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Soffer DE, Marston NA, Maki KC, Jacobson TA, Bittner VA, Peña JM, Thanassoulis G, Martin SS, Kirkpatrick CF, Virani SS, Dixon DL, Ballantyne CM, Remaley AT. Role of apolipoprotein B in the clinical management of cardiovascular risk in adults: An expert clinical consensus from the national lipid association. J Clin Lipidol 2024:S1933-2874(24)00240-X. [PMID: 39256087 DOI: 10.1016/j.jacl.2024.08.013] [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: 08/16/2024] [Revised: 08/26/2024] [Accepted: 08/27/2024] [Indexed: 09/12/2024]
Abstract
This National Lipid Association (NLA) Expert Clinical Consensus provides an overview of the physiologic and clinical considerations regarding the role of apolipoprotein B (apoB) measurement to guide clinical care based on the available scientific evidence and expert opinion. ApoB represents the total concentration of atherogenic lipoprotein particles in the circulation and more accurately reflects the atherogenic burden of lipoproteins when compared to low-density lipoprotein cholesterol (LDL-C). ApoB is a validated clinical measurement that augments the information found in a standard lipoprotein lipid panel; therefore, there is clinical value in using apoB in conjunction with a standard lipoprotein lipid profile when assessing risk and managing lipid-lowering therapy (LLT). ApoB has been shown to be superior to LDL-C in risk assessment both before and during treatment with LLT. In individuals, there can be discordance between levels of LDL-C and apoB, as well as LDL-C and non-high-density lipoprotein cholesterol (non-HDL-C), despite high levels of population-wide correlation. When there is discordance between LDL-C and apoB, or LDL-C and non-HDL-C, atherosclerotic cardiovascular disease risk generally aligns better with apoB or non-HDL-C. Additionally, apoB can be used in tandem with standard lipoprotein lipid measurements to diagnose distinct lipoprotein phenotypes. ApoB testing can inform clinical prognosis and care, as well as enable family cascade screening, when an inherited lipoprotein syndrome is identified. The NLA and other organizations will continue to educate clinicians about the role of apoB measurement in improving clinical risk assessment and dyslipidemia management. An urgent need exists to improve access and reimbursement for apoB testing.
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Affiliation(s)
- Daniel E Soffer
- Clinical Lipidology, Division of Translational Medicine and Human Genetics, University of Pennsylvania, Philadelphia, PA, USA (Dr Soffer).
| | - Nicholas A Marston
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Dr Marston)
| | - Kevin C Maki
- Midwest Biomedical Research, Addison, IL, USA (Drs Maki and Kirkpatrick); Indiana University School of Public Health, Department of Applied Health Science, Bloomington, IN, USA (Dr Maki)
| | - Terry A Jacobson
- Lipid Clinic and Cardiovascular Risk Reduction Program, Emory Department of Medicine, Emory University, Atlanta, GA, USA (Dr Jacobson)
| | - Vera A Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA (Dr Bittner)
| | - Jessica M Peña
- Departments of Medicine and Radiology, Weill Cornell Medicine, New York, NY, USA (Dr Peña)
| | - George Thanassoulis
- Preventive and Genomic Cardiology, Department of Medicine, McGill University, and the McGill University Health Center Research Institute, Montréal, Québec, Canada (Dr Thanassoulis)
| | - Seth S Martin
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD, USA (Dr Martin)
| | - Carol F Kirkpatrick
- Midwest Biomedical Research, Addison, IL, USA (Drs Maki and Kirkpatrick); Kasiska Division of Health Sciences, Idaho State University, Pocatello, ID, USA (Dr Kirkpatrick)
| | - Salim S Virani
- Department of Medicine, The Aga Khan University, Karachi, Pakistan (Dr Virani); Texas Heart Institute and Baylor College of Medicine, Houston, TX, USA (Dr Virani)
| | - Dave L Dixon
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA (Dr Dixon)
| | - Christie M Ballantyne
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA (Dr Ballantyne)
| | - Alan T Remaley
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA (Dr Remaley)
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Watts GF, Rosenson RS, Hegele RA, Goldberg IJ, Gallo A, Mertens A, Baass A, Zhou R, Muhsin M, Hellawell J, Leeper NJ, Gaudet D. Plozasiran for Managing Persistent Chylomicronemia and Pancreatitis Risk. N Engl J Med 2024. [PMID: 39225259 DOI: 10.1056/nejmoa2409368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
BACKGROUND Persistent chylomicronemia is a genetic recessive disorder that is classically caused by familial chylomicronemia syndrome (FCS), but it also has multifactorial causes. The disorder is associated with the risk of recurrent acute pancreatitis. Plozasiran is a small interfering RNA that reduces hepatic production of apolipoprotein C-III and circulating triglycerides. METHODS In a phase 3 trial, we randomly assigned 75 patients with persistent chylomicronemia (with or without a genetic diagnosis) to receive subcutaneous plozasiran (25 mg or 50 mg) or placebo every 3 months for 12 months. The primary end point was the median percent change from baseline in the fasting triglyceride level at 10 months. Key secondary end points were the percent change in the fasting triglyceride level from baseline to the mean of values at 10 months and 12 months, changes in the fasting apolipoprotein C-III level from baseline to 10 months and 12 months, and the incidence of acute pancreatitis. RESULTS At baseline, the median triglyceride level was 2044 mg per deciliter. At 10 months, the median change from baseline in the fasting triglyceride level (the primary end point) was -80% in the 25-mg plozasiran group, -78% in the 50-mg plozasiran group, and -17% in the placebo group (P<0.001). The key secondary end points showed better results in the plozasiran groups than in the placebo group, including the incidence of acute pancreatitis (odds ratio, 0.17; 95% confidence interval, 0.03 to 0.94; P = 0.03). The risk of adverse events was similar across groups; the most common adverse events were abdominal pain, nasopharyngitis, headache, and nausea. Severe and serious adverse events were less common with plozasiran than with placebo. Hyperglycemia with plozasiran occurred in some patients with prediabetes or diabetes at baseline. CONCLUSIONS Patients with persistent chylomicronemia who received plozasiran had significantly lower triglyceride levels and a lower incidence of pancreatitis than those who received placebo. (Funded by Arrowhead Pharmaceuticals; PALISADE ClinicalTrials.gov number, NCT05089084.).
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Affiliation(s)
- Gerald F Watts
- From the School of Medicine, University of Western Australia, and the Department of Cardiology, Royal Perth Hospital - both in Perth, Australia (G.F.W.); the Metabolism and Lipids Program, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai (R.S.R.), and New York University (NYU) Grossman School of Medicine, NYU Langone Health (I.J.G) - both in New York; Robarts Research Institute, London, ON (R.A.H.), and the Department of Medicine, McGill University, and the Genetic Dyslipidemia Clinic, Montreal Clinical Research Institute (A.B.) and Université de Montréal and ECOGENE-21 (D.G.), Montreal - all in Canada; Sorbonne University, INSERM UMR1166, Lipidology and Cardiovascular Prevention Unit, Department of Nutrition, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris (A.G.); the Department of Endocrinology, University Hospitals Leuven-KU Leuven, Leuven, Belgium (A.M.); and Arrowhead Pharmaceuticals, Pasadena (R.Z., M.M., J.H.), and Stanford University, Palo Alto (N.J.L.) - both in California
| | - Robert S Rosenson
- From the School of Medicine, University of Western Australia, and the Department of Cardiology, Royal Perth Hospital - both in Perth, Australia (G.F.W.); the Metabolism and Lipids Program, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai (R.S.R.), and New York University (NYU) Grossman School of Medicine, NYU Langone Health (I.J.G) - both in New York; Robarts Research Institute, London, ON (R.A.H.), and the Department of Medicine, McGill University, and the Genetic Dyslipidemia Clinic, Montreal Clinical Research Institute (A.B.) and Université de Montréal and ECOGENE-21 (D.G.), Montreal - all in Canada; Sorbonne University, INSERM UMR1166, Lipidology and Cardiovascular Prevention Unit, Department of Nutrition, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris (A.G.); the Department of Endocrinology, University Hospitals Leuven-KU Leuven, Leuven, Belgium (A.M.); and Arrowhead Pharmaceuticals, Pasadena (R.Z., M.M., J.H.), and Stanford University, Palo Alto (N.J.L.) - both in California
| | - Robert A Hegele
- From the School of Medicine, University of Western Australia, and the Department of Cardiology, Royal Perth Hospital - both in Perth, Australia (G.F.W.); the Metabolism and Lipids Program, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai (R.S.R.), and New York University (NYU) Grossman School of Medicine, NYU Langone Health (I.J.G) - both in New York; Robarts Research Institute, London, ON (R.A.H.), and the Department of Medicine, McGill University, and the Genetic Dyslipidemia Clinic, Montreal Clinical Research Institute (A.B.) and Université de Montréal and ECOGENE-21 (D.G.), Montreal - all in Canada; Sorbonne University, INSERM UMR1166, Lipidology and Cardiovascular Prevention Unit, Department of Nutrition, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris (A.G.); the Department of Endocrinology, University Hospitals Leuven-KU Leuven, Leuven, Belgium (A.M.); and Arrowhead Pharmaceuticals, Pasadena (R.Z., M.M., J.H.), and Stanford University, Palo Alto (N.J.L.) - both in California
| | - Ira J Goldberg
- From the School of Medicine, University of Western Australia, and the Department of Cardiology, Royal Perth Hospital - both in Perth, Australia (G.F.W.); the Metabolism and Lipids Program, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai (R.S.R.), and New York University (NYU) Grossman School of Medicine, NYU Langone Health (I.J.G) - both in New York; Robarts Research Institute, London, ON (R.A.H.), and the Department of Medicine, McGill University, and the Genetic Dyslipidemia Clinic, Montreal Clinical Research Institute (A.B.) and Université de Montréal and ECOGENE-21 (D.G.), Montreal - all in Canada; Sorbonne University, INSERM UMR1166, Lipidology and Cardiovascular Prevention Unit, Department of Nutrition, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris (A.G.); the Department of Endocrinology, University Hospitals Leuven-KU Leuven, Leuven, Belgium (A.M.); and Arrowhead Pharmaceuticals, Pasadena (R.Z., M.M., J.H.), and Stanford University, Palo Alto (N.J.L.) - both in California
| | - Antonio Gallo
- From the School of Medicine, University of Western Australia, and the Department of Cardiology, Royal Perth Hospital - both in Perth, Australia (G.F.W.); the Metabolism and Lipids Program, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai (R.S.R.), and New York University (NYU) Grossman School of Medicine, NYU Langone Health (I.J.G) - both in New York; Robarts Research Institute, London, ON (R.A.H.), and the Department of Medicine, McGill University, and the Genetic Dyslipidemia Clinic, Montreal Clinical Research Institute (A.B.) and Université de Montréal and ECOGENE-21 (D.G.), Montreal - all in Canada; Sorbonne University, INSERM UMR1166, Lipidology and Cardiovascular Prevention Unit, Department of Nutrition, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris (A.G.); the Department of Endocrinology, University Hospitals Leuven-KU Leuven, Leuven, Belgium (A.M.); and Arrowhead Pharmaceuticals, Pasadena (R.Z., M.M., J.H.), and Stanford University, Palo Alto (N.J.L.) - both in California
| | - Ann Mertens
- From the School of Medicine, University of Western Australia, and the Department of Cardiology, Royal Perth Hospital - both in Perth, Australia (G.F.W.); the Metabolism and Lipids Program, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai (R.S.R.), and New York University (NYU) Grossman School of Medicine, NYU Langone Health (I.J.G) - both in New York; Robarts Research Institute, London, ON (R.A.H.), and the Department of Medicine, McGill University, and the Genetic Dyslipidemia Clinic, Montreal Clinical Research Institute (A.B.) and Université de Montréal and ECOGENE-21 (D.G.), Montreal - all in Canada; Sorbonne University, INSERM UMR1166, Lipidology and Cardiovascular Prevention Unit, Department of Nutrition, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris (A.G.); the Department of Endocrinology, University Hospitals Leuven-KU Leuven, Leuven, Belgium (A.M.); and Arrowhead Pharmaceuticals, Pasadena (R.Z., M.M., J.H.), and Stanford University, Palo Alto (N.J.L.) - both in California
| | - Alexis Baass
- From the School of Medicine, University of Western Australia, and the Department of Cardiology, Royal Perth Hospital - both in Perth, Australia (G.F.W.); the Metabolism and Lipids Program, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai (R.S.R.), and New York University (NYU) Grossman School of Medicine, NYU Langone Health (I.J.G) - both in New York; Robarts Research Institute, London, ON (R.A.H.), and the Department of Medicine, McGill University, and the Genetic Dyslipidemia Clinic, Montreal Clinical Research Institute (A.B.) and Université de Montréal and ECOGENE-21 (D.G.), Montreal - all in Canada; Sorbonne University, INSERM UMR1166, Lipidology and Cardiovascular Prevention Unit, Department of Nutrition, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris (A.G.); the Department of Endocrinology, University Hospitals Leuven-KU Leuven, Leuven, Belgium (A.M.); and Arrowhead Pharmaceuticals, Pasadena (R.Z., M.M., J.H.), and Stanford University, Palo Alto (N.J.L.) - both in California
| | - Rong Zhou
- From the School of Medicine, University of Western Australia, and the Department of Cardiology, Royal Perth Hospital - both in Perth, Australia (G.F.W.); the Metabolism and Lipids Program, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai (R.S.R.), and New York University (NYU) Grossman School of Medicine, NYU Langone Health (I.J.G) - both in New York; Robarts Research Institute, London, ON (R.A.H.), and the Department of Medicine, McGill University, and the Genetic Dyslipidemia Clinic, Montreal Clinical Research Institute (A.B.) and Université de Montréal and ECOGENE-21 (D.G.), Montreal - all in Canada; Sorbonne University, INSERM UMR1166, Lipidology and Cardiovascular Prevention Unit, Department of Nutrition, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris (A.G.); the Department of Endocrinology, University Hospitals Leuven-KU Leuven, Leuven, Belgium (A.M.); and Arrowhead Pharmaceuticals, Pasadena (R.Z., M.M., J.H.), and Stanford University, Palo Alto (N.J.L.) - both in California
| | - Ma'an Muhsin
- From the School of Medicine, University of Western Australia, and the Department of Cardiology, Royal Perth Hospital - both in Perth, Australia (G.F.W.); the Metabolism and Lipids Program, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai (R.S.R.), and New York University (NYU) Grossman School of Medicine, NYU Langone Health (I.J.G) - both in New York; Robarts Research Institute, London, ON (R.A.H.), and the Department of Medicine, McGill University, and the Genetic Dyslipidemia Clinic, Montreal Clinical Research Institute (A.B.) and Université de Montréal and ECOGENE-21 (D.G.), Montreal - all in Canada; Sorbonne University, INSERM UMR1166, Lipidology and Cardiovascular Prevention Unit, Department of Nutrition, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris (A.G.); the Department of Endocrinology, University Hospitals Leuven-KU Leuven, Leuven, Belgium (A.M.); and Arrowhead Pharmaceuticals, Pasadena (R.Z., M.M., J.H.), and Stanford University, Palo Alto (N.J.L.) - both in California
| | - Jennifer Hellawell
- From the School of Medicine, University of Western Australia, and the Department of Cardiology, Royal Perth Hospital - both in Perth, Australia (G.F.W.); the Metabolism and Lipids Program, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai (R.S.R.), and New York University (NYU) Grossman School of Medicine, NYU Langone Health (I.J.G) - both in New York; Robarts Research Institute, London, ON (R.A.H.), and the Department of Medicine, McGill University, and the Genetic Dyslipidemia Clinic, Montreal Clinical Research Institute (A.B.) and Université de Montréal and ECOGENE-21 (D.G.), Montreal - all in Canada; Sorbonne University, INSERM UMR1166, Lipidology and Cardiovascular Prevention Unit, Department of Nutrition, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris (A.G.); the Department of Endocrinology, University Hospitals Leuven-KU Leuven, Leuven, Belgium (A.M.); and Arrowhead Pharmaceuticals, Pasadena (R.Z., M.M., J.H.), and Stanford University, Palo Alto (N.J.L.) - both in California
| | - Nicholas J Leeper
- From the School of Medicine, University of Western Australia, and the Department of Cardiology, Royal Perth Hospital - both in Perth, Australia (G.F.W.); the Metabolism and Lipids Program, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai (R.S.R.), and New York University (NYU) Grossman School of Medicine, NYU Langone Health (I.J.G) - both in New York; Robarts Research Institute, London, ON (R.A.H.), and the Department of Medicine, McGill University, and the Genetic Dyslipidemia Clinic, Montreal Clinical Research Institute (A.B.) and Université de Montréal and ECOGENE-21 (D.G.), Montreal - all in Canada; Sorbonne University, INSERM UMR1166, Lipidology and Cardiovascular Prevention Unit, Department of Nutrition, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris (A.G.); the Department of Endocrinology, University Hospitals Leuven-KU Leuven, Leuven, Belgium (A.M.); and Arrowhead Pharmaceuticals, Pasadena (R.Z., M.M., J.H.), and Stanford University, Palo Alto (N.J.L.) - both in California
| | - Daniel Gaudet
- From the School of Medicine, University of Western Australia, and the Department of Cardiology, Royal Perth Hospital - both in Perth, Australia (G.F.W.); the Metabolism and Lipids Program, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai (R.S.R.), and New York University (NYU) Grossman School of Medicine, NYU Langone Health (I.J.G) - both in New York; Robarts Research Institute, London, ON (R.A.H.), and the Department of Medicine, McGill University, and the Genetic Dyslipidemia Clinic, Montreal Clinical Research Institute (A.B.) and Université de Montréal and ECOGENE-21 (D.G.), Montreal - all in Canada; Sorbonne University, INSERM UMR1166, Lipidology and Cardiovascular Prevention Unit, Department of Nutrition, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris (A.G.); the Department of Endocrinology, University Hospitals Leuven-KU Leuven, Leuven, Belgium (A.M.); and Arrowhead Pharmaceuticals, Pasadena (R.Z., M.M., J.H.), and Stanford University, Palo Alto (N.J.L.) - both in California
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Masson W, Lobo M, Nogueira JP, Corral P, Barbagelata L, Siniawski D. Inhibitors of apolipoprotein C3, triglyceride levels, and risk of pancreatitis: a systematic review and meta-analysis. Rev Endocr Metab Disord 2024:10.1007/s11154-024-09893-x. [PMID: 38997541 DOI: 10.1007/s11154-024-09893-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2024] [Indexed: 07/14/2024]
Abstract
In recent years, novel apoC3 inhibitor therapies for the treatment of hypertriglyceridemia have been developed and assessed through phase II and III clinical trials. The objective of this study was to perform an updated meta-analysis on the impact of new apoC3 inhibitor drugs on triglyceride and apoC3 levels, as well as on the incidence of pancreatitis. We conducted a meta-analysis of randomized, placebo-controlled studies assessing the effects of apoC3 inhibitors therapy (antisense oligonucleotides and small interfering RNA) on triglyceride levels, apoC3 levels, and the occurrence of acute pancreatitis. This meta-analysis was performed according to PRISMA guidelines. The random-effects model was performed. Nine randomized clinical trials (n = 717 patients) were considered eligible for this systematic review. ApoC3 inhibitor drugs were consistently associated with decreased triglyceride levels (MD -57.0%; 95% CI -61.9 to -52.1, I2 82%) and lowered apoC3 values (MD -76; 95% CI -80.1 to -71.8, I2 77%) when compared to placebo. Furthermore, the use of apoC3 inhibitor drugs demonstrated a reduction in the risk of acute pancreatitis (OR 0.11; 95% CI 0.04 to 0.27, I2 0%). The present updated meta-analysis of randomized clinical trials demonstrated that the utilization of apoC3 inhibitors in patients with hypertriglyceridemia correlated with reduced apoC3 and triglyceride levels, along with a decreased risk of acute pancreatitis compared to the placebo.
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Affiliation(s)
- Walter Masson
- Department of Cardiology, Hospital Italiano de Buenos Aires, Peron 4190, Buenos Aires, C1199ABB, Argentina.
| | - Martín Lobo
- Department of Cardiology, Hospital Militar Campo de Mayo, Buenos Aires, Argentina
| | - Juan P Nogueira
- Endocrinology, Nutrition and Metabolism Research Center, Faculty of Health Sciences, Universidad Nacional de Formosa, Formosa, Argentina
- International University of the Americas, San José, Costa Rica
| | - Pablo Corral
- Faculty of Medicine, Fasta University, Mar del Plata, Argentina
| | - Leandro Barbagelata
- Department of Cardiology, Hospital Italiano de Buenos Aires, Peron 4190, Buenos Aires, C1199ABB, Argentina
| | - Daniel Siniawski
- Department of Cardiology, Hospital Italiano de Buenos Aires, Peron 4190, Buenos Aires, C1199ABB, Argentina
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4
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Bardey F, Rieck L, Spira D, März W, Binner P, Schwab S, Kleber ME, Danyel M, Barkowski R, Bobbert T, Spranger J, Steinhagen-Thiessen E, Demuth I, Kassner U. Clinical characterization and mutation spectrum of patients with hypertriglyceridemia in a German outpatient clinic. J Lipid Res 2024:100589. [PMID: 38969064 DOI: 10.1016/j.jlr.2024.100589] [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: 04/10/2023] [Revised: 06/13/2024] [Accepted: 06/21/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND Severe hypertriglyceridemia (HTG) has predominantly multifactorial causes (MCS). Yet a small subset of patients have the monogenetic form (FCS). It remains a challenge to distinguish patients clinically, since decompensated MCS might mimic FCS´s severity. Aim of the current study was to determine clinical criteria that could sufficiently distinguish both forms as well as to apply the FCS score proposed by Moulin and colleagues. METHODS We retrospectively studied 72 patients who presented with severe HTG in our clinic during a time span of seven years and received genetic testing. We classified genetic variants (ACMG-criteria), followed by genetic categorization into MCS or FCS. Clinical data were gathered from the medical records and the FCS score was calculated for each patient. RESULTS Molecular genetic screening revealed eight FCS patients and 64 MCS patients. Altogether, we found 13 pathogenic variants of which four have not been described before. The FCS patients showed a significantly higher median triglyceride level compared to the MCS. The FCS score yielded a sensitivity of 75% and a specificity of 93.7% in our cohort, and significantly differentiated between the FCS and MCS group (p<0.001). CONCLUSIONS In our cohort we identified several variables that significantly differentiated FCS from MCS. The FCS score performed similar to the original study by Moulin, thereby further validating the discriminatory power of the FCS score in an independent cohort.
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Affiliation(s)
- Frieda Bardey
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Endocrinology and Metabolic Diseases (including Division of Lipid Metabolism), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Lorenz Rieck
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Endocrinology and Metabolic Diseases (including Division of Lipid Metabolism), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Dominik Spira
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Endocrinology and Metabolic Diseases (including Division of Lipid Metabolism), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Winfried März
- Synlab Academy, P5, 7, 68167 Mannheim, Germany; Vth Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Auenbrugger Platz 15, 8036 Graz
| | - Priska Binner
- Synlab Center of Human Genetics, Harrlachweg 1, 68163 Mannheim, Germany
| | - Stefanie Schwab
- Synlab Center of Human Genetics, Harrlachweg 1, 68163 Mannheim, Germany
| | - Marcus E Kleber
- Vth Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; Synlab Center of Human Genetics, Harrlachweg 1, 68163 Mannheim, Germany
| | - Magdalena Danyel
- Berlin Institute of Health (BIH), Berlin, Germany; Institute of Medical Genetics and Human Genetics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Rasmus Barkowski
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Endocrinology and Metabolic Diseases (including Division of Lipid Metabolism), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Thomas Bobbert
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Endocrinology and Metabolic Diseases (including Division of Lipid Metabolism), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Joachim Spranger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Endocrinology and Metabolic Diseases (including Division of Lipid Metabolism), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Elisabeth Steinhagen-Thiessen
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Endocrinology and Metabolic Diseases (including Division of Lipid Metabolism), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Ilja Demuth
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Endocrinology and Metabolic Diseases (including Division of Lipid Metabolism), Augustenburger Platz 1, 13353 Berlin, Germany; Charité - Universitätsmedizin Berlin, BCRT - Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany.
| | - Ursula Kassner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Endocrinology and Metabolic Diseases (including Division of Lipid Metabolism), Augustenburger Platz 1, 13353 Berlin, Germany
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5
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Chait A, Eckel RH, Vrablik M, Zambon A. Lipid-lowering in diabetes: An update. Atherosclerosis 2024; 394:117313. [PMID: 37945448 DOI: 10.1016/j.atherosclerosis.2023.117313] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/11/2023] [Accepted: 09/22/2023] [Indexed: 11/12/2023]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) is accelerated in people with diabetes. Dyslipidemia, hyperglycemia, oxidative stress, and inflammation play a role via a variety of mechanisms operative in the artery wall. In addition, some unique features predispose people with type 1 diabetes to accelerated atherosclerosis. Various organizations have created guidelines that provide advice regarding screening, risk assessment, and roadmaps for treatment to prevent ASCVD in diabetes. Management of dyslipidemia, especially with statins, has proven to be of immense benefit in the prevention of clinical CVD. However, since many patients fail to attain the low levels of low-density lipoproteins (LDL) recommended in these guidelines, supplemental therapy, such as the addition of ezetimibe, bempedoic acid or PCSK9 inhibitors, is often required to reach LDL goals. As a result, the upfront use of combination therapies, particularly a statin plus ezetimibe, is a rational initial approach. The addition to statins of drugs that specifically lower triglyceride levels has not proven beneficial, although the addition of icosapent-ethyl has been shown to be of value, likely by mechanisms independent of triglyceride lowering. Newer treatments in development, including apoC-III and ANGPTL3 inhibitors, seem promising in further reducing apoB-containing lipoproteins.
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Affiliation(s)
- Alan Chait
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, WA, USA
| | - Robert H Eckel
- Department of Medicine, Division of Endocrinology, Metabolism and Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Michal Vrablik
- 3rd Department of Internal Medicine, General University Hospital and 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Alberto Zambon
- Department of Medicine - DIMED, University of Padova, and IRCCS Multimedica Milan, Italy.
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6
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Ain Q, Cevc M, Marusic T, Sikonja J, Sadiq F, Sustar U, Mlinaric M, Kovac J, Batool H, Khan MI, Trebusak Podkrajsek K, Bizjan BJ, Battelino T, Fras Z, Ajmal M, Groselj U. Genetic and clinical characteristics of patients with lipoprotein lipase deficiency from Slovenia and Pakistan: case series and systematic literature review. Front Endocrinol (Lausanne) 2024; 15:1387419. [PMID: 38911039 PMCID: PMC11190153 DOI: 10.3389/fendo.2024.1387419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 05/21/2024] [Indexed: 06/25/2024] Open
Abstract
Introduction Hypertriglyceridemia (HTG) is a complex disorder caused by genetic and environmental factors that frequently results from loss-of-function variants in the gene encoding lipoprotein lipase (LPL). Heterozygous patients have a range of symptoms, while homozygous LPL deficiency presents with severe symptoms including acute pancreatitis, xanthomas, and lipemia retinalis. Methods We described the clinical characteristics of three Slovenian patients (an 8-year-old female, an 18-year-old man, and a 57-year-old female) and one Pakistani patient (a 59-year-old male) with LPL deficiency. We performed next-generation sequencing (NGS) targeting all coding exons and intron-exon boundaries of the LPL gene, and Sanger sequencing for variant confirmation. In addition, we performed a systematic literature review of all cases with three identified variants and described their clinical characteristics. Results Two Slovenian patients with a heterozygous pathogenic variant NM_000237.3:c.984G>T (p.Met328Ile) were diagnosed within the first three years of life and had triglyceride (TG) values of 16 and 20 mmol/L. An asymptomatic Pakistani patient with TG values of 36.8 mmol/L until the age of 44 years, was identified as heterozygous for a pathogenic variant NM_000237.3:c.724G>A (p.Asp242Asn). His TG levels dropped to 12.7 mmol/L on dietary modifications and by using fibrates. A Slovenian patient who first suffered from pancreatitis at the age of 18 years with a TG value of 34 mmol/L was found to be homozygous for NM_000237.3:c.337T>C (p.Trp113Arg). Conclusions Patients with LPL deficiency had high TG levels at diagnosis. Homozygous patients had worse outcomes. Good diet and medication compliance can reduce severity.
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Affiliation(s)
- Quratul Ain
- Translational Genomics Laboratory, Department of Biosciences, COMSATS University Islamabad, Islamabad, Pakistan
- Directorate of Research, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Matija Cevc
- Division of Medicine, Centre for Preventive Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Tatiana Marusic
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jaka Sikonja
- Department of Endocrinology, Diabetes and Metabolic Diseases, Division of Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Fouzia Sadiq
- Directorate of Research, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Ursa Sustar
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Matej Mlinaric
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jernej Kovac
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Hijab Batool
- Department of Clinical Chemistry and Immunology, Chughtai Institute of Pathology, Lahore, Pakistan
| | - Mohammad Iqbal Khan
- Directorate of Research, Shifa Tameer-e-Millat University, Islamabad, Pakistan
- Department of Vascular Surgery, Shifa International Hospital, Islamabad, Pakistan
| | - Katarina Trebusak Podkrajsek
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Barbara Jenko Bizjan
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Tadej Battelino
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Zlatko Fras
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Muhammad Ajmal
- Translational Genomics Laboratory, Department of Biosciences, COMSATS University Islamabad, Islamabad, Pakistan
| | - Urh Groselj
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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7
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Ahmad M, Kennedy BA, Son S, McIntyre AD, Lazarte J, Wang J, Hegele RA. Carotid intima-medial thickness in patients with severe hypertriglyceridemia. ATHEROSCLEROSIS PLUS 2024; 56:7-11. [PMID: 38694144 PMCID: PMC11060956 DOI: 10.1016/j.athplu.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/16/2024] [Accepted: 04/19/2024] [Indexed: 05/04/2024]
Abstract
Background and aims Severe hypertriglyceridemia (HTG), defined as plasma triglyceride (TG) concentration > 10 mmol/L, is relatively uncommon, and its implications for atherosclerotic cardiovascular disease (ASCVD) risk remain somewhat unclear. We evaluated the association between severe HTG and carotid intima-media thickness (IMT), a marker for ASCVD. Methods We studied three clinical cohorts: 88 patients with severe HTG (mean TG level 20.6 mmol/L), 271 patients with familial hypercholesterolemia (FH) as a contrast group, and 70 normolipidemic controls. Carotid IMT was measured using standardized ultrasound imaging. Statistical analysis was conducted using one-way analysis of variance (ANOVA) to compare mean IMT values, analysis of covariance (ANCOVA) to adjust for confounding variables, specifically age and sex, as well as Spearman pairwise correlation analysis between variables. Results Unadjusted mean carotid IMT was greater in severe HTG and FH groups compared to controls, however, this was no longer significant for severe HTG after adjustment for age and sex. In contrast, adjusted carotid IMT remained significantly different between the FH and control groups. Conclusions Our findings suggest that extreme TG elevations in severe HTG patients are not significantly associated with carotid IMT, in contrast to the increased IMT seen in FH patients. These findings add perspective to the complex relationship between severe HTG and ASCVD risk.
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Affiliation(s)
- Maud Ahmad
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, N6A 5B7, Canada
| | - Brooke A. Kennedy
- Robarts Research Institute, Western University, London, Ontario, N6A 5B7, Canada
| | - Surim Son
- Department of Epidemiology and Biostatistics, Western University, London, ON, N6A 5B7, Canada
| | - Adam D. McIntyre
- Robarts Research Institute, Western University, London, Ontario, N6A 5B7, Canada
| | - Julieta Lazarte
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, N6A 5B7, Canada
| | - Jian Wang
- Robarts Research Institute, Western University, London, Ontario, N6A 5B7, Canada
| | - Robert A. Hegele
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, N6A 5B7, Canada
- Robarts Research Institute, Western University, London, Ontario, N6A 5B7, Canada
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8
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Berberich AJ, Hegele RA. Pancreatitis risk in genetic subtypes of multifactorial chylomicronemia syndrome. Atherosclerosis 2024; 392:117528. [PMID: 38594114 DOI: 10.1016/j.atherosclerosis.2024.117528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 03/21/2024] [Indexed: 04/11/2024]
Affiliation(s)
- Amanda J Berberich
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, N6A 5B7, Canada
| | - Robert A Hegele
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, N6A 5B7, Canada.
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9
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Guay SP, Paquette M, Taschereau A, Girard L, Desgagné V, Bouchard L, Bernard S, Baass A. Acute pancreatitis risk in multifactorial chylomicronemia syndrome depends on the molecular cause of severe hypertriglyceridemia. Atherosclerosis 2024; 392:117489. [PMID: 38448342 DOI: 10.1016/j.atherosclerosis.2024.117489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/22/2024] [Accepted: 02/23/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND AND AIMS Multifactorial chylomicronemia syndrome (MCS) is a severe form of hypertriglyceridemia (hyperTG) associated with an increased risk of acute pancreatitis (AP). Severe hyperTG is mainly polygenic in nature, either caused by the presence of heterozygous pathogenic variants (PVs) in TG-related metabolism genes or by accumulation of common variants in hyperTG susceptibility genes. This study aims to determine if the risk of AP is similar amongst MCS patients with different molecular causes of severe hyperTG. METHODS This study included 114 MCS patients who underwent genetic testing for PVs in TG-related metabolism genes and 16 single nucleotide polymorphisms (SNPs) in hyperTG susceptibility genes. A weighted TG-polygenic risk score (TG-PRS) was calculated. A TG-PRS score ≥ 90th percentile was used to define a high TG-PRS. RESULTS Overall, 66.7% of patients had severe hyperTG of polygenic origin. MCS patients with only a PV and those with both a PV and high TG-PRS were more prone to have maximal TG concentration ≥ 40 mmol/L (OR 5.33 (1.55-18.36); p = 0.008 and OR 5.33 (1.28-22.25); p = 0.02), as well as higher prevalence of AP (OR 3.64 (0.89-14.92); p = 0.07 and OR 11.90 (2.54-55.85); p = 0.002) compared to MCS patients with high TG-PRS alone. CONCLUSIONS This is the first study to show that MCS caused by a high TG-PRS and a PV is associated with higher risk of AP, similar to what is seen in the monogenic form of severe hyperTG. This suggests that determining the molecular cause of severe hyperTG could be useful to stratify the risk of pancreatitis in MCS.
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Affiliation(s)
- Simon-Pierre Guay
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Montréal, Québec, Canada; Department of Medicine, Division of Endocrinology, Université de Montréal, Montréal, Québec, Canada
| | - Martine Paquette
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Montréal, Québec, Canada
| | - Amélie Taschereau
- Department of Biochemistry and Functional Genomics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Lysanne Girard
- Department of Biochemistry and Functional Genomics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Véronique Desgagné
- Department of Biochemistry and Functional Genomics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada; Clinical Department of Laboratory Medicine, Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) Du Saguenay-Lac-Saint-Jean - Hôpital de Chicoutimi, Saguenay, Québec, Canada
| | - Luigi Bouchard
- Department of Biochemistry and Functional Genomics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada; Department of Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Sophie Bernard
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Montréal, Québec, Canada
| | - Alexis Baass
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Montréal, Québec, Canada; Department of Medicine, Divisions of Experimental Medicine and Medical Biochemistry, McGill University, Montréal, Québec, Canada.
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10
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Chait A. Multifactorial chylomicronemia syndrome. Curr Opin Endocrinol Diabetes Obes 2024; 31:78-83. [PMID: 37994661 DOI: 10.1097/med.0000000000000846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
PURPOSE OF REVIEW The aim of this review was to understand the role of multifactorial chylomicronemia syndrome (MFCS) as a cause of severe hypertriglyceridemia; to distinguish it from other causes of severe hypertriglyceridemia; and to provide a rational approach to treatment. RECENT FINDINGS There have been advances in understanding the genetic underpinning of MFCS, and a better appreciation as to how to differentiate it from the much rarer familial chylomicronemia syndrome, in which there are substantial differences in the approach to their treatment. New approaches to triglyceride lowering will help reduce the risk of pancreatitis, the major complication of MFCS. SUMMARY MCSF is a condition in which plasma triglyceride levels are severely elevated, usually to due exacerbation of common genetic forms of hypertriglyceridemia by secondary causes of hypertriglyceridemia and/or triglyceride-raising drugs. Triglyceride-induced pancreatitis can be prevented by markedly reducing triglyceride levels by treating secondary causes and/or eliminating of triglyceride-raising drugs, and by using triglyceride-lowering drugs, especially fibrates. MFCS also increases cardiovascular disease risk, for which lifestyle measures and drugs are required.
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Affiliation(s)
- Alan Chait
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, Seattle, USA
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11
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Zheng C, Zheng Y, Zheng Z. Therapeutic plasma exchange decreases serum triglyceride level rapidly and reduces early recurrence rate but no advantages in improving outcomes for patients with hyperlipidemic acute pancreatitis: a retrospective propensity score matching analysis based on twenty year's experience. BMC Endocr Disord 2024; 24:32. [PMID: 38443883 PMCID: PMC10916013 DOI: 10.1186/s12902-024-01562-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 02/23/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Hyperlipidaemic acute pancreatitis (HLAP) has become the most common cause of acute pancreatitis (AP) not due to gallstones or alcohol (Mosztbacher et al, Pancreatology 20:608-616, 2020; Yin et al, Pancreas 46:504-509, 2017). Therapeutic plasma exchange (TPE) has been reported to be effective in reducing serum TG levels which is important in management of HLAP (World J Clin Cases 9:5794-803, 2021). However, studies on TPE are mostly focusing on cases reports, TPE remains poorly evaluated till date and need to be compared with conservative therapy with a well-designed study. METHODS A retrospectively cohort study on HLAP patients between January 2003 and July 2023 was conducted. Factors correlated with efficacy of TPE were included in a propensity model to balance the confounding factors and minimize selection bias. Patients with and without TPE were matched 1:2 based on the propensity score to generate the compared groups. Lipid profiles were detected on admission and consecutive 7 days. The triglyceride (TG) level decline rates, percentage of patients to reach the target TG levels, early recurrence rate, local complications and mortality were compared between groups. RESULTS A total of 504 HLAP patients were identified. Since TPE was scarcely performed on patients with TG < 11.3 mmol/L, 152 patients with TG level 5.65 to 11.3 mmol/L were excluded while 352 with TG ≧11.3 mmol/L were enrolled. After excluding 25 cases with incomplete data or pregnancy, 327 patients, of whom 109 treated without TPE while 218 treated with TPE, were included in data analysis. One-to-two propensity-score matching generated 78 pairs, 194 patients with well-balanced baseline characteristics. Of 194 patients enrolled after matching done, 78 were treated without while 116 with TPE. In the matched cohort (n = 194), patients treated with TPE had a higher TG decline rate in 48 h than those without TPE (70.00% vs 54.00%, P = 0.001); the early recurrence rates were 8.96% vs 1.83%, p = 0.055. If only SAP patients were analyzed, the early recurrence rates were 14.81% vs 0.00% (p = 0.026) respectively. For patients with CT severity index (CTSI) rechecked within 14 days, early CTSI improment rate were 40.90% vs 31.91%. Local complications checked 6 months after discharge were 44.12% vs 38.30%. Mortality was 1.28% vs 1.72%. No differences were found in early stage CTSI improment rate (P = .589), local complications (P = .451) or motality between two groups. CONCLUSIONS TPE reduces TG levels more quickly in 48 h compared with those with conservative treatment, but no difference in the consecutive days. TPE tends to reduce the early recurrence rate comparing with conventional therapy, but TPE has no advantages in improving CTSI in early stage, and no improvement for outcomes including local complications and mortalty.
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Affiliation(s)
- Canbin Zheng
- Department of Endocrine and Metabolic Disease, Shantou Central Hospital, Shantou, Guangdong, China
| | - Yongping Zheng
- Department of Gastroenterology, Shantou Central Hospital, 114 Waima Road, Shantou,, 515031, Guangdong, China.
| | - Zihui Zheng
- Department of Anesthesiology, Shantou Central Hospital, Shantou, Guangdong, China
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Majumdar SK. Triglyceride Clearance in Hypertriglyceridemic Pancreatitis: Time Course and Its Implications for Management. Endocr Pract 2023; 29:971-979. [PMID: 37714331 DOI: 10.1016/j.eprac.2023.09.002] [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: 07/04/2023] [Revised: 08/25/2023] [Accepted: 09/05/2023] [Indexed: 09/17/2023]
Abstract
OBJECTIVE To characterize the time course of triglyceride (Tg) lowering in hypertriglyceridemic (HTg) pancreatitis according to the initial Tg values, causes, and interventions. METHODS Patients hospitalized from October 2013 through December of 2018 with a diagnosis of pancreatitis associated with HTg (Tg level, ≥500 mg/dL), in the absence of other causes, were identified by medical record review. Tg lowering was retrospectively assessed for differences in relation to the initial Tg values, use of intravenous insulin, ethanol-associated versus nonethanol-associated causes, and time to Tg values of <500 versus <1000 mg/dL. RESULTS Sixty-six cases were identified, and 45 had multiple measurements for time-course evaluation. Those with initial Tg values of <4000 mg/dL achieved Tg levels of <1000 mg/dL in <3 days, whereas 18.8% with higher values took 5-9 days. Insulin therapy was associated with a longer duration of HTg, whereas ethanol was associated with a shorter duration. Tg clearance in ethanol-associated HTg appeared independent of insulin treatment. Time to Tg levels of <500 mg/dL versus <1000 mg/dL was significantly longer when the initial Tg levels were >2000 mg/dL. CONCLUSION A threshold of 4000 mg/dL for the initial Tg levels in HTg pancreatitis appears to separate patients who are likely to achieve Tg levels of <1000 mg/dL in <3 versus >3 days, independent of cause or treatment. Insulin therapy is appropriate for patients with hyperglycemia but appears unnecessary for those with isolated ethanol-associated HTg. A threshold Tg level of <1000 mg/dL appears more practical than that of <500 mg/dL for resuming nutritional intake.
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Affiliation(s)
- Sachin K Majumdar
- Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut; Departments of Endocrinology and Internal Medicine, Bridgeport Hospital, Yale New Haven Health System, Bridgeport, Connecticut.
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Gaudet D, Clifton P, Sullivan D, Baker J, Schwabe C, Thackwray S, Scott R, Hamilton J, Given B, Melquist S, Zhou R, Chang T, San Martin J, Watts GF, Goldberg IJ, Knowles JW, Hegele RA, Ballantyne CM. RNA Interference Therapy Targeting Apolipoprotein C-III in Hypertriglyceridemia. NEJM EVIDENCE 2023; 2:EVIDoa2200325. [PMID: 38320498 DOI: 10.1056/evidoa2200325] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Apolipoprotein C-III (APOC3) inhibits triglyceride clearance by reducing lipoprotein lipase–mediated hydrolysis and hepatocyte uptake of triglyceride-rich lipoproteins. ARO-APOC3, a hepatocyte-targeting RNA interference therapeutic, inhibits APOC3 messenger ribonucleic acid expression, lowering triglyceride levels. The objective of this trial was to assess the safety, pharmacodynamic variables, and pharmacokinetic variables of ARO-APOC3 treatment. METHODS: Healthy participants and adults with hypertriglyceridemia were randomly assigned to receive escalating single (day 1) or repeat (days 1 and 29) doses, respectively, of subcutaneous injections of ARO-APOC3 10, 25, 50, or 100 mg or placebo; they were followed up until day 113. Additional cohorts of healthy participants and adults with chylomicronemia received repeat doses of open-label ARO-APOC3. The primary objective was to evaluate the safety and side effect profile of ARO-APOC3. Key secondary and exploratory objectives included pharmacokinetic variables and changes in serum APOC3, triglyceride, and cholesterol levels. RESULTS: Eighty-eight participants received ARO-APOC3 and 24 participants received placebo across double-blind and open-label cohorts. Treatment-emergent adverse events (AEs) of transient, mild to moderate liver transaminase changes occurred in 10 participants: 1 patient receiving ARO-APOC3 25 mg, 5 patients receiving ARO-APOC3 50 mg, and 4 participants receiving ARO-APOC3 100 mg (1 healthy participant and 3 patients with hypertriglyceridemia). These events were asymptomatic, and transaminase levels returned to near baseline by the end of the trial. No AEs related to thrombocytopenia or platelet declines were reported. In the hypertriglyceridemia cohorts, the day 113 mean changes from baseline in APOC3 at the 10-, 25-, 50-, and 100-mg doses were −62.0%, −81.7%, −90.1%, and −94.4%, respectively, compared with −1.6% with placebo. This corresponded to median changes in triglyceride levels of −65.6%, −69.9%, −81.2%, and −81.0% compared with −2.8% with placebo. CONCLUSIONS: In this small trial of short duration, ARO-APOC3 was associated with few AEs and reduced serum levels of APOC3 and triglycerides in healthy participants and patients with hypertriglyceridemia. (Funded by Arrowhead Pharmaceuticals, Inc.; ClinicalTrials.gov number, NCT03783377.)
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Affiliation(s)
- Daniel Gaudet
- Department of Medicine, Université de Montréal and ECOGENE 21 Clinical Research Center, Chicoutimi, Quebec, QC, Canada
| | | | - David Sullivan
- NSW Health Pathology, Royal Prince Alfred Hospital, Sydney
| | - John Baker
- Middlemore Hospital, Auckland, New Zealand
| | | | - Susan Thackwray
- University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | | | | | - Bruce Given
- Arrowhead Pharmaceuticals, Inc., Pasadena, CA
| | | | - Rong Zhou
- Arrowhead Pharmaceuticals, Inc., Pasadena, CA
| | - Ting Chang
- Arrowhead Pharmaceuticals, Inc., Pasadena, CA
| | | | - Gerald F Watts
- School of Medicine, University of Western Australia, Perth, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Australia
| | | | - Joshua W Knowles
- Stanford Division of Cardiovascular Medicine and Cardiovascular Institute, School of Medicine, Stanford, CA
| | - Robert A Hegele
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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14
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Gligorijevic N, Stefanovic-Racic M, Kershaw EE. Medical management of hypertriglyceridemia in pancreatitis. Curr Opin Gastroenterol 2023:00001574-990000000-00085. [PMID: 37421386 DOI: 10.1097/mog.0000000000000956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
PURPOSE OF REVIEW Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) should be considered in all cases of acute pancreatitis and triglyceride levels measured early, so that appropriate early and long-term treatment can be initiated. RECENT FINDINGS In most cases of HTG-AP, conservative management (nothing by mouth, intravenous fluid resuscitation and analgesia) is sufficient to achieve triglyceride levels less than 500 mg/dl. Intravenous insulin and plasmapheresis are sometimes used, although prospective studies showing clinical benefits are lacking. Pharmacological management of hypertriglyceridemia (HTG) should start early and target triglyceride levels of less than 500 mg/dl to reduce the risk or recurrent acute pancreatitis. In addition to currently used fenofibrate and omega-3 fatty acids, several novel agents are being studied for long-term treatment of HTG. These emerging therapies focus mainly on modifying the action of lipoprotein lipase (LPL) through inhibition of apolipoprotein CIII and angiopoietin-like protein 3. Dietary modifications and avoidance of secondary factors that worsen triglyceride levels should also be pursued. In some cases of HTG-AP, genetic testing may help personalize management and improve outcomes. SUMMARY Patients with HTG-AP require acute and long-term management of HTG with the goal of reducing and maintaining triglyceride levels to less than 500 mg/dl.
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Affiliation(s)
- Nikola Gligorijevic
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Mangeshkar S, Nazarenko N, Varrias D, Spanos M, Borkowski P, Alhuarrat MAD, Li W, Kishore P, Faillace RT. A Case of Type V Hyperlipoproteinemia Resistant to Insulin Treatment. Cureus 2023; 15:e41424. [PMID: 37546045 PMCID: PMC10403339 DOI: 10.7759/cureus.41424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2023] [Indexed: 08/08/2023] Open
Abstract
Type V hyperlipoproteinemia or multifactorial chylomicronemia syndrome is a rare lipid disorder triggered mainly by uncontrolled diabetes, obesity, poor diet, or particular medications. It is associated with an increased risk of acute pancreatitis and accelerated coronary artery disease which may manifest in younger age groups. We present a case of a 42-year-old male who presented to the emergency department (ED) complaining of a non-healing hand injury. Upon laboratory workup, the patient was found to have an elevated total cholesterol (TC) of 1129 mg/dL, very low levels of high-density lipoprotein (HDL) and triglycerides (TG) > 4000 mg/dL with an inability to calculate low-density lipoprotein (LDL). Lipoprotein electrophoresis revealed an actual TG level of > 7000 mg/dL, increased chylomicrons, normal B and pre-B-lipoproteins, and increased L-lipoproteins with an elevated Apolipoprotein B. Despite these derangements, the patient did not exhibit any abdominal complaints, demonstrating a normal lipase level. The physical exam was indicative of bilateral arcus senilis and obesity. Insulin drip was initiated along with intravenous (IV) hydration and it required 12 days to bring triglycerides down to less than 1000 mg/dL. The total cholesterol was also seen to be down trending to around 500 mg/dL and the HDL improved to 22 mg/dL. We present this case as a unique presentation of asymptomatic chylomicronemia resistant to insulin treatment with an elevated ApoB but with no evidence of pancreatitis or coronary artery disease.
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Affiliation(s)
- Shaunak Mangeshkar
- Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, USA
| | - Natalia Nazarenko
- Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, USA
| | - Dimitrios Varrias
- Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, USA
| | - Michail Spanos
- Cardiovascular Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Pawel Borkowski
- Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, USA
| | - Majd Al Deen Alhuarrat
- Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, USA
| | - Weijia Li
- Cardiology, AdventHealth Orlando, Orlando, USA
| | | | - Robert T Faillace
- Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, USA
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16
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Hegele RA. Apolipoprotein C-II: a new look at an old protein. Eur Heart J 2023; 44:2345-2347. [PMID: 37161516 PMCID: PMC10314325 DOI: 10.1093/eurheartj/ehad237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023] Open
Affiliation(s)
- Robert A Hegele
- Department of Medicine and Robarts Research Institute, Western University, 4288A-1151 Richmond Street North, London, Ontario N6A 5B7, Canada
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17
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Kirkpatrick CF, Sikand G, Petersen KS, Anderson CAM, Aspry KE, Bolick JP, Kris-Etherton PM, Maki KC. Nutrition interventions for adults with dyslipidemia: A Clinical Perspective from the National Lipid Association. J Clin Lipidol 2023; 17:428-451. [PMID: 37271600 DOI: 10.1016/j.jacl.2023.05.099] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 06/06/2023]
Abstract
Lifestyle habits can have a profound impact on atherosclerotic cardiovascular disease (ASCVD) risk. The National Lipid Association previously published recommendations for lifestyle therapies to manage dyslipidemia. This Clinical Perspective provides an update with a focus on nutrition interventions for the three most common dyslipidemias in adults: 1) low-density lipoprotein cholesterol (LDL-C) elevation; 2) triglyceride (TG) elevation, including severe hypertriglyceridemia with chylomicronemia; and 3) combined dyslipidemia, with elevations in both LDL-C and TG levels. Lowering LDL-C and non-high-density lipoprotein cholesterol are the primary objectives for reducing ASCVD risk. With severe TG elevation (≥500 mg/dL), the primary objective is to prevent pancreatitis and ASCVD risk reduction is secondary. Nutrition interventions that lower LDL-C levels include reducing cholesterol-raising fatty acids and dietary cholesterol, as well as increasing intakes of unsaturated fatty acids, plant proteins, viscous fibers, and reducing adiposity for patients with overweight or obesity. Selected dietary supplements may be employed as dietary adjuncts. Nutrition interventions for all patients with elevated TG levels include restricting intakes of alcohol, added sugars, and refined starches. Additional lifestyle factors that reduce TG levels are participating in daily physical activity and reducing adiposity in patients with overweight or obesity. For patients with severe hypertriglyceridemia, an individualized approach is essential. Nutrition interventions for addressing concurrent elevations in LDL-C and TG include a combination of the strategies described for lowering LDL-C and TG. A multidisciplinary approach is recommended to facilitate success in making and sustaining dietary changes and the assistance of a registered dietitian nutritionist is highly recommended.
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Affiliation(s)
- Carol F Kirkpatrick
- Midwest Biomedical Research, Addison, IL, USA; Kasiska Division of Health Sciences, Idaho State University, Pocatello, ID, USA
| | - Geeta Sikand
- University of California Irvine Heart Disease Prevention Program, Irvine, CA, USA
| | | | - Cheryl A M Anderson
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, USA
| | - Karen E Aspry
- Lifespan Cardiovascular Institute, and Alpert Medical School, Brown University, Providence, RI, USA
| | | | - Penny M Kris-Etherton
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA, USA
| | - Kevin C Maki
- Midwest Biomedical Research, Addison, IL, USA; Indiana University School of Public Health-Bloomington, Bloomington, IN, USA.
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18
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Witztum JL, Gaudet D, Arca M, Jones A, Soran H, Gouni-Berthold I, Stroes ESG, Alexander VJ, Jones R, Watts L, Xia S, Tsimikas S. Volanesorsen and triglyceride levels in familial chylomicronemia syndrome: Long-term efficacy and safety data from patients in an open-label extension trial. J Clin Lipidol 2023; 17:342-355. [PMID: 37100699 DOI: 10.1016/j.jacl.2023.03.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/13/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Familial chylomicronemia syndrome (FCS) is a rare, autosomal recessive genetic disorder characterized by a marked increase in plasma triglyceride (TG) levels and recurrent episodes of pancreatitis. The response to conventional TG-lowering therapies is suboptimal. Volanesorsen, an antisense oligonucleotide that targets hepatic apoC-III mRNA, has been shown to significantly reduce TGs in patients with FCS. OBJECTIVE To further evaluate the safety and efficacy of extended treatment with volanesorsen in patients with FCS. METHODS This phase 3 open-label extension study evaluated the efficacy and safety of extended treatment with volanesorsen in three groups of patients with FCS: Those who had previously received volanesorsen or placebo in the APPROACH and COMPASS studies, and treatment-naive patients not participating in either study. Key endpoints included change in fasting TG and other lipid measurements, and safety over 52 weeks. RESULTS Volanesorsen treatment resulted in sustained reductions in plasma TG levels in previously treated patients from the APPROACH and COMPASS studies. Volanesorsen-treated patients from the three populations studied had mean decreases in fasting plasma TGs from index study baseline to months 3, 6, 12 and 24 as follows: decreases of 48%, 55%, 50%, and 50%, respectively (APPROACH); decreases of 65%, 43%, 42%, and 66%, respectively (COMPASS); and decreases of 60%, 51%, 47%, and 46%, respectively (treatment-naive). Common adverse events were injection site reactions and platelet count decrease, consistent with previous studies. CONCLUSION Extended open-label treatment with volanesorsen in patients with FCS resulted in sustained reductions of plasma TG levels and safety consistent with the index studies.
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Affiliation(s)
- Joseph L Witztum
- Department of Medicine, University of California San Diego, Room 1081, 9500 Gilman Drive, La Jolla, CA 92093 USA (Drs Joseph L. Witztum; Sotirios Tsimikas).
| | - Daniel Gaudet
- Lipidology Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal and ECOGENE-21, 930 Jacques-Cartier Est, Chicoutimi, Quebec G7H 7K9, Canada (Dr Daniel Gaudet)
| | - Marcello Arca
- Department of Translational and Precision Medicine, Viale Università, La Sapienza University of Rome, 37 - 00185, Rome, Italy (Dr Marcello Arca)
| | - Alan Jones
- Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Bordesley Green E, Birmingham B9 5SS, United Kingdom (Dr Alan Jones)
| | - Handrean Soran
- Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Oxford Rd, Manchester M13 9WL, United Kingdom (Dr Handrean Soran)
| | - Ioanna Gouni-Berthold
- Center for Endocrinology, Diabetes, and Preventive Medicine, University of Cologne, Faculty of Medicine and University Hospital, Kerpener, Str. 62, Cologne 50937, Germany (Dr Ioanna Gouni-Berthold)
| | - Erik S G Stroes
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, AZ Amsterdam 1105, the Netherlands (Dr Erik S. G. Stroes)
| | - Veronica J Alexander
- Ionis Pharmaceuticals, 2855 Gazelle Court, Carlsbad, CA 92010, USA (Drs Veronica J. Alexander; Lynnetta Watts; Shuting Xia; Sotirios Tsimikas)
| | - Richard Jones
- Akcea Therapeutics, St. James House, 72 Adelaide Road 2 D02 Y017, Dublin, Ireland (Dr Richard Jones)
| | - Lynnetta Watts
- Ionis Pharmaceuticals, 2855 Gazelle Court, Carlsbad, CA 92010, USA (Drs Veronica J. Alexander; Lynnetta Watts; Shuting Xia; Sotirios Tsimikas)
| | - Shuting Xia
- Ionis Pharmaceuticals, 2855 Gazelle Court, Carlsbad, CA 92010, USA (Drs Veronica J. Alexander; Lynnetta Watts; Shuting Xia; Sotirios Tsimikas)
| | - Sotirios Tsimikas
- Department of Medicine, University of California San Diego, Room 1081, 9500 Gilman Drive, La Jolla, CA 92093 USA (Drs Joseph L. Witztum; Sotirios Tsimikas); Ionis Pharmaceuticals, 2855 Gazelle Court, Carlsbad, CA 92010, USA (Drs Veronica J. Alexander; Lynnetta Watts; Shuting Xia; Sotirios Tsimikas)
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19
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Brisson D, Larouche M, Chebli J, Khoury E, Gaudet D. Correlation between chylomicronemia diagnosis scores and post-heparin lipoprotein lipase activity. Clin Biochem 2023; 114:67-72. [PMID: 36780934 DOI: 10.1016/j.clinbiochem.2023.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/30/2023] [Accepted: 02/01/2023] [Indexed: 02/13/2023]
Abstract
INTRODUCTION Sustained chylomicronemia is a defect in post-prandial triglyceride management characterized by severe hypertriglyceridemia (triglyceride > 10 mmol/L) due to functional or genetic defects in lipoprotein lipase (LPL)-mediated triglyceride-rich lipoprotein lipolysis. Familial chylomicronemia syndrome (FCS) is a rare mendelian form of chylomicronemia caused by loss-of-function variants in LPL or LPL-related genes. Most individuals with chylomicronemia however present multifactorial chylomicronemia (MCS), in which LPL bio-availability and activity are variable. FCS and MCS differ in terms of clinical characteristics and risk of disease, and diagnosis scoring systems have been proposed to accurately distinguish FCS from MCS. OBJECTIVE The aim of this study was to assess the strength of the relationship between plasma post-heparin LPL activity and two published chylomicronemia diagnosis scoring systems. DESIGN AND METHODS Post-heparin plasma LPL activity was measured using colorimetric assays in a sample of 29 subjects with sustained chylomicronemia (20 FCS and 9 MCS). Chylomicronemia diagnosis scores were obtained for all subjects using the scoring system A (model A), which integrates apolipoprotein B and free glycerol, a surrogate marker of triglyceride hydrolysis, and the scoring system B (model B). Correlation analyses were conducted to estimate the linear relationship between LPL activity and the two diagnosis scoring systems. RESULTS There was a significant (p < 0.001) difference in post-heparin LPL activity between FCS and MCS. Both scoring systems significantly correlated with post-heparin LPL activity (model A: rs = -0.64, p < 0.001; model B: rs = -0.54, p = 0.002). CONCLUSIONS These result suggest that chylomicronemia diagnosis scoring systems correlate with LPL activity and adequately contribute to distinguish FCS from MCS.
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Affiliation(s)
- Diane Brisson
- Lipidology Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal and ECOGENE-21 Clinical and Translational Research Center, Chicoutimi, Quebec, Canada
| | - Miriam Larouche
- Lipidology Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal and ECOGENE-21 Clinical and Translational Research Center, Chicoutimi, Quebec, Canada
| | - Jasmine Chebli
- Lipidology Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal and ECOGENE-21 Clinical and Translational Research Center, Chicoutimi, Quebec, Canada
| | - Etienne Khoury
- Lipidology Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal and ECOGENE-21 Clinical and Translational Research Center, Chicoutimi, Quebec, Canada
| | - Daniel Gaudet
- Lipidology Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal and ECOGENE-21 Clinical and Translational Research Center, Chicoutimi, Quebec, Canada.
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20
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Perera SD, Wang J, McIntyre AD, Dron JS, Hegele RA. The longitudinal triglyceride phenotype in heterozygotes with LPL pathogenic variants. J Clin Lipidol 2023; 17:87-93. [PMID: 36476373 DOI: 10.1016/j.jacl.2022.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/07/2022] [Accepted: 11/14/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Biallelic pathogenic variants in lipoprotein lipase (LPL) cause familial chylomicronemia syndrome with severe hypertriglyceridemia (HTG), defined as plasma triglycerides (TG) > 10 mmol/L (> 885 mg/dL). TG levels in individuals with one copy of a pathogenic LPL gene variant is less familiar; some assume that the phenotype is intermediate between homozygotes and controls. OBJECTIVE We undertook an evaluation of the longitudinal TG phenotype of individuals heterozygous for pathogenic LPL variants. METHODS Medically stable outpatients were evaluated based on having: (1) a single copy of a rare pathogenic LPL variant; and (2) serial fasting TG measurements obtained over > 1.5 years of follow-up. RESULTS Fifteen patients with a single pathogenic LPL variant were followed for a mean of 10.3 years (range 1.5 to 30.3 years). TG levels varied widely both within and between patients. One patient had normal TG levels < 2.0 mmol/L (< 175 mg/dL) continuously, while four patients had at least one normal TG level. Most patients fluctuated between mild-to-moderate and severe HTG: five patients had only mild-to-moderate HTG, with TG levels ranging from 2.0 to 9.9 mmol/L (175 to 885 mg/dL), while 6 patients had at least one instance of severe HTG. Of the 203 total TG measurements from these patients, 14.8%, 67.0% and 18.2% were in the normal, mild-to-moderate and severe HTG ranges, respectively. CONCLUSION The heterozygous LPL deficient phenotype is highly variable both within and between patients. Heterozygosity confers susceptibility to a wide range of TG phenotypes, with severity likely depending on secondary factors.
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Affiliation(s)
- Shehan D Perera
- Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, 4288A-1151 Richmond Street North, London, Ontario N6A 5B7, Canada (Perera, Wang, McIntyre and Hegele); Department of Biochemistry, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada (Perera and Hegele)
| | - Jian Wang
- Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, 4288A-1151 Richmond Street North, London, Ontario N6A 5B7, Canada (Perera, Wang, McIntyre and Hegele)
| | - Adam D McIntyre
- Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, 4288A-1151 Richmond Street North, London, Ontario N6A 5B7, Canada (Perera, Wang, McIntyre and Hegele)
| | - Jacqueline S Dron
- Center for Genomic Medicine, Massachusetts General Hopsital, Boston, Massachusetts, USA (Dron)
| | - Robert A Hegele
- Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, 4288A-1151 Richmond Street North, London, Ontario N6A 5B7, Canada (Perera, Wang, McIntyre and Hegele); Department of Biochemistry, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada (Perera and Hegele); Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada (Hegele).
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21
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Nozue T, Tada H, Murakami M, Michishita I. A case of hyperchylomicronemia associated with GPIHBP1 autoantibodies and fluctuating thyroid autoimmune disease. J Clin Lipidol 2023; 17:68-72. [PMID: 36402671 DOI: 10.1016/j.jacl.2022.10.005] [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: 08/08/2022] [Revised: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
Recent studies have reported that patients with autoimmune hyperchylomicronemia caused by glycosylphosphatidylinositol-anchored high-density lipoprotein binding protein 1 (GPIHBP1) autoantibodies are associated with rheumatoid arthritis, systemic lupus erythematosus, Sjogren's syndrome, Hashimoto's thyroiditis, Basedow's disease, and immune thrombocytopenia. We report a rare case of hyperchylomicronemia due to GPIHBP1 autoantibodies and fluctuating thyroid autoimmune disease. A 28-year-old woman, diagnosed with Hashimoto's thyroiditis at 26 years of age, started taking 50 µg/day of levothyroxine sodium. She had an episode of acute pancreatitis at 27 years of age; her serum triglyceride (TG) level was 1291 mg/dL at that time. The patient was referred to our hospital because her hyperchylomicronemia (hypertriglyceridemia) did not improve on treatment with pemafibrate and eicosapentaenoic acid (EPA). Serum total cholesterol and TG levels were 237 mg/dL and 2535 mg/dL, respectively, while plasma pre-heparin lipoprotein lipase (LPL) mass was 15 ng/mL (26.5-105.5 ng/mL). We diagnosed her as Basedow's disease based on autoimmune antibodies and ultrasound examination. Targeted exome sequencing revealed no pathogenic variants in the LPL or GPIHBP1 genes. The serum GPIHBP1 autoantibody level was 686.0 U/mL (<58.4 U/mL) and GPIHBP1 mass was 301.9 pg/mL (570.6-1625.6 pg/mL). The patient showed hyperchylomicronemia during periods of hypothyroidism and hyperthyroidism, whereas GPIHBP1 autoantibodies were positive during episode of hyperchylomicronemia but negative during periods of normal TG levels. Based on these findings, the patient was diagnosed with hyperchylomicronemia due to GPIHBP1 autoantibodies and treated with rituximab. GPIHBP1 autoantibodies remained undetectable and TG levels were controlled at approximately 200 mg/dL.
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Affiliation(s)
- Tsuyoshi Nozue
- Division of Cardiology, Department of Internal Medicine, Yokohama Sakae Kyosai Hospital, Yokohama, Japan.
| | - Hayato Tada
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Masami Murakami
- Department of Clinical Laboratory Medicine, Gunma University, Graduate School of Medicine, Maebashi, Japan
| | - Ichiro Michishita
- Division of Cardiology, Department of Internal Medicine, Yokohama Sakae Kyosai Hospital, Yokohama, Japan
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22
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Hegele RA. Is Genetic Testing in Hypertriglyceridemia Useful? Arterioscler Thromb Vasc Biol 2022; 42:1468-1470. [PMID: 36325898 DOI: 10.1161/atvbaha.122.318621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Robert A Hegele
- Robarts Research Institute and Department of Medicine, Schulich School of Medicine and Dentistry' Western University, London, Ontario, Canada
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23
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Deshotels MR, Hadley TD, Roth M, Agha AM, Pulipati VP, Nugent AK, Virani SS, Nambi V, Moriarty PM, Davidson MH, Ballantyne CM. Genetic Testing for Hypertriglyceridemia in Academic Lipid Clinics: Implications for Precision Medicine-Brief Report. Arterioscler Thromb Vasc Biol 2022; 42:1461-1467. [PMID: 36325899 DOI: 10.1161/atvbaha.122.318445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Severe hypertriglyceridemia is often caused by variants in genes of triglyceride metabolism. These variants include rare, heterozygous pathogenic variants (PVs), or multiple common, small-effect single nucleotide polymorphisms that can be quantified using a polygenic risk score (PRS). The role of genetic testing to examine PVs and PRS in predicting risk for pancreatitis and severity of hypertriglyceridemia is unknown. METHODS We examined the relationship of PVs and PRSs associated with hypertriglyceridemia with the highest recorded plasma triglyceride level and risk for acute pancreatitis in 363 patients from 3 academic lipid clinics who underwent genetic testing (GBinsight's Dyslipidemia Comprehensive Panel). Categories of hypertriglyceridemia included: normal triglyceride (<200 mg/dL), moderate (200-499 mg/dL), severe (500-999 mg/dL), or very severe (≥1000 mg/dL). RESULTS PVs and high PRSs were identified in 37 (10%) and 59 (16%) individuals, respectively. Patients with both had increased risk for very severe hypertriglyceridemia compared with those with neither genetic risk factor. Risk for acute pancreatitis was also increased in individuals with both genetic risk factors (odds ratio, 5.1 [P=0.02] after controlling for age, race, sex, body mass index, and highest triglyceride level), but not in individuals with PV or high PRS alone. CONCLUSIONS The presence of both PV and high PRS significantly increased risk for very severe hypertriglyceridemia and acute pancreatitis, whereas PV or PRS alone only modestly increased risk. Genetic testing may help identify patients with hypertriglyceridemia who have the greatest risk for developing pancreatitis and may derive the greatest benefit from novel triglyceride-lowering therapies.
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Affiliation(s)
- Matthew R Deshotels
- Sections of Cardiovascular Research and Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX (M.R.D., T.D.H., A.M.A., S.S.V., V.N., C.M.B.)
| | - Trevor D Hadley
- Sections of Cardiovascular Research and Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX (M.R.D., T.D.H., A.M.A., S.S.V., V.N., C.M.B.)
| | | | - Ali M Agha
- Sections of Cardiovascular Research and Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX (M.R.D., T.D.H., A.M.A., S.S.V., V.N., C.M.B.)
| | - Vishnu Priya Pulipati
- Section of Cardiology, Department of Medicine, University of Chicago, IL (V.P.P., M.H.D.)
| | - Anne K Nugent
- Division of Clinical Pharmacology, University of Kansas Medical Center, Kansas City (A.K.N., P.M.M.)
| | - Salim S Virani
- Section of Cardiology, Michael E. DeBakey VA Medical Center, Houston, TX (S.S.V., V.N.)
| | - Vijay Nambi
- Section of Cardiology, Michael E. DeBakey VA Medical Center, Houston, TX (S.S.V., V.N.)
| | - Patrick M Moriarty
- Division of Clinical Pharmacology, University of Kansas Medical Center, Kansas City (A.K.N., P.M.M.)
| | - Michael H Davidson
- Section of Cardiology, Department of Medicine, University of Chicago, IL (V.P.P., M.H.D.)
| | - Christie M Ballantyne
- Sections of Cardiovascular Research and Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX (M.R.D., T.D.H., A.M.A., S.S.V., V.N., C.M.B.)
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24
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Berberich AJ, Hegele RA. Genetic testing in dyslipidaemia: An approach based on clinical experience. Best Pract Res Clin Endocrinol Metab 2022; 37:101720. [PMID: 36682941 DOI: 10.1016/j.beem.2022.101720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We have used DNA sequencing in our lipid clinic for >20 years. Dyslipidaemia is typically ascertained biochemically. For moderate deviations in the lipid profile, the etiology is often a combination of a polygenic susceptibility component plus secondary non-genetic factors. For severe dyslipidaemia, a monogenic etiology is more likely, although a discrete single-gene cause is frequently not found. A severe phenotype can also result from strong polygenic predisposition that is aggravated by secondary factors. A young age of onset plus a family history of dyslipidaemia or atherosclerotic cardiovascular disease can suggest a monogenic etiology. With severe dyslipidaemia, clinical examination focuses on detecting manifestations of monogenic syndromic conditions. For all patients with dyslipidaemia, secondary causes must be ruled out. Here we describe an experience-based practical approach to genetic testing of patients with severe deviations of low-density lipoprotein, triglycerides, high-density lipoprotein and also combined hyperlipidaemia and dysbetalipoproteinemia.
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Affiliation(s)
- Amanda J Berberich
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, ON, N6A 5C1, Canada; Western University, Division of Endocrinology & Metabolism, St. Joseph's Hospital, 268 Grosvenor Street, London, Ontario, Canada.
| | - Robert A Hegele
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, ON, N6A 5C1, Canada; Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, 4288A-1151 Richmond Street North, London, ON, N6A 5B7, Canada.
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25
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Hegele RA. APOC3 Interference for Familial Chylomicronaemia Syndrome. TOUCHREVIEWS IN ENDOCRINOLOGY 2022; 18:82-83. [PMID: 36694895 PMCID: PMC9835816 DOI: 10.17925/ee.2022.18.2.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 09/13/2022] [Indexed: 12/13/2022]
Abstract
Patients with familial chylomicronaemia syndrome (FCS) have severe hypertriglyceridaemia due to genetically absent lipolytic capacity. They have a poor response to conventional therapies. To reduce the risk of potentially fatal pancreatitis, the management of FCS relies principally on a strict low-fat diet, which is difficult to follow and compromises quality of life. Targeted reduction of apolipoprotein C-III using new anti-APOC3 agents, such as the short interfering RNA ARO-APOC3, represents a promising approach to correct the severe biochemical disturbance in FCS.
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Affiliation(s)
- Robert A Hegele
- Departments of Medicine, (Division of Endocrinology) and Biochemistry, Western University, London, Canada
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26
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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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Young SG, Song W, Yang Y, Birrane G, Jiang H, Beigneux AP, Ploug M, Fong LG. A protein of capillary endothelial cells, GPIHBP1, is crucial for plasma triglyceride metabolism. Proc Natl Acad Sci U S A 2022; 119:e2211136119. [PMID: 36037340 PMCID: PMC9457329 DOI: 10.1073/pnas.2211136119] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 07/18/2022] [Indexed: 11/18/2022] Open
Abstract
GPIHBP1, a protein of capillary endothelial cells (ECs), is a crucial partner for lipoprotein lipase (LPL) in the lipolytic processing of triglyceride-rich lipoproteins. GPIHBP1, which contains a three-fingered cysteine-rich LU (Ly6/uPAR) domain and an intrinsically disordered acidic domain (AD), captures LPL from within the interstitial spaces (where it is secreted by parenchymal cells) and shuttles it across ECs to the capillary lumen. Without GPIHBP1, LPL remains stranded within the interstitial spaces, causing severe hypertriglyceridemia (chylomicronemia). Biophysical studies revealed that GPIHBP1 stabilizes LPL structure and preserves LPL activity. That discovery was the key to crystallizing the GPIHBP1-LPL complex. The crystal structure revealed that GPIHBP1's LU domain binds, largely by hydrophobic contacts, to LPL's C-terminal lipid-binding domain and that the AD is positioned to project across and interact, by electrostatic forces, with a large basic patch spanning LPL's lipid-binding and catalytic domains. We uncovered three functions for GPIHBP1's AD. First, it accelerates the kinetics of LPL binding. Second, it preserves LPL activity by inhibiting unfolding of LPL's catalytic domain. Third, by sheathing LPL's basic patch, the AD makes it possible for LPL to move across ECs to the capillary lumen. Without the AD, GPIHBP1-bound LPL is trapped by persistent interactions between LPL and negatively charged heparan sulfate proteoglycans (HSPGs) on the abluminal surface of ECs. The AD interrupts the HSPG interactions, freeing LPL-GPIHBP1 complexes to move across ECs to the capillary lumen. GPIHBP1 is medically important; GPIHBP1 mutations cause lifelong chylomicronemia, and GPIHBP1 autoantibodies cause some acquired cases of chylomicronemia.
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Affiliation(s)
- Stephen G. Young
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90095
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095
| | - Wenxin Song
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90095
| | - Ye Yang
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90095
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095
| | - Gabriel Birrane
- Division of Experimental Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215
| | - Haibo Jiang
- Department of Chemistry, The University of Hong Kong, Hong Kong, China
| | - Anne P. Beigneux
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90095
| | - Michael Ploug
- Finsen Laboratory, Rigshospitalet, Copenhagen 2200N, Denmark
- Biotech Research and Innovation Centre, University of Copenhagen, Copenhagen, Denmark
| | - Loren G. Fong
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90095
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Abstract
Mild to moderate hypertriglyceridemia usually results from multiple small-effect variants in genes that control triglyceride metabolism. Hypertriglyceridemia is a critical component of the metabolic syndrome but can also occur secondary to several other conditions or drugs. Hypertriglyceridemia frequently is associated with an increased risk of cardiovascular disease (CVD). Statins are the mainstay of CVD prevention in hypertriglyceridemia, but eicosapentaenoic ethyl esters should be added in very-high-risk individuals. Although fibrates lower triglyceride levels, their role in CVD prevention remains unclear. Familial partial lipodystrophy is another relatively rare cause, although its true incidence is unknown.
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Affiliation(s)
- Alan Chait
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, 850 Republican, Box 358062, Seattle, WA 98109, USA.
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29
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Identifying Patients with Familial Chylomicronemia Syndrome Using FCS Score-Based Data Mining Methods. J Clin Med 2022; 11:jcm11154311. [PMID: 35893402 PMCID: PMC9331828 DOI: 10.3390/jcm11154311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/14/2022] [Accepted: 07/22/2022] [Indexed: 02/01/2023] Open
Abstract
Background: There are no exact data about the prevalence of familial chylomicronemia syndrome (FCS) in Central Europe. We aimed to identify FCS patients using either the FCS score proposed by Moulin et al. or with data mining, and assessed the diagnostic applicability of the FCS score. Methods: Analyzing medical records of 1,342,124 patients, the FCS score of each patient was calculated. Based on the data of previously diagnosed FCS patients, we trained machine learning models to identify other features that may improve FCS score calculation. Results: We identified 26 patients with an FCS score of ≥10. From the trained models, boosting tree models and support vector machines performed the best for patient recognition with overall AUC above 0.95, while artificial neural networks accomplished above 0.8, indicating less efficacy. We identified laboratory features that can be considered as additions to the FCS score calculation. Conclusions: The estimated prevalence of FCS was 19.4 per million in our region, which exceeds the prevalence data of other European countries. Analysis of larger regional and country-wide data might increase the number of FCS cases. Although FCS score is an excellent tool in identifying potential FCS patients, consideration of some other features may improve its accuracy.
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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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31
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Patel RS, Pasea L, Soran H, Downie P, Jones R, Hingorani AD, Neely D, Denaxas S, Hemingway H. Elevated plasma triglyceride concentration and risk of adverse clinical outcomes in 1.5 million people: a CALIBER linked electronic health record study. Cardiovasc Diabetol 2022; 21:102. [PMID: 35681241 PMCID: PMC9185961 DOI: 10.1186/s12933-022-01525-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Assessing the spectrum of disease risk associated with hypertriglyceridemia is needed to inform potential benefits from emerging triglyceride lowering treatments. We sought to examine the associations between a full range of plasma triglyceride concentration with five clinical outcomes. METHODS We used linked data from primary and secondary care for 15 M people, to explore the association between triglyceride concentration and risk of acute pancreatitis, chronic pancreatitis, new onset diabetes, myocardial infarction and all-cause mortality, over a median of 6-7 years follow up. RESULTS Triglyceride concentration was available for 1,530,411 individuals (mean age 56·6 ± 15·6 years, 51·4% female), with a median of 1·3 mmol/L (IQR: 0.9.to 1.9). Severe hypertriglyceridemia, defined as > 10 mmol/L, was identified in 3289 (0·21%) individuals including 620 with > 20 mmol/L. In multivariable analyses, a triglyceride concentration > 20 mmol/L was associated with very high risk for acute pancreatitis (Hazard ratio (HR) 13·55 (95% CI 9·15-20·06)); chronic pancreatitis (HR 25·19 (14·91-42·55)); and high risk for diabetes (HR 5·28 (4·51-6·18)) and all-cause mortality (HR 3·62 (2·82-4·65)) when compared to the reference category of ≤ 1·7 mmol/L. An association with myocardial infarction, however, was only observed for more moderate hypertriglyceridaemia between 1.7 and 10 mmol/L. We found a risk interaction with age, with higher risks for all outcomes including mortality among those ≤ 40 years compared to > 40 years. CONCLUSIONS We highlight an exponential association between severe hypertriglyceridaemia and risk of incident acute and chronic pancreatitis, new diabetes, and mortality, especially at younger ages, but not for myocardial infarction for which only moderate hypertriglyceridemia conferred risk.
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Affiliation(s)
- Riyaz S Patel
- Institute of Cardiovascular Sciences, University College London, 222 Euston Rd, London, NW1 2DA, UK.
- London Biomedical Research Centre, NIHR University College, University College London and University College London Hospitals NHS Foundation Trust, London, UK.
- UCL BHF Research Accelerator, UCL, London, UK.
| | - Laura Pasea
- Health Data Research UK London, University College London, London, UK
- Institute of Health Informatics, University College London, London, UK
| | - Handrean Soran
- Department of Endocrinology, Diabetes and Metabolism, Manchester Royal Infirmary, Manchester, UK
| | - Paul Downie
- Department of Clinical Biochemistry, Bristol Royal Infirmary, Bristol, UK
| | - Richard Jones
- Global Medical Affairs, Akcea Therapeutics, Reading, UK
| | - Aroon D Hingorani
- Institute of Cardiovascular Sciences, University College London, 222 Euston Rd, London, NW1 2DA, UK
- London Biomedical Research Centre, NIHR University College, University College London and University College London Hospitals NHS Foundation Trust, London, UK
- UCL BHF Research Accelerator, UCL, London, UK
| | - Dermot Neely
- Academic Health Science Network North East and North Cumbria (AHSN), Newcastle, UK
| | - Spiros Denaxas
- UCL BHF Research Accelerator, UCL, London, UK
- Health Data Research UK London, University College London, London, UK
- The Alan Turing Institute, London, UK
| | - Harry Hemingway
- UCL BHF Research Accelerator, UCL, London, UK
- Health Data Research UK London, University College London, London, UK
- Institute of Health Informatics, University College London, London, UK
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32
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Abstract
Hypertriglyceridemia is a common lipid disorder encountered in clinical practice. Plasma triglycerides are a marker for the concentration of triglycerides carried in chylomicrons and very low-density lipoprotein particles. A fasting triglyceride level <150 mg/dL is accepted widely as the upper limit of normal range. Guidelines for hypertriglyceridemia are variable without a global consensus on classification and goals for triglyceride levels. A general classification of hypertriglyceridemia is mild < 200 mg/dL, moderate = 200 to 500 mg/dL, moderate to severe = 500 to 1000 mg/dL, and severe > 1000 mg/dL. Because moderate hypertriglyceridemia does increase atherosclerotic cardiovascular disease risk, it is important to determine the underlying etiology to guide appropriate and timely management. This article provides stepwise recommendations on the diagnosis and management of moderate hypertriglyceridemia, based on 3 common scenarios encountered in clinical practice. Initial steps in management include evaluating for secondary contributors, especially diabetes mellitus. Based on patient characteristics, appropriate management decisions include lifestyle adjustments aimed at weight loss and decreasing alcohol consumption and use of statin and nonstatin therapies.
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Affiliation(s)
- Savitha Subramanian
- Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle WA, USA
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33
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Cheng Y, Li T, Tan P, Du Y, Huang Z, Shi H, Cai T, Chen Y, Fu W. Efficacy and safety of the apolipoprotein C-III inhibitor Volanesorsen: a systematic evaluation and meta-analysis. Endocrine 2022; 76:253-262. [PMID: 35298785 DOI: 10.1007/s12020-022-03025-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/19/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Familial celiac disease syndrome (FCS) is a form of hypertriglyceridemia (HTG) caused by the accumulation of celiac particles. Currently, volanesorsen is considered to be used to treat patients with FCS and HTG to improve symptoms. To evaluate the effect of volanesorsen on lipid metabolism in patients with FCS, we performed a systematic evaluation and meta-analysis. METHODS A systematic search of PubMed, Embase, ClinicalTrials.gov, and the Cochrane Library was conducted, and the bibliographies of original articles were checked manually. The quality of the studies was assessed using the Cochrane Risk of Bias tool. RESULTS Four randomized, controlled trials involving 246 patients were analyzed in this study. Patients treated with volanesorsen showed (MD = -78.85%; 95% CI = -96.04 to -61.65, P = 0.67, I2 = 0%) decrease in TG and (MD = -80.08%; 95% CI = -90.02 to -71.54, P = 0.25, I2 = 29%) decrease in ApoC-III levels compared to patients in the placebo group showing a significant decrease. In addition, HDL-C increased (MD = 46.01% 95% CI = 41.03 to 50.99, P = 0.41, I2 = 0%), NHDL-C decreased (MD = -32.12%; 95% CI = -44.39 to -19.85, P = 0.11, I2 = 55%), VLDL-C decreased (MD = -65.88%; 95% CI = -83.97 to -47.79, P = 0.71, I2 = 0%), apo A1 increased (MD = 13.12%; 95% CI = 7.83 to 18.40, P = 0.72, I2 = 0%), and apoB increased (MD = 7.94 %; 95% CI = -1.90 to 17.78, P = 0.54, I2 = 0%) all suggest that volanesorsen has an overall FCS with a therapeutic effect. However, LDL-C increased (MD = 99.59%; 95% CI = 69.19 to 130.00, P = 0.61, I2 = 0%) and apo B48 decreased (MD = 82.89%; 95% CI = -100.88 to -64.91, P = 0.42, I2 = 0%), showing an inverse effect, suggesting that volanesorsen's did not target all proteins of lipid metabolism.
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Affiliation(s)
- Yonglang Cheng
- Department of General Surgery (Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Tongxi Li
- Department of General Surgery (Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Peng Tan
- Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Yichao Du
- Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Zhiwei Huang
- Department of General Surgery (Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Hao Shi
- Department of General Surgery (Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Tianying Cai
- Department of General Surgery (Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Yifan Chen
- Department of General Surgery (Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Wenguang Fu
- Department of General Surgery (Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China.
- Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China.
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Chait A, Feingold KR. Approach to patients with hypertriglyceridemia. Best Pract Res Clin Endocrinol Metab 2022; 37:101659. [PMID: 35459627 DOI: 10.1016/j.beem.2022.101659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Elevated triglyceride levels increase the risk of arteriosclerotic cardiovascular disease (ASCVD) and severely elevated triglyceride levels also increase the risk of triglyceride-induced pancreatitis. Although substantially reducing triglyceride levels will prevent pancreatitis, whether lowering triglycerides per se will reduce CVD risk is unclear. In this review, we outline several principles that will help in deciding who and how to treat patients with elevated triglyceride levels in order to prevent both ASCVD and pancreatitis. Using these principles will help in making decisions regarding the treatment of elevated triglyceride levels.
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Affiliation(s)
- Alan Chait
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, WA, USA.
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35
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Li Y, Hu M, Han L, Feng L, Yang L, Chen X, Du T, Yao H, Chen X. Case Report: Next-Generation Sequencing Identified a Novel Pair of Compound-Heterozygous Mutations of LPL Gene Causing Lipoprotein Lipase Deficiency. Front Genet 2022; 13:831133. [PMID: 35309119 PMCID: PMC8927541 DOI: 10.3389/fgene.2022.831133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Lipoprotein lipase deficiency (LPLD) is a rare disease characterized by the accumulation of chylomicronemia with early-onset. Common symptoms are abdominal pain, hepatosplenomegaly, eruptive xanthomas and lipemia retinalis. Serious complications include acute pancreatitis. Gene LPL is one of causative factors of LPLD. Here, we report our experience on an asymptomatic 3.5-month-old Chinese girl with only milky blood. Whole-exome sequencing was performed and identified a pair of compound-heterozygous mutations in LPL gene, c.862G>A (p.A288T) and c.461A>G (p.H154R). Both variants are predicted “deleterious” and classified as “likely pathogenic”. This study expanded the LPL mutation spectrum of disease LPLD, thereby offering exhaustive and valuable experience on early diagnosis and proper medication of LPLD.
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Affiliation(s)
- Yakun Li
- Department of Endocrinology and Metabolism, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Man Hu
- Department of Endocrinology and Metabolism, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lin Han
- Running Gene Inc., Beijing, China
| | - Lifang Feng
- Department of Endocrinology and Metabolism, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Luhong Yang
- Department of Endocrinology and Metabolism, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoqian Chen
- Department of Endocrinology and Metabolism, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tingting Du
- Department of Endocrinology and Metabolism, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hui Yao
- Department of Endocrinology and Metabolism, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaohong Chen
- Department of Endocrinology and Metabolism, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Xiaohong Chen,
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Volanesorsen: A New Era in the Treatment of Severe Hypertriglyceridemia. J Clin Med 2022; 11:jcm11040982. [PMID: 35207255 PMCID: PMC8880470 DOI: 10.3390/jcm11040982] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/31/2022] [Accepted: 02/08/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction: Familial chylomicronemia syndrome (FCS) is a rare inherited disease, mainly due to lipoprotein lipase (LPL) gene mutations, leading to lipid abnormalities. Volanesorsen, a second-generation 2′-O-methoxyethyl (2′-MOE) chimeric antisense therapeutic oligonucleotide, can decrease plasma apolipoprotein C3 and triglycerides (TG) levels through LPL-independent pathways. The European Medicines Agency has approved volanesorsen as an adjunct to diet in adult FCS patients with an inadequate response to TG-lowering therapy. Areas covered: Available clinical data on volanesorsen efficacy and safety are presented. Furthermore, we discuss the yearly treatment with volanesorsen of a 21-year-old female FCS patient with LPL mutation. Volanesorsen was well-tolerated and decreased patient’s TG levels (from >5000 mg/dL (56 mmol/L) to 350–500 mg/dL (4–5.6 mmol/L)) at 12 months. Lipoprotein apheresis (LA) was stopped and there were no episodes of pancreatitis or abdominal pain. Expert opinion: Severe hypertriglyceridemia can potentially be fatal. Until recently, there was no specific treatment for FCS, apart from hypotriglyceridemic diet, fibrates, omega-3 fatty acids, and LA sessions. Therefore, volanesorsen represents a promising therapeutic solution for these patients. The main side effect of volanesorsen therapy is thrombocytopenia, which should be monitored and treated accordingly. Increasing evidence will further elucidate the clinical implications of volanesorsen use in daily practice.
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37
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Paragh G, Németh Á, Harangi M, Banach M, Fülöp P. Causes, clinical findings and therapeutic options in chylomicronemia syndrome, a special form of hypertriglyceridemia. Lipids Health Dis 2022; 21:21. [PMID: 35144640 PMCID: PMC8832680 DOI: 10.1186/s12944-022-01631-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 01/30/2022] [Indexed: 02/07/2023] Open
Abstract
The prevalence of hypertriglyceridemia has been increasing worldwide. Attention is drawn to the fact that the frequency of a special hypertriglyceridemia entity, named chylomicronemia syndrome, is variable among its different forms. The monogenic form, termed familial chylomicronemia syndrome, is rare, occuring in 1 in every 1 million persons. On the other hand, the prevalence of the polygenic form of chylomicronemia syndrome is around 1:600. On the basis of the genetical alterations, other factors, such as obesity, alcohol consumption, uncontrolled diabetes mellitus and certain drugs may significantly contribute to the development of the multifactorial form. In this review, we aimed to highlight the recent findings about the clinical and laboratory features, differential diagnosis, as well as the epidemiology of the monogenic and polygenic forms of chylomicronemias. Regarding the therapy, differentiation between the two types of the chylomicronemia syndrome is essential, as well. Thus, proper treatment options of chylomicronemia and hypertriglyceridemia will be also summarized, emphasizing the newest therapeutic approaches, as novel agents may offer solution for the effective treatment of these conditions.
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Affiliation(s)
- György Paragh
- Division of Metabolic Diseases, Department of Internal Medicine, University of Debrecen Faculty of Medicine, Nagyerdei krt. 98, Debrecen, H-4032, Hungary.
| | - Ákos Németh
- Division of Metabolic Diseases, Department of Internal Medicine, University of Debrecen Faculty of Medicine, Nagyerdei krt. 98, Debrecen, H-4032, Hungary
| | - Mariann Harangi
- Division of Metabolic Diseases, Department of Internal Medicine, University of Debrecen Faculty of Medicine, Nagyerdei krt. 98, Debrecen, H-4032, Hungary
| | - Maciej Banach
- Department of Hypertension, WAM University Hospital in Lodz, Medical University of Lodz, Lodz, Poland.,Polish Mother's Memorial Hospital Research Institute (PMMHRI), Lodz, Poland
| | - Péter Fülöp
- Division of Metabolic Diseases, Department of Internal Medicine, University of Debrecen Faculty of Medicine, Nagyerdei krt. 98, Debrecen, H-4032, Hungary
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Continuous insulin therapy versus apheresis in patients with hypertriglyceridemia-associated pancreatitis. Eur J Gastroenterol Hepatol 2022; 34:146-152. [PMID: 33323759 DOI: 10.1097/meg.0000000000002025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The optimal treatment modality for lowering the triglyceride level in patients with hypertriglyceridemia (HTG)-associated acute pancreatitis is unknown. We evaluated the efficacy of continuous insulin infusion and apheresis procedures as triglyceride-lowering therapy. MATERIALS AND METHODS Clinical, demographic, and laboratory data were retrospectively evaluated for patients with HTG-associated pancreatitis who received continuous insulin infusion or apheresis in a single tertiary center. The endpoints were modality effectiveness and clinical outcomes. RESULTS The study included 48 patients (mean age, 40.4 ± 9.9 years). Apheresis and insulin infusion were performed in 19 and 29 patients, respectively, in the first 24 h of hospital admission. Apheresis procedures included therapeutic plasma exchange in 10 patients and double filtration plasmapheresis in nine patients. Baseline mean triglyceride level was higher in the apheresis group. The two groups were similar in terms of other baseline clinical and demographic characteristics. Seventeen patients (58.6%) in the insulin group and nine patients (47.4%) in the apheresis group exhibited Balthazar grades D-E. There was a rapid reduction (78.5%) in triglyceride level after the first session of apheresis. Insulin infusion resulted in a 44.4% reduction in mean triglyceride level in the first 24 h. The durations of fasting and hospital stay, and the rates of respiratory failure and hypotension, were similar between groups. More patients in the apheresis group experienced acute renal failure or altered mental status. Prognosis did not significantly differ between groups. CONCLUSION Although apheresis treatments are safe and effective, they provided no clear benefit over insulin infusion for HTG-associated pancreatitis.
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Both low-fat and low-carbohydrate diets reduce triglyceride concentration in subjects with multifactorial chylomicronemia syndrome: a randomized crossover study. Nutr Res 2022; 101:43-52. [DOI: 10.1016/j.nutres.2022.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 02/02/2022] [Accepted: 02/10/2022] [Indexed: 12/19/2022]
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Basheer H, Nakhaee B, Jialal I. Chylomicronemia Due to the Rare Hyperlipoproteinemia Type 3 Complicated by a Circulating Monoclonal Protein. Lab Med 2022; 53:e117-e119. [PMID: 35041007 DOI: 10.1093/labmed/lmab127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The polygenic variety of chylomicronemia occurs in adults in whom factors such as obesity, diabetes, alcoholism, renal disease, and certain drugs can precipitate chylomicronemia. A rare cause of polygenic chylomicronemia is hyperlipoproteinemia type 3 (HLP3). We report on a 54-year-old male who presented with chylomicronemia with triglycerides (TG) >2000 mg/dL. From admission, the ratio of total cholesterol to total triglycerides was not below 0.2 but was closer to 0.5, suggesting that his condition was not classic chylomicronemia. We confirmed that the patient had HLP3 based on his very-low-density lipoprotein cholesterol (VLDL-C)/TG ratio, which was ≥0.3, and lipoprotein electrophoresis showing a broad beta band. Because he was not responsive to initial therapy, we considered an interferent impairing lipolysis and TG reduction. The interferent was an M-protein that may also have falsely elevated both apolipoprotein-B and direct-LDL-C levels. In this case study, we report on a patient with chylomicronemia resulting from HLP3 complicated by a circulating M-protein.
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Affiliation(s)
- Hiba Basheer
- Veterans Affairs Medical Center, Mather, California, United States
| | | | - Ishwarlal Jialal
- Veterans Affairs Medical Center, Mather, California, United States
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Metzner T, Leitner DR, Mellitzer K, Beck A, Sourij H, Stojakovic T, Reishofer G, März W, Landmesser U, Scharnagl H, Toplak H, Silbernagel G. Effects of Alirocumab on Triglyceride Metabolism: A Fat-Tolerance Test and Nuclear Magnetic Resonance Spectroscopy Study. Biomedicines 2022; 10:biomedicines10010193. [PMID: 35052871 PMCID: PMC8774139 DOI: 10.3390/biomedicines10010193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/13/2022] [Accepted: 01/14/2022] [Indexed: 01/06/2023] Open
Abstract
Background: PCSK9 antibodies strongly reduce LDL cholesterol. The effects of PCSK9 antibodies on triglyceride metabolism are less pronounced. The present study aimed to investigate in detail the effects of alirocumab on triglycerides, triglyceride-rich lipoproteins, and lipase regulators. Methods: A total of 24 patients with an indication for treatment with PCSK9 antibodies were recruited. There were two visits at the study site: the first before initiation of treatment with alirocumab and the second after 10 weeks of treatment. Fat-tolerance tests, nuclear magnetic resonance spectroscopy, and enzyme-linked immunosorbent assays were performed to analyze lipid metabolism. Results: A total of 21 participants underwent the first and second investigation. Among these, two participants only received alirocumab twice and 19 patients completed the trial per protocol. All of them had atherosclerotic vascular disease. There was no significant effect of alirocumab treatment on fasting triglycerides, post-prandial triglycerides, or lipoprotein-lipase regulating proteins. Total, large, and small LDL particle concentrations decreased, while the HDL particle concentration increased (all p < 0.001). Mean total circulating PCSK9 markedly increased in response to alirocumab treatment (p < 0.001). Whereas PCSK9 increased more than three-fold in all 19 compliant patients, it remained unchanged in those two patients with two injections only. Conclusion: Significant effects of alirocumab on triglyceride metabolism were not detectable in the ALIROCKS trial. The total circulating PCSK9 concentration might be a useful biomarker to differentiate non-adherence from non-response to PCSK9 antibodies.
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Affiliation(s)
- Thomas Metzner
- Department of Internal Medicine, Division of Angiology, Medical University of Graz, 8036 Graz, Austria
- Department of Medical Affairs, Sanofi-Aventis GmbH, 1100 Vienna, Austria
| | - Deborah R Leitner
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, 8036 Graz, Austria
| | - Karin Mellitzer
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, 8036 Graz, Austria
| | - Andrea Beck
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, 8036 Graz, Austria
| | - Harald Sourij
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, 8036 Graz, Austria
| | - Tatjana Stojakovic
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, University Hospital Graz, 8036 Graz, Austria
| | - Gernot Reishofer
- Department of Radiology, Clinical Division of Neuroradiology, Vascular and Interventional Radiology, Medical University of Graz, 8036 Graz, Austria
| | - Winfried März
- Department of Internal Medicine 5 (Nephrology, Hypertensiology, Endocrinology, Diabetology, Rheumatology), Mannheim Medical Faculty, University of Heidelberg, 68167 Mannheim, Germany
- Synlab Academy, Synlab Holding Germany GmbH, 86156 Augsburg, Germany
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, 8036 Graz, Austria
| | - Ulf Landmesser
- German Center for Cardiovascular Research (DZHK)-Partner Site Berlin, Department of Cardiology, Berlin Institute of Health, Charité University Medicine Berlin, 12200 Berlin, Germany
| | - Hubert Scharnagl
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, 8036 Graz, Austria
| | - Hermann Toplak
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, 8036 Graz, Austria
| | - Günther Silbernagel
- Department of Internal Medicine, Division of Angiology, Medical University of Graz, 8036 Graz, Austria
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Berberich AJ, Ouédraogo AM, Shariff SZ, Hegele RA, Clemens KK. Incidence, predictors and patterns of care of patients with very severe hypertriglyceridemia in Ontario, Canada: a population-based cohort study. Lipids Health Dis 2021; 20:98. [PMID: 34479547 PMCID: PMC8417954 DOI: 10.1186/s12944-021-01517-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 08/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The incidence of severe (S-HTG) and very severe hypertriglyceridemia (VS-HTG) among Canadians is unknown. This study aimed to determine the incidence, characteristics, predictors and care patterns for individuals with VS-HTG. METHODS Using linked administrative healthcare databases, a population-based cohort study of Ontario adults was conducted to determine incidence of new onset S-HTG (serum triglycerides (TG) > 10-20 mmol/L) and VS-HTG (TG > 20 mmol/L) between 2010 and 2015. Socio-demographic and clinical characteristics of those with VS-HTG were compared to those who had no measured TG value > 3 mmol/L. Univariable and multivariable logistic regression were used to determine predictors for VS-HTG. Healthcare patterns were evaluated for 2 years following first incidence of TG > 20 mmol/L. RESULTS Incidence of S-HTG and VS-HTG in Ontario was 0.16 and 0.027% among 10,766,770 adults ≥18 years and 0.25 and 0.041% among 7,040,865 adults with at least one measured TG, respectively. Predictors of VS-HTG included younger age [odds ratios (OR) 0.64/decade, 95% confidence intervals (CI) 0.62-0.66], male sex (OR 3.83; 95% CI 3.5-4.1), diabetes (OR 5.38; 95% CI 4.93-5.88), hypertension (OR 1.69; 95% CI 1.54-1.86), chronic liver disease (OR 1.71; 95% CI 1.48-1.97), alcohol abuse (OR 2.47; 95% CI 1.90-3.19), obesity (OR 1.49; 95% CI 1.13-1.98), and chronic kidney disease (OR 1.39; 95% CI 1.19-1.63). CONCLUSION The 5-year incidence of S-HTG and VS-HTG in Canadian adults was 1 in 400 and 1 in 2500, respectively. Males, those with diabetes, obese individuals and those with alcohol abuse are at highest risk for VS-HTG and may benefit from increased surveillance.
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Affiliation(s)
- Amanda J Berberich
- Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, Ontario, N6A 5B7, Canada. .,St. Joseph's Health Care London, 268 Grosvenor St, London, ON, N6A 4V2, Canada.
| | | | - Salimah Z Shariff
- ICES, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada
| | - Robert A Hegele
- Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, Ontario, N6A 5B7, Canada.,Lawson Health Research Institute, London, Ontario, Canada
| | - Kristin K Clemens
- St. Joseph's Health Care London, 268 Grosvenor St, London, ON, N6A 4V2, Canada.,ICES, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada.,Departments of Medicine and Epidemiology and Biostatistics, Western University, London, Ontario, N6A 5B7, Canada
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Kaewkrasaesin C, Chatchomchuan W, Muanpetch S, Khovidhunkit W. ANGPTL3 and ANGPTL8 in Thai subjects with hyperalphalipoproteinemia and severe hypertriglyceridemia. J Clin Lipidol 2021; 15:752-759. [PMID: 34535418 DOI: 10.1016/j.jacl.2021.08.059] [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: 05/09/2021] [Revised: 08/21/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The role of ANGPTL3 and ANGPTL8 in lipid regulation in patients with very high levels of HDL-cholesterol and triglyceride is unknown. OBJECTIVE We examined plasma levels of ANGPTL3 and ANGPTL8 in subjects with hyperalphalipoproteinemia (HALP) and in those with severe hypertriglyceridemia (HTG). METHODS Plasma ANGPTL3 and ANGPTL8 levels were measured by ELISA in 320 subjects, consisting of HALP subjects with HDL-cholesterol ≥100 mg/dl (n=90) and healthy controls (n=90) and subjects with triglyceride ≥886 mg/dl (n=89) and control subjects (n=51). RESULTS The mean plasma ANGPTL3 level was significantly higher in the HALP group compared to that of the controls (297 ± 112 ng/mL vs. 230 ± 100 ng/mL, p<0.001). Similarly, the mean plasma ANGPTL8 level was also higher in the HALP group (30 ± 11 ng/mL vs. 20 ± 8 ng/mL, p<0.001). Both ANGPTL3 and ANGPTL8 levels positively correlated with HDL-cholesterol levels. In the severe HTG group, plasma ANGPTL3 level was significantly higher than those in the control group (223 ± 105 ng/mL vs. 151 ± 60 ng/mL, p<0.001), but not ANGPTL8 (23 ± 20 ng/mL vs. 31 ± 23 ng/mL in controls, p=0.028). Only ANGPTL3, but not ANGPTL8, levels positively correlated with triglyceride levels. CONCLUSION Plasma level of ANGPTL3 was increased in both HALP and severe HTG whereas an increase in plasma level of ANGPTL8 was found only in HALP, and not in severe HTG, suggesting that both ANGPTL3 and ANGPTL8 might play distinct roles in lipid regulation on these two extremes of dyslipidemia.
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Affiliation(s)
- Chatchon Kaewkrasaesin
- Division of Endocrinology and Metabolism, Department of Medicine, and Hormonal and Metabolic Disorders Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Department of Medicine, and Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Waralee Chatchomchuan
- Division of Endocrinology and Metabolism, Department of Medicine, and Hormonal and Metabolic Disorders Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Department of Medicine, and Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Suwanna Muanpetch
- Department of Medicine, and Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Weerapan Khovidhunkit
- Division of Endocrinology and Metabolism, Department of Medicine, and Hormonal and Metabolic Disorders Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Department of Medicine, and Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
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Virani SS, Morris PB, Agarwala A, Ballantyne CM, Birtcher KK, Kris-Etherton PM, Ladden-Stirling AB, Miller M, Orringer CE, Stone NJ. 2021 ACC Expert Consensus Decision Pathway on the Management of ASCVD Risk Reduction in Patients With Persistent Hypertriglyceridemia: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2021; 78:960-993. [PMID: 34332805 DOI: 10.1016/j.jacc.2021.06.011] [Citation(s) in RCA: 139] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Abstract
INTRODUCTION Familial chylomicronemia syndrome (FCS) is a rare subtype of severe hypertriglyceridemia that affects ~1 in 100, 000 to 1,000,000 individuals. The major risk to health is acute pancreatitis. FCS is defined by biallelic loss-of-function mutations in one of five canonical genes that encode proteins critical to lipolysis of large triglyceride-rich lipoprotein particles. Unlike the vast majority of patients with severe hypertriglyceridemia, FCS patients lack any lipolytic capacity and are thus resistant to standard medications. AREAS COVERED This review focuses on a mechanism that effectively reduces elevated triglyceride levels in FCS, namely interference of synthesis of apolipoprotein (apo) C-III. Volanesorsen is an antisense RNA drug administered subcutaneously that knocks down apo C-III, resulting in dramatic reductions in triglyceride levels both in FCS patients and in the wider population of subjects with severe hypertriglyceridemia. EXPERT OPINION Volanesorsen is a highly effective treatment to reduce elevated triglycerides in FCS patients, providing proof-of-concept of the validity of targeting apo C-III. However, off target effects of volanesorsen, including thrombocytopenia, may ultimately limit its use. Nonetheless, building on the knowledge derived from the volanesorsen experience, there is intensified interest in promising newer agents that also target apo C-III but have technical modifications that limit potential off target adverse effects.
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Affiliation(s)
- Julieta Lazarte
- Departments of Medicine, Medicine and Dentistry, Western University, London, Canada.,Biochemistry, Medicine and Dentistry, Western University, London, Canada.,Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Robert A Hegele
- Departments of Medicine, Medicine and Dentistry, Western University, London, Canada.,Biochemistry, Medicine and Dentistry, Western University, London, Canada.,Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, Canada
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Laufs U, Parhofer KG, Ginsberg HN, Hegele RA. Clinical review on triglycerides. Eur Heart J 2021; 41:99-109c. [PMID: 31764986 PMCID: PMC6938588 DOI: 10.1093/eurheartj/ehz785] [Citation(s) in RCA: 271] [Impact Index Per Article: 90.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 08/20/2019] [Accepted: 10/23/2019] [Indexed: 12/23/2022] Open
Abstract
Hypertriglyceridaemia is a common clinical problem. Epidemiologic and genetic studies have established that triglyceride-rich lipoproteins (TRL) and their remnants as important contributors to ASCVD while severe hypertriglyceridaemia raises risk of pancreatitis. While low-density lipoprotein is the primary treatment target for lipid lowering therapy, secondary targets that reflect the contribution of TRL such as apoB and non-HDL-C are recommended in the current guidelines. Reduction of severely elevated triglycerides is important to avert or reduce the risk of pancreatitis. Here we discuss interventions for hypertriglyceridaemia, including diet and lifestyle, established treatments such as fibrates and omega-3 fatty acid preparations and emerging therapies, including various biological agents. ![]()
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Affiliation(s)
- Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstr. 20, Leipzig, Germany
| | - Klaus G Parhofer
- University Munich, Medical Department 4 - Grosshadern, Marchioninistr. 15, Munich, Germany
| | - Henry N Ginsberg
- Irving Institute for Clinical and Translational Medicine, Vagelos College of Physicians and Surgeons, Columbia University, 630 West 168th Street, New York, NY, USA
| | - Robert A Hegele
- Department of Medicine, Robarts Research Institute, Western University, London, Ontario, Canada
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Muñiz-Grijalvo O, Diaz-Diaz JL. Familial chylomicronemia and multifactorial chylomicronemia. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2021; 33 Suppl 2:56-62. [PMID: 34006355 DOI: 10.1016/j.arteri.2021.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/17/2021] [Indexed: 11/19/2022]
Abstract
The accumulation of chylomicrons in plasma beyond the postprandial period is a pathological event secondary to the partial or complete lack of activity of lipoprotein lipase that can lead to recurrent episodes of abdominal pain and acute pancreatitis. This article reviews the pathophysiology of this syndrome and the differential characteristics depending on whether it is due to congenital monogenic causes or acquired on a polygenic basis in which multiple factors may inluence.
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Affiliation(s)
| | - José Luis Diaz-Diaz
- Unidad de Lípidos, Servicio de Medicina interna, Complexo Hospitalario Universitario de A Coruña
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Treatment of chylomicronemia. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2021; 33 Suppl 2:75-79. [PMID: 34006359 DOI: 10.1016/j.arteri.2021.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 01/25/2021] [Indexed: 02/03/2023]
Abstract
Fasting chylomicronaemia appears in type V (multifactorial chylomicronaemia syndrome, MCS), and in type I (familial chylomicronaemia syndrome, FCS). MCS needs to be treated as in any general hypertriglyceridaemia: low-calorie diet, avoid sugar and alcohol, reduce body weight, control of diabetes and, in some cases, common lipid lowering-drugs, such as fibrates or omega-3 fatty acids. For type I HLP, FCS, patients should adhere to a strict very low fat diet, usually less than 15-20 g per day. In spite of this, many patients with FCS suffer from recurrent abdominal pain and/or acute pancreatitis. Volanesorsen, an antisense oligonucleotide against apolipoprotein C-III, is the only drug approved to control the disease. As shown in the APPROACH study, the administration of volanesorsen at a weekly dose of 285 mg induced at three month a reduction of triglycerides of 77% (primary end-point) and a reduction of 1712 mg/dL from the baseline. Among patient receiving volanesorsen, 77% reached a fasting triglyceride value below 750 mg/dL. The most frequent side effects were a skin reaction at injection site and low platelet levels, which should be monitored.
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Lahoz C, Mostaza JM. Familial hypertriglyceridemia/polygenic hypertrigliceridemia. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2021; 33 Suppl 2:37-42. [PMID: 34006352 DOI: 10.1016/j.arteri.2020.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/29/2020] [Indexed: 12/26/2022]
Abstract
For decades, familial hypertriglyceridemia (HTG) has been considered a specific entity characterized by an increase in VLDL particles and an autosomal dominant inheritance pattern. In the genomics era, it has been proven that familial HTG, although it could be grouped in families, had a polygenic inheritance in which the phenotype would be determined by concomitant environmental factors. Hence its inclusion in the group of polygenic HTGs. Clinically, they are characterized by moderate HTG, with the consequent increase in cardiovascular risk, and in rare cases, by severe HTG with risk of acute pancreatitis. Treatment will be based on controlling environmental factors, implementing hygienic-dietetic measures and sometimes drugs, to reduce cardiovascular risk in moderate HTGs and acute pancreatitis risk in severe HTGs.
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Affiliation(s)
- Carlos Lahoz
- Unidad de Lípidos y Riesgo Vascular, Hospital Carlos III, Madrid, España.
| | - José María Mostaza
- Unidad de Lípidos y Riesgo Vascular, Hospital Carlos III, Madrid, España
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50
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Novel PPARG mutation in multiple family members with chylomicronemia. J Clin Lipidol 2021; 15:431-434. [PMID: 33832869 DOI: 10.1016/j.jacl.2021.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 11/23/2022]
Abstract
Chylomicronemia is characterized by severe hypertriglyceridemia when chylomicrons persist in plasma despite a fasting state. The recessive monogenic form is due to homozygous or compound heterozygous loss-of-function mutations in the LPL gene or genes involved in the assembly, transport, or function of LPL, including APOC2, APOA5, GP1HBP1, and LMF1. The multifactorial form of chylomicronemia is due to both common small-effect variants and rare heterozygous large-effect variants in genes in which mutations are associated secondarily with hypertriglyceridemia. The combined inheritance of these variants increases susceptibility to chylomicronemia, and the number of hypertriglyceridemia-associated alleles carried by an individual represents a genetic or polygenic triglyceride risk score. Among these genes associated with hypertriglyceridemia is PPARG. PPARγ is a nuclear transcription factor encoded by the PPARG gene expressed predominantly in adipocytes that is involved in glucose, lipid, and adipose tissue metabolism. Known rare mutations and common polymorphisms in the PPARG genes are associated with a broad range of clinical phenotypes, including hypertriglyceridemia. Here, we present multiple family members with a novel heterozygous PPARG mutation that has not been previously reported.
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