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Rastegar TF, Khan IA, Christopher-Stine L. Decoding the Intricacies of Statin-Associated Muscle Symptoms. Curr Rheumatol Rep 2024:10.1007/s11926-024-01143-y. [PMID: 38575845 DOI: 10.1007/s11926-024-01143-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 04/06/2024]
Abstract
PURPOSE OF REVIEW Hyperlipidemia is the major cardiovascular morbidity and mortality risk factor. Statins are the first-line treatment for hyperlipidemia. Statin-associated muscle symptoms (SAMS) are the main reason for the discontinuation of statins among patients. The purpose of this review is to guide clinicians to recognize the difference between self-limited and autoimmune statin myopathy in addition to the factors that potentiate them. Finally, treatment strategies will be discussed. This review mostly focuses on new data in the past 3 years. RECENT FINDINGS Recent findings suggest that SAMS is a complex and multifactorial condition that involves mitochondrial dysfunction, oxidative stress, and immune-mediated mechanisms. Effective management of SAMS requires a thorough evaluation of the patient's symptoms, risk factors, and medication history, as well as consideration of alternative treatment options. While statins are effective in reducing the risk of cardiovascular events, their use is associated with a range of adverse effects, including SAMS.
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Affiliation(s)
- Tara Fallah Rastegar
- Johns Hopkins Myositis Center, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Imtiaz Ahmed Khan
- Department of Internal Medicine, Texas Tech University Health Science Center, Amarillo, TX, USA
| | - Lisa Christopher-Stine
- Johns Hopkins Myositis Center, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Abrahams T, Nelson AJ, Nicholls SJ. How Will Our Practice Change After the CLEAR Outcomes Trial? Curr Atheroscler Rep 2024; 26:83-89. [PMID: 38294660 PMCID: PMC10881600 DOI: 10.1007/s11883-024-01188-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2024] [Indexed: 02/01/2024]
Abstract
PURPOSE OF REVIEW Bempedoic acid is a novel therapeutic agent that is designed to reduce levels of low-density lipoprotein cholesterol (LDL-C). The purpose of this review is to provide the background for development of bempedoic acid, findings from clinical trials and to discuss clinical implications. RECENT FINDINGS Bempedoic acid inhibits ATP citrate lyase within the liver and reduces cholesterol synthesis, with the potential to avoid muscle symptoms experienced by patients treated with statins. Early clinical studies demonstrated that administration of bempedoic acid resulted in lowering of LDL-C by 20-30% as monotherapy and by 40-50% when combined with ezetimibe, in addition to lowering of high sensitivity C-reactive protein by 20-30%. The CLEAR Outcomes trial of high cardiovascular risk patients, with elevated LDL-C levels and either unable or unwilling to take statins demonstrated that bempedoic acid reduced the rate of major adverse cardiovascular events. A greater incidence of elevation of hepatic transaminase and creatinine, gout, and cholelithiasis were consistently observed in bempedoic acid-treated patients. Bempedoic acid presents an additional therapeutic option to achieve more effective lowering of LDL-C levels and reduction in cardiovascular risk.
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Affiliation(s)
- Timothy Abrahams
- Victorian Heart Institute, MonashUniversity, 631 Blackburn Road, Clayton, VIC, 3168, Australia
| | - Adam J Nelson
- Victorian Heart Institute, MonashUniversity, 631 Blackburn Road, Clayton, VIC, 3168, Australia
| | - Stephen J Nicholls
- Victorian Heart Institute, MonashUniversity, 631 Blackburn Road, Clayton, VIC, 3168, Australia.
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Laufs U, Birkenfeld AL, Fraass U, Hohenstein B, Siegert C, Klotsche J, Steinhagen-Thiessen E, Pittrow D, Dexl S, Salmen S, Schettler VJJ, Parhofer KG. Novel Insights into the Management of Patients with Very High Cardiovascular Risk Eligible for PCSK9 Inhibitor Treatment: Baseline Findings from the PERI-DYS Study. Cardiovasc Drugs Ther 2024; 38:119-129. [PMID: 36178485 PMCID: PMC10876819 DOI: 10.1007/s10557-022-07386-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2022] [Indexed: 11/30/2022]
Abstract
AIM The PERI-DYS study aims to characterize two groups of patients with dyslipidaemia at very high CV risk: PCSK9i receivers and patients qualifying for but not receiving PCSK9i. METHODS This is an observational study by office-based and clinic-based physicians, mainly cardiologists and other internists in Germany, with data extracted from patient charts. CLINICALTRIALS gov identifier NCT03110432. RESULTS A total of 1659 patients were enrolled across 70 sites. The majority of patients (91.0%) were reported as having mixed dyslipidaemia or non-familial or heterozygous familial hypercholesterolemia. At enrolment, 794 (47.9%) of patients were PCSK9i receivers (of these 65.9% ongoing, and 34.1% newly treated within 30 days before their baseline visit). Among PCSK9i receivers, the majority had evolocumab 140 mg (n = 632, 38.1% of total). PCSK9i receivers compared to non-receivers were about 2 years younger and had a lower proportion of males. In terms of comorbidities, they had (statistically significantly) more often CAD, and less often PAD, diabetes mellitus, arterial hypertension and chronic renal disease. The calculated untreated median LDL-C was 187 mg/dl (IQR 127; 270) in ongoing PCSK9i receivers, 212 mg/dl (IQR 132; 277) in newly treated PCSK9i receivers, and 179 mg/dl (IQR 129; 257) in non-receivers. Physician-reported statin intolerance was much more common in the two PCSK9i receiver groups as compared to non-receivers (67.3% versus 15.3%). Consequently, patients in the PCSK9i groups received fewer concomitant statins. Mean total cholesterol (143 vs. 172 mg/dl) and LDL-C (69 vs. 99 mg/dl) were considerably lower in ongoing PCSK9i receivers compared to non-receivers. CONCLUSIONS PCSK9i receivers are characterized by higher baseline LDL-C and a higher portion of statin intolerance compared to those qualified for but not-receiving PCSK9i treatment. On-treatment, LDL-C was lower in PCSK9i receivers. Ongoing follow-up will determine the prognostic importance of these findings.
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Affiliation(s)
- Ulrich Laufs
- Klinik und Poliklinik Für Kardiologie, Universitätsklinikum, Leipzig, Germany.
| | - Andreas L Birkenfeld
- Innere Medizin IV - Diabetologie, Endokrinologie Und Nephrologie Am Universitätsklinikum, Tübingen, Germany
- Institut Für Diabetesforschung und Metabolische Erkankungen (IDM) des Helmholtz Zentrums München, Partner des Deutschen Zentrums Für Diabetesforschung (DZD E.V.), Munich, Germany
| | | | - Bernd Hohenstein
- Nephrologisches Zentrum Villingen-Schwenningen, Göttingen, Germany
| | | | | | | | - David Pittrow
- Medizinische Fakultät, Technische Universität, Dresden, Germany
- Innovationszentrum Real-World Evidence, GWT-TUD GmbH, Dresden, Germany
| | | | | | | | - Klaus G Parhofer
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
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Goyal A, Changez MIK, Tariq MD, Mushtaq F, Shamim U, Sohail AH, Mahalwar G. Efficacy and outcomes of Bempedoic acid versus placebo in patients with statin-intolerance: A pilot systematic review and meta-analysis of randomized controlled trials. Curr Probl Cardiol 2024; 49:102236. [PMID: 38043880 DOI: 10.1016/j.cpcardiol.2023.102236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 11/28/2023] [Indexed: 12/05/2023]
Abstract
INTRODUCTION Bempedoic acid (BA) has shown significant progress in reducing cholesterol levels and is relatively free from the many side effects encountered with the use of other hyperlipidemic drugs such as statins. However, its efficacy in patients with statin intolerance is controversial with inconsistent results among studies. MATERIALS AND METHODS An electronic literature search was performed using various databases such as Medline, Google Scholar, and the International Registry of Clinical Trials. The primary endpoint was the change in LDL-C levels. The secondary endpoints included changes in HDL-C, non-HDL-C, triglycerides (TG), clinical outcomes such as MACE, all-cause mortality (ACM), cardiovascular mortality, myocardial infarction (MI), and additional safety outcomes. The least-square mean (LSM) percent change for assessing changes in lipid parameter levels from the baseline and the risk ratio (RR) were used for the evaluation of binary endpoints, with statistical significance set at p<0.05. Random-effects meta-analyses were performed for all the outcomes. RESULTS Our analysis included 5 randomized controlled trials (RCTs) with a total of 18,848 participants. BA showed a significant reduction in LDL-C [LSM difference in %: -25.24; 95 % CI: -30.79 to -19.69; p < 0.00001], total cholesterol [LSM difference in %:-21.28; 95 % CI:-30.58 to-11.98; p < 0.00001], non-HDL-C [LSM difference in %: -23.27; 95 % Cl: -29.80 to -16.73 p < 0.00001], and HDL-C [LSM difference in %:-3.37, 95 % CI:-3.73 to-3.01, p < 0.00001] compared to placebo. In terms of clinical efficacy, BA was associated with a lower risk of coronary revascularization [RR:0.81; 95 % CI:0.66 to 0.99; p = 0.04], hospitalization for unstable angina [RR:0.67; 95 % CI:0.50 to 0.88; p = 0.005], and myocardial infarction [RR:0.76; 95 % CI:0.66 to 0.88;p = 0.0004]. No significant difference was observed in MACE [RR:0.81; p = 0.15], ACM [RR:0.86; p = 0.46], cardiovascular-related mortality [RR:0.79; p = 0.44], and stroke [RR:0.83; p = 0.08] between the two groups. In terms of safety efficacy, the risk for myalgia was significantly lower in BA-treated patients than in placebo [RR:0.80; p = 0.0002], while the risk for gout [RR:1.46; p < 0.0001] and hyperuricemia [RR:1.93; p < 0.00001] was higher for BA than for placebo. The risks for other adverse effects, such as neurocognitive disorder, nasopharyngitis urinary tract infection, upper respiratory infection, muscular disorder, and worsening hyperglycemia/DM were comparable between the two groups. CONCLUSION Our analysis demonstrated that BA significantly reduced the levels of LDL-C, total cholesterol, non-HDL-C, HDL-C, ApoB, and hs-CRP compared with the placebo group. Additionally, patients who received BA had a lower likelihood of coronary revascularization and hospitalization due to unstable angina, MI, and myalgia. Further large-scale RCTs are required to generate more robust evidence.
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Affiliation(s)
- Aman Goyal
- Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Mah I Kan Changez
- Department of Surgery, Quetta Institute of Medical Sciences, Quetta, Pakistan
| | - Muhammad Daoud Tariq
- Department of Internal Medicine, Foundation University Medical College, Islamabad, Pakistan
| | - Fiza Mushtaq
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Pakistan
| | - Urooj Shamim
- Department of Internal Medicine Aga Khan University Hospital, Karachi, Pakistan
| | - Amir Humza Sohail
- Department of Surgery, University of New Mexico Health Sciences, Albuquerque, NM, USA
| | - Gauranga Mahalwar
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA.
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Park JK, Balarbar N, Agarwala A. Bempedoic Acid: A Contemporary Review of Its Pharmacology, Efficacy, and Safety Profile, Including Recent Data from the CLEAR Outcomes Clinical Trial. Curr Cardiol Rep 2023; 25:969-978. [PMID: 37405598 DOI: 10.1007/s11886-023-01911-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2023] [Indexed: 07/06/2023]
Abstract
PURPOSE OF REVIEW To provide an updated review of bempedoic acid's clinical application in lowering LDL-C in the setting of statin intolerance and the recent findings in the CLEAR Outcomes trial as well as summarize and synthesize the current state of knowledge regarding bempedoic acid while providing an in-depth analysis of the drug's pharmacological properties, mechanism of action, clinical trials, safety, and efficacy. RECENT FINDINGS The CLEAR Outcomes trial has provided evidence to support bempedoic acid as a viable alternative to statins for the primary and secondary prevention of cardiovascular disease. Bempedoic acid is a promising treatment option for patients with hypercholesterolemia who are unable to tolerate statin therapy or require additional LDL-C reduction in the treatment of cardiovascular disease, with the newest lipid-lowering cardiovascular outcomes trials expanding on their generalizability particularly in the inclusion of women.
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Affiliation(s)
- Jong Kun Park
- The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Noah Balarbar
- Center for Cardiovascular Disease Prevention, Baylor Scott and White Health Heart Hospital Baylor Plano, Plano, TX, USA
| | - Anandita Agarwala
- Center for Cardiovascular Disease Prevention, Baylor Scott and White Health Heart Hospital Baylor Plano, Plano, TX, USA.
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Abstract
PURPOSE OF REVIEW To review recent international and domestic definitions, considerations, and treatment algorithms for statin intolerance, and specifically, statin-associated muscle symptoms (SAMS). RECENT FINDINGS Multiple organizations around the world have produced guidance documents to aid clinicians on managing statin intolerance. A common theme resides among all the guidance documents that most patients can tolerate statins. For those patients who cannot, healthcare teams need to evaluate, rechallenge, educate, and ensure adequate reduction of atherogenic lipoproteins. Statin therapy remains the cornerstone of lipid-lowering therapies to reduce atherosclerotic cardiovascular disease (ASCVD) and reduce mortality and morbidity. The common theme throughout all these guidance documents is the importance of statin therapy to reduce ASCVD and continual adherence to treatment. Because adverse events occur and inhibit patients from achieving adequate lowering of their atherogenic lipoproteins, trial and rechallenge of statin therapy, as well as addition of non-statin therapies, especially in high-risk patients, is also undisputed. The main differences stem from laboratory monitoring and the classification of the severity of the adverse effect. Future research should focus on consistently diagnosing SAMS so that these patients can be easily identified in the electronic health records.
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Affiliation(s)
| | - Katarina Clegg
- Geisinger Commonwealth School of Medicine, Scranton, PA 18510 USA
- Department of Genomic Medicine, Geisinger, Danville, PA 17822 USA
| | | | - Tyler J. Schubert
- Geisinger Commonwealth School of Medicine, Scranton, PA 18510 USA
- Department of Genomic Medicine, Geisinger, Danville, PA 17822 USA
| | - Laney K. Jones
- Department of Genomic Medicine, Geisinger, Danville, PA 17822 USA
- Heart and Vascular Institute, Geisinger, Danville, PA 17822 USA
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Cao W, Li L, Mathur P, Thompson J, Milks MW. A mobile health application for patients eligible for statin therapy: app development and qualitative feedback on design and usability. BMC Med Inform Decis Mak 2023; 23:128. [PMID: 37468892 PMCID: PMC10357764 DOI: 10.1186/s12911-023-02221-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 06/28/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Cardiovascular disease is the leading cause of death in the United States (US). Despite the well-recognized efficacy of statins, statin discontinuation rates remain high. Statin intolerance is a major cause of statin discontinuation. To accurately diagnose statin intolerance, healthcare professionals must distinguish between statin-associated and non-statin-associated muscle symptoms, because many muscle symptoms can be unrelated to statin therapy. Patients' feedback on muscle-related symptoms would help providers make decisions about statin treatment. Given the potential benefits and feasibility of existing apps for cardiovascular disease (CVD) management and the unmet need for an app specifically addressing statin intolerance management, the objectives of the study were 1) to describe the developmental process of a novel app designed for patients who are eligible for statin therapy to lower the risk of CVD; 2) to explore healthcare providers' feedback of the app; and 3) to explore patients' app usage experience. METHODS The app was developed by an interdisciplinary team. Healthcare provider participants and patient participants were recruited in the study. Providers were interviewed to provide their feedback about the app based on screenshots of the app. Patients were interviewed after a 30 days of app usage. RESULTS The basic features of the app included symptom logging, vitals tracking, patient education, and push notifications. Overall, both parties provided positive feedback about the app. Areas to be improved mentioned by both parties included: the pain question asked in symptom tracking and the patient education section. Both parties agreed that it was essential to add the trend report of the logged symptoms. CONCLUSIONS The results indicated that providers were willing to use patient-reported data for disease management and perceived that the app had the potential to facilitate doctor-patient communication. Results also indicated that user engagement is the key to the success of app efficacy. To promote app engagement, app features should be tailored to individual patient's needs and goals. In the future, after it is upgraded, we plan to test the app usability and feasibility among a more diverse sample.
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Affiliation(s)
- Weidan Cao
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH, 43210, USA.
| | - Lang Li
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH, 43210, USA
| | - Puneet Mathur
- Department of Research Information Technology, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - John Thompson
- Department of Research Information Technology, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - M Wesley Milks
- Division of Cardiovascular Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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Sayed A, Shazly O, Slipczuk L, Krittanawong C, Baloch F, Virani SS. The Clinical Efficacy and Safety of Bempedoic Acid in Patients at Elevated Risk of Cardiovascular Disease: A Meta-Analysis of Randomized Clinical Trials. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07474-9. [PMID: 37261676 DOI: 10.1007/s10557-023-07474-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/22/2023] [Indexed: 06/02/2023]
Abstract
PURPOSE Statins are first-line agents to reduce low-density lipoprotein cholesterol (LDL-C) and cardiovascular risk, however, they are insufficient and/or intolerable in many patients. To that end, we conducted a meta-analysis of Bempedoic Acid (BA), a novel LDL-C lowering agent. METHODS We retrieved randomized clinical trials (RCTs) of BA by searching Pubmed, the Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov. We used the Mantel-Haenszel method to pool estimates. The I2 measure was used to quantify heterogeneity. Treatment effects are provided as relative risks (RR), absolute risk differences (ARD), and number needed to treat/harm (NNTB/H). Analyses were conducted using R, version 4.1.2. RESULTS 11 trials enrolling 18,496 patients were included. Compared to placebo, BA reduced the risk of major adverse cardiovascular events (RR: 0.87; 95% CI: 0.80 to 0.95; ARD: -1.63%; NNT: 62), myocardial infarction (RR: 0.76; 95% CI: 0.66 to 0.89; ARD: -1.03%; NNT: 98), unstable angina hospitalization (RR: 0.70; 95%: CI: 0.55 to 0.89; ARD: -0.57%; NNT: 177), revascularization (RR: 0.81; 95% CI: 0.72 to 0.91; ARD: -1.31%; NNT: 77), and myalgia (RR: 0.85; 95% CI: 0.75 to 0.95; ARD: -0.99%; NNT: 102). BA significantly increased the risk of gout (RR: 1.56; 95% CI: 1.27 to 1.91; ARD: 0.99%; NNH: 101), renal impairment (RR: 1.35; 95% CI: 1.22 to 1.49; ARD: 2.54%; NNH: 40), and cholelithiasis (RR: 1.87; 95% CI: 1.43 to 2.44; ARD: 1.01%; NNH: 100). CONCLUSION BA effectively reduces the risk of cardiovascular events and myalgia but increases the risk of gout, cholelithiasis, and renal impairment.
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Affiliation(s)
- Ahmed Sayed
- Faculty of Medicine, Ain Shams University, 38 Abbassia, Cairo, 1181, Egypt.
| | - Omar Shazly
- Faculty of Medicine, Ain Shams University, 38 Abbassia, Cairo, 1181, Egypt
| | - Leandro Slipczuk
- Department of Medicine (Cardiology), Albert Einstein College of Medicine, Montefiore, Bronx, NY, USA
| | | | - Farhala Baloch
- Section of Cardiology, Department of Medicine, Aga Khan University Karachi, Karachi, Pakistan
| | - Salim S Virani
- Department of Medicine, Aga Khan University, Karachi, Pakistan
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Jacomelli I, Monzo L, Panattoni G, Lanzillo C, Rebecchi M, Calò L. Bempedoic acid: what prospective uses? Eur Heart J Suppl 2023; 25:C109-C111. [PMID: 37125277 PMCID: PMC10132602 DOI: 10.1093/eurheartjsupp/suad012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
There is still the need to lower LDL-c, although the use of statins, ezetimibe and proprotein convertase subtilisin/kexin type 9. Patients with atherosclerotic cardiovascular disease and/or familial hypercholesterolaemia are treated with statins at maximum tolerated dose, with or without further lipid-lowering drugs, but very often, we can't reach the goal, so bempedoic acid treatment lead to a significant reduction in low-density lipoprotein cholesterol, in different groups of patients, with a favourable safety profile.
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Affiliation(s)
| | - Luca Monzo
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
- Centre d'investigation Cliniques Plurithématique, Universitè de Lorraine INSERM, Nancy, France
| | - Germana Panattoni
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
| | - Chiara Lanzillo
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
| | - Marco Rebecchi
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
| | - Leonardo Calò
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
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Jennings DL, Sultan L, Mingov J, Choe J, Latif F, Restaino S, Clerkin K, Habal MV, Colombo PC, Yuzefpulskaya M, Sayer G, Uriel N, Baker WL. PCSK9 inhibitors safely and effectively lower LDL after heart transplantation: a systematic review and meta-analysis. Heart Fail Rev 2023; 28:149-56. [PMID: 35687219 DOI: 10.1007/s10741-022-10255-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2022] [Indexed: 02/07/2023]
Abstract
Coronary allograft vasculopathy (CAV) continues to afflict a high number of heart transplant (HT) recipients, and elevated LDL is a key risk factor. Many patients cannot tolerate statin medications after HT; however, data for alternative agents remains scarce. To address this key evidence gap, we evaluated the safety and efficacy of the PCSK9i after HT through systematic review and meta-analysis. We searched Medline, Cochrane Central, and Scopus from the earliest date through July 15th, 2021. Citations were included if they were a report of PCSK9i use in adults after HT and reported an outcome of interest. Outcomes included change in LDL cholesterol from baseline, incidence of adverse events, and evidence of CAV. Changes from baseline and outcome incidences were pooled using contemporary random-effects model methodologies. A total of six studies including 97 patients were included. Over a mean follow-up of 13 months (range 3-21), PCSK9i use lowered LDL by 82.61 mg/dL (95% CI - 119.15 to - 46.07; I2 = 82%) from baseline. Serious adverse drug reactions were rarely reported, and none was attributable to the PCSK9i therapy. Four studies reported stable calcineurin inhibitor levels during PCSK9i initiation. One study reported outcomes in 33 patients with serial coronary angiography and intravascular ultrasound, and PCSK9i were associated with stable coronary plaque thickness and lumen area. One study reported on immunologic safety, showing no DSA development within 1 month of therapy. Preliminary data suggest that long-term PCSK9i therapy is safe, significantly lowers LDL, and may attenuate CAV after HT. Additional study on larger cohorts is warranted to confirm these findings.
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Saseen JJ, Virani SS. Lipid lowering therapy in 2022 and beyond - How far we have come. Prog Cardiovasc Dis 2022; 75:1-3. [PMID: 36503836 DOI: 10.1016/j.pcad.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Joseph J Saseen
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Skaggs School of Pharmacy; Aurora, CO, USA; Department of Family Medicine, University of Colorado Anschutz Medical Campus, School of Medicine; Aurora, CO, USA.
| | - Salim S Virani
- Section of Cardiology and Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA; Health Policy, Quality & Informatics Program, Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
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Bytyçi I, Penson PE, Mikhailidis DP, Wong ND, Hernandez AV, Sahebkar A, Thompson PD, Mazidi M, Rysz J, Pella D, Reiner Ž, Toth PP, Banach M. Prevalence of statin intolerance: a meta-analysis. Eur Heart J 2022; 43:3213-3223. [PMID: 35169843 PMCID: PMC9757867 DOI: 10.1093/eurheartj/ehac015] [Citation(s) in RCA: 124] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 01/10/2022] [Indexed: 07/25/2023] Open
Abstract
AIMS Statin intolerance (SI) represents a significant public health problem for which precise estimates of prevalence are needed. Statin intolerance remains an important clinical challenge, and it is associated with an increased risk of cardiovascular events. This meta-analysis estimates the overall prevalence of SI, the prevalence according to different diagnostic criteria and in different disease settings, and identifies possible risk factors/conditions that might increase the risk of SI. METHODS AND RESULTS We searched several databases up to 31 May 2021, for studies that reported the prevalence of SI. The primary endpoint was overall prevalence and prevalence according to a range of diagnostic criteria [National Lipid Association (NLA), International Lipid Expert Panel (ILEP), and European Atherosclerosis Society (EAS)] and in different disease settings. The secondary endpoint was to identify possible risk factors for SI. A random-effects model was applied to estimate the overall pooled prevalence. A total of 176 studies [112 randomized controlled trials (RCTs); 64 cohort studies] with 4 143 517 patients were ultimately included in the analysis. The overall prevalence of SI was 9.1% (95% confidence interval 8.0-10%). The prevalence was similar when defined using NLA, ILEP, and EAS criteria [7.0% (6.0-8.0%), 6.7% (5.0-8.0%), 5.9% (4.0-7.0%), respectively]. The prevalence of SI in RCTs was significantly lower compared with cohort studies [4.9% (4.0-6.0%) vs. 17% (14-19%)]. The prevalence of SI in studies including both primary and secondary prevention patients was much higher than when primary or secondary prevention patients were analysed separately [18% (14-21%), 8.2% (6.0-10%), 9.1% (6.0-11%), respectively]. Statin lipid solubility did not affect the prevalence of SI [4.0% (2.0-5.0%) vs. 5.0% (4.0-6.0%)]. Age [odds ratio (OR) 1.33, P = 0.04], female gender (OR 1.47, P = 0.007), Asian and Black race (P < 0.05 for both), obesity (OR 1.30, P = 0.02), diabetes mellitus (OR 1.26, P = 0.02), hypothyroidism (OR 1.37, P = 0.01), chronic liver, and renal failure (P < 0.05 for both) were significantly associated with SI in the meta-regression model. Antiarrhythmic agents, calcium channel blockers, alcohol use, and increased statin dose were also associated with a higher risk of SI. CONCLUSION Based on the present analysis of >4 million patients, the prevalence of SI is low when diagnosed according to international definitions. These results support the concept that the prevalence of complete SI might often be overestimated and highlight the need for the careful assessment of patients with potential symptoms related to SI.
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Affiliation(s)
- Ibadete Bytyçi
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- Clinic of Cardiology, University Clinical Centre of Kosovo, Prishtina, Kosovo
| | - Peter E Penson
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Nathan D Wong
- Heart Disease Prevention Program, Division of Cardiology, University of California, Irvine School of Medicine Predictive Health Diagnostics, Irvine, CA, USA
| | - Adrian V Hernandez
- Health Outcomes, Policy, and Evidence Synthesis (HOPES) Group, University of Connecticut School of Pharmacy, Storrs, CT, USA
- Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Paul D Thompson
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, USA
- Department of Internal Medicine, University of Connecticut, Farmington, CT, USA
| | - Mohsen Mazidi
- Department of Twin Research and Genetic Epidemiology, King’s College London, London, UK
- Department of Nutritional Sciences, King’s College London, London, UK
| | - Jacek Rysz
- Department of Hypertension, Nephrology and Family Medicine, Medical University of Lodz (MUL), Lodz, Poland
| | - Daniel Pella
- 2nd Department of Cardiology, Faculty of Medicine, Pavol Jozef Safarik University and East Slovak Institute of Cardiovascular Diseases, Kosice, Slovakia
| | - Željko Reiner
- Department of Internal Diseases, University Hospital Center Zagreb, School of Medicine, Zagreb University, Zagreb, Croatia
| | - Peter P Toth
- CGH Medical Center, Sterling, IL, USA
- Cicarrone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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13
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Solomon R, Anne P, Swisher J, Nazeer B, Rosman H, Mehta RH, Maciejko JJ. Evaluating Statin Tolerability in Historically Intolerant Patients After Correcting for Subclinical Hypothyroidism and Vitamin D Insufficiency. High Blood Press Cardiovasc Prev 2022; 29:409-415. [PMID: 36063342 DOI: 10.1007/s40292-022-00537-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/12/2022] [Indexed: 10/14/2022] Open
Abstract
INTRODUCTION Atherosclerotic cardiovascular disease (ASCVD) is the major cause of morbidity and mortality worldwide. Statins provide primary and secondary ASCVD prevention. Intolerance due to statin-associated myalgias reduces long-term adherence, thus muting potential benefits. AIM Our analysis sought to determine whether transition from a lipophilic statin to a water-soluble statin, or correction of subclinical hypothyroidism and/or vitamin D insufficiency/deficiency (metabolic abnormalities), improved statin tolerance. METHODS We performed a retrospective analysis of the data from patients referred to our lipid clinic because of statin intolerance. Patients intolerant to a lipophilic statin were switched to a water-soluble statin. Patients having vitamin D insufficiency/deficiency or subclinical hypothyroidism were re-challenged with a water-soluble statin (or lipophilic statin with minimal systemic exposure) after correction of the metabolic abnormality. RESULTS 169 patients were statin intolerant. 86% (n = 145) were white and 48% (n = 81) were male. 82 of these patients had one or both metabolic abnormalities. The remaining patients (n = 87) had no metabolic abnormality, however, were unable to tolerate a lipophilic statin. 72% (n = 73) of eligible patients (n = 101), defined as those with a corrected metabolic abnormality or without a metabolic abnormality on a lipophilic statin, were able to tolerate a water-soluble statin or lipophilic statin with minimal systemic exposure. In addition, 75% (n = 127) of this total cohort met their LDL-C goal. CONCLUSIONS Our findings suggest that either correction of subclinical hypothyroidism and/or vitamin D insufficiency/deficiency or transition from a lipophilic statin to water-soluble statin (or lipophilic statin with minimal systemic exposure) improves statin tolerance.
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Affiliation(s)
- Robert Solomon
- Division of Cardiology, Ascension St. John Hospital, 22101 Moross Rd, Detroit, Michigan, 48236, United States.
| | - Premchand Anne
- Department of Internal Medicine, Ascension St. John Hospital, 22101 Moross Rd, Detroit, Michigan, 48236, United States
| | - Jordan Swisher
- Division of Cardiology, Ascension St. John Hospital, 22101 Moross Rd, Detroit, Michigan, 48236, United States
| | - Beshoy Nazeer
- Department of Internal Medicine, Ascension St. John Hospital, 22101 Moross Rd, Detroit, Michigan, 48236, United States
| | - Howard Rosman
- Division of Cardiology, Ascension St. John Hospital, 22101 Moross Rd, Detroit, Michigan, 48236, United States
| | - Rajendra H Mehta
- Division of Cardiology, Ascension St. John Hospital, 22101 Moross Rd, Detroit, Michigan, 48236, United States
| | - James J Maciejko
- Division of Cardiology, Ascension St. John Hospital, 22101 Moross Rd, Detroit, Michigan, 48236, United States.,Department of Internal Medicine, Ascension St. John Hospital, 22101 Moross Rd, Detroit, Michigan, 48236, United States
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14
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Orringer CE, Grant JK, Tokgozoglu L. A Review of Statin Intolerance: a Focus on Statin-Attributed Muscle Symptoms. Curr Atheroscler Rep 2022. [PMID: 36001213 DOI: 10.1007/s11883-022-01059-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW To provide a systematic approach to management of the patient with statin-attributed muscle symptoms. RECENT FINDINGS We examined the prevalence of statin intolerance, the role of the nocebo effect, key findings in the patient's history and laboratory studies, the potential value of coronary calcium scoring, and the importance of shared decision-making in considering statin re-initiation. Most patients with statin-attributed muscle symptoms can be successfully treated with statins or a combination of statins and non-statins to achieve successful ASCVD risk reduction.
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15
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Teo CB, Tan PY, Tay RYK, Khoo J, Watts GF, Loh WJ. Association Between Vitamin D Supplementation and Statin-Associated Muscle Symptoms: A Systematic Review. High Blood Press Cardiovasc Prev 2022; 29:337-351. [PMID: 35768686 DOI: 10.1007/s40292-022-00526-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Although low vitamin D levels are associated with statin-associated muscle symptoms (SAMS), it remains unclear if vitamin D supplementation leads to symptom improvement. AIM We performed a systematic review to evaluate the association of vitamin D supplementation with resolution of SAMS. METHODS We searched Medline (PubMed), Embase and Cochrane Library till 12 December 2021. Full length articles that reported on the association between vitamin D supplementation in adult patients with SAMS were included. RESULTS We identified 8 interventional studies comprising 669 participants. Majority of the participants were of Caucasian ethnicity and the mean age of participants ranged from 59.5 to 64.8 years old. The studies recruited patients with initial mean pre-treatment vitamin D levels ranging from 17.8 to 22.0ng/mL. Follow up duration ranged from 2 to 24 months and mean post-treatment vitamin D levels ranged from 34.3 to 56.0ng/mL. We found that vitamin D supplementation was associated with improved statin tolerance in 509 out of 606 (83.9%) patients across the 7 studies which reported patient numbers after supplementation (95% CI = 0.81-0.87, I2 = 72% n = 7). None of the studies were randomized controlled trials (RCTs) and hence placebo effect of vitamin D could not be ruled out. Nocebo effect of statin was also not assessed by any of the studies. CONCLUSION Vitamin D supplementation in patients with mild-moderate vitamin D insufficiency was associated with improvement of SAMS. However, quantitative efficacy analysis was not possible and this observed association is likely confounded by nocebo and placebo effects. RCTs are required to conclusively assess the utility of vitamin D supplementation in improving SAMS.
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Affiliation(s)
- Chong Boon Teo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Pek Yan Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ryan Yong Kiat Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Gerald F Watts
- School of Medicine, University of Western Australia, Perth, Australia.,Department of Cardiology, Royal Perth Hospital, Perth, Australia
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore.
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16
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Abstract
PURPOSE OF REVIEW Statins are essential medications in the treatment of atherosclerotic cardiovascular disease; however, remain widely underutilized in large part due to concerns regarding adverse side effects. We describe the role of the nocebo effect in the perception of statin intolerance and provide management recommendations utilizing both statin and non-statin lipid-lowering therapies. RECENT FINDINGS The recent Self-Assessment Method for Statin side-effects Or Nocebo (SAMSON) trial demonstrated that 90% of adverse symptoms related to statins were also elicited by placebo, a powerful demonstration of the nocebo effect. Importantly, 50% of the study patients were able to successfully reinitiate statin therapy. Statin intolerance is common and can often be managed with expectation setting and adjustment of doses and/or dosing regimens. In those who remain unable to tolerate statins, numerous alternative lipid-lowering therapies exist with strong safety and efficacy profiles.
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Affiliation(s)
- Amrita Krishnamurthy
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Avenue, 8th Floor, New York, NY, 10021, USA
| | - Corey Bradley
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Rebecca Ascunce
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Avenue, 8th Floor, New York, NY, 10021, USA
| | - Samuel M Kim
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Avenue, 8th Floor, New York, NY, 10021, USA.
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17
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Cheeley MK, Saseen JJ, Agarwala A, Ravilla S, Ciffone N, Jacobson TA, Dixon DL, Maki KC. NLA scientific statement on statin intolerance: a new definition and key considerations for ASCVD risk reduction in the statin intolerant patient. J Clin Lipidol 2022; 16:361-375. [PMID: 35718660 DOI: 10.1016/j.jacl.2022.05.068] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 05/26/2022] [Indexed: 12/14/2022]
Abstract
Although statins are generally well tolerated, statin intolerance is reported in 5-30% of patients and contributes to reduced statin adherence and persistence, as well as higher risk for adverse cardiovascular outcomes. This Scientific Statement from the National Lipid Association was developed to provide an updated definition of statin intolerance and to inform clinicians and researchers about its identification and management. Statin intolerance is defined as one or more adverse effects associated with statin therapy which resolves or improves with dose reduction or discontinuation and can be classified as a complete inability to tolerate any dose of a statin or partial intolerance with inability to tolerate the dose necessary to achieve the patient-specific therapeutic objective. To classify a patient as having statin intolerance, a minimum of two statins should have been attempted, including at least one at the lowest approved daily dosage. This Statement acknowledges the importance of identifying modifiable risk factors for statin intolerance and recognizes the possibility of a "nocebo" effect (patient expectation of harm resulting in perceived side effects). To identify a tolerable statin regimen it is recommended that clinicians consider using several different strategies (e.g., different statin, dose, and/or dosing frequency). Non-statin therapy may be required for patients who cannot reach therapeutic objectives with lifestyle and maximal tolerated statin therapy. If so, therapies with outcomes data from randomized trials showing reduced cardiovascular events are favored. In high and very high risk patients who are statin intolerant, clinicians should consider initiating non-statin therapy while additional attempts are made to identify a tolerable statin in order to limit the time of exposure to elevated levels of atherogenic lipoproteins.
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Affiliation(s)
| | - Joseph J Saseen
- Departments of Clinical Pharmacy and Family Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States (Dr Saseen)
| | - Anandita Agarwala
- Center for Cardiovascular Disease Prevention, Cardiovascular Division, Baylor Scott and White Health Heart Hospital Baylor Plano, Plano, TX, United States (Dr Agarwala)
| | - Sudha Ravilla
- Tallahassee Memorial Healthcare Lipid Center, Tallahassee, FL, United States (Dr Ravilla)
| | - Nicole Ciffone
- Arizona Center for Advanced Lipidology, Tucson, AZ, United States (Dr Ciffone)
| | - Terry A Jacobson
- Department of Medicine, Lipid Clinic and CVD Risk Reduction Program, Emory University School of Medicine, Atlanta, GA, United States (Dr Jacobson)
| | - Dave L Dixon
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA, United States (Dr Dixon)
| | - Kevin C Maki
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, IN and Midwest Biomedical Research, 211 E. Lake St., Ste 3, Addison, IL 60101, United States (Dr Maki).
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18
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Parham JS, Goldberg AC. Major Concepts in Treatment with Bempedoic Acid and Inclisiran that Clinicians Need To Know. Curr Atheroscler Rep 2022. [PMID: 35666408 DOI: 10.1007/s11883-022-01036-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW There have been recent developments of novel therapeutic agents for lipid lowering. This article reviews treatment concepts for two of the newest lipid-lowering medications. RECENT FINDINGS Bempedoic acid inhibits adenosine citrate lyase, decreasing intracellular lipogenesis. This oral medication is a prodrug and requires activation by enzymes present in hepatocytes but absent in the skeletal muscle. Clinical trials demonstrated additive benefit with statin therapy, and it was well tolerated in statin-intolerant populations. Inclisiran uses RNA interference to prevent translation of PCSK9 mRNA. Due to its stability, it can be given as an injection every 6 months and produces consistent, durable, and potent cholesterol lowering. Bempedoic acid and inclisiran represent new avenues of treatment for the prevention and treatment of cardiovascular disease. This will allow for more comprehensive care by addressing challenges with medication adherence, such as adverse effects to prior medications as well as ease of dosing.
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19
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Penson PE, Bruckert E, Marais D, Reiner Ž, Pirro M, Sahebkar A, Bajraktari G, Mirrakhimov E, Rizzo M, Mikhailidis DP, Sachinidis A, Gaita D, Latkovskis G, Mazidi M, Toth PP, Pella D, Alnouri F, Postadzhiyan A, Yeh HI, Mancini GBJ, von Haehling S, Banach M, Al‐Khnifsawi M, Alnouri F, Amar F, Atanasov AG, Bajraktari G, Banach M, Bhaskar S, Bytyçi I, Bjelakovic B, Bruckert E, Cafferata A, Ceska R, Cicero AF, Collet X, Daccord M, Descamps O, Djuric D, Durst R, Ezhov MV, Fras Z, Gaita D, Hernandez AV, Jones SR, Jozwiak J, Kakauridze N, Kallel A, Katsiki N, Khera A, Kostner K, Kubilius R, Latkovskis G, Mancini GJ, Marais AD, Martin SS, Martinez JA, Mazidi M, Mikhailidis DP, Mirrakhimov E, Miserez AR, Mitchenko O, Mitkovskaya NP, Moriarty PM, Nabavi SM, Nair D, Panagiotakos DB, Paragh G, Pella D, Penson PE, Petrulioniene Z, Pirro M, Postadzhiyan A, Puri R, Reda A, Reiner Ž, Radenkovic D, Rakowski M, Riadh J, Richter D, Rizzo M, Ruscica M, Sahebkar A, Sattar N, Serban M, Shehab AM, Shek AB, Sirtori CR, Stefanutti C, Tomasik T, Toth PP, Viigimaa M, Valdivielso P, Vinereanu D, Vohnout B, von Haehling S, Vrablik M, Wong ND, Yeh H, Zhisheng J, Zirlik A. Step-by-step diagnosis and management of the nocebo/drucebo effect in statin-associated muscle symptoms patients: a position paper from the International Lipid Expert Panel (ILEP). J Cachexia Sarcopenia Muscle 2022; 13:1596-1622. [PMID: 35969116 PMCID: PMC9178378 DOI: 10.1002/jcsm.12960] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/17/2022] [Accepted: 02/01/2022] [Indexed: 12/11/2022] Open
Abstract
Statin intolerance is a clinical syndrome whereby adverse effects (AEs) associated with statin therapy [most commonly statin-associated muscle symptoms (SAMS)] result in the discontinuation of therapy and consequently increase the risk of adverse cardiovascular outcomes. However, complete statin intolerance occurs in only a small minority of treated patients (estimated prevalence of only 3-5%). Many perceived AEs are misattributed (e.g. physical musculoskeletal injury and inflammatory myopathies), and subjective symptoms occur as a result of the fact that patients expect them to do so when taking medicines (the nocebo/drucebo effect)-what might be truth even for over 50% of all patients with muscle weakness/pain. Clear guidance is necessary to enable the optimal management of plasma in real-world clinical practice in patients who experience subjective AEs. In this Position Paper of the International Lipid Expert Panel (ILEP), we present a step-by-step patient-centred approach to the identification and management of SAMS with a particular focus on strategies to prevent and manage the nocebo/drucebo effect and to improve long-term compliance with lipid-lowering therapy.
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Affiliation(s)
- Peter E Penson
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | - Eric Bruckert
- Pitié-Salpetrière Hospital and Sorbonne University, Cardio metabolic Institute, Paris, France
| | - David Marais
- Chemical Pathology Division of the Department of Pathology, University of Cape Town Health Science Faculty, Cape Town, South Africa
| | - Željko Reiner
- Department of Internal Medicine, University Hospital Centre Zagreb, School of Medicine University of Zagreb, Zagreb, Croatia
| | - Matteo Pirro
- Department of Medicine, University of Perugia, Perugia, Italy
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.,Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Clinic of Cardiology, University Clinical Centre of Kosova, Medical Faculty, University of Prishtina, Prishtina, Kosovo
| | - Gani Bajraktari
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.,Department of Internal Disease, Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan
| | - Erkin Mirrakhimov
- Department of Atherosclerosis and Coronary Heart Disease, National Center of Cardiology and Internal Diseases, Bishkek, Kyrgyzstan
| | - Manfredi Rizzo
- Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy.,Division of Endocrinology, Diabetes and Metabolism, School of Medicine, University of South Carolina, Columbia, SC, USA
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, University College London Medical School, University College London (UCL), London, UK
| | - Alexandros Sachinidis
- Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy.,2nd Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dan Gaita
- Universitatea de Medicina si Farmacie Victor Babes, Timisoara, Romania.,Clinica de Cardiologie, Institutul de Boli Cardiovasculare Timisoara, Timisoara, Romania
| | - Gustavs Latkovskis
- Pauls Stradins Clinical University Hospital, Riga, Latvia.,University of Latvia, Riga, Latvia
| | - Mohsen Mazidi
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK.,Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Peter P Toth
- CGH Medical Center, Sterling, IL, USA.,Cicarrone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel Pella
- 2nd Department of Cardiology of the East Slovak Institute of Cardiovascular Disease and Faculty of Medicine, PJ Safarik University, Kosice, Slovak Republic
| | - Fahad Alnouri
- Cardiovascular Prevention Unit, Adult Cardiology Department, Prince Sultan Cardiac Centre Riyadh, Riyadh, Saudi Arabia
| | - Arman Postadzhiyan
- Department of General Medicine, Emergency University Hospital 'St. Anna', Medical University of Sofia, Sofia, Bulgaria
| | - Hung-I Yeh
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - G B John Mancini
- Department of General Medicine, Emergency University Hospital 'St. Anna', Medical University of Sofia, Sofia, Bulgaria
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, Heart Center, University of Göttingen Medical Center, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Maciej Banach
- Polish Moother's Memorial Hospital Research Institute (PMMHRI), Lodz, Poland.,Department of Preventive Cardiology and Lipidology, Medical University of Lodz (MUL), Lodz, Poland.,Cardiovascular Research Centre, University of Zielona Gora, Zielona Gora, Poland
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Baessler A, Fischer M. [Novel options to maximize oral lipid lowering treatment : Role of bempedoic acid in combination treatment]. Herz 2022; 47:212-219. [PMID: 35486131 DOI: 10.1007/s00059-022-05111-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 11/26/2022]
Abstract
Epidemiological, randomized, controlled, clinical and genetic studies confirm that low-density lipoprotein cholesterol (LDL-C) is a causative factor for atherosclerotic diseases. The current European Society of Cardiology and European Atherosclerosis Society (ESC/EAS) guidelines on the management of dyslipidemia recommend a target LDL-C < 55 mg/dl and at least a 50% reduction in baseline LDL‑C for high-risk patients; however, these target values are often not achieved in routine clinical practice, as shown by recent cross-sectional data from EUROASPIRE or DaVinci. Therefore, combination treatment is recommended, which, as with treatment of blood pressure, can improve the success of treatment. Bempedoic acid is a new substance, which is suitable for combination treatment and represents an alternative particularly for patients with statin-associated muscular symptoms. Bempedoic acid reduces LDL‑C by approximately 25% in statin-naïve patients and by some 18% in addition to statins. In a fixed doses combination with ezetimibe, bempedoic acid can lower LDL‑C by up to 45% in statin-naïve patients and by 38% (placebo-corrected) in addition to statins. Bempedoic acid is generally very well tolerated: however, it can lead to a reversible increase in uric acid. Occasionally, a slight decrease in hemoglobin has been documented. Therefore, it is recommended that not only changes in lipid levels but also uric acid and hematological parameters should be monitored in the first 3 months.
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Affiliation(s)
- Andrea Baessler
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
| | - Marcus Fischer
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
- Klinik für Kardiologie, Angiologie, Pneumologie und Intensivmedizin, Goldberg-Klinik Kelheim, Kelheim, Deutschland
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21
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Affiliation(s)
- Scott M Grundy
- Center for Human Nutrition; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas; The Veterans Administration North Texas Health Care System at Dallas.
| | - Gloria L Vega
- Center for Human Nutrition; The Veterans Administration North Texas Health Care System at Dallas; Department of Clinical Nutrition, University of Texas Southwestern Medical Center, Dallas
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Mostaza JM, Lahoz C. Main barriers in the management of dyslipidaemias: Intolerants. Clin Investig Arterioscler 2021; 33 Suppl 1:40-5. [PMID: 33966812 DOI: 10.1016/j.arteri.2020.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 12/22/2020] [Indexed: 11/20/2022]
Abstract
The lack of achieving the LDL-cholesterol goal observed in epidemiological studies, highlights the difficulty of transferring the benefit of the hypolipidaemic treatment noted in clinical trials, to current clinical practice. Although the reasons for not reaching LDL targets are probably multiple, i.e. treatment non-adherence, or therapeutic inertia, or treatment discontinuation as a consequence of statin intolerance, is frequently described. Statins are safe medications. However, 10 to 20% of the population refer to myalgias associated with their use, and 1 to 3% abandon treatment for this cause. In these subjects, it is necessary to change to a different statin, to use lower doses of statins, or to use irregular prescription regimes. If these actions are not useful, emphasis should be placed on the importance of hygienic and dietary recommendations and, when needed and depending on the cholesterol goal to achieve, the need of other lipid lowering treatments, like ezetimibe, bile acid sequestrants, bempedoic acid, or PCSK9i, often in combination.
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Susekov AV, Korol LA, Watts GF. Bempedoic Acid in the Treatment of Patients with Dyslipidemias and Statin Intolerance. Cardiovasc Drugs Ther 2021; 35:841-52. [PMID: 33502687 DOI: 10.1007/s10557-020-07139-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 12/21/2022]
Abstract
An elevated plasma low-density lipoprotein cholesterol (LDL-C) level is a well-established atherosclerotic cardiovascular disease (ACSVD) risk factor. Randomized studies with statins (alone or in combination with other lipid-lowering drugs) have demonstrated their clinical efficacy in lowering LDL-C. Several classes of new, non-statin agents have been successfully studied and used (e.g., ezetimibe and inhibitors of proprotein convertase subtilisin/kexin type 9 [i-PSCK9]). However, many high ACSVD risk patients remain at a high residual cardiovascular risk, with at least 10% being statin intolerant. Bempedoic acid (ETC-1002) is a new inhibitor of cholesterol synthesis that targets ATP citrate lyase (ACL). Importantly, ETC-1002 is only converted into an active form in the liver and is free of muscle side effects.Area Covered: Mechanism of action of ETC-1002, clinical pharmacology, completed clinical studies with bempedoic acid, lipid-lowering efficacy/safety issues, and recent meta-analyses of trials with ETC-1002.Expert Opinion: ETC-1002 has been extensively studied in phase I-III clinical studies in over 4000 individuals from different patient populations (statin intolerance, familial hypercholesterolemia, and high ACSVD risk patients), ETC-1002 has been demonstrated to have moderate cholesterol-lowering efficacy and a good safety profile at a dose of 180 mg/day as a monotherapy and in combination with statins and ezetimibe. The ongoing study CLEAR Outcomes, with composite cardiovascular endpoints, will elucidate the role of bempedoic acid in the management of high ACSVD risk and statin-intolerant patients with hypercholesterolemia. Long-term safety data on bempedoic acid are needed to fully establish this agent in evidence-informed guidelines for managing of patients with dyslipidemias.
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Dong I, Klodas E. Healthcare Cost Implications of Utilizing a Dietary Intervention to Lower LDL Cholesterol: Proof of Concept Actuarial Analysis and Recommendations. Curr Cardiol Rep 2020; 22:138. [PMID: 32910320 DOI: 10.1007/s11886-020-01397-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW To determine if subsidizing the cost of a food-based intervention for managing hyperlipidemia could be cost-effective under commercial insurance and/or Medicare coverage scenarios. RECENT FINDINGS A large number of patients eligible for pharmaceutical treatment of hyperlipidemia either cannot or will not use lipid lowering drugs, leaving them at increased cardiovascular risk. Lipid levels can be modified by diet, but food has never enjoyed covered benefit status. We evaluated the financial implications of providing insurance coverage for a specifically formulated suite of food products previously documented to yield statistically significant lipid reductions, using multiple product uptake and lipid impact scenarios in both commercially covered and Medicare-covered populations. Even after controlling for multiple confounders, we noted positive payback on subsidizing the cost of lipid-lowering foods under all scenarios. Addressing a root cause of hyperlipidemia by directly encouraging dietary modification provides a cost-effective alternative for cholesterol management, especially for statin intolerant or statin unwilling patients.
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Abstract
PURPOSE OF REVIEW Statins have proven efficacy with a favorable safety profile yet, despite being widely affordable, remain profoundly underutilized. Statins have acquired a bad reputation, which is likely contributing to high rates of nonadherence and discontinuation. The degree to which negative media perceptions contribute to underutilization is unclear. RECENT FINDINGS The media has a key role in informing discussion on the public agenda but also on how issues are framed. In this context, the majority of studies evaluating news coverage suggest that the content on statins is predominantly negative and focused on potential harm. Studies utilizing quasi-experimental and interrupted time series design have shown periods of negative news stories on statins in multiple countries are associated with (a) less statin commencement in eligible patients, (b) high rates of discontinuation, and (c) poor long-term adherence. This review highlights the deleterious impact of negative media coverage on statin utilization through misattribution of muscle complaints and the nocebo effect. Academia must work with the media to harmonize the public health messaging; however, individual physicians have a critical role in mitigating a harmful narrative of misinformation and actively discredit malinformation.
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Affiliation(s)
- Adam J Nelson
- Duke Clinical Research Institute, Duke University, Durham, NC, US.,South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Rishi Puri
- Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research (C5R), Cleveland Clinic, Cleveland Clinic JB-20, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Steven E Nissen
- Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research (C5R), Cleveland Clinic, Cleveland Clinic JB-20, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
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26
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Katsiki N, Mikhailidis DP, Bajraktari G, Miserez AR, Cicero AFG, Bruckert E, Serban MC, Mirrakhimov E, Alnouri F, Reiner Ž, Paragh G, Sahebkar A, Banach M. Statin therapy in athletes and patients performing regular intense exercise - Position paper from the International Lipid Expert Panel (ILEP). Pharmacol Res 2020; 155:104719. [PMID: 32087236 DOI: 10.1016/j.phrs.2020.104719] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 02/18/2020] [Indexed: 02/08/2023]
Abstract
Acute and chronic physical exercises may enhance the development of statin-related myopathy. In this context, the recent (2019) guidelines of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS) for the management of dyslipidemias recommend that, although individuals with dyslipidemia should be advised to engage in regular moderate physical exercise (for at least 30 min daily), physicians should be alerted with regard to myopathy and creatine kinase (CK) elevation in statin-treated sport athletes. However it is worth emphasizing that abovementioned guidelines, previous and recent ESC/EAS consensus papers on adverse effects of statin therapy as well as other previous attempts on this issue, including the ones from the International Lipid Expert Panel (ILEP), give only general recommendations on how to manage patients requiring statin therapy on regular exercises. Therefore, these guidelines in the form of the Position Paper are the first such an attempt to summary existing, often scarce knowledge, and to present this important issue in the form of step-by-step practical recommendations. It is critically important as we might observe more and more individuals on regular exercises/athletes requiring statin therapy due to their cardiovascular risk.
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Affiliation(s)
- Niki Katsiki
- First Department of Internal Medicine, Division of Endocrinology and Metabolism, Diabetes Center, Medical School, AHEPA University Hospital, Thessaloniki, Greece.
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Campus, University College London Medical School, University College London (UCL), London, UK
| | - Gani Bajraktari
- Clinic of Cardiology, University Clinical Centre of Kosovo, Prishtina, Kosovo, Serbia; Medical Faculty, University of Prishtina, Prishtina, Kosovo, Serbia; Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Andre R Miserez
- Diagene Research Institute, Reinach, Switzerland; University of Basel, Basel, Switzerland
| | - Arrigo F G Cicero
- Department of Medicine and Surgery Sciences, University of Bologna, Bologna, Italy
| | - Eric Bruckert
- Pitié-Salpêtrière Hospital and Sorbonne University, Cardio Metabolic Institute, Paris, France
| | - Maria-Corina Serban
- Department of Functional Sciences, Discipline of Pathophysiology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Erkin Mirrakhimov
- Kyrgyz State Medical Academy, Named after Akhunbaev I.K., Bishkek, Kyrgyzstan
| | - Fahad Alnouri
- Cardiovascular Prevention Unit, Adult Cardiology Department, Prince Sultan Cardiac Centre Riyadh, Saudi Arabia
| | - Željko Reiner
- Department of Internal Diseases University Hospital Center Zagreb School of Medicine, Zagreb University, Zagreb, Croatia
| | - György Paragh
- Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran; School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Lodz, Poland; Polish Mother's Memorial Hospital Research Institute (PMMHRI), Lodz, Poland; Cardiovascular Research Centre, University of Zielona Gora, Zielona Gora, Poland.
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27
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Giurgea GA, Karkutli E, Granegger S, Berent R, Derfler K, Sinzinger H. One year follow-up of patients with reduced left ventricular ejection fraction (LVEF) on lipoprotein apheresis. ATHEROSCLEROSIS SUPP 2019; 40:44-48. [PMID: 31818449 DOI: 10.1016/j.atherosclerosissup.2019.08.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Left ventricular ejection fraction (LVEF) is a valuable measure to assess left ventricular systolic function. Lipid lowering therapy by statins has been shown to have an impact on LVEF already after a 6 months treatment. Higher doses of statins have been claimed to be more effective as compared to a conventional one and even a difference between lipophilic and hydrophilic compounds has been reported. The effect of regular lipoprotein-apheresis (LP-apheresis) on LVEF was previously poorly examined. Patients involved in a regular LP-apheresis program are supposed to undergo a number of follow-up investigations among them myocardial scintigraphy and LVEF, measured by radionuclide ventriculography. METHODS We examined 18 patients before initiation and after one year of ongoing LP-apheresis. 13 patients (11 males, 2 females, mean age 58.3 ± 5.3 years, groups A) were since more than a year on stable, unchanged statin treatment (atorvastatin 40 mg, simvastatin 40 mg, rosuvastatin 20 mg±ezetimibe), the other 5 patients (3 males, 2 females, mean age 57.1 ± 4.6 years, group B) were intolerant to statins being on micronized fenofibrate±resorption inhibitors (cholestyramine). All patients had a Lp(a) < 30 mg/dl. As part of the usual follow-up monitoring, LVEF was determined by means of radionuclide ventriculography after application of 550 MBq 99m Tc-pertechnetate. RESULTS The follow-up LVEF was checked at a mean of 48.7 weeks in group A and 51.2 weeks in group B. Except in 1 patient (LVEF 46.8% before vs. 45.2% after LP-apheresis initiation) in group A we noted a significant increase in LVEF in 12 patients of group A (92%) and in all patients of group B. Mean LVEF increased significantly in both groups (A: 42.7±8.1 → 46.5±7.5% (p < 0.001) and B: 41.9±8.4 → 46.5±6.3 %; p < 0.001). The relative rise was nearly identical (group A 9.6%, in group B 9.7%). CONCLUSIONS Our findings indicate that regular long-term LP-apheresis treatment apparently increases LVEF, independently on current statin treatment. This implies a role of lowering of atherogenic lipoproteins as underlying mechanism. A prospective study should clarify the relative extent of LVEF improvement induced by LP-apheresis.
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Affiliation(s)
| | - Elodie Karkutli
- Institute for Diagnosis and Treatment of Lipid Disorders and Atherosclerosis (ATHOS), Austria
| | - Susanne Granegger
- Institute for Diagnosis and Treatment of Lipid Disorders and Atherosclerosis (ATHOS), Austria
| | - Robert Berent
- HerzReha Bad Ischl, Center for Cardiovascular Rehabilitation, Bad Ischl, Austria
| | - Kurt Derfler
- Institute for Diagnosis and Treatment of Lipid Disorders and Atherosclerosis (ATHOS), Austria
| | - Helmut Sinzinger
- Institute for Diagnosis and Treatment of Lipid Disorders and Atherosclerosis (ATHOS), Austria; Department of Lipid Metabolism, Faculty of Medicine, Sigmund Freud University, Vienna, Austria; Isotopix, Institute for Nuclear Medicine, Vienna, Austria.
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28
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Koba S, Inoue I, Cyrille M, Lu C, Inomata H, Shimauchi J, Kajinami K. Evolocumab vs. Ezetimibe in Statin-Intolerant Hyperlipidemic Japanese Patients: Phase 3 GAUSS-4 Trial. J Atheroscler Thromb 2019; 27:471-484. [PMID: 31748467 PMCID: PMC7242224 DOI: 10.5551/jat.50963] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Aim: In patients with hyperlipidemia, intolerance to statins presents a challenge in reducing the risk of events associated with cardiovascular disease. This phase 3, randomized, double-blind trial in Japanese patients with statin intolerance aimed to evaluate the efficacy and safety of evolocumab vs. ezetimibe in lowering low-density lipoprotein-cholesterol (LDL-C). Methods: This study was conducted in a 12-week, double-blind period followed by an open-label extension designed to characterize 1 year of evolocumab treatment. Statin intolerance was defined as failure of two or more statins due to myalgia, myositis, or rhabdomyolysis. Eligible patients were randomized at 2:2:1:1 into four groups: 420 mg evolocumab every 4 weeks (Q4W) + oral placebo daily, 140 mg evolocumab every 2 weeks (Q2W) + oral placebo daily, subcutaneous (SC) placebo Q4W + 10 mg ezetimibe daily, and SC placebo Q2W + 10 mg ezetimibe daily. Results: Sixty-one patients were randomized to evolocumab (n = 40) or ezetimibe (n = 21). For the co-primary endpoints of percent change from the baseline in mean LDL-C to the mean of weeks 10 and 12 and to week 12, the evolocumab-ezetimibe treatment differences were −39.4% (95% CI, −47.2% to −31.5%) and −40.1% (95% CI, −48.7% to −31.6%), respectively (adjusted p < 0.0001). The most common adverse events were diarrhea (9.5%) and nasopharyngitis (12.5%) in the ezetimibe and evolocumab groups, respectively, during the double-blind period and nasopharyngitis (29%) during the open-label extension. Conclusion: Evolocumab was superior to ezetimibe in reducing LDL-C during the 12-week double-blind period in this population of Japanese patients with statin intolerance, with efficacy and safety results maintained for 1 year. Trial registration: ClinicalTrials.gov, NCT02634580
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Affiliation(s)
- Shinji Koba
- Department of Medicine, Division of Cardiology, Showa University School of Medicine
| | - Ikuo Inoue
- Department of Endocrinology and Diabetes, Saitama Medical University
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29
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Kajinami K, Tsukamoto K, Koba S, Inoue I, Yamakawa M, Suzuki S, Hamano T, Saito H, Saito Y, Masuda S, Nakayama T, Okamura T, Yamashita S, Kagawa T, Kaneyama J, Kuriyama A, Tanaka R, Hirata A. Statin Intolerance Clinical Guide 2018. J Atheroscler Thromb 2019; 27:375-396. [PMID: 31588101 PMCID: PMC7192817 DOI: 10.5551/jat.50948] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
| | | | - Shinji Koba
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Ikuo Inoue
- Department of Endocrinology and Diabetes, Saitama Medical University
| | - Masashi Yamakawa
- Department of Endocrinology and Diabetes, Yokohama City University Medical Center
| | | | - Tadanori Hamano
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui
| | | | - Yoshiro Saito
- Division of Medicinal Safety Science, National Institute of Health Sciences
| | | | - Takeo Nakayama
- Graduate School of Medicine and Public Health, Kyoto University
| | - Tomonori Okamura
- Department of Preventive Medicine and Public Health, Keio University School of Medicine
| | - Shizuya Yamashita
- Department of Cardiovascular Medicine, Rinku General Medical Center.,The Institute of Scientific and Industrial Research, Osaka University
| | - Tatehiro Kagawa
- Division of Hepatology and Gastroenterology, Department of Internal Medicine, Tokai University School of Medicine
| | - Junji Kaneyama
- Department of Cardiovascular Medicine, Tokyo Medical University
| | - Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital
| | - Rumi Tanaka
- Department of Pharmacy, Kyushu University Hospital
| | - Aya Hirata
- Department of Preventive Medicine and Public Health, Keio University School of Medicine
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30
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Brandts J, Müller-Wieland D. PCSK9 Inhibition: New Treatment Options and Perspectives to Lower Atherogenic Lipoprotein Particles and Cardiovascular Risk. Curr Atheroscler Rep 2019; 21:40. [PMID: 31350672 DOI: 10.1007/s11883-019-0802-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW To summarize latest clinical studies and to put them into perspectives for clinical relevant subgroups and new therapeutic options. RECENT FINDINGS Have investigated PCSK9 inhibitors in patients with very high cardiovascular risk and insufficient LDL cholesterol lowering under current maximal tolerated lipid-lowering therapy, patients with statin intolerance, or genetic forms of familiar hypercholesterolemia, and patients on LDL apheresis. Purpose of recent cardiovascular endpoint trials has proven cardiovascular benefit of this new approach. PCSK9 inhibition with fully humanized antibodies has proven to be effective, safe, and well-tolerated in reducing cardiovascular risk by LDL cholesterol lowering. Therefore, research interests are to elucidate additional roles and effects of PCSK9 modulation on inflammation and cellular processes of the atherosclerotic plaque and to develop alternative therapeutic strategies addressing PCSK9 as a proven and therefore promising drug target.
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Affiliation(s)
- Julia Brandts
- Department of Medicine I, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Dirk Müller-Wieland
- Department of Medicine I, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany.
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31
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Hai JJ, Wong YK, Wong CK, Un KC, Chan PH, Siu CW, Yiu KH, Lau CP, Tse HF. Prognostic implications of statin intolerance in stable coronary artery disease patients with different levels of high-sensitive troponin. BMC Cardiovasc Disord 2019; 19:168. [PMID: 31307391 PMCID: PMC6633694 DOI: 10.1186/s12872-019-1152-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 07/08/2019] [Indexed: 12/27/2022] Open
Abstract
Background The prognostic implication of statin in tolerance (SI) in those with stable CAD remains unclear. We hypothesized that SI is of higher prognostic significance in stable CAD patients with elevated high-sensitive cardiac troponin I (hs-cTnI). Methods A total of 952 stable CAD patients from the prospective Hong Kong CAD study who had complete clinical data, biomarker measurements and who were prescribed statin therapy were studied. Results We identified 13 (1.4%) and 125 (13.1%) patients with complete and partial SI, respectively. At baseline, patients with SI were more likely to have diabetes mellitus and a higher hs-cTnI level, but no difference in LDL-C level compared with those without SI. After 51 months of follow-up, patients with SI had a higher mean LDL-C level than those without SI. A total of 148 (15.5%) patients developed major adverse cardiovascular events (MACEs). Both SI (HR 1.52, 95% CI 1.06–2.19, P = 0.02) and elevated hs-cTnI (HR 3.18, 95% CI 2.07–4.89, P < 0.01) were independent predictors of a MACE in patients with stable CAD. When stratified by hs-cTnI level, SI independently predicted MACE-free survival only in those with elevated hs-cTnI (HR 1.51, 95% CI 1.01–2.24, P = 0.04). Conclusions SI independently predicted MACE in patients with stable CAD and high hs-cTnI, but not in those with low hs-cTnI. Hs-cTnI may be used to stratify stable CAD patients who have SI for intensive lipid-lowering therapy using non-statin agents. Electronic supplementary material The online version of this article (10.1186/s12872-019-1152-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jo-Jo Hai
- Cardiology Division, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China.,Division of Cardiology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Yuen-Kwun Wong
- Cardiology Division, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Chun-Ka Wong
- Cardiology Division, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Ka-Chun Un
- Cardiology Division, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Pak-Hei Chan
- Cardiology Division, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Chung-Wah Siu
- Cardiology Division, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Kai-Hang Yiu
- Cardiology Division, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China.,Division of Cardiology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Chu-Pak Lau
- Cardiology Division, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Hung-Fat Tse
- Cardiology Division, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China. .,Division of Cardiology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China. .,The University of Hong Kong-Shenzhen Institute of Research and Innovation, Shenzhen, China. .,Hong Kong-Guangdong Joint Laboratory on Stem Cell and Regenerative Medicine, the University of Hong Kong, Hong Kong, China.
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32
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Affiliation(s)
- Hayato Tada
- Division of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Masa-Aki Kawashiri
- Division of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medical Sciences
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33
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Marco-Benedí V, Jarauta E, Pérez-Calahorra S, Bea AM, Civeira F. Treatment of a high cardiovascular risk patient with McArdle's disease with PCSK9 inhibitors. Clin Investig Arterioscler 2019; 31:89-92. [PMID: 30738610 DOI: 10.1016/j.arteri.2018.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/25/2018] [Accepted: 11/18/2018] [Indexed: 06/09/2023]
Abstract
A 60-year-old male with familial combined hyperlipidemia, ischemic heart disease and type 2 diabetes. Since childhood, intolerance to intense exercise. The patient was diagnosed of McArdle's disease after an episode of rhabdomyolysis associated with statins as treatment after a myocardial infarction. Since then, he had been treated with diet, fibrates and ezetimibe with good tolerance, despite this, LDL cholesterol (cLDL) remained >180mg/dl. He started to be treated with alirocumab 150mg/sc every 14 days, with excellent clinical response and a decrease in cLDL to 15mg/dl. Our case shows that PCSK9 inhibitors are effective and safe in patients with muscle diseases who have statin contraindication, and they are a good therapeutic tool for these patients.
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Affiliation(s)
- Victoria Marco-Benedí
- Unidad Clínica y de Investigación en Lípidos y Arteriosclerosis, Hospital Universitario Miguel Servet, IIS Aragón, CIBERCV, Zaragoza, España.
| | - Estíbaliz Jarauta
- Unidad Clínica y de Investigación en Lípidos y Arteriosclerosis, Hospital Universitario Miguel Servet, IIS Aragón, CIBERCV, Zaragoza, España; Universidad de Zaragoza, Zaragoza, España
| | - Sofía Pérez-Calahorra
- Unidad Clínica y de Investigación en Lípidos y Arteriosclerosis, Hospital Universitario Miguel Servet, IIS Aragón, CIBERCV, Zaragoza, España
| | - Ana M Bea
- Unidad Clínica y de Investigación en Lípidos y Arteriosclerosis, Hospital Universitario Miguel Servet, IIS Aragón, CIBERCV, Zaragoza, España
| | - Fernando Civeira
- Unidad Clínica y de Investigación en Lípidos y Arteriosclerosis, Hospital Universitario Miguel Servet, IIS Aragón, CIBERCV, Zaragoza, España; Universidad de Zaragoza, Zaragoza, España
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34
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Harrison TN, Hsu JWY, Rosenson RS, Levitan EB, Muntner P, Cheetham TC, Wei R, Scott RD, Reynolds K. Unmet Patient Need in Statin Intolerance: the Clinical Characteristics and Management. Cardiovasc Drugs Ther 2019; 32:29-36. [PMID: 29417422 DOI: 10.1007/s10557-018-6775-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE A substantial percentage of patients report intolerance or side effects of statin treatment leading to treatment changes or discontinuation. The purpose of this study was to examine statin therapy changes and subsequent effects on low-density lipoprotein cholesterol (LDL-C) among patients with statin intolerance (SI). METHODS We identified 45,037 adults from Kaiser Permanente Southern California with SI documented between 2006 and 2012. Changes in statin therapy in the year before and after the SI index date were examined. We categorized patients into those who initiated statin therapy, discontinued, up-titrated, down-titrated, or did not switch therapy. We calculated the percentage change in LDL-C from the year before to the year after SI, and the percentage of patients attaining LDL-C < 100 and < 70 mg/dL. RESULTS In the year prior to the SI date, 77.8% of patients filled a statin prescription. Following SI, 44.6% had no treatment change, 25.5% discontinued, and 30.0% altered their statin therapy. Of those who altered statin therapy, 52.6% down-titrated and 17.2% up-titrated their dose. Rhabdomyolysis was documented in < 1% of the cohort. The largest changes in LDL-C were experienced by patients who were on a high-intensity statin then discontinued treatment (35.6% increase) and those who initiated a high-intensity statin (25.5% decrease). The proportion of patients achieving LDL-C < 100 mg/dL and LDL-C < 70 mg/dL was the lowest among those who discontinued therapy. CONCLUSIONS Although adjustments to the statin dosage may be appropriate upon documentation of SI, many of these patients will have high LDL-C. Strategies for LDL-C reduction in patients with SI may be necessary.
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Affiliation(s)
- Teresa N Harrison
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles, 2nd Floor, Pasadena, CA, 91101, USA
| | - Jin-Wen Y Hsu
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles, 2nd Floor, Pasadena, CA, 91101, USA
| | - Robert S Rosenson
- Icahn School of Medicine at Mount Sinai, Mount Sinai Heart, New York, NY, USA
| | - Emily B Levitan
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Paul Muntner
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Rong Wei
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles, 2nd Floor, Pasadena, CA, 91101, USA
| | - Ronald D Scott
- West Los Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, CA, USA
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles, 2nd Floor, Pasadena, CA, 91101, USA.
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Cho L, Dent R, Stroes ESG, Stein EA, Sullivan D, Ruzza A, Flower A, Somaratne R, Rosenson RS. Persistent Safety and Efficacy of Evolocumab in Patients with Statin Intolerance: a Subset Analysis of the OSLER Open-Label Extension Studies. Cardiovasc Drugs Ther 2018; 32:365-72. [PMID: 30073585 DOI: 10.1007/s10557-018-6817-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE Evolocumab reduced low-density lipoprotein cholesterol (LDL-C) in 12-week trials in statin-intolerant patients (GAUSS-1 and GAUSS-2); however, the persistence of efficacy during longer-term treatment is unknown. This subset analysis of the open-label extension studies (OSLER-1 and OSLER-2) aimed to evaluate the safety and efficacy of evolocumab up to 2 years in statin-intolerant patients. METHODS Patients who completed GAUSS-1 and GAUSS-2 were enrolled in the OSLER studies and rerandomized 2:1 to evolocumab (140 mg biweekly or 420 mg monthly) plus standard of care (SOC) or SOC during year 1, and thereafter, evolocumab plus SOC. RESULTS A total of 382 statin-intolerant patients who completed the GAUSS-1 and GAUSS-2 parent studies were enrolled and rerandomized into the OSLER studies. After year 1, 246 (98%) patients randomized to evolocumab plus SOC and 124 (95%) on SOC during year 1 remained in the OSLER studies; after year 2, 364 (95%) remained on study. Mean parent study baseline LDL-C concentration was 4.97-5.02 mmol/L (192-194 mg/dL). The median percentage reduction from baseline in LDL-C was 13% for SOC and 57% for evolocumab plus SOC at year 1, and 59% for evolocumab plus SOC at year 2. The patient incidence of muscle-related adverse events during year 1 in the SOC and evolocumab plus SOC groups was 16% and 14%, respectively, and 11% for evolocumab plus SOC at year 2. No patient discontinued the study due to adverse events. CONCLUSION Evolocumab plus SOC was persistently safe, tolerable, and efficacious for up to 2 years in statin-intolerant patients.
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Abstract
Statins are the main treatment for hypercholesterolemia and the cornerstone of atherosclerotic cardiovascular disease prevention. Many patients taking statins report muscle-related symptoms, one of the most important causes of statin treatment discontinuation, which is associated with an increased risk of cardiovascular events. Therefore, it is important to identify patients who are truly statin intolerant to avoid unnecessary discontinuation of this beneficial treatment. Some studies indicate that not all muscle complaints are caused by statins, and most patients can tolerate a statin upon re-challenge, down-titration of dose, or switching to another statin. In this paper, we review the definitions of statin intolerance and approaches to reducing cardiovascular risk among individuals reporting statin-associated muscle symptoms.
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Affiliation(s)
| | - Ada Cuevas
- Department of Nutrition, Clinica Las Condes
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Abstract
The past decade has witnessed considerable progress in the field of lipids. New drugs have been "rapidly" developed and some of these drugs have already been evaluated in event-based large trials. This evidence has led to the guidelines recommending new, more aggressive treatment goals for low-density lipoprotein cholesterol (LDL-C) levels. Although LDL-C remains the principal goal for cardiovascular disease (CVD) risk reduction, there has also been considerable interest in other lipid variables, such as high-density lipoprotein cholesterol, triglycerides, and lipoprotein(a). Statin intolerance is now considered a very important topic in daily clinical practice. This has resulted in more attention focusing on non-statin drugs [e.g., ezetimibe and proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors] and statin-related side effects. The latter mainly involve muscles, but there is also a need to consider other adverse effects associated with statin use (e.g., new onset diabetes). New specific areas of statin use have attracted interest. For example, statin-loading before procedures (e.g., coronary stenting), the prevention of stroke, and the treatment of non-alcoholic fatty liver disease (NAFLD). Statins will remain the most widely used drugs to treat dyslipidaemia and decrease CVD risk. However, we also need to briefly consider some other lipid-lowering drugs, including those that may become available in the future.
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Affiliation(s)
- Niki Katsiki
- Second Department of Propaedeutic Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Thessaloniki, Greece
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), Pond Street, London, NW3 2QG, UK.
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Abstract
Since the first approval of lovastatin in 1987, hydroxy-methyl-glutaryl CoA (HMG CoA) reductase inhibitors, or statins, have been effective and widely popular cholesterol-lowering agents with substantial benefits for the prevention and treatment of cardiovascular disease. Not all patients can tolerate these drugs, however, and statin intolerance is most frequently associated with a range of side effects directed toward skeletal muscle, termed statin-associated muscle symptoms or SAMS. SAMS are particularly difficult to treat because there are no validated biomarkers or tests that can be used to confirm patient self-reports of SAMS, and a number of patients who report SAMS have non-specific muscle pain not attributable to statin therapy. This review summarizes the most recent evidence related to diagnosis and management of SAMS. First, the range of skeletal muscle side effects associated with statin therapy is described. Second, data regarding the incidence and prevalence of SAMS, the most frequently experienced muscle side effect, are presented. Third, the most promising new techniques to confirm diagnosis of SAMS are explored. Finally, the most effective strategies for the clinical management of SAMS are summarized. Better diagnostic and treatment strategies for SAMS will increase the number of patients using these life-saving statins, thereby increasing statin adherence and reducing the costs of avoidable cardiovascular events.
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Affiliation(s)
- Beth A Taylor
- Division of Cardiology, Hartford Healthcare, Hartford, CT, USA.
- Department of Kinesiology, University of Connecticut, Storrs, CT, USA.
- University of Connecticut School of Medicine, Farmington, CT, USA.
| | - Paul D Thompson
- Division of Cardiology, Hartford Healthcare, Hartford, CT, USA
- University of Connecticut School of Medicine, Farmington, CT, USA
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Abstract
BACKGROUND AND AIMS Statin-associated muscle symptoms (SAMS) frequently cause statin non-adherence, switching and discontinuation, contributing to adverse cardiovascular (CV) outcomes. Therefore, the management of SAMS is key in the effective treatment of patients with cardiovascular disease (CVD), through achievement of maximum-tolerated statin dosing and other practical aspects. The aim of this article is to provide practical, focused advice for healthcare professionals on the management of patients with SAMS. METHODS An expert working group combined current evidence, published guidelines and experiences surrounding a number of topics concerning SAMS to provide recommendations on how to best assess and manage this condition and reach the highest tolerated dose of statin for each individual patient. RESULTS The group collaborated to provide guidance on definitions in the SAMS field, psychological issues, re-challenging and switching treatments, as well as interpretation of current guidelines and optimal treatment of SAMS in different patient populations. An algorithm was developed to guide the management of patients with SAMS. In addition, the expert working group considered some of the more complex scenarios in a series of frequently asked questions and suggested answers. CONCLUSIONS The expert working group gave recommendations for healthcare professionals on the management of SAMS but highlighted the importance of tailoring the treatment approach to each individual patient. Evidence supporting the role of nutraceuticals and complementary therapies, such as vitamin D, was lacking, however the majority of the group favoured combination therapy with ezetimibe and the addition of PCSK9 inhibitors in high-risk patients.
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Affiliation(s)
- Ulrich Laufs
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, Saarland University Medical Center, Homburg, Germany.
| | - Krysztof J Filipiak
- First Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Ioanna Gouni-Berthold
- Polyclinic for Endocrinology, Diabetes and Preventive Medicine, University of Cologne, Cologne, Germany
| | - Alberico L Catapano
- Department of Pharmacological and Biomolecular Sciences, University of Milan, and IRCCS Multimedica, Milan, Italy
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Affiliation(s)
- Željko Reiner
- Department of Internal Medicine, University Hospital Centre Zagreb, School of Medicine University of Zagreb, Croatia.
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Rosenson RS, Miller K, Bayliss M, Sanchez RJ, Baccara-Dinet MT, Chibedi-De-Roche D, Taylor B, Khan I, Manvelian G, White M, Jacobson TA. The Statin-Associated Muscle Symptom Clinical Index (SAMS-CI): Revision for Clinical Use, Content Validation, and Inter-rater Reliability. Cardiovasc Drugs Ther 2017; 31:179-86. [PMID: 28421332 DOI: 10.1007/s10557-017-6723-4] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Purpose The Statin-Associated Muscle Symptom Clinical Index (SAMS-CI) is a method for assessing the likelihood that a patient’s muscle symptoms (e.g., myalgia or myopathy) were caused or worsened by statin use. The objectives of this study were to prepare the SAMS-CI for clinical use, estimate its inter-rater reliability, and collect feedback from physicians on its practical application. Methods For content validity, we conducted structured in-depth interviews with its original authors as well as with a panel of independent physicians. Estimation of inter-rater reliability involved an analysis of 30 written clinical cases which were scored by a sample of physicians. A separate group of physicians provided feedback on the clinical use of the SAMS-CI and its potential utility in practice. Results Qualitative interviews with providers supported the content validity of the SAMS-CI. Feedback on the clinical use of the SAMS-CI included several perceived benefits (such as brevity, clear wording, and simple scoring process) and some possible concerns (workflow issues and applicability in primary care). The inter-rater reliability of the SAMS-CI was estimated to be 0.77 (confidence interval 0.66–0.85), indicating high concordance between raters. With additional provider feedback, a revised SAMS-CI instrument was created suitable for further testing, both in the clinical setting and in prospective validation studies. Conclusions With standardized questions, vetted language, easily interpreted scores, and demonstrated reliability, the SAMS aims to estimate the likelihood that a patient’s muscle symptoms were attributable to statins. The SAMS-CI may support better detection of statin-associated muscle symptoms in clinical practice, optimize treatment for patients experiencing muscle symptoms, and provide a useful tool for further clinical research. Electronic supplementary material The online version of this article (doi:10.1007/s10557-017-6723-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gerald Klose
- Praxen Dres. T. Beckenbauer & S. Maierhof, Am Markt 11, D-28195, Bremen, Deutschland.
- Dres. I. van de Loo & K. Spieker, Gerold Janssen Straße 2 A, D-28359, Bremen, Deutschland.
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Cho L, Rocco M, Colquhoun D, Sullivan D, Rosenson RS, Dent R, Xue A, Scott R, Wasserman SM, Stroes E. Clinical Profile of Statin Intolerance in the Phase 3 GAUSS-2 Study. Cardiovasc Drugs Ther 2016; 30:297-304. [PMID: 26936841 DOI: 10.1007/s10557-016-6655-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE Recent evidence suggests that statin intolerance may be more common than reported in randomized trials. However, the statin-intolerant population is not well characterized. The goal of this report is to characterize the population enrolled in the phase 3 Goal Achievement after Utilizing an anti-PCSK9 antibody in Statin Intolerant Subjects Study (GAUSS-2; NCT 01763905). METHODS GAUSS-2 compared evolocumab, a fully human monoclonal antibody to proprotein convertase subtilisin/kexin type 9 (PCSK9) to ezetimibe in hypercholesterolemic patients who discontinued statin therapy due to statin-associated muscle symptoms (SAMS). GAUSS-2 was a 12-week, double-blind, placebo-controlled, randomized study that enrolled patients with elevated LDL-C who were either not on a statin or able to tolerate only a low-dose due to SAMS. Patients had received ≥2 statins and were unable to tolerate any statin dose or increase in dose above a specified weekly dose due to SAMS. RESULTS Three hundred seven patients (mean [SD] age, 62 [10] years; 54 % males) were randomized 2:1 (evolocumab:ezetimibe). Mean (SD) LDL-C was 4.99 (1.51) mmol/L. Patients had used ≥2 (100 %), ≥3 (55 %), or ≥4 (21 %) statins. Coronary artery disease was present in 29 % of patients. Statin-intolerant symptoms were myalgia in 80 % of patients, weakness in 39 %, and more serious complications in 20 %. In 98 % of patients, SAMS interfered with normal daily activity; in 52 %, symptoms precluded moderate exertion. CONCLUSION Evaluation of the GAUSS-2 trial population of statin-intolerant patients demonstrates that most patients were high risk with severely elevated LDL-C and many had statin-associated muscle symptoms that interfered with their quality of life.
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Kazi DS, Penko JM, Bibbins-Domingo K. Statins for Primary Prevention of Cardiovascular Disease: Review of Evidence and Recommendations for Clinical Practice. Med Clin North Am 2017; 101:689-699. [PMID: 28577620 DOI: 10.1016/j.mcna.2017.03.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Numerous large randomized clinical trials have shown that statin therapy is effective and safe for primary prevention of atherosclerotic cardiovascular disease (CVD) for adults aged 40 to 75 years and support the use of 10-year CVD risk as a means to identify individuals for treatment. Uncertainty exists in those older than 75 years who may be more likely to benefit because of their underlying CVD risk, but also face uncertain harms. Several high-quality mathematical simulation models have shown that statin therapy is cost-effective for primary prevention of atherosclerotic CVD. Despite effectiveness and safety, statins are underutilized for primary prevention.
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Affiliation(s)
- Dhruv S Kazi
- Department of Medicine, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA 94122, USA; Department of Epidemiology, University of California San Francisco, 550 16th Street, San Francisco, CA 94158, USA; UCSF Center for Vulnerable Populations, 2789 25th Street, Suite 350, San Francisco, CA 94110, USA; UCSF Center for Healthcare Value, 3333 California Street, Suite 265, San Francisco, CA 94118, USA; Division of Cardiology, Zuckerberg San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110, USA
| | - Joanne M Penko
- UCSF Center for Vulnerable Populations, 2789 25th Street, Suite 350, San Francisco, CA 94110, USA; Division of General Internal Medicine, Zuckerberg San Francisco General Hospital, UCSF Box 1364, San Francisco, CA 94143-1364, USA
| | - Kirsten Bibbins-Domingo
- Department of Medicine, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA 94122, USA; Department of Epidemiology, University of California San Francisco, 550 16th Street, San Francisco, CA 94158, USA; UCSF Center for Vulnerable Populations, 2789 25th Street, Suite 350, San Francisco, CA 94110, USA; Division of General Internal Medicine, Zuckerberg San Francisco General Hospital, UCSF Box 1364, San Francisco, CA 94143-1364, USA.
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Teramoto T, Kondo A, Kiyosue A, Harada-Shiba M, Ishigaki Y, Tobita K, Kawabata Y, Ozaki A, Baccara-Dinet MT, Sata M. Efficacy and safety of alirocumab in patients with hypercholesterolemia not adequately controlled with non-statin lipid-lowering therapy or the lowest strength of statin: ODYSSEY NIPPON study design and rationale. Lipids Health Dis 2017. [PMID: 28623954 PMCID: PMC5474052 DOI: 10.1186/s12944-017-0513-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background Statins are generally well-tolerated and serious side effects are infrequent, but some patients experience adverse events and reduce their statin dose or discontinue treatment altogether. Alirocumab is a highly specific, fully human monoclonal antibody to proprotein convertase subtilisin/kexin type 9 (PCSK9), which can produce substantial and sustained reductions of low-density lipoprotein cholesterol (LDL-C). Methods The randomized, double-blind, placebo-controlled, parallel-group, phase 3 ODYSSEY NIPPON study will explore alirocumab 150 mg every 4 weeks (Q4W) in 163 Japanese patients with hypercholesterolemia who are on the lowest-strength dose of atorvastatin (5 mg/day) or are receiving a non-statin lipid-lowering therapy (LLT) (fenofibrate, bezafibrate, ezetimibe, or diet therapy alone). Hypercholesterolemia is defined as LDL-C ≥ 100 mg/dL (2.6 mmol/L) in patients with heterozygous familial hypercholesterolemia or non-familial hypercholesterolemia with a history of documented coronary heart disease, or ≥120 mg/dL (3.1 mmol/L) in patients with non-familial hypercholesterolemia classified as primary prevention category III (i.e. high-risk patients). During the 12-week double-blind treatment period, patients will be randomized (1:1:1) to receive alirocumab subcutaneously (SC) 150 mg Q4W alternating with placebo for alirocumab Q4W, or alirocumab 150 mg SC every 2 weeks (Q2W), or SC placebo Q2W. The primary efficacy endpoint is the percentage change in calculated LDL-C from baseline to week 12. The long-term safety and tolerability of alirocumab will also be investigated. Discussion The ODYSSEY NIPPON study will provide insights into the efficacy and safety of alirocumab 150 mg Q4W or 150 mg Q2W among Japanese patients with hypercholesterolemia who are on the lowest-strength dose of atorvastatin, or are receiving a non-statin LLT (including diet therapy alone). Trial registration ClinicalTrials.gov number: NCT02584504
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Affiliation(s)
- Tamio Teramoto
- Teikyo Academic Research Center, Teikyo University, 2-11-1, Kaga, Itabashi-ku, Tokyo, 173-8605, Japan.
| | - Akira Kondo
- Asia Pacific Development, R&D, Sanofi, Tokyo, Japan
| | - Arihiro Kiyosue
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Mariko Harada-Shiba
- Department of Molecular Innovation in Lipidology, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Yasushi Ishigaki
- Division of Diabetes and Metabolism, Department of Internal Medicine, Iwate Medical University, Iwate, Japan
| | | | | | | | | | - Masataka Sata
- Department of Cardiovascular Medicine, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
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Abstract
The achievement of low-density lipoprotein (LDL) therapeutic targets is especially difficult in some patients at high cardiovascular risk. These patients include persons with statin intolerance and those with very high LDL cholesterol (LDLc) levels such as persons with familial hypercholesterolemia. The proportion of statin-intolerant patients is between 7% and 29%. Alternative lipid-lowering drugs (including ezetimibe) are less effective and are not free from adverse effects. Both alirocumab, with the ODYSSEY ALTERNATIVE study, and evolocumab, with the GAUSS study, have shown strong lipid-lowering efficacy, with much greater tolerability than currently available alternatives, with the result that a larger number of patients achieve therapeutic targets. In familial hypercholesterolemia, the monogenic metabolic disease most frequently associated with high cardiovascular risk, early intervention is cost-effective. Although statins have substantially improved the prognosis of familial hypercholesterolemia, many affected individuals are far from achieving the recommended therapeutic targets. In this patient group, PCSK9 inhibition with monoclonal antibodies has also been shown to be highly effective in reducing LDLc, especially in heterozygous individuals. The studies performed to date have shown that these drugs are safe and effective and can help many patients with familial hypercholesterolemia to drastically reduce their cardiovascular risk.
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Affiliation(s)
- Luis Masana
- Unitat de Medicina Vascular i Metabolisme, Hospital Universitari Sant Joan, Universitat Rovira i Virgili, IISPV, CIBERDEM, Reus, Tarragona, España.
| | - Fernando Civeira
- Unidad Clínica y de Investigación en Lípidos y Arteriosclerosis, Servicio de Medicina Interna, Hospital Universitario Miguel Servet, IIS Aragón, Red de Investigación Cardiovascular (RIC), Zaragoza, España
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Orringer CE, Jacobson TA, Saseen JJ, Brown AS, Gotto AM, Ross JL, Underberg JA. Update on the use of PCSK9 inhibitors in adults: Recommendations from an Expert Panel of the National Lipid Association. J Clin Lipidol 2017; 11:880-890. [PMID: 28532784 DOI: 10.1016/j.jacl.2017.05.001] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 05/02/2017] [Indexed: 12/25/2022]
Abstract
An Expert Panel convened by the National Lipid Association was charged with updating the recommendations on the use of proprotein convertase subtilisin/kexin type 9 (PCSK9) antibody therapy that were provided by the 2015 National Lipid Association Recommendations for the Patient-Centered Management of Dyslipidemia: Part 2. Recent studies have demonstrated the efficacy of these agents in reducing low-density lipoprotein cholesterol and non-high-density lipoprotein cholesterol and have confirmed their excellent safety profile. A cardiovascular outcomes study has shown that these agents reduce incident atherosclerotic cardiovascular disease (ASCVD) events in patents with stable ASCVD and concomitant risk factors. The current update provides the Expert Panel's evidence-based recommendations on the clinical utility of PCSK9 inhibitors in patients with stable ASCVD, progressive ASCVD, LDL-C ≥ 190 mg/dL (including polygenic hypercholesterolemia, heterozygous familial hypercholesterolemia and the homozygous familial hypercholesterolemia phenotype) and very-high-risk patients with statin intolerance.
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Affiliation(s)
- Carl E Orringer
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Terry A Jacobson
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Joseph J Saseen
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Alan S Brown
- Division of Cardiology, Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Antonio M Gotto
- Cardiac Disease Prevention, Weill Cornell Medical College, New York, NY, USA
| | - Joyce L Ross
- University of Pennsylvania Health System, Philadelphia, PA, USA
| | - James A Underberg
- NYU School of Medicine & NYU Center for Prevention of Cardiovascular Disease, New York, NY, USA
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Sahebkar A, Saboni N, Pirro M, Banach M. Curcumin: An effective adjunct in patients with statin-associated muscle symptoms? J Cachexia Sarcopenia Muscle 2017; 8:19-24. [PMID: 27897416 PMCID: PMC5326825 DOI: 10.1002/jcsm.12140] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 07/12/2016] [Indexed: 12/14/2022] Open
Abstract
In spite of the unequivocal efficacy of statins in reducing primary and secondary cardiovascular events, the use of these drugs in a considerable number of patients is limited because of statin intolerance, mainly statin-associated muscle symptoms (SAMS). SAMS encompass a broad spectrum of clinical presentations, including mild muscular aching and other types of myalgias, myopathy with the significant elevation of creatine kinase, and the rare but life-threatening rhabdomyolysis. Among several pathophysiologic mechanisms of SAMS, mitochondrial dysfunction is thought to be one of the main one. Curcumin is the polyphenolic ingredient of Curcuma longa L., which has various pharmacological properties against a vast range of diseases. Curcumin has several mechanisms of actions relevant to the treatment of SAMS. These effects include the capacity to prevent and reduce delayed onset muscle soreness by blocking the nuclear factor inflammatory pathway, attenuation of muscular atrophy, enhancement of muscle fibre regeneration following injury, and analgesic and antioxidant effects. Curcumin can also increase the levels of cyclic adenosine monophosphate, which leads to an increase in the number of mitochondrial DNA duplicates in skeletal muscle cells. Finally, owing to its essential lipid-modifying properties, curcumin might serve as an adjunct to statin therapy in patients with SAMS, allowing for effective lowering of low-density lipoprotein cholesterol and possibly for statin dose reduction. Owing to the paucity of effective treatments, and the safety of curcumin in clinical practice, proof-of-concept trials are recommended to assess the potential benefit of this phytochemical in the treatment of SAMS.
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Affiliation(s)
- Amirhossein Sahebkar
- Biotechnology Research CenterMashhad University of Medical SciencesMashhad9177948564Iran
- Metabolic Research Centre, Royal Perth Hospital, School of Medicine and PharmacologyUniversity of Western AustraliaPerthAustralia
| | - Nikou Saboni
- Neurogenic Inflammation Research CenterMashhad University of Medical SciencesMashhad9177948564Iran
| | - Matteo Pirro
- Unit of Internal Medicine, Angiology and Arteriosclerosis Diseases, Department of MedicineUniversity of PerugiaPerugiaItaly
| | - Maciej Banach
- Department of Hypertension, Chair of Nephrology and HypertensionMedical University of LodzŁódźPoland
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Graham JH, Sanchez RJ, Saseen JJ, Mallya UG, Panaccio MP, Evans MA. Clinical and economic consequences of statin intolerance in the United States: Results from an integrated health system. J Clin Lipidol 2016; 11:70-79.e1. [PMID: 28391913 DOI: 10.1016/j.jacl.2016.10.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 09/26/2016] [Accepted: 10/03/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although statins are considered safe and effective, they have been associated with statin intolerance (SI) in clinical and observational studies. OBJECTIVE The objective of this study was to describe the clinical and economic consequences of SI through comparison of an SI cohort of patients with matched controls. METHODS This study used data extracted from an integrated health system's electronic health records from 2008 to 2014. Adults with SI were matched to controls using a propensity score. Patients were hierarchically classified into 6 mutually exclusive cardiovascular (CV)-risk categories: recent acute coronary syndrome (ACS; ≤12 months preindex), coronary heart disease, ischemic stroke, peripheral artery disease, diabetes, or primary prevention. The study endpoints, low-density lipoprotein cholesterol (LDL-C) goal attainment, medical costs, and time to first CV event were compared using conditional logistic regression, generalized linear, and Cox proportional hazards models, respectively. RESULTS Patients with SI (n = 5190) were matched with controls (n = 15,570). Patients with SI incurred higher medical costs and were less likely to reach LDL-C goals than controls. Patients with SI were at higher risk for revascularization procedures in all CV risk categories except ACS, and those in the diabetes risk category were at higher risk for any CV event. There was a lower risk of all-cause death among patients with SI. CONCLUSIONS Patients with SI were less likely to reach LDL-C goals, incurred higher health care costs, and experienced a higher risk for nonfatal CV events than patients without SI. Alternative management strategies are needed to better treat high CV risk patients.
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Affiliation(s)
| | | | - Joseph J Saseen
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Millán J, Pedro-Botet J, Climent E, Millán J, Rius J. [Statin associated myopathy in clinical practice. Results of DAMA study]. Clin Investig Arterioscler 2016; 29:7-12. [PMID: 27717598 DOI: 10.1016/j.arteri.2016.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 07/06/2016] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND OBJECTIVE Muscle symptoms, with or without elevation of creatin kinase are one of the main adverse effects of statin therapy, a fact that sometimes limits their use. The aim of this study was to evaluate the clinical characteristics of patients treated with statins who have complained muscle symptoms and to identify possible predictive factors. PATIENTS AND METHODS A cross-sectional one-visit, non-interventional, national multicenter study including patients of both sexes over 18 years of age referred for past or present muscle symptoms associated with statin therapy was conducted. 3,845 patients were recruited from a one-day record from 2,001 physicians. RESULTS Myalgia was present in 78.2% of patients included in the study, myositis in 19.3%, and rhabdomyolysis in 2.5%. Patients reported muscle pain in 77.5% of statin-treated individuals, general weakness 42.7%, and cramps 28.1%. Kidney failure, intense physical exercise, alcohol consumption (>30g/d in men and 20g/d in women) and abdominal obesity were the clinical situations associated with statin myopathy. CONCLUSIONS Myalgia followed by myositis are the most frequent statin-related side effects. It should be recommended control environmental factors such as intense exercise and alcohol intake as well as abdominal obesity and renal function of the patient treated with statins.
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Affiliation(s)
- Jesús Millán
- Unidad de Lípidos, Hospital Universitario Gregorio Marañón, Universidad Complutense, Madrid, España.
| | - Juan Pedro-Botet
- Unidad de Lípidos y Riesgo Vascular, Servicio de Endocrinología y Nutrición, Hospital del Mar, Universidad Autónoma de Barcelona, Barcelona, España
| | - Elisenda Climent
- Unidad de Lípidos y Riesgo Vascular, Servicio de Endocrinología y Nutrición, Hospital del Mar, Universidad Autónoma de Barcelona, Barcelona, España
| | - Joaquín Millán
- Unidad de Lípidos, Hospital Universitario Gregorio Marañón, Universidad Complutense, Madrid, España
| | - Joan Rius
- Asesor Médico Cardiovascular. Medicina Familiar y Comunitaria, Barcelona, España
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