Case report of one month and 15 days old baby with type V hyperlipoproteinemia (HLP)

BACKGROUND

Most of the patients with type 1 and V hyperlipoproteinemia (HLP) present with symptoms and signs of acute pancreatitis due to marked elevation of triglycerides, but this baby presented with a chest infection, which was later diagnosed as type V HLP on laboratory workup.

CASE PRESENTATION

We report a case of a 1 month and 15 days old baby boy, product of 2-nd degree consanguinity admitted to a nearby hospital with complaints of refusal to feed, cough and excessive crying. On examination his heart rate was 102 beats/min, respiratory rate was 55 breaths/min and temperature was within the normal range, provisional diagnosis of Pneumonia was made. His samples were tested at our laboratory, the lipid Profile at age of 1 month 15 days showed total cholesterol (TC) of 1400 mg/dl reference range (RR < 200 mg/dl), triglycerides (TG) of > 885 mg/dl after dilution it was 31,400 mg/dl (RR < 150 mg/dl), High density Cholesterol (HDL) of 35 mg/dl (RR > 40 mg/dl) and low density cholesterol (LDL) of 200 mg/dl (RR < 100 mg/dl). The patient's blood sample was grossly milky and lipemic in appearance. A "Refrigerator test" was performed after overnight storage of the sample in refrigerator at 4 °C, which gave a creamy layer at the top and clear infranatant due to caking of the Chylomicrons. Lipoprotein electrophoresis performed 1 month later showed Chylomicrons of 4.7% (RR 0-2%), Pre-beta lipoproteins of 51.5% (RR 5-22%), beta lipoproteins of 16.5% (RR 39-70%) and alpha of 27.3% (RR 23-53%). Initially he was diagnosed as type 1 HLP, but later on he was correctly diagnosed as type V HLP. Cholestyramine (Questran sachet) powder was started at a dose of 100 mg/kg on t.i.d basis with NAN-1 formula Milk at the age of 1 month and 15 days. On follow up, detailed advices regarding the weaning food was given to the mother (using olive oil in cooking, giving proteins and avoiding heavy fatty meals). His lipid profile was repeated at age of 3 months, which showed some improvement, his TGs were 1986 mg/dl and TC 105 mg/dl.

CONCLUSION

There is no universal diagnostic criterion for diagnosing Type V HLP, most likely, due to a scanty literature on this disorder. It stimulated us to report this case so that our findings may help for a timely diagnosis of the affected patients.

[The fixed combination of pravastatin and fenofibrate: what can it provide?]

The treatment of patients with high cardiovascular risk and mixed hyperlipidemia is difficult due to multiple quantitative and qualitative lipid abnormalities. The priority is to reduce LDL-c levels, for which statins are the drug of choice. Despite the benefits of statins, the residual cardiovascular risk is very high in patients with atherogenic dyslipidemia. To reduce this risk, we also need to control non-HDL cholesterol levels, decreasing triglyceride levels and increasing HDL-c levels. To achieve these objectives and lifestyle changes, the use of combined therapy is often required. Fibrates are drugs that can be used in combination with statins to reduce this residual risk. Fenofibrate is well tolerated in combination with statins. The fixed combination of pravastatin/ fenofibrate has been shown to have complementary benefits in the atherogenic lipid profile in general. The combination is well tolerated and is indicated in patients with high risk and mixed hyperlipidemia who have controlled or are close to their objectives for LDL-c levels, using 40-mg pravastatin in monotherapy. The beneficial eff ect of the combination on LDL-c levels is minimal and is primarily observed in non-HDL cholesterol, triglycerides and HDL-c. The combination of pravastatin 40 and fenofibrate 160 can provide a considerable clinical benefit to patients with high risk and mixed atherogenic dyslipidemia, to patients with LDL-c levels that are controlled or near the objectives for decreasing their residual risk of lipid origin and is especially useful for patients with type 2 diabetes, obesity and combined metabolic syndrome and familial hyperlipidemia.

Medical resource use and costs associated with chylomicronemia

BACKGROUND

The prevalence of severe hypertriglyceridemia (TG > 1000 mg/dl) is estimated at 150-400 per 100,000 individuals in North America. Severe hypertriglyceridemia in the fasting state is associated with increased acute pancreatitis risk and is a sign of chylomicronemia which reflects the accumulation in the bloodstream of chylomicrons, the large lipoprotein particles produced in the gut after a meal.

OBJECTIVE

To assess medical resource use and costs associated with chylomicronemia.

METHODS

Patients with chylomicronemia of different causes (≥2 diagnoses with ICD-9 code 272.3) were identified from a large US claims database (years 2000 to 2009) and matched 1:1 to controls free of chylomicronemia based on age, gender, demographics, comorbidities, and use of lipid lowering drugs. During a 1-year study period, medical resource use and costs associated with chylomicronemia or acute pancreatitis were compared between matched cases and controls.

RESULTS

Among 6472 matched pairs, annual per-patient medical costs, calculated independently of the occurrence of acute pancreatitis, were significantly greater by $808 for chylomicronemia cases vs controls ($8029 vs $7220, p < 0.01), half of which was attributable to chylomicronemia-related services (p < 0.01). Chylomicronemia cases with a history of acute pancreatitis (n = 46) had greater rates of inpatient visits (p < 0.05) and greater average costs for subsequent acute pancreatitis or abdominal pain (p < 0.01) as well as greater total medical costs ($33,587 vs $4402, p < 0.01) vs matched controls. The average episode of acute pancreatitis (n = 104 episodes) generated medical costs of $31,820, almost entirely due to inpatient stays.

LIMITATIONS

Triglyceride levels were not available to characterize disease severity.

CONCLUSIONS

Patients with chylomicronemia, and especially those with a history of acute pancreatitis, incurred significantly greater total medical costs compared with individuals without chylomicronemia but with an otherwise comparable health profile.

The work-up for mixed hyperlipidemia: a case study

This case demonstrates that a history, physical exam, and laboratory studies are all needed to determine if the disorder is primary, secondary, or both.

Safety and efficacy of colesevelam hydrochloride in combination with fenofibrate for the treatment of mixed hyperlipidemia

OBJECTIVE

The aim of this study was to evaluate the amount of low-density lipoprotein cholesterol (LDL-C) reduction achieved by adding the specifically engineered bile acid sequestrant (SE-BAS) colesevelam HCl to a stable dose of fenofibrate in patients with mixed hyperlipidemia.

RESEARCH DESIGN AND METHODS

Patients with mixed hyperlipidemia (n = 129) were enrolled in a randomized, double-blind, placebo-controlled, parallel-group study investigating the efficacy of fenofibrate plus colesevelam HCl versus fenofibrate monotherapy. After a 4- to 8-week washout period, subjects received fenofibrate 160 mg/day for 8 weeks and were then randomized to receive colesevelam HCl 3.75 g/day or placebo, in addition to fenofibrate 160 mg/day, for 6 weeks.

MAIN OUTCOMES MEASURES

The primary efficacy endpoint was mean percent change in LDL-C during randomized treatment. Secondary endpoints included absolute and percent changes in mean levels of LDL-C, triglycerides (TGs), high-density lipoprotein cholesterol (HDL-C), non-HDL-C, total cholesterol (TC), and apolipoproteins (apo) A-I and B during randomized treatment and from washout to end of randomized treatment.

RESULTS

Of the 129 patients randomized to treatment, 119 completed the study. After 6 weeks of treatment, fenofibrate plus colesevelam HCl produced a mean percent change in LDL-C of -10.4% versus +2.3% with fenofibrate monotherapy (p < 0.0001). Fenofibrate plus colesevelam HCl was significantly more effective than fenofibrate alone at reducing levels of non-HDL-C, TC, and apo B (p < or = 0.0002). Colesevelam HCl did not significantly affect the TG-lowering effects of fenofibrate. Both treatment regimens were safe and well tolerated.

CONCLUSIONS

Compared with fenofibrate monotherapy in patients with mixed hyperlipidemia, fenofibrate/colesevelam HCl combination therapy significantly reduced mean LDL-C, non-HDL-C, TC, and apo B levels without significantly affecting the TG-lowering or HDL-C-raising effects of fenofibrate. Fenofibrate/colesevelam HCl combination therapy is a safe, useful alternative for the treatment of mixed hyperlipidemia.

A case of hypothyroidism and type 2 diabetes associated with type V hyperlipoproteinemia and eruptive xanthomas

Primary hypothyroidism and type 2 diabetes are both typically associated with the increased level of triglycerides. To date, there have been only a few case reports of type 2 diabetes patients with both type V hyperlipoproteinemia and eruptive xanthomas, but there have been no reports of hypothyroidism patients associated with eruptive xanthomas. We report here on a case of a 48-yr old female patient who was diagnosed with type 2 diabetes and primary hypothyroidism associated with both type V hyperlipoproteinemia and eruptive xanthomas. We found rouleaux formation of RBCs in peripheral blood smear, elevated TSH, and low free T4 level, and dyslipidemia (total cholesterol 18.1 mM/L, triglyceride 61.64 mM/L, HDL 3.0 mM/L, and LDL 2.54 mM/L). She has taken fenofibrate, levothyroxine, and oral hypoglycemic agent for 4 months. After treatment, both TSH level and lipid concentration returned to normal range, and her yellowish skin nodules have also disappeared.

[Efficacy and safety of combination therapy with simvastatin and fenofibrate for combined hyperlipidemia]

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of combination therapy with simvastatin and fenofibrate in patients with combined hyperlipidemia.

METHODS

A total of 221 patients with combined hyperlipidemia were randomly assigned to receive 10 mg simvastatin (n = 72) or 200 mg fenofibrate (n = 68), or a combination of 10 mg simvastatin + 200 mg fenofibrate (n = 81) for 6 months. Lipid profiles, physical and laboratory investigations for adverse effects were assessed.

RESULTS

(1) Combination treatment were more effective in normalizing lipid profile than any monotherapy. Serum TC, LDL-C, and TG were reduced by 30%, 37% and 56% respectively, whilst HDL-C significantly increased by 24% (all P < 0.01). The improvement in TG and HDL-C achieved by combination treatment was superior to fenofibrate or simvastatin alone. (2) The success rate of TC, LDL-C and TG control in the combination therapy group were 51%, 55% and 61% respectively, with an overall success rate (all three together) of 45%, which was superior to either drug given as monotherapy. (3) All treatments were well tolerated with no increase in adverse events for combination therapy versus monotherapy.

CONCLUSION

The results of this study demonstrated that combination therapy with fenofibrate (200 mg/day) and low-dose simvastatin (10 mg/day) is more effective than monotherapy in patients with combined hyperlipidemia, and is generally safe and well tolerated.

[Long-term hypolipidemic treatment of mixed hyperlipidemia with a combination of statins and fibrates]

BACKGROUND

It is difficult to achieve satisfactory decreases of both plasma LDL-cholesterol (LDL-C) and triglycerides (TG) and increase of HDL-C with only single statin or fibrate treatment of patients with mixed hyperlipoproteinaemias (HLP). Combination treatment with both statin and fibrate has been shown to enhance achieving of recommended targets in these patients with high-risk of coronary heart disease. On the other hand unpleasant side effects including myopathy and rhabdomyolysis were described in some cases after statin-fibrate combination therapy. Aim of the study was to evaluate efficacy and safety of long-term treatment of pravastatin + fenofibrate or simvastatin + ciprofibrate therapy in the high-risk group of patients with severe mixed hyperlipoproteinemia.

METHODS AND RESULTS

A set of 86 patients (55 M/31 F) was followed for a period at least one year (median 3 years). These patients were randomly assigned to combination of pravastatin 20 mg + fenofibrate 200 mg (n = 46) (group A), or simvastatin 20 mg + ciprofibrate 100 mg (n = 40) (group B). We have observed significant reduction in plasma TC (22% in group A, 20% in group B), in LDL-C (36%, resp. 33%), reduction of TG (44%, resp. 46%), apo-B (35%, resp. 33%) whilst HDL-C significantly increased (18%, resp. 16%). Concomitantly we have seen significant decreases in uricaemia (14%, resp. 18%). No patient needed to stop treatment due to abnormalities in liver function tests. Levels of creatinkinase became non-significantly elevated (by 16%, resp. 13%). No patient exhibited myopathy or rhabdomyolysis.

CONCLUSIONS

The long-term combined therapy with statin-fibrate (pravastatin 20 mg + fenofirbrate 200 mg, or simvastatin 20 mg + ciprofibrate 100 mg) in severe mixed HLP was safe and effectively improved plasma lipid and apolipoprotein levels. Both combinations seemed to be similarly efficient and safe.

Autoimmune hyperlipidemia in a child with autoimmune hepatitis

The first reported case of a girl with a combination of autoimmune hyperlipidemia and autoimmune hepatitis is described. She presented at the age of 9 years with fever, headaches, and abnormal lipid profile. Months later, she had clinical manifestations, biochemical findings, and the histologic picture of autoimmune hepatitis. Subsequently, she also showed signs and symptoms of systemic lupus erythematosus. All of her clinical manifestations and biochemical abnormalities dramatically improved with immunosuppression. The overlapping syndrome of systemic lupus erythematosus, autoimmune hepatitis, and autoimmune hyperlipidemia is discussed.

Effect of atorvastatin and bezafibrate on plasma levels of C-reactive protein in combined (mixed) hyperlipidemia

C-reactive protein (CRP) is a non-specific but sensitive marker of underlying systemic inflammation. High CRP plasma levels correlate with risk for future cardiovascular events. The present study evaluated the effects of atorvastatin (10-40 mg) and bezafibrate (400 mg) on CRP concentrations after 6 and 12 months of treatment in 103 patients with combined (mixed) hyperlipidemia. The number of cardiovascular risk factors present in a given patient was associated with baseline CRP levels. After 6 months and 1 year, atorvastatin treatment was associated with significant (P<0.001) decreases from baseline of CRP concentrations by 29 and 43%, respectively, while bezafibrate-treated patients showed non-significant reductions of 2.3 and 14.6%, respectively (P=0.056 and 0.005 for the respective differences between the two treatment arms at 6 months and 1 year). The magnitude of change in CRP after 1 year was directly related to baseline CRP levels. Covariance analysis showed that CRP decreases in the atorvastatin group were unrelated to total cholesterol and LDL cholesterol reductions; however, they were directly related to triglyceride changes (r=0.28, P=0.047) and inversely related to HDL cholesterol changes (r=-0.28, P=0.045). A model including baseline CRP values and treatment effect showed that atorvastatin use was a significant predictor of change in CRP levels over time (beta=0.82, P=0.023). These results suggest a potential anti-atherosclerotic additional benefit of atorvastatin in patients at a risk of cardiovascular disease.

Combined treatment with fibrates and small doses of atorvastatin in patients with mixed hyperlipidemia

Combined statin and fibrate therapy is often imperative for the improvement of the serum lipid profile in patients with mixed hyperlipidemia. However, the potential risk of myopathy has limited the widespread use of such therapy. Preferably this treatment should involve low optimally tolerable doses of hypolipidemic drugs. Thus, we undertook a study to determine the safety and efficacy of combination therapy with fibrates and small doses of atorvastatin. Twenty-two patients with mixed hyperlipidemia were started on a fibrate regimen (micronised fenofibrate 200mg/day or ciprofibrate 100 mg/day). Because after 12 weeks of therapy the fibrate failed to normalise the serum lipid profile, small doses of atorvastatin (5 mg/day) were added for a further 12 weeks. The administration of the fibrates resulted in a significant decrease in total and LDL-cholesterol levels, as well as in triglycerides, and an increase in HDL-cholesterol levels. The addition of atorvastatin (5 mg/day) resulted in a further decrease in total and LDL-cholesterol levels. Consequently, the hypolipidemic therapy target was achieved in most of the patents. Combination therapy was well tolerated and no significant increases in serum liver and muscle enzymes were noticed. We conclude that the careful administration of small doses of atorvastatin in patients with mixed dyslipidemia receiving fibrates is associated with a significant amelioration of lipid abnormalities.

Homocysteine and lipid lowering agents. A comparison between atorvastatin and fenofibrate in patients with mixed hyperlipidemia

BACKGROUND

Hyperhomocysteinemia is a risk factor for cardiovascular disease. Elevation in homocysteine levels has recently been demonstrated during lipid lowering treatment with fibrates. We compared the effect of a statin and a fibrate (atorvastatin and fenofibrate) on plasma levels of homocysteine and other thiol compounds in hyperlipidemic patients.

METHOD AND RESULTS

The study was of open randomized, parallel design with a preliminary screening phase, and a 6 week placebo period. After the placebo period, patients were allocated randomly to atorvastatin or fenofibrate for a 6 month period. Plasma thiols were assayed by high pressure liquid chromatography with fluorescence detection. There were 29 patients in the fenofibrate group and 24 in the atorvastatin group. Fenofibrate induced a significant increase in both homocysteine and cysteine plasma levels (+35.8 and +18%, respectively, P<0.0001); by contrast, cysteinylglycine remained stable. There were no significant changes in any thiol compounds in the atorvastatin group. Both treatments induced a significant decrease in uric acid, although fenofibrate was noticeably more effective than atorvastatin (-22.8 and -6.4%, respectively). Fenofibrate induced a non-significant increase in creatinine (12%) while atorvastatin reduced it (4.7%, NS).

CONCLUSION

Our study confirms that the induction of elevations in plasma homocysteine and cysteine levels are a distinct feature of the pleiotropic effects of fibrates. Further studies are needed not only to investigate the potential deleterious effects of this modification, but also to define the specific mechanism which underlies such fibrate-mediated action.

The effect of atorvastatin on serum lipids, lipoprotein(a) and plasma fibrinogen levels in primary dyslipidaemia--a pilot study involving serial sampling

We conducted an open-label study to test the effects of atorvastatin on serum lipids, lipoprotein(a) [Lp(a)] and plasma fibrinogen levels. A total of 90 dyslipidaemic, non-smoking patients (45 patients with primary hypercholesterolaemia and 45 patients with primary mixed hyperlipidaemia) aged 48 +/- 11 years were studied. The patients were treated with 20 mg of atorvastatin for 24 weeks, in a single nocturnal dose. At baseline and every eight weeks, the fasting lipid profile, together with serum Lp(a) and plasma fibrinogen levels (Clauss method), were measured. Atorvastatin was highly effective in normalising the serum lipid profile. No significant change in median serum Lp(a) levels was observed in the whole group of patients (0.14 g/l before, vs. 0.16 g/l after, treatment) as well as in patients with raised (> 0.30 g/l) baseline levels (n = 32). A small non-significant increase of plasma fibrinogen was found (3.04 g/l vs. 3.14 g/l) after 24 weeks of atorvastatin administration. The effects of atorvastatin on both these variables did not differ in patients with hypercholesterolaemia or mixed hyperlipidaemia. In conclusion, our findings suggest that the effect of atorvastatin on plasma fibrinogen levels in dyslipidaemic patients without evident vascular disease is not clinically relevant. Furthermore, any rise in fibrinogen levels that may occur is likely to be transient in nature. Further studies are necessary to clarify this issue. There was no evidence that atorvastatin influences serum Lp(a) levels.

Scalp pain and hyperlipidaemia

Acute pancreatitis and eruptive xanthomata are the only recognised direct complications of severe hypertriglyceridaemia, although peripheral neuropathy has been described in patients with hyperlipidaemia. We describe a patient with mixed hyperlipidaemia presenting with severe scalp pain and eruptive xanthomata. Both resolved with treatment. We suspect that high triglyceride concentration can affect the function of sensory nerve fibres.

Efficacy and safety of a combination of fluvastatin and bezafibrate in patients with mixed hyperlipidaemia (FACT study)

Preliminary data suggest that fluvastatin may be safely combined with fibrates. The Fluvastatin Alone and in Combination Treatment Study examined the effects on plasma lipids and safety of a combination of fluvastatin and bezafibrate in patients with coronary artery disease and mixed hyperlipidaemia. A total of 333 patients were randomly allocated in this multicentre double-blind trial to receive 40 mg fluvastatin alone (n=80), 400 mg bezafibrate (n=86), 20 mg fluvastatin+400 mg bezafibrate (n=85) or 40 mg fluvastatin+400 mg bezafibrate (n=82) for 24 weeks. Low-density lipoprotein (LDL)-cholesterol decreased >20% in all fluvastatin-containing regimens, with significantly greater decreases compared with bezafibrate alone (P<0.001). Bezafibrate alone and fluvastatin+bezafibrate combinations resulted in greater increases in high-density lipoprotein (HDL)-cholesterol and decreases in triglycerides compared with fluvastatin alone (P<0.001). Fluvastatin (40 mg)+bezafibrate was the most effective for all lipid parameters with a decrease from baseline at endpoint in LDL-cholesterol of 24%, a decrease in triglycerides of 38% and an increase in HDL-cholesterol of 22%. All treatments were well tolerated with no increase in adverse events for combination therapy versus monotherapy, or between combination regimens. No clinically relevant liver (aspartate aminotransferase [ASAT] or alanine aminotransferase [ALAT]) greater than three times the upper limit of normal) or muscular (creatine phosphokinase (CPK) greater than four times the upper limit of normal) laboratory abnormalities were reported. This large study shows 40 mg fluvastatin in combination with 400 mg bezafibrate to be highly effective and superior to either drug given as monotherapy in mixed hyperlipidaemia, and to be safe and well tolerated.

HDL steady state levels are not affected, but HDL apoA-I turnover is enhanced by Lifibrol in patients with hypercholesterolemia and mixed hyperlipidemia

Lifibrol (4-(4'-tert-butylphenyl)-1-(4'carboxyphenoxy)-2-butanol) is a new hypocholesterolemic drug effectively reducing total cholesterol, LDL cholesterol, and apolipoprotein (apo) B in experimental animals and in humans. In contrast to fibrates and HMG-CoA reductase inhibitors the cholesterol and triglyceride lowering effect of Lifibrol is not accompanied by increases in HDL cholesterol and apoA-I levels. We examined the impact of Lifibrol on the metabolism of HDL apoA-I in patients with hyperlipoproteinemia, using endogenous labeling with stable isotopes. Kinetic studies were performed in five male hypercholesterolemic individuals (type IIa), before and on treatment with 450 mg of Lifibrol daily for 4 weeks and in five male individuals suffering from mixed hyperlipidemia (type IIb), before and on therapy, for 12 weeks. Lifibrol reduced total cholesterol by 14% (P=0.02) and LDL cholesterol by 16% (P=0. 014) in all patients, and decreased triglycerides by 34% in type IIb patients. During Lifibrol therapy, HDL cholesterol and ApoA-I concentrations did not change. Tracer kinetics revealed that the fractional catabolic rate (FCR) of HDL apoA-I increased by 22% (P=0. 013). This increase in the apoA-I FCR was accompanied by a 23% increase in HDL apoA-I production rate (P=0.006). We conclude that Lifibrol, although not changing HDL steady state concentrations, enhances the turnover of apoA-I containing HDL particles.

Effectiveness and safety of alternate-day simvastatin and fenofibrate on mixed hyperlipidemia

This randomized prospective clinical study evaluated the lipid-lowering effects and safety of a new combination regimen in patients with mixed hyperlipidemia. The data show that alternate-day simvastatin and fenofibrate therapy was as effective as the standard daily combination of the same drugs at the same doses, and it was safer, less expensive, and more tolerable.

Cerivastatin in the treatment of mixed hyperlipidemia: the RIGHT study. The Cerivastatin Study Group. Cerivastatin Gemfibrozil Hyperlipidemia Treatment

The Cerivastatin Gemfibrozil Hyperlipidemia Treatment (RIGHT) study--a multicenter, randomized, double-blind, placebo-controlled study--compared the lipid-lowering effects of cerivastatin, once daily at doses of 0.1, 0.2, and 0.3 mg with those of twice-daily gemfibrozil 600 mg in 751 patients with primary mixed hyperlipidemia. Randomization to the first 16 weeks of treatment followed an initial 4-week washout period and subsequent 6-week diet-controlled, placebo run-in phase. Patients continued to receive study medication for a further 36 weeks, with those previously on placebo switched to 0.1 mg/day cerivastatin at the end of week 16. Additional cholestyramine therapy was permitted at week 36 in patients with uncontrolled low-density lipoprotein (LDL) cholesterol levels. Cerivastatin achieved significant dose-dependent reductions in LDL cholesterol of 15-24% after 16 weeks of treatment, compared with reductions of 7.5% with gemfibrozil. Over this period both cerivastatin (0.3 mg) and gemfibrozil (1,200 mg) significantly decreased levels of triglycerides (20.3% vs 50.3%, respectively) and very low-density lipoprotein (VLDL) cholesterol (30.8% vs 47.1%, respectively), as well as increasing high-density lipoprotein (HDL) cholesterol (11.3% vs 13.3%, respectively). The reductions in LDL cholesterol and other atherogenic lipids and lipoproteins at 16 weeks were sustained in the subsequent 36-week double-blind continuation phase, during which time <10% of patients received additional cholestyramine therapy. Both study drugs were well tolerated, with the incidence of adverse events similar to that of placebo treatment. Clinically significant increases in hepatic transaminases and creatine phosphokinase occurred at a similar low frequency of around 1%. This study demonstrated that cerivastatin is a safe, well-tolerated, and effective treatment for lowering elevated LDL cholesterol and triglycerides in patients with mixed hyperlipidemia.

Diabetic lipemia with maturity-onset diabetes of the young

A 19-year-old woman with diabetic lipemia and maturity-onset diabetes of the young (MODY) is reported. Though her insulin secretory activity was preserved, she fell into mild diabetic ketoacidosis (DKA) and showed type V hyperlipidemia. Post-heparin plasma activity of lipoprotein lipase (LPL) was decreased even 10 days after initiating insulin injection but not deficient. The abnormalities in lipid metabolism were improved by long-term insulin treatment. Though the contribution of the genetic background to the lipid abnormalities is not clear, the characteristics of MODY in this patient including insulin secretory capacity under stress conditions such as DKA might play a role in the development of diabetic lipemia.

Familial type V hyperlipoproteinemia with hyper-remnant-like particle-cholesterol accompanied with apolipoprotein E3/E4 phenotype

A 41-year-old woman and her 2 sons had Type V hyperlipoproteinemia. Interestingly, the patient and her younger son had higher levels of remnant-like particle (RLP)-cholesterol than her elder son; the former two had apolipoprotein E phenotype E3/E4, while the latter had E3/E3. Hyper-RLP-ch levels may be associated with the apolipoprotein E4 phenotype. Moreover, after administration of bezafibrate, the patient's triglyceride, RLP-cholesterol and RLP-triglyceride levels decreased markedly and the chylomicron fraction disappeared. Further studies may be necessary to determine if hypertriglyceridemic patients with or without apolipoprotein E4 show a greater reduction in serum TG levels with lipid-lowering agents.

Combined bezafibrate and simvastatin treatment for mixed hyperlipidaemia

The safety and efficacy of combined bezafibrate-simvastatin therapy was evaluated in 49 patients with diet-resistant mixed hyperlipidaemia (type IIb). After a two-month placebo phase, patients were randomized to receive either Bezafibrate Slow Release (SR) 400 mg mane or simvastatin 20 mg nocte followed by three months combination therapy. Total cholesterol, triglycerides and high-density lipoprotein (HDL) cholesterol were measured at monthly intervals. Apolipoproteins (apo) A1 and B, lipoprotein (a) [Lp(a)] and fibrinogen were measured before and after each treatment. Simvastatin was more effective than Bezafibrate SR in reducing total cholesterol (2.0 vs. 1.1 mmol/l, p = 0.003) and lowering LDL cholesterol (1.7 vs. 0.4 mmol/l, p = 0.0001) whereas Bezafibrate SR was more effective in reducing triglycerides (by 41% vs. 17%, p = 0.001) and fibrinogen (by 23% vs. 3%, p = 0.004). Compared with simvastatin monotherapy, combined drug therapy induced further reductions in triglycerides (by 26%, p = 0.0003) and apoB (by 11 mg/dl, p = 0.03) and an increase in apoA1 (by 21 mg/dl, p = 0.0008). Symptomatic and biochemical adverse events did not occur more frequently on combined drug therapy than on monotherapy. The combination of bezafibrate and simvastatin was more effective in controlling mixed hyperlipidaemia than either drug alone and did not provoke more adverse events.

[Use of etofyllinclofibrate (Duolip Forte) in combined hyperlipidemia]

BACKGROUND

Duolip forte (ethophyllinclofibrate) is a lipid lowering drug, the effect of which was not yet adequately verified in our conditions, namely from the point of its effect on various types of hyperlipoproteinaemias.

METHOD AND RESULTS

The therapy was applied on 45 patients with combined hyperlipidaemia, 25 men and 20 women, mean age 53.8 years (age range 41-65). About one half of patients were treated for hypertension, almost one quart of them manifested ischemic heart disease, 13% had a history of myocardial infarction and the same percentage suffered from associated diabetes type 2. Duolip forte was administered perorally in a dose of 500 mg once daily for 12-16 weeks to the patients who had complied with the prescribed diet (weight loss, improvement of lipid levels) during three-month preliminary period, but did not reach desirable parameters. After the therapy, the whole group studied manifested a significant decrease of total cholesterol (-10.8%), LDL-cholesterol (-13%), triglycerides (-40.8%) and free fatty acids (-20.6%), while the increase of HDL-cholesterol and its fractions was not significant. In hyperlipoproteinaemias of IIa type (n = 15), only a significant decrease of LDL-cholesterol appeared, in hyperlipoproteinaemias of IIb type (n = 15), a significant decrease was evidenced only in triglycerides (-33.9%). In hyperlipoproteineaemias of IV type (n = 15), a significant decrease was observed in triglycerides (-50.3%), while HDL-2 cholesterol values increased (+32.3%). A slight decrease of uric acid level and of body mass index observed in all groups was statistically not significant, as well as a slight increase of glycaemia and changes of serum transaminases. No unwanted side effects of Duolip were found.

CONCLUSIONS

Ethophyllinclofibrate has proved as effective namely at hypertriglyceridemic primary hyperlipidaemias. Besides decreasing triglycerides, it increases significantly HDL-2 cholesterol. A convenient dosage, small lithogenic effect and minimum of side effects make it a drug of choice for some groups of elderly high-risk patients.

Effect of pravastatin on metabolic parameters of apolipoprotein B in patients with mixed hyperlipoproteinemia

3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors reduce plasma cholesterol in different forms of hyperlipoproteinemia. Although an increase in low-density lipoprotein (LDL) receptor activity is the proven mechanism of this therapy in familial hypercholesterolemia, the mechanism remains controversial in mixed hyperlipoproteinemia. A decreased production of apolipoprotein B (apoB) and/or an increased removal of lipoproteins could mediate the hypocholesterolemic effect of these drugs. The effect of pravastatin on the metabolism of apoB was evaluated in a randomized, double blind, placebo controlled, cross-over study in five men with mixed hyperlipoproteinemia. Metabolic parameters for apoB were determined using endogenous labeling with [1-13C]leucine and [15N]glycine and multicompartmental modeling. During pravastatin therapy cholesterol, LDL cholesterol, apoB, and LDL apoB levels were significantly reduced (P < 0.01) by 18%, 20%, 27%, and 29%, respectively, while triglyceride and high-density lipoprotein cholesterol levels remained unchanged. Pravastatin therapy increased the fractional catabolic rate of very low density lipoprotein apoB from 3.9 +/- 0.6 to 5.1 +/- 1.7 per day (P = 0.08) and that of LDL apoB from 0.37 +/- 0.09 to 0.46 +/- 0.10 per day (P < 0.01). The apoB production (placebo 35.2 +/- 11.9 mg/kg per day; pravastatin 25.8 +/- 8.7 mg/kg per day) and conversion of very low density lipoprotein apoB to LDL apoB (placebo 65%, pravastatin 57%) remained stable. Thus, also in mixed hyperlipoproteinemia 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors increase the catabolism of apoB-containing lipoproteins without significantly affecting the production of apoB.

Double-blind multicenter trial on a new medium molecular weight glycosaminoglycan. Current therapeutic effects and perspectives for clinical use

The ability of glycosaminoglycans to bind to a wide number of biologically active macromolecules has already been investigated. Recent clinical trials on the possible therapeutic benefits of glycosaminoglycans must be placed in perspective, even if they appear to be particularly encouraging, especially as regards the glycosaminoglycan effects on certain coagulation factors. A multicenter, medium-term, double-blind, crossover trial was performed by several Italian Lipid Clinics to determine whether administration of a medium molecular weight glycosaminoglycan (Sulodexide) has a significant clinical effect. Patients affected by peripheral vascular disease and/or hyperlipidemia (type IIa, IIb and IV) were submitted to a 4-week wash-out period, followed by parenteral Sulodexide (S) or placebo (P) administration for 2 weeks, another 2 week wash-out period, parenteral crossover drug or P administration for 2 weeks and, finally, oral S administration for 6 months. Sulodexide lowered plasma viscosity and plasma fibrinogen in all patients. There was also a drop in triglycerides together with a rise in apo A-I and HDL-C in type IV hyperlipoproteinemics, whereas there was no significant effect on total or LDL-plasma cholesterol in type IIa and IIb patients. Moreover, there was a percent increase in peak flow and rest flow in the lower limbs of peripheral vascular disease patients. No side effects or intolerance phenomena were detected. The results indicate that Sulodexide administration may be useful in long-term treatment of patients with peripheral vascular disease and a concomitant increase in plasma triglycerides and/or fibrinogen and/or viscosity.

The hypolipidemic effects of gemfibrozil in type V hyperlipidemia. A double-blind, crossover study

Thirteen patients with phenotypic type V hyperlipidemia were treated with either gemfibrozil (Lopid) or a placebo in a randomized, double-blind, crossover study for two 8-week periods. A 4-week baseline period of a low-fat diet preceded the study and served as a dietary control period. A 4-week washout period followed the two 8-week periods. Compared with the placebo phase, gemfibrozil produced a significant reduction in the concentrations of total plasma triglycerides (21.03 vs 5.50 mmol/L) and very low-density lipoprotein triglycerides (14.40 vs 4.59 mmol/L) as well as in total plasma cholesterol levels (10.88 vs 5.62 mmol/L) and very low-density lipoprotein cholesterol (6.66 vs 2.15 mmol/L). Chylomicronemia was virtually abolished by the drug treatment. As expected in treated patients with type V hyperlipidemia, concentrations of low-density lipoprotein cholesterol rose after therapy with gemfibrozil (3.08 mmol/L) as compared with placebo (1.84 mmol/L); high-density lipoprotein cholesterol also increased (0.85 mmol/L after therapy with gemfibrozil, 0.62 mmol/L after placebo). The previously very low values for both of these lipoproteins increased at the same time that the total plasma cholesterol value decreased. We conclude that gemfibrozil is a well-tolerated and effective hypolipidemic agent for the treatment of patients with severe hypertriglyceridemia when used in conjunction with a low-fat diet.

Effects of slow-release bezafibrate on serum lipids, lipoproteins, apolipoproteins, and postheparin lipolytic activities in patients with type IV and type V hypertriglyceridemia

The effects of bezafibrate on serum lipids, lipoproteins, apolipoproteins, and post-heparin lipolytic activities were studied in 17 patients with hypertriglyceridemia. All patients received 400 mg of slow-release (SR) bezafibrate daily for four months. In the nine patients with type IV hypertriglyceridemia, mean serum triglyceride (TG) levels decreased significantly, by 53% (P less than 0.01) at two months and 50% (P less than 0.001) after four months of bezafibrate, while in the eight patients with type V, the levels decreased by 61% (P less than 0.001) and 51% (P less than 0.001), respectively. Total cholesterol levels decreased significantly (P less than 0.05) in type V patients at two and four months, by 19% and 18%, respectively, while low-density lipoprotein cholesterol levels increased significantly (P less than 0.05) in type IV patients at two and four months, by 63% and 62%, respectively. High-density lipoprotein (HDL) levels increased significantly (P less than 0.05) at two months in both patient groups. HDL subfraction analysis showed a significant (P less than 0.05) rise in HDL3-cholesterol levels in type V but not in type IV patients. Apolipoprotein (apo) A-I, A-II, and B levels increased, while apo C-II, C-III, and E levels decreased in both groups. The apo A-I/apo A-II ratio decreased significantly (P less than 0.05) at two and four months in type V patients, which also supports increased HDL3 fractions in that group. Lipoprotein lipase and hepatic TG lipase levels tended to rise, and the particle size of TG-rich lipoprotein (TGRL) and the TGRL-apo C-III/TGRL-apo C-II ratio decreased in both patient groups. These data indicate that bezafibrate-induced changes in lipoprotein profiles differed slightly in type IV and type V patients. The results confirm the usefulness of bezafibrate as a lipid-lowering agent.

Fenofibrate in type IV and type V hyperlipoproteinemia

A US multicenter, double-blind, placebo-controlled study was performed to evaluate the efficacy and safety of fenofibrate in patients with type IV or V hyperlipoproteinemia. One hundred forty-seven patients entered the study and all were stabilized on a low-fat diet. Following a placebo baseline period, patients were stratified according to plasma triglyceride (TG) levels (group A, 350-499 mg/dl; group B, 500-1,500 mg/dl) and randomly assigned to treatment with either 100 mg fenofibrate or one placebo capsule three times a day with meals. Demographically, the treatment groups were similar. A dramatic reduction in total TG levels occurred in the fenofibrate-treated patients but not in the placebo-treated patients. This effect was seen in both group A (46%) and group B (55%) patients and reached near-maximum reduction in only 2 weeks of treatment. In both groups, fenofibrate treatment also decreased very low-density lipoprotein (VLDL) TG, total cholesterol and VLDL cholesterol, and increased high-density lipoprotein levels. Adverse effects of fenofibrate were minimal compared with placebo and resolved when the drug was discontinued. Overall, fenofibrate was found to be effective in patients with type IV or V hyperlipoproteinemia, and caused no clinically significant adverse effects that would preclude its use in these patients.

Effects of acipimox on serum lipids, lipoproteins and lipolytic enzymes in hypertriglyceridemia

Two separate studies were carried out with acipimox, a new antilipolytic agent with long-lasting activity. First, in a randomized, double-blind, cross-over study a dose of 750 mg/day of acipimox versus placebo was employed for 60 days in 11 patients with type IV hyperlipoproteinemia. Mean plasma triglyceride levels were reduced after acipimox compared to placebo (434 +/- 60 vs 777 +/- 224 mg/dl, P less than 0.01). Serum total cholesterol fell also significantly after acipimox compared to placebo. No significant alteration was observed in the HDL2/HDL3 ratio or in the concentration or composition of the HDL subfractions. Six patients with severe hypertriglyceridemia (2 type IV and 4 type V) and low lipoprotein lipase (LPL) activity took part in a second, open study, lasting for 9 months. Acipimox was given at a dose of 750 mg/day for the first 6 months and 1200 mg/day for the last period. The response of serum total and VLDL triglycerides was inconsistent. HDL cholesterol was significantly raised (+33.3%) after 9 months of treatment due to changes of HDL2 and HDL3 cholesterol, phospholipid and protein concentrations. LPL activity was markedly reduced in adipose tissue at 9 months. No significant changes occurred in postheparin plasma LPL activity. In contrast, hepatic lipase activity showed a reduction of about 25% from 6 months of treatment onwards.

Morphometric study of human hepatic cell modifications induced by fenofibrate

We have studied liver biopsies obtained in 12 hyperlipoproteinemic (HLP) patients (type II, 6; type IV, 6) treated with diet and fenofibrate, and in 15 patients (type II, 11; type IV, 4) receiving diet only. Electron microscopy of liver biopsies and the morphometric analysis according to the method of Weibel and Rohr showed mitrochondrial changes in patients treated with fenofibrate, these changes depending on the type of hyperlipoproteinemia. In type II HLP, we found a decreased volume of normal mitochondria (fenofibrate, 125.72 +/- 17.04 X 10(-3) cm3/cm3; diet only, 185.84 +/- 8.96 10(-3), P less than .05). In type IV HLP we found a decreased number of giant mitochondria (fenofibrate, 0.08 +/- 0.03 X 10(10) cm-3; diet only, 0.32 +/- 0.08 X 10(10) cm-3, P less than .05) and a decreased volume of altered mitochondria (fenofibrate, 6.00 +/- 1.44 X 10(-3) cm3/cm3; diet only, 13.61 +/- 1.17 X 10(-3), P less than .05). In contrast with the rodent studies, the present study shows no change in the number of volume of peroxisomes.

Effects of short-term treatment with coenzyme A or sulodexide on plasma lipids in patients with hypertriglyceridemia (type IV) or mixed hyperlipemia (type IIb)

Twenty-seven inpatients suffering from type II and IV dyslipidemia, randomly divided into two groups of 14 and 13 subjects, were treated with coenzyme A (2,000 Lipmann U daily) and sulodexide (300 Lipasemic U daily), respectively, in both cases administered intravenously for 20 days. The principial plasma lipid parameters (total and HDL-cholesterol, LDL-cholesterol in subjects with triglyceridemia less than 400 mg/dl, triglycerides, apoproteins and lipoproteins) were recorded before and after treatment. Tests on patients included an assessment, on a semiquantitative scale, of symptoms arising from modifications of blood flow to the various organs. Statistical analysis of data demonstrated that coenzyme A has a significant cholesterol-lowering action (with an increase in HDL-cholesterol) and a more pronounced hypotriglyceridemic effect in both types of dyslipidemia considered, results on both variables proving more satisfactory than with the control drug.

Apolipoprotein E phenotypes in hyperlipidaemic patients and their implications for treatment

Apolipoprotein E phenotypes were determined on 417 consecutive lipid clinic patients using an isoelectric focussing technique. Of the 15 patients with phenotype E2/2, 13 (3.1%) had type III hyperlipoproteinaemia and 2 obese identical twins had type V. A further 20 patients (4.8%) had similar plasma and lipoprotein lipid levels but were E2 heterozygotes (14 E3/2 and 6 E4/2). They displayed a widened pre-beta-band almost confluent with the beta-band rather than the broad beta-band shown in classical E2/2 type III patients. In view of the similarities between these heterozygotes and the classical homozygous (E2/2) type III patients and their occurrence in the same families we suggest the nomenclature homozygous and heterozygous type III. In a subsequent comparison between 30 E2/2, 22 E3/2 and 8 E4/2 type III individuals the only significant difference in plasma and lipoprotein lipid parameters was a lower VLDL cholesterol to triglyceride ratio of 0.85 in E3/2 patients than that of 1.24 in E2/2 patients (P less than 0.01). Both homozygous and heterozygous patients showed premature ischaemic heart disease and both responded dramatically and similarly to treatment with clofibrate. These observations indicate that apo E phenotyping is worthwhile in all patients with combined hyperlipidaemia and that homozygous and heterozygous type III hyperlipoproteinaemia is not uncommon.

[Effective long-term treatment of primary hyperlipoproteinemias with bezafibrate]

Bezafibrate, a new hypolipidemic agent, was evaluated in a single blind, placebo-controlled study lasting 14 months to 3 years in 40 patients with primary hyperlipoproteinemia of various types (23 patients with type II, 15 with type IV and 2 with type V). Bezafibrate in a dose of 200 mg 3 times daily reduced total serum cholesterol by an average of 17% (p less than 0.001) in hyperlipoproteinemia type II and by 24% (p less than 0.001) in type IV or V, lowered serum triglycerides by 31% (p less than 0.001) in hyperlipoproteinemia type II and by 58% (p less than 0.001) in type IV or V, while high-density-lipoprotein-cholesterol was increased by 17% (p less than 0.001) in type II and by 36% (p less than 0.001) in type IV or V. The few side effects encountered were only mild and transient. These findings show that bezafibrate affords safe and effective long-term treatment of patients with hyperlipoproteinemia.

On the effects of dietary n-3 fatty acids (Maxepa) on plasma lipids and lipoproteins in patients with hyperlipidaemia

An encapsulated preparation of fish oil (Maxepa) was administered to hyperlipidaemic patients in order to establish the responsiveness of the common lipid phenotypes to dietary supplementation with n-3 fatty acids. 13 patients took 6 g/day of fish oil and 12 patients took 16 g/day in a randomized, double-blind crossover study, whereby each subject took fish oil for 3 months and matching placebo for 3 months. The study was conducted against a background diet restricted in saturated fat and cholesterol. In Types IIa and IIb hyperlipoproteinaemia there was no substantial fall in plasma cholesterol concentration. Plasma triglyceride concentrations were reduced significantly in Types IIb and IV (28% and 41% respective reductions). In a separate study using 16 g/day of fish oil in patients with Type V hyperlipoproteinaemia, plasma triglycerides were reduced by 58% and plasma cholesterol concentration by 34%. The change in plasma triglyceride concentration was significantly correlated with the basal triglyceride level (r = -0.94), and was dose-related (33% fall on 6 g/day and 58% fall on 16 g/day). The fall in plasma triglyceride concentration was accompanied by a significant reduction in the concentration of very low-density lipoprotein cholesterol (-42%), a significant rise in low density lipoprotein cholesterol (+7%), and a significant rise in high-density lipoprotein cholesterol concentration (+6%), there being no significant change in the ratio of low density to high density lipoprotein cholesterol. There were changes in the fatty acid composition of plasma and platelet lipids which reflected dietary supplementation with n-3 fatty acids, notably an increase in the proportion of eicosapentaenoic and docosahexaenoic acids which occurred in a dose-dependent fashion. Despite these changes there was no significant variation in the bleeding time, platelet count or blood viscosity during the treatment.

[The therapeutic efficacy of bezafibrate in hyperlipoproteinemias of various types]

17 patients with hyperlipoproteinemia of type 11 (9 type IIa and 8 type IIb), 4 with hyperlipoproteinemia of type IV and 1 with hyperlipoproteinemia of type V were treated for 4.6 +/- 0.7 months with the new lipid lowering agent bezafibrate in a dose of 200 mg three times daily. Bezafibrate markedly lowered total serum cholesterol and triglycerides and increased HDL-cholesterol in each of these types of hyperlipoproteinemia. These data suggest that bezafibrate may be effective in reducing the possibly atherogenic LDL- and VLDL-fractions while increasing the antiatherogenic HDL-fraction.

Serum profile of non-esterified fatty acids (NEFA) in patients with hyperlipoproteinemia under xantinol--nicotinate (XN) medication

The effect of 50 mg/kg body weight Xantinol-nicotinate (XN) on serum lipids and on non-esterified fatty acids (NEFA) was tested in 94 out-patients with hyperlipoproteinemia Types IIa, IIb, IV and V. The lipids were measured before treatment, during a 3-week period of drug administration and 10 days after rejection. In each group of hyperlipoproteinemic patients the lipid lowering effect of XN was accompanied by a constant fall in serum NEFA levels. The time dependent course of NEFA showed that the higher the initial level, the longer the time span required to achieve the lowest values. In the context of the partially conflicting data on the hypolipidemic action of nicotinic acid and its derivatives, it is suggested that the constant decrease in NEFA induced by XN treatment might contribute significantly to the lipid lowering effect of this drug.