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d'Erasmo L, Steward K, Cefalù AB, Di Costanzo A, Boersma E, Bini S, Arca M, van Lennep JR. EFFICACY AND SAFETY OF LOMITAPIDE IN HOMOZYGOUS FAMILIAL HYPERCHOLESTEROLEMIA: THE PAN-EUROPEAN RETROSPECTIVE OBSERVATIONAL STUDY. Eur J Prev Cardiol 2021; 29:832-841. [PMID: 34971394 DOI: 10.1093/eurjpc/zwab229] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/18/2021] [Accepted: 12/27/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND Lomitapide is a lipid-lowering agent indicated as adjunct therapy for adult HoFH. OBJECTIVES This study evaluated the medium-term effectiveness and safety of lomitapide in a large cohort of HoFH patients in Europe. METHODS In a multicenter retrospective, observational study including 75 HoFH patients treated with lomitapide in a real-world clinical setting from 9 European countries, LDL-C changes, adverse events (AEs) as well as major adverse cardiovascular events (MACE) were assessed. RESULTS After a median 19 months (IQR 11-41 months) of treatment with a mean dosage of 20 mg of lomitapide. LDL-C decreased by 60%, from baseline 280.5 mg/dL (191.8-405.0 mg/dl) to 121.6 mg/dl (61.0-190.5 mg/dl). At the last visit, 32.0% of patients achieved LDL-C < 100mg/dL and 18.7% <70 mg/dL. At baseline, 38 HoFH patients were receiving LDL apheresis (LA), but after initiation of lomitapide 36.8% of patients discontinued LA. During follow-up, lomitapide was permanently interrupted in 13% of patients. Gastrointestinal (GI) AEs occurred in 40% and liver transaminases increased (3-5 x ULN) in 13% of patients. Among patients with liver ultrasound evaluation (n = 45), a modest increase in hepatic steatosis was noted during treatment; however liver stiffness measured by elastography in 30 of them remained within the normal range. Among HoFH patients exposed to lomitapide for at least 2 years, MACE incident rate was 7.4 per 1000 person-years in the 2 years after as compared to 21.2 per 1000 person-years before treatment with lomitapide. CONCLUSIONS In this medium-term real-world experience, lomitapide proved to be very effective in reducing LDL-C in HoFH. GI AEs were common, but liver safety was reassuring with no sign of increased risk of liver fibrosis. A signal of cardiovascular protection was also observed.
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Affiliation(s)
- Laura d'Erasmo
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Kim Steward
- Department of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam, the Netherlands
| | - Angelo Baldassare Cefalù
- Dipartimento di Promozione della Salute Materno Infantile, Medicina Interna e Specialistica Di Eccellenza "G. D'Alessandro" (PROMISE), Università degli Studi di Palermo, Palermo, Italy
| | - Alessia Di Costanzo
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Eric Boersma
- Department of Cardiology, Erasmus MC, University Medical Centre Rotterdam, the Netherland
| | - Simone Bini
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Marcello Arca
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
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Hindi NN, Alenbawi J, Nemer G. Pharmacogenomics Variability of Lipid-Lowering Therapies in Familial Hypercholesterolemia. J Pers Med 2021; 11:jpm11090877. [PMID: 34575654 PMCID: PMC8468752 DOI: 10.3390/jpm11090877] [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] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 08/27/2021] [Accepted: 08/29/2021] [Indexed: 01/10/2023] Open
Abstract
The exponential expansion of genomic data coupled with the lack of appropriate clinical categorization of the variants is posing a major challenge to conventional medications for many common and rare diseases. To narrow this gap and achieve the goals of personalized medicine, a collaborative effort should be made to characterize the genomic variants functionally and clinically with a massive global genomic sequencing of "healthy" subjects from several ethnicities. Familial-based clustered diseases with homogenous genetic backgrounds are amongst the most beneficial tools to help address this challenge. This review will discuss the diagnosis, management, and clinical monitoring of familial hypercholesterolemia patients from a wide angle to cover both the genetic mutations underlying the phenotype, and the pharmacogenomic traits unveiled by the conventional and novel therapeutic approaches. Achieving a drug-related interactive genomic map will potentially benefit populations at risk across the globe who suffer from dyslipidemia.
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Affiliation(s)
- Nagham N. Hindi
- Division of Genomics and Translational Biomedicine, College of Health and Life Sciences, Hamad Bin Khalifa University, Doha P.O. Box 34110, Qatar; (N.N.H.); (J.A.)
| | - Jamil Alenbawi
- Division of Genomics and Translational Biomedicine, College of Health and Life Sciences, Hamad Bin Khalifa University, Doha P.O. Box 34110, Qatar; (N.N.H.); (J.A.)
| | - Georges Nemer
- Division of Genomics and Translational Biomedicine, College of Health and Life Sciences, Hamad Bin Khalifa University, Doha P.O. Box 34110, Qatar; (N.N.H.); (J.A.)
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut DTS-434, Lebanon
- Correspondence: ; Tel.: +974-445-41330
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Sunil B, Foster C, Wilson DP, Ashraf AP. Novel therapeutic targets and agents for pediatric dyslipidemia. Ther Adv Endocrinol Metab 2021; 12:20420188211058323. [PMID: 34868544 PMCID: PMC8637781 DOI: 10.1177/20420188211058323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 10/19/2021] [Indexed: 02/04/2023] Open
Abstract
Landmark studies have convincingly demonstrated that atherosclerosis begins in youth. While generally asymptomatic, an increasing number of youth with disorders of lipid and lipoprotein metabolism, such as familial hypercholesterolemia, are being identified through selective and universal screening. While a heart healthy lifestyle is the foundation of treatment for all youth with dyslipidemia, lipid-lowering therapy may be required by some to prevent morbidity and premature mortality, especially when initiated at a young age. When appropriate, use of statins has become standard of care for reducing low-density lipoprotein cholesterol, while fibrates may be beneficial in helping to lower triglycerides. Many therapeutic options commonly used in adults are not yet approved for use in youth less than 18 years of age. Although currently available lipid-lowering therapy is well tolerated and safe when administered to youth, response to treatment may vary and some conditions lack an efficient therapeutic option. Thus, newer agents are needed to aid in management. Many are in development and clinical trials in youth are currently in progress but will require FDA approval before becoming commercially available. Many utilize novel approaches to favorably alter lipid and lipoprotein metabolism. In the absence of long-term outcome data of youth who were treated beginning at an early age, clinical registries may prove to be useful in monitoring safety and efficacy and help to inform clinical decision-making. In this manuscript, we review currently available and novel therapeutic agents in development for the treatment of elevated cholesterol and triglycerides.
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Affiliation(s)
- Bhuvana Sunil
- Division of Pediatric Endocrinology &
Diabetes, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Christy Foster
- Division of Pediatric Endocrinology &
Diabetes, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Don P. Wilson
- Cardiovascular Health and Risk Prevention,
Pediatric Endocrinology and Diabetes, Cook Children’s Medical Center, Fort
Worth, TX, USA
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Stefanutti C. Lomitapide-a Microsomal Triglyceride Transfer Protein Inhibitor for Homozygous Familial Hypercholesterolemia. Curr Atheroscler Rep 2020; 22:38. [PMID: 32557261 PMCID: PMC7303073 DOI: 10.1007/s11883-020-00858-4] [Citation(s) in RCA: 28] [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] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Homozygous familial hypercholesterolemia (HoFH) is a rare, genetic condition characterized by high levels of Low density lipoprotein cholesterol (LDL-C); overt, early-onset atherosclerotic cardiovascular disease (ASCVD); and premature cardiovascular events and mortality. Lomitapide is a first-in-class microsomal triglyceride transfer protein inhibitor for the treatment of HoFH. This review provides an update on data emerging from real-world studies of lomitapide following on from its pivotal phase 3 clinical trial in HoFH. RECENT FINDINGS Recent registry data have confirmed that HoFH is characterized by delayed diagnosis, with many patients not receiving effective therapy until they are approaching the age when major adverse cardiovascular events may occur. Data from case series of varying sizes, and from a 163-patient registry of HoFH patients receiving lomitapide, have demonstrated that lomitapide doses are lower and adverse events less severe than in the phase 3 study. Lomitapide enables many patients to reach European Atherosclerosis Society LDL-C targets. Some patients are able to reduce frequency of lipoprotein apheresis or, in some cases, stop the procedure altogether-unless there is significant elevation of lipoprotein (a). Modelling analyses based on historical and clinical trial data indicate that lomitapide has the potential to improve cardiovascular outcomes and survival in HoFH. Real-world clinical experience with lomitapide has shown the drug to be effective with manageable, less marked adverse events than in formal clinical studies. Event modelling data suggest a survival benefit with lomitapide in HoFH.
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Affiliation(s)
- Claudia Stefanutti
- Extracorporeal Therapeutic Techniques Unit, Lipid Clinic and Atherosclerosis Prevention Centre, Regional Centre (Lazio) for Rare Diseases, Immunohematology and Transfusion Medicine, Department of Molecular Medicine, "Sapienza" University of Rome, "Umberto I" Hospital, Rome, Italy.
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Alonso R, Cuevas A, Mata P. Lomitapide: a review of its clinical use, efficacy, and tolerability. CORE EVIDENCE 2019; 14:19-30. [PMID: 31308834 PMCID: PMC6615460 DOI: 10.2147/ce.s174169] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 05/08/2019] [Indexed: 12/17/2022]
Abstract
Lomitapide is an inhibitor of MTP, an enzyme located in the endoplasmic reticulum of hepatocytes and enterocytes. This enzyme is responsible for the synthesis of very low-density lipoproteins in the liver and chylomicrons in the intestine. Lomitapide has been approved by the US Food and Drug Administration, European Medicines Agency, and other regulatory agencies for the treatment of hypercholesterolemia in adult patients with homozygous familial hypercholesterolemia. Clinical trials have shown that lomitapide reduces low-density-lipoprotein cholesterol levels by around 40% in homozygous familial hypercholesterolemia patients on treatment with statins with or without low-density-lipoprotein apheresis, with an acceptable safety and tolerance profile. The most common adverse events are gastrointestinal symptoms that decrease in frequency with long-term treatment, and the increase in liver fat remains stable. This review analyzes the clinical use, efficacy, and tolerability of lomitapide.
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Affiliation(s)
- Rodrigo Alonso
- Department of Nutrition, Clínica Las Condes, Santiago, Chile.,Familial Hypercholesterolemia Foundation, Madrid, Spain
| | - Ada Cuevas
- Department of Nutrition, Clínica Las Condes, Santiago, Chile
| | - Pedro Mata
- Familial Hypercholesterolemia Foundation, Madrid, Spain
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Ben-Omran T, Masana L, Kolovou G, Ariceta G, Nóvoa FJ, Lund AM, Bogsrud MP, Araujo M, Hussein O, Ibarretxe D, Sanchez-Hernández RM, Santos RD. Real-World Outcomes with Lomitapide Use in Paediatric Patients with Homozygous Familial Hypercholesterolaemia. Adv Ther 2019; 36:1786-1811. [PMID: 31102204 PMCID: PMC6824397 DOI: 10.1007/s12325-019-00985-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Homozygous familial hypercholesterolaemia (HoFH) is a rare, autosomal disease affecting the clearance of low-density lipoprotein cholesterol (LDL-C) from circulation, and leading to early-onset atherosclerotic cardiovascular disease (ASCVD). Treatment consists mainly of statins, lipoprotein apheresis (LA) and, more recently, the microsomal triglyceride transfer protein inhibitor lomitapide. Lomitapide is not licensed for use in children, but has been made available through an expanded access programme or on a named patient basis. METHODS This case series includes 11 HoFH patients in 10 different centres in eight countries, less than 18 years of age (mean 11.6 ± 1.1 years, 64% male), with signs of ASCVD, and who have received treatment with lomitapide (mean dose 24.5 ± 4.3 mg/day; mean exposure 20.0 ± 2.9 months). Background lipid-lowering therapy was given according to local protocols. Lomitapide was commenced with a stepwise dose escalation from 2.5 mg or 5 mg/day; dietary advice and vitamin supplements were provided as per the product label for adults. Laboratory analysis was conducted as part of regular clinical care. RESULTS In the 11 cases, mean baseline LDL-C was 419 ± 74.6 mg/dL and was markedly reduced by lomitapide to a nadir of 176.7 ± 46.3 mg/dL (58.4 ± 6.8% decrease). Six patients achieved recommended target levels for children below 135 mg/dL, five of whom had LA frequency reduced. In one case, LDL-C levels were close to target when lomitapide was started but remained stable despite 75% reduction in LA frequency (from twice weekly to biweekly). Adverse events were mainly gastrointestinal in nature, occurred early in the treatment course and were well managed. Three patients with excursions in liver function tests were managed chiefly without intervention; two patients had decreases in lomitapide dose. CONCLUSIONS Lomitapide demonstrated promising effectiveness in paediatric HoFH patients. Adverse events were manageable, and the clinical profile of the drug is apparently similar to that in adult patients. FUNDING Amryt Pharma.
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Affiliation(s)
- Tawfeg Ben-Omran
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, Hamad Medical Corporation and Sidra Medicine, Doha, Qatar
| | - Luis Masana
- Vascular Medicine and Metabolism Unit, Universitat Rovira i Virgili, IISPV, CIBERDEM, Reus, Spain
| | | | - Gema Ariceta
- Pediatric Kidney Diseases, University Hospital Vall d' Hebron, Barcelona, Spain
| | - F Javier Nóvoa
- Endocrinology Department, University Hospital Insular de Gran Canaria, University Institute of Biomedical and Health Research of the University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Allan M Lund
- Center for Inherited Metabolic Diseases, Departments of Paediatrics and Clinical Genetics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Martin P Bogsrud
- National Advisory Unit for Familial Hypercholesterolemia, Oslo University Hospital, Oslo, Norway
| | - María Araujo
- Nutrition Service, Hospital Nacional de Pediatría 'Dr Juan P. Garrahan', Buenos Aires, Argentina
| | - Osamah Hussein
- Internal Medicine Department 'A, Ziv Medical Centre, Azreili Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Daiana Ibarretxe
- Vascular Medicine and Metabolism Unit, Universitat Rovira i Virgili, IISPV, CIBERDEM, Reus, Spain
| | - Rosa M Sanchez-Hernández
- Endocrinology Department, University Hospital Insular de Gran Canaria, University Institute of Biomedical and Health Research of the University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Raul D Santos
- Lipid Clinic, Heart Institute (InCor), University of Sao Paulo and Hospital Israelita Albert Einstein, São Paulo, Brazil.
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