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Habib N, Yuan C, Lightle A, Monrroy M, Mehta S. A rare case of alirocumab (PCSK9 inhibitor)-associated acute interstitial nephritis. Clin Nephrol Case Stud 2024; 12:48-51. [PMID: 39290799 PMCID: PMC11407299 DOI: 10.5414/cncs111443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 07/11/2024] [Indexed: 09/19/2024] Open
Abstract
Acute interstitial nephritis (AIN) is a common cause of hospital-acquired acute kidney injury (AKI) [1]. The most common cause of AIN is drug-induced AIN, which accounts for 60 - 70% of cases [2]. Alirocumab, a proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9 inhibitor) is a monoclonal antibody that lowers low-density lipoprotein-C levels by inhibiting the PCSK9 protein [3]. Common adverse events reported with alirocumab include injection-site reactions, myalgia, neurocognitive disorders, and ophthalmologic disorders [4]. There is paucity of data, with few reported cases of AKI, mostly in the form of acute tubular necrosis (ATN) associated with alirocumab [5]. In this article, we present a novel case of AIN associated with the use of alirocumab.
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Affiliation(s)
- Nazia Habib
- Department of Medicine, Division of Nephrology, Albany Medical Center
| | | | - Andrea Lightle
- Department of Pathology, Albany Medical Center, Albany, NY, USA
| | - Mauricio Monrroy
- Department of Medicine, Division of Nephrology, Albany Medical Center
| | - Swati Mehta
- Department of Medicine, Division of Nephrology, Albany Medical Center
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2
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Zhao W, Cheng Z, Ji X, Pei Z, Yang K, Huang Z, Wu Y, Wang G, Wang M, Zhao Y, Bai X, Zhao S. Efficacy and safety of ongericimab given by prefilled syringe or autoinjector in primary hypercholesterolemia and mixed hyperlipidemia. Nutr Metab Cardiovasc Dis 2024; 34:2217-2225. [PMID: 38866609 DOI: 10.1016/j.numecd.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 04/15/2024] [Accepted: 04/19/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND AND AIMS Limited evidence exist regarding the association between ongericimab, a novel recombinant humanized anti-PCSK9 monoclonal antibody, and primary hypercholesterolemia and mixed dyslipidemia. This study aimed to evaluate the efficacy and safety of ongericimab administered by prefilled syringe (PFS) or autoinjector (AI) in Chinese patients with primary hypercholesterolemia and mixed dyslipidemia on stable optimized lipid-lowering therapy. METHODS AND RESULTS A total of 255 patients on stable optimized lipid-lowering therapy were randomized in a 2:1:2:1 ratio to receive PFS for the subcutaneous injection of ongericimab 150 mg every 2 weeks (Q2W) or a matching placebo, or AI for the subcutaneous injection of ongericimab 150 mg Q2W or a matching placebo. The primary efficacy endpoint was the percent change in low-density lipoprotein cholesterol (LDL-C) levels from baseline to week 12. Safety was also evaluated. At week 12, the least squares mean percent changes were -72.7% (3.9%) for PFS and -71.1% (3.8%) for AI (all P < 0.001) compared to respective matching placebo groups. Beneficial effects were also seen for all secondary lipid parameters, notably with robust reduction in Lp (a). Treatment-emergent adverse events (TEAEs) and serious AEs with ongericimab were reported in 46.2% and 2.4% of patients, compared to 44.2% and 3.5% with placebo. CONCLUSION In Chinese patients with primary hypercholesterolemia and mixed dyslipidemia, a 12-week treatment regimen with ongericimab administered by PFS or AI significantly reduced LDL-C and other lipid parameters, proving to be safe and well tolerated. Patients experienced consistent effects from PFS or AI devices. CLINICAL TRIAL REGISTRATION CTR20220027; January 11, 2022; http://www.chinadrugtrials.org.cn/index.html.
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Affiliation(s)
- Wang Zhao
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, PR China
| | - Zhifeng Cheng
- Department of Endocrinology and Metabolism, The Fourth Hospital of Harbin Medical University, Harbin, Heilongjiang, PR China
| | - Xianyou Ji
- Department of Cardiology, Daqing People's Hospital, Daqing, Heilongjiang, PR China
| | - Zhaohui Pei
- Department of Cardiology, Third Hospital of Nanchang, Nanchang, Jiangxi, PR China
| | - Keping Yang
- Department of Cardiology, Jingzhou Central Hospital, Jingzhou, Hubei, PR China
| | - Zhouqing Huang
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Yanqing Wu
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China
| | - Gaopin Wang
- Department of Cardiology, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, Liaoning, PR China
| | - Minghui Wang
- Shanghai Junshi Biosciences Co., Ltd., Shanghai, PR China
| | - Yi Zhao
- Shanghai Junshi Biosciences Co., Ltd., Shanghai, PR China
| | - Xuelian Bai
- Shanghai Junshi Biosciences Co., Ltd., Shanghai, PR China
| | - Shuiping Zhao
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, PR China.
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Li W, Sun L, Yan S. PCSK9 inhibitors and inclisiran with or without statin therapy on incident muscle symptoms and creatine kinase: a systematic review and network meta-analysis. Front Cardiovasc Med 2024; 11:1375040. [PMID: 39040999 PMCID: PMC11260805 DOI: 10.3389/fcvm.2024.1375040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 06/24/2024] [Indexed: 07/24/2024] Open
Abstract
Background Atherosclerotic cardiovascular disease (ASCVD), a leading cause of global fatalities, has inconsistent findings regarding the impact of muscle symptoms despite promising clinical trials involving PCSK9 inhibitors (PCSK9i) and siRNA as potential therapeutic options. Methods The databases EMBASE, PubMed, Web of Science, Cochrane, and ClinicalTrials.gov were thoroughly searched without any restrictions on language. Review Manager 5.3 software was utilized to calculate relative risks with 95% confidence intervals (CIs) for dichotomous data and mean differences or standardized mean differences with 95%CIs for continuous data. To evaluate publication bias, Egger's test was employed using Stata/SE software. Results This analysis included 26 studies comprising 28 randomized controlled trials (RCTs) involving a total of 100,193 patients, and 4 different lipid-lowering therapy combinations. For events with creatine kinase >3ULN, evolocumab and alirocumab demonstrated significant advantages compared to inclisiran. Evolocumab showed the best results in terms of both new muscle symptom events and creatine kinase >3ULN. Conclusions Based on this network meta-analysis (NMA) results, evolocumab has emerged as a promising treatment option for patients with hyperlipidemia and muscle disorders compared to other PCSK9 inhibitors and inclisiran. Systematic Review Registration PROSPERO [CRD42023459558].
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Affiliation(s)
- Wenshu Li
- Department of Pharmacy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Lichaoyue Sun
- Department of Pharmacy, Aerospace Central Hospital, Beijing, China
| | - Sichao Yan
- Department of Pharmacy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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Woods RH. Postmarketing Reports of Incomplete Dosing-Related Complications with Self-Injected PCSK9 Inhibitors: A Descriptive Study and Disproportionality Analysis. BioDrugs 2024; 38:589-600. [PMID: 38874875 DOI: 10.1007/s40259-024-00664-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Evolocumab and alirocumab are self-injected proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors indicated for low-density lipoprotein cholesterol reduction. Complications in the use or functionality of self-injection devices may precipitate incomplete dosing. OBJECTIVE This study sought to characterize postmarketing dosing failure reports involving self-injected PCSK9 inhibitors. METHODS US Food and Drug Administration Adverse Event Reporting System (FAERS) [2016-second quarter of 2023] data were utilized for a disproportionality analysis. Eight self-injected comparator medications served as referents. Medical Dictionary for Regulatory Activities preferred terms indicating explicit or probable failure to administer a complete dose classified cases. Proportional reporting ratios (PRRs) > 2.0 and lower 95% confidence intervals (CIs) > 1.0 indicated disproportionality signals. US FDA Manufacturer and User Facility Device Experience (MAUDE) [2013-2023] data underwent a narrative review. RESULTS During the study period, 194,781 (evolocumab, n = 152,831; alirocumab, n = 41,950) drug-event pairs and 43,725 (evolocumab, n = 38,489; alirocumab, n = 5236) cases reported to FAERS identified PCSK9 inhibitors. MAUDE contained six evolocumab reports, half describing dose omission, and no alirocumab reports. A potential dosing failure signal was detected for evolocumab (PRR 2.01; 95% CI 1.98-2.03), but not alirocumab (PRR 0.99; 95% CI 0.97-1.02), relative to pooled comparator reports. Across three case term subcategories, incomplete dosing disproportionality signals were further identified for evolocumab patient usage complication terms (PRR 3.44; 95% CI 3.38-3.50) and alirocumab device malfunction terms (PRR 2.09; 95% CI 1.98-2.22). CONCLUSIONS Proprotein convertase subtilisin kexin type 9 inhibitor incomplete dosing-related complications are frequently reported in the postmarketing setting. Systematic efforts to understand the incidence and mechanisms of dosing failure and associated patient burdens are needed.
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Affiliation(s)
- Richard H Woods
- Levin, Papantonio, Rafferty, Proctor, Buchanan, O'Brien, Barr and Mougey, P.A., 316 South Baylen Street, Pensacola, FL, 32502, USA.
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van Bruggen FH, Zuidema SU, Luijendijk HJ. Quantitative assessment of baseline imbalances in evolocumab and alirocumab trials: a meta-epidemiological study. BMC Med Res Methodol 2024; 24:137. [PMID: 38909176 PMCID: PMC11193208 DOI: 10.1186/s12874-024-02260-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 06/07/2024] [Indexed: 06/24/2024] Open
Abstract
BACKGROUND Baseline imbalances have been identified in randomized trials of evolocumab and alirocumab. Our aim was to quantitatively assess (1) the presence of systematic baseline differences, and (2) the relationship of baseline differences with effects on low-density lipoprotein-cholesterol (LDL-c) and clinical outcomes in the trials. METHODS We performed a meta-epidemiological study. PubMed, Embase, regulatory reports, ClinicalTrials.gov and company websites were searched for trials. Seven baseline characteristics (mean age, LDL-c, BMI, percentage males, diabetics, smokers, and hypertensives) and five outcomes (LDL-c, major adverse cardiac events, serious adverse events, any adverse events, all-cause mortality) were extracted. We calculated (1) range and distribution of baseline imbalances (sign-test), (2) pooled baseline differences and heterogeneity (meta-analysis), (3) differences in SDs around continuous variables (sign-test and pooling), and (4) the relationship of baseline differences with outcomes (meta-regression). The comparisons of PCSK9-inhibitor groups with either placebo or ezetimibe were analysed separately and combined. RESULTS We identified 43 trials with 63,193 participants. Baseline characteristics were frequently missing. Many trials showed small baseline imbalances, but some large imbalances. Only baseline BMI showed a statistically significant lower pooled mean for the drug versus placebo groups (MD -0.16; 95% CI -0.24 to -0.09). Heterogeneity in baseline imbalances was present in six placebo- and five ezetimibe-comparisons. Heterogeneity was statistically significant for BMI, males, diabetics and hypertensives in the combined comparisons. There was a statistically significant preponderance for larger SDs in the PCSK9-inhibitor versus control groups (sign-test age 0.014; LDL-c 0.014; BMI 0.049). Meta-regression showed clinically relevant relationships of baseline imbalances in age, BMI and diabetics with the risk of any adverse events and the risk of mortality. Two relationships were statistically significant: A higher mean BMI in the drug versus control group with a decreased risk of mortality (beta - 0.56; 95% CI -1.10 to -0.02), and a higher proportion of diabetics with an increased risk of any adverse events (beta 0.02; 95% 0.01 to 0.04). CONCLUSIONS Heterogeneous baseline imbalances and systematically different SDs were present in evolocumab and alirocumab trials, so study groups cannot be assumed to be comparable. These findings raise concerns about the design and conduct of the randomization procedures.
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Affiliation(s)
- F H van Bruggen
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen (UMCG), PO Box 196, Groningen, AD, 9700, The Netherlands
| | - S U Zuidema
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen (UMCG), PO Box 196, Groningen, AD, 9700, The Netherlands
| | - H J Luijendijk
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen (UMCG), PO Box 196, Groningen, AD, 9700, The Netherlands.
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Rivera FB, Cha SW, Aparece JP, Rocimo A, Ong BA, Golbin JM, Alfonso PG, Enkhmaa B, Khan SU, Cainzos-Achirica M, Volgman AS, Navar AM, Shah NP. Sex Differences in Cardiovascular Outcomes and Cholesterol-Lowering Efficacy of PCSK9 Inhibitors: Systematic Review and Meta-Analysis. JACC. ADVANCES 2023; 2:100669. [PMID: 38938736 PMCID: PMC11198239 DOI: 10.1016/j.jacadv.2023.100669] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 07/31/2023] [Accepted: 08/26/2023] [Indexed: 06/29/2024]
Abstract
Background Guideline-recommended low-density lipoprotein cholesterol (LDL-C) thresholds are often not achieved in women. The proprotein convertase subtilisin/kexin type-9 inhibitor (PCSK9i) monoclonal antibodies can help further reduce LDL-C and major adverse cardiovascular events (MACE) although differences in efficacy by sex and type are less understood. Objectives The authors sought to determine if there are differences in the efficacy of LDL-C lowering and reduction in the risk of MACE by sex and type of PCSK9i. Methods A comprehensive literature search was done through October 17, 2022, for published trials comparing PCSK9i vs control. Outcomes assessed were LDL-C reduction and incidence of MACE following the use of PCSK9i vs placebo, stratified by sex and type of PCSK9i used. Results We identified 16 trials with 54,996 adults, and 15,143 (27.5%) of them were female. PCSK9i significantly reduced MACE compared to placebo in both women (HR: 0.86, 95% CI: 0.74-0.97, P < 0.001) and men (HR: 0.85, 95% CI: 0.79-0.91, P < 0.001) with no significant sex difference (MD -0.01, 95% CI: -0.14 to -0.13, P = 0.930). PCSK9i also significantly reduced LDL-C levels in both sexes at 12 weeks (females: MD -62.57, 95% CI: -70.24 to -54.91, P < 0.001; males: MD -66.19, 95% CI: -72.03 to -60.34, P < 0.001) and 24 weeks (females: MD -47.52, 95% CI: -52.94 to -42.09, P < 0.001; males: MD -54.07, 95% CI: -59.46 to -48.68, P < 0.001). Significant sex difference was seen in the LDL reduction of PCSK9i for both 12 weeks (males vs females: MD -4.55, 95% CI: -7.34 to -1.75, P < 0.01) and 24 weeks (males vs females: MD -7.11, 95% CI: -9.99 to -4.23, P < 0.001). Conclusions The use of PCSK9i results in significant LDL-C and MACE reduction in both males and females. While there is no significant sex difference in MACE reduction, LDL-C reduction is greater in males than in females. Our data support the equal use of PCSK9i in all eligible patients, regardless of sex.
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Affiliation(s)
| | - Sung Whoy Cha
- Department of Medicine, Cebu Institute of Medicine, Cebu City, Cebu, Philippines
| | - John Paul Aparece
- Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Aubrey Rocimo
- Department of Medicine, University of the Philippines System, Manila, National Capital Region, Philippines
| | - Bradley Ashley Ong
- Department of Medicine, University of the Philippines System, Manila, National Capital Region, Philippines
| | - Jem Marie Golbin
- Department of Medicine, University of the Philippines System, Manila, National Capital Region, Philippines
| | - Pia Gabrielle Alfonso
- Department of Medicine, University of the Philippines System, Manila, National Capital Region, Philippines
| | - Byambaa Enkhmaa
- Section of Endocrinology, Diabetes & Metabolism, UC Davis Health Systems, Davis, California, USA
| | - Safi U. Khan
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Miguel Cainzos-Achirica
- Cardiólogo y epidemiólogo cardiovascular, Hospital del Mar/Parc de Recerca Biomèdica de Barcelona, Barcelona, Spain
| | | | - Ann Marie Navar
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nishant P. Shah
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
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7
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Bodapati AP, Hanif A, Okafor DK, Katyal G, Kaur G, Ashraf H, Khan S. PCSK-9 Inhibitors and Cardiovascular Outcomes: A Systematic Review With Meta-Analysis. Cureus 2023; 15:e46605. [PMID: 37937036 PMCID: PMC10626223 DOI: 10.7759/cureus.46605] [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: 09/01/2023] [Accepted: 10/05/2023] [Indexed: 11/09/2023] Open
Abstract
Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been approved to treat dyslipidaemia. However, there is a lack of knowledge on the most efficient PCSK9 therapies that target PCSK9 for secondary prevention in subjects at high risk for cardiovascular (CV) events. Thus, this study aimed to assess the efficacy and safety of anti-PCSK9 antibodies in randomized controlled trials (RCTs). A comprehensive review of the available literature was done to identify RCTs that compared the use of PCSK9 inhibitors coupled with placebo or ezetimibe for the secondary prevention of CV events in patients on statin-background therapy. All-cause mortality was the major efficacy endpoint, while severe adverse events were the key safety outcome. A random effects model was used, and data were presented as risk ratio (RR) or risk difference with their corresponding 95% confidence intervals (CI). The heterogeneity of the publications was determined using Cochran's Q test, and publication bias was visually examined using funnel plots. All the chosen studies' quality was assessed using the Critical Appraisal Checklists for Studies created by the Joanna Briggs Institute (JBI). Forty-one studies (76,304 patients: 49,086 on evolocumab, and 27,218 on alirocumab) were included, and their years of publication spanned from 2010 to 2023. Overall, no significant differences were observed in CV and all-cause mortality between PCSK9 inhibitors and controls. However, alirocumab use was linked to a reduced risk of all-cause death compared to control, but not evolocumab. Each of the drugs, evolocumab and alirocumab, significantly reduced the risk of myocardial infarction (MI), coronary revascularization, and ischemic stroke. In comparison to the control therapy, the risk of major detrimental sequelae was significantly reduced by alirocumab therapy in the subgroup analysis of each PCSK9 inhibitor, whereas evolocumab treatment did not demonstrate significant differences (RR = 0.88; 95% CI = 0.72-1.04; evolocumab: RR = 0.99; 95% CI = 0.87-1.11). Both evolocumab and alirocumab are well-tolerated, safe medications that significantly lower low-density lipoprotein (LDL) levels.
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Affiliation(s)
- Adi Prasad Bodapati
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ayesha Hanif
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Donatus K Okafor
- Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Gitika Katyal
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Gursharan Kaur
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Hafsa Ashraf
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Yu Z, Hu L, Sun C, Wang Z, Zhang X, Wu M, Liu L. Effect of Different Types and Dosages of Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors on Lipoprotein(a) Levels: A Network Meta-analysis. J Cardiovasc Pharmacol 2023; 81:445-453. [PMID: 36972559 DOI: 10.1097/fjc.0000000000001419] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 02/19/2023] [Indexed: 03/29/2023]
Abstract
ABSTRACT Lipoprotein(a) [Lp(a)] has become an important component of the residual risk of cardiovascular diseases. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors display promising effects in controlling Lp(a) levels. However, the effects of different types and dosages of PCSK9 inhibitors on Lp(a) have not been studied in detail. These include 2 monoclonal antibodies, alirocumab and evolocumab, and inclisiran, a small interfering RNA. We searched PubMed, Web of Science, Embase, and Cochrane Library for randomized controlled trials to investigate the efficacy of PCSK9 inhibitors at the Lp(a) level. Although changes in Lp(a) levels were not the primary endpoint in any of these studies, they all described these valuable data. Forty-one randomized controlled trials with 17,601 participants were included, involving 23 unduplicated interventions. Most PCSK9 inhibitors significantly reduced Lp(a) levels compared with placebo. The pairwise comparison demonstrated no significant difference among most PCSK9 inhibitors. However, in the comparison among different dosages of alirocumab, the dosage of 150 mg Q2W showed a significant reduction in Lp(a) levels compared with the dosages of 150, 200, and 300 mg Q4W. In addition, the comparison results demonstrated the significant efficacy of evolocumab 140 mg Q2W compared with alirocumab at a dosage of 150 mg Q4W. The cumulative rank probabilities demonstrated that evolocumab 140 mg Q2W showed the highest efficacy. This study showed that PCSK9 inhibitors reduced Lp(a) levels by up to 25.1%. A biweekly dose of either 140 mg evolocumab or 150 mg alirocumab was the best treatment option. However, the reduction in Lp(a) levels with a single kind of PCSK9 inhibitor alone did not demonstrate sufficient clinical benefit. Therefore, for patients with very high Lp(a) levels who remain at high residual risk in the context of statin administration, it may be acceptable to use a kind of PCSK9 inhibitor, but the clinical benefit needs further investigation.
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Affiliation(s)
- Zongliang Yu
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Lanqing Hu
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Changxin Sun
- Graduate School of Beijing University of Chinese Medicine, Beijing, China; and
| | - Zeping Wang
- Graduate School of Beijing University of Chinese Medicine, Beijing, China; and
| | - Xiaonan Zhang
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Min Wu
- Guang'an Men Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Longtao Liu
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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Bellino M, Galasso G, Silverio A, Tedeschi M, Formisano C, Romei S, Esposito L, Cancro FP, Vassallo MG, Accarino G, Verdoia M, Di Muro FM, Vecchione C, De Luca G. Soluble PCSK9 Inhibition: Indications, Clinical Impact, New Molecular Insights and Practical Approach-Where Do We Stand? J Clin Med 2023; 12:jcm12082922. [PMID: 37109259 PMCID: PMC10146045 DOI: 10.3390/jcm12082922] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
Current research on cardiovascular prevention predominantly focuses on risk-stratification and management of patients with coronary artery disease (CAD) to optimize their prognosis. Several basic, translational and clinical research efforts aim to determine the etiological mechanisms underlying CAD pathogenesis and to identify lifestyle-dependent metabolic risk factors or genetic and epigenetic parameters responsible for CAD occurrence and/or progression. A log-linear association between the absolute exposure of LDL cholesterol (LDL-C) and the risk of atherosclerotic cardio-vascular disease (ASCVD) was well documented over the year. LDL-C was identified as the principal enemy to fight against, and soluble proprotein convertase subtilisin kexin type 9 (PCSK9) was attributed the role of a powerful regulator of blood LDL-C levels. The two currently available antibodies (alirocumab and evolocumab) against PCSK9 are fully human engineered IgG that bind to soluble PCSK9 and avoid its interaction with the LDLR. As documented by modern and dedicated "game-changer" trials, antibodies against soluble PCSK9 reduce LDL-C levels by at least 60 percent when used alone and up to 85 percent when used in combination with high-intensity statins and/or other hypolipidemic therapies, including ezetimibe. Their clinical indications are well established, but new areas of use are advocated. Several clues suggest that regulation of PCSK9 represents a cornerstone of cardiovascular prevention, partly because of some pleiotropic effects attributed to these newly developed drugs. New mechanisms of PCSK9 regulation are being explored, and further efforts need to be put in place to reach patients with these new therapies. The aim of this manuscript is to perform a narrative review of the literature on soluble PCSK9 inhibitor drugs, with a focus on their indications and clinical impact.
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Affiliation(s)
- Michele Bellino
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy
| | - Gennaro Galasso
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy
| | - Angelo Silverio
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy
| | - Michele Tedeschi
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy
| | - Ciro Formisano
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy
| | - Stefano Romei
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy
| | - Luca Esposito
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy
| | - Francesco Paolo Cancro
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy
| | - Maria Giovanna Vassallo
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy
| | - Giulio Accarino
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy
| | - Monica Verdoia
- Division of Cardiology, Ospedale Degli Infermi, ASL Biella, 13900 Biella, Italy
| | - Francesca Maria Di Muro
- Structural Interventional Cardiology, Department of Clinical and Experimental Medicine, Clinica Medica, Careggi University Hospital, 50139 Florence, Italy
| | - Carmine Vecchione
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy
- Vascular Physiopathology Unit, IRCCS Neuromed Mediterranean Neurological Institute, 86077 Pozzilli, Italy
| | - Giuseppe De Luca
- Division of Cardiology, AOU "Policlinico G. Martino", Department of Clinical and Experimental Medicine, University of Messina, 98166 Messina, Italy
- Division of Cardiology, IRCCS Hospital Galeazzi-Sant'Ambrogio, 20161 Milan, Italy
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Romandini A, Baldassarre D, Genovese S, Capri S, Pompilio G, Scatigna M, Werba JP. Atherogenic Dyslipidemias: Unmet Needs and the Therapeutic Potential of Emerging and Novel Approaches and Drugs. Pharmaceuticals (Basel) 2023; 16:176. [PMID: 37259324 PMCID: PMC9963828 DOI: 10.3390/ph16020176] [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: 12/06/2022] [Revised: 01/16/2023] [Accepted: 01/19/2023] [Indexed: 09/14/2024] Open
Abstract
Innovative lipid-modifying agents are valuable resources to improve the control of atherogenic dyslipidemias and reduce the lipid-related residual cardiovascular risk of patients with intolerance or who are not fully responsive to a consolidated standard of care (statins plus ezetimibe). Moreover, some of the upcoming compounds potently affect lipid targets that are thus far considered "unmodifiable". The present paper is a viewpoint aimed at presenting the incremental metabolic and cardiovascular benefits of the emerging lipid-modulating agents and real-life barriers, hindering their prescription by physicians and their assumption by patients, which need to be worked out for a more diffuse and appropriate drug utilization.
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Affiliation(s)
| | - Damiano Baldassarre
- Centro Cardiologico Monzino, IRCCS, 20138 Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20133 Milan, Italy
| | | | - Stefano Capri
- School of Economics and Management, Cattaneo-LIUC University, 21053 Castellanza, Varese, Italy
| | - Giulio Pompilio
- Centro Cardiologico Monzino, IRCCS, 20138 Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20122 Milan, Italy
| | - Marco Scatigna
- Centro Cardiologico Monzino, IRCCS, 20138 Milan, Italy
- Post-Graduate School of Clinical Pharmacology and Toxicology, University of Milan, 20133 Milan, Italy
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11
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Choi HD, Kim JH. An Updated Meta-Analysis for Safety Evaluation of Alirocumab and Evolocumab as PCSK9 Inhibitors. Cardiovasc Ther 2023; 2023:7362551. [PMID: 36704607 PMCID: PMC9834631 DOI: 10.1155/2023/7362551] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/10/2022] [Accepted: 12/17/2022] [Indexed: 01/06/2023] Open
Abstract
Background Alirocumab and evolocumab, as protein convertase subtilisin kexin type 9 (PCSK9) inhibitors, have been reported to reduce cardiovascular risk. This meta-analysis is aimed at updating the safety data of PCSK9 inhibitors. Methods We assessed the relative risk for all treatment-related adverse events, serious adverse events, diabetes-related adverse events, and neurocognitive and neurologic adverse events with PCSK9 inhibitors compared to controls (placebo or ezetimibe). In addition, we conducted a meta-analysis to quantitatively integrate and estimate the adverse event rates in long-term studies. Results There were no significant differences between PCSK9 inhibitors and controls in the relative risk analysis. In a subgroup analysis of each PCSK9 inhibitor, alirocumab treatment significantly reduced the risk of serious adverse events compared to control treatment (risk ratio (RR) = 0.937; 95% confidence interval (CI), 0.896-0.980), but no significant difference was observed with evolocumab treatment (RR = 1.003; 95% CI, 0.963-1.054). Moreover, alirocumab treatment afforded a significant reduction in the risk of diabetes-related adverse events compared to control treatment (RR = 0.9137; 95% CI, 0.845-0.987). The overall incidence (event rate) of long-term adverse events was 75.1% (95% CI, 71.2%-78.7%), and the incidence of serious long-term event rate was 16.2% (95% CI, 11.6%-22.3%). Conclusions We suggest that alirocumab and evolocumab are generally safe and well tolerated and that their addition to background lipid-lowering therapy is not associated with an increased risk of adverse events or toxicity.
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Affiliation(s)
- Hye Duck Choi
- College of Pharmacy, Yeungnam University, Gyeongbuk, Republic of Korea
| | - Ji Hae Kim
- College of Pharmacy, Yeungnam University, Gyeongbuk, Republic of Korea
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12
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Goksøyr L, Skrzypczak M, Sampson M, Nielsen MA, Salanti A, Theander TG, Remaley AT, De Jongh WA, Sander AF. A cVLP-Based Vaccine Displaying Full-Length PCSK9 Elicits a Higher Reduction in Plasma PCSK9 Than Similar Peptide-Based cVLP Vaccines. Vaccines (Basel) 2022; 11:vaccines11010002. [PMID: 36679847 PMCID: PMC9864010 DOI: 10.3390/vaccines11010002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/09/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Administration of PCSK9-specific monoclonal antibodies, as well as peptide-based PCSK9 vaccines, can lower plasma LDL cholesterol by blocking PCSK9. However, these treatments also cause an increase in plasma PCSK9 levels, presumably due to the formation of immune complexes. Here, we utilize a versatile capsid virus-like particle (cVLP)-based vaccine platform to deliver both full-length (FL) PCSK9 and PCSK9-derived peptide antigens, to investigate whether induction of a broader polyclonal anti-PCSK9 antibody response would mediate more efficient clearance of plasma PCSK9. This head-to-head immunization study reveals a significantly increased capacity of the FL PCSK9 cVLP vaccine to opsonize and clear plasma PCSK9. These findings may have implications for the design of PCSK9 and other vaccines that should effectively mediate opsonization and immune clearance of target antigens.
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Affiliation(s)
- Louise Goksøyr
- Centre for Medical Parasitology at Department for Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- AdaptVac Aps, 2200 Copenhagen, Denmark
| | | | - Maureen Sampson
- Lipoprotein Metabolism Section, Translational Vascular Medicine Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Morten A. Nielsen
- Centre for Medical Parasitology at Department for Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Ali Salanti
- Centre for Medical Parasitology at Department for Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Thor G. Theander
- Centre for Medical Parasitology at Department for Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Alan T. Remaley
- Lipoprotein Metabolism Section, Translational Vascular Medicine Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | | | - Adam F. Sander
- Centre for Medical Parasitology at Department for Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- AdaptVac Aps, 2200 Copenhagen, Denmark
- Correspondence:
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13
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Toth PP, Bray S, Villa G, Palagashvili T, Sattar N, Stroes ESG, Worth GM. Network Meta-Analysis of Randomized Trials Evaluating the Comparative Efficacy of Lipid-Lowering Therapies Added to Maximally Tolerated Statins for the Reduction of Low-Density Lipoprotein Cholesterol. J Am Heart Assoc 2022; 11:e025551. [PMID: 36073669 PMCID: PMC9683660 DOI: 10.1161/jaha.122.025551] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/31/2022] [Indexed: 11/16/2022]
Abstract
Background Lowering low-density lipoprotein cholesterol (LDL-C) levels decreases major cardiovascular events and is recommended for patients at elevated cardiovascular risk. However, appropriate doses of statin therapy are often insufficient to reduce LDL-C in accordance with current guidelines. In such cases, treatment could be supplemented with nonstatin lipid-lowering therapy. Methods and Results A systematic literature review and network meta-analysis were conducted on randomized controlled trials of nonstatin lipid-lowering therapy added to maximally tolerated statins, including statin-intolerant patients. The primary objective was to assess relative efficacy of nonstatin lipid-lowering therapy in reducing LDL-C levels at week 12. Secondary objectives included the following: LDL-C level reduction at week 24 and change in non-high-density lipoprotein cholesterol and apolipoprotein B at week 12. There were 48 randomized controlled trials included in the primary network meta-analysis. All nonstatin agents significantly reduced LDL-C from baseline versus placebo, regardless of background therapy. At week 12, evolocumab, 140 mg every 2 weeks (Q2W)/420 mg once a month, and alirocumab, 150 mg Q2W, were the most efficacious regimens, followed by alirocumab, 75 mg Q2W, alirocumab, 300 mg once a month, inclisiran, bempedoic acid/ezetimibe fixed-dose combination, and ezetimibe and bempedoic acid used as monotherapies. Primary end point results were generally consistent at week 24, and for other lipid end points at week 12. Conclusions Evolocumab, 140 mg Q2W/420 mg once a month, and alirocumab, 150 mg Q2W, were consistently the most efficacious nonstatin regimens when added to maximally tolerated statins to lower LDL-C, non-high-density lipoprotein cholesterol, and apolipoprotein B levels and facilitate attainment of guideline-recommended risk-stratified lipoprotein levels.
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Affiliation(s)
- Peter P. Toth
- Cicarrone Center for the Prevention of Cardiovascular DiseaseJohns Hopkins University School of MedicineBaltimoreMD
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14
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Jia X, Al Rifai M, Saeed A, Ballantyne CM, Virani SS. PCSK9 Inhibitors in the Management of Cardiovascular Risk: A Practical Guidance. Vasc Health Risk Manag 2022; 18:555-566. [PMID: 35898405 PMCID: PMC9309324 DOI: 10.2147/vhrm.s275739] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/13/2022] [Indexed: 01/19/2023] Open
Abstract
Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are potent medications in the toolkit for treatment of atherosclerotic cardiovascular disease. These agents have been well studied in clinical trials supporting their efficacy in dramatically reducing low-density lipoprotein cholesterol (LDL-C) and impact on cardiovascular outcomes. Since the approval of commercial use for PCSK9 inhibitors in 2015, we have also gained significant experience in the use of these therapeutics in the real-world setting. In this article, we review current guideline recommendations, clinical trial evidence on efficacy and safety as well as data on cost-effectiveness, prescription and adherence. We focus primarily on the monoclonal antibody class of PCSK9 inhibitors in this review while also touching on other types of therapeutics that are under development.
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Affiliation(s)
- Xiaoming Jia
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Mahmoud Al Rifai
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Anum Saeed
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Salim S Virani
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
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15
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Ginsberg HN, Rosenson RS, Hovingh GK, Letierce A, Samuel R, Poulouin Y, Cannon CP. LDL-C calculated by Friedewald, Martin-Hopkins, or NIH equation 2 versus beta-quantification: pooled alirocumab trials. J Lipid Res 2022; 63:100148. [PMID: 34774485 PMCID: PMC8953656 DOI: 10.1016/j.jlr.2021.100148] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 11/03/2021] [Accepted: 11/07/2021] [Indexed: 12/31/2022] Open
Abstract
Accurate assessment of LDL-C levels is important, as they are often used for treatment recommendations. For many years, plasma LDL-C levels were calculated using the Friedewald equation, but there are limitations to this method compared with direct measurement via beta-quantification (BQ). Here, we assessed differences between the Friedewald, Martin-Hopkins, and NIH equation 2 methods of calculating LDL-C and the "gold standard" BQ method using pooled phase 3 data with alirocumab. All randomized patients were included irrespective of the treatment arm (n = 6,122). We compared pairs of LDL-C values (n = 17,077) determined by each equation and BQ. We found that BQ-derived LDL-C values ranged from 1 to 397 mg/dl (mean 90.68 mg/dl). There were strong correlations between Friedewald-calculated, Martin-Hopkins-calculated, and NIH equation 2-calculated LDL-C with BQ-determined LDL-C values (Pearson's correlation coefficient = 0.985, 0.981, and 0.985, respectively). Importantly, for BQ-derived LDL-C values ≥70 mg/dl, only 3.2%, 1.4%, and 1.8% of Friedewald-calculated, Martin-Hopkins-calculated, and NIH equation 2-calculated values were <70 mg/dl, respectively. When triglyceride (TG) levels were <150 mg/dl, differences between calculated and BQ-derived LDL-C values were minimal, regardless of the LDL-C level (<40, <55, or <70 mg/dl). However, when TG levels were >150 mg/dl, NIH equation 2 provided greater accuracy than Friedewald or Martin-Hopkins. When TGs were >250 mg/dl, inaccuracies were seen with all three methods, although NIH equation 2 remained the most accurate. In conclusion, LDL-C calculated by any of the three methods can guide treatment decisions for most patients, including those treated with proprotein convertase subtilisin/kexin type 9 inhibitors.
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Affiliation(s)
| | | | - G Kees Hovingh
- Academic Medical Center, Amsterdam, The Netherlands; Novo Nordisk AS, Copenhagen, Denmark
| | | | - Rita Samuel
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
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16
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Efficacy and Safety of PCSK9 Inhibitors in Stroke Prevention. J Stroke Cerebrovasc Dis 2021; 30:106057. [PMID: 34450482 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106057] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 08/09/2021] [Indexed: 12/19/2022] Open
Abstract
Proprotein convertase subtilisin/kexin type 9 (PCSK9) interacts with the low-density lipoprotein (LDL) receptor and, by enhancing its degradation, has a pivotal role in the regulation of cholesterol homeostasis. Two fully humanized monoclonal antibodies targeting PCSK9, evolocumab and alirocumab, are available for clinical use. PCSK9 inhibitors reduce LDL-C 30% more than ezetimibe and 60% more than placebo when added to statins. This reduction in LDL-C is accompanied by a decrease in the risk of major cardiovascular and cerebrovascular events. However, questions have been raised in relation to the cost-effectiveness of these medications. In this article, we review the clinical evidence on the use of PCSK9 inhibitors in lowering LDL-C and their effect on cerebrovascular health.
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17
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Farmaki P, Damaskos C, Garmpis N, Garmpi A, Savvanis S, Diamantis E. PCSK9 Inhibitors and Cardiovascular Disease: Impact on Cardiovascular Outcomes. Curr Drug Discov Technol 2021; 17:138-146. [PMID: 30526464 DOI: 10.2174/1570163816666181211112358] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 10/21/2018] [Accepted: 11/09/2018] [Indexed: 12/20/2022]
Abstract
Cardiovascular Disease (CVD) remains the leading cause of morbidity and mortality in the western world. Hypolipidemic drugs have long been used for the primary and secondary prevention of heart disease. However, the high frequency of recurrent events in patients despite hypolipidemic therapy has increased the need for new more targeted therapeutic approaches. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are monoclonal antibodies to the PCSK9 gene and represent a new class of drugs that have been shown to further decrease LDL-C when administered as a monotherapy or in combination with statins. In addition to LDL reduction, PCSK9 inhibitors are shown to decrease apolipoprotein B and lipoprotein (a) levels without major adverse effects. Whether or not PCSK9 inhibitors can actually reduce the incidence of cardiovascular events and ameliorate CVD prognosis is yet to be clarified. This review summarizes recent literature on the safety and efficacy of PCSK9 inhibitors on CVD outcome and its potential role in the management of patients with high-risk cardiovascular disease.
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Affiliation(s)
- Paraskevi Farmaki
- First Department of Pediatrics, Aghia Sophia Children's Hospital, Athens, Greece
| | - Christos Damaskos
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Garmpis
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Anna Garmpi
- Internal Medicine Department, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyridon Savvanis
- Department of Internal Medicine, General Hospital of Athens "Elpis", Athens, Greece
| | - Evangelos Diamantis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
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18
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Meta-analysis of randomized clinical trials comparing PCSK9 monoclonal antibody versus ezetimibe/placebo in patients at high cardiovascular risk. Atherosclerosis 2021; 326:25-34. [PMID: 34004550 DOI: 10.1016/j.atherosclerosis.2021.04.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/24/2021] [Accepted: 04/16/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND AIMS Proprotein convertase subtilisin/kexin type 9 monoclonal antibodies (PCSK9 mAbs) reduce circulating low-density lipoprotein cholesterol (LDL-C) by controlling the expression of LDL-receptor on the surface of hepatocytes. This meta-analysis aimed at evaluating the efficacy of PCSK9 mAbs on clinical and lipid-lowering outcomes. METHODS PubMed, Embase, and ClinicalTrials.gov were searched from inception until November 2020 for randomized controlled trials (RCTs) that compared PCSK9 mAbs with ezetimibe or placebo in patients at high cardiovascular risk. RESULTS Twenty eight RCTs with a total of 89,115 participants were included. Compared with placebo, PCSK9 mAbs significantly reduced the risk of major adverse cardiac events (MACEs) (RR 0.83, 95% CI 0.79 to 0.88, p < 0.00001). However, no difference was observed in occurring MACEs between PCSK9 mAbs and ezetimibe (RR 0.70, 95% CI 0.40 to 1.20, p = 0.20). Secondary analyses show that PCSK9 mAbs were not superior to ezetimibe in preventing stroke (RR 0.38, 95% CI 0.09 to 1.69, p = 0.20), myocardial infarction (RR 0.95, 95% CI 0.47 to 1.90, p = 0.88), and cardiovascular death (RR 0.44, 95% CI 0.14 to 1.43, p = 0.17). Compared with placebo, PCSK9 mAbs significantly reduced the incidence of stroke (RR 0.75, 95% CI 0.66 to 0.86, p < 0.0001) and myocardial infarction (RR 0.81, 95% CI 0.76 to 0.87, p < 0.00001), but not the risk of cardiovascular death (RR 0.96, 95% CI 0.86 to 1.07, p = 0.45). As for lipid-lowering efficacy, PCSK9 mAbs markedly reduced percent change of LDL-C from baseline to week 12 and 24 compared to ezetimibe or placebo. CONCLUSIONS In patients at high cardiovascular risk, PCSK9 mAbs could effectively reduce MACEs, stroke, and myocardial infarction compared with placebo. However, PCSK9 mAbs were not superior to ezetimibe in preventing adverse cardiovascular events in our study; RCTs with long-term follow-up and cardiovascular events as the research endpoint are still needed.
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19
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Hirsh Raccah B, Yanovsky A, Treves N, Rotshild V, Renoux C, Danenberg H, Eliaz R, Matok I. Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) inhibitors and the risk for neurocognitive adverse events: A systematic review, meta-analysis and meta-regression. Int J Cardiol 2021; 335:7-14. [PMID: 33892045 DOI: 10.1016/j.ijcard.2021.04.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/17/2021] [Accepted: 04/16/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND It has been suggested that lipid lowering therapy causes impaired cognitive changes. The association between the use of Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) inhibitors and the risk of neurocognitive adverse events remains unclear. This meta-analysis aims to assess neurocognitive safety of PCSK9 inhibitors in randomized controlled trials (RCTs). METHODS AND RESULTS The research was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed (MEDLINE), Embase and Cochrane library were searched through September 2019. Selection criteria included RCTs that addressed to neurocognitive adverse events of participants using Alirocumab, Evolocumab or Bococizumab, with a follow up duration of at least 6 months. The search results were screened by two independent reviewers. Safety data from included papers were extracted. Random effects meta-analysis was used to pool results, and meta-regression was utilized when applicable. Twenty-one studies were included. Among 59,733 patients, 31,611 were treated with PCSK9 inhibitors. The follow-up period ranged from 24 weeks to 48 months. No significant difference in the incidence of neurocognitive adverse effects between the groups was identified (RR = 1.01, 95% CI: 0.86-1.19, I2 = 3%). Similar results were seen in subgroup analysis for each of the medications (alirocumab- RR = 0.88, 95% CI: 0.72-1.08, I2 = 0%, evolocumab- RR = 1.42, 95% CI: 0.74-2.73, I2 = 55%). A meta-regression analysis for evolocumab revealed that prolonged study duration was associated with decreased risk for neurocognitive adverse events (βweek = -0.0037, p-value = 0.03). CONCLUSIONS Pooled results of our meta-analysis and meta-regression show that exposure to PCSK9 inhibitors is not associated with an increased risk of neurocognitive adverse effects.
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Affiliation(s)
- Bruria Hirsh Raccah
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy Faculty of Medicine, The Hebrew University of Jerusalem, Israel; Department of Cardiology, Hadassah University Hospital, Israel
| | - Alona Yanovsky
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy Faculty of Medicine, The Hebrew University of Jerusalem, Israel
| | - Nir Treves
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy Faculty of Medicine, The Hebrew University of Jerusalem, Israel
| | - Victoria Rotshild
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy Faculty of Medicine, The Hebrew University of Jerusalem, Israel
| | - Christel Renoux
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Department of Epidemiology, Montreal, Québec, Canada; Department of Neurology and Neurosurgery, McGill University, Montreal, Québec, Canada
| | - Haim Danenberg
- Department of Cardiology, Hadassah University Hospital, Israel
| | - Ran Eliaz
- Department of Cardiology, Hadassah University Hospital, Israel
| | - Ilan Matok
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy Faculty of Medicine, The Hebrew University of Jerusalem, Israel.
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20
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Lipoprotein(a) Reduction With Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors: A Systematic Review and Meta-analysis. J Cardiovasc Pharmacol 2021; 77:397-407. [PMID: 33298738 DOI: 10.1097/fjc.0000000000000963] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/15/2020] [Indexed: 12/29/2022]
Abstract
ABSTRACT Lipoprotein(a) [Lp(a)] is a cardiovascular factor, for which there is no approved specific lowering treatment. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been shown to have lowering effects on Lp(a). Aim of this systematic review is to synthesize the current literature and quantify the effects of PCSK9 inhibitors on the serum Lp(a) levels in human subjects. Double-blind, phase 2 or 3, randomized-controlled trials comparing PCSK9 inhibitors (alirocumab or evolocumab) to placebo and/or ezetimibe and/or other lipid-lowering therapy were deemed eligible for inclusion. We searched MEDLINE (via PubMed), CENTRAL, Scopus, and Web of Science as of 17 June 2020. Quality assessment was performed using the Revised Cochrane risk-of-bias tool for randomized trials. Forty-three studies were identified (64,107 patients randomized) and 41 studies were included in the quantitative analysis. PCSK9 inhibitors reduced Lp(a) levels by -26.7% (95% CI, -29.5% to -23.9%) with a significant heterogeneity within studies. There was significant difference in Lp(a) change from baseline according to comparator (placebo: mean -27.9%; 95% CI, -31.1% to -24.6% vs. ezetimibe: mean, -22.2%; 95% CI, -27.2% to -17.2%; P = 0.04) and duration of treatment (≤12 weeks: mean, -30.9%; 95% CI, -34.7% to -27.1% vs. >12 weeks: mean, -21.9%; 95% CI, -25.2% to -18.6%; P < 0.01). Meta-regression analysis showed that only the mean percentage change from baseline low-density lipoprotein cholesterol due to the intervention is significantly associated with the effect size difference (P < 0.0001). PCSK9 inhibitors reduced low-density lipoprotein cholesterol by -54% (95% CI -57.6% to -50.6%). There is substantial efficacy of the currently approved PCSK9 inhibitors in the lowering of Lp(a) levels. Dedicated randomized controlled trials are needed to establish the benefit of this intervention.
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21
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Schmidt AF, Carter JPL, Pearce LS, Wilkins JT, Overington JP, Hingorani AD, Casas JP. PCSK9 monoclonal antibodies for the primary and secondary prevention of cardiovascular disease. Cochrane Database Syst Rev 2020; 10:CD011748. [PMID: 33078867 PMCID: PMC8094613 DOI: 10.1002/14651858.cd011748.pub3] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Despite the availability of effective drug therapies that reduce low-density lipoprotein (LDL)-cholesterol (LDL-C), cardiovascular disease (CVD) remains an important cause of mortality and morbidity. Therefore, additional LDL-C reduction may be warranted, especially for people who are unresponsive to, or unable to take, existing LDL-C-reducing therapies. By inhibiting the proprotein convertase subtilisin/kexin type 9 (PCSK9) enzyme, monoclonal antibodies (PCSK9 inhibitors) reduce LDL-C and CVD risk. OBJECTIVES Primary To quantify the effects of PCSK9 inhibitors on CVD, all-cause mortality, myocardial infarction, and stroke, compared to placebo or active treatment(s) for primary and secondary prevention. Secondary To quantify the safety of PCSK9 inhibitors, with specific focus on the incidence of influenza, hypertension, type 2 diabetes, and cancer, compared to placebo or active treatment(s) for primary and secondary prevention. SEARCH METHODS We identified studies by systematically searching CENTRAL, MEDLINE, Embase, and Web of Science in December 2019. We also searched ClinicalTrials.gov and the International Clinical Trials Registry Platform in August 2020 and screened the reference lists of included studies. This is an update of the review first published in 2017. SELECTION CRITERIA All parallel-group and factorial randomised controlled trials (RCTs) with a follow-up of at least 24 weeks were eligible. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed and extracted data. Where data were available, we calculated pooled effect estimates. We used GRADE to assess certainty of evidence and in 'Summary of findings' tables. MAIN RESULTS We included 24 studies with data on 60,997 participants. Eighteen trials randomised participants to alirocumab and six to evolocumab. All participants received background lipid-lowering treatment or lifestyle counselling. Six alirocumab studies used an active treatment comparison group (the remaining used placebo), compared to three evolocumab active comparison trials. Alirocumab compared with placebo decreased the risk of CVD events, with an absolute risk difference (RD) of -2% (odds ratio (OR) 0.87, 95% confidence interval (CI) 0.80 to 0.94; 10 studies, 23,868 participants; high-certainty evidence), decreased the risk of mortality (RD -1%; OR 0.83, 95% CI 0.72 to 0.96; 12 studies, 24,797 participants; high-certainty evidence), and MI (RD -2%; OR 0.86, 95% CI 0.79 to 0.94; 9 studies, 23,352 participants; high-certainty evidence) and for any stroke (RD 0%; OR 0.73, 95% CI 0.58 to 0.91; 8 studies, 22,835 participants; high-certainty evidence). Compared to active treatment the alirocumab effects, for CVD, the RD was 1% (OR 1.37, 95% CI 0.65 to 2.87; 3 studies, 1379 participants; low-certainty evidence); for mortality, RD was -1% (OR 0.51, 95% CI 0.18 to 1.40; 5 studies, 1333 participants; low-certainty evidence); for MI, RD was 1% (OR 1.45, 95% CI 0.64 to 3.28, 5 studies, 1734 participants; low-certainty evidence); and for any stroke, RD was less than 1% (OR 0.85, 95% CI 0.13 to 5.61; 5 studies, 1734 participants; low-certainty evidence). Compared to placebo the evolocumab, for CVD, the RD was -2% (OR 0.84, 95% CI 0.78 to 0.91; 3 studies, 29,432 participants; high-certainty evidence); for mortality, RD was less than 1% (OR 1.04, 95% CI 0.91 to 1.19; 3 studies, 29,432 participants; high-certainty evidence); for MI, RD was -1% (OR 0.72, 95% CI 0.64 to 0.82; 3 studies, 29,432 participants; high-certainty evidence); and for any stroke RD was less than -1% (OR 0.79, 95% CI 0.65 to 0.94; 2 studies, 28,531 participants; high-certainty evidence). Compared to active treatment, the evolocumab effects, for any CVD event RD was less than -1% (OR 0.66, 95% CI 0.14 to 3.04; 1 study, 218 participants; very low-certainty evidence); for all-cause mortality, the RD was less than 1% (OR 0.43, 95% CI 0.14 to 1.30; 3 studies, 5223 participants; very low-certainty evidence); and for MI, RD was less than 1% (OR 0.66, 95% CI 0.23 to 1.85; 3 studies, 5003 participants; very low-certainty evidence). There were insufficient data on any stroke. AUTHORS' CONCLUSIONS: The evidence for the clinical endpoint effects of evolocumab and alirocumab were graded as high. There is a strong evidence base to prescribe PCSK9 monoclonal antibodies to people who might not be eligible for other lipid-lowering drugs, or to people who cannot meet their lipid goals on more traditional therapies, which was the main patient population of the available trials. The evidence base of PCSK9 inhibitors compared with active treatment is much weaker (low very- to low-certainty evidence) and it is unclear whether evolocumab or alirocumab might be effectively used as replacement therapies. Related, most of the available studies preferentially enrolled people with either established CVD or at a high risk already, and evidence in low- to medium-risk settings is minimal. Finally, there is very limited evidence on any potential safety issues of both evolocumab and alirocumab. While the current evidence synthesis does not reveal any adverse signals, neither does it provide evidence against such signals. This suggests careful consideration of alternative lipid lowering treatments before prescribing PCSK9 inhibitors.
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Affiliation(s)
- Amand F Schmidt
- Institute of Cardiovascular Science, University College London, London, UK
- Department of Cardiology, Division Heart and Lungs, UMC Utrecht, Utrecht, Netherlands
| | - John-Paul L Carter
- Department of Clinical Pharmacology and Therapeutics, University College London Hospital, London, UK
| | - Lucy S Pearce
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - John T Wilkins
- The Department of Medicine (Cardiology) and the Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Aroon D Hingorani
- Institute of Cardiovascular Science, University College London, London, UK
| | - J P Casas
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, Massachusetts, USA
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Panagiotopoulou O, Chiesa ST, Tousoulis D, Charakida M. Dyslipidaemias and Cardiovascular Disease: Focus on the Role of PCSK9 Inhibitors. Curr Med Chem 2020; 27:4494-4521. [PMID: 31453780 DOI: 10.2174/0929867326666190827151012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 12/23/2018] [Accepted: 01/15/2019] [Indexed: 12/19/2022]
Abstract
Genetic, experimental and clinical studies have consistently confirmed that inhibition of Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) can result in significant lowering of LDL-C and two fully human PCSK9 monoclonal antibodies have received regulatory approval for use in highrisk patients. Co-administration of PCSK9 with statins has resulted in extremely low LDL-C levels with excellent short-term safety profiles. While results from Phase III clinical trials provided significant evidence about the role of PCSK9 inhibitors in reducing cardiovascular event rates, their impact on mortality remains less clear. PCSK9 inhibitor therapy can be considered for high-risk patients who are likely to experience significant cardiovascular risk reduction.
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Affiliation(s)
- Olga Panagiotopoulou
- School of Biomedical Engineering and Imaging Sciences, King's College London, 4th Floor, Lambeth Wing St. Thomas' Hospital, London SE1 7EH, United Kingdom
| | - Scott T Chiesa
- UCL Institute of Cardiovascular Sciences, London, United Kingdom
| | | | - Marietta Charakida
- School of Biomedical Engineering and Imaging Sciences, King's College London, 4th Floor, Lambeth Wing St. Thomas' Hospital, London SE1 7EH, United Kingdom
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23
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Cho KH, Hong YJ. Proprotein convertase subtilisin/kexin type 9 inhibition in cardiovascular disease: current status and future perspectives. Korean J Intern Med 2020; 35:1045-1058. [PMID: 32921006 PMCID: PMC7487297 DOI: 10.3904/kjim.2020.140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/20/2020] [Indexed: 01/14/2023] Open
Abstract
Proprotein convertase subtilisin/kexin type 9 (PCSK9) targets the degradation of low-density lipoprotein (LDL) receptors; it has been proved that its inhibition improves cardiovascular outcomes in patients with established atherosclerotic cardiovascular disease (ASCVD). Herein, we review the current status of PCSK9 inhibitors in clinical practice and the future scope of PCSK9 inhibition. The results of two recent large clinical trials reveal that two PCSK9 monoclonal antibodies evolocumab and alirocumab reduce the risk of a cardiovascular event on top of background statin therapy in patients with stable ASCVD and those with recent acute coronary syndrome, respectively. However, there are several ongoing concerns regarding the efficacy in reducing mortality, cost-effectiveness, and long-term safety of extremely low LDL cholesterol levels with PCSK9 inhibition. The results of ongoing cardiovascular outcomes trials with PCSK9 monoclonal antibodies for primary prevention and with small interfering RNA to PCSK9 for secondary prevention may help to shape the use of this new therapeutic class.
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Affiliation(s)
- Kyung Hoon Cho
- Division of Cardiology, Chonnam National University Medical School, Gwangju, Korea
| | - Young Joon Hong
- Division of Cardiology, Chonnam National University Medical School, Gwangju, Korea
- Correspondence to Young Joon Hong, M.D. Division of Cardiology, Chonnam National University Hospital, 42 Jebong-ro, Dong-gu, Gwangju 61469, Korea Tel: +82-62-220-5778 Fax: +82-62-223-3105 E-mail:
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24
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Kaddoura R, Orabi B, Salam AM. Efficacy and safety of PCSK9 monoclonal antibodies: an evidence-based review and update. J Drug Assess 2020; 9:129-144. [PMID: 32939318 PMCID: PMC7470150 DOI: 10.1080/21556660.2020.1801452] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Objective Treatment of dyslipidemia lowers cardiovascular (CV) risk. Although statin use is a cornerstone therapy, many patients are not achieving their risk-specific low-density lipoprotein cholesterol (LDL-C) goals. The proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibodies have been extensively studied as lipid-lowering therapy (LLT). Herein, we present an updated evidence-based review of the efficacy and safety of PCSK9 monoclonal antibodies in the treatment of familial and non-familial hypercholesterolemia. Methods PubMed database was searched to review Phase III studies on PCSK9 monoclonal antibodies. Then, the US National Institutes of Health Registry and the WHO International Clinical Trial Registry Platform were searched to identify and present the ongoing research. Results PCSK9 monoclonal antibodies were investigated for the treatment of dyslipidemia, as a single therapeutic agent or as an add-on therapy to the traditional LLT. They proved effective and safe in the treatment of familial and non-familial hypercholesterolemia, and in the prevention of adverse CV events. Conclusions The use of PCSK9 monoclonal antibodies in the treatment of dyslipidemia is currently recommended to achieve risk-specific LDL-C goal to reduce adverse CV events. Future results of the ongoing research might expand their clinical generalizability to broader patient populations.
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Affiliation(s)
- Rasha Kaddoura
- Hamad Medical Corporation, Heart Hospital Pharmacy, Doha, Ad Dawhah, Qatar
| | - Bassant Orabi
- Hamad Medical Corporation, Heart Hospital Pharmacy, Doha, Ad Dawhah, Qatar
| | - Amar M Salam
- Department of Cardiology, Hamad Medical Corporation, Al-khor Hospital, Doha, Ad Dawhah, Qatar
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25
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Impact of Lowering Low-Density Lipoprotein Cholesterol with Contemporary Lipid-Lowering Medicines on Cognitive Function: A Systematic Review and Meta-Analysis. Cardiovasc Drugs Ther 2020; 35:153-166. [PMID: 32770521 DOI: 10.1007/s10557-020-07045-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE To evaluate the potential association between the lowering of low-density lipoprotein cholesterol (LDL-C) with contemporary lipid-lowering medicines and cognitive function. METHODS Randomized controlled trials (RCTs) in databases including PubMed, Embase, and the Web of Science and all databases in the Cochrane Library and ClinicalTrials.gov were collected from inception to January 1, 2020. The cognitive function of patients receiving proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, statins and ezetimibe was evaluated using meta-analysis. RESULTS A total of 2910 studies were obtained from databases and other sources. Thirty-three studies were selected by screening, including 11 studies on alirocumab, 9 studies on evolocumab, 11 studies on statins and 2 studies on ezetimibe. In our study, a total of 128,691 patients with no cognitive impairment were divided into an intervention group (66,330 patients) and a control group (62,361 patients). The data were subjected to a random-effects model or a fixed-effects model for meta-analysis. The contemporary lipid-lowering medicines significantly reduced LDL-C in terms of both percentage (WMD: -45.06%, 95% CI -50.12% to -40.00%, P < 0.001) and absolute value (WMD: -64.01 mg/dL, 95% CI -72.25 to -55.78, P < 0.001). Compared with the control group, patients receiving treatment with contemporary lipid-lowering medicines did not show a significant difference in the rate of neurocognitive disorder (RR: 1.02, 95% CI 0.90 to 1.16, I2 = 0.0%, p = 0.696). Subgroup analysis was performed according to the intervention and LDL-C stratification. The result of this subgroup analysis was consistent with the main findings. Regarding global cognitive performance, no difference in major cognition was found among the pooled data (SMD: 0.02, 95% CI -0.01 to 0.04, P = 0.002), except for psychomotor speed (SMD: 0.09, 95% CI 0.02 to 0.16, P = 0.0024). CONCLUSIONS Contemporary lipid-lowering medicines were not associated with cognitive impairment in RCTs. A low LDL-C level did not influence the incidence of cognitive disorder or global cognitive performance.
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van Bruggen FH, Nijhuis GBJ, Zuidema SU, Luijendijk H. Serious adverse events and deaths in PCSK9 inhibitor trials reported on ClinicalTrials.gov: a systematic review. Expert Rev Clin Pharmacol 2020; 13:787-796. [DOI: 10.1080/17512433.2020.1787832] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- F. H. van Bruggen
- University of Groningen, University Medical Center Groningen, Department of General Practice and Elderly Care Medicine, Groningen, The Netherlands
| | - G. B. J. Nijhuis
- University of Groningen, University Medical Center Groningen, Department of General Practice and Elderly Care Medicine, Groningen, The Netherlands
| | - S. U. Zuidema
- University of Groningen, University Medical Center Groningen, Department of General Practice and Elderly Care Medicine, Groningen, The Netherlands
| | - Hendrika Luijendijk
- University of Groningen, University Medical Center Groningen, Department of General Practice and Elderly Care Medicine, Groningen, The Netherlands
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27
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Guedeney P, Sorrentino S, Giustino G, Chapelle C, Laporte S, Claessen BE, Ollier E, Camaj A, Kalkman DN, Vogel B, De Rosa S, Indolfi C, Lattuca B, Zeitouni M, Kerneis M, Silvain J, Collet JP, Mehran R, Montalescot G. Indirect comparison of the efficacy and safety of alirocumab and evolocumab: a systematic review and network meta-analysis. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:225-235. [PMID: 32275743 DOI: 10.1093/ehjcvp/pvaa024] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/03/2020] [Accepted: 04/04/2020] [Indexed: 12/22/2022]
Abstract
AIMS Although alirocumab and evolocumab have both been associated with improved outcomes in patients with dyslipidaemia or established atherosclerotic cardiovascular disease, data on their respective performances are scarce. This study aimed at providing an indirect comparison of the efficacy and safety of alirocumab vs. evolocumab. METHODS AND RESULTS We conducted a systematic review and network meta-analysis of randomized trials comparing alirocumab or evolocumab to placebo with consistent background lipid-lowering therapy up to November 2018. We estimated the relative risk (RR) and the 95% confidence intervals (CIs) using fixed-effect model in a frequentist pairwise and network meta-analytic approach. A total of 30 trials, enrolling 59 026 patients were included. Eligibility criteria varied significantly across trials evaluating alirocumab and evolocumab. Compared with evolocumab, alirocumab was associated with a significant reduction in all-cause death (RR 0.80, 95% CI 0.66-0.97) but not in cardiovascular death (RR 0.83, 95% CI 0.65-1.05). This study did not find any significant differences in myocardial infarction (RR 1.15, 95% CI 0.99-1.34), stroke (RR 0.96, 95% CI 0.71-1.28), or coronary revascularization (RR 1.13, 95% CI 0.99-1.29) between the two agents. Alirocumab was associated with a 27% increased risk of injection site reaction compared to evolocumab; however, no significant differences were found in terms of treatment discontinuations, systemic allergic reaction, neurocognitive events, ophthalmologic events, or new-onset of or worsening of pre-existing diabetes. CONCLUSION Alirocumab and evolocumab share a similar safety profile except for injection site reaction. No significant differences were observed across the efficacy endpoints, except for all-cause death, which may be related to the heterogeneity of the studied populations treated with the two drugs.
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Affiliation(s)
- Paul Guedeney
- Department of Cardiology, Sorbonne Université, ACTION study group, UMR_S 1166, Institut de Cardiologie, Pitié Salpêtrière Hospital (AP-HP), Paris, France.,Department of Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sabato Sorrentino
- Department of Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Cardiology, Department of Medical and Surgical Science, Magna Graecia University, Catanzaro, Italy
| | - Gennaro Giustino
- Department of Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Celine Chapelle
- Unité de Recherche Clinique Innovation et Pharmacologie CHU de Saint-Etienne, Saint-Etienne, France
| | - Silvy Laporte
- Unité de Recherche Clinique Innovation et Pharmacologie CHU de Saint-Etienne, Saint-Etienne, France
| | - Bimmer E Claessen
- Department of Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Edouard Ollier
- Unité de Recherche Clinique Innovation et Pharmacologie CHU de Saint-Etienne, Saint-Etienne, France
| | - Anton Camaj
- Department of Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deborah N Kalkman
- Department of Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Heart Center, Amsterdam Cardiovascular Sciences, Meibergdreef 9, Amsterdam, The Netherlands
| | - Birgit Vogel
- Department of Cardiology, Sorbonne Université, ACTION study group, UMR_S 1166, Institut de Cardiologie, Pitié Salpêtrière Hospital (AP-HP), Paris, France
| | - Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Science, Magna Graecia University, Catanzaro, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Science, Magna Graecia University, Catanzaro, Italy
| | - Benoit Lattuca
- Department of Cardiology, Sorbonne Université, ACTION study group, UMR_S 1166, Institut de Cardiologie, Pitié Salpêtrière Hospital (AP-HP), Paris, France
| | - Michel Zeitouni
- Department of Cardiology, Sorbonne Université, ACTION study group, UMR_S 1166, Institut de Cardiologie, Pitié Salpêtrière Hospital (AP-HP), Paris, France
| | - Mathieu Kerneis
- Department of Cardiology, Sorbonne Université, ACTION study group, UMR_S 1166, Institut de Cardiologie, Pitié Salpêtrière Hospital (AP-HP), Paris, France
| | - Johanne Silvain
- Department of Cardiology, Sorbonne Université, ACTION study group, UMR_S 1166, Institut de Cardiologie, Pitié Salpêtrière Hospital (AP-HP), Paris, France
| | - Jean-Philippe Collet
- Department of Cardiology, Sorbonne Université, ACTION study group, UMR_S 1166, Institut de Cardiologie, Pitié Salpêtrière Hospital (AP-HP), Paris, France
| | - Roxana Mehran
- Department of Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gilles Montalescot
- Department of Cardiology, Sorbonne Université, ACTION study group, UMR_S 1166, Institut de Cardiologie, Pitié Salpêtrière Hospital (AP-HP), Paris, France
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28
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Kaddoura R, Orabi B, Salam AM. PCSK9 Monoclonal Antibodies: An Overview. Heart Views 2020; 21:97-103. [PMID: 33014302 PMCID: PMC7507904 DOI: 10.4103/heartviews.heartviews_20_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 03/08/2020] [Indexed: 12/24/2022] Open
Abstract
PCSK9 monoclonal antibodies are novel lipid-lowering therapy that have been extensively studied in patients with hypercholesterolemia either as monotherapy or as an add-on to other LLTs. PCSK9 monoclonal antibodies have significantly reduced the low-density lipoprotein cholesterol (LDL-C) plasma level resulting in a better LDL-C goal attainment. The commercially available PCSK9 monoclonal antibodies, alirocumab and evolocumab, have demonstrated reductions in major adverse cardiovascular events such as myocardial infarction, stroke, unstable angina, and the need for coronary revascularization but not mortality. PCSK9 monoclonal antibodies have demonstrated a favorable safety profile. The most reported side effects are mild injection site with no causal relationship proven between the inhibition of PCSK9 and neurocognitive or glycemic adverse events. In this overview, the efficacy and safety of PCSK9 monoclonal antibodies in the treatment of primary and familial hypercholesterolemia will be discussed.
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Affiliation(s)
- Rasha Kaddoura
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Bassant Orabi
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Amar M Salam
- Department of Cardiology, Al Khor Hospital, Hamad Medical Corporation, Doha, Qatar
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29
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Pasta A, Cremonini AL, Pisciotta L, Buscaglia A, Porto I, Barra F, Ferrero S, Brunelli C, Rosa GM. PCSK9 inhibitors for treating hypercholesterolemia. Expert Opin Pharmacother 2020; 21:353-363. [DOI: 10.1080/14656566.2019.1702970] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Andrea Pasta
- Department of Internal Medicine (DIMI), University of Genoa, Genova, Italy
| | | | - Livia Pisciotta
- Department of Internal Medicine (DIMI), University of Genoa, Genova, Italy
| | - Angelo Buscaglia
- Department of Internal Medicine (DIMI), University of Genoa, Genova, Italy
| | - Italo Porto
- Department of Internal Medicine (DIMI), University of Genoa, Genova, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genova, Italy
| | - Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genova, Italy
| | - Claudio Brunelli
- Clinic of Cardiovascular Diseases, University of Genoa, Genova, Italy
| | - Gian Marco Rosa
- Clinic of Cardiovascular Diseases, University of Genoa, Genova, Italy
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30
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AlTurki A, Marafi M, Dawas A, Dube MP, Vieira L, Sherman MH, Gregoire J, Thanassoulis G, Tardif JC, Huynh T. Meta-analysis of Randomized Controlled Trials Assessing the Impact of Proprotein Convertase Subtilisin/Kexin Type 9 Antibodies on Mortality and Cardiovascular Outcomes. Am J Cardiol 2019; 124:1869-1875. [PMID: 31679643 DOI: 10.1016/j.amjcard.2019.09.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/05/2019] [Accepted: 09/05/2019] [Indexed: 11/19/2022]
Abstract
Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition by monoclonal antibodies has been shown to reduce low density lipoprotein (LDL-C) but its effects on cardiovascular (CV) outcomes have not been fully described. The aim of this study is to assess the impact of PCSK9 inhibition on mortality and CV outcomes by pooling data from all available randomized clinical trials (RCT) of PCSK9 inhibitors. We conducted a comprehensive search of electronic databases, up to December 1, 2018, for all RCTs comparing PCSK9 inhibition to placebo or ezetimibe in patients with hypercholesterolemia or coronary artery disease receiving maximally tolerated statin for primary or secondary prevention of mortality and cardiovascular outcomes. We used random-effects meta-analyses to summarize the studies. We retained 23 RCTs having included 88,041 patients in primary and secondary prevention. The follow-up ranged from 6 to 36 months. PCSK9 inhibition was not significantly associated with reductions in total mortality (odds ratio [OR] 0.91, 95% confidence interval [CI] 078 to 1.06; p = 0.22) and CV mortality (OR 0.95, 95% CI 0.84 to 1.07; p = 0.37). In contrast, PCSK9 inhibition was associated with reductions in myocardial infarction (OR 0.80, 95% CI 0.71 to 0.91; p <0.0001), stroke (OR 0.75, 95% CI 0.65 to 0.85; p <0.0001), and coronary revascularization (OR 0.82, 95% CI 0.77 to 0.88; p <0.0001). In conclusion, PCSK9 inhibition was associated with reductions in myocardial infarction, stroke, and coronary revascularization. Future analyses may identify high-risk patients who may benefit more from these agents and longer follow-up of current or new trials may show a mortality benefit.
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Affiliation(s)
- Ahmed AlTurki
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Mariam Marafi
- Department of Neurology, Montreal Neurological Institute, Montreal, Quebec, Canada
| | - Ahmed Dawas
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Marie-Pierre Dube
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Lucy Vieira
- Department of Neurology, Montreal Neurological Institute, Montreal, Quebec, Canada
| | - Mark H Sherman
- Division of Endocrinology, McGill University Health Center, Montreal, Quebec, Canada
| | - Jean Gregoire
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - George Thanassoulis
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Jean-Claude Tardif
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Thao Huynh
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada.
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Guarnieri F, Kulp JL, Kulp JL, Cloudsdale IS. Fragment-based design of small molecule PCSK9 inhibitors using simulated annealing of chemical potential simulations. PLoS One 2019; 14:e0225780. [PMID: 31805108 PMCID: PMC6894869 DOI: 10.1371/journal.pone.0225780] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 11/12/2019] [Indexed: 12/20/2022] Open
Abstract
PCSK9 is a protein secreted by the liver that binds to the low-density lipoprotein receptor (LDLR), causing LDLR internalization, decreasing the clearance of circulating LDL particles. Mutations in PCSK9 that strengthen its interactions with LDLR result in familial hypercholesterolemia (FH) and early onset atherosclerosis, while nonsense mutations of PCSK9 result in cardio-protective hypocholesterolemia. These observations led to PCSK9 inhibition for cholesterol lowering becoming a high-interest therapeutic target, with antibody drugs reaching the market. An orally-available small molecule drug is highly desirable, but inhibiting the PCSK9/LDLR protein-protein interaction (PPI) has proven challenging. Alternate approaches to finding good lead candidates are needed. Motivated by the FH mutation data on PCSK9, we found that modeling the PCSK9/LDLR interface revealed extensive electron delocalization between and within the protein partners. Based on this, we hypothesized that compounds assembled from chemical fragments could achieve the affinity required to inhibit the PCSK9/LDLR PPI if they were selected to interact with PCSK9 in a way that, like LDLR, also involves significant fractional charge transfer to form partially covalent bonds. To identify such fragments, Simulated Annealing of Chemical Potential (SACP) fragment simulations were run on multiple PCSK9 structures, using optimized partial charges for the protein. We designed a small molecule, composed of several fragments, predicted to interact at two sites on the PCSK9. This compound inhibits the PPI with 1 μM affinity. Further, we designed two similar small molecules where one allows charge delocalization though a linker and the other doesn’t. The first inhibitor with charge delocalization enhances LDLR surface expression by 60% at 10 nM, two orders of magnitude more potent than the EGF domain of LDLR. The other enhances LDLR expression by only 50% at 1 μM. This supports our conjecture that fragments can have surprisingly outsized efficacy in breaking PPI’s by achieving fractional charge transfer leading to partially covalent bonding.
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Affiliation(s)
- Frank Guarnieri
- Center for Drug Discovery, Northeastern University, Boston, MA, United States of America
- PAKA Pulmonary Pharmaceuticals, Acton, MA, United States of America
- * E-mail:
| | - John L. Kulp
- Conifer Point Pharmaceuticals, Doylestown, PA, United States of America
| | - John L. Kulp
- Conifer Point Pharmaceuticals, Doylestown, PA, United States of America
- Department of Chemistry, Baruch S. Blumberg Institute, Doylestown, PA, United States of America
| | - Ian S. Cloudsdale
- Conifer Point Pharmaceuticals, Doylestown, PA, United States of America
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Robinson JG, Farnier M, Kastelein JJ, Roth EM, Taskinen MR, Colhoun HM, Brunet A, DiCioccio AT, Lecorps G, Pordy R, Baccara-Dinet MT, Cannon CP. Relationship between alirocumab, PCSK9, and LDL-C levels in four phase 3 ODYSSEY trials using 75 and 150 mg doses. J Clin Lipidol 2019; 13:979-988.e10. [DOI: 10.1016/j.jacl.2019.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/25/2019] [Accepted: 10/03/2019] [Indexed: 11/30/2022]
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Steffens D, Bramlage P, Scheeff C, Kasner M, Hassanein A, Friebel J, Rauch-Kröhnert U. PCSK9 inhibitors and cardiovascular outcomes. Expert Opin Biol Ther 2019; 20:35-47. [PMID: 31593483 DOI: 10.1080/14712598.2020.1677604] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Dyslipidemia, particularly elevated low-density lipoprotein cholesterol (LDL-C), is a key risk factor for atherosclerotic cardiovascular disease (ASCVD), and lipid-lowering drugs are beneficial for the primary and secondary prevention of cardiovascular (CV) disease. While statins are clear first-line drugs, new drug developments such as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been shown to improve cardiovascular outcomes when added to statins. Evolocumab reduced the risk of cardiovascular events in patients with ASCVD when added to maximally tolerated statin therapy (± ezetimibe), and recent data from the ODYSSEY OUTCOMES trial indicate that alirocumab added to maximally tolerated statin therapy (± other lipid-lowering drugs) reduces the risk of cardiovascular events in patients with a recent acute coronary syndrome. In this article the authors review the available data on the effect of PCSK9 inhibitors on cardiovascular outcomes.Areas covered: This article reviews the available data on the effect of PCSK9 inhibitors on CV outcomes. Relevant papers were identified from a search of PubMed/Medline and the Cochrane Central Register of Controlled Trials (CENTRAL).Expert opinion: The authors conclude that PCSK9 inhibitors provide substantial and durable reductions in LDL-C levels and improve cardiovascular outcomes.
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Affiliation(s)
- Daniel Steffens
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Céline Scheeff
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Mario Kasner
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Adel Hassanein
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Julian Friebel
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Ursula Rauch-Kröhnert
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
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Sokolov V, Helmlinger G, Nilsson C, Zhudenkov K, Skrtic S, Hamrén B, Peskov K, Hurt-Camejo E, Jansson-Löfmark R. Comparative quantitative systems pharmacology modeling of anti-PCSK9 therapeutic modalities in hypercholesterolemia. J Lipid Res 2019; 60:1610-1621. [PMID: 31292220 PMCID: PMC6718444 DOI: 10.1194/jlr.m092486] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 06/27/2019] [Indexed: 12/21/2022] Open
Abstract
Since the discovery of proprotein convertase subtilisin/kexin type 9 (PCSK9) as an attractive target in the treatment of hypercholesterolemia, multiple anti-PCSK9 therapeutic modalities have been pursued in drug development. The objective of this research is to set the stage for the quantitative benchmarking of two anti-PCSK9 pharmacological modality classes, monoclonal antibodies (mAbs) and small interfering RNA (siRNA). To this end, we developed an integrative mathematical model of lipoprotein homeostasis describing the dynamic interplay between PCSK9, LDL-cholesterol (LDL-C), VLDL-cholesterol, HDL-cholesterol (HDL-C), apoB, lipoprotein a [Lp(a)], and triglycerides (TGs). We demonstrate that LDL-C decreased proportionally to PCSK9 reduction for both mAb and siRNA modalities. At marketed doses, however, treatment with mAbs resulted in an additional ∼20% LDL-C reduction compared with siRNA. We further used the model as an evaluation tool and determined that no quantitative differences were observed in HDL-C, Lp(a), TG, or apoB responses, suggesting that the disruption of PCSK9 synthesis would provide no additional effects on lipoprotein-related biomarkers in the patient segment investigated. Predictive model simulations further indicate that siRNA therapies may reach reductions in LDL-C levels comparable to those achieved with mAbs if the current threshold of 80% PCSK9 inhibition via siRNA could be overcome.
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Affiliation(s)
| | - Gabriel Helmlinger
- Clinical Pharmacology & Safety Sciences R&D BioPharmaceuticals, AstraZeneca, Boston, MA
| | - Catarina Nilsson
- Clinical Pharmacology & Safety SciencesCardiovascular, R&D BioPharmaceuticals, AstraZeneca, Gothenburg, Sweden
| | | | - Stanko Skrtic
- Clinical Pharmacology & Safety SciencesCardiovascular, R&D BioPharmaceuticals, AstraZeneca, Gothenburg, Sweden; Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Bengt Hamrén
- Clinical Pharmacology & Safety SciencesCardiovascular, R&D BioPharmaceuticals, AstraZeneca, Gothenburg, Sweden
| | - Kirill Peskov
- M&S Decisions, Moscow, Russia; I. M. Sechenov First Moscow State Medical University of the Russian Ministry of Health Moscow, Russia
| | - Eva Hurt-Camejo
- Renal and Metabolism R&D BioPharmaceuticals, AstraZeneca, Gothenburg, Sweden
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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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Schuster S, Rubil S, Endres M, Princen HMG, Boeckel JN, Winter K, Werner C, Laufs U. Anti-PCSK9 antibodies inhibit pro-atherogenic mechanisms in APOE*3Leiden.CETP mice. Sci Rep 2019; 9:11079. [PMID: 31366894 PMCID: PMC6668462 DOI: 10.1038/s41598-019-47242-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 07/09/2019] [Indexed: 12/15/2022] Open
Abstract
LDL-cholesterol (LDL-C) is a causal pathogenic factor in atherosclerosis. Monoclonal anti-proprotein convertase subtilisin/kexin type 9 (PCSK9) neutralizing antibodies are novel potent LDL-lowering drugs which reduce cardiovascular events. To characterize their effect on atherogenesis, APOE*3Leiden.CETP mice were fed a high cholesterol/high fat diet (WTD) or normal chow (NC) for 18 weeks. Mice on WTD were injected with the human anti-PCSK9 antibody mAb1 (PL-45134, 10 mg*kg-1 s.c.) or 0.9% saline every 10 days. PCSK9 inhibition decreased total cholesterol in serum of APOE*3Leiden.CETP mice and prevented the development of atherosclerosis. The plaque area in the aortic root was reduced by half and macrophage infiltration determined by Ly6c and Mac-3 staining was ameliorated. PCSK9 inhibition decreased markers of inflammation in mononuclear cells (Il-6, Tnfa mRNA), and in serum (CXCL-1,-10,-13; complement factor C5a) compared to control WTD fed animals. The number of circulating Sca-1/VEGF-R2 positive endothelial progenitor cells of the peripheral blood and spleen-derived diLDL/lectin double positive circulating angiogenic cells was increased. To conclude, the PCSK9-mediated anti-atherosclerotic effect involves the upregulation of pro-regeneratory endothelial progenitor cells, a reduction of inflammation and change of plaque composition.
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Affiliation(s)
- Susanne Schuster
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig University, Leipzig, Germany.
| | - Sandra Rubil
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universität/Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Matthias Endres
- Department of Neurology with Experimental Neurology, Center for Stroke Research Berlin (CSB), and NeuroCure, Charité University Medicine Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK) and German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Berlin, Germany
| | - Hans M G Princen
- TNO-Metabolic Health Research, Gaubius Laboratory, Leiden, The Netherlands
| | - Jes-Niels Boeckel
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig University, Leipzig, Germany
| | - Karsten Winter
- Institute of Anatomy, Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Christian Werner
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universität/Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig University, Leipzig, Germany
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Abstract
Proprotein convertase subtilisin kexin 9 (PCSK9) is a serine protease with a key role in regulating plasma low-density lipoprotein (LDL) concentration. Since its discovery via parallel molecular biology and clinical genetics studies in 2003, work to characterize PCSK9 has shed new light on the life-cycle of the low-density lipoprotein receptor and the molecular basis of familial hypercholesterolaemia. These discoveries have also led to the advent of the PCSK9 inhibitors, a new generation of low-density lipoprotein cholesterol (LDL-C) lowering drugs. Clinical trials have shown these agents to be both safe and capable of unprecedented reductions in LDL-C, and it is hoped they may herald a new era of cardiovascular disease prevention. As such, the still evolving PCSK9 story serves as a particularly successful example of translational medicine. This review provides a summary of the principal PCSK9 research findings, which underpin our current understanding of its function and clinical relevance.
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Affiliation(s)
- Jonathan Malo
- Clinical Biochemistry, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Arun Parajuli
- Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - Simon W Walker
- Clinical Biochemistry, Royal Infirmary Edinburgh, Edinburgh, UK
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Alkhalil M. Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors, Reality or Dream in Managing Patients with Cardiovascular Disease. Curr Drug Metab 2019; 20:72-82. [PMID: 30112987 DOI: 10.2174/1389200219666180816141827] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 06/28/2018] [Accepted: 08/01/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Statins have been a major keystone in the management of patients with atherosclerotic cardiovascular disease. The benefits of inhibiting HMG CoA reductase, via statins, were translated into reduction in LDL-c with proportionate decrease in cardiovascular events in response to the magnitude of LDL-c reduction. Despite major advances in pharmacological treatments, including the use of high-dose statins, there are urgent need to further reduce future cardiovascular risk. This is in particularly important since 1 out of 5 high-risk atherosclerotic patients who achieve low LDL-c return with a second cardiovascular event within five years. Although this residual risk post-statin is largely heterogeneous, lowering LDL-c beyond 'normal' or guidelines-recommended level using novel therapies has resulted in further reduction in cardiovascular events. OBJECTIVE The current review will discuss the use of PCSK9 inhibitors in patients with atherosclerotic disease. PCSK9 inhibitors are a new class of lipid-lowering drugs that are either fully human monoclonal antibodies (evolocumab and alirocumab) or humanised monoclonal antibodies (bococizumab) that effectively reduce LDL-c to unprecedented level. By blocking circulating PCSK9, these drugs would preserve LDL receptors and prevent them from cellular degradation. This process promotes recycling of LDL receptors back to hepatocytes surface, leading into further reduction of LDL-c. Combining PCSK9 inhibitors with statin have led into lower LDL-c, reduction in plaque volume and more importantly reduction in future cardiovascular events. CONCLUSION These drugs are very promising, nonetheless, the unselective approach of applying these monoclonal antibodies may not prove to be cost-effective and potentially exposing some patients to unnecessary side effects.
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Affiliation(s)
- Mohammad Alkhalil
- Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom.,Cardiology Department, Royal Victoria Hospital, Belfast HSC Trust, Belfast, United Kingdom
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Strilchuk L, Fogacci F, Cicero AF. Safety and tolerability of injectable lipid-lowering drugs: an update of clinical data. Expert Opin Drug Saf 2019; 18:611-621. [DOI: 10.1080/14740338.2019.1620730] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Larysa Strilchuk
- Department of Therapy and Medical Diagnostics, Lviv National Medical University, Lviv, Ukraine
| | - Federica Fogacci
- Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy AQ1: The ORCID of Federica Fogacci is OK
| | - Arrigo Fg Cicero
- Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy AQ1: The ORCID of Federica Fogacci is OK
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Casula M, Olmastroni E, Boccalari MT, Tragni E, Pirillo A, Catapano AL. Cardiovascular events with PCSK9 inhibitors: an updated meta-analysis of randomised controlled trials. Pharmacol Res 2019; 143:143-150. [PMID: 30926528 DOI: 10.1016/j.phrs.2019.03.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 02/15/2019] [Accepted: 03/25/2019] [Indexed: 12/15/2022]
Abstract
The therapy with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors efficiently reduces plasma cholesterol levels, which has been recently associated with improvement in cardiovascular outcomes. This meta-analysis aimed at investigating the safety and efficacy of treatment with the clinically available anti-PCSK9 monoclonal antibodies (mAbs) in all published randomized clinical trials (RCTs), updating the available results with the recently published ODYSSEY OUTCOMES trial. Data search was carried out using PubMed/MEDLINE and EMBASE (inception - January 2019). Inclusion criteria were: (1) phase 2 or 3 RCTs; (2) comparing anti-PCSK9 mAbs (specifically evolocumab and alirocumab) with placebo; (3) with effects on outcomes reported; (4) with treatment duration longer than 8 weeks. Odds ratios (ORs) with 95% CIs were used as summary statistics. We pooled the estimates by using both the DerSimonian & Laird method (random-effects model). Between-study heterogeneity was tested by Cochrane's Q test and measured with the I2 statistics. Twenty-eight RCTs comprising 62,281 participants (33,204 in the mAb arm, 29,077 in the placebo arm) were included in the meta-analysis. The treatment follow-up ranged from 8 weeks up to 208 weeks. Overall, no significant difference in all-cause mortality was observed between the two groups (OR 0.93 [95% CI, 0.85-1.03]). The treatment with an anti-PCSK9 mAb was associated with a significant reduction of CV events compared with placebo (OR 0.83 [95% CI, 0.78-0.87]), being the FOURIER and ODYSSEY OUTCOMES studies the major contributors. Both myocardial infarction and stroke were significantly reduced following the treatment with an anti-PCSK9 mAb. No significant difference was observed in cardiovascular mortality (OR 0.94 [95% CI, 0.83-1.07]). The incidence of serious adverse events was similar in the two groups (OR: 0.95, [95% CI, 0.91-0.99]). Thus, the pharmacological approach with anti-PCSK9 mAbs significantly and safely improves cardiovascular outcomes. Despite that, the pooled analysis failed to show a significant cardiovascular mortality benefit with anti-PCSK9 mAb treatment, suggesting that specific longer-term studies are warranted to address this issue. We suggest that the observed delay between the rapid effect on plasma cholesterol levels and the emergence of the clinical benefit, observed both in FOURIER and ODYSSEY OUTCOMES trials, might explain this finding.
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Affiliation(s)
- Manuela Casula
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; Epidemiology and Preventive Pharmacology Centre (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Elena Olmastroni
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; Epidemiology and Preventive Pharmacology Centre (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Mezio T Boccalari
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; Epidemiology and Preventive Pharmacology Centre (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Elena Tragni
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; Epidemiology and Preventive Pharmacology Centre (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Angela Pirillo
- Center for the Study of Atherosclerosis, E. Bassini Hospital, Cinisello Balsamo, Milan, Italy; IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy
| | - Alberico L Catapano
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy.
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A Meta-Analysis of the Effect of PCSK9-Monoclonal Antibodies on Circulating Lipoprotein (a) Levels. Am J Cardiovasc Drugs 2019; 19:87-97. [PMID: 30229525 DOI: 10.1007/s40256-018-0303-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Lipoprotein (a) [Lp(a)] is an atherogenic lipoprotein. While no effective therapy for Lp(a) is currently available, recently, several pooled analyses with small sample sizes have suggested that proprotein convertase subtilisin/kexin type 9 monoclonal antibodies (PCSK9-mAbs) could reduce circulating Lp(a) levels. This meta-analysis was performed to comprehensively investigate the efficacy of PCSK9-mAbs with respect to serum Lp(a) concentrations. METHODS PubMed, MEDLINE, Embase, ClinicalTrials.gov, Cochrane CENTRAL, Web of Science and recent conferences up to July 2018 were searched. Randomized clinical trials evaluating the effect of PCSK9-mAbs and control treatment on plasma Lp(a) concentrations were included. Mean differences and odds ratios with 95% confidence intervals (CIs) were used. RESULTS Twenty-seven randomized clinical trials with a total of 11,864 participants were included. PCSK9-mAbs showed a significant efficacy in reducing Lp(a) (- 21.9%, 95% CI - 24.3 to - 19.5), irrespective of PCSK9-mAb types, treatment duration, participant characteristics, treatment methods, differences of control treatment, baseline Lp(a) levels, and test methods. The greatest reduction was achieved with 150 mg alirocumab biweekly (- 24.6%, 95% CI - 28.0 to - 21.2) and 140 mg evolocumab monthly (- 26.8%, 95% CI - 31.6 to - 21.9). Meta-regression analyses found that the more intense low-density lipoprotein cholesterol levels declined during PCSK9-mAb treatment, the greater the reduction in Lp(a) levels. Safety was in accordance with previous reports. CONCLUSIONS The results of this analysis suggested that PCSK9-mAbs could significantly reduce circulating Lp(a) levels. Long-term studies may be needed to confirm the effect of PCSK9-mAbs on Lp(a) in the future.
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Karpov YA. The Role of PCSK9 Inhibitors in the Improvement of Outcomes in Patients after Acute Coronary Syndrome: Results of ODYSSEY OUTCOMES Trial. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2019. [DOI: 10.20996/1819-6446-2018-14-6-922-934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The aim of this review was to present the recently published results of ODYSSEY OUTCOMES trial and discuss the clinical perspective of these data. Patients with acute coronary syndrome are at very high risk of recurrent ischemic cardiovascular complications, especially during the first year after the event. The use of high-intensity statin therapy in this group of patients does not always lead to the achievement of target levels of atherogenic lipoproteins. PCSK9 inhibitors, administered in addition to statins, can provide additional reduction of low-density lipoprotein cholesterol, which leads to further improvements of outcomes in patients with atherosclerotic cardiovascular disease. According to the latest results from ODYSSEY OUTCOMES trial, among patients with recent acute coronary syndrome, who were receiving high-intensity statin therapy, the risk of recurrent ischemic cardiovascular events was lower among those who were treated with alirocumab then among those who received placebo. The treatment with alirocumab in patients with recent acute coronary syndrome was associated with reduction in death from any causes. The absolute risk reduction with alirocumab was the most prominent in the subpopulation of patients with low-density lipoprotein cholesterol ≥2,6 mmol/l at baseline. These results have implication for clinical practice and may play an important role for the improvement of outcomes in patients at highest cardiovascular risk after acute cardiovascular syndrome.
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Abstract
Ischemic heart disease and stroke are the leading causes of death in the world currently. Both of these conditions are primarily caused by atherosclerosis, the underlying pathophysiology of which is the deposition of lipid, specifically low-density lipoprotein cholesterol (LDL-C) within the arterial bed. PCSK9, is a proteolytic enzyme, which indirectly increases LDL-C levels by causing the destruction of LDL receptors, the main way that humans regulate their serum LDL-C levels. Inhibitors of PCSK9 in conjunction with statins have allowed achievement of very low LDL-C levels. This review will provide an in-depth efficacy and safety review of alirocumab, a monoclonal antibody inhibitor of PCSK9, including the ODYSSEY OUTCOMES trial.
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Affiliation(s)
- Eli M Roth
- President, Sterling Research Group & Clinical Professor, Division of Cardiovascular Health & Disease, University of Cincinnati, Cincinnati, OH 45219-513, USA
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Handelsman Y, Lepor NE. PCSK9 Inhibitors in Lipid Management of Patients With Diabetes Mellitus and High Cardiovascular Risk: A Review. J Am Heart Assoc 2018; 7:JAHA.118.008953. [PMID: 29934421 PMCID: PMC6064883 DOI: 10.1161/jaha.118.008953] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Lin XL, Xiao LL, Tang ZH, Jiang ZS, Liu MH. Role of PCSK9 in lipid metabolism and atherosclerosis. Biomed Pharmacother 2018; 104:36-44. [PMID: 29758414 DOI: 10.1016/j.biopha.2018.05.024] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 05/01/2018] [Accepted: 05/07/2018] [Indexed: 12/11/2022] Open
Abstract
Elevated plasma low-density lipoprotein cholesterol (LDL-C) is an important risk factor for cardiovascular diseases. Statins are the most widely used therapy for patients with hyperlipidemia. However, a significant residual cardiovascular risk remains in some patients even after maximally tolerated statin therapy. Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a new pharmacologically therapeutic target for decreasing LDL-C. PCSK9 reduces LDL intake from circulation by enhancing LDLR degradation and preventing LDLR recirculation to the cell surface. Moreover, PCSK9 inhibitors have been approved for patients with either familial hypercholesterolemia or atherosclerotic cardiovascular disease, who require additional reduction of LDL-C. In addition, PCSK9 inhibition combined with statins has been used as a new approach to help reduce LDL-C levels in patients with either statin intolerance or unattainable LDL goal. This review will discuss the emerging anti-PCSK9 therapies in the regulation of cholesterol metabolism and atherosclerosis.
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Affiliation(s)
- Xiao-Long Lin
- Department of Pathology, Hui Zhou Third People's Hospital, Guangzhou Medical University, Huizhou City, Guangdong Province, 516002, China
| | - Le-Le Xiao
- Huzhou University, Huzhou City, Zhejiang Province, 313000, China
| | - Zhi-Han Tang
- Institute of Cardiovascular Disease, Key Laboratory for Arteriosclerology of Hunan Province, University of South China, Hengyang, Hunan, 421001, China
| | - Zhi-Sheng Jiang
- Institute of Cardiovascular Disease, Key Laboratory for Arteriosclerology of Hunan Province, University of South China, Hengyang, Hunan, 421001, China
| | - Mi-Hua Liu
- Institute of Cardiovascular Disease, Key Laboratory for Arteriosclerology of Hunan Province, University of South China, Hengyang, Hunan, 421001, China; Centre for Lipid Research & Key Laboratory of Molecular Biology for Infectious Diseases (Ministry of Education), Institute for Viral Hepatitis, Department of Infectious Diseases, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China.
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Gil-Extremera B, Jiménez-López P, Mediavilla-García J. Clinical trials. A pending subject. Rev Clin Esp 2018. [DOI: 10.1016/j.rceng.2017.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Gebauer K, Reinecke H. PCSK9 inhibition for LDL lowering and beyond – implications for patients with peripheral artery disease. VASA 2018; 47:165-176. [DOI: 10.1024/0301-1526/a000689] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Abstract. Low-density lipoprotein cholesterol (LDL-C) has been proven to be a causal factor of atherosclerosis and, along with other triggers like inflammation, the most frequent reason for peripheral arterial disease. Moreover, a linear correlation between LDL-C concentration and cardiovascular outcome in high-risk patients could be established during the past century. After the development of statins, numerous randomized trials have shown the superiority for LDL-C reduction and hence the decrease in cardiovascular outcomes including mortality. Over the past decades it became evident that more intense LDL-C lowering, by either the use of highly potent statin supplements or by additional cholesterol absorption inhibitor application, accounted for an even more profound cardiovascular risk reduction. Proprotein convertase subtilisin/kexin type 9 (PCSK9), a serin protease with effect on the LDL receptor cycle leading to its degradation and therefore preventing continuing LDL-C clearance from the blood, is the target of a newly developed monoclonal antibody facilitating astounding LDL-C reduction far below to what has been set as target level by recent ESC/EAS guidelines in management of dyslipidaemias. Large randomized outcome trials including subjects with PAD so far have been able to prove significant and even more intense cardiovascular risk reduction via further LDL-C debasement on top of high-intensity statin medication. Another approach for LDL-C reduction is a silencing interfering RNA muting the translation of PCSK9 intracellularly. Moreover, PCSK9 concentrations are elevated in cells involved in plaque composition, so the potency of intracellular PCSK9 inhibition and therefore prevention or reversal of plaques may provide this mechanism of action on PCSK9 with additional beneficial effects on cells involved in plaque formation. Thus, simultaneous application of statins and PCSK9 inhibitors promise to reduce cardiovascular event burden by both LDL-C reduction and pleiotropic effects of both agents.
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Affiliation(s)
- Katrin Gebauer
- Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany
| | - Holger Reinecke
- Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany
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Abstract
Elevated low-density lipoprotein cholesterol (LDL-C) plays a major role in the development of atherosclerotic cardiovascular disease. Statins are the first-line treatment to lower LDL-C in patients with hypercholesterolemia; however, some high cardiovascular risk patients may have inadequate responses to statin therapy or are intolerant to statins, and may need additional and/or alternative non-statin therapies to further reduce their LDL-C levels. Monoclonal antibodies that inhibit proprotein convertase subtilisin/kexin type 9 (PCSK9), a key regulator of circulating LDL-C levels, have received considerable attention as promising non-statin therapeutic options for the management of hypercholesterolemia. This review provides a brief overview of the history and science of PCSK9 inhibitors, focusing on two PCSK9 monoclonal antibodies that have been approved by the US Food and Drug Administration: alirocumab and evolocumab. Recently released and forthcoming clinical trial data will be discussed, as well as the practical application of patient populations that may benefit from PCSK9 inhibitors. Finally, the recent expert recommendations regarding the use of PCSK9 inhibitors and other non-statin therapies to treat patients with inadequate LDL-C-lowering on statin therapy will be summarized.
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Affiliation(s)
- Gregory S Pokrywka
- a Baltimore Lipid Center / Johns Hopkins University School of Medicine, General Internal Medicine , Towson , MD , USA
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Bajaj NS, Patel N, Kalra R, Ahmad A, Venkatraman A, Arora G, Arora P. Neurological effects of proprotein convertase subtilisin/kexin type 9 inhibitors: direct comparisons. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2018; 4:132-141. [PMID: 29121222 PMCID: PMC5884103 DOI: 10.1093/ehjqcco/qcx037] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 08/02/2017] [Accepted: 10/05/2017] [Indexed: 01/21/2023]
Abstract
Aims Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors considerably alter the lipid profile. We sought to examine the rates of ischaemic stroke and neurocognitive deficits in patients treated with and without PCSK9 inhibitors. Methods and results Randomized controlled trials (RCTs) reporting rates of ischaemic stroke and neurocognitive deficits in patients using PCSK9 inhibitors were identified. Standard meta-analysis techniques were used to compare these outcomes among patients treated with and without PCSK9 inhibitors and the two US Food and Drug Administration-approved PCSK9 inhibitors, evolocumab and alirocumab. The results were presented in terms of risk ratio (RR) with 95% confidence intervals (CIs). Sixteen RCTs with 39 104 patients were included. Evolocumab was used in six RCTs with 33 450 patients, whereas alirocumab was used in 10 RCTs with 5654 patients. We observed a significantly lower risk of ischaemic stroke among those treated with PCSK9 inhibitors (RR 0.77, 95% CI 0.64-0.93) when compared with those without. We did not observe any difference in the risk of neurocognitive deficits between the aforementioned groups (RR 1.11, 95% CI 0.93-1.32). The lower stroke risk in the PCSK9 inhibitors group was driven by evolocumab studies. We observed no difference in the risk of neurocognitive deficits among evolocumab and alirocumab when compared with no PCSK9 inhibitors group. Conclusion Treatment with PCSK9 inhibitors significantly lowers the risk of ischaemic stroke, without any increased risk of neurocognitive deficits. PCSK9 inhibitors are neuroprotective due to the decrease in ischaemic-mediated neurovascular events and should be considered cognitively innocuous medications.
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Affiliation(s)
- Navkaranbir S Bajaj
- Department of Cardiovascular Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, 1900 University Boulevard Birmingham, AL 35233, USA
| | - Nirav Patel
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, 1900 University Boulevard Birmingham, AL 35233, USA
| | - Rajat Kalra
- Department of Medicine, Cardiovascular Division, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455, USA
| | - Amier Ahmad
- Department of Medicine, University of Alabama at Birmingham, 1808 7th Ave South, Birmingham, AL 35233, USA
| | - Anand Venkatraman
- Department of Neurology, University of Alabama at Birmingham, 1720 2nd Ave South, Birmingham, AL 35294, USA
| | - Garima Arora
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, 1900 University Boulevard Birmingham, AL 35233, USA
| | - Pankaj Arora
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, 1900 University Boulevard Birmingham, AL 35233, USA
- Department of Veterans Affairs, Section of Cardiology, Birmingham Veterans Affairs Medical Center, 1720 2nd Ave South, Birmingham, AL 35294, USA
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Kandaswamy E, Zuo L. Recent Advances in Treatment of Coronary Artery Disease: Role of Science and Technology. Int J Mol Sci 2018; 19:ijms19020424. [PMID: 29385089 PMCID: PMC5855646 DOI: 10.3390/ijms19020424] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/06/2018] [Accepted: 01/15/2018] [Indexed: 12/11/2022] Open
Abstract
Coronary artery disease (CAD) is one of the most common causes of death worldwide. In the last decade, significant advancements in CAD treatment have been made. The existing treatment is medical, surgical or a combination of both depending on the extent, severity and clinical presentation of CAD. The collaboration between different science disciplines such as biotechnology and tissue engineering has led to the development of novel therapeutic strategies such as stem cells, nanotechnology, robotic surgery and other advancements (3-D printing and drugs). These treatment modalities show promising effects in managing CAD and associated conditions. Research on stem cells focuses on studying the potential for cardiac regeneration, while nanotechnology research investigates nano-drug delivery and percutaneous coronary interventions including stent modifications and coatings. This article aims to provide an update on the literature (in vitro, translational, animal and clinical) related to these novel strategies and to elucidate the rationale behind their potential treatment of CAD. Through the extensive and continued efforts of researchers and clinicians worldwide, these novel strategies hold the promise to be effective alternatives to existing treatment modalities.
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Affiliation(s)
- Eswar Kandaswamy
- Radiologic Sciences and Respiratory Therapy Division, School of Health and Rehabilitation Sciences, The Ohio State University College of Medicine, Columbus, OH 43210, USA.
| | - Li Zuo
- Radiologic Sciences and Respiratory Therapy Division, School of Health and Rehabilitation Sciences, The Ohio State University College of Medicine, Columbus, OH 43210, USA.
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