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Erbay MI, Gamarra Valverde NN, Patel P, Ozkan HS, Wilson A, Banerjee S, Babazade A, Londono V, Sood A, Gupta R. Fish Oil Derivatives in Hypertriglyceridemia: Mechanism and Cardiovascular Prevention: What Do Studies Say? Curr Probl Cardiol 2024; 49:102066. [PMID: 37657524 DOI: 10.1016/j.cpcardiol.2023.102066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 08/26/2023] [Indexed: 09/03/2023]
Abstract
Hypertriglyceridemia is a type of dyslipidemia characterized by high triglyceride levels in the blood and increases the risk of cardiovascular disease. Conventional management includes antilipidemic medications such as statins, lowering LDL and triglyceride levels as well as raising HDL levels. However, the treatment may be stratified using omega-3 fatty acid supplements such as eicosatetraenoic acid (EPA) and docosahexaenoic acid (DHA), aka fish oil derivatives. Studies have shown that fish oil supplements reduce the risk of cardiovascular diseases; however, the underlying mechanism and the extent of reduction in CVD need more clarification. Our paper aims to review the clinical trials and observational studies in the current literature, investigating the use of fish oil and its benefits on the cardiovascular system as well as the proposed underlying mechanism.
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Affiliation(s)
- Muhammed Ibrahim Erbay
- Department of Medicine, Istanbul University Cerrahpasa, Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Norma Nicole Gamarra Valverde
- Department of Medicine, Alberto Hurtado Faculty of Human Medicine, Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Parth Patel
- Department of Medicine, University of Missouri Kansas City School of Medicine, Kansas City, MI
| | - Hasan Selcuk Ozkan
- Department of Medicine, Ege University, School of Medicine, Izmir, Turkey
| | - Andre Wilson
- Department of Medicine, Howard University College of Medicine, Washington, D.C
| | - Suvam Banerjee
- Department of Health and Family Welfare, Burdwan Medical College and Hospital, The West Bengal University of Health Sciences, Government of West Bengal, India
| | - Aydan Babazade
- Department of Medicine, Azerbaijan Medical University, School of Medicine, Baku, Azerbaijan
| | - Valeria Londono
- Department of Medicine, Georgetown University School of Medicine, Washington, D.C
| | - Aayushi Sood
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA
| | - Rahul Gupta
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA.
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Ambrosy AP, Malik UI, Thomas RC, Parikh RV, Tan TC, Goh CH, Selby VN, Solomon MD, Avula HR, Fitzpatrick JK, Skarbinski J, Philip S, Granowitz C, Bhatt DL, Go AS. Rationale and design of the pragmatic randomized trial of icosapent ethyl for high cardiovascular risk adults (MITIGATE). Am Heart J 2021; 235:54-64. [PMID: 33516752 PMCID: PMC7843090 DOI: 10.1016/j.ahj.2021.01.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 01/25/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The MITIGATE study aims to evaluate the real-world clinical effectiveness of pre-treatment with icosapent ethyl (IPE), compared with usual care, on laboratory-confirmed viral upper respiratory infection (URI)-related morbidity and mortality in adults with established atherosclerotic cardiovascular disease (ASCVD). BACKGROUND IPE is a highly purified and stable omega-3 fatty acid prescription medication that is approved for cardiovascular risk reduction in high-risk adults on statin therapy with elevated triglycerides. Preclinical data and clinical observations suggest that IPE may have pleiotropic effects including antiviral and anti-inflammatory properties that may prevent or reduce the downstream sequelae and cardiopulmonary consequences of viral URIs. METHODS MITIGATE is a virtual, electronic health record-based, open-label, randomized, pragmatic clinical trial enrolling ∼16,500 participants within Kaiser Permanente Northern California - a fully integrated and learning health care delivery system with 21 hospitals and >255 ambulatory clinics serving ∼4.5 million members. Adults ≥50 years with established ASCVD and no prior history of coronavirus disease 2019 (COVID-19) will be prospectively identified and pre-randomized in a 1:10 allocation ratio (∼ 1,500 IPE: ∼15,000 usual care) stratified by age and previous respiratory health status to the intervention (IPE 2 grams by mouth twice daily with meals) vs the control group (usual care) for a minimum follow-up duration of 6 months. The co-primary endpoints are moderate-to-severe laboratory-confirmed viral URI and worst clinical status due to a viral URI at any point in time. CONCLUSION The MITIGATE study will inform clinical practice by providing evidence on the real-world clinical effectiveness of pretreatment with IPE to prevent and/or reduce the sequelae of laboratory-confirmed viral URIs in a high-risk cohort of patients with established ASCVD.
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Affiliation(s)
- Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA; Division of Research, Kaiser Permanente Northern California, Oakland, CA.
| | - Umar I Malik
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Rachel C Thomas
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Rishi V Parikh
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Thida C Tan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Choon H Goh
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Van N Selby
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Matthew D Solomon
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Cardiology, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Harshith R Avula
- Department of Cardiology, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA
| | - Jesse K Fitzpatrick
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Jacek Skarbinski
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Infectious Disease, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | | | | | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA; Departments of Medicine (Nephrology), Epidemiology, and Biostatistics, University of California, San Francisco, San Francisco, CA; Department of Medicine (Nephrology), Stanford University, Palo Alto, CA
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Lakshmanan S, Budoff MJ. The Evolving Role of Omega 3 Fatty Acids in Cardiovascular Disease: Is Icosapent Ethyl the Answer? Heart Int 2021; 15:7-13. [DOI: 10.17925/hi.2021.15.1.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 02/18/2021] [Indexed: 11/24/2022] Open
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Suh W, Urits I, Viswanath O, Kaye AD, Patel H, Hall W, Eskander JP. Three Cases of COVID-19 Pneumonia That Responded to Icosapent Ethyl Supportive Treatment. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e928422. [PMID: 33311431 PMCID: PMC7751801 DOI: 10.12659/ajcr.928422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/17/2020] [Accepted: 10/09/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Icosapent ethyl, a form of eicosapentaenoic acid with anti-inflammatory activity, has been approved as an adjunctive treatment with statins in patients with hypertriglyceridemia. Icosapent ethyl is currently undergoing clinical trials to determine its anti-inflammatory effects in patients with coronavirus disease 2019 (COVID-19). This report describes 3 intensive care unit (ICU) patients with moderate to severe COVID-19 pneumonia treated with icosapent ethyl as part of their supportive care who had favorable outcomes. CASE REPORT Case 1 was a 75-year-old man with a past medical history of hyperlipidemia, hypertension, type 2 diabetes mellitus, obesity, and benign prostatic hyperplasia. Case 2 was a 23-year old man with a past medical history of type 2 diabetes mellitus and obesity. Case 3 was a 24-year old man with a history of autism. All cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were confirmed from a nasopharyngeal swab using the Becton Dickinson nasopharyngeal reverse-transcription polymerase chain reaction. All patients in these cases were treated with a course of 2 g of icosapent ethyl twice a day by nasogastric tube. CONCLUSIONS This report of 3 cases describes the use of icosapent ethyl as a component of supportive treatments in ICU patients with moderate to severe COVID-19 pneumonia. However, as of yet there are no evidence-based treatments for SARS-CoV-2 infection from controlled clinical trials. The outcomes of ongoing clinical trials are awaited to determine whether icosapent ethyl has anti-inflammatory effects in patients with SARS-CoV-2 infection and which patients might benefit from the use of this adjunctive treatment.
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Affiliation(s)
- Winston Suh
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, U.S.A
| | - Ivan Urits
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, U.S.A
| | - Omar Viswanath
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, U.S.A
- University of Arizona College of Medicine-Phoenix, Phoenix, AZ, U.S.A
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, U.S.A
- Valley Anesthesiology and Pain Consultants–Envision Physician Services, Phoenix, AZ, U.S.A
| | - Alan D. Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, U.S.A
| | - Haresh Patel
- Department of Critical Care Medicine, Maryview Medical Center, Portsmouth, VA, U.S.A
| | - Wade Hall
- Old Dominion University, Norfolk, VA, U.S.A
| | - Jonathan P. Eskander
- Department of Anesthesiology and Pain Medicine, Portsmouth Anesthesia Associates, Portsmouth, VA, U.S.A
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Berger AA, Sherburne R, Urits I, Patel H, Eskander J. Icosapent Ethyl (Vascepa®) for the Treatment of Acute, Severe Pancreatitis. Cureus 2020; 12:e11551. [PMID: 33365220 PMCID: PMC7748593 DOI: 10.7759/cureus.11551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Acute pancreatitis is the most common gastrointestinal pathology that warrants hospital admission, with an estimated incidence of 13-45/100,000 annually in the US. The overall mortality is low but is significantly increased in 15-25% of patients that develop severe disease, likely secondary to an increase in inflammation and an exaggerated response, sometimes referred to as a cytokine storm. Management is largely supportive, and no specific cure exists to hasten recovery. Icosapent Ethyl (IPE, Vascepa®) is an omega-3 fatty acid derivative that is indicated for the treatment of hypertriglyceridemia and has been shown to improve mortality from cardiovascular causes, likely through an anti-inflammatory mechanism. We report here a case of very severe, abrupt acute alcoholic pancreatitis in a 31-year-old male, requiring intensive care unit admission, ventilation, and support with multiple vasoactive medications. Shortly after the initiation of IPE, the patient started to improve and ultimately made a complete recovery. His initially greatly elevated inflammatory markers downtrended quickly under IPE treatment and he followed with a remarkable clinical recovery. Several previous studies, such as the Patients With Persistent High Triglyceride Levels (≥ 200 mg/dL and < 500 mg/dL) Despite Statin Therapy (ANCHOR; NCT01047501) and the Multi-Center, PlAcebo-Controlled, Randomized, Double-BlINd, 12-week study with an open-label Extension (MARINE; NCT01047683), provided evidence of the anti-inflammatory activity of IPE. In our case, we provide the first evidence to support its use as a direct anti-inflammatory in severe disease. With the absence of direct therapy and the significant mortality from severe acute pancreatitis, IPE can be a breakthrough therapy. Its treatment is not limited to pancreatitis only, and it may also be beneficial in other cases of severe inflammation. Though anecdotal, this case provides evidence to support further study of IPE in states of exaggerated inflammation.
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Affiliation(s)
- Amnon A Berger
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Robert Sherburne
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Ivan Urits
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Haresh Patel
- Critical Care Medicine, Maryview Medical Center, Portsmouth, USA
| | - Jonathan Eskander
- Anesthesiology and Pain Medicine, Portsmouth Anesthesia Associates, Portsmouth, USA
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Berger AA, Sherburne R, Urits I, Patel H, Eskander J. Icosapent Ethyl - A Successful Treatment for Symptomatic COVID-19 Infection. Cureus 2020; 12:e10211. [PMID: 33033686 PMCID: PMC7532870 DOI: 10.7759/cureus.10211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
COVID-19 is a fatal, universal pandemic caused by the SARS-CoV-2 virus that has directly caused at least 95,235 deaths in the US by May 2020. It has a poor prognosis with a mortality rate as high as 21% in the general population at the height of the pandemic, a rate that is much higher in elderly patients, as well as those requiring intensive care unit (ICU) care. The role of inflammation in symptomatic COVID-19 is being studied, and it is hypothesized that hyper-inflammation is a causative factor in severe COVID-19 disease. Treatment options are limited and mostly rely on supportive care. Icosapent ethyl (IPE) is an Omega-3 fatty acid derivative that has been shown to significantly reduce cardiovascular mortality and is used as an adjunct to statin therapy. Though it has been shown to act as an anti-inflammatory, it is not currently indicated for that purpose. Here, we describe, for the first time, the successful treatment of a COVID-19 patient with IPE.
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Affiliation(s)
- Amnon A Berger
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Robert Sherburne
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Ivan Urits
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Haresh Patel
- Critical Care Medicine, Maryview Medical Center, Portsmouth, USA
| | - Jonathan Eskander
- Anesthesiology and Pain Medicine, Portsmouth Anesthesia Associates, Portsmouth, USA
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Sirtori CR, Yamashita S, Greco MF, Corsini A, Watts GF, Ruscica M. Recent advances in synthetic pharmacotherapies for dyslipidaemias. Eur J Prev Cardiol 2019; 27:1576-1596. [DOI: 10.1177/2047487319845314] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Despite the demonstrated benefits of statins and injectable biologics, there is a need for new and safe oral agents for addressing classical lipid targets, low-density lipoprotein cholesterol (LDL-C), triglycerides and high-density lipoprotein cholesterol (HDL-C). LDL-C is unquestionably causal in the development of atherogenesis and atherosclerotic cardiovascular disease, but new options are required to address triglyceride-rich lipoproteins and lipoprotein(a). For hypercholesterolaemia, pitavastatin provides a very low dose and potent statin that does not adversely affect glucose metabolism; bempedoic acid acts at a biochemical step preceding hydroxymethylglutaryl-CoA reductase and is not associated with muscular side effects. For hypertriglyceridaemia, pemafibrate displays a unique and selective agonist activity on peroxisomal proliferator activated receptor-α that does not elevate homocysteine or creatinine. Although omega-3 fatty acids supplementation is not effective in secondary prevention, high dose eicosapentaenoic ethyl ester can lead to a remarkable fall in first and recurrent events in high risk patients with hypertriglyceridaemia/low HDL-C. Gemcabene, a dicarboxylic acid regulating apolipoprotein B-100, is effective in reducing both cholesterol and triglycerides. Among cholesteryl ester transfer protein antagonists that elevate HDL-C, only anacetrapib reduces cardiovascular events. Probucol stimulates reverse cholesteryl ester transport, lowers LDL-C stabilizing plaques and may lower incidence of cardiovascular events. These agents, which act through novel mechanisms, afford good and potentially safe treatment choices that may increase adherence and the attainment of therapeutic targets.
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Affiliation(s)
- Cesare R Sirtori
- Centro Dislipidemie, A.S.S.T. Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Shizuya Yamashita
- Rinku General Medical Centre, Izumisano, Japan
- Department of Community Medicine, Osaka University Graduate School of Medicine, Suita, Japan
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Maria Francesca Greco
- Department of Pharmacological and Bimolecular Sciences, Università degli Studi di Milano, Milan, Italy
| | - Alberto Corsini
- Department of Pharmacological and Bimolecular Sciences, Università degli Studi di Milano, Milan, Italy
- Multimedica, IRCCS, Sesto San Giovanni, MI, Italy
| | - Gerald F Watts
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
- Lipid Disorders Clinic, Cardiometabolic Services, Department of Cardiology, Royal Perth Hospital, Australia
| | - Massimiliano Ruscica
- Department of Pharmacological and Bimolecular Sciences, Università degli Studi di Milano, Milan, Italy
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Doggrell SA. Clinical trials of eicosapentaenoic acid (EPA) prescription products for the treatment of hypertriglyceridemia. Expert Opin Pharmacother 2019; 20:1221-1225. [DOI: 10.1080/14656566.2019.1609942] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Sheila A Doggrell
- Faculty of Health, Queensland University of Technology, Brisbane, Australia
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Botta M, Audano M, Sahebkar A, Sirtori CR, Mitro N, Ruscica M. PPAR Agonists and Metabolic Syndrome: An Established Role? Int J Mol Sci 2018; 19:E1197. [PMID: 29662003 PMCID: PMC5979533 DOI: 10.3390/ijms19041197] [Citation(s) in RCA: 156] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 04/10/2018] [Accepted: 04/11/2018] [Indexed: 12/14/2022] Open
Abstract
Therapeutic approaches to metabolic syndrome (MetS) are numerous and may target lipoproteins, blood pressure or anthropometric indices. Peroxisome proliferator-activated receptors (PPARs) are involved in the metabolic regulation of lipid and lipoprotein levels, i.e., triglycerides (TGs), blood glucose, and abdominal adiposity. PPARs may be classified into the α, β/δ and γ subtypes. The PPAR-α agonists, mainly fibrates (including newer molecules such as pemafibrate) and omega-3 fatty acids, are powerful TG-lowering agents. They mainly affect TG catabolism and, particularly with fibrates, raise the levels of high-density lipoprotein cholesterol (HDL-C). PPAR-γ agonists, mainly glitazones, show a smaller activity on TGs but are powerful glucose-lowering agents. Newer PPAR-α/δ agonists, e.g., elafibranor, have been designed to achieve single drugs with TG-lowering and HDL-C-raising effects, in addition to the insulin-sensitizing and antihyperglycemic effects of glitazones. They also hold promise for the treatment of non-alcoholic fatty liver disease (NAFLD) which is closely associated with the MetS. The PPAR system thus offers an important hope in the management of atherogenic dyslipidemias, although concerns regarding potential adverse events such as the rise of plasma creatinine, gallstone formation, drug-drug interactions (i.e., gemfibrozil) and myopathy should also be acknowledged.
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Affiliation(s)
- Margherita Botta
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133 Milan, Italy.
| | - Matteo Audano
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133 Milan, Italy.
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad 9177948564, Iran.
- Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad 9177948564, Iran.
- School of Pharmacy, Mashhad University of Medical Sciences, Mashhad 9177948564, Iran.
| | - Cesare R Sirtori
- Centro Dislipidemie, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy.
| | - Nico Mitro
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133 Milan, Italy.
| | - Massimiliano Ruscica
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133 Milan, Italy.
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Abstract
PURPOSE OF REVIEW We provide an overview of current evidence about the independent role of high triglyceride levels for cardiovascular risk and for acute pancreatitis. RECENT FINDINGS Natural experiments of Mendelian randomization have given us a deeper understanding about the molecular pathways involved in triglyceride metabolism. Individuals with low-triglyceride levels generally have lower rates of cardiovascular disease (CVD). There has been a significant growth in the development of new agents that modulate enzymes involved in a variety of aspects of triglyceride packaging into VLDL or chylomicron particles, and triglyceride catabolism. Antisense inhibitors of apolipoprotein CIII are being tested, as are a variety of agents designed to increase lipoprotein lipase activity. Large-scale trials are underway with purified fatty acid (FA) formulations in over 20 000 individuals in aggregate. A large study of a new fibrate is underway. SUMMARY A focus on patients with elevated triglyceride levels is a new paradigm not previously the focus of large trials. Clinical outcome data on cardiovascular risk reductions remains sparse. Some drugs are already approved for use in rare inherited disorders predisposing to severe hypertriglyceridaemia and acute pancreatitis. Safety and costs issues are critical.
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Affiliation(s)
- Anthony C Keech
- aNHMRC Clinical Trials Centre, The University of Sydney bDepartment of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales cDepartment of Diabetes and Endocrinology, St. Vincents Health, Melbourne, Victoria, Australia
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Abstract
PURPOSE OF REVIEW We provide an overview of orally administered lipid-lowering therapies under development. RECENT FINDINGS Recent data support statins for intermediate risk primary prevention, and ezetimibe for high-risk secondary prevention. Novel agents in development include bempedoic acid and gemcabene, and work continues on one remaining cholesteryl ester transfer protein inhibitor, anacetrapib, to determine whether this class can reduce cardiovascular risk. Selective peroxisome proliferator-activated receptor modulators such as K-877 are under study to determine whether they have an advantage over older fibrates. Diacylglycerol transferase inhibitors such as pradigastat appear to have potent triglyceride-lowering effects, even for patients with familial chylomicronemia syndrome. Finally, novel ω-3 preparations are available with significant triglyceride lowering, although their role in therapy remains unclear. SUMMARY Statins will remain the backbone of lipid-lowering therapy, although several novel oral agents are promising. The common theme across drugs in development is the demonstration of good lipid-lowering effect, although lacking cardiovascular outcomes data, which will likely be necessary before any of them, can be recommended or approved for widespread use.
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Affiliation(s)
- Steven E Gryn
- Department of Medicine, Schulich School of Medicine and Dentistry, London Health Sciences Centre-University Hospital, Western University, London, Ontario, Canada
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Crandell JR, Tartaglia C, Tartaglia J. Lipid effects of switching from prescription EPA+DHA (omega-3-acid ethyl esters) to prescription EPA only (icosapent ethyl) in dyslipidemic patients. Postgrad Med 2016; 128:859-864. [PMID: 27684412 DOI: 10.1080/00325481.2016.1241129] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Residual cardiovascular risk and persistently elevated triglycerides (TGs) may remain despite statin therapy in patients with dyslipidemia. Prescription omega-3 fatty acid formulations containing docosahexaenoic acid (DHA) and/or eicosapentaenoic acid (EPA) have been shown to reduce TGs and may potentially lower residual cardiovascular risk. However, DHA may raise low-density lipoprotein cholesterol (LDL-C) and compromise treatment goals. Icosapent ethyl (Vascepa®), a high-purity prescription EPA formulation, has been shown to lower TGs and other lipid parameters without raising LDL-C. There are no prospective, randomized, controlled trials of the effects of switching patients from omega-3-acid ethyl esters (Lovaza®), a prescription formulation containing EPA+DHA, to icosapent ethyl. METHODS This retrospective chart review included records of high-risk patients aged ≥18 years receiving stable statin therapy for dyslipidemia who had been switched from prescription omega-3-acid ethyl esters 4 g/day to prescription icosapent ethyl 4 g/day and had available laboratory lipid profiles after receiving each for ≥2 months. Lipid assessments were conducted by local laboratories. Patient records were excluded if there were changes in medication or health condition that could affect lipid parameters. RESULTS The records of 8 patients (6 women and 2 men; 54-83 years) met eligibility criteria. Following the switch to icosapent ethyl, LDL-C changes ranged from +3.2% to -69.1% (reduced in 7 patients), total cholesterol was reduced in all patients (-3.5% to -44.3%), and TG changes ranged from +32.4% to -59.0% (reduced in 6 patients). Decreases or no changes in non-high-density lipoprotein cholesterol were observed; changes in high-density lipoprotein cholesterol varied. No adverse events related to either product were reported. CONCLUSION In this real-world retrospective analysis, switching high-risk statin-treated patients from omega-3-acid ethyl esters to icosapent ethyl resulted in favorable lipid changes. The analysis was limited by the small patient numbers, but lipid results were consistent with randomized controlled trials and previous case series.
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Chiesa G, Busnelli M, Manzini S, Parolini C. Nutraceuticals and Bioactive Components from Fish for Dyslipidemia and Cardiovascular Risk Reduction. Mar Drugs 2016; 14:md14060113. [PMID: 27338419 PMCID: PMC4926072 DOI: 10.3390/md14060113] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/11/2016] [Accepted: 05/26/2016] [Indexed: 12/12/2022] Open
Abstract
Cardiovascular disease remains the most common health problem in developed countries, and residual risk after implementing all current therapies is still high. Permanent changes in lifestyle may be hard to achieve and people may not always be motivated enough to make the recommended modifications. Emerging research has explored the application of natural food-based strategies in disease management. In recent years, much focus has been placed on the beneficial effects of fish consumption. Many of the positive effects of fish consumption on dyslipidemia and heart diseases have been attributed to n-3 polyunsaturated fatty acids (n-3 PUFAs, i.e., EPA and DHA); however, fish is also an excellent source of protein and, recently, fish protein hydrolysates containing bioactive peptides have shown promising activities for the prevention/management of cardiovascular disease and associated health complications. The present review will focus on n-3 PUFAs and bioactive peptides effects on cardiovascular disease risk factors. Moreover, since considerable controversy exists regarding the association between n-3 PUFAs and major cardiovascular endpoints, we have also reviewed the main clinical trials supporting or not this association.
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Affiliation(s)
- Giulia Chiesa
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, via Balzaretti 9, Milano 20133, Italy.
| | - Marco Busnelli
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, via Balzaretti 9, Milano 20133, Italy.
| | - Stefano Manzini
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, via Balzaretti 9, Milano 20133, Italy.
| | - Cinzia Parolini
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, via Balzaretti 9, Milano 20133, Italy.
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Tajuddin N, Shaikh A, Hassan A. Prescription omega-3 fatty acid products: considerations for patients with diabetes mellitus. Diabetes Metab Syndr Obes 2016; 9:109-18. [PMID: 27143943 PMCID: PMC4846047 DOI: 10.2147/dmso.s97036] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) and metabolic syndrome contribute to hypertriglyceridemia, which may increase residual risk of cardiovascular disease in patients with elevated triglyceride (TG) levels despite optimal low-density lipoprotein cholesterol (LDL-C) levels with statin therapy. Prescription products containing the long-chain omega-3 fatty acids (OM3FAs) eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are an effective strategy for reducing TG levels. This article provides an overview of prescription OM3FAs, including relevant clinical data in patients with T2DM and/or metabolic syndrome. Prescription OM3FAs contain either combinations of DHA and EPA (omega-3-acid ethyl esters, omega-3-carboxylic acids, omega-3-acid ethyl esters A) or EPA alone (icosapent ethyl). These products are well tolerated and can be used safely with statins. Randomized controlled trials have demonstrated that all prescription OM3FAs produce statistically significant reductions in TG levels compared with placebo; however, differential effects on LDL-C levels have been reported. Products containing DHA may increase LDL-C levels, whereas the EPA-only product did not increase LDL-C levels compared with placebo. Because increases in LDL-C levels may be unwanted in patients with T2DM and/or dyslipidemia, the EPA-only product should not be replaced with products containing DHA. Available data on the effects of OM3FAs in patients with diabetes and/or metabolic syndrome support that these products can be used safely in patients with T2DM and have beneficial effects on atherogenic parameters; in particular, the EPA-only prescription product significantly reduced TG, non-high-density lipoprotein cholesterol, Apo B, remnant lipoprotein cholesterol, and high-sensitivity CRP levels without increasing LDL-C levels compared with placebo. Ongoing studies of the effects of prescription OM3FAs on cardiovascular outcomes will help determine whether these products will emerge as effective add-on options to statin therapy for reduction of residual cardiovascular disease risk.
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Affiliation(s)
- Nadeem Tajuddin
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Ali Shaikh
- Clinic of Endocrinology, Houston, TX, USA
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Lyseng-Williamson K, McCormack PL, Kim ES. Icosapent ethyl in hypertriglyceridaemia: a guide to its use. DRUGS & THERAPY PERSPECTIVES 2016. [DOI: 10.1007/s40267-016-0278-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
PURPOSE OF REVIEW We provide an overview of recent advances in the therapy of hypertriglyceridemia, focusing on several new therapies with potential for treating of familial chylomicronemia, other forms of hypertriglyceridemia, and for triglyceride-lowering in patients with other lipid disorders. RECENT FINDINGS Newer triglyceride-lowering modalities under evaluation include gene therapy for lipoprotein lipase deficiency (alipogene tiparvovec), and antisense oligonucleotides against mRNA for apolipoproteins B (mipomersen) and C3 (volanesorsen, ISIS 304801). Other potential therapies include small molecule inhibitors of microsomal triglyceride transfer protein (lomitapide) and diacylglycerol acyltransferase-1 (pradigastat), and a monoclonal antibody against angiopoietin-like protein 3 (REGN1500). There is also renewed interest in omega-3 fatty acids, and in developing potent and selective agonists of peroxisome proliferator-activated receptors. SUMMARY Several promising triglyceride-lowering therapies are at various stages of development; a few are even available in some markets. Although existing data suggest good biochemical efficacy, data on long-term clinical outcomes are still limited. For some therapies, cost will be an important consideration, and use will likely be restricted to orphan indications, for example very severe cases of hypertriglyceridemia as seen in familial chylomicronemia syndrome, although some therapies could theoretically be more broadly used one day for cardiovascular disease prevention.
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Affiliation(s)
- Steven E Gryn
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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Kedia AW, Lynch E. Effects of switching from omega-3-acid ethyl esters to icosapent ethyl in a statin-treated patient with elevated triglycerides. Postgrad Med 2015; 127:869-73. [DOI: 10.1080/00325481.2015.1100086] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Borow KM, Nelson JR, Mason RP. Biologic plausibility, cellular effects, and molecular mechanisms of eicosapentaenoic acid (EPA) in atherosclerosis. Atherosclerosis 2015; 242:357-66. [DOI: 10.1016/j.atherosclerosis.2015.07.035] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 07/06/2015] [Accepted: 07/20/2015] [Indexed: 01/08/2023]
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