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Spagnuolo CM, Hegele RA. Etiology and emerging treatments for familial chylomicronemia syndrome. Expert Rev Endocrinol Metab 2024; 19:299-306. [PMID: 38866702 DOI: 10.1080/17446651.2024.2365787] [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: 03/27/2024] [Accepted: 06/05/2024] [Indexed: 06/14/2024]
Abstract
INTRODUCTION Familial chylomicronemia syndrome (FCS) is a rare autosomal recessive condition. Effective treatment is important as patients are at risk for severe and potentially fatal acute pancreatitis. We review recent developments in pharmacologic treatment for FCS, namely biological inhibitors of apolipoprotein (apo) C-III and angiopoietin-like protein 3 (ANGPTL3). AREAS COVERED FCS follows a biallelic inheritance pattern in which an individual inherits two pathogenic loss-of-function alleles of one of the five causal genes - LPL (in 60-80% of patients), GPIHBP1, APOA5, APOC2, and LMF1 - leading to the absence of lipolytic activity. Patients present from childhood with severely elevated triglyceride (TG) levels >10 mmol/L. Most patients with severe hypertriglyceridemia do not have FCS. A strict low-fat diet is the current first-line treatment, and existing lipid-lowering therapies are minimally effective in FCS. Apo C-III inhibitors are emerging TG-lowering therapies shown to be efficacious and safe in clinical trials. ANGPTL3 inhibitors, another class of emerging TG-lowering therapies, have been found to require at least partial lipoprotein lipase activity to lower plasma TG in clinical trials. ANGPTL3 inhibitors reduce plasma TG in patients with multifactorial chylomicronemia but not in patients with FCS who completely lack lipoprotein lipase activity. EXPERT OPINION Apo C-III inhibitors currently in development are promising treatments for FCS.
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Affiliation(s)
- Catherine M Spagnuolo
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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Yoldas Celik M, Canda E, Yazici H, Erdem F, Yuksel Yanbolu A, Atik Altinok Y, Pariltay E, Akin H, Kalkan Ucar S, Coker M. Long-term clinical outcomes and management of hypertriglyceridemia in children with Apo-CII deficiency. Nutr Metab Cardiovasc Dis 2024; 34:1798-1806. [PMID: 38503616 DOI: 10.1016/j.numecd.2024.02.006] [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: 11/12/2023] [Revised: 01/26/2024] [Accepted: 02/13/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND AND AIM APO CII, one of several cofactors which regulate lipoprotein lipase enzyme activity, plays an essential role in lipid metabolism. Deficiency of APO CII is an ultra-rare autosomal recessive cause of familial chylomicronemia syndrome. We present the long-term clinical outcomes of 12 children with APO CII deficiency. METHODS AND RESULTS The data of children with genetically confirmed APO CII deficiency were evaluated retrospectively. Twelve children (8 females) with a mean follow-up of 10.1 years (±3.9) were included. At diagnosis, the median age was 60 days (13 days-10 years). Initial clinical findings included lipemic serum (41.6%), abdominal pain (41.6%), and vomiting (16.6%). At presentation, the median triglyceride (TG) value was 4341 mg/dL (range 1277-14,110). All patients were treated with a restricted fat diet, medium-chain triglyceride (MCT), and omega-3-fatty acids. In addition, seven patients (58.3%) received fibrate. Fibrate was discontinued in two patients due to rhabdomyolysis and in one patient because of cholelithiasis. Seven (58.3%) patients experienced pancreatitis during the follow-up period. One female experienced recurrent pancreatitis and was treated with fresh frozen plasma (FFP). CONCLUSIONS Apo CII deficiency is an ultra-rare autosomal recessive condition of hypertriglyceridemia associated with significant morbidity and mortality. Low-fat diet and MCT supplementation are the mainstays of therapy, while the benefit of TG-lowering agents are less well-defined.
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Affiliation(s)
- Merve Yoldas Celik
- Ege University, Medical Faculty, Department of Pediatric Metabolism and Nutrition, Izmir, Turkey.
| | - Ebru Canda
- Ege University, Medical Faculty, Department of Pediatric Metabolism and Nutrition, Izmir, Turkey
| | - Havva Yazici
- Ege University, Medical Faculty, Department of Pediatric Metabolism and Nutrition, Izmir, Turkey
| | - Fehime Erdem
- Ege University, Medical Faculty, Department of Pediatric Metabolism and Nutrition, Izmir, Turkey
| | - Ayse Yuksel Yanbolu
- Ege University, Medical Faculty, Department of Pediatric Metabolism and Nutrition, Izmir, Turkey
| | - Yasemin Atik Altinok
- Ege University, Medical Faculty, Department of Pediatric Metabolism and Nutrition, Izmir, Turkey
| | - Erhan Pariltay
- Ege University, Medical Faculty, Department of Medical Genetics, Izmir, Turkey
| | - Haluk Akin
- Ege University, Medical Faculty, Department of Medical Genetics, Izmir, Turkey
| | - Sema Kalkan Ucar
- Ege University, Medical Faculty, Department of Pediatric Metabolism and Nutrition, Izmir, Turkey
| | - Mahmut Coker
- Ege University, Medical Faculty, Department of Pediatric Metabolism and Nutrition, Izmir, Turkey
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Scicchitano P, Amati F, Ciccone MM, D’Ascenzi F, Imbalzano E, Liga R, Paolillo S, Pastore MC, Rinaldi A, Mattioli AV, Cameli M. Hypertriglyceridemia: Molecular and Genetic Landscapes. Int J Mol Sci 2024; 25:6364. [PMID: 38928071 PMCID: PMC11203941 DOI: 10.3390/ijms25126364] [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: 04/21/2024] [Revised: 06/03/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
Lipid disorders represent one of the most worrisome cardiovascular risk factors. The focus on the impact of lipids on cardiac and vascular health usually concerns low-density lipoprotein cholesterol, while the role of triglycerides (TGs) is given poor attention. The literature provides data on the impact of higher plasma concentrations in TGs on the cardiovascular system and, therefore, on the outcomes and comorbidities of patients. The risk for coronary heart diseases varies from 57 to 76% in patients with hypertriglyceridemia. Specifically, the higher the plasma concentrations in TGs, the higher the incidence and prevalence of death, myocardial infarction, and stroke. Nevertheless, the metabolism of TGs and the exact physiopathologic mechanisms which try to explain the relationship between TGs and cardiovascular outcomes are not completely understood. The aims of this narrative review were as follows: to provide a comprehensive evaluation of the metabolism of triglycerides and a possible suggestion for understanding the targets for counteracting hypertriglyceridemia; to describe the inner physiopathological background for the relationship between vascular and cardiac damages derived from higher plasma concentrations in TGs; and to outline the need for promoting further insights in therapies for reducing TGs plasma levels.
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Affiliation(s)
- Pietro Scicchitano
- Cardiology Department, Hospital “F Perinei” ASL BA, 70022 Altamura, Italy
| | - Francesca Amati
- Cardiovascular Diseases Section, University of Bari, 70124 Bari, Italy; (F.A.); (M.M.C.)
| | - Marco Matteo Ciccone
- Cardiovascular Diseases Section, University of Bari, 70124 Bari, Italy; (F.A.); (M.M.C.)
| | - Flavio D’Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy; (F.D.); (M.C.P.); (M.C.)
| | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy;
| | - Riccardo Liga
- Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, 56126 Pisa, Italy;
| | - Stefania Paolillo
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80138 Naples, Italy;
| | - Maria Concetta Pastore
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy; (F.D.); (M.C.P.); (M.C.)
| | - Andrea Rinaldi
- Unit of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Sant’Orsola-Malpighi Hospital, IRCCS, 40138 Bologna, Italy;
| | - Anna Vittoria Mattioli
- Department of Science of Quality of Life, University of Bologna “Alma Mater Studiorum”, 40126 Bologna, Italy;
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy; (F.D.); (M.C.P.); (M.C.)
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Mori Y, Masuda M, Yoshida-Shimizu R, Aoyagi S, Adachi Y, Nguyen AT, Maruyama Y, Okumura Y, Kamei Y, Sakai M, Ohnishi K, Ohminami H, Taketani Y. All-trans retinoic acid induces lipophagy through the activation of the AMPK-Beclin1 signaling pathway and reduces Rubicon expression in adipocytes. J Nutr Biochem 2024; 126:109589. [PMID: 38295886 DOI: 10.1016/j.jnutbio.2024.109589] [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: 10/16/2023] [Revised: 12/27/2023] [Accepted: 01/22/2024] [Indexed: 02/18/2024]
Abstract
Lipophagy is defined as a lipolysis pathway that degrades lipid droplet (LD) via autophagy. All-trans retinoic acid (atRA), a metabolite of vitamin A, stimulates lipolysis through hormone-sensitive lipase and β-oxidation. However, the regulation of lipolysis by atRA-induced autophagy in adipocytes remains unclear. In this study, we investigated the effect of atRA on autophagy in epididymal fat of mice and the molecular mechanisms of autophagy in 3T3-L1 adipocytes. Western blotting showed that atRA decreased the expression of p62, a cargo receptor for autophagic degradation, and increased the expression of the lipidated LC3B (LC3B-II), an autophagy marker, in epididymal fat. Next, we confirmed that atRA increased autophagic flux in differentiated 3T3-L1 cells using the GFP-LC3-RFP-LC3ΔG probe. Immunofluorescent staining revealed that the colocalization of LC3B with perilipin increased in differentiated 3T3-L1 cells treated with atRA. The knockdown of Atg5, an essential gene in autophagy induction, partly suppressed the atRA-induced release of non-esterified fatty acid (NEFA) from LDs in differentiated 3T3-L1 cells. atRA time-dependently elicited the phosphorylation of AMPK and Beclin1, autophagy-inducing factors, in mature 3T3-L1 adipocytes. Inversely, atRA decreased the protein expression of Rubicon, an autophagy repressor, in differentiated 3T3-L1 cells and epididymal fat. Interestingly, the expression of ALDH1A1, atRA-synthesizing enzymes, increased in epididymal fat with decreased protein expression of Rubicon in aged mice. These results suggest that atRA may partially induce lipolysis through lipophagy by activating the AMPK-Beclin1 signaling pathway in the adipocytes and increased atRA levels may contribute to decreased Rubicon expression in the epididymal fat of aged mice. (248/250 words).
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Affiliation(s)
- Yuki Mori
- Department of Clinical Nutrition and Food Management, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Tokushima 770-8503, Japan
| | - Masashi Masuda
- Department of Clinical Nutrition and Food Management, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Tokushima 770-8503, Japan.
| | - Risa Yoshida-Shimizu
- Department of Clinical Nutrition and Food Management, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Tokushima 770-8503, Japan
| | - Saki Aoyagi
- Department of Clinical Nutrition and Food Management, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Tokushima 770-8503, Japan
| | - Yuichiro Adachi
- Department of Clinical Nutrition and Food Management, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Tokushima 770-8503, Japan
| | - Anh The Nguyen
- Department of Clinical Nutrition and Food Management, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Tokushima 770-8503, Japan
| | - Yusuke Maruyama
- Department of Clinical Nutrition and Food Management, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Tokushima 770-8503, Japan
| | - Yosuke Okumura
- Department of Clinical Nutrition and Food Management, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Tokushima 770-8503, Japan
| | - Yuki Kamei
- Department of Clinical Nutrition and Food Management, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Tokushima 770-8503, Japan
| | - Maiko Sakai
- Department of Clinical Nutrition and Food Management, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Tokushima 770-8503, Japan
| | - Kohta Ohnishi
- Department of Clinical Nutrition and Food Management, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Tokushima 770-8503, Japan
| | - Hirokazu Ohminami
- Department of Clinical Nutrition and Food Management, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Tokushima 770-8503, Japan
| | - Yutaka Taketani
- Department of Clinical Nutrition and Food Management, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Tokushima 770-8503, Japan
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Abstract
PURPOSE OF REVIEW This review aims to discuss the most recent evidence exploring the role of lipid droplets in steatotic liver disease (SLD). We highlight the breadth of mechanisms by which lipid droplets may contribute to the progression of SLD with a particular focus on the role of lipid droplets as inducers of mechanical stress within hepatocytes and genetic mutations in lipid droplet associated proteins. Finally, this review provides an update on clinical trials exploring the therapeutic potential and strategies targeting lipid droplets. RECENT FINDINGS The size, composition and location of hepatic lipid droplets strongly influence the pathological role of these organelles in SLD. Emerging studies are beginning to elucidate the importance of lipid droplet induced hepatocyte mechanical stress. Novel strategies targeting lipid droplets, including the effects of lipid droplet associated protein mutations, show promising therapeutic potential. SUMMARY Much more than a histological feature, lipid droplets are complex heterogenous organelles crucial to cellular metabolism with important causative roles in the development and progression of SLD. Lipid droplet induced mechanical stress may exacerbate hepatic inflammation and fibrogenesis and potentially contribute to the development of a pro-carcinogenic hepatic environment. The integration of advancements in genetics and molecular biology in upcoming treatments aspires to transcend symptomatic alleviation and address the fundamental causes and pathological development of SLD.
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Affiliation(s)
- Josh Bilson
- School of Human Development and Health, Faculty of Medicine, University of Southampton
- National Institute for Health Research Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton National Health Service Foundation Trust, Southampton, UK
| | - Eleonora Scorletti
- School of Human Development and Health, Faculty of Medicine, University of Southampton
- National Institute for Health Research Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton National Health Service Foundation Trust, Southampton, UK
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Aljouda L, Nagy L, Schulze A. Long-Term Treatment of Lipoprotein Lipase Deficiency with Medium-Chain Triglyceride-Enriched Diet: A Case Series. Nutrients 2023; 15:3535. [PMID: 37630727 PMCID: PMC10458522 DOI: 10.3390/nu15163535] [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: 06/30/2023] [Revised: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
Background: Lipoprotein lipase (LPL) deficiency is a genetic condition. Affected individuals typically develop symptoms related to severe and persistent hypertriglyceridemia, such as abdominal pain and recurrent pancreatitis, before 10 years of age. No pharmacological treatment sustainably lowering triglycerides (TGs) in LPL deficiency patients has been proven to be effective. This study investigated whether a long-chain triglyceride (LCT)-restricted, medium-chain triglyceride (MCT)-supplemented diet enables a meaningful reduction in TGs and reduces LPL-related symptoms in children with LPL deficiency. Methods: A single-center retrospective case series study of LPL deficiency patients treated at the Hospital of Sick Children between January 2000 and December 2022 was carried out. Data, extracted from hospital charts, included demographics, diagnosis confirmation, clinical and imaging observations, and biochemical profiles. Results: Seven patients with hypertriglyceridemia > 20 mmol/L suspected of an LPL deficiency diagnosis were included. Six patients had a confirmed molecular diagnosis of LPL deficiency, and one had glycogen storage disease type 1a (GSD1a). Clinical presentation was at a median of 30 days of age (range 1-105), and treatment start, excluding one late-treated patient, was at a median of 42 days (range 2-106). The observation and treatment period of the LPL patients was 48.0 patient years (median 7.1, range 4.3-15.5). The LCT-restricted and MCT-supplemented diet led to an immediate drop in TGs in six out of six LPL patients. TGs improved from a median of 40.9 mmol/L (range 11.4-276.5) pre-treatment to a median of 12.0 mmol/L (range 1.1-36.6) during treatment, total cholesterol from 7.6 mmol/L (4.9-27.0) to 3.9 mmol/L (1.7-8.2), and pancreatic lipase from 631 IU/L (30-1200) to 26.5 IU/L (5-289). In 48 patient years, there was only one complication of pancreatitis and no other disease-specific manifestations or complications. Catch-up growth was observed in one late-treated patient. All patients maintained normal growth and development. As expected, the diet failed to treat hypertriglyceridemia in the GSD1a patient. Conclusions: The dietary restriction of LCT in combination with MCT supplementation as long-term management of pediatric patients with LPL deficiency was feasible, well tolerated, and clinically effective in reducing TG levels and in preventing LPL-related complications.
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Affiliation(s)
- Liali Aljouda
- Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, ON M5G 1E8, Canada (L.N.)
| | - Laura Nagy
- Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, ON M5G 1E8, Canada (L.N.)
| | - Andreas Schulze
- Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, ON M5G 1E8, Canada (L.N.)
- Department of Pediatrics, University of Toronto, Toronto, ON M5S 1A1, Canada
- Department of Biochemistry, University of Toronto, Toronto, ON M5S 1A1, Canada
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Kozan DW, Derrick JT, Ludington WB, Farber SA. From worms to humans: Understanding intestinal lipid metabolism via model organisms. Biochim Biophys Acta Mol Cell Biol Lipids 2023; 1868:159290. [PMID: 36738984 PMCID: PMC9974936 DOI: 10.1016/j.bbalip.2023.159290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 01/10/2023] [Accepted: 01/19/2023] [Indexed: 02/05/2023]
Abstract
The intestine is responsible for efficient absorption and packaging of dietary lipids before they enter the circulatory system. This review provides a comprehensive overview of how intestinal enterocytes from diverse model organisms absorb dietary lipid and subsequently secrete the largest class of lipoproteins (chylomicrons) to meet the unique needs of each animal. We discuss the putative relationship between diet and metabolic disease progression, specifically Type 2 Diabetes Mellitus. Understanding the molecular response of intestinal cells to dietary lipid has the potential to undercover novel therapies to combat metabolic syndrome.
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Affiliation(s)
- Darby W Kozan
- Department of Biology, Johns Hopkins University, Baltimore, MD, United States; Department of Embryology, Carnegie Institute for Science, Baltimore, MD, United States
| | - Joshua T Derrick
- Department of Biology, Johns Hopkins University, Baltimore, MD, United States; Department of Embryology, Carnegie Institute for Science, Baltimore, MD, United States
| | - William B Ludington
- Department of Biology, Johns Hopkins University, Baltimore, MD, United States; Department of Embryology, Carnegie Institute for Science, Baltimore, MD, United States
| | - Steven A Farber
- Department of Biology, Johns Hopkins University, Baltimore, MD, United States; Department of Embryology, Carnegie Institute for Science, Baltimore, MD, United States.
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Loh WJ, Bakthavachalam R, Subramaniam T, Pek S, Chua F, Lee L, Watts GF. Chylomicronemia through a burr hole: A case report. Front Cardiovasc Med 2022; 9:1020397. [PMID: 36312279 PMCID: PMC9596755 DOI: 10.3389/fcvm.2022.1020397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
Chylomicronemia has either a monogenic or multifactorial origin. Multifactorial chylomicronemia is the more common form and is due to the interaction of genetic predisposition and secondary factors such as obesity, diabetes, unhealthy diet, and medications. We report a case of a 38-year-old man who was diagnosed with multifactorial chylomicronemia following presentation with a subarachnoid hemorrhage requiring emergency surgery through a burr hole; lactescent cerebrospinal fluid mixed with blood was observed through the burr hole. The serum triglyceride concentration was 52⋅4 mmol/L with a detectable triglyceride concentration in the cerebrospinal fluid. Rapid weight gain leading to obesity and related unfavorable lifestyle factors were identified as key secondary causes of chylomicronemia. Gene testing revealed a homozygous variant in APOA5 and a heterozygous common variant in GPIHBP1. Accompanied with secondary causes, the interactions of gene and environmental conditions contribute to chylomicronemia. With aggressive medical treatment including excess weight loss, healthy diet, cessation of alcohol, and combination of anti-lipemic medications, normal plasma triglyceride levels were achieved.
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Affiliation(s)
- Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore,Medical School, University of Western Australia, Perth, WA, Australia,Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, WA, Australia,Duke-NUS Medical School, Singapore, Singapore,*Correspondence: Wann Jia Loh, ;
| | | | - Tavintharan Subramaniam
- Diabetes Centre, Admiralty Medical Centre, Singapore, Singapore,Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Sharon Pek
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Fionn Chua
- Department of Dietetics, Changi General Hospital, Singapore, Singapore
| | - Lester Lee
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Gerald F. Watts
- Medical School, University of Western Australia, Perth, WA, Australia,Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, WA, Australia
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Abstract
INTRODUCTION Primary chylomicronemia is characterized by pathological accumulation of chylomicrons in the plasma causing severe hypertriglyceridemia, typically >10 mmol/L (>875 mg/dL). Patients with the ultra-rare familial chylomicronemia syndrome (FCS) subtype completely lack lipolytic capacity and respond minimally to traditional triglyceride-lowering therapies. The mainstay of treatment is a low-fat diet, which is difficult to follow and compromises quality of life. New therapies are being developed primarily to prevent episodes of life-threatening acute pancreatitis. AREAS COVERED Antagonists of apolipoprotein (apo) C-III, such as the antisense oligonucleotide (ASO) volanesorsen, significantly reduce triglyceride levels in chylomicronemia. However, approval of and access to volanesorsen are restricted since a substantial proportion of treated FCS patients developed thrombocytopenia. Newer apo C-III antagonists, namely, the ASO olezarsen (formerly AKCEA-APOCIII-LRx) and short interfering RNA (siRNA) ARO-APOC3, appear to show efficacy with less risk of thrombocytopenia. Potential utility of antagonists of angiopoietin-like protein 3 (ANGPTL3) such as evinacumab and the siRNA ARO-ANG3 in subtypes of chylomicronemia remains to be defined. EXPERT OPINION Emerging pharmacologic therapies for chylomicronemia show promise, particularly apo C-III antagonists. However, these treatments are still investigational. Further study of their efficacy and safety in patients with both rare FCS and more common multifactorial chylomicronemia is needed.
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Affiliation(s)
- Isabel Shamsudeen
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Robert A Hegele
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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