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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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Abstract
Life expectancy, and longevity have been increasing in recent years. However, this is, in most cases, accompanied by age-related diseases. Thus, it became essential to better understand the mechanisms inherent to aging, and to establish biomarkers that characterize this physiological process. Among all biomolecules, lipids appear to be a good target for the study of these biomarkers. In fact, some lipids have already been associated with age-related diseases. With the development of analytical techniques such as Mass Spectrometry, and Nuclear Magnetic Resonance, Lipidomics has been increasingly used to study pathological, and physiological states of an organism. Thus, the study of serum, and plasma lipidome in centenarians, and elderly individuals without age-related diseases can be a useful tool for the identification of aging biomarkers, and to understand physiological aging, and longevity. This review focus on the importance of lipids as biomarkers of aging, and summarize the changes in the lipidome that have been associated with aging, and longevity.
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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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Colhoun HM, Leiter LA, Müller-Wieland D, Cariou B, Ray KK, Tinahones FJ, Domenger C, Letierce A, Israel M, Samuel R, Del Prato S. Effect of alirocumab on individuals with type 2 diabetes, high triglycerides, and low high-density lipoprotein cholesterol. Cardiovasc Diabetol 2020; 19:14. [PMID: 32035487 PMCID: PMC7007683 DOI: 10.1186/s12933-020-0991-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/22/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Mixed dyslipidemia [elevated non-high-density lipoprotein cholesterol (non-HDL-C) and triglycerides (TGs), and decreased HDL-C] is common in type 2 diabetes mellitus (T2DM) and is associated with increased cardiovascular risk. Non-HDL-C and apolipoprotein B (ApoB) are the preferred therapeutic targets for mixed dyslipidemia. Alirocumab is a monoclonal antibody to proprotein convertase subtilisin/kexin type 9 (PCSK9) that effectively reduces low-density lipoprotein cholesterol (LDL-C), non-HDL-C, ApoB, and lipoprotein(a) (Lp[a]), and is well-tolerated in individuals with T2DM. METHODS The previously reported open-label ODYSSEY DM-DYSLIPIDEMIA trial data demonstrated the effects of alirocumab on individuals with non-HDL-C ≥ 100 mg/dL and TGs ≥ 150 and < 500 mg/dL receiving stable maximally tolerated statin (n = 413). This post hoc subgroup analysis of the primary trial investigated the effects of alirocumab [75 mg every 2 weeks (Q2W) with possible increase to 150 mg Q2W at Week 12] versus usual care [ezetimibe, fenofibrate, or no additional lipid-lowering therapy (LLT)] on non-HDL-C and other lipids in individuals with T2DM and baseline TGs ≥ 200 mg/dL and HDL-C < 40 mg/dL (men) or < 50 mg/dL (women). RESULTS Alirocumab significantly reduced non-HDL-C [LS mean difference (standard error (SE)), - 35.0% (3.9)], ApoB [LS mean difference (SE), - 34.7% (3.6)], LDL-C [LS mean difference (SE), - 47.3% (5.2)], LDL particle number [LS mean difference (SE), - 40.8% (4.1)], and Lp(a) [LS mean difference (SE), - 29.9% (5.4)] versus usual care from baseline to Week 24 (all P < 0.0001). Results were similar for alirocumab versus usual care. TG reductions were similar between alirocumab and usual care (no significant difference), but greater with fenofibrate versus alirocumab (P = 0.3371). Overall, alirocumab significantly increased HDL-C versus usual care [LS mean difference (SE), 7.9% (3.6); P < 0.05], although differences with alirocumab versus ezetimibe or fenofibrate were non-significant. Most individuals receiving alirocumab achieved ApoB < 80 mg/dL (67.9%) and non-HDL-C < 100 mg/dL (60.9%). Adverse event frequency was similar between alirocumab (67.2%) and usual care (70.7%). Additionally, no clinically relevant effect of alirocumab on change in glycemic parameters or use of antihyperglycemic agents was observed. CONCLUSIONS Alirocumab is an effective therapeutic option for individuals with T2DM, TGs ≥ 200 mg/dL, and HDL-C < 40 mg/dL (men) or < 50 mg/dL (women). Atherogenic lipid (ApoB and non-HDL) reductions were greater with alirocumab than ezetimibe, fenofibrate, or no LLT. Consistent with previous studies, alirocumab was generally well tolerated. Trial registration Clinicaltrials.gov, NCT02642159. Registered December 24, 2015, https://clinicaltrials.gov/ct2/show/NCT02642159.
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Affiliation(s)
- Helen M Colhoun
- The Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU, UK.
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Dirk Müller-Wieland
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany
| | - Bertrand Cariou
- l'institut du thorax, CHU Nantes, INSERM, CNRS, UNIV Nantes, Nantes, France
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, Imperial College, London, UK
| | - Francisco J Tinahones
- Department of Clinical Endocrinology and Nutrition (IBIMA), Hospital Virgen de la Victoria, University of Málaga, CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Málaga, Spain
| | | | - Alexia Letierce
- Biostatistics and Programming Department, Sanofi, Chilly-Mazarin, France
| | - Marc Israel
- Regeneron Pharmaceuticals, Inc, Tarrytown, NY, USA
| | - Rita Samuel
- Regeneron Pharmaceuticals, Inc, Tarrytown, NY, USA
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Ray KK, Del Prato S, Müller-Wieland D, Cariou B, Colhoun HM, Tinahones FJ, Domenger C, Letierce A, Mandel J, Samuel R, Bujas-Bobanovic M, Leiter LA. Alirocumab therapy in individuals with type 2 diabetes mellitus and atherosclerotic cardiovascular disease: analysis of the ODYSSEY DM-DYSLIPIDEMIA and DM-INSULIN studies. Cardiovasc Diabetol 2019; 18:149. [PMID: 31706300 PMCID: PMC6842201 DOI: 10.1186/s12933-019-0951-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 10/24/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Individuals with diabetes often have high levels of atherogenic lipoproteins and cholesterol reflected by elevated low-density lipoprotein cholesterol (LDL-C), non-high-density lipoprotein cholesterol (non-HDL-C), apolipoprotein B (ApoB), and LDL particle number (LDL-PN). The presence of atherosclerotic cardiovascular disease (ASCVD) increases the risk of future cardiovascular events. We evaluated the efficacy and safety of the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, alirocumab, among individuals with type 2 diabetes (T2DM), high LDL-C or non-HDL-C, and established ASCVD receiving maximally tolerated statin in ODYSSEY DM-DYSLIPIDEMIA (NCT02642159) and DM-INSULIN (NCT02585778). METHODS In DM-DYSLIPIDEMIA, individuals with T2DM and mixed dyslipidemia (non-HDL-C ≥ 100 mg/dL; n = 413) were randomized to open-label alirocumab 75 mg every 2 weeks (Q2W) or usual care (UC) for 24 weeks, with UC options selected before stratified randomization. In DM-INSULIN, insulin-treated individuals with T2DM (LDL-C ≥ 70 mg/dL; n = 441) were randomized in a double-blind fashion to alirocumab 75 mg Q2W or placebo for 24 weeks. Study participants also had a glycated hemoglobin < 9% (DM-DYSLIPIDEMIA) or < 10% (DM-INSULIN). Alirocumab dose was increased to 150 mg Q2W at week 12 if week 8 LDL-C was ≥ 70 mg/dL (DM-INSULIN) or non-HDL-C was ≥ 100 mg/dL (DM-DYSLIPIDEMIA). Lipid reductions and safety were assessed in patients with ASCVD from these studies. RESULTS This analysis included 142 DM-DYSLIPIDEMIA and 177 DM-INSULIN participants with ASCVD, including 95.1% and 86.4% with coronary heart disease, and 32.4% and 49.7% with microvascular diabetes complications, respectively. At week 24, alirocumab significantly reduced LDL-C, non-HDL-C, ApoB, and LDL-PN from baseline versus control. This translated into a greater proportion of individuals achieving non-HDL-C < 100 mg/dL (64.6% alirocumab/23.8% UC [DM-DYSLIPIDEMIA]; 65.4% alirocumab/14.9% placebo [DM-INSULIN]) and ApoB < 80 mg/dL (75.1% alirocumab/35.4% UC and 76.8% alirocumab/24.8% placebo, respectively) versus control at week 24 (all P < 0.0001). In pooling these studies, 66.4% (alirocumab) and 67.0% (control) of individuals reported treatment-emergent adverse events. The adverse event pattern was similar with alirocumab versus controls. CONCLUSIONS Among individuals with T2DM and ASCVD who had high non-HDL-C/LDL-C levels despite maximally tolerated statin, alirocumab significantly reduced atherogenic cholesterol and LDL-PN versus control. Alirocumab was generally well tolerated. Trial registration Clinicaltrials.gov. NCT02642159. Registered 30 December 2015 and Clinicaltrials.gov. NCT02585778. Registered 23 October 2015.
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MESH Headings
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Anticholesteremic Agents/adverse effects
- Anticholesteremic Agents/therapeutic use
- Atherosclerosis/blood
- Atherosclerosis/diagnosis
- Atherosclerosis/drug therapy
- Atherosclerosis/epidemiology
- Biomarkers/blood
- Cholesterol, HDL/blood
- Cholesterol, LDL/blood
- Clinical Trials, Phase III as Topic
- Clinical Trials, Phase IV as Topic
- Coronary Disease/blood
- Coronary Disease/diagnosis
- Coronary Disease/drug therapy
- Coronary Disease/epidemiology
- Diabetes Mellitus, Type 2/blood
- Diabetes Mellitus, Type 2/diagnosis
- Diabetes Mellitus, Type 2/drug therapy
- Diabetes Mellitus, Type 2/epidemiology
- Drug Therapy, Combination
- Dyslipidemias/blood
- Dyslipidemias/diagnosis
- Dyslipidemias/drug therapy
- Dyslipidemias/epidemiology
- Humans
- Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use
- Multicenter Studies as Topic
- PCSK9 Inhibitors
- Randomized Controlled Trials as Topic
- Risk Factors
- Serine Proteinase Inhibitors/adverse effects
- Serine Proteinase Inhibitors/therapeutic use
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, Imperial College, Kensington, London, SW7 2AZ, UK.
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Dirk Müller-Wieland
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany
| | - Bertrand Cariou
- l'institut du thorax, Department of Endocrinology, CHU Nantes, INSERM, 1413, Nantes, France
| | | | - Francisco J Tinahones
- Department of Clinical Endocrinology and Nutrition (IBIMA), Hospital Virgen de la Victoria, University of Málaga, CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Málaga, Spain
| | | | - Alexia Letierce
- Biostatistics and Programming Department, Sanofi, Chilly-Mazarin, France
| | | | - Rita Samuel
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, NY, USA
| | | | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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Brandts J, Müller-Wieland D. PCSK9 Inhibition: New Treatment Options and Perspectives to Lower Atherogenic Lipoprotein Particles and Cardiovascular Risk. Curr Atheroscler Rep 2019; 21:40. [PMID: 31350672 DOI: 10.1007/s11883-019-0802-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW To summarize latest clinical studies and to put them into perspectives for clinical relevant subgroups and new therapeutic options. RECENT FINDINGS Have investigated PCSK9 inhibitors in patients with very high cardiovascular risk and insufficient LDL cholesterol lowering under current maximal tolerated lipid-lowering therapy, patients with statin intolerance, or genetic forms of familiar hypercholesterolemia, and patients on LDL apheresis. Purpose of recent cardiovascular endpoint trials has proven cardiovascular benefit of this new approach. PCSK9 inhibition with fully humanized antibodies has proven to be effective, safe, and well-tolerated in reducing cardiovascular risk by LDL cholesterol lowering. Therefore, research interests are to elucidate additional roles and effects of PCSK9 modulation on inflammation and cellular processes of the atherosclerotic plaque and to develop alternative therapeutic strategies addressing PCSK9 as a proven and therefore promising drug target.
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Affiliation(s)
- Julia Brandts
- Department of Medicine I, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Dirk Müller-Wieland
- Department of Medicine I, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany.
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Ascaso JF, Civeira F, Guijarro C, López Miranda J, Masana L, Mostaza JM, Pedro-Botet J, Pintó X, Valdivielso P. Indications of PCSK9 inhibitors in clinical practice. Recommendations of the Spanish Sociey of Arteriosclerosis (SEA), 2019. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS 2019; 31:128-139. [PMID: 31130361 DOI: 10.1016/j.arteri.2019.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 04/11/2019] [Indexed: 02/06/2023]
Abstract
A group of experts convened by the Spanish Society of Arteriosclerosis (SEA) has been in charge of updating the SEA document on the indications of PCSK9 inhibitors (PCSK9i) in clinical practice that was published in 2016. This update is justified by the fact that the data from clinical trials carried out on a large scale with PCSK9i have shown that in addition to their high potency to lower atherogenic cholesterol, they reduce the risk of atherosclerotic cardiovascular disease, both in patients with stable disease, and with recent disease, and with a high degree of security. This update provides the recommendations and level of evidence for the prescription of iPCSK9 in patients with homozygous and heterozygous familial hypercholesterolemia, with atherosclerotic cardiovascular disease, and in primary prevention in patients with very high cardiovascular risk. These recommendations have been established taking into account the concentration of LDL-C, the clinical situation of the patient, the additional risk factors and the cost-effectiveness of their use.
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Affiliation(s)
| | - Fernando Civeira
- Hospital Universitario Miguel Servet, IIS Aragón, CIBERCV, Universidad de Zaragoza, Zaragoza, España
| | - Carlos Guijarro
- Hospital Universitario Fundación Alcorcón, Universidad Rey Juan Carlos, Alcorcón, Madrid, España
| | - José López Miranda
- Hospital Universitario Reina Sofía, IMIBIC, Universidad de Córdoba, CIBEROBN, Córdoba, España
| | - Luis Masana
- Hospital Universitario de Reus, Universidad Rovira y Virgili, IISPV, CIBERDEM, Reus, Tarragona, España
| | | | - Juan Pedro-Botet
- Hospital del Mar, Universidad Autónoma de Barcelona, Barcelona, España
| | - Xavier Pintó
- Hospital Universitario de Bellvitge-Idibell, Universidad de Barcelona, CIBEROBN, Hospitalet de Llobregat, Barcelona, España.
| | - Pedro Valdivielso
- Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, España
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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: 44] [Impact Index Per Article: 7.3] [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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Dijk W, Le May C, Cariou B. Beyond LDL: What Role for PCSK9 in Triglyceride-Rich Lipoprotein Metabolism? Trends Endocrinol Metab 2018; 29:420-434. [PMID: 29665987 DOI: 10.1016/j.tem.2018.03.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 03/10/2018] [Accepted: 03/15/2018] [Indexed: 10/17/2022]
Abstract
Elevated plasma triglyceride (TG) levels are an independent risk factor for cardiovascular disease (CVD). Proprotein convertase subtilisin-kexin 9 (PCSK9) - a protein therapeutically targeted to lower plasma cholesterol levels - might regulate plasma TG-rich lipoprotein (TRL) levels. We provide a timely and critical review of the current evidence for a role of PCSK9 in TRL metabolism by assessing the impact of PCSK9 gene variants, by reviewing recent clinical data with PCSK9 inhibitors, and by describing the potential mechanisms by which PCSK9 might regulate TRL metabolism. We conclude that the impact of PCSK9 on TRL metabolism is relatively modest, especially compared to its impact on cholesterol metabolism.
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Affiliation(s)
- Wieneke Dijk
- L'institut du thorax, INSERM, CNRS, Université de Nantes, Nantes, France
| | - Cédric Le May
- L'institut du thorax, INSERM, CNRS, Université de Nantes, Nantes, France
| | - Bertrand Cariou
- L'institut du thorax, INSERM, CNRS, Université de Nantes, Nantes, France; L'institut du thorax, Department of Endocrinology, CHU NANTES, Nantes, France.
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10
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Ray KK, Leiter LA, Müller‐Wieland D, Cariou B, Colhoun HM, Henry RR, Tinahones FJ, Bujas‐Bobanovic M, Domenger C, Letierce A, Samuel R, Del Prato S. Alirocumab vs usual lipid-lowering care as add-on to statin therapy in individuals with type 2 diabetes and mixed dyslipidaemia: The ODYSSEY DM-DYSLIPIDEMIA randomized trial. Diabetes Obes Metab 2018; 20:1479-1489. [PMID: 29436756 PMCID: PMC5969299 DOI: 10.1111/dom.13257] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 01/29/2018] [Accepted: 02/06/2018] [Indexed: 01/14/2023]
Abstract
AIM To compare alirocumab, a proprotein convertase subtilisin-kexin type 9 inhibitor, with usual care (UC) in individuals with type 2 diabetes (T2DM) and mixed dyslipidaemia not optimally managed by maximally tolerated statins in the ODYSSEY DM-DYSLIPIDEMIA trial (NCT02642159). MATERIALS AND METHODS The UC options (no additional lipid-lowering therapy; fenofibrate; ezetimibe; omega-3 fatty acid; nicotinic acid) were selected prior to stratified randomization to open-label alirocumab 75 mg every 2 weeks (with increase to 150 mg every 2 weeks at week 12 if week 8 non-HDL cholesterol concentration was ≥2.59 mmol/L [100 mg/dL]) or UC for 24 weeks. The primary efficacy endpoint was percentage change in non-HDL cholesterol from baseline to week 24. RESULTS The randomized population comprised 413 individuals (intention-to-treat population, n = 409; safety population, n = 412). At week 24, the mean non-HDL cholesterol reductions were superior with alirocumab (-32.5% difference vs UC, 97.5% confidence interval -38.1 to -27.0; P < .0001). Overall, 63.6% of alirocumab-treated individuals were maintained on 75 mg every 2 weeks. Alirocumab also reduced LDL cholesterol (-43.0%), apolipoprotein B (-32.3%), total cholesterol (-24.6%) and LDL particle number (-37.8%) at week 24 vs UC (all P < .0001). Consistent with the overall trial comparison, alirocumab reduced non-HDL cholesterol to a greater degree within each UC stratum at week 24. The incidence of treatment-emergent adverse events was 68.4% (alirocumab) and 66.4% (UC). No clinically meaningful effect on glycated haemoglobin, or change in number of glucose-lowering agents, was seen. CONCLUSIONS In individuals with T2DM and mixed dyslipidaemia on maximally tolerated statin, alirocumab showed superiority to UC in non-HDL cholesterol reduction and was generally well tolerated.
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Affiliation(s)
- Kausik K. Ray
- Department of Primary Care and Public Health, Imperial Centre for Cardiovascular Disease PreventionImperial CollegeLondonUK
| | - Lawrence A. Leiter
- Li Ka Shing Knowledge Institute, St. Michael's HospitalUniversity of TorontoTorontoOntarioCanada
| | | | - Bertrand Cariou
- Department of Endocrinology, l'institut du thorax, CHU Nantes, Nantes, INSERM, CNRSUNIV NantesNantesFrance
| | | | - Robert R. Henry
- University of California San Diego School of Medicine and Center for Metabolic Research, Veterans Affairs, San Diego Healthcare SystemSan DiegoCalifornia
| | - Francisco J. Tinahones
- Department of Clinical Endocrinology and Nutrition (IBIMA), Hospital Virgen de la VictoriaUniversity of Málaga, CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos IIIMálagaSpain
| | | | | | - Alexia Letierce
- Biostatistics and Programming DepartmentSanofiChilly‐MazarinFrance
| | - Rita Samuel
- Regeneron Pharmaceuticals, Inc.TarrytownNew York
| | - Stefano Del Prato
- Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
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11
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Zhang J, Tecson KM, Rocha NA, McCullough PA. Usefulness of alirocumab and evolocumab for the treatment of patients with diabetic dyslipidemia. Proc (Bayl Univ Med Cent) 2018; 31:180-184. [PMID: 29706812 DOI: 10.1080/08998280.2018.1441255] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 12/27/2017] [Accepted: 12/28/2017] [Indexed: 02/07/2023] Open
Abstract
In 2015, the US Food and Drug Administration (FDA) approved the anti-proprotein convertase subtilsin/kexin type 9 (PCSK9) monoclonal antibodies, alirocumab and evolocumab, to treat patients with hypercholesterolemia and mixed dyslipidemia. Since then, considerable attention has been paid to the use of these monoclonal antibodies for the treatment of diabetic dyslipidemia with a goal of reducing the risk for cardiovascular disease. Recently, consensus statements on the clinical use of PCSK9 inhibitors in patients with type 2 diabetes mellitus, who are unable to achieve the goal of low-density lipoprotein cholesterol (<70 mg/dL or <1.8 mmol/L), have been published by panels of experts in Greece, Europe (European Society of Cardiology and European Atherosclerosis Society Task Force), and the United States (American College of Cardiology Consensus Committee). On December 1, 2017, the FDA approved evolocumab to prevent heart attack, stroke, and coronary revascularization. In this article, we review recent advances concerning the pathophysiology of diabetic dyslipidemia, the physiology of PCSK9, the mechanisms of action of PCSK9 inhibitors, clinical trials examining PCSK9 inhibitors in type 2 diabetes, and perspectives of nonstatin therapy in the treatment of diabetic dyslipidemia.
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Affiliation(s)
- Jun Zhang
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas
| | - Kristen M Tecson
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas
| | - Natalia A Rocha
- Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Peter A McCullough
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas.,Division of Cardiology, Baylor Jack and Jane Hamilton Hospital, Dallas, Texas
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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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Scicali R, Di Pino A, Ferrara V, Urbano F, Piro S, Rabuazzo AM, Purrello F. New treatment options for lipid-lowering therapy in subjects with type 2 diabetes. Acta Diabetol 2018; 55:209-218. [PMID: 29260404 DOI: 10.1007/s00592-017-1089-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 12/11/2017] [Indexed: 12/15/2022]
Abstract
Dyslipidemias represent a variety of quantitative and/or qualitative lipoprotein abnormalities. According to etiology, we distinguish primary dyslipidemias with strictly genetic background and secondary ones with their origin in other disease or pathological states. Diabetic dyslipidemia is a type of secondary dyslipidemia and plays an important role in determining the cardiovascular risk of subjects with type 2 diabetes. In these patients, insulin resistance is responsible for overproduction and secretion of atherogenic very low density lipoprotein. In addition, insulin resistance promotes the production of small dense low-density lipoprotein (LDL) and reduces high-density lipoprotein (HDL) production. Cardiovascular disease remains a leading cause of morbidity and mortality in diabetic patients. Previous results support the role for small, dense LDL particles in the etiology of atherosclerosis and their association with coronary artery disease. Moreover, lowering LDL cholesterol reduces the risk of cardiovascular death. Therefore, the European guidelines for the management of dyslipidemias recommend an LDL cholesterol goal < 100 mg/dL in diabetic subjects without cardiovascular events. Moreover, if triglycerides (TG) are elevated (> 400 mg/dL), they recommend a non-HDL cholesterol goal < 130 mg/dL in diabetic individuals without cardiovascular events. Statins are the first line of LDL-lowering therapy in diabetic patients and combined therapy with ezetimibe and statins could be useful in very high cardiovascular risk diabetic subjects. Furthermore, the effect of a fibrate as an add-on treatment to a statin could improve the lipid profile in diabetic individuals with high TG and low HDL cholesterol. Regarding new therapies, recent data from phase III trials show that proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors considerably decrease LDL cholesterol. Thus, they may be useful in diabetic patients with concomitant diseases such as familial dyslipidemia, recurrent cardiovascular events, and elevated LDL cholesterol after second drug administration in addition to maximal statin dose or statin intolerance.
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Affiliation(s)
- Roberto Scicali
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Antonino Di Pino
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Viviana Ferrara
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Francesca Urbano
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Salvatore Piro
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Agata Maria Rabuazzo
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Francesco Purrello
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy.
- Department of Clinical and Experimental Medicine, Internal Medicine, Garibaldi Hospital, University of Catania, Via Palermo, 636, 95122, Catania, Italy.
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Page MM, Watts GF. PCSK9 in context: A contemporary review of an important biological target for the prevention and treatment of atherosclerotic cardiovascular disease. Diabetes Obes Metab 2018; 20:270-282. [PMID: 28736830 DOI: 10.1111/dom.13070] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 07/19/2017] [Accepted: 07/19/2017] [Indexed: 12/16/2022]
Abstract
The identification of the critical role of proprotein convertase subtilisin/kexin type 9 (PCSK9) has rapidly led to the development of PCSK9 inhibition with monoclonal antibodies (mAbs). PCSK9 mAbs are already in limited clinical use and are the subject of major cardiovascular outcomes trials, which, if universally positive, could see much wider clinical application of these agents. Patients with familial hypercholesterolaemia are the most obvious candidates for these drugs, but other patients with elevated cardiovascular risk, statin intolerance or hyperlipoproteinaemia(a) may also benefit. PCSK9 mAbs, administered once or twice monthly, reduce LDL cholesterol levels by 50% to 70%, and appear to be safe and acceptable to patients over at least 2 years of treatment; however, treatment-emergent adverse effects are not always identified in clinical trials, as well-evidenced by statin myopathy. Inclisiran is a promising RNA-based therapy that promotes the degradation of PCSK9 mRNA transcripts and has similar efficacy to mAbs, but with a much longer duration of action. The cost-effectiveness and long-term safety of therapies targeted at inhibiting PCSK9 remain to be demonstrated if they are to be used widely in coronary prevention.
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Affiliation(s)
- Michael M Page
- Department of Clinical Biochemistry, PathWest Laboratory Medicine, Fiona Stanley Hospital, Perth, Western Australia
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia
| | - Gerald F Watts
- Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth, Western Australia
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia
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Leiter LA, Müller‐Wieland D, Baccara‐Dinet MT, Letierce A, Samuel R, Cariou B. Efficacy and safety of alirocumab in people with prediabetes vs those with normoglycaemia at baseline: a pooled analysis of 10 phase III ODYSSEY clinical trials. Diabet Med 2018; 35:121-130. [PMID: 28799203 PMCID: PMC5763418 DOI: 10.1111/dme.13450] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2017] [Indexed: 12/17/2022]
Abstract
AIM To assess the lipid-lowering efficacy and safety of alirocumab, a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, in people with hypercholesterolaemia and prediabetes at baseline vs people with normoglycaemia at baseline in a pooled analysis of 10 ODYSSEY phase III trials. METHODS People classified as having prediabetes had baseline HbA1c ≥39 mmol/mol (5.7%) and <48 mmol/mol (6.5%), or two baseline fasting plasma glucose values ≥5.6 mmol/l (100 mg/dl) but no more than one fasting plasma glucose value ≥7.0 mmol/l (126 mg/dl), or had specific terms reported in their medical history; people diagnosed with diabetes at baseline were excluded, and the remainder were classified as having normoglycaemia. Participants received alirocumab or control (placebo/ezetimibe) for 24-104 weeks, with maximally tolerated statin in most cases. The primary efficacy endpoint was LDL cholesterol reductions from baseline to week 24 in the intention-to-treat population using the mixed-effect model with a repeated measures approach. RESULTS Reductions in LDL cholesterol from baseline to week 24 with alirocumab were 44.0-61.8% (prediabetes group) and 45.8-59.5% (normoglycaemia group). In both subgroups, LDL cholesterol reductions were generally similar in those with and without baseline triglycerides ≥1.7 mmol/l (150 mg/dl). Alirocumab was not associated with changes in HbA1c or fasting plasma glucose over time in either subgroup (up to 24 months' follow-up). Adverse event rates were generally similar in those with and without prediabetes. CONCLUSIONS Over a mean follow-up of 24-104 weeks, alirocumab treatment resulted in significant LDL cholesterol reductions from baseline that were similar in participants with prediabetes and those with normoglycaemia at baseline, with no effect on glycaemia and a safety profile similar to that of the control.
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Affiliation(s)
- L. A. Leiter
- Li Ka Shing Knowledge Institute of St Michael's HospitalUniversity of TorontoOntarioCanada
| | - D. Müller‐Wieland
- Department of Internal Medicine IUniversity Hospital RWTH AachenAachenGermany
| | | | | | - R. Samuel
- Regeneron Pharmaceuticals IncTarrytownNYUSA
| | - B. Cariou
- Institut du ThoraxCHU NantesNantesFrance
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Chan P, Shao L, Tomlinson B, Liu ZM. The ODYSSEY DM-DYSLIPIDEMIA trial: confirming the benefits of alirocumab in diabetic mixed dyslipidemia. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:477. [PMID: 29285510 PMCID: PMC5733316 DOI: 10.21037/atm.2017.10.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 10/26/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Paul Chan
- Division of Cardiology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Li Shao
- The VIP Department, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Brian Tomlinson
- Research Center for Translational Medicine, Shanghai East Hospital Affiliated to Tongji University School of Medicine, Shanghai 200120, China
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Zhong-Min Liu
- Department of Cardiac Surgery, Shanghai East Hospital, Tongji University, Shanghai 200120, China
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Farnier M. Alirocumab for the treatment of hyperlipidemia in high-risk patients: an updated review. Expert Rev Cardiovasc Ther 2017; 15:923-932. [DOI: 10.1080/14779072.2017.1409115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Michel Farnier
- Department of Cardiology, CHU Dijon Bourgogne and Point Medical, Dijon, France
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Kohli M, Patel K, MacMahon Z, Ramachandran R, Crook MA, Reynolds TM, Wierzbicki AS. Pro-protein subtilisin kexin-9 (PCSK9) inhibition in practice: lipid clinic experience in 2 contrasting UK centres. Int J Clin Pract 2017; 71. [PMID: 28994502 DOI: 10.1111/ijcp.13032] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 09/13/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Prescribing criteria have been suggested for proprotein convertase subtilisin kexin-9 (PCSK-9) inhibitors but few studies exist of their real-world effectiveness. METHODS This study audited PCSK-9 inhibitor therapy in 105 consecutive patients from two hospital centres-a university hospital (UH; n = 70) and a district general hospital (DGH; n = 35). Baseline characteristics including cardiovascular disease risk factors, NICE qualification criteria, efficacy and side effects were assessed. RESULTS Baseline LDL-C levels were similar in both centres. NICE criteria were met for 2.05 items in the whole study (UH patients 1.7 and DGH patients 2.7). District general hospital patients were more likely to have familial hypercholesterolaemia (89 vs 69%; P = .02); intolerance to statins (94 vs 52%; P < .001) and polyvascular disease (42% vs 17%; P = .005). Prescriptions (evolocumab 73%; alirocumab 23%) were collected by 76% of patients (UH 64% vs DGH 100%). Therapy was discontinued by time of review in 15% of patients (UH 7% vs DGH 25%; P = .02). In adherent patients PCSK-9 inhibitor treatment reduced TC by 28% (2.24 ± 2.39 mmol/L; P < .001) and LDL-C by 49% (2.10 ± 1.33 mmol/L; P < .001). A LDL-C < 2.5 mmol/L was achieved in 30% of patients and <2.0 mmol/L in 20%. PCSK-9 therapy was effective and safe in patients with increased lipoprotein (a), diagnosed muscle diseases (including myopathies and muscular dystrophy) or poststatin rhabdomyolysis, nephrotic syndrome or HIV disease. Mixed results were obtained in patients with significant mixed hyperlipidaemia. CONCLUSIONS This study suggests that PCSK-9 inhibitors are effective but that prescriptions should not be changed to long-term delivery until patients have been reviewed and shown to be adherent.
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Affiliation(s)
- Monika Kohli
- Department of Metabolic Medicine/Chemical Pathology, Guy's & St Thomas' Hospitals, London, UK
| | - Kinjal Patel
- Department of Metabolic Medicine/Chemical Pathology, Queen's Hospital, Burton-on-Trent, UK
| | - Zofia MacMahon
- Department of Metabolic Medicine/Chemical Pathology, Guy's & St Thomas' Hospitals, London, UK
| | - Radha Ramachandran
- Department of Metabolic Medicine/Chemical Pathology, Guy's & St Thomas' Hospitals, London, UK
| | - Martin A Crook
- Department of Metabolic Medicine/Chemical Pathology, Guy's & St Thomas' Hospitals, London, UK
| | - Timothy M Reynolds
- Department of Metabolic Medicine/Chemical Pathology, Queen's Hospital, Burton-on-Trent, UK
| | - Anthony S Wierzbicki
- Department of Metabolic Medicine/Chemical Pathology, Guy's & St Thomas' Hospitals, London, UK
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