Perspective on cataractogenic potential of HMG-CoA reductase inhibitors

The Toxicology of HMG—CoA Reductase Inhibitors: Prediction of Human Risk

The discovery that 3-hydroxy-3-methyglutaryl coenzyme A reductase was a rate-determining step in the biosynthesis of cholesterol led to the discovery of inhibitors of this enzyme. To support the development of these agents (statins) as potential hypocholesterolemic drugs, a variety of preclinical studies were conducted in several animal species. Not unexpectedly due to the central role played by mevalonic acid and its products including cholesterol in development and maintenance of cellular homeostasis, administration of high dosage levels of these agents led to the expression of a broad variety of adverse effects in many different tissues. Using the tools of toxicologic pathology and classical risk assessment, these varied toxicities were evaluated by many groups relative to the conditions of use in human therapy and a perspective was developed on potential human risk. These approaches of mechanism-based risk assessment predicted that most of the adverse effects observed in animals would not be seen under conditions of human use and supported the successful introduction of one of the most important classes of human medicines.

Isoprenoid metabolism in the vertebrate retina

Herein, studies concerning the biosynthesis, intracellular transport and utilization of isoprenoid lipids in vertebrate retinas are reviewed, with particular regard to rod photoreceptor cells and the assembly of rod outer segment (ROS) disk membranes. Initial in vitro studies with bovine retinas showed that [3H]mevalonate is metabolized primarily to squalene and 'methylated' sterols, rather than to cholesterol. Subsequently, similar results were obtained with frog retinas using [3H]acetate as a precursor, and the absolute rate of the sterol pathway was determined in vitro with 3H2O. With the aid of vesicular transport inhibitors, energy poisons, and reduced temperature, it was demonstrated that lipid and protein trafficking mechanisms in the rod cell are separate and independent from one another. In vivo, the majority of newly synthesized squalene in the frog retina is not metabolized to sterols; rather, it is transported to the ROS, where it turns over in parallel with the disk membranes. The remaining squalene is converted slowly to cholesterol, much of which becomes incorporated into the ROS. In contrast, the in vivo metabolism of [3H]acetate to cholesterol in the rat retina is relatively efficient and rapid. However, in both frog and rat, retinal cholesterol turnover is slow (> 60 days), suggesting the existence of a retention mechanism that minimizes the need for de novo biosynthesis. The use of pharmacological approaches to assess the biological roles of isoprenoid lipids and protein prenylation in the retina and the mechanism of retinal cholesterol homeostasis are discussed.

Cholesterol and cataracts

Inherited defects in enzymes of cholesterol metabolism and use of drugs which inhibit lens cholesterol biosynthesis can be associated with cataracts in animals and man. The basis of this relationship apparently lies in the need of the lens to satisfy its sustained requirement for cholesterol by on-site synthesis, and impairing this synthesis can lead to alteration of lens membrane structure. Lens membrane contains the highest cholesterol content of any known membrane. The Smith-Lemli-Opitz syndrome, mevalonic aciduria, and cerebrotendinous xanthomatosis all involve mutations in enzymes of cholesterol metabolism, and affected patients can develop cataracts. Two established models of rodent cataracts are based on treatment with inhibitors of cholesterol biosynthesis. The long-term ocular safety of the very widely used vastatin class of hypocholesterolemic drugs is controversial. Some vastatins are potent inhibitors of cholesterol biosynthesis by animal lenses, can block cholesterol accumulation by these lenses and can produce cataracts in dogs. Whether these drugs inhibit cholesterol biosynthesis in human lenses at therapeutic doses is unknown. Results of clinical trials of 1-5 years duration in older patient populations indicate high ocular safety. However, considering the slow life-long growth of the lens and its continuing need for cholesterol, longterm safety of the vastatins should perhaps be viewed in units of 10 or 20 years, particularly with younger patients.