Efficacy of Colestimide Coadministered With Atorvastatin in Japanese Patients With Heterozygous Familial Hypercholesterolemia (FH)

Target achievement with maximal statin-based lipid-lowering therapy in Korean patients with familial hypercholesterolemia: A study supported by the Korean Society of Lipid and Atherosclerosis

BACKGROUND

Data on treatment results of lipid-lowering therapy (LLT) in familial hypercholesterolemia (FH) are limited, particularly in Asian patients.

HYPOTHESIS

We sought to evaluate the target achievement rate and associated variables in Korean patients with FH after maximal statin-based LLT.

METHODS

We enrolled 146 patients with heterozygous FH, and 90 patients were finally analyzed. Patients were initially prescribed rosuvastatin 10 mg or atorvastatin 20 mg, and the regimen was adjusted to achieve the low-density lipoprotein cholesterol (LDL-C) target of 100 mg/dL. The primary evaluation point was the achievement rate of the LDL-C targets at 12 months: LDL-C < 100 mg/dL and ≥50% LDL-C reduction. The associations between clinical variables and target achievement were also analyzed.

RESULTS

At 12 months, 58% of patients were receiving high-intensity regimens, whereas 46% were receiving combination therapy. The mean pre- and post-treatment LDL-C levels were 229 and 118 mg/dL, respectively. Twenty-eight percent of patients achieved LDL-C < 100 mg/dL, and 47% achieved ≥50% LDL-C reduction. Pretreatment LDL-C and high-intensity regimens indicated a negative tendency toward the attainment of LDL-C < 100 mg/dL. Conversely, pretreatment LDL-C and diabetes mellitus were positively associated with a higher rate of ≥50% LDL-C reduction.

CONCLUSIONS

The target achievement of LDL-C < 100 mg/dL was low, and 50% LDL-C reduction was moderately achieved in Korean patients with FH receiving maximal statin-based LLT. Pretreatment LDL-C levels and diabetes mellitus were associated with target achievement. Our results provide rare and informative data on FH treatment in Asian patients.

Characteristics and Vascular Complications of Familial Hypercholesterolemia in Korea

Familial hypercholesterolemia (FH) is presently an important health issue worldwide. This condition shows phenotypic and genetic variations among affected people, and clinical and genetic data on FH are critical for effective diagnosis and management. Korean FH patients have relatively low levels of cholesterol and prevalence of xanthoma than patients from other countries, as determined by previous studies. The best predictive value of low-density lipoprotein cholesterol (LDL-C) for pathogenic mutations is suggested as 225 mg/dL. Many known and novel mutations on LDLR and some on APOB or PCSK9 have been identified in one-third of clinically diagnosed probands, and their locations on genes varied. Coronary artery disease was reported in 28% Korean FH patients, and traditional cardiovascular risk factors were associated with this complication. Aortic valve changes were also prevalent. However, the achievement rate of LDL-C target using lipid-lowering therapy is not satisfactory and is only 21%-44%. A further expanded registry and additional analysis may provide a more useful clinical tool for the diagnosis and treatment of Korean FH patients.

Efficacy and safety of coadministration of rosuvastatin, ezetimibe, and colestimide in heterozygous familial hypercholesterolemia

Aggressive low-density lipoprotein (LDL) cholesterol-lowering therapy is important for high-risk patients. However, sparse data exist on the impact of combined aggressive LDL cholesterol-lowering therapy in familial hypercholesterolemia (FH), particularly on side effects to changes in plasma coenzyme Q10 and proprotein convertase subtilisin/kexin type 9 levels. We enrolled 17 Japanese patients with heterozygous FH (12 men, 63.9 ± 7.4 years old) with single LDL receptor gene mutations in a prospective open randomized study. Permitted maximum doses of rosuvastatin (20 mg/day), ezetimibe (10 mg/day), and granulated colestimide (3.62 g/day) were introduced sequentially. Serum levels of LDL cholesterol decreased significantly by -66.4% (p <0.001) and 44% of participants achieved LDL cholesterol levels <100 mg/dl. There were no serious side effects or abnormal laboratory data that would have required the protocol to have been terminated except for 1 patient with myalgia. Coadministration of ezetimibe and granulated colestimide further lowered serum LDL cholesterol more than rosuvastatin alone without changing plasma coenzyme Q10 and proprotein convertase subtilisin/kexin type 9 levels. In conclusion, adequate introduction of this aggressive cholesterol-lowering regimen can improve the lipid profile of FH.

Apolipoprotein E polymorphism influences lipid phenotypes in Chinese families with familial combined hyperlipidemia

BACKGROUND

Apolipoprotein E (apoE) polymorphism is associated with changes in the lipoprotein profile of individuals with familial combined hyperlipidemia (FCHL), but its effects on the lipoprotein profiles of members of Chinese families with FCHL remain uncertain.

METHODS AND RESULTS

43 FCHL families (n=449) and 9 normolipidemic families (n=73) were recruited to assess the influence of apoE polymorphism on plasma lipids. The relative frequency of the epsilon4 allele in affected and unaffected FCHL relatives, spouses and normolipidemic members was 13.8%, 5.3%, 9.1% and 6.8%, respectively, with a significantly higher frequency in affected FCHL relatives, compared with unaffected FCHL relatives or normolipidemic members (p=0.0002 or p=0.029). In FCHL relatives, the apoE4 subset (E4/4 and E4/3) exhibited significantly higher levels of apoB, total cholesterol and low-density lipoprotein-cholesterol (LDL-C) than did the apoE3 (E3/3) subset, especially in women (all p<0.05), and there was significant elevation of LDL-C concentrations in men only (p<0.05). In men, the apoE2 (E3/2) subset indicated a decreased level of apoB and increased apoA1 compared with those in the apoE3 subset (p<0.05).

CONCLUSIONS

ApoE polymorphism appears to be associated with variance of the lipoprotein phenotype in Chinese families with FCHL.

Effects of late administration of immunoglobulin on experimental atherosclerosis in apolipoprotein E-deficient mice

BACKGROUND

Although immunoglobulin treatment, beginning simultaneously with the initiation of atherosclerosis, suppresses experimental atherosclerosis in apolipoprotein E-deficient mice, it remains unclear whether the treatment at a subsequent stage of atherosclerosis would be effective.

METHODS AND RESULTS

Experimental atherosclerosis was induced in mice fed a high-fat diet containing 0.3% cholesterol. After confirming the presence of atherosclerotic lesions at 11 weeks, the mice were treated with an intraperitoneal injection of either intact type of immunoglobulin or F(ab')2 fragments of immunoglobulin (both, 1 g.kg-1.day-1) on alternate days over 4 weeks. Fatty streak lesion was suppressed by intact immunoglobulin administration, but not by F(ab')2 fragments of immunoglobulin. Immunohistochemical analysis showed that macrophage and CD4+ T-cell accumulation in the fatty streak lesion was suppressed in mice that received intact immunoglobulin but not in those that received F(ab')2 fragments.

CONCLUSIONS

Immunoglobulin treatment, even at a later stage of atherosclerosis, suppresses the development of lesions associated with the reduced expression of immune-activated cells in fatty streak plaques, demonstrating the benefits of immunoglobulin therapy for prevention of atherosclerosis.

Cross-Over Trial of Intensive Monotherapy With Atorvastatin and Combined Therapy With Atorvastatin and Colestimide for Japanese Familial Hypercholesterolemia

BACKGROUND

In familial hypercholesterolemia (FH), low-density lipoprotein-cholesterol (LDL-C)-lowering therapy is important to avoid predisposition to coronary artery disease. This study investigated the advantages of combined therapy with atorvastatin and colestimide vs intensive monotherapy with atorvastatin.

METHODS AND RESULTS

The trial used a randomized cross-over design consisting of 2 16-week periods of open-label drug therapy. Among the 24 initial patients, 17 heterozygous FH patients (age: 54.1 years; 5 males) were enrolled after 20 mg/day atorvastatin failed to achieve their target level. The patients received 20 mg/day atorvastatin and 3 g/day colestimide or 40 mg/day atorvastatin. Fifteen patients completed the trial and their LDL-C reduced from 5.07 +/- 1.10 mmol/L to 3.76 +/- 0.90 mmol/L with the combined therapy and to 3.81 +/- 0.50 mmol/L with the intensive monotherapy. Although the 2 therapies showed comparable mean effects for decreasing LDL-C, similar adverse reaction and cost, each therapy was predominantly more effective in some patients than in others. The triglyceride and high-density lipoprotein cholesterol levels were similar in both therapies.

CONCLUSIONS

To achieve the therapeutic target of LDL-C level for refractory FH, the LDL-C-lowering therapy selected can be either intensive monotherapy or combined therapy as the next to standard statin therapy.