Hypertriglyceridemia-Associated Pancreatitis: New Concepts and Potential Mechanisms

Probiotics and triglyceride manipulation: potential implications for alleviating hypertriglyceridemia

BACKGROUND

Hypertriglyceridemia is one of the most prevalent lipid abnormalities encountered in clinical practice. Although many monogenic disorders causing severe hypertriglyceridemia have been identified, in most patients, triglyceride elevations result from a combination of multiple genetic variations with small effects and environmental factors. Common secondary causes include obesity, uncontrolled diabetes, alcohol abuse, high-fat foods, and the use of various commonly prescribed drugs. Notably, manipulating the gut microbiota through probiotic intervention may reduce triglyceride levels by targeting intestinal lipid absorption and host lipid metabolism.

AIM OF REVIEW

This paper reviews recent animal and human studies on probiotic interventions, summarizing the mechanisms through which probiotics reduce triglyceride levels and exploring the potential of next-generation probiotics in alleviating hypertriglyceridemia.

KEY SCIENTIFIC CONCEPTS OF REVIEW

To discuss the link between gut microbiota and hypertriglyceridemia and the next generation of probiotics with the potential to reduce hypertriglyceridemia. Meanwhile, we also elucidate the mechanisms through which probiotics and their metabolites, such as short-chain fatty acids and bile acids, mediate multiple pathways to reduce triglyceride levels. Finally, the challenges and prospects of the application of probiotics were prospected.

Recognition and management of persistent chylomicronemia: A joint expert clinical consensus by the National Lipid Association and the American Society for Preventive Cardiology

Extreme hypertriglyceridemia, defined as triglyceride (TG) levels ≥1000 mg/dL, is almost always indicative of chylomicronemia. The current diagnostic approach categorizes individuals with chylomicronemia into familial chylomicronemia syndrome (FCS; prevalence 1-10 per million), caused by the biallelic combination of pathogenic variants that impair the lipolytic action of lipoprotein lipase (LPL), or multifactorial chylomicronemia syndrome (MCS, 1 in 500). A pragmatic framework should emphasize the severity of the phenotype and the risk of complications. Therefore, we endorse the term "persistent chylomicronemia" defined as TG ≥1000 mg/dL in more than half of the measurements to encompass patients with the highest risk for pancreatitis, regardless of their genetic predisposition. We suggest classification of PC into four subtypes: 1) genetic FCS, 2) clinical FCS, 3) PC with "alarm" features, and 4) PC without alarm features. Although patients with FCS most likely have PC, the vast majority with PC do not have genetic FCS. Proposed alarm features are: (a) history of recurrent TG-induced acute pancreatitis, (b) recurrent hospitalizations for severe abdominal pain without another identified cause, (c) childhood pancreatitis, (d) family history of TG-induced pancreatitis, and/or (e) post-heparin LPL activity <20 % of normal value. Alarm features constitute the strongest risk factors for future acute pancreatitis risk. Patients with PC and alarm features have very high risk of pancreatitis, comparable to that in patients with FCS. Effective, innovative treatments for PC, like apoC-III inhibitors, have been developed. Combined with lifestyle modifications, these agents markedly lower TG levels and risk of pancreatitis in the very-high-risk groups, irrespective of the monogenic etiology. Pragmatic definitions, education, and focus on patients with PC specifically those with alarm features could help mitigate the risk of acute pancreatitis and other complications.

Nicotinamide mononucleotide ameliorates hypertriglyceridemia pancreatitis via NAD+/SIRT1-mediated TXNIP suppression and NOTCH pathway for accelerated repair-associated processes

BACKGROUND & AIMS

Acute pancreatitis (AP) is a life-threatening condition, and hypertriglyceridemia (HTG) is recognized as a factor exacerbating AP and impeding pancreatic regeneration. Nicotinamide mononucleotide (NMN), a precursor in the biosynthesis of nicotinamide adenine dinucleotide (NAD+), is extensively utilized to restore NAD+ levels. However, the impact of NMN on HTG-AP has not been previously addressed, which prompted our investigation into its effects and underlying mechanisms in this study.

METHODS & RESULTS

Here, through bioinformatics analysis and in vivo experiments, we identified abnormalities in the thioredoxin system. In vitro studies revealed that NMN rescued oleic acid (OA)- and palmitic acid (PA)-induced mitochondrial dysfunction and cellular injury in pancreatic acinar cells by suppressing thioredoxin-interacting protein (TXNIP) through NAD+/sirtuin 1 (SIRT1) signaling. Repeated administration of NMN significantly ameliorated P407 and caerulein (CER)-induced pancreatic injury and dysfunction in mice. Consistently, NMN exhibited the potential to reduce inflammatory responses, lower serum lipid levels, and mitigate the accumulation of reactive oxygen species (ROS). More importantly, sustained NMN treatment inhibited the NOTCH pathway and promoted M2-type macrophage dominance during the pancreatic repair phase, influencing early or late macrophage polarization, which significantly enhanced inflammation resolution. As expected, in vitro models using mouse bone marrow-derived macrophage (BMDM), RAW 264.7, and THP-1 cells confirmed that NMN influences macrophage phenotype through the NOTCH pathway.

CONCLUSIONS

Therefore, NMN ameliorates pancreatic acinar cell injury via NAD+/SIRT1-mediated TXNIP suppression and may influence macrophage polarization by inhibiting NOTCH activation, offering a novel therapeutic strategy for the treatment and repair of HTG-AP.

A systematic review of the epidemiology and risk factors for severity and recurrence of hypertriglyceridemia-induced acute pancreatitis

This systematic review aims to comprehensively assess the epidemiology and identify risk factors associated with the severity and recurrence of hypertriglyceridemia-induced acute pancreatitis (HTG-AP). A search of PubMed, Web of Science, and Cochrane databases was conducted to identify all relevant randomized controlled trials (RCTs), prospective, or retrospective cohort studies on HTG-AP. Data related to epidemiology and risk factors for severity and recurrence of HTG-AP were extracted and analyzed. Seventy-seven studies met the inclusion criteria, comprising 1 RCT, 21 prospective studies, and 55 retrospective studies. A total of 56,617 acute pancreatitis (AP) patients were included, of which 19.99% were diagnosed with HTG-AP (n = 11,315). Compared to non-HTG-AP patients, HTG-AP patients were more likely to be male (68.7% vs. 57.3%) and younger (mean age 41.47 ± 4.32 vs. 50.25 ± 7.70 years). HTG-AP patients exhibited higher mortality rates (up to 20% vs. 15.2%), increased severity (8.3% to 100% vs. 3.8% to 47.2%), and higher recurrence rates (up to 64.8% vs. 23.3%). Analysis of temporal trends from 2002 to 2023 showed a range of HTG-AP prevalence in overall AP patients from 1.6% to 47.6%, with a slight upward trend that was not statistically significant (P = 0.1081). Regional analysis indicated relatively stable prevalence in North America (P = 0.5787), Europe (P = 0.0881), other regions (P = 0.738), while prevalence in China showed a significant increase (P = 0.0119). Thirteen studies investigated risk factors affecting HTG-AP severity, with elevated serum triglyceride (TG) levels associated with increased risk of complications such as pancreatic necrosis, systemic inflammatory response syndrome (SIRS), shock, and multi-organ failure. Additional factors including high neutrophil-to-lymphocyte ratio (NLR), elevated levels of amylase and C-reactive protein (CRP), hypocalcemia, and hypoalbuminemia were also implicated in HTG-AP severity. Smoking history, poor lipid control (TG > 3.1 mmol/L), or recurrent hypertriglyceridemia during follow-up were identified as potential predictors of HTG-AP recurrence. Our findings indicate a stable global prevalence of HTG-AP within AP patients, but a notable increase in China, possibly attributed to socio-economic and dietary factors.

Genetic determinants of pancreatitis risk in hypertriglyceridemia

PURPOSE OF REVIEW

In recent years, studies have shed light on the concept of risk heterogeneity among patients with severe hypertriglyceridemia (HTG). Several clinical risk factors for acute pancreatitis have been identified in this population, but the importance of different genetic factors above and beyond triglyceride concentration remains unclear. This review endeavours to summarize recent developments in this field.

RECENT FINDINGS

Recent studies suggest that the molecular basis of severe HTG (polygenic susceptibility vs. rare pathogenic variants) can modulate the risk of acute pancreatitis independently of triglyceride level. Furthermore, a pancreatitis polygenic risk score has been developed and validated using data from the largest GWAS meta-analysis of acute pancreatitis published to date. In patients with severe HTG, a high polygenic susceptibility for pancreatitis was associated with a three-fold increased risk of acute pancreatitis compared with those with a lower polygenic risk score.

SUMMARY

In the past months, there have been substantial advances in understanding the prediction of acute pancreatitis in patients with severe HTG. However, further efforts at developing risk-stratification strategies and predictive models may help identifying the patients who would benefit most from early and effective interventions to reduce the risk of pancreatitis, including treatment with APOC3 inhibitors.

Recognition and management of persistent chylomicronemia: A joint expert clinical consensus by the National Lipid Association and the American Society for Preventive Cardiology

Extreme hypertriglyceridemia, defined as triglyceride (TG) levels ≥1000 mg/dL, is almost always indicative of chylomicronemia. The current diagnostic approach categorizes individuals with chylomicronemia into familial chylomicronemia syndrome (FCS; prevalence 1-10 per million), caused by the biallelic combination of pathogenic variants that impair the lipolytic action of lipoprotein lipase (LPL), or multifactorial chylomicronemia syndrome (MCS, 1 in 500). A pragmatic framework should emphasize the severity of the phenotype and the risk of complications. Therefore, we endorse the term "persistent chylomicronemia (PC)" defined as TG ≥1000 mg/dL in more than half of the measurements to encompass patients with the highest risk for pancreatitis, regardless of their genetic predisposition. We suggest classification of PC into 4 subtypes: (1) genetic FCS, (2) clinical FCS, (3) PC with "alarm" features, and (4) PC without alarm features. Although patients with FCS most likely have PC, the vast majority with PC do not have genetic FCS. Proposed alarm features are: (a) history of recurrent TG-induced acute pancreatitis, (b) recurrent hospitalizations for severe abdominal pain without another identified cause, (c) childhood pancreatitis, (d) family history of TG-induced pancreatitis, and/or (e) postheparin LPL activity <20% of normal value. Alarm features constitute the strongest risk factors for future acute pancreatitis risk. Patients with PC and alarm features have very high risk of pancreatitis, comparable to that in patients with FCS. Effective, innovative treatments for PC, like apolipoprotein C-III inhibitors, have been developed. Combined with lifestyle modifications, these agents markedly lower TG levels and risk of pancreatitis in the very-high-risk groups, irrespective of the monogenic etiology. Pragmatic definitions, education, and focus on patients with PC, specifically those with alarm features, could help mitigate the risk of acute pancreatitis and other complications.

LESS IS MORE: classified management of hypertriglyceridemia-induced acute pancreatitis on the basis of a propensity score matching cohort study

BACKGROUND

Effective management of hypertriglyceridemia is crucial in the treatment of hypertriglyceridemia-induced acute pancreatitis (HTG-AP). The prognosis of HTG-AP may vary with different serum triglyceride levels, suggesting the need for stratified treatment approaches. In this study, we investigated hypertriglyceridemia management in HTG-AP patients and the optimal strategy.

METHODS

Patients with HTG-AP from October 2020 to October 2022 were included in the study. Propensity score matching was used to balance the bias and confounding variables. A mixed-effects model was used to analyse the decreasing tendency of triglycerides.

RESULTS

A total of 171 patients who were diagnosed with HTG-AP were enrolled in this cohort. Patients with very severe serum triglycerides (> 22.6mmol/L) had a higher proportion of severe acute pancreatitis (p < 0.05) than patients with severe hypertriglyceridemia (11.3-22.6 mmol/L). For the very severe hypertriglyceridemia group, no significant differences in prognosis were noted between the insulin and heparin group and the plasma exchange group. The cost of the insulin and heparin group was significantly lower than that of the plasma exchange group (p < 0.01). In patients with severe hypertriglyceridemia, no significant differences in prognosis were noted between the nothing-by-mouth (NPO) group and the insulin and heparin group. Compared with the insulin and heparin group, the NPO group had lower hospital costs (p < 0.05).

CONCLUSION

HTG-AP patients with very severe hypertriglyceridemia may be treated safely and effectively with insulin and heparin, potentially offering a more cost-effective treatment approach. Similarly, patients with severe hypertriglyceridemia might benefit from treatment involving NPO, which may be associated with lower costs. Further studies are needed to validate these findings in diverse populations and through long-term follow-up.

MRG15 promotes cell apoptosis through inhibition of mitophagy in hyperlipidemic acute pancreatitis

Hyperlipidemia is a common cause of acute pancreatitis (AP), often leading to more severe clinical symptoms. The mortality factor 4-like protein 1 (MORF4L1, also called MRG15) plays a crucial role in regulating lipid metabolism. Therefore, this study aimed to explore the mechanism of MRG15 in hyperlipidemic acute pancreatitis (HAP). Mendelian randomization, transcriptome analysis, and single-cell analysis were employed to explore the association between MRG15 and AP by utilizing publicly available databases. In vivo, hypertriglyceridemia mouse models were created by intraperitoneal injection of P407 or using APOE-deficient mice. Subsequently, the HAP model was induced by cerulean. In vitro, a cell model of HAP was established by initially exposing cells to palmitic acid to simulate a high-fat environment, followed by cerulein treatment. Subsequently, MRG15-related indicators were measured. Through Mendelian randomization, it was discovered that there is a positive correlation between genetic expression of MRG15 and the risk of AP. Transcriptome and single-cell analysis revealed that elevated MRG15 expression in AP contributes to lipid metabolism disorders and the activation of apoptosis pathways in pancreatic acinar cells. MRG15 is found to be significantly upregulated in cases of HAP. Knocking down MRG15 led to an increase in mitophagy and a decrease in apoptosis in pancreatic cells, and this effect was reversed when the mitochondrial Tu translation elongation factor (TUFM) was simultaneously knocked down. MRG15 inhibits mitophagy by degrading TUFM, ultimately promoting cell apoptosis and worsening the progression of HAP.

Interplay between BMI, neutrophil, triglyceride and uric acid: a case-control study and bidirectional multivariate mendelian randomization analysis

BACKGROUND

This study aims to explore the interplay between body mass index (BMI), neutrophils, triglyceride levels, and uric acid (UA). Understanding the causal correlation between UA and health indicators, specifically its association with the body's inflammatory conditions, is crucial for preventing and managing various diseases.

METHODS

A retrospective analysis was conducted on 4,286 cases utilizing the Spearman correlation method. BMI, neutrophil count, and triglyceride levels were determined as key exposure factors. To further investigate the causal correlation, a two-sample Mendelian randomization(MR) design was utilized, leveraging data from genome-wide association study (GWAS). Within this framework, and multivariable Mendelian randomization(MVMR) was applied to explore the linkage between multiple genetic variants and complex traits.

RESULTS

The study primarily focused on UA, employing genetic variation as a natural tool to assess the causal impact of various factors on UA. Spearman correlation analysis revealed significant association between UA and BMI (ρ = 0.230,p<0.01), neutrophils (ρ = 0.164,p<0.01), and triglyceride levels (ρ = 0.154,p<0.01). Additionally, two-sample MR analysis affirmed a reciprocal causal association between neutrophils and UA (OR = 1.035,95%CI:1.009-1.061,p = 0.008), as well as positive causal connection between UA and both BMI (OR = 1.083,95%CI:1.042-1.126,p<0.001) and triglyceride levels (OR = 1.090,95%CI:1.037-1.146,p<0.001). Neutrophils also demonstrated a positive causal linkage with BMI (OR = 1.034,95%CI:1.009-1.078,p = 0.012) and triglyceride levels (OR = 1.077,95%CI:1.033-1.122,p<0.001), and BMI exhibited a similar causal association with triglyceride levels (OR = 1.300,95%CI:1.212-1.385,p<0.001). These findings shed light on the causal networks connecting UA, BMI, neutrophils, and triglyceride levels. By integrating Spearman correlation analysis with various MR study designs, this study provided a robust framework for identifying key factors influencing hyperuricemia and related health issues, thereby enhancing our understanding of the interplay between inflammatory markers and these health indicators.

CONCLUSIONS

Our study presents strong evidence of the complex interconnection between BMI, neutrophils, triglyceride, and UA, revealing complex causal links and highlighting potential inflammatory states as key mediators. The findings may contribute to a better understanding of these factors and potentially lead to improved clinical outcomes and patients' health.

Plozasiran for Managing Persistent Chylomicronemia and Pancreatitis Risk

BACKGROUND

Persistent chylomicronemia is a genetic recessive disorder that is classically caused by familial chylomicronemia syndrome (FCS), but it also has multifactorial causes. The disorder is associated with the risk of recurrent acute pancreatitis. Plozasiran is a small interfering RNA that reduces hepatic production of apolipoprotein C-III and circulating triglycerides.

METHODS

In a phase 3 trial, we randomly assigned 75 patients with persistent chylomicronemia (with or without a genetic diagnosis) to receive subcutaneous plozasiran (25 mg or 50 mg) or placebo every 3 months for 12 months. The primary end point was the median percent change from baseline in the fasting triglyceride level at 10 months. Key secondary end points were the percent change in the fasting triglyceride level from baseline to the mean of values at 10 months and 12 months, changes in the fasting apolipoprotein C-III level from baseline to 10 months and 12 months, and the incidence of acute pancreatitis.

RESULTS

At baseline, the median triglyceride level was 2044 mg per deciliter. At 10 months, the median change from baseline in the fasting triglyceride level (the primary end point) was -80% in the 25-mg plozasiran group, -78% in the 50-mg plozasiran group, and -17% in the placebo group (P<0.001). The key secondary end points showed better results in the plozasiran groups than in the placebo group, including the incidence of acute pancreatitis (odds ratio, 0.17; 95% confidence interval, 0.03 to 0.94; P = 0.03). The risk of adverse events was similar across groups; the most common adverse events were abdominal pain, nasopharyngitis, headache, and nausea. Severe and serious adverse events were less common with plozasiran than with placebo. Hyperglycemia with plozasiran occurred in some patients with prediabetes or diabetes at baseline.

CONCLUSIONS

Patients with persistent chylomicronemia who received plozasiran had significantly lower triglyceride levels and a lower incidence of pancreatitis than those who received placebo. (Funded by Arrowhead Pharmaceuticals; PALISADE ClinicalTrials.gov number, NCT05089084.).

Association between serum hypertriglyceridemia and hematological indices: data mining approaches

BACKGROUND

High triglyceride (TG) affects and is affected of other hematological factors. The determination of serum fasted triglycerides concentrations, as part of a lipid profile, is crucial key point in hematological factors and significantly affect various systemic diseases. This study was carried out to assess the potential relation between the concentration of TG and hematological factors.

METHOD

Our sample size was 9704 participants beginning in 2007 and ending in 2020 aged between 35 and 65 years, sourced from the MASHAD cohort (northeastern Iran). Machine learning methodologies, specifically logistic regression, decision tree, and random forest algorithms, were utilized for data analysis in the investigation of individuals with normal and high TG levels.

RESULTS

The highest Gini score belongs to RLR (Red cell distribution width/Lymphocyte) (236.10), RPR (Red cell distribution width/Platelets) (215.78), and PHR (Platelets/high-density lipoprotein) (273.66). We also found that factors such as age are statistically associated with the level of TG in women probably due to the drop in menopausal estrogen. RF model showed to have higher accuracy in predicting the TG level in both males and females.

CONCLUSION

Our model assessed the association between serum TG with several hematological factors like RLR, RPR, and PHR. Other hematological factors also have been reported to be related to the TG level. As these results give us new insights into the association of TG on various hematological factors and their possible interactions with each other. future studies are needed to provide sufficient data for the mechanism and the pathophysiology of the findings.

Impact of Remnant Cholesterol on Cardiovascular Risk in Diabetes

PURPOSE OF REVIEW

Individuals with diabetes face increased risk of atherosclerotic cardiovascular disease (ASCVD), in part due to hyperlipidemia. Even after LDL cholesterol-lowering, residual ASCVD risk persists, part of which may be attributed to elevated remnant cholesterol. We describe the impact of elevated remnant cholesterol on ASCVD risk in diabetes.

RECENT FINDINGS

Preclinical, observational, and Mendelian randomization studies robustly suggest that elevated remnant cholesterol causally increases risk of ASCVD, suggesting remnant cholesterol could be a treatment target. However, the results of recent clinical trials of omega-3 fatty acids and fibrates, which lower levels of remnant cholesterol in individuals with diabetes, are conflicting in terms of ASCVD prevention. This is likely partly due to neutral effects of these drugs on the total level of apolipoprotein B(apoB)-containing lipoproteins. Elevated remnant cholesterol remains a likely cause of ASCVD in diabetes. Remnant cholesterol-lowering therapies should also lower apoB levels to reduce risk of ASCVD.

Global and regional burden of pancreatitis: epidemiological trends, risk factors, and projections to 2050 from the global burden of disease study 2021

BACKGROUND

Pancreatitis is a significant global health concern with rising incidence, complex management, and substantial mortality. This study aimed to assess global and regional trends in pancreatitis from 1990 to 2021 and project future trends to 2050 using data from the Global Burden of Disease (GBD) Study 2021.

METHODS

We analyzed GBD 2021 data to evaluate age-standardized incidence (ASIR), mortality (ASMR), and disability-adjusted life years (DALYs) rates of pancreatitis. Regional trends, gender disparities, and correlations with the Socio-demographic Index (SDI) were examined. Key risk factors, including alcohol consumption, smoking, and metabolic disorders such as hyperlipidemia, were extracted and evaluated. A Bayesian age-period-cohort model (BAPC) was used for future projections.

RESULTS

From 1990 to 2021, global pancreatitis cases increased from 1.73 million to 2.75 million, representing a rise of 59%. Despite this, ASIR decreased slightly from 37.62 to 32.81 per 100,000, a 12.8% reduction. Deaths rose from 68,490 to 122,416, an increase of 78.7%, while ASMR decreased from 1.69 to 1.45 per 100,000, a reduction of 14.2%. DALYs increased from 2.58 million to 4.10 million (59%). Significant regional variations were found, with Eastern Europe showing the highest ASIR, ASMR, and DALY rates. Projections indicate continued declines in ASIR, ASMR, and DALYs through 2050.

CONCLUSIONS

While global age-standardized rates of pancreatitis have declined, significant regional and socioeconomic disparities persist. Targeted prevention efforts, particularly in high-burden areas like Eastern Europe, and addressing modifiable risk factors such as alcohol use are crucial for reducing the future burden of pancreatitis.

Efficacy and safety of olezarsen in lowering apolipoprotein C-III and triglycerides in healthy Japanese Americans

BACKGROUND

Olezarsen is a GalNAc3-conjugated, hepatic-targeted antisense oligonucleotide that lowers apolipoprotein C-III (apoC-III) and triglyceride levels. The efficacy and safety of olezarsen has not previously been studied in ethnically diverse American populations. The aim of this study is to assess the effect of olezarsen in healthy Japanese Americans.

METHODS

A randomized, placebo-controlled, double-blind phase 1 study was performed in 28 healthy Japanese American participants treated with olezarsen in single-ascending doses (SAD; 30, 60, 90 mg) or multiple doses (MD; 60 mg every 4 weeks for 4 doses). The primary, secondary, and exploratory objectives were safety and tolerability, pharmacokinetics, and effects of olezarsen on fasting serum triglycerides and apoC-III, respectively.

RESULTS

There were 20 participants (16 active:4 placebo) in the SAD part of the study, and 8 participants (6 active:2 placebo) in the MD part of the study. For the primary endpoint, no serious adverse events or clinically relevant laboratory abnormalities were reported. The majority of olezarsen plasma exposure occurred within 24 h post-dose. In the SAD cohorts at Day 15 the percentage reduction in apoC-III/TG was - 39.4%/ - 17.8%, - 60.8%/ - 52.7%, and - 68.1%/ - 39.2% in the 30, 60 and 90 mg doses, respectively, vs 2.3%/44.5% increases in placebo. In the MD cohort, at Day 92 the percentage reduction in apoC-III/TG was - 81.6/ - 73.8% vs - 17.2/ - 40.8% reduction in placebo. Favorable changes were also present in VLDL-C, apoB and HDL-C.

CONCLUSIONS

Single- and multiple-dose administration of olezarsen was safe, was well tolerated, and significantly reduced apoC-III and triglyceride levels in healthy Japanese Americans.

New approaches to triglyceride reduction: Is there any hope left?

Triglycerides play a crucial role in the efficient storage of energy in the body. Mild and moderate hypertriglyceridemia (HTG) is a heterogeneous disorder with significant association with atherosclerotic cardiovascular disease (ASCVD), including myocardial infarction, ischemic stroke, and peripheral artery disease and represents an important component of the residual ASCVD risk in statin treated patients despite optimal low-density lipoprotein cholesterol reduction. Individuals with severe HTG (>1,000 mg/dL) rarely develop atherosclerosis but have an incremental incidence of acute pancreatitis with significant morbidity and mortality. HTG can occur from a combination of genetic (both mono and polygenic) and environmental factors including poor diet, low physical activity, obesity, medications, and diseases like insulin resistance and other endocrine pathologies. HTG represents a potential target for ASCVD risk and pancreatitis risk reduction, however data on ASCVD reduction by treating HTG is still lacking and HTG-associated acute pancreatitis occurs too rarely to effectively demonstrate treatment benefit. In this review, we address the key aspects of HTG pathophysiology and examine the mechanisms and background of current and emerging therapies in the management of HTG.

Olezarsen for Hypertriglyceridemia in Patients at High Cardiovascular Risk

BACKGROUND

Reducing the levels of triglycerides and triglyceride-rich lipoproteins remains an unmet clinical need. Olezarsen is an antisense oligonucleotide targeting messenger RNA for apolipoprotein C-III (APOC3), a genetically validated target for triglyceride lowering.

METHODS

In this phase 2b, randomized, controlled trial, we assigned adults either with moderate hypertriglyceridemia (triglyceride level, 150 to 499 mg per deciliter) and elevated cardiovascular risk or with severe hypertriglyceridemia (triglyceride level, ≥500 mg per deciliter) in a 1:1 ratio to either a 50-mg or 80-mg cohort. Patients were then assigned in a 3:1 ratio to receive monthly subcutaneous olezarsen or matching placebo within each cohort. The primary outcome was the percent change in the triglyceride level from baseline to 6 months, reported as the difference between each olezarsen group and placebo. Key secondary outcomes were changes in levels of APOC3, apolipoprotein B, non-high-density lipoprotein (HDL) cholesterol, and low-density lipoprotein (LDL) cholesterol.

RESULTS

A total of 154 patients underwent randomization at 24 sites in North America. The median age of the patients was 62 years, and the median triglyceride level was 241.5 mg per deciliter. The 50-mg and 80-mg doses of olezarsen reduced triglyceride levels by 49.3 percentage points and 53.1 percentage points, respectively, as compared with placebo (P<0.001 for both comparisons). As compared with placebo, each dose of olezarsen also significantly reduced the levels of APOC3, apolipoprotein B, and non-HDL cholesterol, with no significant change in the LDL cholesterol level. The risks of adverse events and serious adverse events were similar in the three groups. Clinically meaningful hepatic, renal, or platelet abnormalities were uncommon, with similar risks in the three groups.

CONCLUSIONS

In patients with predominantly moderate hypertriglyceridemia at elevated cardiovascular risk, olezarsen significantly reduced levels of triglycerides, apolipoprotein B, and non-HDL cholesterol, with no major safety concerns identified. (Funded by Ionis Pharmaceuticals; Bridge-TIMI 73a ClinicalTrials.gov number, NCT05355402.).

Remnant cholesterol and low-grade inflammation jointly in atherosclerotic cardiovascular disease: implications for clinical trials

PURPOSE OF REVIEW

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death despite the development of effective treatments. Recently, elevated remnant cholesterol and low-grade inflammation have emerged as factors explaining part of the residual ASCVD risk. Interestingly, the coexistence of both high remnant cholesterol and low-grade inflammation can further increase the risk of ASCVD. The aim of this review is to describe the role of elevated remnant cholesterol and low-grade inflammation, separately and combined, in ASCVD.

RECENT FINDINGS

Results from recently published studies, including observational and genetic Mendelian randomization studies, support a causal relationship between elevated remnant cholesterol and low-grade inflammation on risk of ASCVD in both primary and secondary prevention settings. In addition, current evidence from observational studies suggests that the coexistence of elevated remnant cholesterol and low-grade inflammation further increases the risk of ASCVD.

SUMMARY

Recent observational studies suggest that high remnant cholesterol combined with low-grade inflammation may confer a particular high risk for ASCVD. Attention on the dual threat from high remnant cholesterol and low-grade inflammation is necessary, and further research in this field is warranted. The effect of remnant cholesterol-lowering drugs and anti-inflammatory drugs on ASCVD risk alone and combined remains to be elucidated.

VIDEO ABSTRACT

http://links.lww.com/COCN/A20.

Eliminating COVID-19 as the immediate culprit for igniting pancreatitis

The impact of severe acute respiratory syndrome coronavirus 2 infection on the potential development of pancreatitis is a subject of ongoing debate within academic discourse. Establishing a causal link between COVID-19 and pancreatitis may not be fully supported by relying only on retrospective studies or case reports. This study examined the relationship between COVID-19 phenotypes and pancreatitis by Mendelian randomization (MR) method. The identification of instrumental variables (single nucleotide polymorphisms) that exhibit a robust association with the COVID-19 phenotypes was accomplished through a meticulous process of rigorous screening procedures. We included acute pancreatitis and chronic pancreatitis (CP) as the outcomes in the MR analysis, even though no definitive studies exist between COVID-19 and CP. A direct causal relationship between genetically predicted COVID-19 phenotypes and pancreatitis risk cannot be established. There is an ongoing debate over the designation of COVID-19 as a definitive cause of pancreatitis.

Do Triglyceride-Rich Lipoproteins Equal Low-Density Lipoproteins in Risk of ASCVD?

PURPOSE OF REVIEW

Recent large clinical trials have failed to show that triglyceride-rich lipoprotein-lowering therapies decrease the risk of atherosclerotic cardiovascular disease (ASCVD). In this review, we reconcile these findings with evidence showing that elevated levels of triglyceride-rich lipoproteins and the cholesterol they contain, remnant cholesterol, cause ASCVD alongside low-density lipoprotein (LDL) cholesterol.

RECENT FINDINGS

Results from observational epidemiology, genetic epidemiology, and randomized controlled trials indicate that lowering of remnant cholesterol and LDL cholesterol decrease ASCVD risk by a similar magnitude per 1 mmol/L (39 mg/dL) lower non-high-density lipoprotein cholesterol (remnant cholesterol+LDL cholesterol). Indeed, recent guidelines for ASCVD prevention recommend the use of non-high-density lipoprotein cholesterol instead of LDL cholesterol. Current consensus is moving towards recognizing remnant cholesterol and LDL cholesterols as equals per 1 mmol/L (39 mg/dL) higher levels in the risk assessment of ASCVD; hence, triglyceride-rich lipoprotein-lowering therapies should also lower levels of non-HDL cholesterol to reduce ASCVD risk.