Vascular pleiotropy of statins: clinical evidence and biochemical mechanisms

A novel therapeutic effect of statins on nephrogenic diabetes insipidus

Statins competitively inhibit hepatic 3-hydroxy-3-methylglutaryl-coenzyme A reductase, resulting in reduced plasma total and low-density lipoprotein cholesterol levels. Recently, it has been shown that statins exert additional ‘pleiotropic’ effects by increasing expression levels of the membrane water channels aquaporin 2 (AQP2). AQP2 is localized mainly in the kidney and plays a critical role in determining cellular water content. This additional effect is independent of cholesterol homoeostasis, and depends on depletion of mevalonate-derived intermediates of sterol synthetic pathways, i.e. farnesylpyrophosphate and geranylgeranylpyrophosphate. By up-regulating the expression levels of AQP2, statins increase water reabsorption by the kidney, thus opening up a new avenue in treating patients with nephrogenic diabetes insipidus (NDI), a hereditary disease that yet lacks high-powered and limited side effects therapy. Aspects related to water balance determined by AQP2 in the kidney, as well as standard and novel therapeutic strategies of NDI are discussed.

Inappropriate prescribing in patients accessing specialist palliative day care services

BACKGROUND

For patients accessing specialist palliative care day services, medication is prescribed routinely to manage acute symptoms, treat long-term conditions or prevent adverse events associated with these conditions. As such, the pharmacotherapeutic burden for these patients is high and polypharmacy is common. Consequently, the risk of these patients developing drug-related toxicities through drug–drug interactions is exacerbated. Medication use in this group should, therefore, be evaluated regularly to align with achievable therapeutic outcomes considering remaining life expectancy.

OBJECTIVE

To (1) assess the prevalence of inappropriate medication use; (2) identify potential drug–drug interactions; and, (3) determine how many potential drug– drug interactions could be prevented by discontinuing inappropriate medication.

SETTING

A specialist tertiary care palliative care centre in Northern England serving a population of 330,000.

MAIN OUTCOME MEASURE

Prescribing of inappropriate medication.

METHOD

Medication histories for patients accessing a specialist palliative day care centre were established and a modified Delphi method was used to reach consensus of medication appropriateness. The Delphi method utilized a framework considering the following factors: remaining life expectancy of the patient, time until benefit of the treatment, goals of care and treatment targets. Potential drug interactions were established using drug interaction recognition software and categorised by their ability to cause harm.

RESULTS

A total number of 132 patients were assessed during the study period who were prescribed 1,532 (mean = 12/patient) medications; 238 (16 %) were considered inappropriate in the context of limited life expectancy. The most common class of medications considered inappropriate were the statins, observed in 35 (27 %) patients. A total of 267 potential drug–drug interactions were identified; 112 were clinically significant and 155 were not considered clinically significant. Discontinuation of inappropriate medication would reduce the total number of medications taken to 1,294 (mean = 10/patient) and prevent 31 clinically significant potential drug–drug interactions.

CONCLUSION

Patients accessing specialist palliative day care services take many inappropriate medications. These medications not only increase the pharmacotherapeutic burden for the patient but they also contribute to potential drug–drug interactions. These patients should have their medication reviewed in the context of life limiting illness aligned with achievable therapeutic outcomes.

Disparate effects of simvastatin on angiogenesis during hypoxia and inflammation

AIMS

Studies have shown that some of statin's pleiotropic effects were achieved by either promotion or inhibition of angiogenesis, depending on the underlying disease. This study tested the hypothesis that the angiogenic potential of simvastatin is related to the microenvironmental conditions.

MAIN METHODS

Human umbilical vein endothelial cells (HUVEC) were studied after exposure to hypoxia or the inflammatory factors tumor necrosis factor (TNF)-alpha, with or without co-incubation with simvastatin (1 micromol/L) and mevalonate. HUVEC angiogenesis was evaluated by tube formation, migration, and proliferation assays. Hypoxia inducible factor (HIF)-1alpha, vascular endothelial growth factor (VEGF), Akt, endothelium nitric oxide synthase (e-NOS), and oxidative stress were evaluated.

KEY FINDINGS

HUVEC angiogenesis increased during hypoxia (tube length 14.7+/-0.5 vs. 7.8+/-0.6 mm, p<0.05) and further enhanced by simvastatin (19.3+/-1.1 mm, p<0.05 vs. hypoxia alone), which downregulated the expression of the HIF-1 inhibitor PHD2 and upregulated HIF-1alpha, VEGF, and Akt, without changing oxidative stress or eNOS. Incubation with TNF-alpha promoted HUVEC angiogenesis (7.4+/-0.2 vs. 6.5+/-0.2 mm, p<0.05) with increased oxidative stress. However, simvastatin inhibited this promotion (2.5+/-0.3 mm, p<0.001 vs. TNF-alpha alone) by decreasing oxidative stress, VEGF, Akt, and eNOS.

SIGNIFICANCE

We conclude that at the same dosage, simvastatin can either promote or inhibit angiogenesis, possibly by activating upstream regulators of HIF-1alpha in hypoxia, but conversely interfering with angiogenic signaling downstream to inflammation. These opposing angiogenic effects should be considered in the therapeutic strategies with statins.

Pravastatin induces thrombomodulin expression in TNFα-treated human aortic endothelial cells by inhibiting Rac1 and Cdc42 translocation and activity

Expression of functionally active thrombomodulin (TM) on the luminal surface of endothelial cells is critical for vascular thromboresistance. The 3-hydroxyl-3-methyl coenzyme A reductase inhibitor, pravastatin, can protect the vasculature in a manner that is independent of its lipid-lowering activity. We examined the effect of pravastatin on TM expression by human aortic endothelial cells (HAECs) with subsequent tumor necrosis factor alpha (TNFalpha) stimulation and investigated the signaling pathways involved. TNFalpha treatment attenuated TM expression in HAECs in a time-dependent manner. Pravastatin upregulated TM levels in TNFalpha-treated HAECs. Specific inhibition of geranylgeranyltransferase-I or the Rho family by GGTI-286 or TcdB, respectively, enhanced TM expression in TNFalpha-treated HAECs, whereas MAP kinase inhibitors, inactivation of Rho by Clostridium botulinum C3 exoenzyme, or the Rho kinase inhibitor, Y-27632, had no effect. In TNFalpha-treated HAECs, pravastatin inhibited Rac1 and Cdc42 activation and their translocation to the cell membrane. Blocking the transcriptional activation of NF-kappaB prevented the TNFalpha-induced downregulation of TM. The pravastatin-induced increase in TM expression in TNFalpha-treated HAECs was mediated through inhibition of NF-kappaB activation. Pravastatin regulates TM expression by inhibiting the activation of the Rho family proteins, Rac1 and Cdc42, and the transcription factor, NF-kappaB. The increase in endothelial TM activity in response to pravastatin constitutes a novel pleiotropic (nonlipid-related) effect of this commonly used compound and may be of clinical significance in disorders in which deficient endothelial TM plays a pathophysiological role.

Miocardiopatía diabética

The world-wide estimated prevalence of diabetes mellitus for 2025 is of about 300 million, resulting from a higher prevalence of obesity and sedentary lifestyles in the developed world. The group of cardiovascular diseases is responsible for 80% of deaths among diabetic patients. Several authors have suggested that patients with diabetes mellitus have a predisposition to develop a form of cardiomyopathy, known as <<diabetic cardiomyopathy>>, which is not related to ischemic heart disease or hypertension, and may progress to cardiac failure. Such condition is known to be associated with a poor prognosis in patients with diabetes mellitus. The prevalence appears to be high. Thus, tissue Doppler techniques added to conventional echocardiography assessment have estimated it to be as high as 75%. However, the use of echocardiography as a screening tool in the asymptomatic diabetic population is problematic. Biomarkers of cardiac dysfunction have been proposed for diagnosis. In this article, we have assessed the role of biomarkers in the diagnosis of this condition and proposed a diagnostic algorithm that may be useful for the assessment of asymptomatic patients with diabetes.

Lovastatin-Induced Apoptosis in Macrophages through the Rac1/Cdc42/JNK Pathway

Statins, inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A reductase, have been used successfully in the treatment of hypercholesterolemia for more than a decade. Statins also exhibit overall clinical benefits on cardiovascular diseases independent of their effects on lowering serum cholesterol levels. These beneficial effects of statin therapy are believed to be due, at least in part, to the anti-inflammatory and immunomodulatory roles of statins. Statin treatment reduces the levels of inflammatory markers, decreases the activation and recruitment of immune cells, and delays the progression of atherosclerosis, a chronic inflammatory disease. However, little is known about the direct impact of statins on immune cells, particularly on macrophages. We report that lovastatin, a member of the statin family, effectively induces apoptosis in macrophages. Further investigation of the molecular mechanism has revealed that Rac1 and Cdc42, the small GTPase family members, may play an important role in lovastatin-induced macrophage apoptosis. Moreover, the activation of the JNK pathway may contribute to this event. Our findings provide a better understanding of the molecular basis underlying the anti-inflammatory clinical benefits of statin therapy in cardiovascular diseases.

LDL-cholesterol lowering or HDL-cholesterol raising for cardiovascular prevention

A number of reports have indicated that both lowering low density lipoprotein (LDL)-cholesterol and raising high density lipoprotein (HDL)-cholesterol can result in significant cardiovascular benefit, both in terms of reduction of events and also, to a variable extent, of atheromatous lesions. LDL and HDL have opposite roles in body cholesterol regulation and, in theory, both reduced deposition (LDL reduction) and increased removal (raised HDL) can improve vascular disease. A number of reports over the last 30 years have attempted to quantitate with cholesterol balance/turnover studies, the correlations between LDL and HDL levels and body cholesterol pool sizes. More recently, these studies have evaluated the effects of LDL or HDL changes on cholesterol elimination. Data have, at times, been fully consistent with theoretical expectations, whereas at others they have not. Evaluation of these, at times, historical data provides, however, an important clue to the understanding of current results with different medications for the management of lipoprotein disorders.

Statins in nephrotic syndrome: a new weapon against tissue injury

The nephrotic syndrome is characterized by metabolic disorders leading to an increase in circulating lipoproteins levels. Hypertriglyceridemia and hypercholesterolemia in this case may depend on a reduction in triglyceride-rich lipoproteins catabolism and on an increase in hepatic synthesis of Apo B-containing lipoproteins. These alterations are the starting point of a self-maintaining mechanism, which can accelerate the progression of chronic renal failure. Indeed, hyperlipidemia can affect renal function, increase proteinuria and speed glomerulosclerosis, thus determining a higher risk of progression to dialysis. 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase is the rate-limiting enzyme in cholesterol synthesis from mevalonate and its inhibitors, or statins, can therefore interfere with the above-mentioned consequences of hyperlipidemia. Statins are already well known for their effectiveness on primary cardiovascular prevention, which cannot be explained only through their hypolipemic effect. As far as kidney diseases are concerned, statin therapy has been shown to prevent creatinine clearance decline and to slow renal function loss, particularly in case of proteinuria, and its favorable effect may depend only partially on the attenuation of hyperlipidemia. Statins may therefore confer tissue protection through lipid-independent mechanisms, which can be triggered by other mediators, such as angiotensin receptor blockers. Possible pathways for the protective action of statins, other than any hypocholesterolemic effect, are: cellular apoptosis/proliferation balance, inflammatory cytokines production, and signal transduction regulation. Statins also play a role in the regulation of the inflammatory and immune response, coagulation process, bone turnover, neovascularization, vascular tone, and arterial pressure. In this study, we would like to provide scientific evidences for the pleiotropic effects of statins, which could be the starting point for the development of new therapeutical strategies in different clinical areas.

Diabetic cardiomyopathy: mechanisms, diagnosis and treatment

Independent of the severity of coronary artery disease, diabetic patients have an increased risk of developing heart failure. This clinical entity has been considered to be a distinct disease process referred to as 'diabetic cardiomyopathy'. Experimental studies suggest that extensive metabolic perturbations may underlie both functional and structural alterations of the diabetic myocardium. Translational studies are, however, limited and only partly explain why diabetic patients are at increased risk of cardiomyopathy and heart failure. Although a range of diagnostic methods may help to characterize alterations in cardiac function in general, none are specific for the alterations in diabetes. Treatment paradigms are very much limited to interpretation and translation from the results of interventions in non-diabetic patients with heart failure. This suggests that there is an urgent need to conduct pathogenetic, diagnostic and therapeutic studies specifically in diabetic patients with cardiomyopathy to better understand the factors which initiate and progress diabetic cardiomyopathy and to develop more effective treatments.

Monitoring the cellular effects of HMG-CoA reductase inhibitors in vitro and ex vivo

OBJECTIVE

Inhibition of 3hydroxy3methylglutaryl-coenzyme A (HMG-CoA) reductase by statins and the subsequent reduction in Rho protein isoprenylation inactivates these important signaling molecules. The purpose of this study was to directly monitor statin effects on Rho proteins.

METHODS AND RESULTS

We used biphasic Triton X-114 system, 1-dimensional isoelectric focusing, and 2D-electrophoresis for the separation of modified and nonmodified Rho proteins. These methods were evaluated in human fibroblasts treated with simvastatin. 2D-electrophoresis, which proved to be the most sensitive method, revealed 2 major spots of identical molecular weight but different isoelectric points, with the more basic spot representing the carboxymethylated form of RhoA. In control cells, 90% of RhoA was fully modified (carboxymethylated). After treatment with simvastatin, a significant shift toward the unmethylated form was observed, representing inhibition of isoprenylation, which is a prerequisite to further modification. Similar shifts were observed for Rac1 and Cdc42. In freshly isolated peripheral blood mononuclear cells, a shift toward nonmodified RhoA was observed after treatment with atorvastatin in vitro and in vivo. There was a significant increase in unmethylated RhoA in statin-treated individuals versus control individuals.

CONCLUSIONS

2D-electrophoresis is a sensitive method for detecting changes in the amount of nonisoprenylated Rho proteins, allowing monitoring the direct cellular effects of statins.