IMPROVE-IT: what have we learned?

A Phase III Randomized, Double-Blind, Active-Controlled, Multicenter Study on the Efficacy and Safety of Ezetimibe/Atorvastatin/Amlodipine Combination in Patients With Comorbid Primary Hypercholesterolemia and Essential Hypertension

PURPOSE

This study aimed to evaluate the efficacy and safety of triple combination of ezetimibe (Eze)/atorvastatin (Ato) 10/40 mg + amlodipine (Aml) 10 mg therapy for lowering the low-density lipoprotein cholesterol (LDL-C) and blood pressure compared with either Eze/Ato 10/40 mg or Aml 10 mg therapies in patients with comorbid primary hypercholesterolemia and essential hypertension.

METHODS

This was a randomized, multicenter, double-blind, active-controlled, Phase III clinical trial. Participants underwent a wash-out period (2 weeks for nonfibrate medications, 6 weeks for fibrates) followed by 4 weeks of therapeutic lifestyle changes. Subsequently, 109 participants were randomly assigned to 3 groups: (1) Eze/Ato 10/40 mg + Aml 10 mg, (2) Eze/Ato 10/40 mg, and (3) Aml 10 mg. The coprimary end points were percentage change in LDL-C and change in mean sitting systolic blood pressure (SBP) compared with baseline at week 8.

FINDINGS

A total of 109 participants were enrolled in the study, and there were no statistically significant differences in the baseline characteristics of participants across the 3 groups. After 8 weeks of treatment, the least-square (LS) mean (SE) of percent change from baseline in LDL-C was -57.95% (3.52%) for the Eze/Ato 10/40 mg + Aml 10 mg group and 8.93% (3.54%) for the Aml 10 mg group. The LS mean difference (SE) between these 2 groups was statistically significant at -66.88 (4.95) (95% CI, -76.77% to -56.99%) (P < 0.0001). Furthermore, at week 8, the LS mean (SE) change in mean sitting SBP between the Eze/Ato 10/40 mg + Aml 10 mg group and the Eze/Ato 10/40 mg group was -19.24 (2.42) mm Hg and -4.43 (2.56) mm Hg, respectively. The LS mean difference (SE) between the 2 groups was statistically significant -14.81 (3.53) (95% CI, -21.87 to -7.74) mm Hg (P < 0.0001). No serious adverse drug reactions occurred in any of the study groups.

IMPLICATIONS

Triple combination therapy with Eze/Ato + Aml has effectively reduced the LDL-C and SBP independently, compared with either Eze/Ato or Aml therapies over 8 weeks of treatment period. In terms of safety, there were no significant differences among the 3 treatment groups. This research lays the groundwork for the development of a triple fixed-dose combination in the future, which could improve patient convenience and adherence by reducing pill burden. Clinical Research Information Service (CRIS), Republic of Korea: KCT0006283.

Impact of Lipid-Lowering Combination Therapy With Statins and Ezetimibe vs Statin Monotherapy on the Reduction of Cardiovascular Outcomes: A Meta-analysis

OBJECTIVE

To evaluate the efficacy of combination lipid-lowering therapy (LLT) compared with statin monotherapy for low-density lipoprotein cholesterol (LDL-C) reduction, associated adverse events, and outcomes.

METHODS

A systematic literature search was conducted using PubMed, Embase, and ClinicalTrials.gov to identify relevant articles published from inception until the end of June 2024. The outcomes were assessed using pooled odds ratios (ORs) for categorical data and mean difference for continuous data, with corresponding 95% CIs.

RESULTS

A total of 14 studies (11 randomized controlled trials and 3 cohort studies) with 108,373 very high-risk patients were included in the final analysis. The mean age of the patients in the combination LLT group and the statin monotherapy group was 67.31 and 67.89 years, respectively. Pooled analysis revealed that combination LLT significantly more effectively reduced the LDL-C level from baseline (mean difference, -12.96 mg/dL; 95% CI, -17.27 to -8.65; P<.001) and significantly reduced all-cause mortality (OR, 0.81; 95% CI, 0.67 to 0.97; P=.02), major adverse cardiovascular events (OR, 0.82; 95% CI, 0.69 to 0.97; P=.02), and stroke incidence (OR, 0.83; 95% CI, 0.75 to 0.91; P<.001), with an insignificant effect on cardiovascular mortality (OR, 0.86; 95% CI, 0.65 to 1.12; P=.26) when compared with statin monotherapy. The risk of adverse events and the therapy discontinuation rate were comparable between groups.

CONCLUSION

Combination LLT was associated with an overall greater reduction in LDL-C, the same risk of adverse effects, and significantly lower risk of all-cause mortality, major adverse cardiovascular events, and stroke compared with statin monotherapy. Forthcoming guidelines should consider the lipid-lowering combination therapy as early as possible, preferably up-front, for more effective LDL-C goal achievement and significant reduction of cardiovascular disease outcomes and mortality in high- and very high-risk patients.

Step-by-step diagnosis and management of the nocebo/drucebo effect in statin-associated muscle symptoms patients: a position paper from the International Lipid Expert Panel (ILEP)

Statin intolerance is a clinical syndrome whereby adverse effects (AEs) associated with statin therapy [most commonly statin-associated muscle symptoms (SAMS)] result in the discontinuation of therapy and consequently increase the risk of adverse cardiovascular outcomes. However, complete statin intolerance occurs in only a small minority of treated patients (estimated prevalence of only 3-5%). Many perceived AEs are misattributed (e.g. physical musculoskeletal injury and inflammatory myopathies), and subjective symptoms occur as a result of the fact that patients expect them to do so when taking medicines (the nocebo/drucebo effect)-what might be truth even for over 50% of all patients with muscle weakness/pain. Clear guidance is necessary to enable the optimal management of plasma in real-world clinical practice in patients who experience subjective AEs. In this Position Paper of the International Lipid Expert Panel (ILEP), we present a step-by-step patient-centred approach to the identification and management of SAMS with a particular focus on strategies to prevent and manage the nocebo/drucebo effect and to improve long-term compliance with lipid-lowering therapy.

Preformulation Studies of Ezetimibe-Simvastatin Solid Dispersions in the Development of Fixed-Dose Combinations

Two active pharmaceutical ingredients (APIs) with limited solubility, simvastatin and ezetimibe, prepared as a drug-drug solid dispersion (SD) was evaluated for physicochemical, microstructural, and aqueous dissolution properties. The simvastatin-ezetimibe SD was prepared using the co-grinding method in a wide range of weight fractions and differential scanning calorimetry (DSC) and X-ray powder diffraction (XRPD) were used to perform the phase composition analysis. DSC studies confirmed that simvastatin and ezetimibe form a simple eutectic phase equilibrium diagram. Analysis of Fourier transform infrared spectroscopy (FTIR) studies excluded strong interactions between the APIs. Our investigations have revealed that all studied dispersions are characterized by substantially improved ezetimibe dissolution regardless of simvastatin content, and are best when the composition oscillates near the eutectic point. Data obtained in our studies provide an opportunity for the development of well-formulated, ezetimibe-simvastatin fixed-dose combinations (for hypercholesterolemia treatment) with reduced ezetimibe dosages based on its dissolution improvement.

Characteristics of lipid profile and effectiveness of management of dyslipidaemia in patients with acute coronary syndromes - Data from the TERCET registry with 19,287 patients

Despite well-defined therapeutic low-density lipoprotein cholesterol (LDL-C) target in the highest-risk population, low percentage of patients is administered with intensive lipid-lowering therapy and achieves recommended levels. Therefore, based on the Hyperlipidaemia Therapy in tERtiary Cardiological cEnTer (TERCET) Registry data we investigated the characteristics of lipid profile and management of dyslipidemia in acute coronary syndrome (ACS) patients. 19,287 consecutive patients hospitalized between 2006 and 2016 have been included in the study. The lipid profile on admission and long-term laboratory effects (namely the efficacy of achievement of the therapeutic target of LDL-C <70 mg/dl [1.8 mmol/L]) after follow-up of twelve months were assessed. Acute coronary syndromes occurred in 36.1% of the Registry patients including 14.3% with ST-elevated myocardial infarction (STEMI), 10.2% with NSTEMI and 9,9% with unstable angina (UA). The highest LDL-C concentration on admission was observed in the STEMI subgroup (mean level: 127.0 mg/dL [3.28 mmol/L]). In 76.6% of the Registry patients LDL-C concentration was lower than 130 mg/dL and in 20.7% was lower than 70 mg/dL at baseline. The patients with baseline LDL < 70 mg/dL were usually presented with the worst clinical profile. In 91,6% of the patients admitted due to acute coronary syndrome, statin treatment was administered at discharge. Among them, 37.6% received intensive statin therapy. In the 12-month follow-up, in 32.4% of patients admitted due to STEMI, LDL-C concentration was lower than 70 mg/dL, compared to 29.9% in patients with NSTEMI and 27.8% in patients with UA. In conclusion, STEMI patients are less clinically burdened with concomitant risk factors and comorbidities, but present significantly worse baseline lipid profile values. Among the patients already treated with statins, patients with ACS regardless of its type have significantly higher LDL-C than patients with SA. Despite discrepancies in the clinical profile on admission, achievement of the therapeutic target equalizes the outcomes in 12-month follow-up, however with the best results for STEMI patients.

Small, dense LDL: an update

PURPOSE OF REVIEW

In this review, we summarize the latest findings on small, dense LDL (sdLDL) atherogenic particles, including their associations with other biomarkers.

RECENT FINDINGS

Increased sdLDL levels have been reported not only in different metabolic disorders such as diabetes, obesity and metabolic syndrome, but also in patients with rheumatoid and psoriatic arthritis as well as hypothyroidism. A wide range of lipid-lowering, as well as other drug classes, including novel antidiabetic agents and nutraceuticals, exert favourable effects on these atherogenic particles. The 'gold standard' methodology for the assessment of sdLDL has not been established yet. However, the association between sdLDL and several biomarkers could facilitate their assessment.

SUMMARY

Estimation of sdLDL in daily clinical practice may help with the identification of patients at high cardiovascular risk and further contribute in directing specific interventions to prevent and/or decrease such risk.

Obesity and Insulin Resistance Promote Atherosclerosis through an IFNγ-Regulated Macrophage Protein Network

Type 2 diabetes (T2D) is associated with increased risk for atherosclerosis; however, the mechanisms underlying this relationship are poorly understood. Macrophages, which are activated in T2D and causatively linked to atherogenesis, are an attractive mechanistic link. Here, we use proteomics to show that diet-induced obesity and insulin resistance (obesity/IR) modulate a pro-atherogenic "macrophage-sterol-responsive-network" (MSRN), which, in turn, predisposes macrophages to cholesterol accumulation. We identify IFNγ as the mediator of obesity/IR-induced MSRN dysregulation and increased macrophage cholesterol accumulation and show that obesity/IR primes T cells to increase IFNγ production. Accordingly, myeloid cell-specific deletion of the IFNγ receptor (Ifngr1-/-) restores MSRN proteins, attenuates macrophage cholesterol accumulation and atherogenesis, and uncouples the strong relationship between hyperinsulinemia and aortic root lesion size in hypercholesterolemic Ldlr-/- mice with obesity/IR, but does not affect these parameters in Ldlr-/- mice without obesity/IR. Collectively, our findings identify an IFNγ-macrophage pathway as a mechanistic link between obesity/IR and accelerated atherogenesis.

Statin Intolerance: Some Practical Hints

Statin intolerance is the inability to tolerate a dose of statin required to sufficiently reduce cardiovascular risk. With the five-step approach, more than 90% of these patients might be treated with statins. The principal approaches are to try not to discontinue statin therapy and to treat these patients as effectively as possible. New therapies with the proprotein convertase subtilisin-kexin type 9 inhibitors and bempedoic acid might be an effective response to these needs. In case of lack of achieved goal of the therapy nutraceuticals with confirmed low-density lipoprotein cholesterol reduction properties may be considered as a part of the lipid-lowering combination therapy.

Ezetimibe: an update on its clinical usefulness in specific patient groups

The aim of pharmacological lipid modification is to reduce low-density lipoprotein cholesterol (LDL-C) as a means of either secondary or primary prevention of cardiovascular disease. Statins are the first-line therapy for pharmacological lipid modification. Ezetimibe is a drug which reduces LDL-C by selectively inhibiting intestinal cholesterol absorption. This provides an alternative pharmacological approach to that of statin therapy to reduce LDL-C. Ezetimibe has been shown to significantly reduce levels of LDL-C and recently, as demonstrated in the IMPROVE-IT trial, to reduce the rate of cardiovascular events in high-risk patients. Ezetimibe therefore has an important role in pharmacological lipid modification. In this paper, we examine the body of research behind ezetimibe and assess its current clinical applications in different patient subgroups.

Managing the lipid profile of coronary heart disease patients

INTRODUCTION

Lipid profile management is even more critical in patients treated for secondary prevention, since patients with established coronary heart disease are at higher risk of developing events. Current guidelines encourage lifestyle modification and patient engagement in disease prevention. However, the American College of Cardiology/American Heart Association guidelines seem to differ considerably from their predecessors, having an impact on clinical practice of lipid management. Area covered: This review article discusses and provides a summary of the current recommendations for lipid profile management in patients with coronary heart disease, with a view to present lifestyle modification and novel treatment strategies, and to indicate areas of dispute among recent guidelines. Expert commentary: Existing controversies between current guidelines concerning treatment goals and therapeutic decisions may have potential implications on the clinical management of patients. In the meantime, we eagerly wait for the results of randomized controlled trials evaluating promising, potent, safe and prolonged drugs that are in progress.