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Mei X, Zhou H, Song Z, Yang X, Liu X, Fei J, Shen Y, Wang X. PCSK6 mediates Th1 differentiation and promotes chronic colitis progression and mucosal barrier injury via STAT1. Aging (Albany NY) 2023; 15:204739. [PMID: 37211384 DOI: 10.18632/aging.204739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/01/2023] [Indexed: 05/23/2023]
Abstract
This study was aimed at investigating the expression and role of proprotein convertase subtilisin/kexin type (PCSK6) in inflammatory bowel disease (IBD). DSS induced mouse colitis and mucosal barrier injury, down-regulation of TJ proteins, improvement of permeability, and increases of the proportions of Th1 and M1 macrophages. After PCSK6 knockdown, the colitis in KO mice was improved relative to WT mice, the TJ protein levels increased, and the proportions of Th1 and M1 macrophages decreased. STAT1 inhibitor treatment also inhibited chronic colitis in mice. As revealed by in-vitro experiments, PCSK6 overexpression promoted the transformation of Th0 into Th1, while PCSK6 silencing suppressed the transfection. COPI assay results revealed the presence of targeted binding relation between PCSK6 and STAT1. PCSK6 binds to STAT1 to promote STAT1 phosphorylation and regulate Th1 cell differentiation, thus promoting the M1 polarization of macrophages and aggravating colitis progression. PCSK6 is promising as the new target for the treatment of colitis.
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Affiliation(s)
- Xiaoping Mei
- Department of Surgery, Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang, People’s Republic of China
| | - Hongkun Zhou
- Department of Surgery, Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang, People’s Republic of China
| | - Zhengwei Song
- Department of Surgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang, People’s Republic of China
| | - Xiaodan Yang
- Department of Surgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang, People’s Republic of China
| | - Xiaorong Liu
- Department of Surgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang, People’s Republic of China
| | - Jianguo Fei
- Department of Surgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang, People’s Republic of China
| | - Yiyu Shen
- Department of Surgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang, People’s Republic of China
| | - Xiaoguang Wang
- Department of Surgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang, People’s Republic of China
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Derington CG, Colantonio LD, Herrick JS, Cook J, King JB, Rosenson RS, Poudel B, Monda KL, Navar AM, Mues KE, Stevens VW, Nelson RE, Vanneman ME, Muntner P, Bress AP. Factors Associated With PCSK9 Inhibitor Initiation Among US Veterans. J Am Heart Assoc 2021; 10:e019254. [PMID: 33821686 PMCID: PMC8174184 DOI: 10.1161/jaha.120.019254] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Few adults at high risk for atherosclerotic cardiovascular disease events use a PCSK9i (proprotein convertase subtilisin/kexin type 9 inhibitor). Methods and Results Using data from the US Veterans Health Administration, we identified veterans who initiated a PCSK9i between January 2018 and December 2019, matched 1:4 to veterans who did not initiate this medication over this time period (case‐cohort study). Two cohorts of veterans were analyzed: (1) atherosclerotic cardiovascular disease, with a most recent low‐density lipoprotein cholesterol (LDL‐C) ≥70 mg/dL; and (2) severe hypercholesterolemia (ie, familial hypercholesterolemia or any prior LDL‐C ≥190 mg/dL, with most recent LDL‐C ≥100 mg/dL). Conditional logistic regression was used to analyze factors associated with PCSK9i initiation, adjusting for all factors, simultaneously. There were 2394 initiators and 9576 noninitiators in the atherosclerotic cardiovascular disease cohort (median LDL‐C, 141 and 96 mg/dL, respectively; P<0.001). Factors associated with a higher likelihood of PCSK9i initiation included age 65 to <75 versus <65 years, highest versus lowest quartile of median area‐level income, familial hypercholesterolemia, former statin use, and current ezetimibe use. PCSK9i initiation was lower among veterans of a race/ethnicity other than non‐Hispanic White. There were 245 initiators and 980 noninitiators in the severe hypercholesterolemia cohort (median LDL‐C, 183 and 151 mg/dL, respectively; P<0.001). Age ≥75 versus <65 years, history of chronic kidney disease, former statin use, and current ezetimibe use were associated with a higher likelihood of PCSK9i initiation. Conclusions Several patient‐level factors, including age, sex, and race/ethnicity, were significantly associated with PCSK9i initiation, suggesting an unmet treatment need in several patient groups.
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Affiliation(s)
- Catherine G Derington
- Division of Health System Innovation and Research Department of Population Health Sciences University of Utah School of Medicine Salt Lake City UT
| | - Lisandro D Colantonio
- Department of Epidemiology University of Alabama at Birmingham School of Public Health Birmingham AL
| | - Jennifer S Herrick
- Division of Epidemiology Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT.,Informatics, Decision-Enhancement and Analytic Sciences Center of Innovation Veterans Affairs Salt Lake City Health Care System Salt Lake City UT
| | - James Cook
- Division of Epidemiology Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT.,Informatics, Decision-Enhancement and Analytic Sciences Center of Innovation Veterans Affairs Salt Lake City Health Care System Salt Lake City UT
| | - Jordan B King
- Division of Health System Innovation and Research Department of Population Health Sciences University of Utah School of Medicine Salt Lake City UT.,Institute for Health Research Kaiser Permanente Colorado Aurora CO
| | - Robert S Rosenson
- Mount Sinai Heart Icahn School of Medicine at Mount Sinai New York NY
| | - Bharat Poudel
- Department of Epidemiology University of Alabama at Birmingham School of Public Health Birmingham AL
| | - Keri L Monda
- Center for Observational Research and Medical Affairs Amgen Inc Thousand Oaks CA
| | | | - Katherine E Mues
- Center for Observational Research and Medical Affairs Amgen Inc Thousand Oaks CA
| | - Vanessa W Stevens
- Division of Epidemiology Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT.,Informatics, Decision-Enhancement and Analytic Sciences Center of Innovation Veterans Affairs Salt Lake City Health Care System Salt Lake City UT
| | - Richard E Nelson
- Division of Epidemiology Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT.,Informatics, Decision-Enhancement and Analytic Sciences Center of Innovation Veterans Affairs Salt Lake City Health Care System Salt Lake City UT
| | - Megan E Vanneman
- Division of Health System Innovation and Research Department of Population Health Sciences University of Utah School of Medicine Salt Lake City UT.,Division of Epidemiology Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT.,Informatics, Decision-Enhancement and Analytic Sciences Center of Innovation Veterans Affairs Salt Lake City Health Care System Salt Lake City UT
| | - Paul Muntner
- Department of Epidemiology University of Alabama at Birmingham School of Public Health Birmingham AL
| | - Adam P Bress
- Division of Health System Innovation and Research Department of Population Health Sciences University of Utah School of Medicine Salt Lake City UT.,Informatics, Decision-Enhancement and Analytic Sciences Center of Innovation Veterans Affairs Salt Lake City Health Care System Salt Lake City UT
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3
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Rallidis LS, Triantafyllis AS, Iliodromitis E. Eligibility for treatment with PCSK9 inhibitors among patients with stable coronary artery disease presumed to be on maximum hypolipidaemic therapy. Hellenic J Cardiol 2018; 59:293-295. [DOI: 10.1016/j.hjc.2017.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 10/26/2017] [Accepted: 11/01/2017] [Indexed: 01/29/2023] Open
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Shah P. Economic Evaluation of the PCSK9 Inhibitors in Prevention of the Cardiovascular Diseases. Curr Cardiol Rep 2018; 20:51. [DOI: 10.1007/s11886-018-0993-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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5
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Cheng WH, Gaudette É, Goldman DP. PCSK9 Inhibitors Show Value for Patients and the US Health Care System. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:1270-1278. [PMID: 29241886 PMCID: PMC5929151 DOI: 10.1016/j.jval.2017.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 05/13/2017] [Accepted: 05/17/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors were approved by the US Food and Drug Administration (FDA) as cholesterol-lowering therapies for patients with familial hypercholesterolemia or atherosclerotic cardiovascular disease. OBJECTIVES To estimate the long-term health and economic value of PCSK9 inhibitors for Americans (51 years and older). METHODS We conducted simulations using the Future Elderly Model, an established dynamic microsimulation model to project the lifetime outcomes for the US population aged 51 years and older. Health effects estimates and confidence intervals from published meta-analysis studies were used to project changes in life expectancy, quality-adjusted life-years, and lifetime medical spending resulting from the use of PCSK9 inhibitors. We considered two treatment scenarios: 1) current FDA eligibility and 2) an extended eligibility scenario that includes patients with no pre-existing cardiovascular disease but at high risk. We assumed that the price of PCSK9 inhibitors was discounted by 35% in the first 12 years and by 57% thereafter, with gradual uptake of the drug in eligible populations. RESULTS Use of PCSK9 inhibitors by individuals covered by current FDA approval would extend life expectancy at the age of 51 years by an estimated 1.1 years and would yield a lifetime net value of $5800 per person. If use was extended to those at high risk for cardiovascular disease, PCSK9 inhibitors would generate a lifetime net benefit of $14,100 per person. CONCLUSIONS Expanded access to PCSK9 inhibitors would offer positive long-term net value for patients and the US health care system at the current discounted prices.
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Affiliation(s)
- Wei-Han Cheng
- Schaeffer Center for Health Policy and Economics, University of Southern California Price School and School of Pharmacy, Los Angeles, CA, USA.
| | - Étienne Gaudette
- Schaeffer Center for Health Policy and Economics, University of Southern California Price School and School of Pharmacy, Los Angeles, CA, USA
| | - Dana P Goldman
- Schaeffer Center for Health Policy and Economics, University of Southern California Price School and School of Pharmacy, Los Angeles, CA, USA
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Wójcik C. Incorporation of PCSK9 inhibitors into prevention of atherosclerotic cardiovascular disease. Postgrad Med 2017; 129:801-810. [PMID: 28879791 DOI: 10.1080/00325481.2017.1376570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD) has become recently more complex than ever, leaving the clinicians perplexed with outdated guidelines and emerging evidence about new LDL-C lowering therapies. 2013 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines have focused on high intensity statin therapy for specific groups of patients, while abandoning long established LDL-C goals, a strategy which no longer seems valid. PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors have emerged as the add-on therapy on top of statins and/or ezetimibe for the treatment of hypercholesterolemia and ASCVD prevention. In several clinical trials, PCSK9 inhibitors have demonstrated their safety and robust LDL-C-lowering power. One completed cardiovascular (CV) outcomes trial (FOURIER; Further Cardiovascular Outcomes Research with PCSK9 Inhibitions in Subjects with Elevated Risk) has demonstrated that PCSK9 inhibition reduces rates of CV death as well as non-fatal stroke and MI, while another major CV outcome trial is under way (ODYSSEY-OUTCOMES). Several trials studying CV benefits of novel LDL-C-lowering therapies are also being conducted. Prompt revision of ACC/AHA guidelines is necessary. In the meantime, physicians need to use clinical judgment integrating the most recent evidence into their practice.
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Affiliation(s)
- Cezary Wójcik
- a Department of Family Medicine , Oregon Health and Science University , Portland , OR , USA
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7
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Jetty V, Glueck CJ, Lee K, Goldenberg N, Prince M, Kumar A, Goldenberg M, Anand I, Wang P. Eligibility for alirocumab or evolocumab treatment in 1090 hypercholesterolemic patients referred to a regional cholesterol treatment center with LDL cholesterol ≥70 mg/dL despite maximal-tolerated LDL-cholesterol-lowering therapy. Vasc Health Risk Manag 2017; 13:247-253. [PMID: 28740397 PMCID: PMC5505680 DOI: 10.2147/vhrm.s133690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Proprotein convertase subtilisin/kexin type 9 inhibitors, Praluent (alirocumab [ALI]) and Repatha (evolocumab [EVO]) have been approved as adjuncts to the standard-of-care maximal-tolerated dose (MTD) of low-density lipoprotein cholesterol (LDLC)-lowering therapy (LLT), statin therapy, in heterozygous (HeFH) (ALI or EVO) or homozygous (EVO) familial hypercholesterolemia, or clinical atherosclerotic cardiovascular disease (CVD) where LDLC lowering is insufficient (both). Since LDLC lowering has been revolutionized by ALI and EVO, specialty pharmaceutical pricing models will be applied to a mass market. Methods We applied US Food and Drug Administration (FDA) and insurance eligibility criteria for ALI and EVO to 1090 hypercholesterolemic patients serially referred over 3 years who then received ≥2 months maximal-tolerated dose of standard-of-care LDL cholesterol-lowering therapy (MTDLLT) with follow-up LDLC ≥70 mg/dL. MTDLLT did not include ALI or EVO, which had not been commercially approved before completion of this study. Results Of the 1090 patients, 140 (13%) had HeFH by clinical diagnostic criteria and/or CVD with LDLC >100 mg/dL despite ≥2 months on MTDLLT, meeting FDA insurance criteria for ALI or EVO therapy. Another 51 (5%) patients were statin intolerant, without HeFH or CVD. Conclusion If 13% of patients with HeFH-CVD and LDLC >100 mg/dL despite MTDLLT are eligible for ALI or EVO, then specialty pharmaceutical pricing models (~$14,300/year) might be used in an estimated 10 million HeFH-CVD patients. Whether the health care savings arising from the anticipated reduction of CVD events by ALI or EVO justify their costs in populations with HeFH-CVD and LDLC >100 mg/dL despite MTDLLT remains to be determined.
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Affiliation(s)
- Vybhav Jetty
- Department of Internal Medicine, Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Charles J Glueck
- Department of Internal Medicine, Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Kevin Lee
- Department of Internal Medicine, Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Naila Goldenberg
- Department of Internal Medicine, Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Marloe Prince
- Department of Internal Medicine, Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Ashwin Kumar
- Department of Internal Medicine, Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Michael Goldenberg
- Department of Internal Medicine, Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Ishan Anand
- Department of Internal Medicine, Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Ping Wang
- Department of Internal Medicine, Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
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8
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Choi J, Khan AM, Jarmin M, Goldenberg N, Glueck CJ, Wang P. Efficacy and safety of proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors, alirocumab and evolocumab, a post-commercialization study. Lipids Health Dis 2017; 16:141. [PMID: 28738813 PMCID: PMC5525304 DOI: 10.1186/s12944-017-0493-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 05/22/2017] [Indexed: 01/29/2023] Open
Abstract
Background Efficacy-safety of proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors, alirocumab (ALI) and evolocumab (EVO), have previously been evaluated through controlled clinical trials with selective patient groups. Post-commercially, in 69 patients with heterozygous familial hypercholesterolemia (HeFH) and/or cardiovascular disease (CVD) with suboptimal LDL cholesterol (LDLC) lowering on maximal tolerated LDLC therapy, we assessed efficacy and safety of ALI and EVO. Methods Post-commercially, we started 29 patients on ALI 75 mg, 18 on ALI 150 mg, and 22 on EVO 140 mg every 2 weeks added to a maximally tolerated LDLC-lowering regimen. Since LDLC lowering did not differ between ALI 150 and EVO 140 mg, ALI 150-EVO 140 data were pooled (ALI-EVO). Changes in LDLC and AHA and NIH calculated 10-year CVD risks were assessed. Results Of the 69 patients, 25 had HeFH, 25 CVD, and 19 had both. At entry, 23 (33%) took statins and 46 (67%) were statin-intolerant. Mean ± SD and median follow-up were 49 ± 13 and 49 weeks on ALI 75 mg, and 37 ± 12 and 33 weeks on ALI-EVO. In the ALI-EVO group (n = 40), median LDLC fell from 165 mg/dl at entry to 70 mg/dl (median − 59%, p < .0001). AHA 10-year calculated CVD risk fell from 10.2 to 5.5% (median − 28%, p < .0001), and by the NIH calculator from 14.2 to 3.6% (median − 78%, p < .0001). In the ALI 75 mg group (n = 29), entry LDLC fell from 115 to 68 mg/dl (median − 39%, p < .0001). AHA 10-year calculated CVD risk fell from 11.5 to 7.3% (median − 20%, p = .004), and NIH 10-year risk from 12.9 to 5.1% (median 67%, p < .0001). Absolute and percent change in LDLC was independent of statin use. There were flu-like symptoms in 14% of patients. Adverse events did not differ (p > 0.05) between ALI 75 mg and ALI-EVO. Conclusion In patients with HeFH and/or CVD, LDLC decreased from 115 to 68 mg/dl (39%) on ALI 75 mg with mean follow-up of 49 weeks, and from 165 to 70 mg/dl (59%) on ALI-EVO over 37 weeks, p < .0001 for both. Adverse events were minimal and tolerable. ALI and EVO represent paradigm shifts in LDLC lowering.
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Affiliation(s)
- Joshua Choi
- Graduate Medical Education and Research, The Jewish Hospital- Mercy Health, Graduate Medical Education and Research, Cincinnati, USA
| | - Amir M Khan
- Graduate Medical Education and Research, The Jewish Hospital- Mercy Health, Graduate Medical Education and Research, Cincinnati, USA.
| | - Michael Jarmin
- Graduate Medical Education and Research, The Jewish Hospital- Mercy Health, Graduate Medical Education and Research, Cincinnati, USA
| | - Naila Goldenberg
- Graduate Medical Education and Research, The Jewish Hospital- Mercy Health, Graduate Medical Education and Research, Cincinnati, USA
| | - Charles J Glueck
- Graduate Medical Education and Research, The Jewish Hospital- Mercy Health, Graduate Medical Education and Research, Cincinnati, USA
| | - Ping Wang
- Graduate Medical Education and Research, The Jewish Hospital- Mercy Health, Graduate Medical Education and Research, Cincinnati, USA
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Della Pepa G, Bozzetto L, Annuzzi G, Rivellese AA. Alirocumab for the treatment of hypercholesterolaemia. Expert Rev Clin Pharmacol 2017; 10:571-582. [PMID: 28395555 DOI: 10.1080/17512433.2017.1318063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Prescription of statins for low-density lipoprotein cholesterol (LDL-C) reduction is the standard of care in primary and secondary prevention of cardiovascular disease; nevertheless, a large number of patients treated with statins are unable to reach the recommended LDL-C targets. Therefore, there is need for safe and effective novel therapies for the pharmacological management of hypercholesterolaemia, in addition or as alternative to lipid-lowering therapies (LLT) currently in use. Areas covered: In 2015, the Food and Drug Administration and the European Medicines Agency approved alirocumab (Praluent®; Sanofi), a fully human monoclonal antibody against proprotein convertase subtilisin/kexin type 9 (PCSK9), for the treatment of hypercholesterolaemic patients unable to meet LDL-C targets, as an adjunct to diet in addition/alternative to LLT. The authors review the pharmacological features, clinical efficacy, and safety of alirocumab in lowering LDL-C, and discuss its therapeutic perspectives based on the most recent clinical trials. Expert commentary: Alirocumab causes a marked reduction in LDL-C, presents good safety and tolerability, and represents a promising approach for LDL-C lowering, particularly in patients with intolerance to statin or elevated LDL-C despite maximal statin therapy; nevertheless, further long-term data on safety and efficacy are necessary, such as data on the improvement of cardiovascular outcomes.
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Affiliation(s)
- Giuseppe Della Pepa
- a Department of Clinical Medicine and Surgery , Federico II University , Naples , Italy
| | - Lutgarda Bozzetto
- a Department of Clinical Medicine and Surgery , Federico II University , Naples , Italy
| | - Giovanni Annuzzi
- a Department of Clinical Medicine and Surgery , Federico II University , Naples , Italy
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Abstract
INTRODUCTION Cardiovascular morbidity and mortality are of increasing concern, not only to patients but also to the health care profession and service providers. The preventative benefit of treatment of dyslipidaemia is unquestioned but there is a large, so far unmet need to improve clinical outcome. There are exciting new discoveries of targets that may translate into improved clinical outcome. Areas covered: This review highlights some new pathways in cholesterol and triglyceride metabolism and examines new targets, new drugs and new molecules. The review includes the results of recent trials of relatively new drugs that have shown benefit in cardiovascular endpoint outcomes, drugs that have been licenced without endpoint trials yet available and new drugs that have not yet been licenced but have produced exciting results in animal studies and some in early phase 2 human studies. Expert opinion: The new areas that have been discovered as the cause of dyslipidaemia have opened up a host of new targets for new drugs including antisense RNA's, microRNA's and human monoclonal antibodies. The plethora of new targets and new drugs has made it an extraordinarily exciting time in the development of therapeutics to combat atherosclerosis.
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Affiliation(s)
- Gerald H Tomkin
- a Diabetes Institute of Ireland , Beacon Clinic and Trinity College , Dublin 2 , Ireland
| | - Daphne Owens
- a Diabetes Institute of Ireland , Beacon Clinic and Trinity College , Dublin 2 , Ireland
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Shah P, Glueck CJ, Goldenberg N, Min S, Mahida C, Schlam I, Rothschild M, Huda A, Wang P. Efficacy, safety, Low density lipoprotein cholesterol lowering, and calculated 10-year cardiovascular risk reduction of alirocumab and evolocumab in addition to maximal tolerated cholesterol lowering therapy: a post-commercialization study. Lipids Health Dis 2017; 16:19. [PMID: 28115017 PMCID: PMC5259842 DOI: 10.1186/s12944-017-0416-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 01/16/2017] [Indexed: 01/20/2023] Open
Abstract
Background Efficacy and safety of proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors, alirocumab (ALI) and evolocumab (EVO) have previously been evaluated through controlled clinical trials with selective patient groups. Post-commercially, in patients with heterozygous familial hypercholesterolemia (HeFH) and/or cardiovascular disease (CVD) with suboptimal LDL cholesterol (LDLC) lowering on maximal tolerated cholesterol lowering therapy, we assessed efficacy and safety of ALI and EVO. Methods Post-commercially, we started 25 patients on ALI 75 mg, 15 on ALI 150 mg, and 32 on EVO 140 mg bi-weekly added to entry LDLC lowering regimen, with follow-up for a median 24 weeks. History, physical exam, demographics, and adverse event data were collected. Changes in LDLC and AHA and NIH calculated 10-year CVD risks were assessed on ALI and EVO. Results Of 72 patients, 25 had HeFH only, 25 CVD only, 22 had both, median age was 65 years, 63% females, 38% males, 86% Caucasian, 11% African-Americans, 17% diabetics, 63% on anti-hypertensives, and 7% smokers. At entry, 30 (42%) were on a statin and 42 (58%) could not tolerate any statins. At 24-weeks, median LDLC decreased on ALI 75 mg from 117 to 62 mg/dL (−54%), on ALI 150 mg from 175 to 57 mg/dL (−63%), and on EVO 140 mg from 165 to 69 mg/dL (−63%), p <0.0001 for all. Absolute and percent LDLC reduction did not differ (p >.05) between ALI 150 and EVO 140 mg, but were less on ALI 75 mg vs ALI 150 mg and EVO 140 mg (p <.05). Percent reductions in 10-year CVD risks by AHA and NIH calculators, respectively were ALI 75 mg −22 and −44%, ALI 150 mg −31 and −50%, and EVO 140 mg −29 and −56%, p ≤.002 for all. The three most common adverse events included flu-like myositis 10%, respiratory tract symptoms 8%, and injection site reaction 6%. Conclusion In patients with HeFH and/or CVD, LDLC was lowered by 63% on EVO and ALI 150 mg, and 54% on ALI 75 mg. Adverse events were minimal and tolerable. ALI and EVO represent paradigm shifts in LDLC lowering. Long term, post-commercial safety and efficacy remain to be determined.
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Affiliation(s)
- Parth Shah
- Graduate Medical Education Department, Jewish Hospital of Cincinnati, Cincinnati, Ohio, USA.
| | - Charles J Glueck
- Graduate Medical Education Department, Jewish Hospital of Cincinnati, Cincinnati, Ohio, USA
| | - Naila Goldenberg
- Graduate Medical Education Department, Jewish Hospital of Cincinnati, Cincinnati, Ohio, USA
| | - Sarah Min
- The Jewish Hospital Internal Medicine Residency Program, 4777 E Galbraith Rd, Cincinnati, Ohio, 45236, USA
| | - Chris Mahida
- The Jewish Hospital Internal Medicine Residency Program, 4777 E Galbraith Rd, Cincinnati, Ohio, 45236, USA
| | - Ilana Schlam
- The Jewish Hospital Internal Medicine Residency Program, 4777 E Galbraith Rd, Cincinnati, Ohio, 45236, USA
| | - Matan Rothschild
- The Jewish Hospital Internal Medicine Residency Program, 4777 E Galbraith Rd, Cincinnati, Ohio, 45236, USA
| | - Ali Huda
- The Jewish Hospital Internal Medicine Residency Program, 4777 E Galbraith Rd, Cincinnati, Ohio, 45236, USA
| | - Ping Wang
- Graduate Medical Education Department, Jewish Hospital of Cincinnati, Cincinnati, Ohio, USA
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12
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Gupta S. Development of proprotein convertase subtilisin/kexin type 9 inhibitors and the clinical potential of monoclonal antibodies in the management of lipid disorders. Vasc Health Risk Manag 2016; 12:421-433. [PMID: 27877050 PMCID: PMC5108562 DOI: 10.2147/vhrm.s83719] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The aim of this manuscript is to review available data to evaluate the present status of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors in the treatment of hypercholesterolemia. Relevant literature since 2003 is reviewed. The effectiveness of PCSK9 inhibitors in lowering low-density lipoprotein cholesterol and other atherogenic lipid fractions was studied in various Phase 2 and Phase 3 trials of Alirocumab, Evolocumab, and Bococizumab. The results of published long-term ODYSSEY and OSLER studies are summarized. There have been three excellent meta-analysis studies on PCSK9 inhibitors which are outlined. The complex problem of cost-effectiveness was carefully evaluated by the Institute for Clinical and Economic Review (ICER). The draft report (ICER-2015) is summarized herewith. The cardiovascular outcome trials with Evolocumab (FOURIER), Alirocumab (ODYSSEY OUTCOME) and Bococizumab (SPIRE-1 and SPIRE-2) are the ongoing clinical trials, and their results are expected in 2017-2018. The search for new cost-effective analogs of PCSK9 inhibitors is ongoing.
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Affiliation(s)
- Sanjiv Gupta
- Department of Interventional Cardiology, Santokba Durlabhji Memorial Hospital Cum Medical Research Institute, Jaipur, India
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13
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Colletti A, Derosa G, Cicero AF. Retargeting the management of hypercholesterolemia - focus on evolocumab. Ther Clin Risk Manag 2016; 12:1365-76. [PMID: 27660454 PMCID: PMC5019477 DOI: 10.2147/tcrm.s116679] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Hypercholesterolemia is one of the main risk factors for atherosclerosis and cardiovascular diseases. The treatment is based on the modification of the diet and lifestyle and if necessary on a pharmacological therapy. The most widely used drugs are the inhibitors of 3-hydroxy-3-methyl-glutaryl coenzyme A reductase (statins); nevertheless, many patients do not reach optimal levels of low-density lipoprotein-cholesterol (LDL-C) even with maximal dosage of statins (eventually associated to ezetimibe) or present side effects, which do not allow them to continue the treatment. Inhibitors of PCSK9 represent a new therapeutic approach for lowering LDL-C. Evolocumab and alirocumab are human monoclonal antibodies, which bind to extracellular PCSK9 and thus interfere with the degradation of low-density lipoprotein receptor. Evolocumab use is approved for the treatment of patients with heterozygous familial hypercholesterolemia (FH) and homozygous FH as an adjunct to diet and maximally tolerated statin therapy or for subjects with clinical atherosclerotic cardiovascular disease who require additional lowering of LDL-C. Phase III clinical trials have demonstrated the effectiveness of evolocumab (140 mg/every 2 weeks or 420 mg/month, via subcutaneous injection) in monotherapy and in combination with statins, in the treatment of patients intolerant to statins or with FH. In monotherapy, it reduces LDL-C by 55%, and its association with statins leads to a reduction of LDL-C by up to 63%–75%. Evolocumab has been demonstrated to be safe and well tolerated. Ongoing clinical trials are assessing the long-term effects of evolocumab on the incidence of cardiovascular risk, safety, and tolerability. This review resumes the available clinical evidence on the efficacy and safety of evolocumab, for which a relatively large amount of clinical data are currently available, and discusses the retargeting of cholesterol-lowering therapy in clinical practice.
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Affiliation(s)
| | - Giuseppe Derosa
- Department of Internal Medicine and Therapeutics, University of Pavia and Policlinico San Matteo Foundation, Pavia, Italy
| | - Arrigo Fg Cicero
- Department of Medical and Surgical Sciences, University of Bologna, Bologna
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Shah P, Glueck CJ, Jetty V, Goldenberg N, Rothschild M, Riaz R, Duhon G, Wang P. Pharmacoeconomics of PCSK9 inhibitors in 103 hypercholesterolemic patients referred for diagnosis and treatment to a cholesterol treatment center. Lipids Health Dis 2016; 15:132. [PMID: 27538393 PMCID: PMC4991071 DOI: 10.1186/s12944-016-0302-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 08/09/2016] [Indexed: 12/24/2022] Open
Abstract
Background PCSK9 inhibitor therapy has been approved by the FDA as an adjunct to diet-maximal tolerated cholesterol lowering drug therapy for adults with heterozygous familial hypercholesterolemia (HeFH) or clinical atherosclerotic cardiovascular disease (ASCVD) with suboptimal LDL cholesterol (LDLC) lowering despite maximal diet-drug therapy. With an estimated ~24million of US hypercholesterolemic patients potentially eligible for PCSK9 inhibitors, costing ~ $14,300/patient/year, it is important to assess health-care savings arising from PCSK9 inhibitors vs ASCVD cost. Methods In 103 patients with HeFH, and/or ASCVD and/or suboptimal LDLC lowering despite maximally tolerated diet-drug therapy, we assessed pharmacoeconomics of PCSK9 inhibitor therapy with lowering of LDLC. For HeFH diagnosis, we applied Simon Broome’s or WHO Dutch Lipid Criteria (score >8). Estimates of direct and indirect costs for ASCVD events were calculated using American Heart Association (AHA), U.S. DHHS, Healthcare Bluebook, and BMC Health Services Research databases. We used the ACC/AHA 10-year ASCVD risk calculator to estimate 10-year ASCVD risk and estimated corresponding direct and indirect costs. Assuming a 50 % reduction in ASCVD events on PCSK9 inhibitors, we calculated direct and indirect health-care savings. Results We started 103 patients (58 [56 %] women and 45 [44 %] men), on either alirocumab (62 %) or evolocumab (38 %), median age 63, BMI 29.0, and LDLC 149 mg/dl. Of the 103 patients, 28 had both HeFH and ASCVD, 33 with only ASCVD, 33 with only HeFH, and 9 had neither. Of the 103 patients, 61 had a first ASCVD event at median age 55 and on best tolerated cholesterol-lowering therapy median LDLC was 137 mg/dl. In these 61 patients, total direct costs attributable to ASCVD were $8,904,361 ($4,328,623 direct, $4,575,738 indirect), the median 10-year risk of a new CVD event was calculated to be 13.1 % with total cost $1,654,758. Assuming a 50 % reduction in ASCVD events on PCSK9 inhibitors in our 61 patients, $4,452,180 would have been saved in the past; and future 10-year savings would be $1,123,345. Conclusion In the 61 CVD patients, net costs/patient/year were estimated to be $7,000 in the past, with future 10-year intervention net costs/patient/year being $12,459, both below the $50,000/year quality adjusted life-year gained by PCSK9 inhibitor therapy.
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Affiliation(s)
- Parth Shah
- From the Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, USA.
| | - Charles J Glueck
- From the Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, USA
| | - Vybhav Jetty
- From the Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, USA
| | - Naila Goldenberg
- From the Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, USA
| | - Matan Rothschild
- From the Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, USA
| | - Rashid Riaz
- From the Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, USA
| | - Gregory Duhon
- From the Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, USA
| | - Ping Wang
- From the Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, USA
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