The Disposition and Metabolism of Bempedoic Acid, A Potent Inhibitor of ATP Citrate Lyase, In Healthy Human Subjects

The disposition and metabolism of bempedoic acid, a selective inhibitor of ATP citrate lyase, were examined in healthy male subjects. After a single administration of [¹⁴C] bempedoic acid (240 mg, 113 μCi) oral solution, mean concentrations of total radioactivity in plasma as a function of time indicated absorption was rapid with peak concentrations achieved at 1 hour after dose administration. Radioactivity was decreased in a multiexponential fashion with an estimated elimination half-life of 26.0 hours. Radiolabeled dose was predominantly recovered in urine (62.1% of dose) and a smaller amount in feces (25.4% of dose). Bempedoic acid was extensively metabolized with 1.6% to 3.7% of dose excreted unchanged in urine and feces combined. Overall, the major clearance route of bempedoic acid is metabolism by uridine 5'‑diphosphate glucuronosyltransferases. Metabolism in hepatocyte cultures of human and nonclinical species were generally in agreement with clinical metabolite profiles. Pooled plasma samples were characterized by the presence of bempedoic acid, which accounted for 59.3% of total plasma radioactivity, ESP15228 (a reversible keto metabolite of bempedoic acid), and their respective glucuronide conjugates. The acyl glucuronide of bempedoic acid represented 23% to 36% of radioactivity in plasma and accounted for approximately 37% of dose excreted in urine. In feces, the majority of radioactivity was associated with a co-eluting mixture of a carboxylic acid metabolite of bempedoic acid, a taurine conjugate of bempedoic acid and hydroxymethyl-ESP15228, which collectively accounted for 3.1% to 22.9% of bempedoic acid dose across subjects. Significance Statement This study characterizes the disposition and metabolism of bempedoic acid, an inhibitor of ATP citrate lyase for hypercholesterolemia. This work provides further understanding of bempedoic acid clinical pharmacokinetics and clearance pathways in adult subjects.

Bempedoic acid plus ezetimibe fixed-dose combination in patients with hypercholesterolemia and high CVD risk treated with maximally tolerated statin therapy

Aims

The aim of this study was to evaluate the low-density lipoprotein cholesterol lowering efficacy and safety of a bempedoic acid 180 mg and ezetimibe 10 mg fixed-dose combination in patients with hypercholesterolemia and a high risk of cardiovascular disease receiving maximally tolerated statin therapy.

Methods

This phase 3, double-blind clinical trial enrolled adult patients at high risk of cardiovascular disease due to atherosclerotic cardiovascular disease, heterozygous familial hypercholesterolemia, or multiple cardiovascular disease risk factors. Patients were randomly assigned (2:2:2:1) to treatment with the fixed-dose combination, bempedoic acid 180 mg, ezetimibe 10 mg or placebo added to stable background statin therapy for 12 weeks. The primary efficacy endpoint was the percentage change from baseline to week 12 in low-density lipoprotein cholesterol.

Results

Among the 301 patients included in the primary analysis, the mean baseline low-density lipoprotein cholesterol level was 3.87 mmol/L (149.8 mg/dL). At week 12, the fixed-dose combination lowered low-density lipoprotein cholesterol (–36.2%) significantly more than placebo (1.8% (placebo-corrected difference –38.0%); P < 0.001), ezetimibe alone (–23.2%; P < 0.001) or bempedoic acid alone (–17.2%; P < 0.001). The fixed-dose combination lowered low-density lipoprotein cholesterol levels similarly across subgroups, including patients receiving high-intensity, other-intensity or no statin therapy. Improvements with the fixed-dose combination were also observed in secondary efficacy endpoints, including high-sensitivity C-reactive protein. In this trial, fixed-dose combination treatment had a generally similar safety profile compared with bempedoic acid, ezetimibe or placebo.

Conclusion

The bempedoic acid and ezetimibe fixed-dose combination significantly lowered low-density lipoprotein cholesterol versus placebo or other oral monotherapies and had a favourable safety profile when added to maximally tolerated statin therapy in patients with hypercholesterolemia and high cardiovascular disease risk.

Trial Registration

ClinicalTrials.gov identifier: NCT03337308.

Routine immunization of adults by pharmacists: Attitudes and beliefs of the Canadian public and health care providers

Vaccine coverage among adults for recommended vaccines is generally low. In Canada and the US, pharmacists are increasingly becoming involved in the administration of vaccines to adults. This study measured the knowledge, attitudes, beliefs, and behaviors of Canadian adults and health care providers regarding pharmacists as immunizers. Geographically representative samples of Canadian adults (n = 4023) and health care providers (n = 1167) were surveyed, and 8 focus groups each were conducted nationwide with adults and health care providers. Provision of vaccines by pharmacists was supported by 64.6% of the public, 82.3% of pharmacists, 57.4% of nurses, and 38.9% of physicians; 45.7% of physicians opposed pharmacist-delivered vaccination. Pharmacists were considered a trusted source of vaccination information by 75.0% of the public, exceeding public health officials (68.3%) and exceeded only by doctors and nurses (89.2%). Public concerns about vaccination in pharmacies centered on safety (management of adverse events), record keeping (ensuring their family physician was informed), and cost (should be no more expensive than vaccination at public health or physicians' offices). Concerns about the logistics of vaccination delivery were expressed more frequently in regions where pharmacists were not yet immunizing than in jurisdictions with existing pharmacist vaccination programs. These results suggest that the expansion of pharmacists' scope of practice to include delivery of adult vaccinations is generally accepted by Canadian health care providers and the public. Acceptance of this expanded scope of pharmacist practice may contribute to improvements in vaccine coverage rates by improving vaccine accessibility.

Universal tetanus, diphtheria, acellular pertussis (Tdap) vaccination of adults: What Canadian health care providers know and need to know

The tetanus, diphtheria, and acellular pertussis vaccine (Tdap) is recommended for all adults in both Canada and the United States. There are few data on the proportion of Canadian adults vaccinated with Tdap; however, anecdotal reports indicate that uptake is low. This study aimed to explore the knowledge, attitudes, beliefs, and behaviors of Canadian health care providers (HCPs) in an attempt to identify potential barriers and facilitators to Tdap uptake. HCPs were surveyed and a geographic and practice representative sample was obtained (N =1,167). In addition, 8 focus groups and 4 interviews were conducted nationwide. Results from the survey indicate that less than half (47.5%) of all respondents reported being immunized with Tdap themselves, while 58.5% routinely offer Tdap to their adult patients. Knowledge scores were relatively low (63.2% correct answers). The best predictor of following the adult Tdap immunization guidelines was awareness of and agreement with those recommendations. Respondents who were aware of the recommendations were more likely to think that Tdap is safe and effective, that their patients are at significant risk of getting pertussis, and to feel that they have sufficient information (p < 0.0001 for each statement). Focus group data supported the survey results and indicated that there are substantial gaps in knowledge of pertussis and Tdap among Canadian HCPs. Lack of public knowledge about adult immunization, lack of immunization registries, a costing differential between Td and Tdap, workload required to deliver the vaccine, and vaccine hesitancy were identified as barriers to compliance with the national recommendations for universal adult immunization, and suggestions were provided to better translate recommendations to front-line practitioners.

Abstract 62: The Effect of ETC-1002 on Low Density Lipoprotein-Cholesterol and Additional Risk Factors in Patients With Type 2 Diabetes

Background

Patients with type 2 diabetes (T2DM) are at high risk for cardiovascular (CV) disease and over half do not achieve LDL-C goal. Statins lower CV risk by reducing LDL-C and inflammation, but have been associated with worsening glycemic control and new onset diabetes, resulting in class label warnings for all statins. ETC-1002 is an oral investigational drug in Phase 2 development to treat dyslipidemia and other cardio-metabolic risk factors through dual adenosine monophosphate-activated protein kinase activation and adenosine triphosphate-citrate lyase inhibition.

Methods

Sixty T2DM patients received either ETC-1002 (80 mg for 2 weeks followed by 120 mg for 2 weeks) or placebo (PBO) for 4 weeks following a 4 week T2DM drug washout and 1 week PBO run-in.

Results

ETC-1002 lowered LDL-C by 43% (PBO corrected mean -39%; p<.0001) and non-HDL-C by 32% (PBO corrected mean -31%; p<.0001). Median reductions in high sensitivity C-reactive protein (hsCRP) were 41% and 11% for ETC-1002 and PBO (p=.0011). Post hoc analyses showed additional benefits of ETC-1002. An LDL-C goal of <100 mg/dL was achieved by 88% of ETC-1002 (21/24) and 4% of PBO subjects (1/24) not at baseline goal (p<.0001 versus PBO). Reductions in post-prandial hyperglycemia following standard meal challenge were observed which were significant in a subgroup of patients with BMI ≥ 30 kg/m 2 (p=.0246 versus placebo). Using continuous glucose monitoring, ETC-1002 treatment resulted in significant peak glycemic reduction between hours 6-12 and a trend between hours 12-18 and 18-24. A weight loss trend was observed with ETC-1002. In patients with 24 hour diastolic ambulatory blood pressure (DBP) > 80 mmHg, a 7 mmHg reduction versus PBO was observed (p=.0474). ETC-1002 was safe and well tolerated with no drop-outs, dose limiting side effects or serious adverse events, and no liver function tests >2 times upper limit normal.

Conclusion

In patients with T2DM and dyslipidemia, ETC-1002 produced statin-like reduction in LDL-C, robust reduction in hsCRP and was associated with modest to significant improvement of blood pressure, glucose control and weight loss. The novel mechanism of action of ETC-1002 may provide unique benefit to these patients.

Discrimination of 1990s original automotive paint systems: a collaborative study of black nonmetallic base coat/clear coat finishes using infrared spectroscopy

The 1990s saw the introduction of significantly new types of paint binder chemistries into the automotive finish coat market. Considering the pronounced changes in the binders that can now be found in automotive paints and their potential use in a wide variety of finishes worldwide, the Paint Subgroup of the Scientific Working Group for Materials (SWGMAT) initiated a validation study to investigate the ability of commonly accepted methods of forensic paint examination to differentiate between these newer types of paints. Nine automotive paint systems typical of original equipment applications were acquired from General Motors Corporation in 1992. They consisted of steel panels coated with typical electrocoat primers and/or primer surfacers followed by a black nonmetallic base coat and clear coat. The primary purpose of this study was to evaluate the discrimination power of common forensic techniques when applied to the newer generation original automotive finishes. The second purpose was to evaluate interlaboratory reproducibility of automotive paint spectra collected on a variety of Fourier transform infrared (FT-IR) spectrometers and accessories normally used for forensic paint examinations. The results demonstrate that infrared spectroscopy is an effective tool for discriminating between the major automotive paint manufacturers' formulation types which are currently used in original finishes. Furthermore, and equally important, the results illustrate that the mid-infrared spectra of these finishes are generally quite reproducible even when comparing data from different laboratories, commercial FT-IR instruments, and accessories in a "real world," mostly uncontrolled, environment.

Naproxen does not alter indices of muscle damage in resistance-exercise trained men

PURPOSE

Unaccustomed exercise is associated with an elevated plasma creatine kinase (CK), myofibrillar inflammation, and delayed onset muscle soreness (DOMS). Nonsteroidal antiinflammatory drugs (NSAID) may attenuate DOMS and indirect indices of inflammation in humans.

METHODS

We studied the effects of an NSAID (naproxen sodium (500 mg, 2 times a day for 48 h)) taken before and after resistance exercise in eight healthy, moderately trained men in a randomized, double-blind trial. The exercise consisted of unilateral knee concentric/eccentric weight lifting with 6 sets x 10 repetitions at 80-85% of the 1 repetition maximal contraction. Muscle biopsies of each vastus lateralis (EX = exercised/REST = control) were taken 24 h after exercise for immunohistochemical staining of inflammatory cells (leukocyte common antigen). At 24 and 48 h postexercise, we also determined DOMS, plasma CK activity, and knee extensor muscle torque.

RESULTS

Exercise resulted in an increased CK activity at +24 and +48 h (vs preexercise: P < 0.01), with no treatment effect. There were no treatment effects for any of the measured variables except for a return of voluntary knee extension torque to baseline by +48 h postexercise for NSAID treatment (P < 0.05).

CONCLUSIONS

NSAID administration did not alter CK rise, muscle force deficit at 24 h postexercise, nor perceived muscle pain. In addition, the increased CK at 24 h postexercise was not associated with an acute myofibrillar inflammatory cell infiltrate in moderately trained men after resistance exercise.

Mixed carbohydrate supplementation increases carbohydrate oxidation and endurance exercise performance and attenuates potassium accumulation

We studied the effects of different CHO supplements on exercise metabolism (1 hr at 75% VO2max) and performance (fatigue time at 85% VO2max) in 8 male endurance athletes (VO2max = 68.8 +/- 3.8 ml.kg-1.min-1. Four treatments were administered in a randomized, double-blind fashion: Trial A = 3-day pretest, postexercise supplementation (177 kcal [81% carbohydrate, 19% protein] consumed < 10 min after exercise) + 600 ml 8% glucose polymers/ fructose 1 hr pretesting + 600 ml 8% glucose polymers/glucose during testing; Trial B = placebo during 3-day pretest + remainder same as Trial A; Trial C = placebo at all time points; and Trial D = same as Trial B with 8% glucose 1 hr before the test as well as during the test. Time to fatigue at 85% VO2max (increases 24%) and total CHO oxidation were greater for A versus C (p < .05). Plasma glucose concentration was higher for A and B versus C, while increases in plasma potassium concentration were attenuated for A versus C (both p < .05). None of the supplements had differential effects upon hematocrit, plasma sodium [Na+] and lactate, VO2, or rating of perceived exertion during exercise. Three-day preexercise protein + carbohydrate supplements followed by 1-hr pre- and during-exercise mixed carbohydrate supplements increased time to fatigue and carbohydrate oxidation and attenuated rises in plasma [K+] compared to placebo.

Drink composition and the electrolyte balance of children exercising in the heat

Twelve 9- to 12-year-old children (6 boys, 6 girls) performed four exercise-in-heat (35 degrees C, 45% RH) trials which differed in the composition of the fluids they drank. In each trial, subjects cycled for one 20-min and two 15-min bouts at 50% peak VO2 with 10-min rest periods in between. In a fourth bout, they cycled at 90% peak VO2 until exhaustion. Drinks had the same grape flavor and were assigned in a double-blind design and in a Latin-square order. Subjects drank 7 ml.kg-1.h-1 to keep them euhydrated. Three of the drinks had 6% carbohydrates (CHO), with different [Na+]: 0, 8.8, 18.5 mmol.l-1 and one drink had neither CHO nor Na+ (WATER). Among drink trials, there were no differences in the increase in rectal temperature, HR, or performance time to exhaustion. Despite the larger Na+ deficit induced by the Na(+)-free drinks compared with the Na+ drinks (11.8 +/- 1.4 vs 5.7 +/- 0.9 mmol.h-1), neither plasma [Na+] nor osmolality were affected. These results suggest that electrolyte, as in the above conditions, did not affect electrolyte balance, thermoregulatory responses, or aerobic performance of children exercising in the heat. The greater Na+ deficit induced by ion-free drinks was of minor biological importance.

Sweat electrolyte loss during exercise in the heat: effects of gender and maturation

Humans may lose large amounts of water and electrolytes from sweat during prolonged exercise in a hot climate. Gender and maturational differences for the total sweat electrolyte losses have not been reported. The purpose of this study was to compare sweat electrolyte losses of prepubescent (PP), pubescent (P) and young adult (YA) males and females, under the same environmental conditions and relative exercise intensities. Twenty-five females (8 PP, 9 P, 8 YA) and 26 males (10 PP, 8 P, 8 YA) cycled for two 20-min bouts at 50% of their peak VO2 in a climatic chamber (42 degrees C, 18% relative humidity). Sweat was collected from a plastic bag attached to the lower back. Total body sweat loss was calculated from the differences in nude body weight corrected for fluid intake, urine, and respiratory water loss. Sweat [Na+] and [Cl-] tended to increase with maturation while sweat [K+] was lower in YA compared with that of PP. Children had a lower sweating rate than YA, even when corrected for body surface area. As a result, total Na+ and Cl- losses per kg body weight from sweat (mEq.kg-1.h-1) were higher in YA compared with those of PP and P; however, no maturational difference was found in K+ losses. Within the same maturational group, there were no gender differences in any of the electrolyte losses. These results may be useful in recommending "optimal" fluid-electrolyte drinks for children exercising in the heat.

Voluntary and electrically evoked strength characteristics of obese and nonobese preadolescent boys

Overweight and obese children demonstrate inferior motor performance for strength- and power-related activities requiring support or lifting of body weight. Our purpose here was to determine whether the inferior performance could be attributed to a lower strength to muscle area ratio in the obese. Eleven nonobese (16.6% fat) and 13 obese (35.5% fat) boys (9-13 years old) volunteered for the study. Peak torque was measured during voluntary isometric and isokinetic elbow flexion and knee extension at four joint angles and four velocities, respectively. The contractile properties, twitch torque, time to peak torque, and half-relaxation time were evoked for the elbow flexors by percutaneous stimulation. Elbow flexor and knee extensor cross-sectional areas (CSA) were determined by computed axial tomography taken at the mid-upper arm and mid-thigh, respectively. Isometric and isokinetic elbow flexion and knee extension strength normalized for body weight were significantly (p less than 0.05) higher in the nonobese compared to the obese boys. There were no significant (p greater than 0.05) differences, however, between groups for elbow flexor and knee extensor CSA or for absolute and relative (normalized for muscle CSA or the product of muscle CSA and height, the latter accounting for differences in moment arm length) isometric, isokinetic, or evoked twitch torque for elbow flexion or knee extension. Likewise, there were no differences between groups for the time-related contractile properties, time to peak torque, or half-relaxation time. These findings suggest that there is no difference in the intrinsic strength or contractile properties of the elbow flexor and knee extensor muscles between obese and nonobese pre-adolescent boys and that other factors, such as the handicapping effect of excess fat mass, probably account for the reduced motor performance of the obese child.

Pericardial tamponade associated with myeloid metaplasia

A 32-year-old white male with agnogenic myeloid metaplasia developed pericardial tamponade shortly after elective splenectomy. Tamponade was relieved by pericardiocentesis but recurred, necessitating partial pericardiectomy. Following surgery and a course of radiation therapy to the heart, there was no further significant reaccumulation of fluid. Pathologic evaluation demonstrated foci of extramedullary hematopoiesis in the pericardium. To our knowledge, pericardial tamponade has not previously been reported as a biopsy-proven complication of myeloid metaplasia.

Continuous vs. interval training: a review for the athlete and the coach

Both interval and continuous training are necessary in order to maximize the endurance athlete's potential for competition. Continuous submaximal training exerts its greatest effect upon the oxygen transport system of the body, while high intensity endurance-interval training exerts its greatest effect on the structural and biochemical properties of the muscle. The physiological basis for both forms of training is discussed and recommendations are made for year-round training and training to elevate the anaerobic threshold.