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Mercep I, Strikic D, Hrabac P, Pecin I, Reiner Ž. PCSK9 inhibition: from effectiveness to cost-effectiveness. Front Cardiovasc Med 2024; 11:1339487. [PMID: 38988669 PMCID: PMC11234837 DOI: 10.3389/fcvm.2024.1339487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 06/06/2024] [Indexed: 07/12/2024] Open
Abstract
Dyslipidaemia is a complex disorder characterised by abnormal lipid levels in the blood, including cholesterol and triglycerides, and plays an important role in the development of atherosclerotic cardiovascular disease. Most risk factors for cardiovascular disease are modifiable, and dyslipidaemia is a key factor among them. It can result from a combination of genetic and environmental factors. A distinction is made between primary dyslipidaemia, which is mainly caused by inherited genetic changes, and secondary dyslipidaemia, which is due to underlying diseases or certain medications. The treatment of dyslipidaemia has evolved over the years. In the past, statins were the first choice, but newer drugs, such as proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors, have gained prominence due to their effectiveness in lowering lipids. Although recent guidelines recommend PCSK9 inhibitors for high-risk patients and patients who cannot tolerate statins, their widespread use is limited because of cost. Several meta-analyses have confirmed the efficacy and safety of PCSK9 inhibitors and have shown a significant reduction in low-density lipoprotein (LDL) cholesterol levels. However, the long-term side effects and interactions with other risk factors for cardiovascular disease remain uncertain. In addition, cost-effectiveness analyses have shown mixed results, with some countries considering PCSK9 inhibitors to be cost-effective for certain patient groups, while others consider them less economical. Meanwhile, initial data from patients using PCSK9 inhibitors support the results of the clinical trials. To summarise, PCSK9 inhibitors represent a revolutionary solution for lowering LDL cholesterol, but their cost-effectiveness remains controversial. Despite the controversy, they offer clear benefits for high-risk patients and should therefore be considered in the treatment of dyslipidaemia.
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Affiliation(s)
- Iveta Mercep
- Department of Internal Medicine, School of Medicine, University of Zagreb, Zagreb, Croatia
- Division of Clinical Pharmacology, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Dominik Strikic
- Division of Clinical Pharmacology, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Pero Hrabac
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ivan Pecin
- Department of Internal Medicine, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Željko Reiner
- Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
- Department of Cardiology and Congenital Diseases of Adults, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
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van Bruggen FH, Zuidema SU, Luijendijk HJ. Quantitative assessment of baseline imbalances in evolocumab and alirocumab trials: a meta-epidemiological study. BMC Med Res Methodol 2024; 24:137. [PMID: 38909176 PMCID: PMC11193208 DOI: 10.1186/s12874-024-02260-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 06/07/2024] [Indexed: 06/24/2024] Open
Abstract
BACKGROUND Baseline imbalances have been identified in randomized trials of evolocumab and alirocumab. Our aim was to quantitatively assess (1) the presence of systematic baseline differences, and (2) the relationship of baseline differences with effects on low-density lipoprotein-cholesterol (LDL-c) and clinical outcomes in the trials. METHODS We performed a meta-epidemiological study. PubMed, Embase, regulatory reports, ClinicalTrials.gov and company websites were searched for trials. Seven baseline characteristics (mean age, LDL-c, BMI, percentage males, diabetics, smokers, and hypertensives) and five outcomes (LDL-c, major adverse cardiac events, serious adverse events, any adverse events, all-cause mortality) were extracted. We calculated (1) range and distribution of baseline imbalances (sign-test), (2) pooled baseline differences and heterogeneity (meta-analysis), (3) differences in SDs around continuous variables (sign-test and pooling), and (4) the relationship of baseline differences with outcomes (meta-regression). The comparisons of PCSK9-inhibitor groups with either placebo or ezetimibe were analysed separately and combined. RESULTS We identified 43 trials with 63,193 participants. Baseline characteristics were frequently missing. Many trials showed small baseline imbalances, but some large imbalances. Only baseline BMI showed a statistically significant lower pooled mean for the drug versus placebo groups (MD -0.16; 95% CI -0.24 to -0.09). Heterogeneity in baseline imbalances was present in six placebo- and five ezetimibe-comparisons. Heterogeneity was statistically significant for BMI, males, diabetics and hypertensives in the combined comparisons. There was a statistically significant preponderance for larger SDs in the PCSK9-inhibitor versus control groups (sign-test age 0.014; LDL-c 0.014; BMI 0.049). Meta-regression showed clinically relevant relationships of baseline imbalances in age, BMI and diabetics with the risk of any adverse events and the risk of mortality. Two relationships were statistically significant: A higher mean BMI in the drug versus control group with a decreased risk of mortality (beta - 0.56; 95% CI -1.10 to -0.02), and a higher proportion of diabetics with an increased risk of any adverse events (beta 0.02; 95% 0.01 to 0.04). CONCLUSIONS Heterogeneous baseline imbalances and systematically different SDs were present in evolocumab and alirocumab trials, so study groups cannot be assumed to be comparable. These findings raise concerns about the design and conduct of the randomization procedures.
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Affiliation(s)
- F H van Bruggen
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen (UMCG), PO Box 196, Groningen, AD, 9700, The Netherlands
| | - S U Zuidema
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen (UMCG), PO Box 196, Groningen, AD, 9700, The Netherlands
| | - H J Luijendijk
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen (UMCG), PO Box 196, Groningen, AD, 9700, The Netherlands.
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Lin L, Yu H, Xue Y, Wang L, Zhu P. Proteome-wide mendelian randomization investigates potential associations in heart failure and its etiology: emphasis on PCSK9. BMC Med Genomics 2024; 17:59. [PMID: 38383373 PMCID: PMC10882912 DOI: 10.1186/s12920-024-01826-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 02/07/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Heart failure (HF) is a prevalent clinical syndrome with diverse etiologies. It is crucial to identify novel therapeutic targets based on underlying causes. Here, we aimed to use proteome-wide Mendelian randomization (MR) analyses to identify the associations between genetically predicted elevated levels of circulating proteins and distinct HF outcomes, along with specific HF etiologies. METHODS Protein quantitative trait loci (pQTL) data for circulating proteins were sourced from the Atherosclerosis Risk in Communities (ARIC) study, encompassing 7,213 individuals and profiling 4,657 circulating proteins. Genetic associations for outcomes were obtained from the HERMES Consortium and the FinnGen Consortium. Colocalization analysis was employed to assess the impact of linkage disequilibrium on discovered relationships. For replication, two-sample MR was conducted utilizing independent pQTL data from the deCODE study. Multivariable MR (MVMR) and two-step MR were further conducted to investigate potential mediators. RESULTS Two proteins (PCSK9 and AIDA) exhibited associations with HF in patients with coronary heart disease (CHD), and four proteins (PCSK9, SWAP70, NCF1, and RELT) were related with HF in patients receiving antihypertensive medication. Among these associations, strong evidence from subsequent analyses supported the positive relationship between genetically predicted PCSK9 levels and the risk of HF in the context of CHD. Notably, MVMR analysis revealed that CHD and LDL-C did not exert a complete mediating effect in this relationship. Moreover, two-step MR results yielded valuable insights into the potential mediating proportions of CHD or LDL-C in this relationship. CONCLUSIONS Our findings provide robust evidence supporting the association between PCSK9 and concomitant HF and CHD. This association is partly elucidated by the influence of CHD or LDL-C, underscoring the imperative for additional validation of this connection and a thorough exploration of the mechanisms through which PCSK9 directly impacts ischemic HF.
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Affiliation(s)
- Lichao Lin
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, People's Republic of China
| | - Huizhen Yu
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, People's Republic of China
- Department of Geriatric Medicine, Fujian Provincial Hospital, Fuzhou, People's Republic of China
- Fujian Provincial Key Laboratory of Geriatrics, Fuzhou, People's Republic of China
- Fujian Provincial Center for Geriatrics, Fuzhou, People's Republic of China
- Department of Cardiology in South Branch, Fujian Provincial Hospital, Fuzhou, People's Republic of China
| | - Yan Xue
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, People's Republic of China
| | - Liman Wang
- Department of Pharmacy in South Branch, Fujian Provincial Hospital, Fuzhou, People's Republic of China
| | - Pengli Zhu
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, People's Republic of China.
- Department of Geriatric Medicine, Fujian Provincial Hospital, Fuzhou, People's Republic of China.
- Fujian Provincial Key Laboratory of Geriatrics, Fuzhou, People's Republic of China.
- Fujian Provincial Center for Geriatrics, Fuzhou, People's Republic of China.
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Zhou X, Li Z, Liu H, Li Y, Zhao D, Yang Q. Antithrombotic therapy and bleeding risk in the era of aggressive lipid-lowering: current evidence, clinical implications, and future perspectives. Chin Med J (Engl) 2023; 136:645-652. [PMID: 36806078 PMCID: PMC10129148 DOI: 10.1097/cm9.0000000000002057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Indexed: 02/23/2023] Open
Abstract
ABSTRACT The clinical efficacy of proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) in reducing major cardiovascular adverse events related to atherosclerotic cardiovascular disease (ASCVD) has been well established in recent large randomized outcome trials. Although the cardiovascular and all-cause mortality benefit of PCSK9i remains inconclusive, current cholesterol management guidelines have been modified toward more aggressive goals for lowering low-density lipoprotein cholesterol (LDL-C). Consequently, the emerging concept of "the lower the better" has become the paradigm of ASCVD prevention. However, there is evidence from observational studies of a U-shaped association between baseline LDL-C levels and all-cause mortality in population-based cohorts. Among East Asian populations, low LDL-C was associated with an increased risk for hemorrhagic stroke in patients not on antithrombotic therapy. Accumulating evidence showed that low LDL-C was associated with an enhanced bleeding risk in patients on dual antiplatelet therapy following percutaneous coronary intervention. Additionally, low LDL-C was associated with a higher risk for incident atrial fibrillation and thereby, a possible increase in the risk for intracranial hemorrhage after initiation of anticoagulation therapy. The mechanism of low-LDL-C-related bleeding risk has not been fully elucidated. This review summarizes recent evidence of low-LDL-C-related bleeding risk in patients on antithrombotic therapy and discusses potential measures for reducing this risk, underscoring the importance of carefully weighing the pros and cons of aggressive LDL-C lowering in patients on antithrombotic therapy.
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Affiliation(s)
- Xin Zhou
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Ziping Li
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Hangkuan Liu
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Yongle Li
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Dong Zhao
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Qing Yang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin 300052, China
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Traber GM, Yu AM. RNAi-Based Therapeutics and Novel RNA Bioengineering Technologies. J Pharmacol Exp Ther 2023; 384:133-154. [PMID: 35680378 PMCID: PMC9827509 DOI: 10.1124/jpet.122.001234] [Citation(s) in RCA: 78] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 01/26/2023] Open
Abstract
RNA interference (RNAi) provides researchers with a versatile means to modulate target gene expression. The major forms of RNAi molecules, genome-derived microRNAs (miRNAs) and exogenous small interfering RNAs (siRNAs), converge into RNA-induced silencing complexes to achieve posttranscriptional gene regulation. RNAi has proven to be an adaptable and powerful therapeutic strategy where advancements in chemistry and pharmaceutics continue to bring RNAi-based drugs into the clinic. With four siRNA medications already approved by the US Food and Drug Administration (FDA), several RNAi-based therapeutics continue to advance to clinical trials with functions that closely resemble their endogenous counterparts. Although intended to enhance stability and improve efficacy, chemical modifications may increase risk of off-target effects by altering RNA structure, folding, and biologic activity away from their natural equivalents. Novel technologies in development today seek to use intact cells to yield true biologic RNAi agents that better represent the structures, stabilities, activities, and safety profiles of natural RNA molecules. In this review, we provide an examination of the mechanisms of action of endogenous miRNAs and exogenous siRNAs, the physiologic and pharmacokinetic barriers to therapeutic RNA delivery, and a summary of the chemical modifications and delivery platforms in use. We overview the pharmacology of the four FDA-approved siRNA medications (patisiran, givosiran, lumasiran, and inclisiran) as well as five siRNAs and several miRNA-based therapeutics currently in clinical trials. Furthermore, we discuss the direct expression and stable carrier-based, in vivo production of novel biologic RNAi agents for research and development. SIGNIFICANCE STATEMENT: In our review, we summarize the major concepts of RNA interference (RNAi), molecular mechanisms, and current state and challenges of RNAi drug development. We focus our discussion on the pharmacology of US Food and Drug Administration-approved RNAi medications and those siRNAs and miRNA-based therapeutics that entered the clinical investigations. Novel approaches to producing new true biological RNAi molecules for research and development are highlighted.
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Affiliation(s)
| | - Ai-Ming Yu
- Department of Biochemistry and Molecular Medicine, University of California (UC) Davis School of Medicine, Sacramento, California
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Chen H, Chen X. PCSK9 inhibitors for acute coronary syndrome: the era of early implementation. Front Cardiovasc Med 2023; 10:1138787. [PMID: 37200976 PMCID: PMC10185746 DOI: 10.3389/fcvm.2023.1138787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 04/17/2023] [Indexed: 05/20/2023] Open
Abstract
Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, a new cholesterol-lowering strategy, can decrease low-density lipoprotein cholesterol (LDL-C) levels by inhibiting PCSK9 and reducing the degradation of LDL receptors; thus, they are impacting the management of dyslipidemia to the prevention of cardiovascular events. Recent guidelines recommend PCSK9 inhibitors for patients who fail to achieve target lipids after ezetimibe/statin therapy. As PCSK9 inhibitors have been demonstrated to significantly and safely reduce LDL-C, discussions have begun to explore its optimal timing in coronary artery disease, especially in subjects with acute coronary syndrome (ACS). Also, their additional benefits, such as anti-inflammatory effects, plaque regression effects, and cardiovascular event prevention, have become the focus of recent research. Several studies, including EPIC-STEMI, suggest the lipid-lowering effects of early PCSK9 inhibitors in ACS patients, while some studies such as PACMAN-AMI suggest that early PCSK9 inhibitors can decelerate plaque progression and reduce short-term risks of cardiovascular events. Thus, PCSK9 inhibitors are entering the era of early implementation. In this review, we are committed to summarizing the multidimensional benefits of early implementation of PCSK9 inhibitors in ACS.
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7
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Erviti J, Wright J, Bassett K, Ben-Eltriki M, Jauca C, Saiz LC, Leache L, Gutiérrez-Valencia M, Perry TL. Restoring mortality data in the FOURIER cardiovascular outcomes trial of evolocumab in patients with cardiovascular disease: a reanalysis based on regulatory data. BMJ Open 2022; 12:e060172. [PMID: 36585131 PMCID: PMC9809302 DOI: 10.1136/bmjopen-2021-060172] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE The FOURIER trial showed a benefit of the PCSK9 inhibitor evolocumab over placebo with respect to cardiovascular outcomes in patients with cardiovascular disease. However, we observed some inconsistencies between the information in the Clinical Study Report (CSR) and that in the 2017 primary trial results publication. We aimed to restore the mortality data in the FOURIER trial based on the information contained in the death narratives in the CSR. METHODS Mortality data in the primary results publication were compared with that in the CSR. In cases of discrepancy between the sources, an independent committee blindly readjudicated and restored the cause of death according to the information in the CSR narratives. RESULTS For 360/870 deaths (41.4%), the cause of death adjudicated by the FOURIER clinical events committee differed from that declared by the local clinical investigator. When comparing the CSR information with the 2017 primary results publication, we found 11 more deaths from myocardial infarction in the evolocumab group (36 vs 25) and 3 less deaths in the placebo group (27 vs 30, respectively). In the CSR, the number of deaths due to cardiac failure in the evolocumab group was almost double those in the placebo group (31 vs 16). While cardiac and vascular deaths were not assessed as separate outcomes in the original trial analysis, after readjudication, we noted that cardiac deaths were numerically, but non-significantly, higher in the evolocumab group (113) than in the placebo group (88; relative risk (RR) 1.28, 95% CI 0.97 to 1.69, p=0.078), whereas non-cardiac vascular deaths were similar between groups (37 in each; RR 1.00, 95% CI 0.63 to 1.58, p=0.999). The reported HR for cardiovascular mortality in the original trial analysis was 1.05 (95% CI 0.88 to 1.25); after readjudication, we found a greater (although still non-significant) relative increase in cardiovascular mortality in the evolocumab treatment group (RR 1.20, 95% CI 0.95 to 1.51, p=0.13). CONCLUSION After readjudication, deaths of cardiac origin were numerically higher in the evolocumab group than in the placebo group in the FOURIER trial, suggesting possible cardiac harm. At the time the trial was terminated early, a non-significantly higher risk of cardiovascular mortality was observed with evolocumab, which was numerically greater in our readjudication. A complete restoration of the FOURIER trial data is required. In the meantime, clinicians should be sceptical about prescribing evolocumab for patients with established atherosclerotic cardiovascular disease. TRIAL REGISTRATION NUMBERS NCT01764633.
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Affiliation(s)
- Juan Erviti
- Innovation and Organization Unit, Navarre Health Service, Pamplona, Spain
- Navarre Institute for Health Research (IdiSNA), Pamplona, Spain
| | - James Wright
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Ken Bassett
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mohamed Ben-Eltriki
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Ciprian Jauca
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Luis Carlos Saiz
- Innovation and Organization Unit, Navarre Health Service, Pamplona, Spain
- Navarre Institute for Health Research (IdiSNA), Pamplona, Spain
| | - Leire Leache
- Innovation and Organization Unit, Navarre Health Service, Pamplona, Spain
- Navarre Institute for Health Research (IdiSNA), Pamplona, Spain
| | - Marta Gutiérrez-Valencia
- Innovation and Organization Unit, Navarre Health Service, Pamplona, Spain
- Navarre Institute for Health Research (IdiSNA), Pamplona, Spain
| | - Thomas L Perry
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
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Schettler VJJ, Peter C, Zimmermann T, Julius U, Roeseler E, Schlieper G, Heigl F, Grützmacher P, Löhlein I, Klingel R, Hohenstein B, Ramlow W, Vogt A. The German Lipoprotein Apheresis Registry-Summary of the ninth annual report. Ther Apher Dial 2022; 26 Suppl 1:81-88. [PMID: 36468337 DOI: 10.1111/1744-9987.13780] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 11/27/2021] [Accepted: 12/08/2021] [Indexed: 12/11/2022]
Abstract
During 2012-2020, 89 German apheresis centers collected retrospective and prospective observational data of 2028 patients undergoing regular lipoprotein apheresis (LA) for the German Lipoprotein Apheresis Registry (GLAR). More than 47 500 LA sessions are documented in GLAR. In 2020, all patients treated with LA showed a high immediate median reduction rate of LDL-C (68.2%, n = 1055) and Lp(a) (72.4%, n = 994). Patient data were analyzed for the incidence rate of major coronary events (MACE) 1 and 2 years before the beginning of LA treatment (y-2 and y-1) and prospectively up to 7 years on LA (y + 1 to y + 7). During the first 2 years of LA (y + 1 and y + 2), a MACE reduction of 78% was observed. Current analysis of GLAR data shows very low incidence rates of cardiovascular events in patients with high LDL-C and/or high Lp(a) levels, progressive ASCVD, and maximally tolerated lipid lowering medication regular by LA results.
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Affiliation(s)
| | - Christian Peter
- akquinet tech@spree GmbH, Rostock Division, Rostock, Germany
| | | | - Ulrich Julius
- Department of Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
| | - Eberhard Roeseler
- Center for Nephrology, Hypertension, and Metabolic Diseases, Hannover, Germany
| | - Georg Schlieper
- Center for Nephrology, Hypertension, and Metabolic Diseases, Hannover, Germany
| | - Franz Heigl
- Medical Care Center Kempten-Allgäu, Kempten, Germany
| | | | - Iris Löhlein
- German Society of Lipidology and resulting affections (DGFF), Frankfurt, Germany
| | | | - Bernd Hohenstein
- Nephrological Center Villingen-Schwenningen, Villingen-Schwenningen, Germany
| | | | - Anja Vogt
- Medizinische Klinik und Poliklinik 4, Universität München, Munich, Germany
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Ilut S, Pirlog BO, Pirlog R, Nutu A, Vacaras V, Armean SM. Recent Advances on the Roles of PCSK-9 Inhibitors in the Management of Acute Ischemic Stroke Patients. Int J Mol Sci 2022; 23:10221. [PMID: 36142135 PMCID: PMC9499538 DOI: 10.3390/ijms231810221] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/30/2022] [Accepted: 09/02/2022] [Indexed: 11/17/2022] Open
Abstract
Acute ischemic stroke (AIS) represents an important cause of disability and death. Since only a minor percentage of patients with AIS are eligible for acute therapy, the management of risk factors is mandatory. An important risk factor of AIS is hyperlipemia. The current guidelines recommend a strict correction of it. Statins are recommended as the first-line treatment, while proprotein convertase subtilin/kexin type 9 (PCSK-9) inhibitors are administered as a second or even third option when the goal for a low-density lipoprotein cholesterol (LDL-C) level is not achieved. PCSK-9 inhibitors effectively decrease the LDL-C levels through the inhibition of PCSK-9-LDL-receptor complex formation. The in-depth understanding of the PCSK-9 protein mechanism in the metabolism of LDL-C led to the development of effective targeted approaches. Furthermore, a better understanding of the LDL-C metabolic pathway led to the development of newer approaches, which increased the therapeutic options. This article aims to offer an overview of the PCSK-9 inhibitors and their mechanism in reducing the LDL-C levels. Moreover, we will present the main indications of the current guidelines for patients with hyperlipemia and for those who have suffered an acute ischemic stroke, as well as the importance of LDL-C reduction in decreasing the rate of a recurrence.
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Affiliation(s)
- Silvina Ilut
- Department of Neuroscience, University of Medicine, and Pharmacy “Iuliu Hațieganu”, 400012 Cluj-Napoca, Romania
| | - Bianca O. Pirlog
- Department of Neuroscience, University of Medicine, and Pharmacy “Iuliu Hațieganu”, 400012 Cluj-Napoca, Romania
| | - Radu Pirlog
- Research Center for Functional Genomics, Biomedicine and Translational Medicine, University of Medicine, and Pharmacy “Iuliu Hațieganu”, 400337 Cluj-Napoca, Romania
| | - Andreea Nutu
- Research Center for Functional Genomics, Biomedicine and Translational Medicine, University of Medicine, and Pharmacy “Iuliu Hațieganu”, 400337 Cluj-Napoca, Romania
| | - Vitalie Vacaras
- Department of Neuroscience, University of Medicine, and Pharmacy “Iuliu Hațieganu”, 400012 Cluj-Napoca, Romania
| | - Sebastian M. Armean
- Department of Pharmacology, Toxicology and Clinical Pharmacology, University of Medicine, and Pharmacy “Iuliu Hațieganu”, 400337 Cluj-Napoca, Romania
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Maligłówka M, Kosowski M, Hachuła M, Cyrnek M, Bułdak Ł, Basiak M, Bołdys A, Machnik G, Bułdak RJ, Okopień B. Insight into the Evolving Role of PCSK9. Metabolites 2022; 12:metabo12030256. [PMID: 35323699 PMCID: PMC8951079 DOI: 10.3390/metabo12030256] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/12/2022] [Accepted: 03/15/2022] [Indexed: 02/04/2023] Open
Abstract
Proprotein convertase subtilisin/kexin type 9 (PCSK9) is the last discovered member of the family of proprotein convertases (PCs), mainly synthetized in hepatic cells. This serine protease plays a pivotal role in the reduction of the number of low-density lipoprotein receptors (LDLRs) on the surface of hepatocytes, which leads to an increase in the level of cholesterol in the blood. This mechanism and the fact that gain of function (GOF) mutations in PCSK9 are responsible for causing familial hypercholesterolemia whereas loss-of-function (LOF) mutations are associated with hypocholesterolemia, prompted the invention of drugs that block PCSK9 action. The high efficiency of PCSK9 inhibitors (e.g., alirocumab, evolocumab) in decreasing cardiovascular risk, pleiotropic effects of other lipid-lowering drugs (e.g., statins) and the multifunctional character of other proprotein convertases, were the cause for proceeding studies on functions of PCSK9 beyond cholesterol metabolism. In this article, we summarize the current knowledge on the roles that PCSK9 plays in different tissues and perspectives for its clinical use.
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Affiliation(s)
- Mateusz Maligłówka
- Department of Internal Medicine and Clinical Pharmacology, School of Medicine in Katowice, Medical University of Silesia in Katowice, 40-007 Katowice, Poland; (M.K.); (M.H.); (M.C.); (Ł.B.); (M.B.); (A.B.); (G.M.); (B.O.)
- Correspondence:
| | - Michał Kosowski
- Department of Internal Medicine and Clinical Pharmacology, School of Medicine in Katowice, Medical University of Silesia in Katowice, 40-007 Katowice, Poland; (M.K.); (M.H.); (M.C.); (Ł.B.); (M.B.); (A.B.); (G.M.); (B.O.)
| | - Marcin Hachuła
- Department of Internal Medicine and Clinical Pharmacology, School of Medicine in Katowice, Medical University of Silesia in Katowice, 40-007 Katowice, Poland; (M.K.); (M.H.); (M.C.); (Ł.B.); (M.B.); (A.B.); (G.M.); (B.O.)
| | - Marcin Cyrnek
- Department of Internal Medicine and Clinical Pharmacology, School of Medicine in Katowice, Medical University of Silesia in Katowice, 40-007 Katowice, Poland; (M.K.); (M.H.); (M.C.); (Ł.B.); (M.B.); (A.B.); (G.M.); (B.O.)
| | - Łukasz Bułdak
- Department of Internal Medicine and Clinical Pharmacology, School of Medicine in Katowice, Medical University of Silesia in Katowice, 40-007 Katowice, Poland; (M.K.); (M.H.); (M.C.); (Ł.B.); (M.B.); (A.B.); (G.M.); (B.O.)
| | - Marcin Basiak
- Department of Internal Medicine and Clinical Pharmacology, School of Medicine in Katowice, Medical University of Silesia in Katowice, 40-007 Katowice, Poland; (M.K.); (M.H.); (M.C.); (Ł.B.); (M.B.); (A.B.); (G.M.); (B.O.)
| | - Aleksandra Bołdys
- Department of Internal Medicine and Clinical Pharmacology, School of Medicine in Katowice, Medical University of Silesia in Katowice, 40-007 Katowice, Poland; (M.K.); (M.H.); (M.C.); (Ł.B.); (M.B.); (A.B.); (G.M.); (B.O.)
| | - Grzegorz Machnik
- Department of Internal Medicine and Clinical Pharmacology, School of Medicine in Katowice, Medical University of Silesia in Katowice, 40-007 Katowice, Poland; (M.K.); (M.H.); (M.C.); (Ł.B.); (M.B.); (A.B.); (G.M.); (B.O.)
| | - Rafał Jakub Bułdak
- Institute of Medical Sciences, University of Opole, 45-040 Opole, Poland;
| | - Bogusław Okopień
- Department of Internal Medicine and Clinical Pharmacology, School of Medicine in Katowice, Medical University of Silesia in Katowice, 40-007 Katowice, Poland; (M.K.); (M.H.); (M.C.); (Ł.B.); (M.B.); (A.B.); (G.M.); (B.O.)
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11
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Waiz M, Alvi SS, Khan MS. Potential dual inhibitors of PCSK-9 and HMG-R from natural sources in cardiovascular risk management. EXCLI JOURNAL 2022; 21:47-76. [PMID: 35221836 PMCID: PMC8859648 DOI: 10.17179/excli2021-4453] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 12/08/2021] [Indexed: 12/11/2022]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) stands amongst the leading causes of mortality worldwide and has attracted the attention of world's leading pharmaceutical companies in order to tackle such mortalities. The low-density lipoprotein-cholesterol (LDL-C) is considered the most prominent biomarker for the assessment of ASCVD risk. Distinct inhibitors of 3-hydroxy-3-methyl-glutaryl-CoA reductase (HMG-R), the chief hepatic cholesterogenic enzyme, are being used since last seven decades to manage hypercholesterolemia. On the other hand, discovery and the association of proprotein convertase subtilisin/kexin type-9 (PCSK-9) with increased ASCVD risk have established PCSK-9 as a novel therapeutic target in cardiovascular medicine. PCSK-9 is well reckoned to facilitate the LDL-receptor (LDL-R) degradation and compromised LDL-C clearance leading to the arterial atherosclerotic plaque formation. The currently available HMG-R inhibitors (statins) and PCSK-9 inhibitors (siRNA, anti-sense oligonucleotides, and monoclonal antibodies) have shown great promises in achieving LDL-C lowering goals, however, their life long prescriptions have raised significant concerns. These deficits associated with the synthetic HMG-R and PCSK-9 inhibitors called for the discovery of alternative therapeutic candidates with potential dual HMG-R and PCSK-9 inhibitory activities from natural origins. Therefore, this report firstly describes the mechanistic insights into the cholesterol homeostasis through HMG-R, PCSK-9, and LDL-R functionality and then compiles the pharmacological effects of natural secondary metabolites with special emphasis on their dual HMG-R and PCSK-9 inhibitory action. In conclusion, various natural products exhibit atheroprotective effects via targeting HMG-R and PCSK-9 activities and lipoprotein metabolism, however, further clinical assessments are still warranted prior their approval for ASCVD risk management in hypercholesterolemic patients.
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Affiliation(s)
- Mohd Waiz
- IIRC-5, Clinical Biochemistry and Natural Product Research Lab, Department of Biosciences, Integral University, Lucknow, U.P. 226026, India
| | - Sahir Sultan Alvi
- IIRC-5, Clinical Biochemistry and Natural Product Research Lab, Department of Biosciences, Integral University, Lucknow, U.P. 226026, India
| | - M Salman Khan
- IIRC-5, Clinical Biochemistry and Natural Product Research Lab, Department of Biosciences, Integral University, Lucknow, U.P. 226026, India
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12
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van Bruggen FH, Luijendijk HJ. Evolocumab's Long-Term Mortality Risk Unclear Due to Shortened Follow-Up of FOURIER. Am J Cardiovasc Drugs 2022; 22:5-8. [PMID: 34008143 PMCID: PMC8748321 DOI: 10.1007/s40256-021-00480-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2021] [Indexed: 10/28/2022]
Abstract
The FOURIER (Further Cardiovascular Outcomes Research with PCSK9 inhibition in Subjects with Elevated Risk) trial was conducted to study cardiovascular outcomes of treatment with evolocumab. The trial was terminated after a median follow-up of 2.2 years instead of the planned 3.6 years. We question this decision. According to the investigators, the event rate was 50% higher than expected. However, the accrued number of key secondary events (1829) was only 12% higher than the targeted number (1630). Also, around one-third of the events consisted of non-atherosclerotic myocardial infarctions, hemorrhagic strokes, and cardiovascular deaths unrelated to myocardial infarction or stroke. Moreover, halfway through the trial, the sample size changed from 22,500 to 27,500, even though the accrual of the targeted number of events was on track. Finally, the rate of all-cause mortality had started to diverge in favor of placebo after 2 years of follow-up. It was 4.8% for evolocumab and 4.3% for placebo in participants with > 2.5 years of follow-up. A long-term follow-up would have yielded more events and thus more power to evaluate the effect of evolocumab on all-cause mortality. We conclude that adaptive designs carry a recognized risk of false-positive efficacy results, but the risk of false-negative safety results is underappreciated.
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Affiliation(s)
- Folkert H van Bruggen
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Postbus 196, 9700 AD, Groningen, The Netherlands
| | - Hendrika J Luijendijk
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Postbus 196, 9700 AD, Groningen, The Netherlands.
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13
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Momtazi-Borojeni AA, Pirro M, Xu S, Sahebkar A. PCSK9 inhibition-based therapeutic approaches: an immunotherapy perspective. Curr Med Chem 2021; 29:980-999. [PMID: 34711156 DOI: 10.2174/0929867328666211027125245] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 09/04/2021] [Accepted: 09/07/2021] [Indexed: 11/22/2022]
Abstract
Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (PCSK9-I) are novel therapeutic tools to decrease cardiovascular risk. These agents work by lowering the low-density lipoprotein cholesterol (LDL-C) in hypercholesterolemic patients who are statin resistant/intolerant. Current clinically approved and investigational PCSK9-I act generally by blocking PCSK9 activity in the plasma or suppressing its expression or secretion by hepatocytes. The most widely investigated method is the disruption of PCSK9/LDL receptor (LDLR) interaction by fully-humanized monoclonal antibodies (mAbs), evolocumab and alirocumab, which have been approved for the therapy of hypercholesterolemia and atherosclerotic cardiovascular disease (CVD). Besides, a small interfering RNA called inclisiran, which specifically suppresses PCSK9 expression in hepatocytes, is as effective as mAbs but with administration twice a year. Because of the high costs of such therapeutic approaches, several other PCSK9-I have been surveyed, including peptide-based anti-PCSK9 vaccines and small oral anti-PCSK9 molecules, which are under investigation in preclinical and phase I clinical studies. Interestingly, anti-PCSK9 vaccination has been found to serve as a more widely feasible and more cost-effective therapeutic tool over mAb PCSK9-I for managing hypercholesterolemia. The present review will discuss LDL-lowering and cardioprotective effects of PCSK9-I, mainly immunotherapy-based inhibitors including mAbs and vaccines, in preclinical and clinical studies.
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Affiliation(s)
| | - Matteo Pirro
- Unit of Internal Medicine, Department of Medicine, University of Perugia, Perugia, 06129. Italy
| | - Suowen Xu
- Department of Endocrinology, First Affiliated Hospital, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei. China
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad. Iran
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14
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Maligłówka M, Bułdak Ł, Okopień B, Bołdys A. The consequences of PCSK9 inhibition in selected tissues. POSTEP HIG MED DOSW 2021. [DOI: 10.5604/01.3001.0014.9127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Proprotein convertase subtilisin/kexin type 9 (PCSK9) is one of nine members of the proprotein
convertase family. These serine proteases play a pivotal role in the post-translational
modification of proteins and the activation of hormones, enzymes, transcription factors and
growth factors. As a result, they participate in many physiological processes like embryogenesis,
activity of central nervous system and lipid metabolism. Scientific studies show
that the family of convertases is also involved in the pathogenesis of viral and bacterial
infections, osteoporosis, hyperglycaemia, cardiovascular diseases, neurodegenerative disorders
and cancer. The inhibition of PCSK9 by two currently approved for use monoclonal
antibodies (alirocumab, evolocumab) slows down the degradation of low-density lipoprotein
cholesterol receptors (LDLRs). This leads to increased density of LDLRs on the surface
of hepatocytes, resulting in decreased level of low-density lipoprotein cholesterol (LDL-C)
in the bloodstream, which is connected with the reduction of cardiovascular risk. PCSK9 inhibitors (PCSK9i) were created for the patients who could not achieve appropriate level
of LDL-C using current statin and ezetimibe therapy. It seems that high therapeutic efficacy
of PCSK9i will make them more common in the clinical use. The pleiotropic effects
of previously mentioned lipid-lowering therapies were the reasons for literature review of
possible positive and negative effects of PCSK9 inhibition beyond cholesterol metabolism.
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Affiliation(s)
- Mateusz Maligłówka
- Katedra Farmakologii, Klinika Chorób Wewnętrznych i Farmakologii Klinicznej, Wydział Nauk Medycznych Śląskiego Uniwersytetu Medycznego w Katowicach
| | - Łukasz Bułdak
- Katedra Farmakologii, Klinika Chorób Wewnętrznych i Farmakologii Klinicznej, Wydział Nauk Medycznych Śląskiego Uniwersytetu Medycznego w Katowicach
| | - Bogusław Okopień
- Katedra Farmakologii, Klinika Chorób Wewnętrznych i Farmakologii Klinicznej, Wydział Nauk Medycznych Śląskiego Uniwersytetu Medycznego w Katowicach
| | - Aleksandra Bołdys
- Katedra Farmakologii, Klinika Chorób Wewnętrznych i Farmakologii Klinicznej, Wydział Nauk Medycznych Śląskiego Uniwersytetu Medycznego w Katowicach
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15
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Affiliation(s)
- Robert A Hegele
- Departments of Medicine and Biochemistry, and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, Canada
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16
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Feminò R, Feminò G, Cavezzi A, Troiani E. PCSK9 inhibition, LDL and lipopolysaccharides: a complex and "dangerous" relationship. INT ANGIOL 2021; 40:248-260. [PMID: 33739075 DOI: 10.23736/s0392-9590.21.04632-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Literature concerning the causative factors of atherosclerotic cardiovascular disease shows complex and sometimes contrasting evidence. Most guidelines suggest a strategy aimed at lowering circulating low density lipoproteins (LDL) and ApoB lipoprotein levels. The use of statins and of cholesteryl ester transfer protein inhibitors has led to a number of controversial outcomes, generating a certain degree of concern about the real efficacy and especially safety of these drugs. Literature data show that the use of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors results in a dramatic reduction of various markers of lipid metabolism (namely LDL); however, several critical scientific papers have questioned the value, the need and especially the safety of these innovative drugs. LDL are a protective factor against lipopolysaccharides and other microbial derivatives. Similarly, these gram-negative bacteria-derived compounds have been identified as probable culprits of cardiovascular atherogenesis; moreover, lipopolysaccharides increase hepatic synthesis of PCSK9, as defense mechanism. This enzyme modulates LDL receptors level in the liver, as well as in other organs, such as adrenal gland and reproductive organs. Hence, PCSK9 inhibition may influence glucocorticoid secretion and fertility. Lastly, the consequent reduction of circulating LDL may relevantly hindrance immune system and favor lipopolysaccharides diffusion.
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Affiliation(s)
- Raimondo Feminò
- Anesthesia and Intensive Care Unit, Department of General and Specialist Surgeries, Polyclinic of Modena, Modena, Italy
| | - Giovanni Feminò
- Division of Immunology, Euro Medical Center Srl, Florence, Italy
| | - Attilio Cavezzi
- Eurocenter Venalinfa, San Benedetto del Tronto, Ascoli Piceno, Italy -
| | - Emidio Troiani
- Unit of Cardiology, Social Security Institute, State Hospital, Cailungo, San Marino
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Santulli G, Jankauskas SS, Gambardella J. Inclisiran: a new milestone on the PCSK9 road to tackle cardiovascular risk. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 7:e11-e12. [PMID: 33655296 DOI: 10.1093/ehjcvp/pvab014] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Gaetano Santulli
- Department of Medicine, Wilf Family Cardiovascular Research Institute, Einstein Institute for Aging Research, Albert Einstein College of Medicine, New York, NY 10461, USA.,Department of Molecular Pharmacology, Einstein-Mount Sinai Diabetes Research Center (ES-DRC), Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY 10461, USA.,Department of Advanced Biomedical Science, 'Federico II' University, and International Translational Research and Medical Education Consortium (ITME), 80131 Naples, Italy
| | - Stanislovas S Jankauskas
- Department of Medicine, Wilf Family Cardiovascular Research Institute, Einstein Institute for Aging Research, Albert Einstein College of Medicine, New York, NY 10461, USA.,Department of Molecular Pharmacology, Einstein-Mount Sinai Diabetes Research Center (ES-DRC), Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY 10461, USA
| | - Jessica Gambardella
- Department of Medicine, Wilf Family Cardiovascular Research Institute, Einstein Institute for Aging Research, Albert Einstein College of Medicine, New York, NY 10461, USA.,Department of Molecular Pharmacology, Einstein-Mount Sinai Diabetes Research Center (ES-DRC), Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY 10461, USA.,Department of Advanced Biomedical Science, 'Federico II' University, and International Translational Research and Medical Education Consortium (ITME), 80131 Naples, Italy
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18
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van Bruggen FH, Nijhuis GBJ, Zuidema SU, Luijendijk HJ. Response to letter to the editor re: 'serious adverse events and deaths in PCSK9 inhibitor trials reported on ClinicalTrials.gov: a systematic review'. Expert Rev Clin Pharmacol 2021; 14:283-284. [PMID: 33428485 DOI: 10.1080/17512433.2021.1874350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- F H van Bruggen
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - G B J Nijhuis
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - S U Zuidema
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - H J Luijendijk
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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19
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Letter to the editor re: 'serious adverse events and deaths in PCSK9 inhibitor trials reported on ClinicalTrials.gov: a systematic review'. Expert Rev Clin Pharmacol 2021; 14:281-282. [PMID: 33428482 DOI: 10.1080/17512433.2021.1874346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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