias in each study was assessed using ROBINS-I or RoB-2. The GRADE criteria were used for certainty assessment. Our initial search returned 396 articles, of which 6 were included in our analysis. Five of them (83.3%) identified a significant change between baseline and posttreatment lipids. Of the articles recording blood pressure, BMI or weight and significant safety concerns, no significant changes were found. The certainty assessment for this systematic review was rated as moderate. A meta-analysis was not performed. We found that studies continue to demonstrate the use of statin therapy in dyslipidaemia prevention and treatment and, in relation, decrease cardiovascular disease risk through significantly reduced LDL-C levels. Patients at risk of developing dyslipidaemias secondary to antipsychotic treatment should be considered for lipid-lowering therapy with a statin. The limited number of studies included and their heterogeneity demonstrate areas for improvement for future research.
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Affiliation(s)
- Matthew C Ferrell
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences
| | - Zachary Ernst
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences
| | - Sydney C Ferrell
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences
| | - Dev D Jaiswal
- Department of Cardiovascular Medicine, Oklahoma State University Medical Center
| | - Matt Vassar
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences
- Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
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Beltran RA, Zemeir KJ, Kimberling CR, Kneer MS, Mifflin MD, Broderick TL. Is a PCSK9 Inhibitor Right for Your Patient? A Review of Treatment Data for Individualized Therapy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16899. [PMID: 36554779 PMCID: PMC9779535 DOI: 10.3390/ijerph192416899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 06/17/2023]
Abstract
INTRODUCTION In the United States, a significant amount of the population is affected by hyperlipidemia, which is associated with increased levels of serum low-density lipoprotein (LDL-C) and risk of cardiovascular disease. As of 2019, the guidelines set by the American College of Cardiology/American Heart Association advocate for the use of statins as the major contributor to lowering serum LDL-C. While proven to be effective, side effects, including muscle-related symptoms and new-onset diabetes mellitus, can make patients unable to tolerate statin therapy. Additionally, there is a subset of the population which does not approach a recommended LDL-C goal on statin treatment. Due to these findings, it was deemed necessary to review the literature of current statin-alternative lipid-lowering therapies. METHODS A systematic review of preclinical and clinical papers, and a current meta-analysis, was performed using PubMed and Google Scholar. Following the literature review, a meta-analysis was conducted using ProMeta 3. RESULTS Through systematic review and meta-analysis of the current literature, it is suggested that newer lipid-lowering therapies such as proprotein convertase subtilsin-kixen type 9 (PCSK9) inhibitors are a safe and effective statin alternative for the population with statin intolerance. PCSK9 inhibitors were shown to have no significant effect in causing myalgia in patients and showed no increase in adverse cardiovascular outcomes compared to a control of a current antilipemic medication regimen. DISCUSSION There are many statin-alternative therapies that should be investigated further as a potential replacement for patients with statin intolerance or as an addition for patients with statin resistance.
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Affiliation(s)
- Roman A. Beltran
- Department of Biomedical Sciences, College of Graduate Studies, Midwestern University, Glendale, AZ 85308, USA
- College of Osteopathic Medicine, Midwestern University, Glendale, AZ 85308, USA
| | - Kyle J. Zemeir
- Department of Biomedical Sciences, College of Graduate Studies, Midwestern University, Glendale, AZ 85308, USA
- College of Osteopathic Medicine, Midwestern University, Glendale, AZ 85308, USA
| | - Chase R. Kimberling
- Department of Biomedical Sciences, College of Graduate Studies, Midwestern University, Glendale, AZ 85308, USA
| | - Mary S. Kneer
- Department of Biomedical Sciences, College of Graduate Studies, Midwestern University, Glendale, AZ 85308, USA
| | - Michelle D. Mifflin
- College of Osteopathic Medicine, Midwestern University, Glendale, AZ 85308, USA
| | - Tom L. Broderick
- Laboratory of Diabetes and Exercise Metabolism, Department of Physiology, College of Graduate Studies, Midwestern University, Glendale, AZ 85308, USA
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Ahamad S, Bhat SA. Recent Update on the Development of PCSK9 Inhibitors for Hypercholesterolemia Treatment. J Med Chem 2022; 65:15513-15539. [PMID: 36446632 DOI: 10.1021/acs.jmedchem.2c01290] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
The proprotein convertase subtilisin/kexin-type 9 (PCSK9) binds to low-density lipoprotein receptors (LDLR), thereby trafficking them to lysosomes upon endocytosis and enhancing intracellular degradation to prevent their recycling. As a result, the levels of circulating LDL cholesterol (LDL-C) increase, which is a prominent risk factor for developing atherosclerotic cardiovascular diseases (ASCVD). Thus, PCSK9 has become a promising therapeutic target that offers a fertile testing ground for new drug modalities to regulate plasma LDL-C levels to prevent ASCVD. In this review, we have discussed the role of PCSK9 in lipid metabolism and briefly summarized the current clinical status of modalities targeting PCSK9. In particular, a detailed overview of peptide-based PCSK9 inhibitors is presented, which emphasizes their structural features and design, therapeutic effects on patients, and preclinical cardiovascular disease (CVD) models, along with PCSK9 modulation mechanisms. As a promising alternative to monoclonal antibodies (mAbs) for managing LDL-C, anti-PCSK9 peptides are emerging as a prospective next generation therapy.
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Affiliation(s)
- Shakir Ahamad
- Department of Chemistry, Aligarh Muslim University, Aligarh 202002, India
| | - Shahnawaz A Bhat
- Department of Zoology, Aligarh Muslim University, Aligarh 202002, India
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Kakavand H, Aghakouchakzadeh M, Shahi A, Virani SS, Dixon DL, Van Tassell BW, Talasaz AH. A stepwise approach to prescribing novel lipid-lowering medications. J Clin Lipidol 2022; 16:822-832. [DOI: 10.1016/j.jacl.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 09/19/2022] [Accepted: 10/05/2022] [Indexed: 11/05/2022]
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Toth PP, Bray S, Villa G, Palagashvili T, Sattar N, Stroes ESG, Worth GM. Network Meta-Analysis of Randomized Trials Evaluating the Comparative Efficacy of Lipid-Lowering Therapies Added to Maximally Tolerated Statins for the Reduction of Low-Density Lipoprotein Cholesterol. J Am Heart Assoc 2022; 11:e025551. [PMID: 36073669 PMCID: PMC9683660 DOI: 10.1161/jaha.122.025551] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/31/2022] [Indexed: 11/16/2022]
Abstract
Background Lowering low-density lipoprotein cholesterol (LDL-C) levels decreases major cardiovascular events and is recommended for patients at elevated cardiovascular risk. However, appropriate doses of statin therapy are often insufficient to reduce LDL-C in accordance with current guidelines. In such cases, treatment could be supplemented with nonstatin lipid-lowering therapy. Methods and Results A systematic literature review and network meta-analysis were conducted on randomized controlled trials of nonstatin lipid-lowering therapy added to maximally tolerated statins, including statin-intolerant patients. The primary objective was to assess relative efficacy of nonstatin lipid-lowering therapy in reducing LDL-C levels at week 12. Secondary objectives included the following: LDL-C level reduction at week 24 and change in non-high-density lipoprotein cholesterol and apolipoprotein B at week 12. There were 48 randomized controlled trials included in the primary network meta-analysis. All nonstatin agents significantly reduced LDL-C from baseline versus placebo, regardless of background therapy. At week 12, evolocumab, 140 mg every 2 weeks (Q2W)/420 mg once a month, and alirocumab, 150 mg Q2W, were the most efficacious regimens, followed by alirocumab, 75 mg Q2W, alirocumab, 300 mg once a month, inclisiran, bempedoic acid/ezetimibe fixed-dose combination, and ezetimibe and bempedoic acid used as monotherapies. Primary end point results were generally consistent at week 24, and for other lipid end points at week 12. Conclusions Evolocumab, 140 mg Q2W/420 mg once a month, and alirocumab, 150 mg Q2W, were consistently the most efficacious nonstatin regimens when added to maximally tolerated statins to lower LDL-C, non-high-density lipoprotein cholesterol, and apolipoprotein B levels and facilitate attainment of guideline-recommended risk-stratified lipoprotein levels.
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Affiliation(s)
- Peter P. Toth
- Cicarrone Center for the Prevention of Cardiovascular DiseaseJohns Hopkins University School of MedicineBaltimoreMD
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Kong P, Cui ZY, Huang XF, Zhang DD, Guo RJ, Han M. Inflammation and atherosclerosis: signaling pathways and therapeutic intervention. Signal Transduct Target Ther 2022; 7:131. [PMID: 35459215 PMCID: PMC9033871 DOI: 10.1038/s41392-022-00955-7] [Citation(s) in RCA: 284] [Impact Index Per Article: 142.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 03/01/2022] [Accepted: 03/02/2022] [Indexed: 02/08/2023] Open
Abstract
Atherosclerosis is a chronic inflammatory vascular disease driven by traditional and nontraditional risk factors. Genome-wide association combined with clonal lineage tracing and clinical trials have demonstrated that innate and adaptive immune responses can promote or quell atherosclerosis. Several signaling pathways, that are associated with the inflammatory response, have been implicated within atherosclerosis such as NLRP3 inflammasome, toll-like receptors, proprotein convertase subtilisin/kexin type 9, Notch and Wnt signaling pathways, which are of importance for atherosclerosis development and regression. Targeting inflammatory pathways, especially the NLRP3 inflammasome pathway and its regulated inflammatory cytokine interleukin-1β, could represent an attractive new route for the treatment of atherosclerotic diseases. Herein, we summarize the knowledge on cellular participants and key inflammatory signaling pathways in atherosclerosis, and discuss the preclinical studies targeting these key pathways for atherosclerosis, the clinical trials that are going to target some of these processes, and the effects of quelling inflammation and atherosclerosis in the clinic.
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Affiliation(s)
- Peng Kong
- Department of Biochemistry and Molecular Biology, College of Basic Medicine, Key Laboratory of Medical Biotechnology of Hebei Province, Key Laboratory of Neural and Vascular Biology of Ministry of Education, Hebei Medical University, Shijiazhuang, 050017, PR China
| | - Zi-Yang Cui
- Department of Biochemistry and Molecular Biology, College of Basic Medicine, Key Laboratory of Medical Biotechnology of Hebei Province, Key Laboratory of Neural and Vascular Biology of Ministry of Education, Hebei Medical University, Shijiazhuang, 050017, PR China
| | - Xiao-Fu Huang
- Department of Biochemistry and Molecular Biology, College of Basic Medicine, Key Laboratory of Medical Biotechnology of Hebei Province, Key Laboratory of Neural and Vascular Biology of Ministry of Education, Hebei Medical University, Shijiazhuang, 050017, PR China
| | - Dan-Dan Zhang
- Department of Biochemistry and Molecular Biology, College of Basic Medicine, Key Laboratory of Medical Biotechnology of Hebei Province, Key Laboratory of Neural and Vascular Biology of Ministry of Education, Hebei Medical University, Shijiazhuang, 050017, PR China
| | - Rui-Juan Guo
- Department of Biochemistry and Molecular Biology, College of Basic Medicine, Key Laboratory of Medical Biotechnology of Hebei Province, Key Laboratory of Neural and Vascular Biology of Ministry of Education, Hebei Medical University, Shijiazhuang, 050017, PR China
| | - Mei Han
- Department of Biochemistry and Molecular Biology, College of Basic Medicine, Key Laboratory of Medical Biotechnology of Hebei Province, Key Laboratory of Neural and Vascular Biology of Ministry of Education, Hebei Medical University, Shijiazhuang, 050017, PR China.
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Musculoskeletal Adverse Events Associated with PCSK9 Inhibitors: Disproportionality Analysis of the FDA Adverse Event Reporting System. Cardiovasc Ther 2022; 2022:9866486. [PMID: 35140810 PMCID: PMC8808238 DOI: 10.1155/2022/9866486] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/25/2021] [Accepted: 01/12/2022] [Indexed: 01/17/2023] Open
Abstract
Background. Some studies suggest that potential safety issues about PCSK9 inhibitors have not been sufficiently explored in clinical trials, including musculoskeletal adverse events (MAEs). Objective. To examine the association between use of PCSK9 inhibitors with and without concurrent statins and risk of MAEs. Patients and Methods. FDA Adverse Event Reporting System (FAERS) dataset of PCSK9 inhibitors and statins from October 2015 to June 2021 was queried. The reporting odds ratio (ROR) with relevant 95% confidence interval (95% CI) was calculated as the index of disproportionality. Outcome of MAEs of different PCSK9 inhibitors regimens was also investigated. Results. 3,185 cases of PCSK9 inhibitor-associated MAEs were recorded. PCSK9 inhibitor class alone demonstrated a strong link to MAEs (ROR 5.92; 95% CI 5.70-6.15), and evolocumab was associated with more reports of MAEs than alirocumab. Concomitant use with statins leaded to an increased occurrence of MAEs (ROR 32.15 (25.55-40.46)), and the risk differed among different statins. The PCSK9 inhibitors were safer than statins in terms of hospitalization rate and death rate (15.64% vs. 36.83%; 0.72% vs. 3.53%). Conclusions. This pharmacovigilance investigation suggests that PCSK9 inhibitors are associated with MAEs. The risk significantly increases when combined with statins. Increased laboratory and clinical monitoring are required to timely diagnose and manage MAEs.
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Theofilis P, Vordoni A, Koukoulaki M, Vlachopanos G, Kalaitzidis RG. Dyslipidemia in Chronic Kidney Disease: Contemporary Concepts and Future Therapeutic Perspectives. Am J Nephrol 2021; 52:693-701. [PMID: 34569479 DOI: 10.1159/000518456] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 07/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is an increasingly prevalent disease state met with great morbidity and mortality primarily resulting from the high incidence of adverse cardiovascular outcomes. Therapeutic strategies in this patient population aim at controlling modifiable cardiovascular risk factors, including dyslipidemia. SUMMARY In this review article, we first provide the latest pathophysiologic evidence regarding the altered dyslipidemia pattern in CKD, followed by its contemporary management according to the latest guidelines. Moreover, we present the current progress regarding the emerging therapeutic strategies. Key Messages: The presence of renal impairment leads to alterations in cholesterol structure, metabolism, and reverse transport paired with increased oxidative stress. Statins remain the cornerstone of dyslipidemia management in patients with kidney dysfunction who are at risk for cardiovascular events. However, their efficacy is debatable in end-stage renal disease under renal replacement therapy. Therefore, novel treatment approaches aiming at hypertriglyceridemia, proprotein convertase subtilisin/kexin type 9, and lipoprotein(a) are under rigorous investigation while the research of gut microbiome might provide additional mechanistic and therapeutic insight.
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Affiliation(s)
| | - Aikaterini Vordoni
- Department of Nephrology, General Hospital of Nikaia-Piraeus, Athens, Greece
| | - Maria Koukoulaki
- Department of Nephrology, General Hospital of Nikaia-Piraeus, Athens, Greece
| | | | - Rigas G Kalaitzidis
- Department of Nephrology, General Hospital of Nikaia-Piraeus, Athens, Greece
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Qin J, Liu L, Su XD, Wang BB, Fu BS, Cui JZ, Liu XY. The effect of PCSK9 inhibitors on brain stroke prevention: A systematic review and meta-analysis. Nutr Metab Cardiovasc Dis 2021; 31:2234-2243. [PMID: 34052073 DOI: 10.1016/j.numecd.2021.03.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 03/18/2021] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND AIMS Although proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been shown to improve cardiovascular outcomes, their effects on brain stroke risk are unclear. The present meta-analysis aimed to evaluate the effects of PCSK9 inhibitors on brain stroke prevention. METHODS AND RESULTS We searched PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov for research published until December 30, 2020, to find randomized controlled trials (RCTs) of PCSK9 inhibitors for brain stroke prevention. Relative risk (RR) and 95% confidence intervals (CIs) were used to represent the outcomes. Seven RCTs with 57,440 participants, including 29,850 patients treated with PCSK9 inhibitors and 27,590 control participants, were included. PCSK9 inhibitors were associated with significant reductions in total brain stroke risk (RR, 0.77; 95% CI, 0.67-0.88; P < 0.001) and ischemic brain stroke risk (RR, 0.76; 95% CI, 0.66, 0.89; P < 0.001) in comparison with the control group. There was no significant difference in cardiovascular mortality (RR, 0.95; 95% CI, 0.84-1.07; P = 0.382) and the risk of hemorrhagic brain stroke (RR, 1.00; 95% CI, 0.66-1.51; P = 0.999) between patients treated with PCSK9 inhibitors and controls. PCSK9 inhibitors did not significantly increase the incidence of neurocognitive adverse events (RR, 1.02; 95% CI, 0.81-1.29; P = 0.85). Moreover, subgroup analysis showed no difference in cognitive function disorder risks among different PCSK9 inhibitors and treatment times. CONCLUSIONS PCSK9 inhibitors significantly reduced the risk of total brain stroke and ischemic brain stroke without increasing the risk of brain hemorrhage and neurocognitive impairment.
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Affiliation(s)
- Jin Qin
- Neurology Department, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 05000, China
| | - Lin Liu
- Neurology Department, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 05000, China
| | - Xu D Su
- Neurology Department, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 05000, China
| | - Bin B Wang
- Neurology Department, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 05000, China
| | - Bao S Fu
- Neurology Department, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 05000, China
| | - Jun Z Cui
- Neurology Department, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 05000, China
| | - Xiao Y Liu
- Neurology Department, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 05000, China.
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13
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Barale C, Melchionda E, Morotti A, Russo I. PCSK9 Biology and Its Role in Atherothrombosis. Int J Mol Sci 2021; 22:ijms22115880. [PMID: 34070931 PMCID: PMC8198903 DOI: 10.3390/ijms22115880] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/11/2022] Open
Abstract
It is now about 20 years since the first case of a gain-of-function mutation involving the as-yet-unknown actor in cholesterol homeostasis, proprotein convertase subtilisin/kexin type 9 (PCSK9), was described. It was soon clear that this protein would have been of huge scientific and clinical value as a therapeutic strategy for dyslipidemia and atherosclerosis-associated cardiovascular disease (CVD) management. Indeed, PCSK9 is a serine protease belonging to the proprotein convertase family, mainly produced by the liver, and essential for metabolism of LDL particles by inhibiting LDL receptor (LDLR) recirculation to the cell surface with the consequent upregulation of LDLR-dependent LDL-C levels. Beyond its effects on LDL metabolism, several studies revealed the existence of additional roles of PCSK9 in different stages of atherosclerosis, also for its ability to target other members of the LDLR family. PCSK9 from plasma and vascular cells can contribute to the development of atherosclerotic plaque and thrombosis by promoting platelet activation, leukocyte recruitment and clot formation, also through mechanisms not related to systemic lipid changes. These results further supported the value for the potential cardiovascular benefits of therapies based on PCSK9 inhibition. Actually, the passive immunization with anti-PCSK9 antibodies, evolocumab and alirocumab, is shown to be effective in dramatically reducing the LDL-C levels and attenuating CVD. While monoclonal antibodies sequester circulating PCSK9, inclisiran, a small interfering RNA, is a new drug that inhibits PCSK9 synthesis with the important advantage, compared with PCSK9 mAbs, to preserve its pharmacodynamic effects when administrated every 6 months. Here, we will focus on the major understandings related to PCSK9, from its discovery to its role in lipoprotein metabolism, involvement in atherothrombosis and a brief excursus on approved current therapies used to inhibit its action.
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MESH Headings
- Antibodies, Monoclonal, Humanized/therapeutic use
- Atherosclerosis/drug therapy
- Atherosclerosis/enzymology
- Atherosclerosis/genetics
- Atherosclerosis/pathology
- Blood Platelets/drug effects
- Blood Platelets/enzymology
- Blood Platelets/pathology
- Cholesterol, LDL/antagonists & inhibitors
- Cholesterol, LDL/metabolism
- Dyslipidemias/drug therapy
- Dyslipidemias/enzymology
- Dyslipidemias/genetics
- Dyslipidemias/pathology
- Fibrinolytic Agents/therapeutic use
- Gene Expression Regulation
- Humans
- Hypolipidemic Agents/therapeutic use
- Lipid Metabolism/drug effects
- Lipid Metabolism/genetics
- PCSK9 Inhibitors
- Plaque, Atherosclerotic/drug therapy
- Plaque, Atherosclerotic/enzymology
- Plaque, Atherosclerotic/genetics
- Plaque, Atherosclerotic/pathology
- Platelet Activation/drug effects
- Proprotein Convertase 9/biosynthesis
- Proprotein Convertase 9/genetics
- RNA, Small Interfering/therapeutic use
- Receptors, LDL/genetics
- Receptors, LDL/metabolism
- Signal Transduction
- Thrombosis/enzymology
- Thrombosis/genetics
- Thrombosis/pathology
- Thrombosis/prevention & control
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14
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Diener HC, Hankey GJ. Primary and Secondary Prevention of Ischemic Stroke and Cerebral Hemorrhage: JACC Focus Seminar. J Am Coll Cardiol 2020; 75:1804-1818. [PMID: 32299593 DOI: 10.1016/j.jacc.2019.12.072] [Citation(s) in RCA: 172] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/12/2019] [Accepted: 12/22/2019] [Indexed: 01/30/2023]
Abstract
Stroke is a leading cause of permanent disability. Therefore, primary prevention of first stroke and secondary prevention of recurrent stroke are a high priority. Primary prevention of ischemic stroke includes lifestyle modification and diet, treatment of risk factors including hypertension, diabetes mellitus and lipid disorders, antiplatelet therapy for high vascular risk patients, and anticoagulation in atrial fibrillation. Secondary prevention of ischemic stroke includes additional carotid surgery or stenting in selected symptomatic patients, closure of patent foramen ovale after cryptogenic stroke, treatment of insulin resistance, and best medical treatment of intracranial stenosis. The most important preventive strategies in the primary and secondary prevention of cerebral hemorrhage include the treatment of hypertension, reduction in alcohol intake, and occlusion of the left atrial appendage in patients with atrial fibrillation and permanent contraindications for oral anticoagulation.
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Affiliation(s)
- Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty, University Duisburg-Essen, Essen, Germany.
| | - Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
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15
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Estimation of the major cardiovascular events prevention with Inclisiran. Atherosclerosis 2020; 313:76-80. [DOI: 10.1016/j.atherosclerosis.2020.09.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/18/2020] [Accepted: 09/23/2020] [Indexed: 12/17/2022]
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16
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Abstract
PURPOSE OF REVIEW To review the recent evidence for lipid management in type 1 diabetes (T1D) for cardiovascular risk reduction. RECENT FINDINGS Individuals with T1D are at increased risk for cardiovascular morbidity and mortality, with atherosclerosis beginning as early as adolescence. Elevated low-density lipoprotein cholesterol (LDL-C), triglycerides, and lipoprotein (a) are associated with increased cardiovascular risk in T1D. Although high-density lipoprotein cholesterol (HDL-C) in T1D is often normal or higher than in nondiabetic controls, HDL in T1D has structural alterations, which make it proatherogenic rather than cardioprotective. Similarly, although LDL-C is not particularly elevated in T1D, LDL still contributes to cardiovascular risk. Studies in individuals with diabetes have primarily included T2D participants, with a much smaller number of T1D participants; such studies have shown that lipid-lowering therapies, such as statins, ezetimibe, and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors reduce LDL-C levels and cardiovascular events in both those with and without diabetes. Individuals with T1D have increased cholesterol absorption, suggesting that ezetimibe may be particularly effective in T1D. Results of the REDUCE-IT trial show cardiovascular risk reduction from high-dose omega-3 fatty acid (Icosapent Ethyl) therapy in patients with diabetes (primarily type 2 diabetes), independent of triglyceride lowering, but similar data in T1D are currently lacking. SUMMARY Individuals with T1D are at high risk of cardiovascular disease, necessitating close lipid monitoring and management from adolescence through adulthood.
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Affiliation(s)
- Shoshana Tell
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kristen J. Nadeau
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Robert H. Eckel
- Division of Endocrinology and Metabolism, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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17
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Cordero A, Rodríguez-Mañero M, Fácila L, Fernández-Olmo MR, Gómez-Martínez MJ, Valle A, Castellano JM, Toro MM, Seijas-Amigo J, Vicedo A, González-Juanatey JR. Prevention of myocardial infarction and stroke with PCSK9 inhibitors treatment: a metanalysis of recent randomized clinical trials. J Diabetes Metab Disord 2020; 19:759-765. [PMID: 33520801 DOI: 10.1007/s40200-020-00557-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/18/2020] [Accepted: 05/26/2020] [Indexed: 12/11/2022]
Abstract
Purpose Proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors treatment induce large reductions in low-density lipoprotein cholesterol (LDLc) and major cardiovascular events. Clinical trials might have been underpowered to test the effect of PSCK9 inhibitors treatment on myocardial infarction and stroke, two of the most relevant cardiovascular events, since all analyzed a combined endpoint. Methods we performed a meta-analysis, with currently available studies involving PCSK9 inhibitors and event rate adjudication, with the aim of assessing treatment effects on myocardial infarction and stroke. Results We included 81,700 patients, 41,979 treated with a PSCK9 inhibitors: 17,244 with evolocumab; 13,720 with bococizumab and 11,015 with alirocumab. A total of 1,319 cases of myocardial infarctions were registered in the treatment group vs. 1,608 in controls, resulting in 19.0% reduction associated with PCSK9 treatment (RR: 0.81, 95% CI 0.76-0.87). Similarly, PCSK9 inhibitors treatment resulted in a 25% reduction of stroke (RR: 0.75, 95% CI 0.65-0.85) when all studies were analyzed together and the statistically significant heterogeneity was not observed in the analysis restricted to end-point based clinical trials. PCSK9 inhibitors treatment had no effect on mortality (RR: 0.95, 95% CI 0.86-1.04). Conclusions PCSK9 inhibitors reduce the incidence of myocardial infarction by 19% and stroke by 25%.
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Affiliation(s)
- Alberto Cordero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Department, Hospital Universitario de San Juan, Carretera Valencia-Alicante sn, San Juan de Alicante, 03550 Spain
| | - Moisés Rodríguez-Mañero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
| | - Lorenzo Fácila
- Cardiology Department, Hospital General Universitario de Valencia, Valencia, Spain
| | | | | | - Alfonso Valle
- Cardiology Department, Hospital de Denia, Denia, Spain
| | - Jose Mª Castellano
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Cardiology Department, Hospitales de Madrid, Madrid, Spain
| | | | - José Seijas-Amigo
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
| | - Alvaro Vicedo
- Cardiology Department, Hospital de Denia, Denia, Spain
| | - José R González-Juanatey
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
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18
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Ruscica M, Corsini A, Ferri N, Banach M, Sirtori CR. Clinical approach to the inflammatory etiology of cardiovascular diseases. Pharmacol Res 2020; 159:104916. [PMID: 32445957 PMCID: PMC7238995 DOI: 10.1016/j.phrs.2020.104916] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 02/06/2023]
Abstract
Inflammation is an obligatory marker of arterial disease, both stemming from the inflammatory activity of cholesterol itself and from well-established molecular mechanisms. Raised progenitor cell recruitment after major events and clonal hematopoiesis related mechanisms have provided an improved understanding of factors regulating inflammatory phenomena. Trials with inflammation antagonists have led to an extensive evaluation of biomarkers such as the high sensitivity C reactive protein (hsCRP), not exerting a causative role, but frequently indicative of the individual cardiovascular (CV) risk. Aim of this review is to provide indication on the anti-inflammatory profile of agents of general use in CV prevention, i.e. affecting lipids, blood pressure, diabetes as well nutraceuticals such as n-3 fatty acids. A crucial issue in the evaluation of the benefit of the anti-inflammatory activity is the frequent discordance between a beneficial activity on a major risk factor and associated changes of hsCRP, as in the case of statins vs PCSK9 antagonists. In hypertension, angiotensin converting enzyme inhibitors exert an optimal anti-inflammatory activity, vs the case of sartans. The remarkable preventive activity of SLGT-2 inhibitors in heart failure is not associated with a clear anti-inflammatory mechanism. Finally, icosapent ethyl has been shown to reduce the CV risk in hypertriglyceridemia, with a 27 % reduction of hsCRP. The inflammation-based approach to arterial disease has considerably gained from an improved understanding of the clinical diagnostic strategy and from a better knowledge on the mode of action of numerous agents, including nutraceuticals.
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Affiliation(s)
- Massimiliano Ruscica
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, Milan, Italy
| | - Alberto Corsini
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, Milan, Italy; Multimedica IRCCS, Milano, Italy
| | - Nicola Ferri
- Dipartimento di Scienze del Farmaco, Università degli Studi di Padova, Padua, Italy
| | - Maciej Banach
- Department of Hypertension, WAM University Hospital in Lodz, Medical University of Lodz, Lodz, Poland; Polish Mother's Memorial Hospital Research Institute (PMMHRI), Lodz, Poland; Cardiovascular Research Centre, University of Zielona Gora, Zielona Gora, Poland.
| | - Cesare R Sirtori
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, Milan, Italy
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19
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Mu G, Xiang Q, Zhou S, Liu Z, Qi L, Jiang J, Gong Y, Xie Q, Wang Z, Zhang H, Huo Y, Cui Y. Efficacy and Safety of PCSK9 Monoclonal Antibodies in Patients at High Cardiovascular Risk: An Updated Systematic Review and Meta-Analysis of 32 Randomized Controlled Trials. Adv Ther 2020; 37:1496-1521. [PMID: 32108309 DOI: 10.1007/s12325-020-01259-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibodies are powerful lipid-lowering drugs which have been shown to improve clinical endpoints in patients with hypercholesterolemia. However, it is not clear how effective PCSK9 monoclonal antibodies are for patients at high cardiovascular risk. Also, whether the effectiveness of PCSK9 monoclonal antibodies varies between different drug types, dosages, race, and indications for PCSK9 monoclonal antibodies remains unclear. Therefore, we used recently published studies to systematically evaluate the efficacy and safety of PCSK9 monoclonal antibodies by analyzing the lipid profiles, adverse events, and clinical endpoints in patients at high cardiovascular risk. METHODS Randomized controlled trials (RCTs) comparing PCSK9 monoclonal antibodies with placebos or active drugs in patients at high cardiovascular risk were retrieved from electronic databases from their inception until November 2019. Efficacy and safety outcomes included low-density lipoprotein cholesterol (LDL-C) and other lipid profiles, treatment-emergent adverse events (TEAEs) and adverse events of interests, and clinical endpoints. Subgroup analyses based on drug types, dosing, and race were conducted. Statistical analysis was performed using STATA 15.1 and RevMan 5.0. RESULTS Thirty-two RCTs were included in the systematic review, and 25 of them (57,090 individuals) were included in the meta-analysis. PCSK9 monoclonal antibodies significantly improved LDL-C and other lipid profiles (P < 0.05), and no racial differences were found. A recommended dose of 140 mg of evolocumab every 2 weeks was likely to produce a relatively stronger effect than 150 mg of alirocumab every 2 weeks in terms of the absolute change (weighted mean differences (WMD) - 0.36; 95% confidence interval (CI) - 0.71 to - 0.01; P = 0.041) and percent change (WMD - 19.53; 95% CI - 32.02 to - 7.04; P = 0.002) in LDL-C levels. Overall, PCSK9 monoclonal antibodies were safe, except for the significantly increased risk of injection site reactions (relative risks (RR) 1.54; 95% CI 1.38-1.71; P < 0.001). Both alirocumab (RR 0.89; 95% CI 0.83-0.95; P < 0.001) and evolocumab (RR 0.86; 95% CI 0.80-0.92; P < 0.001) were associated with a lower risk of major cardiovascular events (MACEs), especially in secondary preventive patients (alirocumab group: RR 0.88; 95% CI 0.82-0.95; P < 0.001; evolocumab group: RR 0.86; 95% CI 0.80-0.92; P < 0.001). The reduction in MACEs was observed in White but not in Asian subjects. No significant reduction of all-cause mortality was found (RR 0.88; 95% CI 0.72-1.07; P = 0.182). CONCLUSION Both alirocumab and evolocumab are well tolerated and can greatly improve lipid profiles for patients at high cardiovascular risk. Both PCSK9 monoclonal antibodies significantly reduce the risk of nonfatal MACEs in patients with previous cardiovascular events, but the effect on all-cause mortality remains uncertain.
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Affiliation(s)
- Guangyan Mu
- Department of Pharmacy, Peking University First Hospital, 6# Dahongluochang Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, 6# Dahongluochang Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Shuang Zhou
- Department of Pharmacy, Peking University First Hospital, 6# Dahongluochang Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, 6# Dahongluochang Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Litong Qi
- Department of Cardiology, Peking University First Hospital, 8# Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Jie Jiang
- Department of Cardiology, Peking University First Hospital, 8# Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Yanjun Gong
- Department of Cardiology, Peking University First Hospital, 8# Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Qiufen Xie
- Department of Pharmacy, Peking University First Hospital, 6# Dahongluochang Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Zining Wang
- Department of Pharmacy, Peking University First Hospital, 6# Dahongluochang Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Hanxu Zhang
- Department of Pharmacy, Peking University First Hospital, 6# Dahongluochang Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, 8# Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, 6# Dahongluochang Street, Xicheng District, Beijing, 100034, People's Republic of China.
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20
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Pontremoli R, Bellizzi V, Bianchi S, Bigazzi R, Cernaro V, Del Vecchio L, De Nicola L, Leoncini G, Mallamaci F, Zoccali C, Buemi M. Management of dyslipidaemia in patients with chronic kidney disease: a position paper endorsed by the Italian Society of Nephrology. J Nephrol 2020; 33:417-430. [PMID: 32065354 PMCID: PMC7220980 DOI: 10.1007/s40620-020-00707-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 01/24/2020] [Indexed: 12/19/2022]
Abstract
Chronic kidney disease (CKD) represents a major public health issue worldwide and entails a high burden of cardiovascular events and mortality. Dyslipidaemia is common in patients with CKD and it is characterized by a highly atherogenic profile with relatively low levels of HDL-cholesterol and high levels of triglyceride and oxidized LDL-cholesterol. Overall, current literature indicates that lowering LDL-cholesterol is beneficial for preventing major atherosclerotic events in patients with CKD and in kidney transplant recipients while the evidence is less clear in patients on dialysis. Lipid lowering treatment is recommended in all patients with stage 3 CKD or worse, independently of baseline LDL-cholesterol levels. Statin and ezetimibe are the cornerstones in the management of dyslipidaemia in patients with CKD, however alternative and emerging lipid-lowering therapies may acquire a central role in near future. This position paper endorsed by the Italian Society of Nephrology aims at providing useful information on the topic of dyslipidaemia in CKD and at assisting decision making in the management of these patients.
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Affiliation(s)
- Roberto Pontremoli
- Università degli Studi and I.R.C.C.S. Ospedale Policlinico San Martino, Viale Benedetto XV 6, 16132, Genoa, Italy.
| | - Vincenzo Bellizzi
- Division of Nephrology, Dialysis and Transplantation, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Via San Leonardo, 84131, Salerno, Italy
| | - Stefano Bianchi
- Nephrology and Dialysis Complex Operative Unit, Department of Internal Medicine, ASL Toscana Nordovest, Livorno, Italy
| | - Roberto Bigazzi
- Nephrology and Dialysis Complex Operative Unit, Department of Internal Medicine, ASL Toscana Nordovest, Livorno, Italy
| | - Valeria Cernaro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria 1, 98125, Messina, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, A. Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - Luca De Nicola
- Nephrology Division, Department of Advanced Medical and Surgical Sciences, University of Campania "L. Vanvitelli", Piazza Miraglia, 80138, Naples, Italy
| | - Giovanna Leoncini
- Università degli Studi and I.R.C.C.S. Ospedale Policlinico San Martino, Viale Benedetto XV 6, 16132, Genoa, Italy
| | - Francesca Mallamaci
- Nephrology, Dialysis and Transplantation Unit, Ospedali Riuniti, Reggio Calabria, Italy.,CNR-IFC, Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, Nefrologia-Ospedali Riuniti, 89100, Reggio Calabria, Italy
| | - Carmine Zoccali
- Nephrology, Dialysis and Transplantation Unit, Ospedali Riuniti, Reggio Calabria, Italy
| | - Michele Buemi
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria 1, 98125, Messina, Italy
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21
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Macchi C, Sirtori CR, Corsini A, Santos RD, Watts GF, Ruscica M. A new dawn for managing dyslipidemias: The era of rna-based therapies. Pharmacol Res 2019; 150:104413. [PMID: 31449975 DOI: 10.1016/j.phrs.2019.104413] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 08/08/2019] [Accepted: 08/22/2019] [Indexed: 12/24/2022]
Abstract
The high occurrence of atherosclerotic cardiovascular disease (ASCVD) events is still a major public health issue. Although a major determinant of ASCVD event reduction is the absolute change of low-density lipoprotein-cholesterol (LDL-C), considerable residual risk remains and new therapeutic options are required, in particular, to address triglyceride-rich lipoproteins and lipoprotein(a) [Lp(a)]. In the era of Genome Wide Association Studies and Mendelian Randomization analyses aimed at increasing the understanding of the pathophysiology of ASCVD, RNA-based therapies may offer more effective treatment options. The advantage of oligonucleotide-based treatments is that drug candidates are targeted at highly specific regions of RNA that code for proteins that in turn regulate lipid and lipoprotein metabolism. For LDL-C lowering, the use of inclisiran - a silencing RNA that inhibits proprotein convertase subtilisin/kexin type 9 (PCSK9) synthesis - has the advantage that a single s.c. injection lowers LDL-C for up to 6 months. In familial hypercholesterolemia, the use of the antisense oligonucleotide (ASO) mipomersen, targeting apolipoprotein (apoB) to reduce LDL-C, has been a valuable therapeutic approach, despite unquestionable safety concerns. The availability of specific ASOs lowering Lp(a) levels will allow rigorous testing of the Lp(a) hypothesis; by dramatically reducing plasma triglyceride levels, Volanesorsen (APOC3) and angiopoietin-like 3 (ANGPTL3)-LRx will further clarify the causality of triglyceride-rich lipoproteins in ASCVD. The rapid progress to date heralds a new dawn in therapeutic lipidology, but outcome, safety and cost-effectiveness studies are required to establish the role of these new agents in clinical practice.
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Affiliation(s)
- C Macchi
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, Milan, Italy
| | - C R Sirtori
- Dyslipidemia Center, A.S.S.T. Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - A Corsini
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, Milan, Italy; IRCCS Multimedica, Milan, Italy
| | - R D Santos
- Lipid Clinic, Heart Institute (InCor), University of Sao Paulo, Brazil; Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - G F Watts
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia; Lipid Disorders Clinic, Cardiometabolic Services, Department of Cardiology, Royal Perth Hospital, Australia.
| | - M Ruscica
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, Milan, Italy
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