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Gargiulo P, Basile C, Cesaro A, Marzano F, Buonocore D, Asile G, Abbate V, Vicidomini F, Paolillo S, Spaccarotella CAM, Catalano A, Spirito G, Merlini PA, Maloberti A, Iannuzzo G, Ciccone MM, Zito AP, Paloscia L, D'Alleva A, Varbella F, Corleto A, Brunetti ND, Corbo MD, Calabrò P, Indolfi C, Perrone-Filardi P. Efficacy, safety, adherence and persistence of PCSK9 inhibitors in clinical practice: A single country, multicenter, observational study (AT-TARGET-IT). Atherosclerosis 2023; 366:32-39. [PMID: 36696749 DOI: 10.1016/j.atherosclerosis.2023.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/17/2022] [Accepted: 01/10/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND AIMS Proprotein Convertase Subtilisin/Kexin type 9 inhibitors (PCSK9i) are recommended in patients at high and very-high cardiovascular (CV) risk, with documented atherosclerotic CV disease (ASCVD), and for very-high risk patients with familial hypercholesterolaemia not achieving LDL-cholesterol (LDL-C) goal while receiving maximally tolerated dose of lipid-lowering therapy (LLT). However, single country real-life data, reporting the use of PCSK9i in clinical practice, are limited. Therefore, we designed AT-TARGET-IT, an Italian, multicenter, observational registry on the use of PCSK9i in clinical practice. METHODS All data were recorded at the time of the first prescription and at the latest observation preceding inclusion in the study. RESULTS 798 patients were enrolled. The median reduction in LDL-C levels was 64.9%. After stratification for CV risk, 63.8% achieved LDL-C target; of them, 83.3% took LLTs at PCSK9i initiation and 16.7% did not. 760 patients (95.2%) showed high adherence to therapy, 13 (1.6%) partial adherence, and 25 (3.1%) poor adherence. At 6 months, 99.7% of patients enrolled in the study remained on therapy; there were 519 and 423 patients in the study with a follow-up of at least 12 and 18 months, respectively. Persistence in these groups was 98.1% and 97.5%, respectively. Overall, 3.5% of patients discontinued therapy. No differences in efficacy, adherence, and persistence were found between alirocumab and evolocumab. CONCLUSIONS PCSK9i are safe and effective in clinical practice, leading to very high adherence and persistence to therapy, and achievement of recommended LDL-C target in most patients, especially when used as combination therapy.
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Affiliation(s)
- Paola Gargiulo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Christian Basile
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Arturo Cesaro
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | - Davide Buonocore
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Gaetano Asile
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Vincenza Abbate
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Francesca Vicidomini
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Stefania Paolillo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | | | - Angelo Catalano
- Cardiology Division Emergency Department, Roccadaspide Maria SS Addolorata General Hospital, Eboli, Italy
| | - Giulio Spirito
- Cardiology Division Emergency Department, Roccadaspide Maria SS Addolorata General Hospital, Eboli, Italy
| | | | - Alessandro Maloberti
- A. De Gasperis Cardio Center, ASST GOM Niguarda Ca' Granda, Milan, Italy; University of Milano-Bicocca, Milan, Italy
| | - Gabriella Iannuzzo
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Marco Matteo Ciccone
- Section of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Anna Paola Zito
- Section of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | | | | | | | | | | | - Maria Delia Corbo
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Ciro Indolfi
- Department of Medical and Surgical Sciences, University of Catanzaro Magna Graecia, Catanzaro, Italy
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Muacevic A, Adler JR, Ahmad S, Elnaggar MN, Allcock R, Ali S, Kyi NM, Salazar L, Gbegbaje A, Banerjee M. Protein Convertase Subtilisin/Kexin Type 9 Monoclonal Antibodies (PCSK9mab) in Clinical Practice at Secondary Care - Real World Multicentre Experience. Cureus 2022; 14:e33044. [PMID: 36721583 PMCID: PMC9881602 DOI: 10.7759/cureus.33044] [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] [Accepted: 12/28/2022] [Indexed: 12/29/2022] Open
Abstract
Background and Aims Protein convertase subtilisin/Kexin type 9 monoclonal antibodies (PCSK9mab) are a novel addition to the therapeutic options for managing hyperlipidemia. Various guidelines have advocated the addition of these agents if the target low-density lipoprotein-cholesterol ( LDL-C) is not achieved by maximum lipid-lowering therapy. They have shown a robust and consistent reduction in LDL-C in clinical trials. However, the translation of these results in a real-world setting is limited and confined mainly to tertiary lipid centers. This service evaluation aimed to assess their efficacy in a real-world outpatient setting of secondary care centers. Methods Data was collected retrospectively from four hospitals in the North-West of England. Patients were required to attend a lipid clinic for follow-up investigations to continue with the prescription of PCSK9mab. Results A total of 175 patients were identified. Efficacy outcomes were measured in 169 patients. 6 discontinued the agent within 3 months of initiation and were excluded from the efficacy outcomes. 19.5% (n=33) had confirmed familial hypercholesterolemia. 61% (n=103) of the patients were intolerant to statins. 53.2% (n=90) of the patients have been prescribed Alirocumab. Mean LDL-C reduction was 50.6% at 6-month which was sustained at 48.9% at 12 months. There was no difference in % reduction of LDL-C between Alirocumab and Evolocumab. LDL-C reduction was more significant in patients who were on concomitant statins. 9.1% of patients experienced side effects, and 5.1% discontinued the PCSK9mab during treatment. Conclusion The efficacy of lipid reduction and the side effect profile of PCSK9mab from these secondary care services are similar to randomized clinical trials and real-world observational studies from tertiary lipid centers.
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An Untargeted Lipidomic Analysis Reveals Depletion of Several Phospholipid Classes in Patients with Familial Hypercholesterolemia on Treatment with Evolocumab. Biomedicines 2021; 9:biomedicines9121941. [PMID: 34944757 PMCID: PMC8698529 DOI: 10.3390/biomedicines9121941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 11/17/2022] Open
Abstract
Rationale: Familial hypercholesterolemia (FH) is caused by mutations in genes involved in low-density lipoprotein cholesterol (LDL-C) metabolism, including those for pro-protein convertase subtilisin/kexin type 9 (PCSK-9). The effect of PCSK-9 inhibition on the plasma lipidome has been poorly explored. Objective: Using an ultra-high-performance liquid chromatography-electrospray ionization-quadrupole-time of flight-mass spectrometry method, the plasma lipidome of FH subjects before and at different time intervals during treatment with the PCSK-9 inhibitor Evolocumab was explored. Methods and Results: In 25 FH subjects, heterozygotes or compound heterozygotes for different LDL receptor mutations, untargeted lipidomic revealed significant reductions in 26 lipid classes belonging to phosphatidylcholine (PC), sphingomyelin (SM), ceramide (CER), cholesteryl ester (CE), triacylglycerol (TG) and phosphatidylinositol (PI). Lipid changes were graded between baseline and 4- and 12-week treatment. At 12-week treatment, five polyunsaturated diacyl PC, accounting for 38.6 to 49.2% of total PC at baseline; two ether/vinyl ether forms; seven SM; five CER and glucosyl/galactosyl-ceramide (HEX-CER) were reduced, as was the unsaturation index of HEX-CER and lactosyl—CER (LAC-CER). Although non quantitative modifications were observed in phosphatidylethanolamine (PE) during treatment with Evolocumab, shorter and more saturated fatty acyl chains were documented. Conclusions: Depletion of several phospholipid classes occurs in plasma of FH patients during treatment with the PCSK-9 inhibitor Evolocumab. The mechanism underlying these changes likely involves the de novo synthesis of SM and CER through the activation of the key enzyme sphingomyelin synthase by oxidized LDL and argues for a multifaceted system leading to vascular improvement in users of PCSK-9 inhibitors.
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Barrios V, Soronen J, Carter AM, Anastassopoulou A. Lipid management across Europe in the real-world setting: a rapid evidence review. Curr Med Res Opin 2021; 37:2049-2059. [PMID: 34517739 DOI: 10.1080/03007995.2021.1973396] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To provide a contemporary overview of recent real-world lipid-lowering therapy (LLT) practices and outcomes in patients with hypercholesterolemia/dyslipidemia at high/very high risk of atherosclerotic cardiovascular disease in Europe. METHODS A structured literature review of recent (July 2015-July 2020) real-world studies reporting lipid management and outcomes was conducted using a rapid evidence synthesis. Outcomes included patient characteristics, LLT treatment practices, adherence and low-density lipoprotein cholesterol (LDL-C) goal attainment. RESULTS Fifty-three real-world observational studies in high/very high risk patients were selected after screening 5664 records (n = 50 national [sample size range 38-237,279] and n = 3 multinational studies [sample size range 6648-8456]). Mean age ranged from 33 to 77 years; hypertension, diabetes and obesity were commonly reported comorbidities. Statins were the most common LLT; patients without familial hypercholesterolemia (FH) mostly received high or moderate intensity statins/LLT, while patients with FH mostly received high intensity statins/LLT. The proportion of patients receiving ezetimibe was low overall (ezetimibe + statin use in those with and without familial hypercholesterolemia [FH] range 5%-59% and 1%-22%, respectively). Overall, the use of proprotein convertase subtilisin/kexin 9 inhibitor (PCSK9i) therapy was limited. Adherence to LLT therapies was defined variably and ranged from 46%-92%. LDL-C goal attainment was suboptimal, irrespective of LLT (overall range in goal attainment with oral LLT was 2%-73% [FH: 2%-23%] and with PCSK9i was 20%-65%). CONCLUSIONS LDL-C control is suboptimal and the available LLT armamentarium, most importantly combination therapy, is being underutilized in high/very high risk patients leading to inadequate management of cardiovascular risk.
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Chakraborty A, Pang J, Chan DC, Barnett W, Woodward AM, Vorster M, Watts GF. Effectiveness of proprotein convertase subtilisin/kexin-9 monoclonal antibody treatment on plasma lipoprotein(a) concentrations in patients with elevated lipoprotein(a) attending a clinic. Clin Cardiol 2021; 44:805-813. [PMID: 33955565 PMCID: PMC8207967 DOI: 10.1002/clc.23607] [Citation(s) in RCA: 3] [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: 02/12/2021] [Revised: 03/22/2021] [Accepted: 03/29/2021] [Indexed: 01/01/2023] Open
Abstract
Background Lipoprotein(a) (Lp[a]) is a causal risk factor for atherosclerotic cardiovascular disease (ASCVD). Proprotein convertase subtilisin/kexin‐9 monoclonal antibodies (PCSK9mAbs) can lower Lp(a) levels in clinical trials, but their effects in patients with elevated Lp(a) in clinical practice remain unclear. Aims To investigate the effectiveness and safety of PCSK9mAbs in lowering plasma Lp(a) in patients with elevated Lp(a) concentrations in a lipid clinic. Methods This was an open‐label study of 53 adult patients with elevated Lp(a) concentration (≥0.5 g/L). Clinical, biochemical, and safety data were collected before and on treatment with evolocumab or alirocumab over a mean period of 11 months. Results Treatment with a PCSK9mAb resulted in a significant reduction of 0.29 g/L (−22%) in plasma Lp(a) concentration (p<.001). There were also significant reductions in low‐density lipoprotein‐cholesterol (LDL‐C) (−53%), remnant‐cholesterol (−12%) and apolipoprotein B (−43%) concentrations. The change in Lp(a) concentration was significantly different from a comparable group of 35 patients with elevated Lp(a) who were not treated with a PCSK9mAb (−22% vs. −2%, p<.001). The reduction in Lp(a) concentration was not associated with the corresponding changes in LDL‐C, remnant‐cholesterol, and apolipoprotein B (p>.05 in all). 7.5% and 47% of the patients attained a target concentration of Lp(a) <0.5 g/L and LDL‐C <1.8 mmol/L, respectively. PCSK9mAbs were well tolerated, the common adverse effects being pharyngitis (9.4%), nasal congestion (7.6%), myalgia (9.4%), diarrhoea (7.6%), arthralgia (9.4%) and injection site reactions (11%). Conclusion PCSK9mAbs can effectively and safely lower plasma Lp(a) concentrations in patients with elevated Lp(a) in clinical practice; the impact of the fall in Lp(a) on ASCVD outcomes requires further investigation.
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Affiliation(s)
- Anindita Chakraborty
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
| | - Jing Pang
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
| | - Dick C Chan
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
| | - Wendy Barnett
- Lipid Disorders Clinic, Cardiometabolic Services, Department of Cardiology, Royal Perth Hospital, Perth, Australia
| | - Ann Marie Woodward
- Lipid Disorders Clinic, Cardiometabolic Services, Department of Cardiology, Royal Perth Hospital, Perth, Australia
| | - Mary Vorster
- Lipid Disorders Clinic, Cardiometabolic Services, Department of Cardiology, Royal Perth Hospital, Perth, Australia
| | - Gerald F Watts
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia.,Lipid Disorders Clinic, Cardiometabolic Services, Department of Cardiology, Royal Perth Hospital, Perth, Australia
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PCSK9 Inhibitors in a German Single-Center Clinical Practice: Real-World Treatment of Patients at High Cardiovascular Risk Over 68 Weeks. Am J Cardiovasc Drugs 2021; 21:83-92. [PMID: 32514867 PMCID: PMC7838077 DOI: 10.1007/s40256-020-00411-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Aims Several the use of proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) for patients at high/very high cardiovascular risk who are inadequately treated with maximally tolerated lipid-lowering therapies (LLTs). Objectives We assessed the effectiveness and safety of the PCSK9i alirocumab and evolocumab in a single-center clinical practice for up to 68 weeks. Methods In this prospective, open-label study conducted in Germany, 635 enrolled patients were treated with alirocumab [75 or 150 mg every 2 weeks (Q2W)] or evolocumab (140 mg Q2W) according to European Society of Cardiology/European Atherosclerosis Society guidelines (low-density lipoprotein cholesterol [LDL-C] > 1.81/2.59 mmol/L (70/100 mg/dL), depending on cardiovascular risk]. Investigators were able to adjust LLTs, including PCSK9i, according to their own clinical judgment. The primary effectiveness endpoint was LDL-C reduction from baseline to week 68. Results At baseline, approximately 50% of patients were statin intolerant, and approximately 90% reported a history of cardiovascular disease. LDL-C reductions remained generally unchanged from weeks 4 to 68 in each treatment group. At week 68, LDL-C mean percentage changes from baseline were − 41.7% (alirocumab 75 mg Q2W), − 53.7% (alirocumab 150 mg Q2W), and − 54.1% (evolocumab 140 mg Q2W). LDL-C reduction was 7.1% greater in patients receiving statins than in those not receiving statins because of statin intolerance (P < 0.0001). PCSK9i consistently improved levels of other lipoproteins throughout. Overall, 47.1% of patients reported adverse events at week 68. Conclusions Consistent with clinical trial findings, alirocumab and evolocumab improved lipid levels in a real-world setting in patients with high baseline LDL-C levels despite receiving maximally tolerated LLTs. PCSK9i were generally well-tolerated. Electronic supplementary material The online version of this article (10.1007/s40256-020-00411-3) contains supplementary material, which is available to authorized users.
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Busuioc RM, Covic A, Kanbay M, Banach M, Burlacu A, Mircescu G. Protein convertase subtilisin/kexin type 9 biology in nephrotic syndrome: implications for use as therapy. Nephrol Dial Transplant 2020; 35:1663-1674. [PMID: 31157893 DOI: 10.1093/ndt/gfz108] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 04/19/2019] [Indexed: 01/12/2023] Open
Abstract
Low-density lipoprotein cholesterol (LDL-C) levels almost constantly increased in patients with nephrotic syndrome (NS). Protein convertase subtilisin/kexin type 9 (PCSK9) [accelerates LDL-receptor (LDL-R) degradation] is overexpressed by liver cells in NS. Their levels, correlated inversely to LDL-R expression and directly to LDL-C, seem to play a central role in hypercholesterolaemia in NS. Hypersynthesis resulting from sterol regulatory element-binding protein dysfunction, hyperactivity induced by c-inhibitor of apoptosis protein expressed in response to stimulation by tumour necrosis factor-α produced by damaged podocytes and hypo-clearance are the main possible mechanisms. Increased LDL-C may damage all kidney cell populations (podocytes, mesangial and tubular cells) in a similar manner. Intracellular cholesterol accumulation produces oxidative stress, foam cell formation and apoptosis, all favoured by local inflammation. The cumulative effect of cellular lesions is worsened proteinuria and kidney function loss. Accordingly, NS patients should be considered high risk and treated by lowering LDL-C. However, there is still not enough evidence determining whether lipid-lowering agents are helpful in managing dyslipidaemia in NS. Based on good efficacy and safety proved in the general population, therapeutic modulation of PCSK9 via antibody therapy might be a reasonable solution. This article explores the established and forthcoming evidence implicating PCSK9 in LDL-C dysregulation in NS.
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Affiliation(s)
| | - Adrian Covic
- "Gr. T. Popa," University of Medicine and Pharmacy, Iasi, Romania.,Nephrology Clinic, Dialysis and Renal Transplant Center - 'C.I. Parhon' University Hospital Iasi, Romania
| | | | - Maciej Banach
- Department of Hypertension, WAM University Hospital in Lodz, Medical University of Lodz, Lodz, Poland.,Polish Mother's Memorial Hospital Research Institute, Lodz, Poland.,Cardiovascular Research Centre, University of Zielona Gora, Zielona Gora, Poland
| | - Alexandru Burlacu
- "Gr. T. Popa," University of Medicine and Pharmacy, Iasi, Romania.,Head of Department of Interventional Cardiology - Cardiovascular Diseases Institute Iasi, Romania
| | - Gabriel Mircescu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
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Estimation of the major cardiovascular events prevention with Inclisiran. Atherosclerosis 2020; 313:76-80. [DOI: 10.1016/j.atherosclerosis.2020.09.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/18/2020] [Accepted: 09/23/2020] [Indexed: 12/17/2022]
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D'Erasmo L, Commodari D, Di Costanzo A, Minicocci I, Polito L, Ceci F, Montali A, Maranghi M, Arca M. Evolving trend in the management of heterozygous familial hypercholesterolemia in Italy: A retrospective, single center, observational study. Nutr Metab Cardiovasc Dis 2020; 30:2027-2035. [PMID: 32830020 DOI: 10.1016/j.numecd.2020.06.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 05/12/2020] [Accepted: 06/25/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS The effective reduction of LDL-C in patients with heterozygous familial hypercholesterolemia (HeFH) is crucial to reduce their increased cardiovascular risk. Diagnostic and therapeutic (PCSK9 inhibitors) tools to manage HeFH improved in recent years. However, the impact of these progresses in ameliorating the contemporary real-world care of these patients remains to be determined. Aim of this study was to assess the evolution of treatments and LDL-C control in a cohort of HeFH patients in Italy. METHODS AND RESULTS Four hundred six clinically diagnosed HeFH followed in a single, tertiary lipid centre were included in this survey. Data on lipid levels and medications were collected at baseline and during a median 3-year follow-up. At baseline, 19.8% of patients were receiving conventional high-potency lipid lowering therapies (LLT) and this percentage increased up to 50.8% at last visit. The knowledge of results of molecular diagnosis was associated with a significant increase in treatment intensity and LDL-C lowering. Nevertheless, the new LDL-C target (<70 mg/dl) was achieved only in 3.6% of HeFH patients under conventional LLTs and this proportion remained low (2.9%) also in those exposed to maximal conventional LLT. In 51 patients prescribed with PCSK9 inhibitors, 64.6% and 62.1% reached LDL-C<70 mg/dl at 3- and 12-month follow-up, respectively. CONCLUSIONS Although treatments of HeFH improved over time, LDL-C target achievement with conventional LLT remains poor, mainly among women. The use of molecular diagnosis and even more the prescription of PCSK9i may improve LDL-C control in these patients.
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Affiliation(s)
- Laura D'Erasmo
- Department of Translational and Precision Medicine, Università degli studi di Roma, Sapienza, Rome, Italy; Cardiovascular Prevention Unit, Department of Endocrinology and Metabolism, Pitié-Salpêtrière University Hospital, Paris, France.
| | - Daniela Commodari
- Department of Translational and Precision Medicine, Università degli studi di Roma, Sapienza, Rome, Italy
| | - Alessia Di Costanzo
- Department of Translational and Precision Medicine, Università degli studi di Roma, Sapienza, Rome, Italy
| | - Ilenia Minicocci
- Department of Translational and Precision Medicine, Università degli studi di Roma, Sapienza, Rome, Italy
| | - Luca Polito
- Department of Translational and Precision Medicine, Università degli studi di Roma, Sapienza, Rome, Italy
| | - Fabrizio Ceci
- Department of Experimental Medicine, Università degli Studi di Roma, Sapienza, Rome, Italy
| | - Anna Montali
- Department of Translational and Precision Medicine, Università degli studi di Roma, Sapienza, Rome, Italy
| | - Marianna Maranghi
- Department of Translational and Precision Medicine, Università degli studi di Roma, Sapienza, Rome, Italy
| | - Marcello Arca
- Department of Translational and Precision Medicine, Università degli studi di Roma, Sapienza, Rome, Italy
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Jatem E, Lima J, Montoro B, Torres-Bondia F, Segarra A. Efficacy and Safety of PCSK9 Inhibitors in Hypercholesterolemia Associated With Refractory Nephrotic Syndrome. Kidney Int Rep 2020; 6:101-109. [PMID: 33426389 PMCID: PMC7783565 DOI: 10.1016/j.ekir.2020.09.046] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/27/2020] [Accepted: 09/29/2020] [Indexed: 12/27/2022] Open
Abstract
Introduction Treatment of hypercholesterolemia in refractory nephrotic syndrome remains a therapeutic challenge. There is not enough evidence supporting the efficacy of statins, and these drugs can be associated with an increased incidence of adverse effects. Herein we summarize our clinical experience with 12 patients suffering from refractory nephrotic syndrome with associated vascular disease and uncontrolled hypercholesterolemia despite treatment with statins who were treated with proprotein convertase subtilisin kexin 9 (PCSK9) inhibitors. Methods Twelve adult patients with primary nephrotic syndrome refractory to multiple lines of immunosuppressive treatment who suffered from clinical atheromatous vascular disease were treated with PCSK9 inhibitors according to the prescription guidelines for secondary prevention of cardiovascular events. Eight patients with refractory nephrotic syndrome without vascular disease treated with atorvastatin comprised the control group. Results Four weeks after treatment with PCSK9 inhibitors, a statistically significant decrease in total cholesterol and low-density lipoprotein cholesterol (LDL-C) levels was observed without significant changes in serum albumin levels or proteinuria. The mean LDL-C decrease was 36.8% ± 4.9% mmol/L at 4 weeks and remained unchanged throughout the follow-up period. In the control group, there were no significant changes in the levels of total cholesterol or LDL-C during the follow-up period. At the diagnosis of nephrotic syndrome, plasma PCSK9 levels were 334 ± 40 ng/mL and correlated significantly with serum LDL-C levels (r = 0.49, P = 0.023). Six months after starting treatment with PCSK9 inhibitors, plasma PCSK9 levels were significantly reduced to values of 190 ± 36 ng/mL (P = 0.001) with a mean relative reduction of 42.3% ± 12.6%. No local adverse effects were seen at the injection site and no significant changes were seen in the levels of transaminase, creatine phosphokinase, or aldolase. Conclusion PCSK9 inhibitors may be an effective and safe alternative for the treatment of hypercholesterolemia associated with refractory nephrotic syndrome.
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Affiliation(s)
- Elias Jatem
- Servicio de Nefrología, Hospital Arnau de Vilanova, Lleida, Spain
| | - Joan Lima
- Servicio de Medicina Interna, Hospital Vall d'Hebron, Barcelona, Spain
| | - Bruno Montoro
- Servicio de Farmacia Hospitalaria, Hospital Vall d'Hebron, Barcelona, Spain
| | | | - Alfons Segarra
- Servicio de Nefrología, Hospital Arnau de Vilanova, Lleida, Spain
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Han J, Bilgrami S, Ross S, Broadhead H, Attar N. Real-world lipid lowering effects of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors: A single-centre study. Int J Cardiol 2020; 322:240-244. [PMID: 32827563 DOI: 10.1016/j.ijcard.2020.08.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 08/13/2020] [Accepted: 08/17/2020] [Indexed: 10/23/2022]
Affiliation(s)
- J Han
- Department of Cardiology, Royal Lancaster Infirmary, Lancaster, United Kingdom.
| | - S Bilgrami
- Department of Cardiology, Royal Lancaster Infirmary, Lancaster, United Kingdom
| | - S Ross
- Department of Cardiology, Royal Lancaster Infirmary, Lancaster, United Kingdom
| | | | - N Attar
- Department of Cardiology, Royal Lancaster Infirmary, Lancaster, United Kingdom
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12
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Cordero A, Rodríguez-Mañero M, Fácila L, Fernández-Olmo MR, Gómez-Martínez MJ, Valle A, Castellano JM, Toro MM, Seijas-Amigo J, Vicedo A, González-Juanatey JR. Prevention of myocardial infarction and stroke with PCSK9 inhibitors treatment: a metanalysis of recent randomized clinical trials. J Diabetes Metab Disord 2020; 19:759-765. [PMID: 33520801 DOI: 10.1007/s40200-020-00557-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/18/2020] [Accepted: 05/26/2020] [Indexed: 12/11/2022]
Abstract
Purpose Proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors treatment induce large reductions in low-density lipoprotein cholesterol (LDLc) and major cardiovascular events. Clinical trials might have been underpowered to test the effect of PSCK9 inhibitors treatment on myocardial infarction and stroke, two of the most relevant cardiovascular events, since all analyzed a combined endpoint. Methods we performed a meta-analysis, with currently available studies involving PCSK9 inhibitors and event rate adjudication, with the aim of assessing treatment effects on myocardial infarction and stroke. Results We included 81,700 patients, 41,979 treated with a PSCK9 inhibitors: 17,244 with evolocumab; 13,720 with bococizumab and 11,015 with alirocumab. A total of 1,319 cases of myocardial infarctions were registered in the treatment group vs. 1,608 in controls, resulting in 19.0% reduction associated with PCSK9 treatment (RR: 0.81, 95% CI 0.76-0.87). Similarly, PCSK9 inhibitors treatment resulted in a 25% reduction of stroke (RR: 0.75, 95% CI 0.65-0.85) when all studies were analyzed together and the statistically significant heterogeneity was not observed in the analysis restricted to end-point based clinical trials. PCSK9 inhibitors treatment had no effect on mortality (RR: 0.95, 95% CI 0.86-1.04). Conclusions PCSK9 inhibitors reduce the incidence of myocardial infarction by 19% and stroke by 25%.
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Affiliation(s)
- Alberto Cordero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Department, Hospital Universitario de San Juan, Carretera Valencia-Alicante sn, San Juan de Alicante, 03550 Spain
| | - Moisés Rodríguez-Mañero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
| | - Lorenzo Fácila
- Cardiology Department, Hospital General Universitario de Valencia, Valencia, Spain
| | | | | | - Alfonso Valle
- Cardiology Department, Hospital de Denia, Denia, Spain
| | - Jose Mª Castellano
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Cardiology Department, Hospitales de Madrid, Madrid, Spain
| | | | - José Seijas-Amigo
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
| | - Alvaro Vicedo
- Cardiology Department, Hospital de Denia, Denia, Spain
| | - José R González-Juanatey
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
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Kim EJ, Wierzbicki AS. The history of proprotein convertase subtilisin kexin-9 inhibitors and their role in the treatment of cardiovascular disease. Ther Adv Chronic Dis 2020; 11:2040622320924569. [PMID: 32537117 PMCID: PMC7268157 DOI: 10.1177/2040622320924569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/15/2020] [Indexed: 12/22/2022] Open
Abstract
A consensus has formed based on epidemiological studies and clinical trials that intervention to reduce low density lipoprotein cholesterol (LDL-C) will reduce cardiovascular disease (CVD) events. This has progressively reduced the thresholds for intervention and targets for treatment. Whist statins are sufficient for many people in primary prevention, they only partially achieve the newer targets of secondary prevention for established CVD. Increasing use of statins has highlighted that 1–2% cannot tolerate these drugs. Other cholesterol-lowering drugs such as ezetimibe add to the benefits of statins but have limited efficacy. The discovery of activating mutations in proprotein convertase subtilisin kexin-9 (PCSK9) as a cause of familial hypercholesterolaemia while inactivating mutations lower LDL-C led to the idea to develop PCSK9 inhibitors as drugs. This article reviews the history of lipid-lowering therapies, the discovery of PCSK9 and the development of PCSK9 inhibitors. It reviews the key trials of the current antibody-based drugs and how these have influenced new guidelines. It also reviews the controversy caused by their cost and the increasing application of health economics to determine the optimum strategy for implementation of novel therapeutic pathways and surveys other options for targeting PCSK9 as well as other LDL-C lowering compounds in late development.
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Affiliation(s)
- Eun Ji Kim
- Department of Metabolic Medicine/Chemical Pathology, Guy's & St Thomas' Hospitals, London, UK
| | - Anthony S Wierzbicki
- Department of Chemical Pathology, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
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Moriarty PM, Thompson PD, Cannon CP, Guyton JR, Bergeron J, Zieve FJ, Bruckert E, Jacobson TA, Baccara-Dinet MT, Zhao J, Donahue S, Ali S, Manvelian G, Pordy R. Efficacy and safety of alirocumab in statin-intolerant patients over 3 years: open-label treatment period of the ODYSSEY ALTERNATIVE trial. J Clin Lipidol 2020; 14:88-97.e2. [PMID: 32192644 DOI: 10.1016/j.jacl.2020.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/06/2020] [Accepted: 01/06/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The 24-week randomized, double-blind ODYSSEY ALTERNATIVE trial (NCT01709513) demonstrated significant low-density lipoprotein cholesterol (LDL-C) reductions with the PCSK9 inhibitor alirocumab vs ezetimibe in statin-intolerant patients, with significantly fewer skeletal muscle events (SMEs; 32.5%) vs atorvastatin (46.0%; hazard ratio: 0.61, 95% confidence interval: 0.38 to 0.99, P = .042). OBJECTIVE ALTERNATIVE participants could enter an open-label treatment period (OLTP) for assessment of long-term safety. METHODS Two hundred and eighty one patients entered the OLTP; 93.7%, 84.0%, and 92.9% of patients who received atorvastatin, ezetimibe, and alirocumab, respectively, during double-blind treatment, including 216 patients (76.9%) who completed double-blind treatment, as well as patients who either prematurely discontinued treatment due to SME (n = 51 [18.1%]) or other reasons (n = 14 [5.0%]) but completed week 24 assessments. All patients in the OLTP received alirocumab (75 or 150 mg every 2 weeks based on investigator decision) for ∼3 years or until commercial availability, whichever came first. RESULTS SMEs were reported by 38.4% of patients in the OLTP. Safety results from the OLTP were similar to those of the alirocumab group in the double-blind period, except for a lower rate of discontinuations due to SMEs observed with alirocumab in the OLTP (3.2% vs 15.9% in the double-blind period). At OLTP week 8, mean LDL-C reduction from baseline (=week 0 of double-blind period) was 52.0%, with reductions sustained through to the end-of-treatment visits (55.4% and 53.7% reduction at weeks 100 and 148, respectively). CONCLUSIONS In this population of statin-intolerant patients, alirocumab was well tolerated and produced durable LDL-C reductions over 3 years.
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Affiliation(s)
- Patrick M Moriarty
- Division of Clinical Pharmacology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA.
| | | | | | | | - Jean Bergeron
- Lipid Clinic, Centre Hospitalier Universitaire de Quebec, Laval University, Quebec, Canada
| | | | - Eric Bruckert
- Groupe Hospitalier Pitié-Salpêtrière (Assistance Publique-Hôpitaux de Paris), Paris, France
| | | | | | - Jian Zhao
- Regeneron Pharmaceuticals, Inc., Basking Ridge, NJ, USA
| | | | - Shazia Ali
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| | | | - Robert Pordy
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
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15
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Reynolds T, Carey P, George J, Konidaris G, Narayanan D, Ramachandran S, Saunders L, Viljoen A, Ferns G. A Retrospective Observational Study to Determine Baseline Characteristics and Early Prescribing Patterns for Patients Receiving Alirocumab in UK Clinical Practice. Drugs Real World Outcomes 2019; 6:205-213. [PMID: 31741198 PMCID: PMC6879683 DOI: 10.1007/s40801-019-00166-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Alirocumab is a fully human monoclonal antibody to proprotein convertase subtilisin/kexin type 9 (PCSK9) and has been previously shown, in the phase III ODYSSEY clinical trial program, to provide significant lowering of low-density lipoprotein cholesterol (LDL-C) and reduction in risk of major adverse cardiovascular events. However, real-world evidence to date is limited. OBJECTIVE The primary objective was to describe baseline characteristics, clinical history, and prior lipid-lowering therapy (LLT) use of patients initiated on alirocumab in UK clinical practice following publication of health technology appraisal (HTA) body recommendations. Secondary objectives included description of alirocumab use and lipid parameter outcomes over a 4-month follow-up period. METHODS In this retrospective, single-arm, observational, multicenter study, data were collected for 150 patients initiated on alirocumab. RESULTS Mean (standard deviation; SD) age of patients was 61.4 (10.5) years and baseline median (interquartile range; IQR) LDL-C level was 4.8 (4.2-5.8) mmol/l. Alirocumab use occurred predominantly in patients with heterozygous familial hypercholesterolemia (HeFH) (n = 100/150, 66%) and those with statin intolerance (n = 123/150, 82%). Most patients started on alirocumab 75 mg (n = 108/150 [72%]) and 35 (23.3%) were up-titrated to 150 mg. Clinically significant reductions in atherogenic lipid parameters were observed with alirocumab, including LDL-C (median [IQR] change from baseline, - 53.6% [- 62.9 to - 34.9], P < 0.001). CONCLUSION This study highlights the unmet need for additional LLT in patients with uncontrolled hyperlipidemia and demonstrates the clinical utility of alirocumab in early real-world practice, where dosing flexibility is an important attribute of this therapeutic option.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Gordon Ferns
- Brighton and Sussex University Hospital, Brighton, BN1 9PX, UK.
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16
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López Zúñiga M, Martín Toro M, de Damas Medina M. Datos de vida real en el uso de IPCSK9. Rev Clin Esp 2019; 219:466-468. [DOI: 10.1016/j.rce.2019.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 02/05/2019] [Accepted: 06/05/2019] [Indexed: 12/19/2022]
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17
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Interdose lipid profile evaluation of PCSK9i in real life. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2019.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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18
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Gebhardt A, Fichtenbaum CJ. Current pharmacotherapy for the treatment of dyslipidemia associated with HIV infection. Expert Opin Pharmacother 2019; 20:1719-1729. [PMID: 31232617 PMCID: PMC6756942 DOI: 10.1080/14656566.2019.1636033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 06/21/2019] [Indexed: 12/18/2022]
Abstract
Introduction: Cardiovascular disease is an important cause of morbidity and mortality in persons with human immunodeficiency virus (PWH). The risk of atherosclerotic cardiovascular disease (ASCVD) is higher in PWH compared to uninfected persons. Dyslipidemia is a critical link in the pathogenesis of ASCVD in PWH. Chronic inflammation associated with HIV infection may drive both dyslipidemia and ASCVD. Areas covered: The authors review the evidence for using lipid-lowering therapy in PWH and includes an overview of the utility and complexity of using statins in PWH, in particular, drug interactions, safety, and efficacy. In addition, data covering alternate therapies like omega-3 fatty acids, fibrates, niacin, ezetimibe, and PCSK-9 inhibitors are reviewed. Expert opinion: Dyslipidemia is a common problem in PWH. The risk of ASCVD is higher in PWH. Lipid-lowering therapy reduces the risk of ASCVD, but clinical endpoint trials are lacking in PWH. Statin therapy is the mainstay of primary prevention for ASCVD. The timing of when to initiate primary prevention with statins in PWH is unclear. Beyond statins, there are limited data that other lipid-lowering agents have utility in PWH. Ongoing trials like the REPRIEVE trial will inform the community about the optimal approach to lipid-lowering therapy in PWH.
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Affiliation(s)
- Anna Gebhardt
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine , Cincinnati , OH , USA
| | - Carl J Fichtenbaum
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine , Cincinnati , OH , USA
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Parhofer KG, von Stritzky B, Pietschmann N, Dorn C, Paar WD. PEARL: A Non-interventional Study of Real-World Alirocumab Use in German Clinical Practice. Drugs Real World Outcomes 2019; 6:115-123. [PMID: 31280466 PMCID: PMC6702526 DOI: 10.1007/s40801-019-0158-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Several lipid guidelines recommend that proprotein convertase subtilisin/kexin type 9 inhibitors should be considered for patients with atherosclerotic cardiovascular disease who are inadequately treated with maximally tolerated lipid-lowering treatment. OBJECTIVES The PEARL study assessed the efficacy and safety of the proprotein convertase subtilisin/kexin type 9 inhibitor alirocumab in patients with hypercholesterolemia in a real-world setting. METHODS PEARL was an open, prospective, multicenter, non-interventional study conducted in Germany. Patients (n = 619) for whom treating physicians decided to use alirocumab 75 or 150 mg every 2 weeks according to German guidelines (low-density lipoprotein cholesterol > 1.8/2.6 mmol/L [> 70/100 mg/dL], depending on cardiovascular risk, despite maximally tolerated statin therapy with/without other non-alirocumab lipid-lowering therapy) were enrolled and followed for 24 weeks. Physicians could adjust the alirocumab dose based on their clinical judgment. The primary efficacy endpoint was low-density lipoprotein cholesterol reduction from baseline (prior to alirocumab therapy) to week 24. RESULTS Overall, 72.8% of patients reported complete or partial statin intolerance. Mean low-density lipoprotein cholesterol was 4.7 mmol/L (180.5 mg/dL) and 2.3 mmol/L (89.8 mg/dL) at baseline and week 24, respectively. Least-squares mean percentage change from baseline to week 24 in low-density lipoprotein cholesterol was - 48.6%. Initial alirocumab dose was 75 mg in 72.9% of patients and 150 mg in 24.5% of patients; 19.6% of patients received an alirocumab dose increase (75 to 150 mg) and 1.6% of patients received a dose decrease. Adverse events were reported in 10.3% of patients, with myalgia being the most common. CONCLUSIONS In a real-world setting in Germany, alirocumab was used in patients who had high baseline low-density lipoprotein cholesterol levels with/without statin intolerance. Efficacy and safety were consistent with findings observed in the ODYSSEY Phase III program.
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Affiliation(s)
- Klaus G Parhofer
- Medical Department IV-Grosshadern, University of Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | | | | | - Cornelia Dorn
- Medical Department, Sanofi-Aventis Deutschland GmbH, Berlin, Germany
| | - W Dieter Paar
- Medical Department, Sanofi-Aventis Deutschland GmbH, Berlin, Germany
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21
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Gürgöze MT, Muller-Hansma AHG, Schreuder MM, Galema-Boers AMH, Boersma E, Roeters van Lennep JE. Adverse Events Associated With PCSK9 Inhibitors: A Real-World Experience. Clin Pharmacol Ther 2018; 105:496-504. [PMID: 30053327 PMCID: PMC6704355 DOI: 10.1002/cpt.1193] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 07/19/2018] [Indexed: 01/02/2023]
Abstract
In randomized clinical trials (RCTs) proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors showed a favorable safety profile, however, “real‐world” data on adverse events (AEs) is scarce. Three datasets, a hospital registry (n = 164), and two Pharmacovigilance databases, Lareb (n = 149) and VigiLyze (n = 15,554), reporting AEs attributed to PCSK9 inhibitors (alirocumab or evolocumab) prescribed in clinical practice were analyzed. In the hospital registry, 41.5% of the patients reported any AE, most often injection‐site reactions (33.8%) and influenza‐like illness (27.9%). Twelve patients (7%) discontinued PCSK9 inhibitor treatment. Most common AE reported in the Lareb and VigiLyze database was myalgia (12.8% and 8.3%, respectively). No clinically relevant differences in gender or between drugs were observed. No specific subgroup of patients could be identified at risk of developing AEs. During follow‐up, AEs resolved in most patients (71.1%). In a real‐world setting, PCSK9 inhibitors are well tolerated with an overall safety profile comparable to RCTs.
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Affiliation(s)
- Muhammed T Gürgöze
- Erasmus MC, University Medical Centre Rotterdam, Department of Cardiology, Rotterdam, The Netherlands
| | | | - Michelle M Schreuder
- Erasmus MC, University Medical Centre Rotterdam, Department of Internal Medicine, Rotterdam, The Netherlands
| | - Annette M H Galema-Boers
- Erasmus MC, University Medical Centre Rotterdam, Department of Internal Medicine, Rotterdam, The Netherlands
| | - Eric Boersma
- Erasmus MC, University Medical Centre Rotterdam, Department of Cardiology, Rotterdam, The Netherlands
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Wierzbicki AS, Viljoen A, Viljoen S, Martin S, Crook MA, Reynolds TM. Review of referral criteria to lipid clinics and outcomes of treatment in four UK centres. Int J Clin Pract 2018; 72:e13242. [PMID: 32500653 DOI: 10.1111/ijcp.13242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 07/14/2018] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Little data exist on the referral patterns and effectiveness of lipid clinics. METHODS An audit was conducted in four clinics of 100 consecutive referrals each. Data were recorded on referral criteria, cardiovascular disease (CVD) risk factors, drug history, investigations, diagnoses, therapies, results and referrals. RESULTS Patients were aged 56 ± 14 years, 47% were male and 87% were primary prevention. Risk factors included smoking (16%), type 2 diabetes (13%) and hypertension (13%). Referrals were made for hypercholesterolaemia (68%), diagnosis of FH (31%), statin intolerance (23%) and hypertriglyceridaemia (23%). Initial total cholesterol (TC) was 7.65 ± 2.64 mmol/L, triglycerides (TG) 2.17 (0.41-76.9 mmol/L) mmol/L, HDL-C 1.53 ± 0.71 mmol/L, LDL-C 4.57 ± 1.66 mmol/L with non-HDL-C 5.90 ± 2.09 mmol/L. Criteria for FH were met in 21% with genetic testing in 13% and lipid cascade testing in 30% of index cases. Triglycerides >20 mmol/L were present in 4%. The diagnosis was changed in 21%: hypercholesterolaemia (7%), mixed hyperlipidaemia (7%) and hypertriglyceridaemia (7%). Hepatic steatosis was identified in 14.5%. Lipoprotein(a) levels >125 nmol/L occurred in 41% in one clinic. Therapy changes included altered statins (40%), addition of a fibrate (11%) or ezetimibe (8%). These reduced TC by 1.92 mmol/L (19%; P = 0.0001), LDL-C 1.07 mmol/L (15%; P = 0.02), non-HDL-C 1.50 mmol/L (16%; P < 0.001), and TG 2.3 (-4 to 38) mmol/L (16%; P < 0.001) with 11% extra achieving TG <5 mmol/L while HDL-C increased by 7% (P = 0.37). CONCLUSIONS Lipid clinics have diverse functions including diagnosis of FH, managing severe hypercholesterolaemia, mixed hyperlipidaemia and statin intolerance. Effectiveness criteria of average reductions of 1.5 mmol/L in TC or non-HDL-C, 1 mmol/L in LDL-C and 2 mmol/L in TG would be reasonable for newly referred patients.
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Affiliation(s)
- Anthony S Wierzbicki
- Department of Metabolic Medicine/Chemical Pathology, Guy's & St Thomas' Hospitals, London, UK
| | - Adie Viljoen
- Department of Metabolic Medicine/Chemical Pathology, North East Hertfordshire NHS Trust, Lister Hospital, Stevenage, Hertfordshire, UK
| | - Sumarie Viljoen
- Department of Metabolic Medicine/Chemical Pathology, North East Hertfordshire NHS Trust, Lister Hospital, Stevenage, Hertfordshire, UK
| | - Steven Martin
- Department of Clinical Biochemistry and Immunology, Northwest Anglia NHS Foundation Trust, Peterborough, Cambridgeshire, UK
| | - Martin A Crook
- Department of Metabolic Medicine/Chemical Pathology, Guy's & St Thomas' Hospitals, London, UK
| | - Timothy M Reynolds
- Department of Metabolic Medicine/Chemical Pathology, Queen's Hospital, Burton-on-Trent, UK
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Razek O, Cermakova L, Armani H, Lee T, Francis GA, Mancini GJ, Frohlich J, Brunham LR. Attainment of Recommended Lipid Targets in Patients With Familial Hypercholesterolemia: Real-World Experience With PCSK9 Inhibitors. Can J Cardiol 2018; 34:1004-1009. [DOI: 10.1016/j.cjca.2018.04.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 04/12/2018] [Accepted: 04/13/2018] [Indexed: 01/29/2023] Open
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Zafrir B, Jubran A. Lipid-lowering therapy with PCSK9-inhibitors in the real-world setting: Two-year experience of a regional lipid clinic. Cardiovasc Ther 2018; 36:e12439. [PMID: 29863817 DOI: 10.1111/1755-5922.12439] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/26/2018] [Accepted: 05/30/2018] [Indexed: 01/13/2023] Open
Abstract
AIM PCSK9 inhibitors (PCSK9i) effectively lower cholesterol levels in randomized trials with reduction in cardiovascular outcomes and favorable safety profile. However, the access to PCSK9i is limited due to high cost and data regarding the use of PCSK9i in real-world practice is limited. METHODS Data on all patients submitted for approval of PCSK9i at a regional lipid clinic, outside of clinical trials. Patients' profile, approval rates, low-density lipoprotein cholesterol (LDL-C) reduction rates, and adverse events were evaluated. RESULTS Recommendation for PCSK9i was given to 133 patients; 16 did not receive insurance approval and additional 16 were approved but did not initiate therapy. Of the 101 treated patients (47% females; mean age 61 ± 11 years), 52 had probable/definite familial hypercholesterolemia (FH) (peak LDL-C level 305 ± 87 mg/dL vs non-FH 204 ± 39 mg/dL) and 62% had an established cardiovascular disease. Statin intolerance was reported by 77%. Follow-up lipid panel was available in 66/101 patients: mean LDL-C reduction was 59% ± 19. Subjects with heterozygous FH had similar LDL-C decrease than those with non-FH (59% ± 22 vs 60% ± 14, P = .792). LDL-C < 100 mg/dL was achieved by 76%, LDL-C < 70 mg/dL by 58% and LDL-C < 40 mg/dL by 18% of those with follow-up data. Side effects were reported by 10%, mainly musculoskeletal complaints and flu-like symptoms, and 15% have discontinued treatment. CONCLUSIONS Patient selection by a regional lipid clinic resulted in a high real-world PCSK9i insurance approval, with efficacy and safety comparable to randomized clinical trials. Cost and medication nonadherence are potential barriers to successful implementation of therapy in routine clinical care.
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Affiliation(s)
- Barak Zafrir
- Cardiovascular Department, Lady Davis Carmel Medical Center, Haifa, Israel.,Clalit Health Services, Haifa, Israel
| | - Ayman Jubran
- Cardiovascular Department, Lady Davis Carmel Medical Center, Haifa, Israel.,Clalit Health Services, Haifa, Israel
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Stoekenbroek RM, Hartgers ML, Rutte R, de Wijer DD, Stroes ES, Hovingh GK. PCSK9 inhibitors in clinical practice: Delivering on the promise? Atherosclerosis 2018; 270:205-210. [DOI: 10.1016/j.atherosclerosis.2017.11.027] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 11/21/2017] [Accepted: 11/28/2017] [Indexed: 12/13/2022]
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