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Zhao W, Wang Y, Li J, Chen T, Yin D, Dai H, Yao Z, Zhao S. Efficacy and safety of omega-3-acid ethyl acetate 90 capsules in severe hypertriglyceridemia: A randomized, controlled, multicenter study. Lipids 2024. [PMID: 38830807 DOI: 10.1002/lipd.12406] [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: 01/17/2024] [Revised: 05/17/2024] [Accepted: 05/21/2024] [Indexed: 06/05/2024]
Abstract
Omega-3-acid ethyl acetate 90 capsules (containing 465 mg of eicosapentaenoic acid and 375 mg docosahexaenoic acid) is composed of highly purified omega-3 polyunsaturated fatty acid (PUFA) ethyl esters, whose lipid-lowering effect for severe hypertriglyceridemia (HTG) treatment is unclear. This study aimed to evaluate the efficacy and safety of omega-3-acid ethyl acetate 90 capsules in patients with severe HTG. In this randomized, double-blind, placebo-controlled, multicenter study, 239 patients with severe HTG were enrolled and randomized (1:1) into omega-3 group (N = 122) and placebo group (N = 117) to receive 12-week corresponding treatments. Lipid-related indexes were obtained at treatment initiation (W0), 4 weeks (W4), W8, and W12 after treatment. Adverse events and adverse drug reactions were recorded. Triacylglycerols (TAG), total cholesterol (TC), non-high-density lipoprotein cholesterol (non-HDL-C), very-low-density lipoprotein cholesterol (VLDL-C), and apolipoprotein C-III (Apo C-III) at W4, W8, and W12 were decreased in the omega-3 group versus the placebo group (all p < 0.05). Moreover, the percentage changes of TAG, TC, non-HDL-C, and VLDL-C from W0 to W4, W8, and W12, and the percentage change of Apo C-III from W0 to W4 and W8, were more obvious in the omega-3 group compared with the placebo group (all p < 0.05). However, no difference was observed in the percentage changes of HDL-C, low-density lipoprotein cholesterol (LDL-C), and LDL-C/HDL-C ratio during follow-up between groups (all p > 0.05). Additionally, there was no discrepancy in adverse events and adverse drug reactions between groups (all p > 0.05). Omega-3-acid ethyl acetate 90 capsules exhibit satisfied lipid-lowering effect with tolerable safety profile in patients with severe HTG.
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Affiliation(s)
- Wang Zhao
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yangang Wang
- Department of Endocrinology and Metabolism, Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Jin Li
- Department of Cardiology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Tao Chen
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital of SiChuan University, Chengdu, Sichuan, China
| | - Delu Yin
- Department of Cardiology, The First People's Hospital of Lianyungang, The First Affiliated Hospital of Kangda College of Nanjing Medical University, Lianyungang, China
| | - Hailong Dai
- Department of Cardiology, Yan'an Affiliated Hospital of Kunming Medical University, Yunnan Cardiovascular Hospital, Kunming, Yunnan, China
| | - Zhuhua Yao
- Department of Cardiology, Tianjin Union Medical Center, Tianjin, China
| | - Shuiping Zhao
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
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Arai H, Yamashita S, Araki E, Yokote K, Tanigawa R, Saito A, Yamasaki S, Suganami H, Ishibashi S. Efficacy and Safety of Pemafibrate Extended-Release Tablet: a Phase 3, Multicenter, Randomized, Double-Blind, Active-Controlled, Parallel-Group Comparison Trial. J Atheroscler Thromb 2024:64677. [PMID: 38616112 DOI: 10.5551/jat.64677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024] Open
Abstract
AIMS Pemafibrate, a selective peroxisome proliferator-activated receptor α modulator that lowers serum triglyceride levels and increases high-density lipoprotein cholesterol levels, is approved for treating dyslipidemia as twice-daily immediate-release (IR) tablets. A once-daily extended-release (XR) tablet has also been developed. We aimed to confirm the non-inferiority of XR (0.2 or 0.4 mg/day; once daily) to IR (0.2 mg/day; twice daily) in lowering triglyceride levels in patients with hypertriglyceridemia. METHODS This phase 3, multicenter, randomized, double-blind study included patients with fasting triglycerides ≥ 200 mg/dL who received IR (0.2 mg/day) or XR (0.2 or 0.4 mg/day). The primary efficacy endpoint was the percentage change in fasting triglyceride levels from baseline to 4, 8, and 12 weeks. Common treatment effects at weeks 4 through 12 were compared between groups using repeated analysis of covariance. RESULTS In 356 randomized patients, fasting triglyceride levels decreased by 48.0%, 43.8%, and 48.0% with IR 0.2, XR 0.2, and XR 0.4 mg/day, respectively, confirming the non-inferiority of both XR regimens to IR. The proportion of patients who achieved fasting triglycerides <150 mg/dL was 45.7%, 37.4%, and 51.7%, while the percentage change of triglycerides in the subgroup with baseline triglycerides ≥ 500 mg/dL was -59.3%, -52.2%, and -66.3% with IR 0.2, XR 0.2, and XR 0.4 mg/day, respectively. CONCLUSIONS XR (0.2 and 0.4 mg/day) was non-inferior to IR (0.2 mg/day). XR 0.4 mg/day demonstrated a more potent triglyceride-lowering effect than XR 0.2 mg/day and should be considered for patients with high triglyceride levels.
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Affiliation(s)
| | | | - Eiichi Araki
- Kikuchi Medical Association Hospital
- Research Center for Health and Sports Sciences, Kumamoto Health Science University
| | - Koutaro Yokote
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine
| | | | - Ayumi Saito
- Global Clinical Development Department, Kowa Company, Ltd
| | | | | | - Shun Ishibashi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, Jichi Medical University
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Egusa G, Ohno H, Nagano G, Sagawa J, Shinjo H, Yamamoto Y, Himeno N, Morita Y, Kanai A, Baba R, Kobuke K, Oki K, Yoneda M, Hattori N. Selective activation of PPARα maintains thermogenic capacity of beige adipocytes. iScience 2023; 26:107143. [PMID: 37456852 PMCID: PMC10338232 DOI: 10.1016/j.isci.2023.107143] [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: 09/30/2022] [Revised: 04/17/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Beige adipocytes are inducible thermogenic adipocytes used for anti-obesity treatment. Beige adipocytes rapidly lose their thermogenic capacity once external cues are removed. However, long-term administration of stimulants, such as PPARγ and β-adrenergic receptor agonists, is unsuitable due to various side effects. Here, we reported that PPARα pharmacological activation was the preferred target for maintaining induced beige adipocytes. Pemafibrate used in clinical practice for dyslipidemia was developed as a selective PPARα modulator (SPPARMα). Pemafibrate administration regulated the thermogenic capacity of induced beige adipocytes, repressed body weight gain, and ameliorated impaired glucose tolerance in diet-induced obese mouse models. The transcriptome analysis revealed that the E-twenty-six transcription factor ELK1 acted as a cofactor of PPARα. ELK1 was mobilized to the Ucp1 transcription regulatory region with PPARα and modulated its expression by pemafibrate. These results suggest that selective activation of PPARα by pemafibrate is advantageous to maintain the function of beige adipocytes.
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Affiliation(s)
- Gentaro Egusa
- Department of Molecular and Internal Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Haruya Ohno
- Department of Molecular and Internal Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Gaku Nagano
- Department of Molecular and Internal Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Junji Sagawa
- Department of Molecular and Internal Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroko Shinjo
- Department of Molecular and Internal Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yutaro Yamamoto
- Department of Molecular and Internal Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Natsumi Himeno
- Department of Molecular and Internal Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yoshimi Morita
- Department of Molecular and Internal Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akinori Kanai
- Department of Computational Biology and Medical Sciences, Graduate School of Frontier Sciences, The University of Tokyo, Tokyo, Japan
| | - Ryuta Baba
- Department of Molecular and Internal Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazuhiro Kobuke
- Department of Preventive Medicine for Diabetes and Lifestyle-related Diseases, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kenji Oki
- Department of Molecular and Internal Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masayasu Yoneda
- Department of Preventive Medicine for Diabetes and Lifestyle-related Diseases, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Noboru Hattori
- Department of Molecular and Internal Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
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Yamashita S, Rizzo M, Su TC, Masuda D. Novel Selective PPARα Modulator Pemafibrate for Dyslipidemia, Nonalcoholic Fatty Liver Disease (NAFLD), and Atherosclerosis. Metabolites 2023; 13:metabo13050626. [PMID: 37233667 DOI: 10.3390/metabo13050626] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 05/27/2023] Open
Abstract
Statins, the intestinal cholesterol transporter inhibitor (ezetimibe), and PCSK9 inhibitors can reduce serum LDL-C levels, leading to a significant reduction in cardiovascular events. However, these events cannot be fully prevented even when maintaining very low LDL-C levels. Hypertriglyceridemia and reduced HDL-C are known as residual risk factors for ASCVD. Hypertriglyceridemia and/or low HDL-C can be treated with fibrates, nicotinic acids, and n-3 polyunsaturated fatty acids. Fibrates were demonstrated to be PPARα agonists and can markedly lower serum TG levels, yet were reported to cause some adverse effects, including an increase in the liver enzyme and creatinine levels. Recent megatrials of fibrates have shown negative findings on the prevention of ASCVD, which were supposed to be due to their low selectivity and potency for binding to PPAR α. To overcome the off-target effects of fibrates, the concept of a selective PPARα modulator (SPPARMα) was proposed. Kowa Company, Ltd. (Tokyo, Japan), has developed pemafibrate (K-877). Compared with fenofibrate, pemafibrate showed more favorable effects on the reduction of TG and an increase in HDL-C. Fibrates worsened liver and kidney function test values, although pemafibrate showed a favorable effect on liver function test values and little effect on serum creatinine levels and eGFR. Minimal drug-drug interactions of pemafibrate with statins were observed. While most of the fibrates are mainly excreted from the kidney, pemafibrate is metabolized in the liver and excreted into the bile. It can be used safely even in patients with CKD, without a significant increase in blood concentration. In the megatrial of pemafibrate, PROMINENT, for dyslipidemic patients with type 2 diabetes, mild-to-moderate hypertriglyceridemia, and low HDL-C and LDL-C levels, the incidence of cardiovascular events did not decrease among those receiving pemafibrate compared to those receiving the placebo; however, the incidence of nonalcoholic fatty liver disease was lower. Pemafibrate may be superior to conventional fibrates and applicable to CKD patients. This current review summarizes the recent findings on pemafibrate.
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Affiliation(s)
- Shizuya Yamashita
- Department of Cardiology, Rinku General Medical Center, Izumisano 598-8577, Osaka, Japan
| | - Manfredi Rizzo
- Department of Internal Medicine and Medical Specialties, School of Medicine, University of Palermo, 90133 Palermo, Italy
- Promise Department, School of Medicine, University of Palermo, 90133 Palermo, Italy
| | - Ta-Chen Su
- Department of Environmental and Occupational Medicine, National Taiwan University Hospital, Taipei 10002, Taiwan
- Institute of Environmental and Occupational Health Sciences, College of Public Health, National Taiwan University, Taipei 10017, Taiwan
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei 10002, Taiwan
| | - Daisaku Masuda
- Department of Cardiology, Rinku General Medical Center, Izumisano 598-8577, Osaka, Japan
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Pulipati VP, Brinton EA, Hatipoglu B. Management of Mild-to-Moderate Hypertriglyceridemia. Endocr Pract 2022; 28:1187-1195. [PMID: 35850450 DOI: 10.1016/j.eprac.2022.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 07/07/2022] [Accepted: 07/10/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Hypertriglyceridemia is highly prevalent globally and its prevalence is rising with international increases in the incidence of obesity and diabetes. This review examines current management and future therapies METHODS: For this review, hypertriglyceridemia is defined as mild-to-moderate triglyceride elevation, a fasting or non-fasting triglyceride level >150 mg/dL and <500 mg/dL. We reviewed scientific studies published over the last 30 years and current professional society recommendations regarding evaluation and treatment of hypertriglyceridemia. RESULTS Genetics, lifestyle, and other environmental factors impact triglyceride levels. In adults with mild-to-moderate hypertriglyceridemia, clinicians should routinely assess and treat secondary treatable causes (diet, physical activity, obesity, metabolic syndrome, and reduction or cessation of medications that elevate triglyceride levels). Since atherosclerotic cardiovascular disease (ASCVD) risk is the primary clinical concern, statins are usually first-line treatment. Patients with triglyceride levels between >150 mg/dL and <500 mg/dL whose LDL-C is treated adequately with statins (at "maximally tolerated" doses, per some statements) and have either prior cardiovascular disease or diabetes mellitus plus at least 2 additional cardiovascular disease risk factors should be considered for added icosapent ethyl treatment to further reduce their cardiovascular disease risk. Fibrates, niacin, and other approved agents or agents under development are also reviewed in detail. CONCLUSION The treatment paradigm for mild-to-moderate hypertriglyceridemia is changing based on data from recent clinical trials. Recent trials suggest that the addition of icosapent ethyl to background statin therapy may further reduce ASCVD risk in patients with moderate HTG, though a particular TG goal has not been identified.
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Affiliation(s)
| | | | - Betul Hatipoglu
- Case Western Reserve University School of Medicine, Department of Medicine; University Hospitals Cleveland Medical Center, Department of Medicine, Adult Endocrinology, 11100 Euclid Avenue, Cleveland, OH 44106.
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Yamaguchi M, Asano T, Arisaka T, Mashima H, Irisawa A, Tamano M. Effects of pemafibrate on primary biliary cholangitis with dyslipidemia. Hepatol Res 2022; 52:522-531. [PMID: 35072975 DOI: 10.1111/hepr.13747] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/11/2022] [Accepted: 01/20/2022] [Indexed: 02/08/2023]
Abstract
AIM The purpose of this study was to examine the effect of pemafibrate (PEM) in primary biliary cholangitis (PBC) patients with dyslipidemia. METHODS Patients who were diagnosed with PBC between June 2018 and December 31, 2020 were included in the study if they also had dyslipidemia and their alkaline phosphatase (ALP) or gamma-glutamyl transferase (GGT) levels remained above the normal range despite taking 600 mg/day ursodeoxycholic acid (UDCA) for at least 6 months. Patients who were treated with UDCA alone were administered PEM as an add-on (PEM-add group), and patients who were treated with UDCA and bezafibrate (BEZ) for at least 6 months were given PEM instead of BEZ (PEM-switch group). Clinical parameters were compared in all patients, and the levels of ALP, GGT, the estimated glomerular filtration rate (eGFR), and creatinine (Cr) were compared between the PEM-add and PEM-switch groups. Improvement in cholangitis was also evaluated. RESULTS In the PEM-add group, both ALP and GGT improved in 40 of 46 patients (87.0%). In the PEM-switch group, both ALP and GGT improved in 15 of 29 patients (51.7%). In the PEM-switch group, however, significant improvement was seen in eGFR and Cr. CONCLUSIONS Administration of PEM is effective in PBC patients with dyslipidemia who are refractory to UDCA monotherapy. In patients using both UDCA and BEZ, there was an advantage in switching to PEM if they had renal damage; however, improvement of ALP and GGT occurred in about 50%.
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Affiliation(s)
- Mayumi Yamaguchi
- Department of Gastroenterology, Dokkyo Medical University Saitama Medical Center, Minami-Koshigaya, Koshigaya, Japan
| | - Takeharu Asano
- Department of Gastroenterology, Jichi Medical University Saitama Medical Center, Amanuma, Omiya-ku, Japan
| | - Takahiro Arisaka
- Department of Gastroenterology, Dokkyo Medical University, Kitakobayashi, Mibu, Japan
| | - Hirosato Mashima
- Department of Gastroenterology, Jichi Medical University Saitama Medical Center, Amanuma, Omiya-ku, Japan
| | - Atsushi Irisawa
- Department of Gastroenterology, Dokkyo Medical University, Kitakobayashi, Mibu, Japan
| | - Masaya Tamano
- Department of Gastroenterology, Dokkyo Medical University Saitama Medical Center, Minami-Koshigaya, Koshigaya, Japan
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Association between Pemafibrate Therapy and Triglyceride to HDL-Cholesterol Ratio. J Clin Med 2022; 11:jcm11102820. [PMID: 35628945 PMCID: PMC9148088 DOI: 10.3390/jcm11102820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/10/2022] [Accepted: 05/15/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Pemafibrate is a novel selective peroxisome proliferator-activated receptor-α modulator, which was demonstrated to reduce serum triglyceride level with few drug-related adverse events in phase II and III clinical trials. However, its clinical implication in real-world practice remains unknown. Triglyceride/HDL-cholesterol ratio is a surrogate of small dense LDL-cholesterol, which is a newly proposed cardiovascular risk factor independent of LDL-cholesterol levels. Methods: Consecutive patients who received pemafibrate between April 2020 and September 2021 and continued therapy for at least 3 months were included in this retrospective analysis. The primary outcome was the trend in triglyceride/HDL-cholesterol ratio during the 3-month treatment period. The change in cardiovascular event rate between the one-year pre-treatment period and the on-treatment period was also analyzed. Results: A total of 19 patients (median age 63 years, 74% men) were included and continued pemafibrate therapy for 3 months without any drug-related adverse events. Sixteen were add-on and three were conversions from other fibrates. Triglyceride/HDL-cholesterol ratio decreased significantly from 5.85 (4.19, 16.1) to 3.14 (2.39, 4.62) (p < 0.001). The cardiovascular event rate decreased significantly from 0.632 events/year to 0.080 events/year (p < 0.001). Conclusions: Pemafibrate therapy might have the potential to lower triglyceride/HDL-cholesterol ratio and decrease cardiovascular events.
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Gouni-Berthold I, Schwarz J. New therapeutic approaches for the treatment of hypertriglyceridemia. Herz 2022; 47:220-227. [PMID: 35451595 DOI: 10.1007/s00059-022-05113-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 12/17/2022]
Abstract
Patients with hypertriglyceridemia (> 150 mg/dl) have an increased risk for atherosclerotic cardiovascular disease, and those with severe hypertriglyceridemia (> 880 mg/dl) also for pancreatitis. The currently available medications to decrease triglyceride levels, such as fibrates, statins, and omega‑3 fatty acids, are in many cases not able to achieve normal triglyceride levels. Therefore, new drugs are in development to address this unmet need. Recently, icosapent ethyl, a purified formulation of the omega-3-fatty acid eicosapentaenoic acid, was approved in Germany for the reduction of cardiovascular events in patients with hypertriglyceridemia and established cardiovascular disease or with diabetes and other risk factors on top of statins. Other new drugs in development are the more selective peroxisome proliferator-activated receptor α (PPARα) modulator, pemafibrate, already approved for the treatment of hypertriglyceridemia in Japan, and inhibitors of ApoC-III and angiopoietin-like 3 (ANGPTL3) in the form of antisense oligonucleotides or siRNAs or fully human monoclonal binding antibodies. Apolipoprotein C-III and ANGPTL3 protein seem to be quite promising targets based on solid genetic data. Larger studies of long duration, many of them currently ongoing, are needed to establish the role these medications will play in the treatment of hypertriglyceridemia in clinical practice.
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Affiliation(s)
- Ioanna Gouni-Berthold
- Center for Endocrinology, Diabetes and Preventive Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937, Köln, Germany.
| | - Jonas Schwarz
- Center for Endocrinology, Diabetes and Preventive Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937, Köln, Germany
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Lange NF, Graf V, Caussy C, Dufour JF. PPAR-Targeted Therapies in the Treatment of Non-Alcoholic Fatty Liver Disease in Diabetic Patients. Int J Mol Sci 2022; 23:ijms23084305. [PMID: 35457120 PMCID: PMC9028563 DOI: 10.3390/ijms23084305] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/06/2022] [Accepted: 04/08/2022] [Indexed: 02/06/2023] Open
Abstract
Peroxisome proliferator-activated receptors (PPAR), ligand-activated transcription factors of the nuclear hormone receptor superfamily, have been identified as key metabolic regulators in the liver, skeletal muscle, and adipose tissue, among others. As a leading cause of liver disease worldwide, non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) cause a significant burden worldwide and therapeutic strategies are needed. This review provides an overview of the evidence on PPAR-targeted treatment of NAFLD and NASH in individuals with type 2 diabetes mellitus. We considered current evidence from clinical trials and observational studies as well as the impact of treatment on comorbid metabolic conditions such as obesity, dyslipidemia, and cardiovascular disease. Future areas of research, such as possible sexually dimorphic effects of PPAR-targeted therapies, are briefly reviewed.
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Affiliation(s)
- Naomi F. Lange
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, 3012 Bern, Switzerland
- Correspondence: (N.F.L.); (J.-F.D.)
| | - Vanessa Graf
- Department of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | - Cyrielle Caussy
- Univ Lyon, CarMen Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, 69495 Pierre-Bénite, France;
- Département Endocrinologie, Diabète et Nutrition, Hôpital Lyon Sud, Hospices Civils de Lyon, 69495 Pierre-Bénite, France
| | - Jean-François Dufour
- Centre des Maladies Digestives, 1003 Lausanne, Switzerland
- Swiss NASH Foundation, 3011 Bern, Switzerland
- Correspondence: (N.F.L.); (J.-F.D.)
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Ginsberg HN, Hounslow NJ, Senko Y, Suganami H, Bogdanski P, Ceska R, Kalina A, Libis RA, Supryadkina TV, Hovingh GK. Efficacy and Safety of K-877 (Pemafibrate), a Selective PPARα Modulator, in European Patients on Statin Therapy. Diabetes Care 2022; 45:898-908. [PMID: 35238894 DOI: 10.2337/dc21-1288] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/29/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE High plasma triglyceride (TG) is an independent risk factor for cardiovascular disease. Fibrates lower TG levels through peroxisome proliferator-activated receptor α (PPARα) agonism. Currently available fibrates, however, have relatively low selectivity for PPARα. The aim of this trial was to assess the safety, tolerability, and efficacy of K-877 (pemafibrate), a selective PPARα modulator, in statin-treated European patients with hypertriglyceridemia. RESEARCH DESIGN AND METHODS A total of 408 statin-treated adults were recruited from 68 European sites for this phase 2, randomized, double-blind, placebo-controlled trial. They had fasting TG between 175 and 500 mg/dL and HDL-cholesterol (HDL-C) ≤50 mg/dL for men and ≤55 mg/dL for women. Participants were randomly assigned to receive placebo or one of six pemafibrate regimens: 0.05 mg twice a day, 0.1 mg twice a day, 0.2 mg twice a day, 0.1 mg once daily, 0.2 mg once daily, or 0.4 mg once daily. The primary end points were TG and non-HDL-C level lowering at week 12. RESULTS Pemafibrate reduced TG at all doses (adjusted P value <0.001), with the greatest placebo-corrected reduction from baseline to week 12 observed in the 0.2-mg twice a day treatment group (54.4%). Reductions in non-HDL-C did not reach statistical significance. Reductions in TG were associated with improvements in other markers for TG-rich lipoprotein metabolism, including reductions in apoB48, apoCIII, and remnant cholesterol and an increase in HDL-C levels. Pemafibrate increased LDL-cholesterol levels, whereas apoB100 was unchanged. Pemafibrate was safe and well-tolerated, with only minor increases in serum creatinine and homocysteine concentrations. CONCLUSIONS Pemafibrate is effective, safe, and well-tolerated for the reduction of TG in European populations with hypertriglyceridemia despite statin treatment.
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Affiliation(s)
- Henry N Ginsberg
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | | | | | | | - Pawel Bogdanski
- Department of Treatment of Obesity, Metabolic Disorders and Clinical Dietetics, Poznan University of Medical Sciences, Poznan, Poland
| | - Richard Ceska
- Department of Internal Medicine, Charles University and University General Hospital, Prague, Czech Republic
| | - Akos Kalina
- Hungarian Defense Forces Medical Centre, Budapest, Hungary
| | | | | | - G Kees Hovingh
- Department of Vascular Medicine, Amsterdam UMC, Amsterdam, the Netherlands
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de la Parra Soto LG, Gutiérrez-Uribe JA, Sharma A, Ramírez-Jiménez AK. Is Apo-CIII the new cardiovascular target? An analysis of its current clinical and dietetic therapies. Nutr Metab Cardiovasc Dis 2022; 32:295-308. [PMID: 34895805 DOI: 10.1016/j.numecd.2021.09.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 09/21/2021] [Accepted: 09/30/2021] [Indexed: 11/23/2022]
Abstract
AIMS Recently, Apolipoprotein CIII (Apo-CIII) has gained remarkable attention since its overexpression has been strongly correlated to cardiovascular disease (CVD) occurrence. The aim of this review was to summarize the latest findings of Apo-CIII as a CVDs and diabetes risk factor, as well as the plausible mechanisms involved in the development of these pathologies, with particular emphasis on current clinical and dietetic therapies. DATA SYNTHESIS Apo-CIII is a small protein (∼8.8 kDa) that, among other functions, inhibits lipoprotein lipase, a key enzyme in lipid metabolism. Apo-CIII plays a fundamental role in the physiopathology of atherosclerosis, type-1, and type-2 diabetes. Apo-CIII has become a potential clinical target to tackle these multifactorial diseases. Dietetic (omega-3 fatty acids, stanols, polyphenols, lycopene) and non-dietetic (fibrates, statins, and antisense oligonucleotides) therapies have shown promising results to regulate Apo-CIII and triglyceride levels. However, more information from clinical trials is required to validate it as a new target for atherosclerosis and diabetes types 1 and 2. CONCLUSIONS There are still several pathways involving Apo-CIII regulation that might be affected by bioactive compounds that need further research. The mechanisms that trigger metabolic responses following bioactive compounds consumption are mainly related to higher LPL expression and PPARα activation, although the complete pathways are yet to be elucidated.
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Affiliation(s)
- Lorenzo G de la Parra Soto
- Tecnologico de Monterrey, School of Engineering and Sciences, Av. Eugenio Garza Sada 2501 Sur, C.P. 64849, Monterrey, N.L., Mexico
| | - Janet A Gutiérrez-Uribe
- Tecnologico de Monterrey, School of Engineering and Sciences, Av. Eugenio Garza Sada 2501 Sur, C.P. 64849, Monterrey, N.L., Mexico
| | - Ashutosh Sharma
- Tecnologico de Monterrey, School of Engineering and Sciences, Centre of Bioengineering, Campus Queretaro, Av. Epigmenio González, No. 500, Fracc. San Pablo, 76130, Querétaro, Mexico
| | - Aurea K Ramírez-Jiménez
- Tecnologico de Monterrey, School of Engineering and Sciences, Av. Eugenio Garza Sada 2501 Sur, C.P. 64849, Monterrey, N.L., Mexico.
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Banach M, Burchardt P, Chlebus K, Dobrowolski P, Dudek D, Dyrbuś K, Gąsior M, Jankowski P, Jóźwiak J, Kłosiewicz-Latoszek L, Kowalska I, Małecki M, Prejbisz A, Rakowski M, Rysz J, Solnica B, Sitkiewicz D, Sygitowicz G, Sypniewska G, Tomasik T, Windak A, Zozulińska-Ziółkiewicz D, Cybulska B. PoLA/CFPiP/PCS/PSLD/PSD/PSH guidelines on diagnosis and therapy of lipid disorders in Poland 2021. Arch Med Sci 2021; 17:1447-1547. [PMID: 34900032 PMCID: PMC8641518 DOI: 10.5114/aoms/141941] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 11/03/2021] [Indexed: 12/18/2022] Open
Abstract
In Poland there are still nearly 20 million individuals with hypercholesterolaemia, most of them are unaware of their condition; that is also why only ca. 5% of patients with familial hypercholesterolaemia have been diagnosed; that is why other rare cholesterol metabolism disorders are so rarely diagnosed in Poland. Let us hope that these guidelines, being an effect of work of experts representing 6 main scientific societies, as well as the network of PoLA lipid centers being a part of the EAS lipid centers, certification of lipidologists by PoLA, or the growing number of centers for rare diseases, with a network planned by the Ministry of Health, improvements in coordinated care for patients after myocardial infarction (KOS-Zawał), reimbursement of innovative agents, as well as introduction in Poland of an effective primary prevention program, will make improvement in relation to these unmet needs in diagnostics and treatment of lipid disorders possible.
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Affiliation(s)
- Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz, Lodz, Poland
- Cardiovascular Research Center, University of Zielona Gora, Zielona Gora, Poland
- Department of Cardiology and Congenital Diseases of Adults, Polish Mother’s Memorial Hospital Research Institute (PMMHRI) in Lodz, Lodz, Poland
| | - Paweł Burchardt
- Department of Hypertensiology, Angiology, and Internal Medicine, K. Marcinkowski Poznan University of Medical Science, Poznan, Poland
- Department of Cardiology, Cardiovascular Unit, J. Strus Hospital, Poznan, Poland
| | - Krzysztof Chlebus
- First Department and Chair of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Piotr Dobrowolski
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Krzysztof Dyrbuś
- 3 Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland; Silesian Center for Heart Diseases in Zabrze, Poland
| | - Mariusz Gąsior
- 3 Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland; Silesian Center for Heart Diseases in Zabrze, Poland
| | - Piotr Jankowski
- Department of Internal Medicine and Geriatric Cardiology, Centre of Postgraduate Medical Education, Warsaw, Poland
- Department of Cardiology and Arterial Hypertension, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Jacek Jóźwiak
- Department of Family Medicine and Public Health, Institute of Medical Sciences, Faculty of Medicine, University of Opole, Opole, Poland
| | | | - Irina Kowalska
- Department of Internal Medicine and Metabolic Diseases, Medical University of Bialystok, Bialystok, Poland
| | - Maciej Małecki
- Department and Chair of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Michał Rakowski
- Department of Molecular Biophysics, Institute of Biophysics, Faculty of Biology and Environmental Protection, University of Lodz, Lodz, Poland
| | - Jacek Rysz
- Chair of Nephrology, Arterial Hypertension, and Family Medicine, Medical University of Lodz, Lodz, Poland
| | - Bogdan Solnica
- Chair of Clinical Biochemistry, Jagiellonian University Medical College, Krakow, Poland
| | - Dariusz Sitkiewicz
- Department of Clinical Chemistry and Laboratory Diagnostics, Medical University of Warsaw, Warsaw, Poland
| | - Grażyna Sygitowicz
- Department of Clinical Chemistry and Laboratory Diagnostics, Medical University of Warsaw, Warsaw, Poland
| | - Grażyna Sypniewska
- Department of Laboratory Medicine, L. Rydygier Medical College in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Tomasz Tomasik
- Chair of Family Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Adam Windak
- Chair of Family Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Dorota Zozulińska-Ziółkiewicz
- Department and Chair of Internal Medicine and Diabetology, K. Marcinkowski Poznan University of Medical Sciences, Poznan, Poland
| | - Barbara Cybulska
- National Institute of Public Health NIH – National Research Institute, Warsaw, Poland
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Abstract
BackgroundThe 2018 American College of Cardiology/American Heart Association (ACC/AHA) guidelines and 2021 ACC Expert Consensus Decision Pathway recommend nonpharmacological interventions and initiation of statin therapy for patients with moderate hypertriglyceridemia and addition of fibrates or omega-3 fatty acids in severe hypertriglyceridemia. Although the association between triglyceride (TG) lowering and atherosclerotic cardiovascular disease (ASCVD) risk reduction remains controversial, patients with hypertriglyceridemia may represent a subgroup that require additional therapy to further reduce residual ASCVD risk. Moreover, medications that target novel pathways could provide alternative options for patients who are intolerant of existing therapies or doses needed to provide adequate triglyceride lowering. Objective: Assess recent evidence for TG-lowering agents including omega-3 fatty acid-based therapies, PPARα modulators, apoC-III mRNA antisense inhibitors, angiopoietin-like 3 (ANGPTL3) antibodies, and herbal supplements. Methods: A literature search was performed using PubMed with hypertriglyceridemia specified as a MeSH term or included in the title or abstract of the article along with each individual agent. For inclusion, trials needed to have a primary or secondary outcome of TG levels or TG lowering. Conclusion: Currently, the only US Food and Drug Administration approved medication for CV risk reduction in patients with hypertriglyceridemia is icosapent ethyl. Results from phase 3 trials for CaPre, pemafibrate, and volanesorsen as well as additional evidence for pipeline pharmacotherapies with novel mechanisms of action (e.g., ApoC-III mRNA antisense inhibitors and ANGPTL3 antibodies) will help to guide future pharmacotherapy considerations for patients with hypertriglyceridemia.
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Affiliation(s)
- Jiashan Xu
- Department of Pharmacy, Michigan Medicine21614, Ann Arbor, MI, USA.,15514University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Emily Ashjian
- 15514University of Michigan College of Pharmacy, Ann Arbor, MI, USA.,21614Michigan Medicine, Ann Arbor, MI, USA
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Yamashita S, Okazaki M, Okada T, Masuda D, Yokote K, Arai H, Araki E, Ishibashi S. Distinct Differences in Lipoprotein Particle Number Evaluation between GP-HPLC and NMR: Analysis in Dyslipidemic Patients Administered a Selective PPARα Modulator, Pemafibrate. J Atheroscler Thromb 2021; 28:974-996. [PMID: 33536398 PMCID: PMC8532064 DOI: 10.5551/jat.60764] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/02/2020] [Indexed: 11/29/2022] Open
Abstract
AIM We established a method to evaluate the lipid concentrations, size and particle numbers (PNs) of lipoprotein subclasses by gel permeation chromatography (GP-HPLC). Nuclear magnetic resonance (NMR) is widely used to analyze these parameters of lipoprotein subclasses, but differences of the two methods are unknown. Current study compared the PNs of each lipoprotein subclass measured by GP-HPLC and NMR, and assessed the effect of a selective PPARα modulator, pemafibrate. METHODS Lipoprotein profiles of 212 patients with dyslipidemia who participated in the phase 2 clinical trial of a selective PPARα modulator, pemafibrate, were analyzed by two methods, GP-HPLC and NMR, which were performed with LipoSEARCH (Skylight Biotech) and LipoProfile 3 (LabCorp), respectively. GP-HPLC evaluated the PNs of 18 subclasses, consisting of CM, VLDL1-5, LDL1-6, and HDL1-6. NMR evaluated the PNs of 9 subclasses, consisting of large VLDL & CM, medium VLDL, small VLDL, IDL, large LDL, small LDL, large HDL, medium HDL and small HDL. RESULTS Three major classes, total CM&VLDL, total LDL and total HDL were obtained by grouping of corresponding subclasses in both methods and PNs of these classes analyzed by GP-HPLC were correlated positively with those by NMR. The correlation coefficients in total CM&VLDL, total LDL and total HDL between GP-HPLC and NMR was 0.658, 0.863 and 0.798 (all p<0.0001), respectively. The PNs of total CM&VLDL, total LDL and total HDL analyzed by GP-HPLC was 249.5±51.7nM, 1,679±359 nM and 13,273±1,564 nM, respectively, while those by NMR was 124.6±41.8 nM, 1,514±386 nM and 31,161±4,839 nM, respectively. A marked difference in the PNs between the two methods was demonstrated especially in total HDL. The number of apolipoprotein (Apo) B molecule per one ApoB-containing lipoprotein particle, total CM&VLDL plus total LDL, was 1.10±0.05 by GP-HPLC, while 1.32±0.18 by NMR. The number of ApoA-I per one HDL particle was 3.40±0.17 by GP-HPLC, but only 1.46±0.15 by NMR, much less than reported previously.From the phase 2 clinical trial, randomizing 212 patients to pemafibrate 0.025-0.2 mg BID, fenofibrate 100 mg QD, or placebo groups, pemafibrate reduced the PNs of CM, large VLDL1-VLDL3 and medium VLDL4, but not small VLDL5 by GP-HPLC. It significantly decreased the PNs of smaller LDL and larger HDL particles, but increased those of larger LDL and smaller HDL particles. In contrast, NMR showed marked variations in the effect of pemafibrate on lipoprotein PNs, and no significant size-dependent changes. CONCLUSIONS GP-HPLC evaluates the lipoprotein PNs more accurately than NMR and can be used for assessing the effects of lipid-lowering drugs on lipoprotein subclasses.
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Affiliation(s)
- Shizuya Yamashita
- Department of Cardiology, Rinku General Medical Center, Osaka, Japan
| | | | - Takeshi Okada
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Daisaku Masuda
- Department of Cardiology, Rinku General Medical Center, Osaka, Japan
| | - Koutaro Yokote
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hidenori Arai
- National Center for Geriatrics and Gerontology, Aichi, Japan
| | - Eiichi Araki
- Department of Metabolic Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Shun Ishibashi
- Division of Endocrinology and Metabolism, Department of Medicine, Jichi Medical University, Tochigi, Japan
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15
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Sascău R, Clement A, Radu R, Prisacariu C, Stătescu C. Triglyceride-Rich Lipoproteins and Their Remnants as Silent Promoters of Atherosclerotic Cardiovascular Disease and Other Metabolic Disorders: A Review. Nutrients 2021; 13:1774. [PMID: 34067469 PMCID: PMC8224751 DOI: 10.3390/nu13061774] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/18/2021] [Accepted: 05/20/2021] [Indexed: 12/13/2022] Open
Abstract
While targeting elevated serum levels of low-density lipoprotein cholesterol has been the mainstay of atherosclerosis prevention and treatment for decades, the evidence regarding the atherogenic role of hypertriglyceridemia is still controversial. Various epidemiological population-based studies on statin-treated subjects nominated triglycerides, triglyceride-rich lipoproteins (namely, chylomicrons and very-low-density lipoprotein particles), and their remnants as major determinants of the substantial residual cardiovascular risk. With the triglyceride-glucose index and triglyceride to high-density lipoprotein ratio emerging as surrogate indicators of peripheral artery disease and atherosclerotic cerebrovascular disease, one can conclude that further research addressing the intricate relationship between triglycerides and atherosclerosis is warranted. Therefore, this review aims to provide insight into the current clinical and epidemiological state of knowledge on the relationship between triglycerides and atherosclerotic cardiovascular disease. It also intends to highlight the connection between triglycerides and other metabolic disorders, including diabetes mellitus, and the potential benefits of triglyceride-lowering agents on cardiovascular outcomes and all-cause mortality.
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Affiliation(s)
- Radu Sascău
- Internal Medicine Department, ”Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (R.S.); (R.R.); (C.P.); (C.S.)
- Cardiology Department, Institute of Cardiovascular Diseases Prof. Dr. George I.M. Georgescu, 700503 Iași, Romania
| | - Alexandra Clement
- Cardiology Department, Institute of Cardiovascular Diseases Prof. Dr. George I.M. Georgescu, 700503 Iași, Romania
| | - Rodica Radu
- Internal Medicine Department, ”Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (R.S.); (R.R.); (C.P.); (C.S.)
- Cardiology Department, Institute of Cardiovascular Diseases Prof. Dr. George I.M. Georgescu, 700503 Iași, Romania
| | - Cristina Prisacariu
- Internal Medicine Department, ”Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (R.S.); (R.R.); (C.P.); (C.S.)
- Cardiology Department, Institute of Cardiovascular Diseases Prof. Dr. George I.M. Georgescu, 700503 Iași, Romania
| | - Cristian Stătescu
- Internal Medicine Department, ”Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (R.S.); (R.R.); (C.P.); (C.S.)
- Cardiology Department, Institute of Cardiovascular Diseases Prof. Dr. George I.M. Georgescu, 700503 Iași, Romania
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16
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Yokote K, Yamashita S, Arai H, Araki E, Matsushita M, Nojima T, Suganami H, Ishibashi S. Effects of pemafibrate on glucose metabolism markers and liver function tests in patients with hypertriglyceridemia: a pooled analysis of six phase 2 and phase 3 randomized double-blind placebo-controlled clinical trials. Cardiovasc Diabetol 2021; 20:96. [PMID: 33947390 PMCID: PMC8097867 DOI: 10.1186/s12933-021-01291-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/27/2021] [Indexed: 12/26/2022] Open
Abstract
Background Increased risk of cardiovascular events is associated not only with dyslipidemias, but also with abnormalities in glucose metabolism and liver function. This study uses pooled analysis to explore the in-depth effects of pemafibrate, a selective peroxisome proliferator-activated receptor α modulator (SPPARMα) already known to decrease elevated triglycerides, on glucose metabolism and liver function in patients with hypertriglyceridemia. Methods We performed a post-hoc analysis of six phase 2 and phase 3 Japanese randomized double-blind placebo-controlled trials that examined the effects of daily pemafibrate 0.1 mg, 0.2 mg, and 0.4 mg on glucose metabolism markers and liver function tests (LFTs). Primary endpoints were changes in glucose metabolism markers and LFTs from baseline after 12 weeks of pemafibrate treatment. All adverse events and adverse drug reactions were recorded as safety endpoints. Results The study population was 1253 patients randomized to placebo (n = 298) or pemafibrate 0.1 mg/day (n = 127), 0.2 mg/day (n = 584), or 0.4 mg/day (n = 244). Participant mean age was 54.3 years, 65.4 % had BMI ≥ 25 kg/m2, 35.8 % had type 2 diabetes, and 42.6 % had fatty liver. Fasting glucose, fasting insulin, and HOMA-IR decreased significantly in all pemafibrate groups compared to placebo. The greatest decrease was for pemafibrate 0.4 mg/day: least square (LS) mean change from baseline in fasting glucose − 0.25 mmol/L; fasting insulin − 3.31 µU/mL; HOMA-IR − 1.28. ALT, γ-GT, ALP, and total bilirubin decreased significantly at all pemafibrate doses vs. placebo, with the greatest decrease in the pemafibrate 0.4 mg/day group: LS mean change from baseline in ALT − 7.6 U/L; γ-GT − 37.3 U/L; ALP − 84.7 U/L; and total bilirubin − 2.27 µmol/L. Changes in HbA1c and AST did not differ significantly from placebo in any pemafibrate groups in the overall study population. The decreases from baseline in LFTs and glucose metabolism markers except for HbA1c were notable among patients with higher baseline values. FGF21 increased significantly in all pemafibrate groups compared to placebo, with the greatest increase in the pemafibrate 0.4 mg/day group. Adverse event rates were similar in all groups including placebo. Conclusions In patients with hypertriglyceridemia, pemafibrate can improve glucose metabolism and liver function, and increase FGF21, without increasing adverse event risk. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-021-01291-w.
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Affiliation(s)
- Koutaro Yokote
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan. .,Department of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan.
| | - Shizuya Yamashita
- Rinku General Medical Center, 2-23 Ohrai-kita, Rinku, Izumisano-shi, Osaka, 598-8577, Japan
| | - Hidenori Arai
- National Center for Geriatrics and Gerontology, 7-430 Morioka-cho, Obu-shi, Aichi, 474-8511, Japan
| | - Eiichi Araki
- Department of Metabolic Medicine, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto-shi, Kumamoto, 860-8556, Japan
| | - Mitsunori Matsushita
- Medical Affairs Department, Kowa Company, Ltd, 3-4-14 Nihonbashi-honcho, Chuo-ku, Tokyo, 103-8433, Japan
| | - Toshiaki Nojima
- Clinical Data Science Department, Kowa Company, Ltd, 3-4-14 Nihonbashi-honcho, Chuo- ku, Tokyo, 103-8433, Japan
| | - Hideki Suganami
- Clinical Data Science Department, Kowa Company, Ltd, 3-4-14 Nihonbashi-honcho, Chuo- ku, Tokyo, 103-8433, Japan
| | - Shun Ishibashi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
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17
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Thibaut R, Gage MC, Pineda-Torra I, Chabrier G, Venteclef N, Alzaid F. Liver macrophages and inflammation in physiology and physiopathology of non-alcoholic fatty liver disease. FEBS J 2021; 289:3024-3057. [PMID: 33860630 PMCID: PMC9290065 DOI: 10.1111/febs.15877] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/05/2021] [Accepted: 04/12/2021] [Indexed: 12/13/2022]
Abstract
Non‐alcoholic fatty liver disease (NAFLD) is the hepatic manifestation of metabolic syndrome, being a common comorbidity of type 2 diabetes and with important links to inflammation and insulin resistance. NAFLD represents a spectrum of liver conditions ranging from steatosis in the form of ectopic lipid storage, to inflammation and fibrosis in nonalcoholic steatohepatitis (NASH). Macrophages that populate the liver play important roles in maintaining liver homeostasis under normal physiology and in promoting inflammation and mediating fibrosis in the progression of NAFLD toward to NASH. Liver macrophages are a heterogenous group of innate immune cells, originating from the yolk sac or from circulating monocytes, that are required to maintain immune tolerance while being exposed portal and pancreatic blood flow rich in nutrients and hormones. Yet, liver macrophages retain a limited capacity to raise the alarm in response to danger signals. We now know that macrophages in the liver play both inflammatory and noninflammatory roles throughout the progression of NAFLD. Macrophage responses are mediated first at the level of cell surface receptors that integrate environmental stimuli, signals are transduced through multiple levels of regulation in the cell, and specific transcriptional programmes dictate effector functions. These effector functions play paramount roles in determining the course of disease in NAFLD and even more so in the progression towards NASH. The current review covers recent reports in the physiological and pathophysiological roles of liver macrophages in NAFLD. We emphasise the responses of liver macrophages to insulin resistance and the transcriptional machinery that dictates liver macrophage function.
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Affiliation(s)
- Ronan Thibaut
- Cordeliers Research Centre, INSERM, IMMEDIAB Laboratory, Sorbonne Université, Université de Paris, France
| | - Matthew C Gage
- Department of Comparative Biomedical Sciences, Royal Veterinary College, London, UK
| | - Inès Pineda-Torra
- Department of Medicine, Centre for Cardiometabolic and Vascular Science, University College London, UK
| | - Gwladys Chabrier
- Department of Comparative Biomedical Sciences, Royal Veterinary College, London, UK
| | - Nicolas Venteclef
- Cordeliers Research Centre, INSERM, IMMEDIAB Laboratory, Sorbonne Université, Université de Paris, France
| | - Fawaz Alzaid
- Cordeliers Research Centre, INSERM, IMMEDIAB Laboratory, Sorbonne Université, Université de Paris, France
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Bando H, Taneda S, Manda N. Efficacy and Safety of Low-Dose Pemafibrate Therapy for Hypertriglyceridemia in Patients with Type 2 Diabetes. JMA J 2021; 4:135-140. [PMID: 33997447 PMCID: PMC8118964 DOI: 10.31662/jmaj.2020-0104] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/12/2021] [Indexed: 12/21/2022] Open
Abstract
Introduction: Pemafibrate is a potent selective peroxisome proliferator-activated receptor α (PPARα) modulator that may be safer than conventional PPARα agonists in the treatment of dyslipidemia. This study was designed to investigate the efficacy of low-dose pemafibrate (0.1 mg/day) therapy for hypertriglyceridemia in 31 patients with type 2 diabetes and high triglyceride (TG) levels at the Manda Memorial Hospital. Methods: TG, remnant lipoprotein cholesterol (RLP-C), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), apolipoprotein (Apo) AI, Apo AII, Apo B, Apo CII, Apo CIII, and Apo E levels were evaluated. Liver, kidney, and muscle toxicity tests were also performed. Pemafibrate (0.1 mg) was administered once daily. Results: This treatment significantly decreased TG, RLP-C, Apo CII, Apo CIII, and Apo E levels while significantly increasing HDL-C, Apo AI, and Apo AII levels. No significant changes were observed in LDL-C and Apo B levels. There were no significant liver-, kidney-, or muscle-related adverse events. Conclusions: The results of this study show that low-dose pemafibrate administration improves the lipid profile in Japanese patients with hypertriglyceridemia and type 2 diabetes.
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Affiliation(s)
| | - Shinji Taneda
- Manda Memorial Hospital, Sapporo City, Hokkaido, Japan
| | - Naoki Manda
- Manda Memorial Hospital, Sapporo City, Hokkaido, Japan
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Wang L, Cai Y, Jian L, Cheung CW, Zhang L, Xia Z. Impact of peroxisome proliferator-activated receptor-α on diabetic cardiomyopathy. Cardiovasc Diabetol 2021; 20:2. [PMID: 33397369 PMCID: PMC7783984 DOI: 10.1186/s12933-020-01188-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/02/2020] [Indexed: 12/21/2022] Open
Abstract
The prevalence of cardiomyopathy is higher in diabetic patients than those without diabetes. Diabetic cardiomyopathy (DCM) is defined as a clinical condition of abnormal myocardial structure and performance in diabetic patients without other cardiac risk factors, such as coronary artery disease, hypertension, and significant valvular disease. Multiple molecular events contribute to the development of DCM, which include the alterations in energy metabolism (fatty acid, glucose, ketone and branched chain amino acids) and the abnormalities of subcellular components in the heart, such as impaired insulin signaling, increased oxidative stress, calcium mishandling and inflammation. There are no specific drugs in treating DCM despite of decades of basic and clinical investigations. This is, in part, due to the lack of our understanding as to how heart failure initiates and develops, especially in diabetic patients without an underlying ischemic cause. Some of the traditional anti-diabetic or lipid-lowering agents aimed at shifting the balance of cardiac metabolism from utilizing fat to glucose have been shown inadequately targeting multiple aspects of the conditions. Peroxisome proliferator-activated receptor α (PPARα), a transcription factor, plays an important role in mediating DCM-related molecular events. Pharmacological targeting of PPARα activation has been demonstrated to be one of the important strategies for patients with diabetes, metabolic syndrome, and atherosclerotic cardiovascular diseases. The aim of this review is to provide a contemporary view of PPARα in association with the underlying pathophysiological changes in DCM. We discuss the PPARα-related drugs in clinical applications and facts related to the drugs that may be considered as risky (such as fenofibrate, bezafibrate, clofibrate) or safe (pemafibrate, metformin and glucagon-like peptide 1-receptor agonists) or having the potential (sodium-glucose co-transporter 2 inhibitor) in treating DCM.
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Affiliation(s)
- Lin Wang
- Department of Anesthesiology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
- Department of Anaesthesiology, The University of Hong Kong, Hong Kong, SAR, China
| | - Yin Cai
- Department of Anesthesiology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
- Department of Anaesthesiology, The University of Hong Kong, Hong Kong, SAR, China
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, SAR, China
| | - Liguo Jian
- Department of Cardiology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chi Wai Cheung
- Department of Anaesthesiology, The University of Hong Kong, Hong Kong, SAR, China
| | - Liangqing Zhang
- Department of Anesthesiology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China.
| | - Zhengyuan Xia
- Department of Anesthesiology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China.
- Department of Anaesthesiology, The University of Hong Kong, Hong Kong, SAR, China.
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Fruchart JC, Hermans MP, Fruchart-Najib J, Kodama T. Selective Peroxisome Proliferator-Activated Receptor Alpha Modulators (SPPARMα) in the Metabolic Syndrome: Is Pemafibrate Light at the End of the Tunnel? Curr Atheroscler Rep 2021; 23:3. [PMID: 33392801 PMCID: PMC7779417 DOI: 10.1007/s11883-020-00897-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2020] [Indexed: 02/06/2023]
Abstract
Purpose of Review Adoption of poor lifestyles (inactivity and energy-dense diets) has driven the worldwide increase in the metabolic syndrome, type 2 diabetes mellitus and non-alcoholic steatohepatitis (NASH). Of the defining features of the metabolic syndrome, an atherogenic dyslipidaemia characterised by elevated triglycerides (TG) and low plasma concentration of high-density lipoprotein cholesterol is a major driver of risk for atherosclerotic cardiovascular disease. Beyond lifestyle intervention and statins, targeting the nuclear receptor peroxisome proliferator-activated receptor alpha (PPARα) is a therapeutic option. However, current PPARα agonists (fibrates) have limitations, including safety issues and the lack of definitive evidence for cardiovascular benefit. Modulating the ligand structure to enhance binding at the PPARα receptor, with the aim of maximising beneficial effects and minimising adverse effects, underlies the SPPARMα concept. Recent Findings This review discusses the history of SPPARM development, latterly focusing on evidence for the first licensed SPPARMα, pemafibrate. Evidence from animal models of hypertriglyceridaemia or NASH, as well as clinical trials in patients with atherogenic dyslipidaemia, are overviewed. Summary The available data set the scene for therapeutic application of SPPARMα in the metabolic syndrome, and possibly, NASH. The outstanding question, which has so far eluded fibrates in the setting of current evidence-based therapy including statins, is whether treatment with pemafibrate significantly reduces cardiovascular events in patients with atherogenic dyslipidaemia. The PROMINENT study in patients with type 2 diabetes mellitus and this dyslipidaemia is critical to evaluating this.
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Affiliation(s)
- Jean-Charles Fruchart
- Residual Risk Reduction Initiative (R3i) Foundation, Picassoplatz 8, 4010, Basel, Switzerland.
| | - Michel P Hermans
- Division of Endocrinology and Nutrition, Cliniques Universitaires St-Luc and Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - Jamila Fruchart-Najib
- Residual Risk Reduction Initiative (R3i) Foundation, Picassoplatz 8, 4010, Basel, Switzerland
| | - Tatsuhiko Kodama
- Laboratory for System Biology and Medicine. Research Center for Advanced Science and Technology, The University of Tokyo, Tokyo, Japan
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Francque S, Szabo G, Abdelmalek MF, Byrne CD, Cusi K, Dufour JF, Roden M, Sacks F, Tacke F. Nonalcoholic steatohepatitis: the role of peroxisome proliferator-activated receptors. Nat Rev Gastroenterol Hepatol 2021; 18:24-39. [PMID: 33093663 DOI: 10.1038/s41575-020-00366-5] [Citation(s) in RCA: 171] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/02/2020] [Indexed: 02/06/2023]
Abstract
The increasing epidemic of obesity worldwide is linked to serious health effects, including increased prevalence of type 2 diabetes mellitus, cardiovascular disease and nonalcoholic fatty liver disease (NAFLD). NAFLD is the liver manifestation of the metabolic syndrome and includes the spectrum of liver steatosis (known as nonalcoholic fatty liver) and steatohepatitis (known as nonalcoholic steatohepatitis), which can evolve into progressive liver fibrosis and eventually cause cirrhosis. Although NAFLD is becoming the number one cause of chronic liver diseases, it is part of a systemic disease that affects many other parts of the body, including adipose tissue, pancreatic β-cells and the cardiovascular system. The pathomechanism of NAFLD is multifactorial across a spectrum of metabolic derangements and changes in the host microbiome that trigger low-grade inflammation in the liver and other organs. Peroxisome proliferator-activated receptors (PPARs) are a group of nuclear regulatory factors that provide fine tuning for key elements of glucose and fat metabolism and regulate inflammatory cell activation and fibrotic processes. This Review summarizes and discusses the current literature on NAFLD as the liver manifestation of the systemic metabolic syndrome and focuses on the role of PPARs in the pathomechanisms as well as in the potential targeting of disease.
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Affiliation(s)
- Sven Francque
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium. .,Translational Research in Inflammation and Immunology (TWI2N), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
| | - Gyongyi Szabo
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Manal F Abdelmalek
- Division of Gastroenterology and Hepatology, Department of Medicine, Duke University Health System, Durham, NC, USA
| | - Christopher D Byrne
- Nutrition & Metabolism, Human Development & Health, Faculty of Medicine, University Hospital Southampton, Southampton, UK
| | - Kenneth Cusi
- Division of Endocrinology, Diabetes and Metabolism, University of Florida, Gainesville, FL, USA
| | - Jean-François Dufour
- Hepatology, Department of Clinical Research, University Hospital of Bern, Bern, Switzerland.,University Clinic for Visceral Surgery and Medicine, Inselspital, Bern, Switzerland
| | - Michael Roden
- Division of Endocrinology and Diabetology, Medical Faculty, Heinrich Heine University Düsseldorf, University Clinics Düsseldorf, Düsseldorf, Germany.,Institute for Clinical Diabetology, German Diabetes Center (DDZ), Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,German Center for Diabetes Research (DZD e.V.), München-Neuherberg, Germany
| | - Frank Sacks
- Departments of Nutrition and Molecular Metabolism, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Channing Division, Department of Medicine Harvard Medical School and Brigham and Women's Hospital, Boston, MA, USA
| | - Frank Tacke
- Department of Hepatology & Gastroenterology, Charité University Medical Center, Berlin, Germany
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Finan B, Parlee SD, Yang B. Nuclear hormone and peptide hormone therapeutics for NAFLD and NASH. Mol Metab 2020; 46:101153. [PMID: 33359400 PMCID: PMC8085542 DOI: 10.1016/j.molmet.2020.101153] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/17/2020] [Accepted: 12/19/2020] [Indexed: 12/13/2022] Open
Abstract
Background Non-alcoholic steatohepatitis (NASH) is a spectrum of histological liver pathologies ranging from hepatocyte fat accumulation, hepatocellular ballooning, lobular inflammation, and pericellular fibrosis. Based on early investigations, it was discovered that visceral fat accumulation, hepatic insulin resistance, and atherogenic dyslipidemia are pathological triggers for NASH progression. As these pathogenic features are common with obesity, type 2 diabetes (T2D), and atherosclerosis, therapies that target dysregulated core metabolic pathways may hold promise for treating NASH, particularly as first-line treatments. Scope of Review In this review, the latest clinical data on nuclear hormone- and peptide hormone-based drug candidates for NASH are reviewed and contextualized, culminating with a discovery research perspective on emerging combinatorial therapeutic approaches that merge nuclear and peptide strategies. Major Conclusion Several drug candidates targeting the metabolic complications of NASH have shown promise in early clinical trials, albeit with unique benefits and challenges, but questions remain regarding their translation to larger and longer clinical trials, as well as their utility in a more diseased patient population. Promising polypharmacological approaches can potentially overcome some of these perceived challenges, as has been suggested in preclinical models, but deeper characterizations are required to fully evaluate these opportunities. Despite no approved treatments for NASH, several drug candidates have shown promise in early clinical trials. Therapies targeting metabolic pathologies of NASH have shown efficacy to reduce hepatic fat content and improve fibrosis. Many of these therapies have been rationally designed to mimic nuclear hormone or peptide hormone action. Despite provocative preclinical findings of nuclear and peptide hormone combination, clinical translation remains unproven.
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Affiliation(s)
- Brian Finan
- Novo Nordisk Research Center Indianapolis, Inc., United States.
| | | | - Bin Yang
- Novo Nordisk Research Center Indianapolis, Inc., United States
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Abstract
PURPOSE OF REVIEW Hypertriglyceridemia (HTG), a form of dyslipidemia characterized by elevated plasma of triglycerides (TG), is associated with an increased risk for acute pancreatitis. Moreover, HTG has recently been shown to be linked to the development of atherosclerotic cardiovascular disease (ASCVD); therefore, there is a great interest in better understanding the pathophysiology of HTG and improving its clinical management. In this review, we briefly describe TG metabolism, recent guidelines for the clinical management of HTG and provide an overview of the current and potential new therapies for HTG. RECENT FINDINGS Screening patients for HTG is valuable for not only identifying patients with extreme TG elevations, who are at risk for pancreatitis, but also for managing ASCVD risk in patients with more moderate forms of HTG. Therefore, the most recent USA guidelines for cardiovascular diseases recommend using TG as a risk enhancer test, leading to a more aggressive treatment of patients with intermediate risk. Currently, there are several available approaches for reducing plasma TG, which include lifestyle changes, fibrates and omega-3 fatty acid treatment. The addition of eicosapentaenoic acid (EPA) on top of statins has recently been shown to significantly reduce ASCVD events. Nevertheless, there is an unmet need for more effective treatment options. Several new therapies based on newly identified targets in TG metabolism, such as apolipoprotein C-III and angiopoietin-like 3 protein, are currently under development. SUMMARY The clinical management of HTG is important in the prevention and treatment of acute pancreatitis and also impacts on how ASCVD risk is managed. More work needs to be done to establish the mechanism for the ability of how EPA lowers ASCVD and how to best integrate it with other lipid-lowering therapies. The efficacy and safety of the novel therapies for HTG should be established soon in the ongoing late-stage clinical trials.
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Affiliation(s)
- Anna Wolska
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Zhi-Hong Yang
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Alan T. Remaley
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, 20892, USA
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Pemafibrate Protects Against Retinal Dysfunction in a Murine Model of Diabetic Retinopathy. Int J Mol Sci 2020; 21:ijms21176243. [PMID: 32872333 PMCID: PMC7503472 DOI: 10.3390/ijms21176243] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/25/2020] [Accepted: 08/25/2020] [Indexed: 12/16/2022] Open
Abstract
Diabetic retinopathy (DR) is one of the leading causes of blindness globally. Retinal neuronal abnormalities occur in the early stage in DR. Therefore, maintaining retinal neuronal activity in DR may prevent vision loss. Previously, pemafibrate, a novel selective peroxisome proliferator-activated receptor alpha modulator, was suggested as a promising drug in hypertriglyceridemia. However, the role of pemafibrate remains obscure in DR. Therefore, we aimed to unravel systemic and retinal changes by pemafibrate in diabetes. Adult mice were intraperitoneally injected with streptozotocin (STZ) to induce diabetes. After STZ injection, diet supplemented with pemafibrate was given to STZ-induced diabetic mice for 12 weeks. During the experiment period, body weight and blood glucose levels were examined. Electroretinography was performed to check the retinal neural function. After sacrifice, the retina, liver, and blood samples were subjected to molecular analyses. We found pemafibrate mildly improved blood glucose level as well as lipid metabolism, boosted liver function, increased serum fibroblast growth factor21 level, restored retinal functional deficits, and increased retinal synaptophysin protein expression in STZ-induced diabetic mice. Our present data suggest a promising pemafibrate therapy for the prevention of early DR by improving systemic metabolism and protecting retinal function.
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Fruchart JC, Hermans MP, Fruchart-Najib J. Selective Peroxisome Proliferator-Activated Receptor Alpha Modulators (SPPARMα): New Opportunities to Reduce Residual Cardiovascular Risk in Chronic Kidney Disease? Curr Atheroscler Rep 2020; 22:43. [PMID: 32671476 PMCID: PMC7363727 DOI: 10.1007/s11883-020-00860-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Chronic kidney disease (CKD) poses a major global challenge, which is exacerbated by aging populations and the pandemic of type 2 diabetes mellitus. Much of the escalating burden of CKD is due to cardiovascular complications. Current treatment guidelines for dyslipidemia in CKD prioritize low-density lipoprotein cholesterol management, but still leave a high residual cardiovascular risk. Targeting elevated triglycerides and low plasma high-density lipoprotein cholesterol, a common feature of CKD, could offer additional benefit. There are, however, safety issues with current fibrates (peroxisome proliferator-activated receptor alpha [PPARα] agonists), notably the propensity for elevation in serum creatinine, indicating the need for new approaches. RECENT FINDINGS Interactions between the ligand and PPARα receptor influence the specificity and potency of receptor binding, and downstream gene and physiological effects. The peroxisome proliferator-activated receptor alpha modulator (SPPARMα) concept aims to modulate the ligand structure so as to enhance binding at the PPARα receptor, thereby improving the ligand's selectivity, potency, and safety profile. This concept has led to the development of pemafibrate, a novel SPPARMα agent. This review discusses evidence that differentiates pemafibrate from current fibrates, especially the lack of evidence for elevation in serum creatinine or worsening of renal function in high-risk patients, including those with CKD. Differentiation of pemafibrate from current fibrates aims to address unmet clinical needs in CKD. The ongoing PROMINENT study will provide critical information regarding the long-term efficacy and safety of pemafibrate in patients with type 2 diabetes mellitus, including those with CKD, and whether the favorable lipid-modifying profile translates to reduction in residual cardiovascular risk.
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Affiliation(s)
- Jean-Charles Fruchart
- Residual Risk Reduction Initiative (R3i) Foundation, Picassoplatz 8, 4010, Basel, Switzerland.
| | - Michel P Hermans
- Division of Endocrinology and Nutrition, Cliniques Universitaires St-Luc and Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - Jamila Fruchart-Najib
- Residual Risk Reduction Initiative (R3i) Foundation, Picassoplatz 8, 4010, Basel, Switzerland
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Wang H, Li H, Zhou Y, Liu J, Wang F, Zhao Q. Pemafibrate Tends to have Better Efficacy in Treating Dyslipidemia than Fenofibrate. Curr Pharm Des 2020; 25:4725-4734. [PMID: 31769360 DOI: 10.2174/1381612825666191126102943] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/14/2020] [Indexed: 12/22/2022]
Abstract
AIMS To compare the efficacy of pemafibrate (PF) and fenofibrate (FF) in treating dyslipidemia. METHODS A comprehensive search was performed on the public database to identify relevant randomized controlled trials (RCTs), which compared the effects of PF and FF treatment in lipid parameters among patients with dyslipidemia. Mean difference (MD) and 95% confidence intervals (CI) were pooled for continuous outcomes, whereas odds ratio (OR) and 95% CI were calculated for dichotomous outcomes. RESULTS Three RCTs were included with a total of 744 patients (PF=547 and FF=197). Compared with the FF group (100mg/day), PF group (0.05 to 0.4mg/day) had a better effect on reducing triglycerides (TGs) (MD, -8.66; 95%CI, -10.91 to -6.41), very low-density lipoprotein cholesterol (VLDL-C, MD, -12.19; 95%CI, -15.37 to - 9.01), remnant lipoprotein cholesterol (MD, -13.16; 95%CI, -17.62 to -8.69), apolipoprotein-B48 (ApoB48, MD, -12.74; 95%CI, -17.71 to -7.76) and ApoCIII (MD, -6.25; 95%CI, -11.85 to -0.64). Although a slightly LDL-Cincreasing effect was found in PF-treated group (MD, 3.10; 95%CI, -0.12 to 6.09), the levels of HDL-C (MD, 3.59; 95%CI, 1.65 to 5.53) and ApoAI (MD, 1.60; 95%CI, 0.38 to 2.82) were significantly increased in the PF group. However, no significant difference was found in the level of total cholesterol (MD, 0.01; 95%CI, -1.37 to - 1.39), non-HDL-C (MD, -0.06; 95%CI, -1.75 to 1.63), ApoB (MD, 0.39; 95%CI, -1.37 to 2.15) and ApoAII (MD, 3.31; 95%CI, -1.66 to 8.29) between the two groups. In addition, the incidence of total adverse events (OR, 0.68; 95%CI, 0.53 to 0.86) and adverse drug reactions (OR, 0.36; 95%CI, 0.24 to 0.54) was lower in the PF group than that in the FF group. CONCLUSIONS Pemafibrate tends to have better efficacy in treating dyslipidemia than fenofibrate.
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Affiliation(s)
- Haizhou Wang
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, China.,Hubei Clinical Center and Key Lab of Intestinal and Colorectal Diseases, Wuhan, China
| | - Haiou Li
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, China.,Hubei Clinical Center and Key Lab of Intestinal and Colorectal Diseases, Wuhan, China
| | - Yunjiao Zhou
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, China.,Hubei Clinical Center and Key Lab of Intestinal and Colorectal Diseases, Wuhan, China
| | - Jing Liu
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, China.,Hubei Clinical Center and Key Lab of Intestinal and Colorectal Diseases, Wuhan, China
| | - Fan Wang
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, China.,Hubei Clinical Center and Key Lab of Intestinal and Colorectal Diseases, Wuhan, China
| | - Qiu Zhao
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, China.,Hubei Clinical Center and Key Lab of Intestinal and Colorectal Diseases, Wuhan, China
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Tomlinson B, Chan P, Zhang Y, Liu Z, Lam CWK. Pharmacokinetics of current and emerging treatments for hypercholesterolemia. Expert Opin Drug Metab Toxicol 2020; 16:371-385. [PMID: 32223657 DOI: 10.1080/17425255.2020.1749261] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Reduction of low-density-lipoprotein cholesterol (LDL-C) and other apolipoprotein B (apoB)-containing lipoproteins reduces cardiovascular (CV) events and greater reductions have greater benefits. Current lipid treatments cannot always achieve desirable LDL-C targets and additional or alternative treatments are often needed.Areas covered: In this article, we review the pharmacokinetics of the available and emerging treatments for hypercholesterolemia and focus on recently approved drugs and those at a late stage of development.Expert opinion: Statin pharmacokinetics are well known and appropriate drugs and doses can usually be chosen for individual patients to achieve LDL-C targets and avoid adverse effects and drug-drug interactions. Ezetimibe, icosapent ethyl and the monoclonal antibodies evolocumab and alirocumab have established efficacy and safety. Newer oral agents including pemafibrate and bempedoic acid have generally favorable pharmacokinetics supporting use in a wide range of patients. RNA-based therapies with antisense oligonucleotides are highly specific for their targets and those inhibiting apoB, apoCIII, angiopoietin-like protein 3 and lipoprotein(a) have shown promising results. The small-interfering RNA inclisiran has the notable advantage that a single subcutaneous administration may be effective for up to 6 months. The CV outcome trial results and long term safety data are eagerly awaited for these new agents.
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Affiliation(s)
- Brian Tomlinson
- Faculty of Medicine, Macau University of Science and Technology, Macau, China
| | - Paul Chan
- Division of Cardiology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei City, Taiwan.,Research Center for Translational Medicine, Shanghai East Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Yuzhen Zhang
- Research Center for Translational Medicine, Shanghai East Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Zhongmin Liu
- Research Center for Translational Medicine, Shanghai East Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
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Pedro-Botet J, Ascaso JF, Blasco M, Brea Á, Díaz Á, Hernández-Mijares A, Pintó X, Millán J. Triglycerides, HDL cholesterol and atherogenic dyslipidaemia in the 2019 European guidelines for the management of dyslipidaemias. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS 2020; 32:209-218. [PMID: 32037300 DOI: 10.1016/j.arteri.2019.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 12/20/2019] [Accepted: 12/30/2019] [Indexed: 12/12/2022]
Abstract
In general, both European and American clinical guidelines have addressed the management of atherogenic dyslipidaemia in an unconvincing and even superficial way, largely because of the available therapeutic limitations. Consequently, this type of dyslipidaemia is underdiagnosed, under-treated, and under-controlled. Given the recent presentation of the 2019 guidelines of the European Atherosclerosis Society and the European Society of Cardiology on the management of dyslipidaemias, it seems appropriate to examine its position with respect to atherogenic dyslipidaemia and/or its main components, the increase in triglyceride-rich lipoproteins, and the decrease of high-density lipoprotein cholesterol.
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Affiliation(s)
- Juan Pedro-Botet
- Unidad de Lípidos y Riesgo Vascular, Servicio de Endocrinología y Nutrición, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, España.
| | - Juan F Ascaso
- Departamento de Medicina, Universitat de València, CIBERDEM ISCIII, Valencia, España
| | - Mariano Blasco
- Área Sanitaria de Delicias, Atención Primaria, Zaragoza, España
| | - Ángel Brea
- Servicio de Medicina Interna, Hospital San Pedro, Logroño, España
| | - Ángel Díaz
- Centro de Salud de Bembibre, Bembibre, León, España
| | - Antonio Hernández-Mijares
- Fundación para la Investigación Sanitaria y Biomédica de la Comunidad Valenciana FISABIO; Departamento de Medicina, Universitat de València, Valencia, España
| | - Xavier Pintó
- Unidad de Lípidos, Servicio de Medicina Interna, Hospital Universitario de Bellvitge, Universitat de Barcelona, CIBERobn-ISCIII, Barcelona, España
| | - Jesús Millán
- Unidad de Lípidos, Servicio de Medicina Interna, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, España
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Yamashita S, Masuda D, Matsuzawa Y. Pemafibrate, a New Selective PPARα Modulator: Drug Concept and Its Clinical Applications for Dyslipidemia and Metabolic Diseases. Curr Atheroscler Rep 2020; 22:5. [PMID: 31974794 PMCID: PMC6978439 DOI: 10.1007/s11883-020-0823-5] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW Reduction of serum low-density lipoprotein cholesterol (LDL-C) levels by statins, ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors has been shown to significantly reduce cardiovascular events risk. However, fasting and postprandial hypertriglyceridemia as well as reduced high-density lipoprotein cholesterol (HDL-C) remain as residual risk factors of atherosclerotic cardiovascular diseases (ASCVD). To treat patients with hypertriglyceridemia and/or low HDL-C, drugs such as fibrates, nicotinic acids, and n-3 polyunsaturated fatty acids have been used. However, fibrates were demonstrated to cause side effects such as liver dysfunction and increase in creatinine levels, and thus large-scale clinical trials of fibrates have shown negative results for prevention of ASCVD. The failure could be attributed to their low selectivity and potency for binding to peroxisome proliferator-activated receptor (PPAR) α. To resolve these issues, the concept of selective PPARα modulator (SPPARMα) with a superior balance of efficacy and safety has been proposed and pemafibrate (K-877) has been developed. RECENT FINDINGS Pemafibrate, one of SPPARMsα, was synthesized by Kowa Company, Ltd. for better efficiency and safety. Clinical trials in Japan have established the superiority of pemafibrate on effects on serum triglycerides (TG) reduction and HDL-C elevation as well safety. Although available fibrates showed worsening of liver and kidney function test values, pemafibrate indicated improved liver function test values and was less likely to increase serum creatinine or decrease estimated glomerular filtration rate (eGFR). Very few drug-drug interactions were observed even when used concomitantly with statins. Furthermore, pemafibrate is metabolized in the liver and excreted into the bile, while many of available fibrates are mainly excreted from the kidney. Therefore, pemafibrate can be used safely even in patients with impaired renal function since there is no significant increase in its blood concentration. A large-scale trial of pemafibrate, PROMINENT, for dyslipidemic patients with type 2 diabetes is ongoing. Pemafibrate is one of novel SPPARMsα and has superior benefit-risk balance compared to conventional fibrates and can be applicable for patients for whom the usage of existing fibrates is difficult such as those who are taking statins or patients with renal dysfunction. In the current review, all the recent data on pemafibrate will be summarized.
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Affiliation(s)
- Shizuya Yamashita
- Department of Cardiology, Rinku General Medical Center, Izumisano, Osaka, 598-8577, Japan.
| | - Daisaku Masuda
- Department of Cardiology, Rinku General Medical Center, Izumisano, Osaka, 598-8577, Japan
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30
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Stahel P, Xiao C, Nahmias A, Lewis GF. Role of the Gut in Diabetic Dyslipidemia. Front Endocrinol (Lausanne) 2020; 11:116. [PMID: 32231641 PMCID: PMC7083132 DOI: 10.3389/fendo.2020.00116] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/21/2020] [Indexed: 12/13/2022] Open
Abstract
Type 2 diabetes (T2D) is associated with increased risk of cardiovascular disease (CVD). In insulin resistant states such as the metabolic syndrome, overproduction and impaired clearance of liver-derived very-low-density lipoproteins and gut-derived chylomicrons (CMs) contribute to hypertriglyceridemia and elevated atherogenic remnant lipoproteins. Although ingested fat is the major stimulus of CM secretion, intestinal lipid handling and ultimately CM secretory rate is determined by numerous additional regulatory inputs including nutrients, hormones and neural signals that fine tune CM secretion during fasted and fed states. Insulin resistance and T2D represent perturbed metabolic states in which intestinal sensitivity to key regulatory hormones such as insulin, leptin and glucagon-like peptide-1 (GLP-1) may be altered, contributing to increased CM secretion. In this review, we describe the evidence from human and animal models demonstrating increased CM secretion in insulin resistance and T2D and discuss the molecular mechanisms underlying these effects. Several novel compounds are in various stages of preclinical and clinical investigation to modulate intestinal CM synthesis and secretion. Their efficacy, safety and therapeutic utility are discussed. Similarly, the effects of currently approved lipid modulating therapies such as statins, ezetimibe, fibrates, and PCSK9 inhibitors on intestinal CM production are discussed. The intricacies of intestinal CM production are an active area of research that may yield novel therapies to prevent atherosclerotic CVD in insulin resistance and T2D.
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Rhainds D, Brodeur MR, Tardif JC. Investigational drugs in development for hypertriglyceridemia: a coming-of-age story. Expert Opin Investig Drugs 2019; 28:1059-1079. [PMID: 31752565 DOI: 10.1080/13543784.2019.1696772] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Elevated triglyceride (TG) level is a prevalent condition in the general population and in patients with cardiovascular (CV) risk even under statin therapy. Severe hypertriglyceridemia (HTG) puts patients at risk for acute pancreatitis. Several TG-lowering drugs failed in clinical trials, but subgroup analyses suggest that high-risk patients, such as those with atherogenic dyslipidemia or diabetes, benefit from TG lowering.Areas covered: We review advances for TG-lowering drugs in clinical development. These include selective PPARα modulators, omega-3 fatty acid formulations that have been approved for severe HTG, and inhibitors of apolipoprotein C-III, angiopoietin-like-3 or microsomal transfer protein. Lessons learned from the success of the phase 3 trial REDUCE-IT with high-dose icosapent ethyl are also reviewed.Expert opinion: We believe that TG-lowering therapies are coming of age as they will allow to treat patients with high CV risk and moderate HTG, including T2D subjects, as well as patients with severe HTG or even homozygous familial hypercholesterolemia, all of which being 'optimally' treated with a statin. More studies on the impact of therapy on quality of life in patients with severe HTG should be conducted with the help of patient registries.
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Affiliation(s)
- David Rhainds
- Montreal Heart Institute Research Center, Montreal Heart Institute, Montreal, Canada
| | - Mathieu R Brodeur
- Montreal Heart Institute Research Center, Montreal Heart Institute, Montreal, Canada
| | - Jean-Claude Tardif
- Montreal Heart Institute Research Center, Montreal Heart Institute, Montreal, Canada.,Faculty of Medicine, Université de Montréal, Montreal, Canada
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Gene Expression Profiles Induced by a Novel Selective Peroxisome Proliferator-Activated Receptor α Modulator (SPPARMα) Pemafibrate. Int J Mol Sci 2019; 20:ijms20225682. [PMID: 31766193 PMCID: PMC6888257 DOI: 10.3390/ijms20225682] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/05/2019] [Accepted: 11/11/2019] [Indexed: 12/16/2022] Open
Abstract
Pemafibrate is the first clinically-available selective peroxisome proliferator-activated receptor α modulator (SPPARMα) that has been shown to effectively improve hypertriglyceridemia and low high-density lipoprotein cholesterol (HDL-C) levels. Global gene expression analysis reveals that the activation of PPARα by pemafibrate induces fatty acid (FA) uptake, binding, and mitochondrial or peroxisomal oxidation as well as ketogenesis in mouse liver. Pemafibrate most profoundly induces HMGCS2 and PDK4, which regulate the rate-limiting step of ketogenesis and glucose oxidation, respectively, compared to other fatty acid metabolic genes in human hepatocytes. This suggests that PPARα plays a crucial role in nutrient flux in the human liver. Additionally, pemafibrate induces clinically favorable genes, such as ABCA1, FGF21, and VLDLR. Furthermore, pemafibrate shows anti-inflammatory effects in vascular endothelial cells. Pemafibrate is predicted to exhibit beneficial effects in patients with atherogenic dyslipidemia and diabetic microvascular complications.
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Araki E, Yamashita S, Arai H, Yokote K, Satoh J, Inoguchi T, Nakamura J, Maegawa H, Yoshioka N, Tanizawa Y, Watada H, Suganami H, Ishibashi S. Efficacy and safety of pemafibrate in people with type 2 diabetes and elevated triglyceride levels: 52-week data from the PROVIDE study. Diabetes Obes Metab 2019; 21:1737-1744. [PMID: 30830727 PMCID: PMC6617746 DOI: 10.1111/dom.13686] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/25/2019] [Accepted: 02/28/2019] [Indexed: 01/03/2023]
Abstract
The aim of this study was to evaluate the efficacy and safety of pemafibrate in people with type 2 diabetes and hypertriglyceridaemia over a 52-week period. Participants were randomly assigned to receive treatment with placebo or pemafibrate at a dose of 0.2 or 0.4 mg/d for 24 weeks (treatment period 1). The main results from treatment period 1 have been reported previously. The assigned treatment was continued up to week 52, except that the placebo was changed to pemafibrate 0.2 mg/d after week 24 (treatment period 2). The percentage changes in fasting serum triglyceride (TG) levels at week 52 (last observation carried forward) were -48.2%, -42.3%, and -46.4% in the placebo/pemafibrate 0.2 mg/d (n = 57), pemafibrate 0.2 mg/d (n = 54), and pemafibrate 0.4 mg/d (n = 55) groups, respectively. Levels of TG, non-HDL cholesterol and total cholesterol stably decreased, whereas levels of HDL cholesterol increased with pemafibrate treatments over 52 weeks. Pemafibrate was well tolerated throughout the study period. The present study is the first to show that pemafibrate treatment substantially ameliorated lipid abnormalities and was well tolerated for 52 weeks in people with type 2 diabetes and hypertriglyceridaemia.
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Affiliation(s)
- Eiichi Araki
- Department of Metabolic Medicine, Faculty of Life SciencesKumamoto UniversityKumamotoJapan
| | - Shizuya Yamashita
- Department of Community Medicine and Department of Cardiovascular MedicineOsaka University Graduate School of MedicineOsakaJapan
- Rinku General Medical CentreOsakaJapan
| | - Hidenori Arai
- National Centre for Geriatrics and GerontologyAichiJapan
| | - Koutaro Yokote
- Department of Diabetes, Metabolism and EndocrinologyChiba University HospitalChibaJapan
- Department of Endocrinology, Haematology and GerontologyChiba University Graduate School of MedicineChibaJapan
| | - Jo Satoh
- Tohoku Medical and Pharmaceutical University Wakabayashi HospitalMiyagiJapan
| | | | - Jiro Nakamura
- Division of Diabetes, Department of Internal MedicineAichi Medical UniversityAichiJapan
| | - Hiroshi Maegawa
- Department of MedicineShiga University of Medical ScienceShigaJapan
| | - Narihito Yoshioka
- Division of Diabetes and Endocrinology, Department of MedicineSapporo Medical Centre, NTT East CorporationHokkaidoJapan
| | - Yukio Tanizawa
- Division of Endocrinology, Metabolism, Haematological Science and TherapeuticsYamaguchi University Graduate School of MedicineYamaguchiJapan
| | - Hirotaka Watada
- Department of Metabolism and EndocrinologyJuntendo University Graduate School of MedicineTokyoJapan
| | | | - Shun Ishibashi
- Division of Endocrinology and Metabolism, Department of MedicineJichi Medical UniversityTochigiJapan
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