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Koschinsky ML, Stroes ESG, Kronenberg F. Daring to dream: Targeting lipoprotein(a) as a causal and risk-enhancing factor. Pharmacol Res 2023; 194:106843. [PMID: 37406784 DOI: 10.1016/j.phrs.2023.106843] [Citation(s) in RCA: 5] [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: 04/07/2023] [Revised: 06/15/2023] [Accepted: 06/27/2023] [Indexed: 07/07/2023]
Abstract
Lipoprotein(a) [Lp(a)], a distinct lipoprotein class, has become a major focus for cardiovascular research. This review is written in light of the recent guideline and consensus statements on Lp(a) and focuses on 1) the causal association between Lp(a) and cardiovascular outcomes, 2) the potential mechanisms by which elevated Lp(a) contributes to cardiovascular diseases, 3) the metabolic insights on the production and clearance of Lp(a) and 4) the current and future therapeutic approaches to lower Lp(a) concentrations. The concentrations of Lp(a) are under strict genetic control. There exists a continuous relationship between the Lp(a) concentrations and risk for various endpoints of atherosclerotic cardiovascular disease (ASCVD). One in five people in the Caucasian population is considered to have increased Lp(a) concentrations; the prevalence of elevated Lp(a) is even higher in black populations. This makes Lp(a) a cardiovascular risk factor of major public health relevance. Besides the association between Lp(a) and myocardial infarction, the relationship with aortic valve stenosis has become a major focus of research during the last decade. Genetic studies provided strong support for a causal association between Lp(a) and cardiovascular outcomes: carriers of genetic variants associated with lifelong increased Lp(a) concentration are significantly more frequent in patients with ASCVD. This has triggered the development of drugs that can specifically lower Lp(a) concentrations: mRNA-targeting therapies such as anti-sense oligonucleotide (ASO) therapies and short interfering RNA (siRNA) therapies have opened new avenues to lower Lp(a) concentrations more than 95%. Ongoing Phase II and III clinical trials of these compounds are discussed in this review.
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Affiliation(s)
- Marlys L Koschinsky
- Robarts Research Institute, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada; Department of Physiology & Pharmacology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Florian Kronenberg
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria.
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2
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Milosavljevic MN, Stefanovic SM, Pejcic AV. Potential Novel RNA-Targeting Agents for Effective Lipoprotein(a) Lowering: A Systematic Assessment of the Evidence From Completed and Ongoing Developmental Clinical Trials. J Cardiovasc Pharmacol 2023; 82:1-12. [PMID: 37070852 DOI: 10.1097/fjc.0000000000001429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 03/25/2023] [Indexed: 04/19/2023]
Abstract
ABSTRACT An increase in blood lipoprotein (a) [Lp(a)] levels, mostly genetically determined, has been identified as an independent risk factor of atherosclerotic cardiovascular disease. No drug has yet been approved that markedly lowers Lp(a) and thereby reduces residual cardiovascular risk. The aim of this article was to critically review the evidence from clinical development studies to date on the efficacy and safety of new RNA-based therapeutics for targeted lowering of Lp(a). PubMed/MEDLINE, Scopus, Web of Science, and ClinicalTrials.gov were searched without any language or date restriction up to November 5, 2022, and a total of 12 publications and 22 trial records were included. Several drugs were found that are currently in various stages of clinical development, such as the antisense oligonucleotide pelacarsen and the small interfering RNA molecule olpasiran and drugs coded as SLN360 and LY3819469. Among them, pelacarsen has progressed the most, currently reaching phase 3. All these drugs have so far shown satisfactory pharmacokinetic properties, consistently high and stable, dose-dependent efficacy in lowering Lp(a) even by more than 90%, with an acceptable safety profile in subjects with highly elevated Lp(a). In addition, reports of early clinical trials with pelacarsen imply a promising suppressive effect on key mechanisms of atherogenesis. Future research should focus on confirming these beneficial clinical effects in patients with lower average Lp(a) levels and clearly demonstrating the association between lowering Lp(a) and reducing adverse cardiovascular outcomes.
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Affiliation(s)
- Milos N Milosavljevic
- Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Srdjan M Stefanovic
- Department of Pharmacy, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia; and
- Department of Clinical Pharmacology, University Clinical Center Kragujevac, Kragujevac, Serbia
| | - Ana V Pejcic
- Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
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3
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Kronenberg F, Mora S, Stroes ESG, Ference BA, Arsenault BJ, Berglund L, Dweck MR, Koschinsky ML, Lambert G, Mach F, McNeal CJ, Moriarty PM, Natarajan P, Nordestgaard BG, Parhofer KG, Virani SS, von Eckardstein A, Watts GF, Stock JK, Ray KK, Tokgözoğlu LS, Catapano AL. Frequent questions and responses on the 2022 lipoprotein(a) consensus statement of the European Atherosclerosis Society. Atherosclerosis 2023; 374:107-120. [PMID: 37188555 DOI: 10.1016/j.atherosclerosis.2023.04.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 04/25/2023] [Indexed: 05/17/2023]
Abstract
In 2022, the European Atherosclerosis Society (EAS) published a new consensus statement on lipoprotein(a) [Lp(a)], summarizing current knowledge about its causal association with atherosclerotic cardiovascular disease (ASCVD) and aortic stenosis. One of the novelties of this statement is a new risk calculator showing how Lp(a) influences lifetime risk for ASCVD and that global risk may be underestimated substantially in individuals with high or very high Lp(a) concentration. The statement also provides practical advice on how knowledge about Lp(a) concentration can be used to modulate risk factor management, given that specific and highly effective mRNA-targeted Lp(a)-lowering therapies are still in clinical development. This advice counters the attitude: "Why should I measure Lp(a) if I can't lower it?". Subsequent to publication, questions have arisen relating to how the recommendations of this statement impact everyday clinical practice and ASCVD management. This review addresses 30 of the most frequently asked questions about Lp(a) epidemiology, its contribution to cardiovascular risk, Lp(a) measurement, risk factor management and existing therapeutic options.
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Affiliation(s)
- Florian Kronenberg
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria.
| | - Samia Mora
- Center for Lipid Metabolomics, Division of Preventive Medicine, and Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Brian A Ference
- Centre for Naturally Randomized Trials, University of Cambridge, Cambridge, UK
| | - Benoit J Arsenault
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, and Department of Medicine, Faculty of Medicine, Université Laval, Québec City, QC, Canada
| | - Lars Berglund
- Department of Internal Medicine, School of Medicine, University of California-Davis, Davis, CA, USA
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, Edinburgh Heart Centre, University of Edinburgh, Chancellors Building, Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Marlys L Koschinsky
- Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Gilles Lambert
- Inserm, UMR 1188 Diabète Athérothrombose Thérapies Réunion Océan Indien (DéTROI), Université de La Réunion, 97400, Saint-Pierre, La Réunion, France
| | - François Mach
- Department of Cardiology, Geneva University Hospital, Geneva, Switzerland
| | - Catherine J McNeal
- Division of Cardiology, Department of Internal Medicine Baylor Scott & White Health, 2301 S. 31st St., Temple, TX, 76508, USA
| | - Patrick M Moriarty
- Atherosclerosis and Lipoprotein-apheresis Clinic, University of Kansas Medical Center, Kansas City, KS, USA
| | - Pradeep Natarajan
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; and Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | - Børge G Nordestgaard
- Department of Clinical Biochemistry and the Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Klaus G Parhofer
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians University Klinikum, Munich, Germany
| | - Salim S Virani
- The Aga Khan University, Karachi, Pakistan; Texas Heart Institute, Baylor College of Medicine, Houston, TX, USA
| | - Arnold von Eckardstein
- Institute of Clinical Chemistry, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Gerald F Watts
- Medical School, University of Western Australia, and Department of Cardiology, Lipid Disorders Clinic, Royal Perth Hospital, Perth, Australia
| | - Jane K Stock
- European Atherosclerosis Society, Mässans Gata 10, SE-412 51, Gothenburg, Sweden
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Lale S Tokgözoğlu
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Alberico L Catapano
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, and IRCCS MultiMedica, Milan, Italy
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Besekar SM, Jogdand SD, Naqvi WM. A Systematic Review of the Randomized Controlled Trials of Gemcabene and Its Therapeutic Uses. Cureus 2023; 15:e36811. [PMID: 37123792 PMCID: PMC10136367 DOI: 10.7759/cureus.36811] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/28/2023] [Indexed: 03/30/2023] Open
Abstract
Statins are the most widely used drugs for reducing lipid and cholesterol levels in the blood. However, statins have shown some adverse effects and less acceptance among patients; hence, new drugs have been promoted in the market. Furthermore, gemcabenes were discovered in 1995 and are now in phase II and III clinical trials. Gemcabene acts by inhibiting incorporation of 14C-acetate into hepatocytes and stops the mechanism of fatty acids and cholesterol synthesis. In this review the six randomized controlled trials (RCTs) were scrutinized from the two databases by using keywords "Gemcabene" AND "Randomized Controlled Trial." The trials were mainly on animal models, and two studies were found to be associated with human subjects. The study concluded that gemcabene was effective as an anti-inflammatory agent and reduced lipid levels and the progression of fibrosis. Hence, further controlled trials are needed to determine its efficacy and safety in human subjects, along with the identification of adverse effects.
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5
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Recent Advances in Gene Therapy for Familial Hypercholesterolemia: An Update Review. J Clin Med 2022; 11:jcm11226773. [PMID: 36431249 PMCID: PMC9699383 DOI: 10.3390/jcm11226773] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/06/2022] [Accepted: 11/10/2022] [Indexed: 11/17/2022] Open
Abstract
(1) Background: Existing lipid-lowering therapies have difficulty in achieving lipid target levels in patients with familial hypercholesterolemia (FH), especially in the treatment of patients with homozygous familial hypercholesterolemia. (2) Method: All of the literature data containing "Familial hypercholesterolemia" and "Gene Therapy" in PubMed and Clinical Trials from 2018 to 2022 were selected. (3) Results: The rapid development of gene therapy technology in recent years is expected to change the treatment status of FH patients. As emerging gene therapy vectors, the optimized adeno-associated viruses, exosomes, and lipid nanoparticles have demonstrated an improved safety and higher transfection efficiency. Various RNA-targeted therapies are in phase 1-3 clinical trials, such as small interfering RNA-based drugs inclisiran, ARO-ANG3, ARO-APOC3, olpasiran, SLN360, and antisense oligonucleotide-based drugs AZD8233, vupanorsen, volanesorsen, IONIS-APO(a)Rx, etc., all of which have demonstrated excellent lipid-lowering effects. With gene editing technologies, such as CRISPR-Cas 9 and meganuclease, completing animal experiments in mice or cynomolgus monkeys and demonstrating lasting lipid-lowering effects, patients with FH are expected to reach a permanent cure in the future. (4) Conclusion: Gene therapy is being widely used for the lipid-lowering treatment of FH patients and has shown excellent therapeutic promise, but the current delivery efficiency, economic burden, immunogenicity and the precision of gene therapy can be further optimized.
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Merćep I, Strikić D, Slišković AM, Reiner Ž. New Therapeutic Approaches in Treatment of Dyslipidaemia—A Narrative Review. Pharmaceuticals (Basel) 2022; 15:ph15070839. [PMID: 35890138 PMCID: PMC9324773 DOI: 10.3390/ph15070839] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/28/2022] [Accepted: 07/02/2022] [Indexed: 02/06/2023] Open
Abstract
Dyslipidaemia is a well-known risk factor for the development of cardiovascular disease, a leading cause of morbidity and mortality in developed countries. As a consequence, the medical community has been dealing with this problem for decades, and traditional statin therapy remains the cornerstone therapeutic approach. However, clinical trials have observed remarkable results for a few agents effective in the treatment of elevated serum lipid levels. Ezetimibe showed good but limited results when used in combination with statins. Bempedoic acid has been thoroughly studied in multiple clinical trials, with a reduction in LDL cholesterol by approximately 15%. The first approved monoclonal antibodies for the treatment of dyslipidaemia, PCSK9 inhibitors, are currently used as second-line treatment for patients with unregulated lipid levels on statin or statin combination therapy. A new siRNA molecule, inclisiran, demonstrates great potential, particularly concerning compliance, as it is administered twice yearly and pelacarsen, an antisense oligonucleotide that targets lipoprotein(a) and lowers its levels. Volanesorsen is the first drug that was designed to target chylomicrons and lower triglyceride levels, and olezarsen, the next in-line chylomicron lowering agent, is currently being researched. The newest possibilities for the treatment of dyslipidaemia are ANGPTL3 inhibitors with evinacumab, already approved by the FDA, and EMA for the treatment of familial hypercholesterolemia. This article provides a short summary of new agents currently used or being developed for lipid lowering treatment.
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Affiliation(s)
- Iveta Merćep
- Division of Clinical Pharmacology, Department of Internal Medicine, University of Zagreb School of Medicine, 10000 Zagreb, Croatia
- Division of Clinical Pharmacology, Department of Internal Medicine, University Hospital Centre Zagreb, 10000 Zagreb, Croatia;
- Correspondence: ; Tel.: +385-1-238-8275
| | - Dominik Strikić
- Division of Clinical Pharmacology, Department of Internal Medicine, University Hospital Centre Zagreb, 10000 Zagreb, Croatia;
| | - Ana Marija Slišković
- Department of Cardiovascular Diseases, University Hospital Centre Zagreb, 10000 Zagreb, Croatia;
| | - Željko Reiner
- Division of Metabolic Diseases, Department of Internal Medicine, University Hospital Centre Zagreb, 10000 Zagreb, Croatia;
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7
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Wang MM, Lu CF, Yan SQ, Wang BZ, Yesitayi G, Tian YL, Xiang-Ma, Ma YT. Association of genetic polymorphisms of PCSK9 with type 2 diabetes in Uygur Chinese population. BMC Cardiovasc Disord 2022; 22:284. [PMID: 35733117 PMCID: PMC9219175 DOI: 10.1186/s12872-022-02710-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 06/02/2022] [Indexed: 11/17/2022] Open
Abstract
Background PCSK9 gene expression is associated with biological processes such as lipid metabolism, glucose metabolism, and inflammation. In the present study, our primary objective was to assess the association between the single-nucleotide polymorphisms in the PCSK9 gene and type 2 diabetes in Uygur subjects, in Xinjiang, China. Methods We designed a case–control study including 662 patients diagnosed with T2DM and 1220 control subjects. Four single-nucleotide polymorphisms (rs11583680, rs2483205, rs2495477 and rs562556) of PCSK9 gene were genotyped using the improved multiplex ligation detection reaction technique. Results For rs2483205, the distribution of genotypes, dominant model (CC vs CT + TT), overdominant model (CC + TT vs CT) showed significant differences between T2DM patients and the controls (P = 0.011 and P = 0.041 respectively). For rs2495477, the distribution of genotypes, the dominant model (AA vs GA + GG) showed significant differences between T2DM patients and the controls (P = 0.024). Logistic regression analysis suggested after adjustment of other confounders, the differences remained significant between the two groups [for rs2483205 CC vs CT + TT: odds ratio (OR) = 1.321, 95% confidence interval (CI) 1.078–1.617, P = 0.007; CC + TT vs CT: OR = 1.255, 95% CI 1.021–1.542, P = 0.03; for rs2495477 AA vs GA + GG: OR = 1.297, 95% CI 1.060–1.588, P = 0.012]. Conclusion The present study indicated that CT + TT genotype and CT genotype of rs2483205, as well as GA + GG genotype of rs2495477 in PCSK9 gene were associated with an increased risk of type 2 diabetes in the Uygur population in Xinjiang. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-022-02710-w.
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Affiliation(s)
- Meng-Meng Wang
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, People's Republic of China
| | - Chen-Fei Lu
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, People's Republic of China
| | - Shi-Qi Yan
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, People's Republic of China
| | - Bao-Zhu Wang
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, People's Republic of China
| | - Gulinazi Yesitayi
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, People's Republic of China
| | - Yong-Liang Tian
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, People's Republic of China
| | - Xiang-Ma
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, People's Republic of China.
| | - Yi-Tong Ma
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, People's Republic of China.
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8
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Gomes D, Wang S, Goodspeed L, Turk KE, Wietecha T, Liu Y, Bornfeldt KE, O'Brien KD, Chait A, den Hartigh LJ. Comparison between genetic and pharmaceutical disruption of LDLR expression for the development of atherosclerosis. J Lipid Res 2022; 63:100174. [PMID: 35101425 PMCID: PMC8953673 DOI: 10.1016/j.jlr.2022.100174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 01/22/2022] [Accepted: 01/24/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Diego Gomes
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA, USA; Diabetes Institute, University of Washington, Seattle, WA, USA
| | - Shari Wang
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA, USA; Diabetes Institute, University of Washington, Seattle, WA, USA
| | - Leela Goodspeed
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA, USA; Diabetes Institute, University of Washington, Seattle, WA, USA
| | - Katherine E Turk
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA, USA; Diabetes Institute, University of Washington, Seattle, WA, USA
| | - Tomasz Wietecha
- Diabetes Institute, University of Washington, Seattle, WA, USA; Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Yongjun Liu
- Department of Pathology and Laboratory Medicine, University of Wisconsin, Madison, WI, USA
| | - Karin E Bornfeldt
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA, USA; Diabetes Institute, University of Washington, Seattle, WA, USA; Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Kevin D O'Brien
- Diabetes Institute, University of Washington, Seattle, WA, USA; Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Alan Chait
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA, USA; Diabetes Institute, University of Washington, Seattle, WA, USA
| | - Laura J den Hartigh
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA, USA; Diabetes Institute, University of Washington, Seattle, WA, USA.
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9
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Watts GF, Raal FJ, Chan DC. Transcriptomic therapy for dyslipidemias utilizing nucleic acids targeted at ANGPTL3. Future Cardiol 2021; 18:143-153. [PMID: 34651521 DOI: 10.2217/fca-2021-0096] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Angiopoietin-like protein 3 (ANGPTL3) is a key physiological regulator of plasma lipid and lipoprotein metabolism that involves the control of enzymes, lipoprotein and endothelial lipases. Inhibition of ANGPTL3 offers a new approach for correcting the health risks of dyslipidemia, including familial hypercholesterolemia, mixed hyperlipidemia, metabolic syndrome and/or severe hypertriglyceridemia. ANGPTL3 inhibition with nucleic acid-based antisense oligonucleotide and siRNA can correct dyslipidemia chiefly by reducing production and increasing catabolism of triglyceride-rich lipoprotein and LDL particles. Early clinical trials have demonstrated that these agents can safely and effectively lower plasma triglyceride and LDL-cholesterol levels by up to 70 and 50%, respectively. However, the long-term safety and cost-effectiveness of these agents await to be confirmed in an ongoing and future clinical trials.
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Affiliation(s)
- Gerald F Watts
- School of Medicine, University of Western Australia, Perth, Australia.,Department of Cardiology & Internal Medicine, Lipid Disorders Clinic, Royal Perth Hospital, Perth, Australia
| | - Frederick J Raal
- Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Dick C Chan
- School of Medicine, University of Western Australia, Perth, Australia
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10
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Biessen EAL, Van Berkel TJC. N-Acetyl Galactosamine Targeting: Paving the Way for Clinical Application of Nucleotide Medicines in Cardiovascular Diseases. Arterioscler Thromb Vasc Biol 2021; 41:2855-2865. [PMID: 34645280 DOI: 10.1161/atvbaha.121.316290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
While the promise of oligonucleotide therapeutics, such as (chemically modified) ASO (antisense oligonucleotides) and short interfering RNAs, is undisputed from their introduction onwards, their unfavorable pharmacokinetics and intrinsic capacity to mobilize innate immune responses, were limiting widespread clinical use. However, these major setbacks have been tackled by breakthroughs in chemistry, stability and delivery. When aiming an intervention hepatic targets, such as lipid and sugar metabolism, coagulation, not to mention cancer and virus infection, introduction of N-acetylgalactosamine aided targeting technology has advanced the field profoundly and by now a dozen of N-acetylgalactosamine therapeutics for these indications have been approved for clinical use or have progressed to clinical trial stage 2 to 3 testing. This technology, in combination with major advances in oligonucleotide stability allows safe and durable intervention in targets that were previously deemed undruggable, such as Lp(a) and PCSK9 (proprotein convertase subtilisin/kexin type 9), at high efficacy and specificity, often with as little as 2 doses per year. Their successful use even the most visionary would not have predicted 2 decades ago. Here, we will review the evolution of N-acetylgalactosamine technology. We shall outline their fundamental design principles and merits, and their application for the delivery of oligonucleotide therapeutics to the liver. Finally, we will discuss the perspectives of N-acetylgalactosamine technology and propose directions for future research in receptor targeted delivery of these gene medicines.
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Affiliation(s)
- Erik A L Biessen
- Institute for Molecular Cardiovascular Research, RWTH Aachen University, Aachen, Germany (E.A.L.B.).,Department of Pathology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, the Netherlands (E.A.L.B.)
| | - Theo J C Van Berkel
- Division of Biopharmaceutics, LACDR, Leiden University, the Netherlands (T.J.C.V.B.)
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11
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Current Management Guidelines on Hyperlipidemia: The Silent Killer. J Lipids 2021; 2021:9883352. [PMID: 34394993 PMCID: PMC8363437 DOI: 10.1155/2021/9883352] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 07/23/2021] [Indexed: 01/06/2023] Open
Abstract
Given the high incidence of cardiovascular events in the United States, strict control of modifiable risk factors is important. Pharmacotherapy is helpful in maintaining control of modifiable risk factors such as elevated lipids or hypercholesterolemia. Hypercholesterolemia can lead to atherosclerotic disease which may increase the risk of acute coronary events. Statin therapy has long been a mainstay in the treatment of hypercholesterolemia, but while highly regarded, statin therapy also has side effects that may lead to patient noncompliance. Therefore, various medicines are being developed to manage hypercholesterolemia. This paper will discuss the role that lipids play in the pathophysiology of atherosclerotic disease, review the current lipid management guidelines, and discuss new treatment options that are alternatives to statin therapy.
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12
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Tessier N, Moawad F, Amri N, Brambilla D, Martel C. Focus on the Lymphatic Route to Optimize Drug Delivery in Cardiovascular Medicine. Pharmaceutics 2021; 13:1200. [PMID: 34452161 PMCID: PMC8398144 DOI: 10.3390/pharmaceutics13081200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 11/26/2022] Open
Abstract
While oral agents have been the gold standard for cardiovascular disease therapy, the new generation of treatments is switching to other administration options that offer reduced dosing frequency and more efficacy. The lymphatic network is a unidirectional and low-pressure vascular system that is responsible for the absorption of interstitial fluids, molecules, and cells from the peripheral tissue, including the skin and the intestines. Targeting the lymphatic route for drug delivery employing traditional or new technologies and drug formulations is exponentially gaining attention in the quest to avoid the hepatic first-pass effect. The present review will give an overview of the current knowledge on the involvement of the lymphatic vessels in drug delivery in the context of cardiovascular disease.
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Affiliation(s)
- Nolwenn Tessier
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1J4, Canada; (N.T.); (N.A.)
- Montreal Heart Institute Research Center, Montreal, QC H1T 1C8, Canada
| | - Fatma Moawad
- Faculty of Pharmacy, Université de Montréal, Montreal, QC H3T 1J4, Canada;
- Department of Pharmaceutics, Faculty of Pharmacy, Beni-Suef University, Beni-Suef 62511, Egypt
| | - Nada Amri
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1J4, Canada; (N.T.); (N.A.)
- Montreal Heart Institute Research Center, Montreal, QC H1T 1C8, Canada
| | - Davide Brambilla
- Faculty of Pharmacy, Université de Montréal, Montreal, QC H3T 1J4, Canada;
| | - Catherine Martel
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1J4, Canada; (N.T.); (N.A.)
- Montreal Heart Institute Research Center, Montreal, QC H1T 1C8, Canada
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13
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Schachtl-Riess JF, Kheirkhah A, Grüneis R, Di Maio S, Schoenherr S, Streiter G, Losso JL, Paulweber B, Eckardt KU, Köttgen A, Lamina C, Kronenberg F, Coassin S. Frequent LPA KIV-2 Variants Lower Lipoprotein(a) Concentrations and Protect Against Coronary Artery Disease. J Am Coll Cardiol 2021; 78:437-449. [PMID: 34325833 PMCID: PMC7613585 DOI: 10.1016/j.jacc.2021.05.037] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/11/2021] [Accepted: 05/24/2021] [Indexed: 12/24/2022]
Abstract
Background Lipoprotein(a) (Lp(a)) concentrations are a major independent risk factor for coronary artery disease (CAD) and are mainly determined by variation in LPA. Up to 70% of the LPA coding sequence is located in the hyper-variable kringle IV type 2 (KIV-2) region. It is hardly accessible by conventional technologies, but may contain functional variants. Objectives This study sought to investigate the new, very frequent splicing variant KIV-2 4733G>A on Lp(a) and CAD. Methods We genotyped 4733G>A in the GCKD (German Chronic Kidney Disease) study (n = 4,673) by allele-specific polymerase chain reaction, performed minigene assays, identified proxy single nucleotide polymorphisms and used them to characterize its effect on CAD by survival analysis in UK Biobank (n = 440,234). Frequencies in ethnic groups were assessed in the 1000 Genomes Project. Results The 4733G>A variant (38.2% carrier frequency) was found in most isoform sizes. It reduces allelic expression without abolishing protein production, lowers Lp(a) by 13.6 mg/dL (95% CI: 12.5-14.7; P < 0.0001) and is the strongest variance-explaining factor after the smaller isoform. Splicing of minigenes was modified. Compound heterozygosity (4.6% of the population) for 4733G>A and 4925G>A, another KIV-2 splicing mutation, reduces Lp(a) by 31.8 mg/dL and most importantly narrows the interquartile range by 9-fold (from 42.1 to 4.6 mg/dL) when compared to the wild type. In UK Biobank 4733G>A alone and compound heterozygosity with 4925G>A reduced HR for CAD by 9% (95% CI: 7%-11%) and 12% (95% CI: 7%-16%) (both P < 0.001). Frequencies in ethnicities differ notably. Conclusions Functional variants in the previously inaccessible LPA KIV-2 region cooperate in determining Lp(a) variance and CAD risk. Even a moderate but lifelong genetic Lp(a) reduction translates to a noticeable CAD risk reduction. (J Am Coll Cardiol 2021;78:437–49)
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Affiliation(s)
- Johanna F Schachtl-Riess
- Institute of Genetic Epidemiology, Department of Genetics and Pharmacology, Medical University of Innsbruck, Innsbruck, Austria
| | - Azin Kheirkhah
- Institute of Genetic Epidemiology, Department of Genetics and Pharmacology, Medical University of Innsbruck, Innsbruck, Austria
| | - Rebecca Grüneis
- Institute of Genetic Epidemiology, Department of Genetics and Pharmacology, Medical University of Innsbruck, Innsbruck, Austria
| | - Silvia Di Maio
- Institute of Genetic Epidemiology, Department of Genetics and Pharmacology, Medical University of Innsbruck, Innsbruck, Austria
| | - Sebastian Schoenherr
- Institute of Genetic Epidemiology, Department of Genetics and Pharmacology, Medical University of Innsbruck, Innsbruck, Austria
| | - Gertraud Streiter
- Institute of Genetic Epidemiology, Department of Genetics and Pharmacology, Medical University of Innsbruck, Innsbruck, Austria
| | - Jamie Lee Losso
- Institute of Genetic Epidemiology, Department of Genetics and Pharmacology, Medical University of Innsbruck, Innsbruck, Austria
| | - Bernhard Paulweber
- First Department of Internal Medicine, Paracelsus Private Medical University, Salzburg, Austria
| | - Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany; Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Köttgen
- Institute of Genetic Epidemiology, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Claudia Lamina
- Institute of Genetic Epidemiology, Department of Genetics and Pharmacology, Medical University of Innsbruck, Innsbruck, Austria
| | - Florian Kronenberg
- Institute of Genetic Epidemiology, Department of Genetics and Pharmacology, Medical University of Innsbruck, Innsbruck, Austria.
| | - Stefan Coassin
- Institute of Genetic Epidemiology, Department of Genetics and Pharmacology, Medical University of Innsbruck, Innsbruck, Austria.
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14
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Schwartz GG, Szarek M, Bittner VA, Bhatt DL, Diaz R, Goodman SG, Jukema JW, Loy M, Manvelian G, Pordy R, White HD, Steg PG. Relation of Lipoprotein(a) Levels to Incident Type 2 Diabetes and Modification by Alirocumab Treatment. Diabetes Care 2021; 44:1219-1227. [PMID: 33722880 PMCID: PMC8132323 DOI: 10.2337/dc20-2842] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/08/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE In observational data, lower levels of lipoprotein(a) have been associated with greater prevalence of type 2 diabetes. Whether pharmacologic lowering of lipoprotein(a) influences incident type 2 diabetes is unknown. We determined the relationship of lipoprotein(a) concentration with incident type 2 diabetes and effects of treatment with alirocumab, a PCSK9 inhibitor. RESEARCH DESIGN AND METHODS In the ODYSSEY OUTCOMES trial alirocumab was compared with placebo in patients with acute coronary syndrome. Incident diabetes was determined from laboratory, medication, and adverse event data. RESULTS Among 13,480 patients without diabetes at baseline, 1,324 developed type 2 diabetes over a median 2.7 years. Median baseline lipoprotein(a) was 21.9 mg/dL. With placebo, 10 mg/dL lower baseline lipoprotein(a) was associated with hazard ratio 1.04 (95% CI 1.02-1.06, P < 0.001) for incident type 2 diabetes. Alirocumab reduced lipoprotein(a) by a median 23.2% with greater absolute reductions from higher baseline levels and no overall effect on incident type 2 diabetes (hazard ratio 0.95, 95% CI 0.85-1.05). At low baseline lipoprotein(a) levels, alirocumab tended to reduce incident type 2 diabetes, while at high baseline lipoprotein(a) alirocumab tended to increase incident type 2 diabetes compared with placebo (treatment-baseline lipoprotein(a) interaction P = 0.006). In the alirocumab group, a 10 mg/dL decrease in lipoprotein(a) from baseline was associated with hazard ratio 1.07 (95% CI 1.03-1.12; P = 0.0002) for incident type 2 diabetes. CONCLUSIONS In patients with acute coronary syndrome, baseline lipoprotein(a) concentration associated inversely with incident type 2 diabetes. Alirocumab had neutral overall effect on incident type 2 diabetes. However, treatment-related reductions in lipoprotein(a), more pronounced from high baseline levels, were associated with increased risk of incident type 2 diabetes. Whether these findings pertain to other therapies that reduce lipoprotein(a) is undetermined.
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Affiliation(s)
- Gregory G Schwartz
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO
| | - Michael Szarek
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO.,CPC Clinical Research, Aurora, CO.,Downstate School of Public Health, State University of New York, Brooklyn, NY
| | | | - Deepak L Bhatt
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Rafael Diaz
- Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Shaun G Goodman
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.,St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | - Harvey D White
- Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand
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15
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Abstract
PURPOSE OF REVIEW Familial hypercholesterolemia is a genetic disorder of defective clearance and subsequent increase in serum LDL cholesterol (LDL-C) with a resultant increased risk of premature atherosclerotic cardiovascular disease. Despite treatment with traditional lipid-lowering therapies (LLT), most patients with familial hypercholesterolemia are unable to achieve target LDL-C. We review current and future novel therapeutic options available for familial hypercholesterolemia. RECENT FINDINGS The use of proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors are effective in lowering LDL-C in patients with familial hypercholesterolemia, with a reduction in LDL-C of 60% in heterozygous familial hypercholesterolemia (HeFH) and up to 35% in homozygous familial hypercholesterolemia (HoFH). Inclisiran, another novel agent, is a small-interfering ribonucleic acid that reduces hepatic production of PCSK9 to provide a prolonged and sustained reduction in LDL-C of nearly 50% in HeFH. However, both agents require LDL receptor (LDLR) activity. Evinacumab, a novel monoclonal antibody against angiopoetin-like 3 (ANGPTL3), reduces LDL-C by 50% independent of LDLR activity. SUMMARY Achieving a target LDL-C in familial hypercholesterolemia can be challenging with standard LLT; however, novel therapeutic modalities show remarkable reductions in LDL-C allowing nearly all patients with HeFH and a significant proportion of patients with HoFH to achieve acceptable LDL-C levels.
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Affiliation(s)
- Farzahna Mohamed
- Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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