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Chen T, Liu N. How safe are proprotein convertase subtilisinekexin type 9 inhibitors in diabetes? Curr Opin Lipidol 2024; 35:187-194. [PMID: 38527426 DOI: 10.1097/mol.0000000000000934] [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] [Indexed: 03/27/2024]
Abstract
PURPOSE OF REVIEW To examine the safety of proprotein convertase subtilisinekexin type 9 (PCSK9) inhibitors in patients with diabetes, specifically focusing on their impact on glucose metabolism. RECENT FINDINGS Patients with diabetes often require intensified lipid-lowering therapy. PCSK9 inhibitors can reduce low-density lipoprotein cholesterol (LDL-C) concentrations by approximately 60%, and significantly reduce cardiovascular risk when added to statin therapy. Some studies have suggested an association between low LDL-C levels and an increased risk of new-onset diabetes, and genetics has almost consistently shown an increased glucose concentration and risk of diabetes. Most clinical trials have not demonstrated a deterioration in glycaemic control in patients with diabetes after the use of PCSK9 inhibitors, and they do not lead to other significant treatment-emergent adverse events. SUMMARY Although the majority of patients with diabetes are undergoing background statin therapy, which may mask potential adverse effects of PCSK9 inhibitors on glycaemic control, current data suggest that the benefits outweigh the risks for diabetic patients using PCSK9 inhibitors. Considering the different nature of genetic studies and of clinical trials, close monitoring of glucose parameters is necessary, especially in individuals with prediabetes.
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Affiliation(s)
- Tian Chen
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
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2
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Zac-Varghese S, Mark P, Bain S, Banerjee D, Chowdhury TA, Dasgupta I, De P, Fogarty D, Frankel A, Goldet G, Karalliedde J, Mallik R, Montero R, Sharif A, Wahba M, Dhatariya K, McCafferty K, Lioudaki E, Winocour P. Clinical practice guideline for the management of lipids in adults with diabetic kidney disease: abbreviated summary of the Joint Association of British Clinical Diabetologists and UK Kidney Association (ABCD-UKKA) Guideline 2024. BMC Nephrol 2024; 25:216. [PMID: 38971750 PMCID: PMC11227212 DOI: 10.1186/s12882-024-03664-1] [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: 04/26/2024] [Accepted: 07/01/2024] [Indexed: 07/08/2024] Open
Abstract
The contribution of chronic kidney disease (CKD) towards the risk of developing cardiovascular disease (CVD) is magnified with co-existing type 1 or type 2 diabetes. Lipids are a modifiable risk factor and good lipid management offers improved outcomes for people with diabetic kidney disease (DKD).The primary purpose of this guideline, written by the Association of British Clinical Diabetologists (ABCD) and UK Kidney Association (UKKA) working group, is to provide practical recommendations on lipid management for members of the multidisciplinary team involved in the care of adults with DKD.
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Affiliation(s)
| | | | | | | | | | | | - Parijat De
- Birmingham City Hospital, Birmingham, UK
| | - Damian Fogarty
- Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | | | | | - Janaka Karalliedde
- Guy's and St Thomas NHS Foundation Trust, London, UK
- Kings College London, London, UK
| | | | | | | | | | | | - Kieran McCafferty
- Barts Health NHS Trust, London, UK
- Queen Mary University of London, London, UK
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Carss KJ, Deaton AM, Del Rio-Espinola A, Diogo D, Fielden M, Kulkarni DA, Moggs J, Newham P, Nelson MR, Sistare FD, Ward LD, Yuan J. Using human genetics to improve safety assessment of therapeutics. Nat Rev Drug Discov 2023; 22:145-162. [PMID: 36261593 DOI: 10.1038/s41573-022-00561-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2022] [Indexed: 02/07/2023]
Abstract
Human genetics research has discovered thousands of proteins associated with complex and rare diseases. Genome-wide association studies (GWAS) and studies of Mendelian disease have resulted in an increased understanding of the role of gene function and regulation in human conditions. Although the application of human genetics has been explored primarily as a method to identify potential drug targets and support their relevance to disease in humans, there is increasing interest in using genetic data to identify potential safety liabilities of modulating a given target. Human genetic variants can be used as a model to anticipate the effect of lifelong modulation of therapeutic targets and identify the potential risk for on-target adverse events. This approach is particularly useful for non-clinical safety evaluation of novel therapeutics that lack pharmacologically relevant animal models and can contribute to the intrinsic safety profile of a drug target. This Review illustrates applications of human genetics to safety studies during drug discovery and development, including assessing the potential for on- and off-target associated adverse events, carcinogenicity risk assessment, and guiding translational safety study designs and monitoring strategies. A summary of available human genetic resources and recommended best practices is provided. The challenges and future perspectives of translating human genetic information to identify risks for potential drug effects in preclinical and clinical development are discussed.
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Affiliation(s)
| | - Aimee M Deaton
- Amgen, Cambridge, MA, USA.,Alnylam Pharmaceuticals, Cambridge, MA, USA
| | - Alberto Del Rio-Espinola
- Novartis Institutes for BioMedical Research, Basel, Switzerland.,GentiBio Inc., Cambridge, MA, USA
| | | | - Mark Fielden
- Amgen, Thousand Oaks, MA, USA.,Kate Therapeutics, San Diego, CA, USA
| | | | - Jonathan Moggs
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | | | | | - Frank D Sistare
- Merck & Co., West Point, PA, USA.,315 Meadowmont Ln, Chapel Hill, NC, USA
| | - Lucas D Ward
- Amgen, Cambridge, MA, USA. .,Alnylam Pharmaceuticals, Cambridge, MA, USA.
| | - Jing Yuan
- Amgen, Cambridge, MA, USA.,Pfizer, Cambridge, MA, USA
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4
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Real-world data on metabolic effects of PCSK9 inhibitors in a tertiary care center in patients with and without diabetes mellitus. Cardiovasc Diabetol 2021; 20:89. [PMID: 33894772 PMCID: PMC8070307 DOI: 10.1186/s12933-021-01283-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 04/20/2021] [Indexed: 12/14/2022] Open
Abstract
Background The lipid-lowering and positive cardiovascular effect of proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors was shown in several studies, hence, they are more widely used in the lipid-lowering management of individuals with high cardiovascular risk. As real-world data are still scarce, specifically in patients with type 2 diabetes (T2D), the aim of this retrospective analysis was to investigate the efficacy of PCSK9 inhibitors in lowering low-density lipoprotein cholesterol (LDL-C) in an outpatient clinic of a tertiary care center in routine care. Methods A retrospective analysis of data extracted from the electronic patient record was performed. Patients who were routinely prescribed with PCSK9 inhibitor therapy (alirocumab or evolocumab) during the years 2016 and 2019 were included in the analysis. Characteristics of the patient population, the effects on LDL-C and HbA1c levels as well as subsequent cardiovascular events were assessed over an observation period of 18 months. Results We identified 237 patients treated with PCSK9 inhibitors between January 2016 and September 2019. Almost all patients (97.5%) received PCSK9 inhibitors for secondary prevention. 26.2% of the population had a concomitant diabetes diagnosis. Intolerance to statins (83.1%), ezetimibe (44.7%) or both agents (42.6%) was reported frequently. Three months after initiation of PCSK9 inhibitor therapy, 61.2% of the patients achieved LDL-C levels < 70 mg/dl, and 44.1% LDL-C levels < 55 mg/dl. The median LDL-C was lowered from 141 mg/dl at baseline, to 60 mg/dl after 3 months and 66 mg/dl after 12 months indicating a reduction of LDL-C as follows: 57.5% after 3 months and 53.6% after 12 months. After 3 months of observation, target achievement of LDL-C was higher in patients with T2D compared to non-diabetes patients; < 55 mg/dl: 51% vs. 41.5%; < 70 mg/dl 69.4 vs. 58.5%. After 12 months even more pronounced target LDL achievement in T2D was demonstrated < 55 mg/dl: 58.8% vs. 30.1%; < 70 mg/dl 70.6 vs. 49.6%. Patients with insufficiently controlled T2D (HbA1c > 54 mmol/mol) had a higher reduction in LDL-C but still were more likely to subsequent cardiovascular events. Conclusions Significant reductions in LDL-C and a high percentage of patients achieving recommended treatment targets were observed. The percentage of patients with T2D meeting recommended LDL-C targets was higher than in those without T2D. Still some patients did not achieve LDL-C levels as recommended in current guidelines. Special attention to the characteristics of these patients is required in the future to enable achievement of treatment goals and avoid adverse cardiovascular outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-021-01283-w.
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Moşteoru S, Gaiţă D, Banach M. An update on PCSK9 inhibitors- pharmacokinetics, drug interactions, and toxicity. Expert Opin Drug Metab Toxicol 2020; 16:1199-1205. [PMID: 32966148 DOI: 10.1080/17425255.2020.1828343] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION While atherosclerotic cardiovascular disease is affecting growing numbers of patients, lipid-lowering therapies have been continuously improving to achieve prevention of cardiovascular events. Thus, the appearance of a novel therapeutic class, PCSK9 inhibitors, has raised both high expectations as well as concern over possible adverse effects. AREAS COVERED This current review aims to analyze adverse events of special interest linked to PCSK9 inhibitors and give recommendations regarding further conduct when dealing with patients on this therapy. The most stringent adverse effect, neurocognitive impairment has been investigated in several studies, concluding that PCSK9 inhibitors neither improved nor worsened cognitive function. While new onset diabetes mellitus has also been a cause of concern due to its possible association with lipid lowering therapies, studies conducted so far have dispelled this possibility by showing that PCSK9 inhibitors do not increase this risk. Also, statin-associated muscle symptoms have not been proven to arise after the use of PCSK9 inhibitors, even in statin-intolerant patients. EXPERT OPINION In conclusion, it can be safely stated that so far, no compelling evidence links PCSK9 inhibitors to these adverse events; however, long-term trials are always welcome to further assess potential adverse effects.
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Affiliation(s)
- Svetlana Moşteoru
- Cardiology Department, "Victor Babeş" University of Medicine and Pharmacy Timişoara , Romania
| | - Dan Gaiţă
- Cardiology Department, "Victor Babeş" University of Medicine and Pharmacy Timişoara , Romania
| | - Maciej Banach
- Polish Mother's Memorial Hospital Research Institute, Medical University of Lodz , Lodz, Poland
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Duprez DA, Handelsman Y, Koren M. Cardiovascular Outcomes and Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors: Current Data and Future Prospects. Vasc Health Risk Manag 2020; 16:403-418. [PMID: 33116551 PMCID: PMC7548340 DOI: 10.2147/vhrm.s261719] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/11/2020] [Indexed: 12/12/2022] Open
Abstract
Cardiovascular (CV) disease remains the leading cause of morbidity and mortality worldwide and poses an ongoing challenge with the aging population. Elevated low-density lipoprotein cholesterol (LDL-C) is an established risk factor for atherosclerotic cardiovascular disease (ASCVD), and the expert consensus is the use of statin therapy (if tolerated) as first line for LDL-C reduction. However, patients with ASCVD may experience recurrent ischemic events despite receiving maximally tolerated statin therapy, including those whose on-treatment LDL-C remains ≥70 mg/dL, patients with familial hypercholesterolemia, high-risk subgroups with comorbidities such as diabetes mellitus, and those who have an intolerance to statin therapy. Optimal therapeutic strategies for this unmet need should deploy aggressive lipid lowering to minimize the contribution of dyslipidemia to their CV risk, particularly for very high-risk populations with additional risk factors beyond hypercholesterolemia and established ASCVD. To understand the current clinical climate and guidelines regarding ASCVD, we primarily searched PubMed for articles published in English regarding lipid-lowering therapies and CV risk reduction, including emerging therapies, and CV outcomes trials with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. This review discusses the findings of recent clinical trial evidence for CV risk reduction with cholesterol-lowering therapies, with a focus on CV outcomes trials with PCSK9 inhibitors, and considers the impact of the study results for secondary prevention and future strategies in patients with hypercholesterolemia and CV risk despite maximally tolerated statin therapy.
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Affiliation(s)
- Daniel A Duprez
- Cardiovascular Division, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | | | - Michael Koren
- Jacksonville Center for Clinical Research, Jacksonville, FL, USA
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Raal FJ, Chilton R, Ranjith N, Rambiritch V, Leisegang RF, Ebrahim IO, Tonder AV, Shunmoogam N, Bouharati C, Musa MG, Karamchand S, Naidoo P, Blom DJ. PCSK9 Inhibitors: From Nature’s Lessons to Clinical Utility. Endocr Metab Immune Disord Drug Targets 2020; 20:840-854. [DOI: 10.2174/1871530320666200213114138] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 10/31/2019] [Accepted: 12/02/2019] [Indexed: 12/21/2022]
Abstract
Background:
Proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors are a novel
class of non-statin lipid lowering therapy that reduce LDL-cholesterol by 50 - 60%. PCSK9 inhibitors
decrease LDL-cholesterol by preventing intracellular degradation of LDL receptors; subsequently, a
greater number of LDL-receptors are available on the cell surface to extract circulating LDL.
Objective:
To describe the origins of PCSK9 inhibitors and their current use in clinical practice.
Methods:
We performed a narrative review of the PCSK9 inhibitor class of drugs.
Results:
Current data indicate that PCSK9 inhibitors effectively reduce LDL-cholesterol and are well
tolerated and safe. PCSK9 inhibitors have also been shown to reduce cardiovascular event rates in
patients with stable atherosclerotic cardiovascular disease and in patients with a recent (up to one year)
acute coronary syndrome. Given the costs, chronicity of the treatment and the potential budget impact,
PCSK9 inhibitors are often limited to patients with the highest absolute risk for major adverse cardiovascular
events despite optimal treatment with high-intensity statin and ezetimibe.
Conclusion:
PCSK9 inhibitors have a favorable safety, efficacy and tolerability profile. Postmarketing
safety surveillance and real-world studies are needed to further support the long-term safety
profile of this class of medicine.
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Affiliation(s)
- Frederick J. Raal
- Department of Medicine, Division of Endocrinology and Metabolism, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Robert Chilton
- Department of Medicine, Faculty of Medicine, Division of Cardiology and Interventional Cardiology, University of Texas Health Science Center at San Antonia, Texas, United States
| | - Naresh Ranjith
- Department of Cardiology, Cardiovascular Research Centre, Durban, South Africa
| | - Virendra Rambiritch
- Department of Pharmacology, Faculty of Health Sciences, Discipline of Pharmaceutical Sciences, University of Kwa-Zulu Natal, Durban, South Africa
| | - Rory F. Leisegang
- Department of Pharmaceutical Biosciences, Faculty of Pharmacy, Uppsala University, Uppsala, Sweden
| | | | - Alet van Tonder
- Department of Diabetes and Cardiovascular Medicine, Medical Affairs, Sanofi, Midrand, South Africa
| | - Nelusha Shunmoogam
- Department of Diabetes and Cardiovascular Medicine, Medical Affairs, Sanofi, Midrand, South Africa
| | - Célia Bouharati
- Department of Clinical Trials, Clinical Study Unit, Sanofi, Midrand, South Africa
| | - Moji G. Musa
- Department of Diabetes and Cardiovascular Medicine, Medical Affairs, Sanofi, Midrand, South Africa
| | - Sumanth Karamchand
- Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Poobalan Naidoo
- Department of Diabetes and Cardiovascular Medicine, Medical Affairs, Sanofi, Midrand, South Africa
| | - Dirk J. Blom
- Department of Medicine, Division of Lipidology and Hatter Institute for Cardiovascular Research in Africa, University of Cape Town, Cape Town, South Africa
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8
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PCSK9 inhibition with alirocumab in pediatric patients with heterozygous familial hypercholesterolemia: The ODYSSEY KIDS study. J Clin Lipidol 2020; 14:322-330.e5. [DOI: 10.1016/j.jacl.2020.03.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/10/2020] [Accepted: 03/11/2020] [Indexed: 01/17/2023]
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Colhoun HM, Leiter LA, Müller-Wieland D, Cariou B, Ray KK, Tinahones FJ, Domenger C, Letierce A, Israel M, Samuel R, Del Prato S. Effect of alirocumab on individuals with type 2 diabetes, high triglycerides, and low high-density lipoprotein cholesterol. Cardiovasc Diabetol 2020; 19:14. [PMID: 32035487 PMCID: PMC7007683 DOI: 10.1186/s12933-020-0991-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/22/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Mixed dyslipidemia [elevated non-high-density lipoprotein cholesterol (non-HDL-C) and triglycerides (TGs), and decreased HDL-C] is common in type 2 diabetes mellitus (T2DM) and is associated with increased cardiovascular risk. Non-HDL-C and apolipoprotein B (ApoB) are the preferred therapeutic targets for mixed dyslipidemia. Alirocumab is a monoclonal antibody to proprotein convertase subtilisin/kexin type 9 (PCSK9) that effectively reduces low-density lipoprotein cholesterol (LDL-C), non-HDL-C, ApoB, and lipoprotein(a) (Lp[a]), and is well-tolerated in individuals with T2DM. METHODS The previously reported open-label ODYSSEY DM-DYSLIPIDEMIA trial data demonstrated the effects of alirocumab on individuals with non-HDL-C ≥ 100 mg/dL and TGs ≥ 150 and < 500 mg/dL receiving stable maximally tolerated statin (n = 413). This post hoc subgroup analysis of the primary trial investigated the effects of alirocumab [75 mg every 2 weeks (Q2W) with possible increase to 150 mg Q2W at Week 12] versus usual care [ezetimibe, fenofibrate, or no additional lipid-lowering therapy (LLT)] on non-HDL-C and other lipids in individuals with T2DM and baseline TGs ≥ 200 mg/dL and HDL-C < 40 mg/dL (men) or < 50 mg/dL (women). RESULTS Alirocumab significantly reduced non-HDL-C [LS mean difference (standard error (SE)), - 35.0% (3.9)], ApoB [LS mean difference (SE), - 34.7% (3.6)], LDL-C [LS mean difference (SE), - 47.3% (5.2)], LDL particle number [LS mean difference (SE), - 40.8% (4.1)], and Lp(a) [LS mean difference (SE), - 29.9% (5.4)] versus usual care from baseline to Week 24 (all P < 0.0001). Results were similar for alirocumab versus usual care. TG reductions were similar between alirocumab and usual care (no significant difference), but greater with fenofibrate versus alirocumab (P = 0.3371). Overall, alirocumab significantly increased HDL-C versus usual care [LS mean difference (SE), 7.9% (3.6); P < 0.05], although differences with alirocumab versus ezetimibe or fenofibrate were non-significant. Most individuals receiving alirocumab achieved ApoB < 80 mg/dL (67.9%) and non-HDL-C < 100 mg/dL (60.9%). Adverse event frequency was similar between alirocumab (67.2%) and usual care (70.7%). Additionally, no clinically relevant effect of alirocumab on change in glycemic parameters or use of antihyperglycemic agents was observed. CONCLUSIONS Alirocumab is an effective therapeutic option for individuals with T2DM, TGs ≥ 200 mg/dL, and HDL-C < 40 mg/dL (men) or < 50 mg/dL (women). Atherogenic lipid (ApoB and non-HDL) reductions were greater with alirocumab than ezetimibe, fenofibrate, or no LLT. Consistent with previous studies, alirocumab was generally well tolerated. Trial registration Clinicaltrials.gov, NCT02642159. Registered December 24, 2015, https://clinicaltrials.gov/ct2/show/NCT02642159.
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Affiliation(s)
- Helen M Colhoun
- The Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU, UK.
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Dirk Müller-Wieland
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany
| | - Bertrand Cariou
- l'institut du thorax, CHU Nantes, INSERM, CNRS, UNIV Nantes, Nantes, France
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, Imperial College, London, UK
| | - Francisco J Tinahones
- Department of Clinical Endocrinology and Nutrition (IBIMA), Hospital Virgen de la Victoria, University of Málaga, CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Málaga, Spain
| | | | - Alexia Letierce
- Biostatistics and Programming Department, Sanofi, Chilly-Mazarin, France
| | - Marc Israel
- Regeneron Pharmaceuticals, Inc, Tarrytown, NY, USA
| | - Rita Samuel
- Regeneron Pharmaceuticals, Inc, Tarrytown, NY, USA
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Abstract
Loss-of-function variants in PCSK9 (proprotein convertase subtilisin-kexin type 9) are associated with lower lifetime risk of atherosclerotic cardiovascular disease) events. Confirmation of these genetic observations in large, prospective clinical trials in participants with atherosclerotic cardiovascular disease has provided guidance on risk stratification and enhanced our knowledge on hitherto unresolved and contentious issues concerning the efficacy and safety of markedly lowering LDL-C (low-density lipoprotein cholesterol). PCSK9 has a broad repertoire of molecular effects. Furthermore, clinical trials with PCSK9 inhibitors demonstrate that reductions in atherosclerotic cardiovascular disease events are more effective in patients with recent myocardial infarction, multiple myocardial infarctions, multivessel coronary artery disease, and lower extremity arterial disease. The potent LDL-C lowering efficacy of PCSK9 inhibitors provides the opportunity for more aggressive LDL-lowering strategies in high-risk patients with atherosclerotic cardiovascular disease and supports the notion that there is no lower limit for LDL-C. Aggressive LDL-C lowering with fully human PCSK9 monoclonal antibodies has been associated by a safety profile superior to that of other classes of LDL-lowering agents. These clinical trials provide evidence that LDL lowering with PCSK9 inhibitors is an effective therapy for lowering cardiovascular events in high-risk patients with LDL-C levels ≥70 mg/dL on maximally tolerated oral therapies, including statins and ezetimibe.
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Affiliation(s)
- Robert S Rosenson
- From the Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry R. Kravis Center for Cardiovascular Health, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY (R.S.R.)
| | - Robert A Hegele
- Department of Medicine and Robarts Research Institute, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Wolfgang Koenig
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany (W.K.).,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany (W.K.).,Institute of Epidemiology and Biostatistics, University of Ulm, Germany (W.K.)
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11
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Müller-Wieland D, Rader DJ, Moriarty PM, Bergeron J, Langslet G, Ray KK, Manvelian G, Thompson D, Bujas-Bobanovic M, Roth EM. Efficacy and Safety of Alirocumab 300 mg Every 4 Weeks in Individuals With Type 2 Diabetes on Maximally Tolerated Statin. J Clin Endocrinol Metab 2019; 104:5253-5262. [PMID: 31166599 PMCID: PMC6763278 DOI: 10.1210/jc.2018-02703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 05/30/2019] [Indexed: 01/14/2023]
Abstract
CONTEXT In the ODYSSEY CHOICE I trial, alirocumab 300 mg every 4 weeks (Q4W) was assessed in patients with hypercholesterolemia. Alirocumab efficacy and safety were evaluated in a patient subgroup with type 2 diabetes mellitus (T2DM) and who were receiving maximally tolerated statins with or without other lipid-lowering therapies. METHODS Participants received either alirocumab 300 mg Q4W (n = 458, including 96 with T2DM) or placebo (n = 230, including 50 with T2DM) for 48 weeks, with alirocumab dose adjustment to 150 mg every 2 weeks at Week (W) 12 if W8 low-density lipoprotein cholesterol (LDL-C) levels were ≥70 mg/dL or ≥ 100 mg/dL, depending on cardiovascular risk, or if LDL-C reduction was <30% from baseline. Efficacy end points included percentage change from baseline to W24 for lipids, and time-averaged LDL-C over W21 to W24. RESULTS In individuals with T2DM, LDL-C reductions from baseline to W24 and the average of W21 to W24 were significantly greater with alirocumab (-61.6% and -68.8%, respectively) vs placebo. At W24, alirocumab significantly reduced levels of non-high-density lipoprotein cholesterol (HDL-C) and other lipids. At W24, 85.9% and 12.5% of individuals in the alirocumab and placebo groups, respectively, reached both non-HDL-C <100 mg/dL and LDL-C <70 mg/dL. At W12, In total, 18% of alirocumab-treated participants received dose adjustment. The most common treatment-emergent adverse events were upper respiratory tract infection and injection-site reaction. No clinically significant changes in fasting plasma glucose and glycated hemoglobin were observed. CONCLUSION In individuals with T2DM, alirocumab 300 mg Q4W was generally well tolerated and efficacious in reducing atherogenic lipoproteins.
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Affiliation(s)
- Dirk Müller-Wieland
- Department of Medicine I, University Hospital, RWTH Aachen University, Aachen, Germany
- Correspondence and Reprint Requests: Dirk Müller-Wieland, MD, Department of Medicine I, University Hospital, RWTH Aachen University, Paulwelsstr. 30, 52074 Aachen, Germany. E-mail:
| | - Daniel J Rader
- Department of Medicine and Genetics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennysylvania
| | - Patrick M Moriarty
- Department of Internal Medicine, Division of Clinical Pharmacology, University of Kansas Medical Center, Kansas City, Kansas
| | - Jean Bergeron
- Clinique des Maladies Lipidiques, Department of Medicine, Centre Hospitalier Universitaire de Québec – Université Laval, Québec, Canada
| | | | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Imperial College London, London, United Kingdom
| | | | | | | | - Eli M Roth
- The Sterling Research Group and University of Cincinnati, Cincinnati, Ohio
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12
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Rana K, Reid J, Rosenwasser JN, Lewis T, Sheikh-Ali M, Choksi RR, Goldfaden RF. A spotlight on alirocumab in high cardiovascular risk patients with type 2 diabetes and mixed dyslipidemia: a review on the emerging data. Diabetes Metab Syndr Obes 2019; 12:1897-1911. [PMID: 31571964 PMCID: PMC6756838 DOI: 10.2147/dmso.s167375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 08/19/2019] [Indexed: 01/05/2023] Open
Abstract
Diabetes is a significant and independent risk factor for atherosclerotic cardiovascular disease (ASCVD), leading to morbidity and mortality among this population. The prevention of macrovascular complications, such as CVD, peripheral arterial disease, and cerebrovascular accident, in patients with diabetes is obtained through multifactorial risk reduction, including mixed dyslipidemia management and adequate glycemic control. For patients with diabetes, it is crucial to initiate adequate dyslipidemia therapy to achieve recommended low-density lipoprotein cholesterol (LDL-C) goal of <70 mg/dL or target non-high-density lipoprotein goal of <100 mg/dL. Lipid-lowering therapies (LLTs), such as statins and ezetimibe, are the cornerstone for plasma LDL-C lowering; however, individuals with diabetes are often unable to achieve target lipid goals with these therapies alone and frequently require additional treatments. A new class of LLTs, proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors, provides a novel approach to lowering lipids in persons with high CV risk, such as those with diabetes. The clinical data presented in this review indicate the potential benefits of alirocumab in patients with diabetes and its value as a treatment option in patients with diabetic dyslipidemia with no significant safety concerns.
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Affiliation(s)
- Khyatiben Rana
- East Coast Institute for Research, Jacksonville, FL, USA
| | - Jessica Reid
- East Coast Institute for Research, Jacksonville, FL, USA
| | | | - Todd Lewis
- Baker-Gilmour Cardiovascular Institute, Jacksonville, FL, USA
| | - Mae Sheikh-Ali
- Northeast Florida Endocrine and Diabetes Associates, Jacksonville, FL, USA
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13
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Strilchuk L, Fogacci F, Cicero AF. Safety and tolerability of injectable lipid-lowering drugs: an update of clinical data. Expert Opin Drug Saf 2019; 18:611-621. [DOI: 10.1080/14740338.2019.1620730] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Larysa Strilchuk
- Department of Therapy and Medical Diagnostics, Lviv National Medical University, Lviv, Ukraine
| | - Federica Fogacci
- Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy AQ1: The ORCID of Federica Fogacci is OK
| | - Arrigo Fg Cicero
- Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy AQ1: The ORCID of Federica Fogacci is OK
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14
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Dijk W, Cariou B. Efficacy and safety of proprotein convertase subtilisin/kexin 9 inhibitors in people with diabetes and dyslipidaemia. Diabetes Obes Metab 2019; 21 Suppl 1:39-51. [PMID: 31002456 DOI: 10.1111/dom.13636] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/05/2019] [Accepted: 01/07/2019] [Indexed: 12/11/2022]
Abstract
Diabetic dyslipidaemia, characterized by quantitative, qualitative and kinetic changes in all major circulating lipids, contributes to the increased cardiovascular risk in patients with type 2 diabetes mellitus (T2DM). A promising therapeutic avenue is the inhibition of the proprotein convertase subtilisin kexin 9 (PCSK9) with human monoclonal antibodies (mAbs) that potently reduce plasma low-density lipoprotein cholesterol (LDL-C) levels on top of statin treatment. The aim of this review is to evaluate the efficacy of PCSK9 inhibitors to lower the residual cardiovascular risk of T2DM patients and to discuss the safety of PCSK9 inhibition in these patients. PCSK9 inhibitors potently lower plasma LDL-C levels in T2DM patients and reduce risk for the development of cardiovascular disease. Anti-PCSK9 mAbs are generally not more or less effective in T2DM patients compared to a general high-risk population. Nevertheless, due to their higher cardiovascular risk, the absolute risk reduction of major cardiovascular events is more significant in T2DM patients. This suggests that treatment of T2DM patients with anti-PCSK9 mAbs could be attractive from a cost-effectiveness perspective. Treatment with anti-PCSK9 mAbs did not result in significant treatment-emergent adverse effects. While genetic studies suggest a potential link between PCSK9 inhibition and glucose homeostasis, anti-PCSK9 mAbs did not worsen glycaemic control in T2DM patients, but their safety should be verified after a longer-term follow-up.
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Affiliation(s)
- Wieneke Dijk
- L'institut du thorax, INSERM, CNRS, University of Nantes, CHU Nantes, Nantes, France
| | - Bertrand Cariou
- L'institut du thorax, INSERM, CNRS, University of Nantes, CHU Nantes, Nantes, France
- CIC INSERM 1413, CHU Nantes, Department of Endocrinology, L'institut du thorax, Nantes, France
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15
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Macchi C, Banach M, Corsini A, Sirtori CR, Ferri N, Ruscica M. Changes in circulating pro-protein convertase subtilisin/kexin type 9 levels - experimental and clinical approaches with lipid-lowering agents. Eur J Prev Cardiol 2019; 26:930-949. [PMID: 30776916 DOI: 10.1177/2047487319831500] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Regulation of pro-protein convertase subtilisin/kexin type 9 (PCSK9) by drugs has led to the development of a still small number of agents with powerful activity on low-density lipoprotein cholesterol levels, associated with a significant reduction of cardiovascular events in patients in secondary prevention. The Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) and Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab (ODYSSEY OUTCOMES) studies, with the two available PCSK9 antagonists, i.e. evolocumab and alirocumab, both reported a 15% reduction in major adverse cardiovascular events. Regulation of PCSK9 expression is dependent upon a number of factors, partly genetic and partly associated to a complex transcriptional system, mainly controlled by sterol regulatory element binding proteins. PCSK9 is further regulated by concomitant drug treatments, particularly by statins, enhancing PCSK9 secretion but decreasing its stimulatory phosphorylated form (S688). These complex transcriptional mechanisms lead to variable circulating levels making clinical measurements of plasma PCSK9 for cardiovascular risk assessment a debated matter. Determination of total PCSK9 levels may provide a diagnostic tool for explaining an apparent resistance to PCSK9 inhibitors, thus indicating the need for other approaches. Newer agents targeting PCSK9 are in clinical development with a major interest in those with a longer duration of action, e.g. RNA silencing, allowing optimal patient compliance. Interest has been expanded to areas not only limited to low-density lipoprotein cholesterol reduction but also investigating other non-lipid pathways raising cardiovascular risk, in particular inflammation associated to raised high-sensitivity C-reactive protein levels, not significantly affected by the present PCSK9 antagonists.
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Affiliation(s)
- C Macchi
- 1 Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, Italy
| | - M Banach
- 2 Department of Hypertension, Medical University of Lodz, Poland.,3 Polish Mother's Memorial Hospital Research Institute (PMMHRI), Poland.,4 Cardiovascular Research Centre, University of Zielona Gora, Poland
| | - A Corsini
- 1 Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, Italy.,5 Multimedica IRCCS, Italy
| | - C R Sirtori
- 6 Dyslipidemia Center, A.S.S.T. Grande Ospedale Metropolitano Niguarda, Italy
| | - N Ferri
- 7 Dipartimento di Scienze del Farmaco, Università degli Studi di Padova, Italy
| | - M Ruscica
- 1 Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, Italy
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16
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Leiter LA, Tinahones FJ, Karalis DG, Bujas-Bobanovic M, Letierce A, Mandel J, Samuel R, Jones PH. Alirocumab safety in people with and without diabetes mellitus: pooled data from 14 ODYSSEY trials. Diabet Med 2018; 35:1742-1751. [PMID: 30183102 PMCID: PMC6585811 DOI: 10.1111/dme.13817] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2018] [Indexed: 02/06/2023]
Abstract
AIM To evaluate the safety of the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor alirocumab according to diabetes mellitus status. METHODS Safety data from 14 trials (8-104-week durations) were analysed by treatment (alirocumab or placebo/ezetimibe control) and diabetes status (yes/no, defined by medical history). Adverse event data were assessed using descriptive statistics and Cox models. RESULTS Of the 5234 trial participants, 1554 (29.7%) had diabetes. Overall, treatment-emergent adverse events were similar in the alirocumab and control groups, except for more frequent local injection site reactions with alirocumab. Fewer people with diabetes experienced local injection site reactions [alirocumab, 3.5%, control, 2.9%; hazard ratio 1.24 (95% CI 0.68-2.25)] than those without diabetes [alirocumab, 7.5%; control, 4.9%; hazard ratio 1.51 (95% CI 1.13-2.01)]. Those with diabetes reported a greater number of serious adverse events (alirocumab, 19.4%; control, 19.7%) than those without diabetes (alirocumab, 14.5%; control, 13.5%). In people with diabetes, major adverse cardiac events occurred in 2.7% of alirocumab-treated people [control, 3.3%; hazard ratio 0.74 (95% CI 0.41-1.35)]; in those without diabetes, 1.8% of alirocumab-treated people had major adverse cardiac events [control, 1.7%; hazard ratio 0.95 (95% CI 0.56-1.62)]. Overall, no increase in HbA1c or fasting plasma glucose vs control treatment groups was observed, regardless of diabetes status. CONCLUSION This pooled analysis across 14 trials demonstrated similar safety for alirocumab vs control treatment, irrespective of diabetes status, except for more frequent local injection site reactions with alirocumab. People with diabetes reported fewer local injection site reactions than those without diabetes.
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Affiliation(s)
- L A Leiter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - F J Tinahones
- Department of Clinical Endocrinology and Nutrition (IBIMA), Hospital Virgen de la Victoria, University of Málaga, CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Málaga, Spain
| | - D G Karalis
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - A Letierce
- Biostatistics and Programming Department, Sanofi, Chilly-Mazarin, France
| | - J Mandel
- IviData Stats, Levallois Perret, France
- Sanofi, Chilly-Mazarin, France
| | - R Samuel
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| | - P H Jones
- Baylor College of Medicine, Houston, TX, USA
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