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Haldar SM. Keeping translational research grounded in human biology. J Clin Invest 2024; 134:e178332. [PMID: 38226617 PMCID: PMC10763720 DOI: 10.1172/jci178332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024] Open
Affiliation(s)
- Saptarsi M. Haldar
- Amgen Research, South San Francisco, California, USA
- UCSF, San Francisco, California, USA
- Gladstone Institutes, San Francisco, California, USA
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Bell AS, Wagner J, Rosoff DB, Lohoff FW. Proprotein convertase subtilisin/kexin type 9 (PCSK9) in the central nervous system. Neurosci Biobehav Rev 2023; 149:105155. [PMID: 37019248 DOI: 10.1016/j.neubiorev.2023.105155] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/29/2023] [Accepted: 04/01/2023] [Indexed: 04/05/2023]
Abstract
The gene encoding proprotein convertase subtilisin/kexin type 9 (PCSK9) and its protein product have been widely studied for their role in cholesterol and lipid metabolism. PCSK9 increases the rate of metabolic degradation of low-density lipoprotein receptors, preventing the diffusion of low-density lipoprotein (LDL) from plasma into cells and contributes to high lipoprotein-bound cholesterol levels in the plasma. While most research has focused on the regulation and disease relevance of PCSK9 to the cardiovascular system and lipid metabolism, there is a growing body of evidence that PCSK9 plays a crucial role in pathogenic processes in other organ systems, including the central nervous system. PCSK9's impact on the brain is not yet fully understood, though several recent studies have sought to illuminate its impact on various neurodegenerative and psychiatric disorders, as well as its connection with ischemic stroke. Cerebral PCSK9 expression is low but is highly upregulated during disease states. Among others, PCSK9 is known to play a role in neurogenesis, neural cell differentiation, central LDL receptor metabolism, neural cell apoptosis, neuroinflammation, Alzheimer's Disease, Alcohol Use Disorder, and stroke. The PCSK9 gene contains several polymorphisms, including both gain-of-function and loss-of-function mutations which profoundly impact normal PCSK9 signaling and cholesterol metabolism. Gain-of-function mutations lead to persistent hypercholesterolemia and poor health outcomes, while loss-of-function mutations generally lead to hypocholesterolemia and may serve as a protective factor against diseases of the liver, cardiovascular system, and central nervous system. Recent genomic studies have sought to identify the end-organ effects of such mutations and continue to identify evidence of a much broader role for PCSK9 in extrahepatic organ systems. Despite this, there remain large gaps in our understanding of PCSK9, its regulation, and its effects on disease risk outside the liver. This review, which incorporates data from a wide range of scientific disciplines and experimental paradigms, is intended to describe PCSK9's role in the central nervous system as it relates to cerebral disease and neuropsychiatric disorders, and to examine the clinical potential of PCSK9 inhibitors and genetic variation in the PCSK9 gene on disease outcomes, including neurological and neuropsychiatric disease.
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Maligłówka M, Kosowski M, Hachuła M, Cyrnek M, Bułdak Ł, Basiak M, Bołdys A, Machnik G, Bułdak RJ, Okopień B. Insight into the Evolving Role of PCSK9. Metabolites 2022; 12:metabo12030256. [PMID: 35323699 PMCID: PMC8951079 DOI: 10.3390/metabo12030256] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/12/2022] [Accepted: 03/15/2022] [Indexed: 02/04/2023] Open
Abstract
Proprotein convertase subtilisin/kexin type 9 (PCSK9) is the last discovered member of the family of proprotein convertases (PCs), mainly synthetized in hepatic cells. This serine protease plays a pivotal role in the reduction of the number of low-density lipoprotein receptors (LDLRs) on the surface of hepatocytes, which leads to an increase in the level of cholesterol in the blood. This mechanism and the fact that gain of function (GOF) mutations in PCSK9 are responsible for causing familial hypercholesterolemia whereas loss-of-function (LOF) mutations are associated with hypocholesterolemia, prompted the invention of drugs that block PCSK9 action. The high efficiency of PCSK9 inhibitors (e.g., alirocumab, evolocumab) in decreasing cardiovascular risk, pleiotropic effects of other lipid-lowering drugs (e.g., statins) and the multifunctional character of other proprotein convertases, were the cause for proceeding studies on functions of PCSK9 beyond cholesterol metabolism. In this article, we summarize the current knowledge on the roles that PCSK9 plays in different tissues and perspectives for its clinical use.
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Affiliation(s)
- Mateusz Maligłówka
- Department of Internal Medicine and Clinical Pharmacology, School of Medicine in Katowice, Medical University of Silesia in Katowice, 40-007 Katowice, Poland; (M.K.); (M.H.); (M.C.); (Ł.B.); (M.B.); (A.B.); (G.M.); (B.O.)
- Correspondence:
| | - Michał Kosowski
- Department of Internal Medicine and Clinical Pharmacology, School of Medicine in Katowice, Medical University of Silesia in Katowice, 40-007 Katowice, Poland; (M.K.); (M.H.); (M.C.); (Ł.B.); (M.B.); (A.B.); (G.M.); (B.O.)
| | - Marcin Hachuła
- Department of Internal Medicine and Clinical Pharmacology, School of Medicine in Katowice, Medical University of Silesia in Katowice, 40-007 Katowice, Poland; (M.K.); (M.H.); (M.C.); (Ł.B.); (M.B.); (A.B.); (G.M.); (B.O.)
| | - Marcin Cyrnek
- Department of Internal Medicine and Clinical Pharmacology, School of Medicine in Katowice, Medical University of Silesia in Katowice, 40-007 Katowice, Poland; (M.K.); (M.H.); (M.C.); (Ł.B.); (M.B.); (A.B.); (G.M.); (B.O.)
| | - Łukasz Bułdak
- Department of Internal Medicine and Clinical Pharmacology, School of Medicine in Katowice, Medical University of Silesia in Katowice, 40-007 Katowice, Poland; (M.K.); (M.H.); (M.C.); (Ł.B.); (M.B.); (A.B.); (G.M.); (B.O.)
| | - Marcin Basiak
- Department of Internal Medicine and Clinical Pharmacology, School of Medicine in Katowice, Medical University of Silesia in Katowice, 40-007 Katowice, Poland; (M.K.); (M.H.); (M.C.); (Ł.B.); (M.B.); (A.B.); (G.M.); (B.O.)
| | - Aleksandra Bołdys
- Department of Internal Medicine and Clinical Pharmacology, School of Medicine in Katowice, Medical University of Silesia in Katowice, 40-007 Katowice, Poland; (M.K.); (M.H.); (M.C.); (Ł.B.); (M.B.); (A.B.); (G.M.); (B.O.)
| | - Grzegorz Machnik
- Department of Internal Medicine and Clinical Pharmacology, School of Medicine in Katowice, Medical University of Silesia in Katowice, 40-007 Katowice, Poland; (M.K.); (M.H.); (M.C.); (Ł.B.); (M.B.); (A.B.); (G.M.); (B.O.)
| | - Rafał Jakub Bułdak
- Institute of Medical Sciences, University of Opole, 45-040 Opole, Poland;
| | - Bogusław Okopień
- Department of Internal Medicine and Clinical Pharmacology, School of Medicine in Katowice, Medical University of Silesia in Katowice, 40-007 Katowice, Poland; (M.K.); (M.H.); (M.C.); (Ł.B.); (M.B.); (A.B.); (G.M.); (B.O.)
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Krittanawong C, Khawaja M, Rosenson RS, Amos CI, Nambi V, Lavie CJ, Virani SS. Association of PCSK9 Variants With the Risk of Atherosclerotic Cardiovascular Disease and Variable Responses to PCSK9 Inhibitor Therapy. Curr Probl Cardiol 2021; 47:101043. [PMID: 34780866 DOI: 10.1016/j.cpcardiol.2021.101043] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/05/2021] [Indexed: 12/29/2022]
Abstract
Genetic polymorphisms or variations, randomly distributed in a population, may cause drug-gene response variations. Investigation into these polymorphisms may identify novel mechanisms contributing to a specific disease process. Such investigation necessitates the use of Mendelian randomization, an analytical method that uses genetic variants as instrumental variables for modifiable risk factors that affect population health.1 In the past decade, advances in our understanding of genetic polymorphisms have enabled the identification of genetic variants in candidate genes that impact low-density lipoprotein cholesterol (LDL-C) regulating pathways and cardiovascular disease (CVD) outcomes. A specific candidate gene of interest is that of the LDL receptor degrading protein, PCSK9. In fact, loss-of-function genetic variants for the PCSK9 gene are what first highlighted this pathway as a candidate for pharmacologic inhibition. PCSK9 inhibitors (PCSK9i) are a class of cholesterol-lowering medications that provide significant reductions in LDL by inhibiting the degradation of LDL receptors (LDLR). These inhibitors have also been found to reduce production and enhance clearance of lipoprotein A (Lp[a]), an LDL-like particle currently under study as a separate risk factor for atherosclerotic CVD. Here, we discuss the promise of personalized medicine in developing a more efficacious and individualized pharmacogenomics-based approach for the use of PCSK9i that considers genetic variation and targets different patient populations. This review explores the pharmacogenomics of PCSK9i in the context of PCSK9 allele variants related to drug-metabolizing enzymes and responses since more studies are demonstrating that some patients are hyporesponsive or non-responsive to PCSK9i.2 In summary, the pharmacogenomics of PCSK9 are a promising therapeutic target and genetic information from prospective randomized clinical trials is warranted to gain a full understanding of the efficacy and cost-effectiveness of such allele and/or gene-guided PCSK9i therapy.
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Affiliation(s)
- Chayakrit Krittanawong
- The Michael E. DeBakey VA Medical Center, Houston, TX; Section of Cardiology, Baylor College of Medicine, Houston, TX.
| | - Muzamil Khawaja
- The Michael E. DeBakey VA Medical Center, Houston, TX; Section of Cardiology, Baylor College of Medicine, Houston, TX
| | - Robert S Rosenson
- Director, Cardiometabolics Unit, Mount Sinai Hospital, Mount Sinai Heart, NY, NY
| | - Christopher I Amos
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, TX
| | - Vijay Nambi
- The Michael E. DeBakey VA Medical Center, Houston, TX; Section of Cardiology, Baylor College of Medicine, Houston, TX
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA
| | - Salim S Virani
- The Michael E. DeBakey VA Medical Center, Houston, TX; Section of Cardiology, Baylor College of Medicine, Houston, TX
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Maligłówka M, Bułdak Ł, Okopień B, Bołdys A. The consequences of PCSK9 inhibition in selected tissues. POSTEP HIG MED DOSW 2021. [DOI: 10.5604/01.3001.0014.9127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Proprotein convertase subtilisin/kexin type 9 (PCSK9) is one of nine members of the proprotein
convertase family. These serine proteases play a pivotal role in the post-translational
modification of proteins and the activation of hormones, enzymes, transcription factors and
growth factors. As a result, they participate in many physiological processes like embryogenesis,
activity of central nervous system and lipid metabolism. Scientific studies show
that the family of convertases is also involved in the pathogenesis of viral and bacterial
infections, osteoporosis, hyperglycaemia, cardiovascular diseases, neurodegenerative disorders
and cancer. The inhibition of PCSK9 by two currently approved for use monoclonal
antibodies (alirocumab, evolocumab) slows down the degradation of low-density lipoprotein
cholesterol receptors (LDLRs). This leads to increased density of LDLRs on the surface
of hepatocytes, resulting in decreased level of low-density lipoprotein cholesterol (LDL-C)
in the bloodstream, which is connected with the reduction of cardiovascular risk. PCSK9 inhibitors (PCSK9i) were created for the patients who could not achieve appropriate level
of LDL-C using current statin and ezetimibe therapy. It seems that high therapeutic efficacy
of PCSK9i will make them more common in the clinical use. The pleiotropic effects
of previously mentioned lipid-lowering therapies were the reasons for literature review of
possible positive and negative effects of PCSK9 inhibition beyond cholesterol metabolism.
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Affiliation(s)
- Mateusz Maligłówka
- Katedra Farmakologii, Klinika Chorób Wewnętrznych i Farmakologii Klinicznej, Wydział Nauk Medycznych Śląskiego Uniwersytetu Medycznego w Katowicach
| | - Łukasz Bułdak
- Katedra Farmakologii, Klinika Chorób Wewnętrznych i Farmakologii Klinicznej, Wydział Nauk Medycznych Śląskiego Uniwersytetu Medycznego w Katowicach
| | - Bogusław Okopień
- Katedra Farmakologii, Klinika Chorób Wewnętrznych i Farmakologii Klinicznej, Wydział Nauk Medycznych Śląskiego Uniwersytetu Medycznego w Katowicach
| | - Aleksandra Bołdys
- Katedra Farmakologii, Klinika Chorób Wewnętrznych i Farmakologii Klinicznej, Wydział Nauk Medycznych Śląskiego Uniwersytetu Medycznego w Katowicach
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Shyamala N, Gundapaneni KK, Galimudi RK, Tupurani MA, Padala C, Puranam K, Kupsal K, Kummari R, Gantala SR, Nallamala KR, Sahu SK, Hanumanth SR. PCSK9 genetic (rs11591147) and epigenetic (DNA methylation) modifications associated with PCSK9 expression and serum proteins in CAD patients. J Gene Med 2021; 23:e3346. [PMID: 33885177 DOI: 10.1002/jgm.3346] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 04/07/2021] [Accepted: 04/17/2021] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Proprotein convertase subtilisin/kexin type 9 (PCSK9) genetic polymorphisms play a significant role in cholesterol homeostasis. Therefore, we aimed to investigate the association of PCSK9 genetic variations NM_174936.3:c.137G>T (R46L, rs11591147) and NM_174936.3:c.1120G>T (D374Y, rs137852912), as well as promoter DNA methylation status, with mRNA expression and circulating serum protein levels in coronary artery disease (CAD) patients. METHODS The present study includes 300 CAD cases and 300 controls from South India. Biochemical assays were performed using commercially available kits. PCSK9 rs11591147 and rs137852912 polymorphisms were analyzed by the polymerase chain reaction (PCR)-restriction fragment length polymorphism method, whereas promoter DNA methylation status and gene expression were determined using methylation specific PCR and quantitative PCR respectively. RESULTS The genotypic distribution of PCSK9 rs11591147 revealed that individuals with the TT-genotype and T-allele have a reduced risk for CAD. Furthermore, patients with the PCSK9 rs11591147 TT genotype have a significantly lower total cholesterol and low-density lipoprotein-cholesterol levels and also higher high-density lipoprotein-cholesterol levels than individuals with the GG genotype. Logistic regression analysis has shown that the GG and GT (p = 1.51 × 10-8 , p = 1.47 × 10-9 ) genotypes predicted the risk for CAD with an odds ratio of 5.8 and 7.3 respectively. In addition, individuals with the TT genotype were hypermethylated at promoter DNA of PCSK9, resulting in lower mRNA expression and circulating serum proteins than in individuals with the GG genotype. In silico analyses revealed that rs11591147 T-allele has protein destabilizing capacity. CONCLUSIONS In conclusion, the present study indicates that the PCSK9 gene expression and circulating serum protein levels are not only associated with rs11591147 genotype, but also with promoter DNA methylation. Furthermore, the findings with respect to both single nucleotide polymorphism and promoter DNA methylation may open avenues for novel treatment possibilities targeting PCSK9 for CAD management.
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Affiliation(s)
- Nivas Shyamala
- Department of Genetics & Biotechnology, Osmania University, Hyderabad, Telangana State, India
| | | | - Rajesh Kumar Galimudi
- Department of Genetics & Biotechnology, Osmania University, Hyderabad, Telangana State, India.,Vascular and Renal Translational Research Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Lleida, Spain
| | | | - Chiranjeevi Padala
- Department of Genetics & Biotechnology, Osmania University, Hyderabad, Telangana State, India.,Department of Biochemistry, School of Life Sciences, University of Hyderabad, Hyderabad, Telangana State, India
| | - Kaushik Puranam
- Department of Genetics & Biotechnology, Osmania University, Hyderabad, Telangana State, India
| | - Keerthi Kupsal
- Department of Genetics & Biotechnology, Osmania University, Hyderabad, Telangana State, India
| | - Ramanjaneyulu Kummari
- Department of Genetics & Biotechnology, Osmania University, Hyderabad, Telangana State, India
| | - Srilatha Reddy Gantala
- Department of Genetics & Biotechnology, Osmania University, Hyderabad, Telangana State, India
| | - Krishna Reddy Nallamala
- CARE cardiac center, Durgabai Deshmukh Hospital and Research Centre, Hyderabad, Telangana State, India
| | - Sanjib K Sahu
- CARE cardiac center, Durgabai Deshmukh Hospital and Research Centre, Hyderabad, Telangana State, India
| | - Surekha Rani Hanumanth
- Department of Genetics & Biotechnology, Osmania University, Hyderabad, Telangana State, India
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Hirsh Raccah B, Yanovsky A, Treves N, Rotshild V, Renoux C, Danenberg H, Eliaz R, Matok I. Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) inhibitors and the risk for neurocognitive adverse events: A systematic review, meta-analysis and meta-regression. Int J Cardiol 2021; 335:7-14. [PMID: 33892045 DOI: 10.1016/j.ijcard.2021.04.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/17/2021] [Accepted: 04/16/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND It has been suggested that lipid lowering therapy causes impaired cognitive changes. The association between the use of Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) inhibitors and the risk of neurocognitive adverse events remains unclear. This meta-analysis aims to assess neurocognitive safety of PCSK9 inhibitors in randomized controlled trials (RCTs). METHODS AND RESULTS The research was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed (MEDLINE), Embase and Cochrane library were searched through September 2019. Selection criteria included RCTs that addressed to neurocognitive adverse events of participants using Alirocumab, Evolocumab or Bococizumab, with a follow up duration of at least 6 months. The search results were screened by two independent reviewers. Safety data from included papers were extracted. Random effects meta-analysis was used to pool results, and meta-regression was utilized when applicable. Twenty-one studies were included. Among 59,733 patients, 31,611 were treated with PCSK9 inhibitors. The follow-up period ranged from 24 weeks to 48 months. No significant difference in the incidence of neurocognitive adverse effects between the groups was identified (RR = 1.01, 95% CI: 0.86-1.19, I2 = 3%). Similar results were seen in subgroup analysis for each of the medications (alirocumab- RR = 0.88, 95% CI: 0.72-1.08, I2 = 0%, evolocumab- RR = 1.42, 95% CI: 0.74-2.73, I2 = 55%). A meta-regression analysis for evolocumab revealed that prolonged study duration was associated with decreased risk for neurocognitive adverse events (βweek = -0.0037, p-value = 0.03). CONCLUSIONS Pooled results of our meta-analysis and meta-regression show that exposure to PCSK9 inhibitors is not associated with an increased risk of neurocognitive adverse effects.
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Affiliation(s)
- Bruria Hirsh Raccah
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy Faculty of Medicine, The Hebrew University of Jerusalem, Israel; Department of Cardiology, Hadassah University Hospital, Israel
| | - Alona Yanovsky
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy Faculty of Medicine, The Hebrew University of Jerusalem, Israel
| | - Nir Treves
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy Faculty of Medicine, The Hebrew University of Jerusalem, Israel
| | - Victoria Rotshild
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy Faculty of Medicine, The Hebrew University of Jerusalem, Israel
| | - Christel Renoux
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Department of Epidemiology, Montreal, Québec, Canada; Department of Neurology and Neurosurgery, McGill University, Montreal, Québec, Canada
| | - Haim Danenberg
- Department of Cardiology, Hadassah University Hospital, Israel
| | - Ran Eliaz
- Department of Cardiology, Hadassah University Hospital, Israel
| | - Ilan Matok
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy Faculty of Medicine, The Hebrew University of Jerusalem, Israel.
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Decourt C, Janin A, Moindrot M, Chatron N, Nony S, Muntaner M, Dumont S, Divry E, Dauchet L, Meirhaeghe A, Marmontel O, Bardel C, Charrière S, Cariou B, Moulin P, Di Filippo M. PCSK9 post-transcriptional regulation: Role of a 3′UTR microRNA-binding site variant in linkage disequilibrium with c.1420G. Atherosclerosis 2020; 314:63-70. [DOI: 10.1016/j.atherosclerosis.2020.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 09/21/2020] [Accepted: 10/07/2020] [Indexed: 02/05/2023]
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Harvey PD, Sabbagh MN, Harrison JE, Ginsberg HN, Chapman MJ, Manvelian G, Moryusef A, Mandel J, Farnier M. No evidence of neurocognitive adverse events associated with alirocumab treatment in 3340 patients from 14 randomized Phase 2 and 3 controlled trials: a meta-analysis of individual patient data. Eur Heart J 2019; 39:374-381. [PMID: 29186504 PMCID: PMC5837381 DOI: 10.1093/eurheartj/ehx661] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 10/27/2017] [Indexed: 11/13/2022] Open
Abstract
Aims Despite patient reports of neurocognitive disorders with lipid-lowering treatments (LLTs), large clinical trials have found no significant association between neurocognitive disorders and LLTs. We assessed incidence of neurocognitive treatment-emergent adverse events (TEAEs) from 14 Phase 2 and 3 trials of the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor alirocumab. Methods and results Patients (most on background maximally tolerated statin) received alirocumab 75/150 mg every 2 weeks (n = 3340; 4029 patient-years of exposure), placebo (n = 1276), or ezetimibe (n = 618). Data were pooled by the control used. Neurocognitive TEAEs were reported by 22 (0.9%) alirocumab-treated patients vs. 9 (0.7%) with placebo in placebo-controlled trials [hazard ratio (HR) 1.24, 95% confidence interval (CI) 0.57–2.68] and 10 (1.2%) with alirocumab vs. 8 (1.3%) with ezetimibe in ezetimibe-controlled trials (HR 0.81, 95% CI 0.32–2.08). Rates of neurocognitive TEAEs were similar in patients receiving alirocumab with LDL cholesterol (LDL-C) levels <25 mg/dL (<0.65 mmol/L; n = 5/839; 0.6%; 0.5/100 patient-years) vs. ≥25 mg/dL (n = 26/2501; 1.0%; 0.8/100 patient-years). One patient (0.1%; ezetimibe-controlled pool) receiving alirocumab had a neurocognitive TEAE leading to discontinuation vs. two (0.2%) patients receiving placebo and three (0.4%) patients receiving ezetimibe. Neurocognitive TEAE incidence was also similar between alirocumab and controls when stratified by age. Conclusions Neurocognitive TEAE incidences were low (≤1.2%), with no significant differences between alirocumab vs. controls up to 104 weeks. No association was found between neurocognitive TEAEs and LDL-C <25 mg/dL based on the completed Phase 2 and 3 trials examined, although long-term effects of very low LDL-C levels induced by PCSK9 inhibitors are currently unknown.
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Affiliation(s)
- Philip D Harvey
- Department of Psychiatry, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 1450, Miami, FL, USA
| | - Marwan N Sabbagh
- Barrow Neurological Institute, 350 W Thomas Rd, Phoenix, AZ 85013, USA
| | - John E Harrison
- Alzheimer Center, VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands.,IoPPN, Kings's College, 16 De Crespigny Park, London SE5 8AF, UK
| | - Henry N Ginsberg
- Columbia University, 622 West 168 Street, New York, NY 10032, USA
| | - M John Chapman
- University of Pierre and Marie Curie, 47-83 Boulevard de l'Hôpital, 75013 Paris, France
| | - Garen Manvelian
- Regeneron Pharmaceuticals, 777 Old Saw River Road, Tarrytown, NY 10591, USA
| | | | - Jonas Mandel
- Sanofi, 1 Avenue Pierre Brossolette, 91380 Chilly-Mazarin, France, and IviData Stats, 79 Baudin Street, 92300 Levallois-Perret, France
| | - Michel Farnier
- Point Médical, Rond Point de la Nation, 21000 Dijon, France, and Department of Cardiology, CHU Dijon Bourgogne, 2 Bd Maréchal de Lattre of Tassigny, 21000 Dijon, France
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Nishikido T, Ray KK. Targeting the peptidase PCSK9 to reduce cardiovascular risk: Implications for basic science and upcoming challenges. Br J Pharmacol 2019; 178:2168-2185. [PMID: 31465540 DOI: 10.1111/bph.14851] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/30/2019] [Accepted: 08/16/2019] [Indexed: 02/06/2023] Open
Abstract
LDL cholesterol (LDL-C) plays a central role in the progression of atherosclerosis. Statin therapy for lowering LDL-C reduces the risk of atherosclerotic cardiovascular disease and is the recommended first-line treatment for patients with high LDL-C levels. However, some patients are unable to achieve an adequate reduction in LDL-C with statins or are statin-intolerant; thus, PCSK9 inhibitors were developed to reduce LDL-C levels, instead of statin therapy. PCSK9 monoclonal antibodies dramatically reduce LDL-C levels and cardiovascular risk, and promising new PCSK9 inhibitors using different mechanisms are currently being developed. The absolute benefit of LDL-C reduction depends on the individual absolute risk and the achieved absolute reduction in LDL-C. Therefore, PCSK9 inhibitors may provide the greatest benefits from further LDL-C reduction for the highest risk patients. Here, we focus on PCSK9-targeted therapies and discuss the challenges of LDL-C reduction for prevention of atherosclerotic cardiovascular disease.
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Affiliation(s)
- Toshiyuki Nishikido
- Imperial Centre for Cardiovascular Disease Prevention (ICCP), Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK.,Department of Cardiovascular Medicine, Saga University, Saga, Japan
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention (ICCP), Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
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Picard C, Poirier A, Bélanger S, Labonté A, Auld D, Poirier J. Proprotein convertase subtilisin/kexin type 9 (PCSK9) in Alzheimer's disease: A genetic and proteomic multi-cohort study. PLoS One 2019; 14:e0220254. [PMID: 31437157 PMCID: PMC6705826 DOI: 10.1371/journal.pone.0220254] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/11/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a hepatic enzyme that regulates circulating low-density lipoprotein (LDL) cholesterol levels by binding to LDL receptors (LDLR) and promoting their degradation. Although PCSK9 inhibitors were shown to reduce the risk of cardiovascular disease, a warning was issued concerning their possible impact on cognitive functions. In Alzheimer's disease (AD), it is believed that cognitive impairment is associated with cholesterol metabolism alterations, which could involve PCSK9. The main objective of this study is to determine if PCSK9 plays a significant role in the pre-symptomatic phase of the disease when the pathophysiological markers of AD unfolds and, later, when cognitive symptoms emerge. METHODS AND FINDINGS To test if PCSK9 is associated with AD pathology, we measured its expression levels in 65 autopsy confirmed AD brains and 45 age and gender matched controls. Messenger ribonucleic acid (mRNA) were quantified using real-time polymerase chain reaction (RT-PCR) and protein levels were quantified using enzyme-linked immunosorbent assay (ELISA). PCSK9 was elevated in frontal cortices of AD subjects compared to controls, both at the mRNA and protein levels. LDLR protein levels were unchanged in AD frontal cortices, despite and upregulation at the mRNA level. To verify if PCSK9 dysregulation was observable before the onset of AD, we measured its expression in the cerebrospinal fluid (CSF) of 104 "at-risk" subjects and contrasted it with known apolipoproteins levels and specific AD biomarkers using ELISAs. Positive correlations were found between CSF PCSK9 and apolipoprotein E (APOE), apolipoprotein J (APOJ or CLU), apolipoprotein B (APOB), phospho Tau (pTau) and total Tau. To investigate if PCSK9 levels were driven by genetic variants, we conducted an expression quantitative trait loci (eQTL) study using bioinformatic tools and found two polymorphisms in strong association. Further investigation of these variants in two independent cohorts showed a female specific association with AD risk and with CSF Tau levels in cognitively impaired individuals. CONCLUSIONS PCSK9 levels differ between control and AD brains and its protein levels correlate with those of other lipoproteins and AD biomarkers even before the onset of the disease. PCSK9 regulation seems to be under tight genetic control in females only, with specific variants that could predispose to increased AD risk.
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Affiliation(s)
- Cynthia Picard
- Douglas Mental Health University Institute, Montréal, Québec, Canada
- Centre for the Studies in the Prevention of Alzheimer’s Disease, Montréal, Québec, Canada
- Department of Psychiatry, McGill University, Montréal, Québec, Canada
| | - Alexandre Poirier
- Douglas Mental Health University Institute, Montréal, Québec, Canada
| | | | - Anne Labonté
- Douglas Mental Health University Institute, Montréal, Québec, Canada
- Centre for the Studies in the Prevention of Alzheimer’s Disease, Montréal, Québec, Canada
| | - Daniel Auld
- Génome Québec Innovation Centre, Montréal, Québec, Canada
| | - Judes Poirier
- Douglas Mental Health University Institute, Montréal, Québec, Canada
- Centre for the Studies in the Prevention of Alzheimer’s Disease, Montréal, Québec, Canada
- Department of Psychiatry, McGill University, Montréal, Québec, Canada
| | - on behalf of the PREVENT-AD Research Group
- Douglas Mental Health University Institute, Montréal, Québec, Canada
- Centre for the Studies in the Prevention of Alzheimer’s Disease, Montréal, Québec, Canada
- Department of Psychiatry, McGill University, Montréal, Québec, Canada
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12
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Abstract
Proprotein convertase subtilisin kexin 9 (PCSK9) is a serine protease with a key role in regulating plasma low-density lipoprotein (LDL) concentration. Since its discovery via parallel molecular biology and clinical genetics studies in 2003, work to characterize PCSK9 has shed new light on the life-cycle of the low-density lipoprotein receptor and the molecular basis of familial hypercholesterolaemia. These discoveries have also led to the advent of the PCSK9 inhibitors, a new generation of low-density lipoprotein cholesterol (LDL-C) lowering drugs. Clinical trials have shown these agents to be both safe and capable of unprecedented reductions in LDL-C, and it is hoped they may herald a new era of cardiovascular disease prevention. As such, the still evolving PCSK9 story serves as a particularly successful example of translational medicine. This review provides a summary of the principal PCSK9 research findings, which underpin our current understanding of its function and clinical relevance.
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Affiliation(s)
- Jonathan Malo
- Clinical Biochemistry, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Arun Parajuli
- Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - Simon W Walker
- Clinical Biochemistry, Royal Infirmary Edinburgh, Edinburgh, UK
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13
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Ward NC, Page MM, Watts GF. Clinical guidance on the contemporary use of proprotein convertase subtilisin/kexin type 9 monoclonal antibodies. Diabetes Obes Metab 2019; 21 Suppl 1:52-62. [PMID: 31002454 DOI: 10.1111/dom.13637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/09/2019] [Accepted: 01/10/2019] [Indexed: 12/01/2022]
Abstract
There is now significant evidence for the benefits of lowering low-density lipoprotein cholesterol (LDL-c) to reduce the risk of atherosclerotic cardiovascular disease (ASCVD). Although statins are the most widely prescribed lipid-lowering therapy that effectively lower LDL-c, especially in combination with ezetimibe, some patients require adjunctive therapy to further lower LDL-c and mitigate attendant risk of ASCVD. The gap can be filled by proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibodies whose use is currently supported by two recent cardiovascular outcome studies and new treatment guidelines. We provide an overview of extant studies investigating PCSK9 monoclonal antibodies in various patient populations, an update of the guidelines regarding their use and a case-based discussion.
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Affiliation(s)
- Natalie C Ward
- School of Public Health, Curtin University, Perth, Australia
- School of Medicine, University of Western Australia, Perth, Australia
| | - Michael M Page
- School of Medicine, University of Western Australia, Perth, Australia
- PathWest Laboratory Medicine, Fiona Stanley Hospital, Perth, Australia
| | - Gerald F Watts
- School of Medicine, University of Western Australia, Perth, Australia
- Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth, Australia
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14
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[Dyslipidemia management in geriatric patients: new guidelines 2017]. Nihon Ronen Igakkai Zasshi 2019; 56:417-426. [PMID: 31761845 DOI: 10.3143/geriatrics.56.417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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15
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Alghamdi J, Matou-Nasri S, Alghamdi F, Alghamdi S, Alfadhel M, Padmanabhan S. Risk of Neuropsychiatric Adverse Effects of Lipid-Lowering Drugs: A Mendelian Randomization Study. Int J Neuropsychopharmacol 2018; 21:1067-1075. [PMID: 29986042 PMCID: PMC6276028 DOI: 10.1093/ijnp/pyy060] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 07/04/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Recent studies have highlighted the possible risk of neuropsychiatric adverse effects during treatment with lipid-lowering medications. However, there are still controversies that require a novel genetic-based approach to verify whether the impact of lipid-lowering drug treatment results in neuropsychiatric troubles including insomnia, depression, and neuroticism. Thus, we applied Mendelian randomization to assess any potential neuropsychiatric adverse effects of conventional lipid-lowering drugs such as statins, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, and ezetimibe. METHODS A 2-sample Mendelian randomization study was conducted based on summary statistics from genome-wide association studies for lipids, insomnia, depression, and neuroticism. Single-nucleotide polymorphisms located in or near drug target genes of HMGCR, PCSK9, and NPC1L1 were used as proxies for statins, PCSK9 inhibitors, and ezetimibe therapy, respectively. To assess the validity of the genetic risk score, their associations with coronary artery disease were used as a positive control. RESULTS The Mendelian randomization analysis showed a statistically significant (P <.004) increased risk of depression after correcting for multiple testing with both statins (odds ratio=1.15, 95% CI: 1.04-1.19) and PCSK9 inhibitor treatment (odds ratio =1.19, 95%CI: 1.1-1.29). The risk of neuroticism was slightly reduced with statin therapy (odds ratio=0.9, 95%CI: 0.83-0.97). No significant adverse effects were associated with ezetimibe treatment. As expected, the 3 medications significantly reduced the risk of coronary artery disease. CONCLUSION Using a genetic-based approach, this study showed an increased risk of depression during statin and PCSK9 inhibitor therapy while their association with insomnia risk was not significant.
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Affiliation(s)
- Jahad Alghamdi
- King Abdullah International Medical Research Center / King Saud bin Abdulaziz University for Health Sciences, Medical Genomics Research Department – Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia,Correspondence: Jahad Alghamdi, PhD, Medical Genomic Research Department (MGRD), King Abdullah International Medical Research Center (KAIMRC), P.O. Box 22490, Riyadh 11426 KSA Mail Code 1515, Saudi Arabia ()
| | - Sabine Matou-Nasri
- King Abdullah International Medical Research Center / King Saud bin Abdulaziz University for Health Sciences, Medical Genomics Research Department – Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Faisal Alghamdi
- King Abdullah International Medical Research Center / King Saud bin Abdulaziz University for Health Sciences, Medical Genomics Research Department – Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Saleh Alghamdi
- King Saud University, College of Medicine, Riyadh, Saudi Arabia
| | - Majid Alfadhel
- King Abdullah International Medical Research Center / King Saud bin Abdulaziz University for Health Sciences, Medical Genomics Research Department – Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Sandosh Padmanabhan
- British Heart Foundation Glasgow Cardiovascular Research Centre, Faculty of Medicine, University of Glasgow, Glasgow, United Kingdom
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16
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PCSK9 and neurocognitive function: Should it be still an issue after FOURIER and EBBINGHAUS results? J Clin Lipidol 2018; 12:1123-1132. [PMID: 30318062 DOI: 10.1016/j.jacl.2018.05.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 05/17/2018] [Accepted: 05/21/2018] [Indexed: 12/20/2022]
Abstract
The serine protease proprotein convertase subtilisin/kexin type 9 (PCSK9) modulates the levels of low-density lipoprotein cholesterol and cardiovascular risk. Potential risks of adverse neurological effects of intensive lipid-lowering treatment have been hypothesized, as cholesterol is a component of the central nervous system. Moreover, several observations suggest that PCSK9 might play a role in neurogenesis, neuronal migration and apoptosis. In rodents, increased expression of PCSK9 has been detected in specific areas of the central nervous system during embryonic development; also, PCSK9 modulates low-density lipoprotein receptor levels in the ischemic brain areas. Despite a putative participation of PCSK9 in nervous system physiology, the absence of PCSK9 in knockout mice or in humans with loss-of-function mutations of PCSK9 gene has not been linked to neurological alterations. In recent years, some concerns have been raised about the potential neurological side effects of cholesterol-lowering treatments and, more specifically of PCSK9 inhibitors. In this review, the evidence regarding the function of PCSK9 in neuron differentiation, apoptosis, and migration and in nervous system development and latest clinical trials evaluating the effects of PCSK9 inhibitors on neurocognitive function will be described.
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17
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Abstract
Blood lipids are important modifiable risk factors for coronary heart disease and various drugs have been developed to target lipid fractions. Considerable efforts have been made to identify genetic variants that modulate responses to drugs in the hope of optimizing their use. Pharmacogenomics and new biotechnologies now allow for meaningful integration of human genetic findings and therapeutic development for increased efficiency and precision of lipid-lowering drugs. Polygenic predictors of disease risk are also changing how patient populations can be stratified, enabling targeted therapeutic interventions to patients more likely to derive the highest benefit, marking a shift from single variant to genomic approaches in pharmacogenomics.
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Affiliation(s)
- Marc-André Legault
- Montreal Heart Institute, Montreal, QC, H1T 1C8, Canada.,Université de Montréal, Faculté de médecine, Montreal, QC, H3T 1J4, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Centre, Montreal, H1T 1C8, QC, Canada
| | - Jean-Claude Tardif
- Montreal Heart Institute, Montreal, QC, H1T 1C8, Canada.,Université de Montréal, Faculté de médecine, Montreal, QC, H3T 1J4, Canada
| | - Marie-Pierre Dubé
- Montreal Heart Institute, Montreal, QC, H1T 1C8, Canada.,Université de Montréal, Faculté de médecine, Montreal, QC, H3T 1J4, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Centre, Montreal, H1T 1C8, QC, Canada
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18
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Bajaj NS, Patel N, Kalra R, Ahmad A, Venkatraman A, Arora G, Arora P. Neurological effects of proprotein convertase subtilisin/kexin type 9 inhibitors: direct comparisons. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2018; 4:132-141. [PMID: 29121222 PMCID: PMC5884103 DOI: 10.1093/ehjqcco/qcx037] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 08/02/2017] [Accepted: 10/05/2017] [Indexed: 01/21/2023]
Abstract
Aims Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors considerably alter the lipid profile. We sought to examine the rates of ischaemic stroke and neurocognitive deficits in patients treated with and without PCSK9 inhibitors. Methods and results Randomized controlled trials (RCTs) reporting rates of ischaemic stroke and neurocognitive deficits in patients using PCSK9 inhibitors were identified. Standard meta-analysis techniques were used to compare these outcomes among patients treated with and without PCSK9 inhibitors and the two US Food and Drug Administration-approved PCSK9 inhibitors, evolocumab and alirocumab. The results were presented in terms of risk ratio (RR) with 95% confidence intervals (CIs). Sixteen RCTs with 39 104 patients were included. Evolocumab was used in six RCTs with 33 450 patients, whereas alirocumab was used in 10 RCTs with 5654 patients. We observed a significantly lower risk of ischaemic stroke among those treated with PCSK9 inhibitors (RR 0.77, 95% CI 0.64-0.93) when compared with those without. We did not observe any difference in the risk of neurocognitive deficits between the aforementioned groups (RR 1.11, 95% CI 0.93-1.32). The lower stroke risk in the PCSK9 inhibitors group was driven by evolocumab studies. We observed no difference in the risk of neurocognitive deficits among evolocumab and alirocumab when compared with no PCSK9 inhibitors group. Conclusion Treatment with PCSK9 inhibitors significantly lowers the risk of ischaemic stroke, without any increased risk of neurocognitive deficits. PCSK9 inhibitors are neuroprotective due to the decrease in ischaemic-mediated neurovascular events and should be considered cognitively innocuous medications.
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Affiliation(s)
- Navkaranbir S Bajaj
- Department of Cardiovascular Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, 1900 University Boulevard Birmingham, AL 35233, USA
| | - Nirav Patel
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, 1900 University Boulevard Birmingham, AL 35233, USA
| | - Rajat Kalra
- Department of Medicine, Cardiovascular Division, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455, USA
| | - Amier Ahmad
- Department of Medicine, University of Alabama at Birmingham, 1808 7th Ave South, Birmingham, AL 35233, USA
| | - Anand Venkatraman
- Department of Neurology, University of Alabama at Birmingham, 1720 2nd Ave South, Birmingham, AL 35294, USA
| | - Garima Arora
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, 1900 University Boulevard Birmingham, AL 35233, USA
| | - Pankaj Arora
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, 1900 University Boulevard Birmingham, AL 35233, USA
- Department of Veterans Affairs, Section of Cardiology, Birmingham Veterans Affairs Medical Center, 1720 2nd Ave South, Birmingham, AL 35294, USA
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19
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Karagiannis AD, Liu M, Toth PP, Zhao S, Agrawal DK, Libby P, Chatzizisis YS. Pleiotropic Anti-atherosclerotic Effects of PCSK9 Inhibitors From Molecular Biology to Clinical Translation. Curr Atheroscler Rep 2018. [DOI: 10.1007/s11883-018-0718-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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20
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Paquette M, Saavedra YGL, Poirier J, Théroux L, Dea D, Baass A, Dufour R. Loss-of-Function PCSK9 Mutations Are Not Associated With Alzheimer Disease. J Geriatr Psychiatry Neurol 2018; 31:90-96. [PMID: 29562810 DOI: 10.1177/0891988718764330] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hypercholesterolemia is a major risk factor for the late-onset form of Alzheimer disease (AD). Loss-of-function (LOF) mutations of PCSK9 and PCSK9 inhibitors lower low-density lipoprotein cholesterol (LDL-C) and have been associated with a reduced risk of cardiovascular disease. The aim of this study was to examine the effect of PCSK9 LOF variants on risk and age of onset of AD. METHODS A total of 878 participants (410 controls and 468 AD cases) from the Quebec Founder Population were included in the study. RESULTS Fifty-four (6.2%) participants carried the R46L mutation, whereas 226 (26.2%) participants carried the InsLEU mutation. There was no protective or no deleterious effect of carrying PCSK9 LOF mutations on AD prevalence nor on age of onset, even when stratified by apolipoprotein E epsilon 4 genotype or by gender. CONCLUSION Our data indicate that carrying PCSK9 LOF mutations has a neutral effect on neurocognitive health and the prevalence of AD.
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Affiliation(s)
- Martine Paquette
- 1 Nutrition, Metabolism and Atherosclerosis Clinic, Montreal Clinical Research Institute, Montreal, Québec, Canada
| | - Yascara Grisel Luna Saavedra
- 1 Nutrition, Metabolism and Atherosclerosis Clinic, Montreal Clinical Research Institute, Montreal, Québec, Canada
| | - Judes Poirier
- 2 Centre for Studies in the Prevention of Alzheimer's disease, Douglas Mental Health University Institute, McGill University, Montreal, Québec, Canada
| | - Louise Théroux
- 2 Centre for Studies in the Prevention of Alzheimer's disease, Douglas Mental Health University Institute, McGill University, Montreal, Québec, Canada
| | - Doris Dea
- 2 Centre for Studies in the Prevention of Alzheimer's disease, Douglas Mental Health University Institute, McGill University, Montreal, Québec, Canada
| | - Alexis Baass
- 1 Nutrition, Metabolism and Atherosclerosis Clinic, Montreal Clinical Research Institute, Montreal, Québec, Canada
- 3 Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, Québec, Canada
- 4 Division of Medical Biochemistry, Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Robert Dufour
- 1 Nutrition, Metabolism and Atherosclerosis Clinic, Montreal Clinical Research Institute, Montreal, Québec, Canada
- 5 Department of Nutrition, Université de Montréal, Montreal, Québec, Canada
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21
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Mefford MT, Rosenson RS, Cushman M, Farkouh ME, McClure LA, Wadley VG, Irvin MR, Bittner V, Safford MM, Somaratne R, Monda KL, Muntner P, Levitan EB. PCSK9 Variants, Low-Density Lipoprotein Cholesterol, and Neurocognitive Impairment: Reasons for Geographic and Racial Differences in Stroke Study (REGARDS). Circulation 2017; 137:1260-1269. [PMID: 29146683 DOI: 10.1161/circulationaha.117.029785] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 10/30/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite concerns about adverse neurocognitive events raised by prior trials, pharmacological PCSK9 (proprotein convertase subtilisin/kexin type-9) inhibition was not associated with neurocognitive effects in a recent phase 3 randomized trial. PCSK9 loss-of-function (LOF) variants that result in lifelong exposure to lower levels of low-density lipoprotein cholesterol can provide information on the potential long-term effects of lower low-density lipoprotein cholesterol on neurocognitive impairment and decline. METHODS We investigated the association between PCSK9 LOF variants and neurocognitive impairment and decline among black REGARDS study (Reasons for Geographic and Racial Differences in Stroke) participants with (n=241) and without (n=10 454) C697X or Y142X LOF variants. Neurocognitive tests included the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) battery (Word List Learning, World List Delayed Recall, Semantic Animal Fluency) and Six-Item Screener (SIS) assessments, administered longitudinally during follow-up. Neurocognitive impairment was defined as a score ≥1.5 SD below age, sex, and education-based stratum-specific means on 2 or 3 CERAD assessments or, separately, a score <5 on any SIS assessment at baseline or during follow-up. Neurocognitive decline was assessed using standardized continuous scores on individual neurocognitive tests. RESULTS The mean sample age was 64 years (SD, 9), 62% were women, and the prevalence of neurocognitive impairment at any assessment was 6.3% by CERAD and 15.4% by SIS definitions. Adjusted odds ratios for neurocognitive impairment for participants with versus without PCSK9 LOF variants were 1.11 (95% confidence interval [CI], 0.58-2.13) using the CERAD battery and 0.89 (95% CI, 0.61-1.30) using the SIS assessment. Standardized average differences in individual neurocognitive assessment scores over the 5.6-year (range, 0.1-9.1) study period ranged between 0.07 (95% CI, -0.06 to 0.20) and -0.07 (95% CI, -0.18 to 0.05) among participants with versus without PCSK9 LOF variants. Patterns of neurocognitive decline were similar between participants with and without PCSK9 LOF variants (all P>0.10). Odds ratios for neurocognitive impairment per 20 mg/dL low-density lipoprotein cholesterol decrements were 1.02 (95% CI, 0.96-1.08) and 0.99 (95% CI, 0.95-1.02) for the CERAD and SIS definitions of impairment, respectively. CONCLUSIONS These results suggest that lifelong exposure to low PCSK9 levels and cumulative exposure to lower levels of low-density lipoprotein cholesterol are not associated with neurocognitive effects in blacks.
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Affiliation(s)
- Matthew T Mefford
- Department of Epidemiology (M.T.M., M.R.I., P.M., E.B.L.).,University of Alabama at Birmingham (M.T.M., M.R.I., P.M., E.B.L.)
| | - Robert S Rosenson
- Icahn School of Medicine at Mount Sinai, Mount Sinai Heart, New York, NY (R.S.R.)
| | - Mary Cushman
- Division of Hematology/Oncology, Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington (M.C.)
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre, University of Toronto, Ontario, Canada (M.E.F.)
| | - Leslie A McClure
- Department of Epidemiology and Biostatistics, Drexel University, Philadelphia, PA (L.A.M.)
| | | | - Marguerite R Irvin
- Department of Epidemiology (M.T.M., M.R.I., P.M., E.B.L.).,University of Alabama at Birmingham (M.T.M., M.R.I., P.M., E.B.L.)
| | | | | | - Ransi Somaratne
- Center for Observational Research, Amgen Inc, Thousand Oaks, CA (R.S., K.L.M.)
| | - Keri L Monda
- Center for Observational Research, Amgen Inc, Thousand Oaks, CA (R.S., K.L.M.)
| | - Paul Muntner
- Department of Epidemiology (M.T.M., M.R.I., P.M., E.B.L.).,University of Alabama at Birmingham (M.T.M., M.R.I., P.M., E.B.L.)
| | - Emily B Levitan
- Department of Epidemiology (M.T.M., M.R.I., P.M., E.B.L.) .,University of Alabama at Birmingham (M.T.M., M.R.I., P.M., E.B.L.)
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22
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Toth PP, Descamps O, Genest J, Sattar N, Preiss D, Dent R, Djedjos C, Wu Y, Geller M, Uhart M, Somaratne R, Wasserman SM. Pooled Safety Analysis of Evolocumab in Over 6000 Patients From Double-Blind and Open-Label Extension Studies. Circulation 2017; 135:1819-1831. [DOI: 10.1161/circulationaha.116.025233] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 02/16/2017] [Indexed: 11/16/2022]
Abstract
Background:
Evolocumab, a fully human monoclonal antibody to PCSK9 (proprotein convertase subtilisin/kexin type 9), markedly reduces low-density lipoprotein cholesterol across diverse patient populations. The objective of this study was to assess the safety and tolerability of evolocumab in a pooled safety analysis from phase 2 or 3 randomized and placebo or comparator-controlled trials (integrated parent trials) and the first year of open-label extension (OLE) trials that included a standard-of-care control group.
Methods:
This analysis included adverse event (AE) data from 6026 patients in 12 phase 2 and 3 parent trials, with a median exposure of 2.8 months, and, of those patients, from 4465 patients who continued with a median follow-up of 11.1 months in 2 OLE trials. AEs were analyzed separately for the parent and OLE trials. Overall AE rates, serious AEs, laboratory assessments, and AEs of interest were evaluated.
Results:
Overall AE rates were similar between evolocumab and control in the parent trials (51.1% versus 49.6%) and in year 1 of OLE trials (70.0% versus 66.0%), as were those for serious AEs. Elevations of serum transaminases, bilirubin, and creatine kinase were infrequent and similar between groups. Muscle-related AEs were similar between evolocumab and control. Neurocognitive AEs were infrequent and balanced during the double-blind parent studies (5 events [0.1%], evolocumab groups versus 6 events [0.3%], control groups). In the OLE trials, 27 patients (0.9%) in the evolocumab groups and 5 patients (0.3%) in the control groups reported neurocognitive AEs. No neutralizing antievolocumab antibodies were detected.
Conclusions:
Overall, this integrated safety analysis of 6026 patients pooled across phase 2/3 trials and 4465 patients who continued in OLE trials for 1 year supports a favorable benefit-risk profile for evolocumab.
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Affiliation(s)
- Peter P. Toth
- From CGH Medical Center, Sterling, IL, and Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (P.P.T.); Lipid Clinic, Centres Hospitaliers Jolimont, Haine-Saint-Paul, Belgium (O.D.); The McGill University Health Centre, Montreal, Canada (J.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK (N.S.); Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and
| | - Olivier Descamps
- From CGH Medical Center, Sterling, IL, and Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (P.P.T.); Lipid Clinic, Centres Hospitaliers Jolimont, Haine-Saint-Paul, Belgium (O.D.); The McGill University Health Centre, Montreal, Canada (J.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK (N.S.); Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and
| | - Jacques Genest
- From CGH Medical Center, Sterling, IL, and Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (P.P.T.); Lipid Clinic, Centres Hospitaliers Jolimont, Haine-Saint-Paul, Belgium (O.D.); The McGill University Health Centre, Montreal, Canada (J.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK (N.S.); Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and
| | - Naveed Sattar
- From CGH Medical Center, Sterling, IL, and Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (P.P.T.); Lipid Clinic, Centres Hospitaliers Jolimont, Haine-Saint-Paul, Belgium (O.D.); The McGill University Health Centre, Montreal, Canada (J.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK (N.S.); Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and
| | - David Preiss
- From CGH Medical Center, Sterling, IL, and Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (P.P.T.); Lipid Clinic, Centres Hospitaliers Jolimont, Haine-Saint-Paul, Belgium (O.D.); The McGill University Health Centre, Montreal, Canada (J.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK (N.S.); Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and
| | - Ricardo Dent
- From CGH Medical Center, Sterling, IL, and Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (P.P.T.); Lipid Clinic, Centres Hospitaliers Jolimont, Haine-Saint-Paul, Belgium (O.D.); The McGill University Health Centre, Montreal, Canada (J.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK (N.S.); Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and
| | - Constantine Djedjos
- From CGH Medical Center, Sterling, IL, and Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (P.P.T.); Lipid Clinic, Centres Hospitaliers Jolimont, Haine-Saint-Paul, Belgium (O.D.); The McGill University Health Centre, Montreal, Canada (J.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK (N.S.); Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and
| | - Yuna Wu
- From CGH Medical Center, Sterling, IL, and Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (P.P.T.); Lipid Clinic, Centres Hospitaliers Jolimont, Haine-Saint-Paul, Belgium (O.D.); The McGill University Health Centre, Montreal, Canada (J.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK (N.S.); Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and
| | - Michelle Geller
- From CGH Medical Center, Sterling, IL, and Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (P.P.T.); Lipid Clinic, Centres Hospitaliers Jolimont, Haine-Saint-Paul, Belgium (O.D.); The McGill University Health Centre, Montreal, Canada (J.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK (N.S.); Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and
| | - Magdalena Uhart
- From CGH Medical Center, Sterling, IL, and Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (P.P.T.); Lipid Clinic, Centres Hospitaliers Jolimont, Haine-Saint-Paul, Belgium (O.D.); The McGill University Health Centre, Montreal, Canada (J.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK (N.S.); Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and
| | - Ransi Somaratne
- From CGH Medical Center, Sterling, IL, and Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (P.P.T.); Lipid Clinic, Centres Hospitaliers Jolimont, Haine-Saint-Paul, Belgium (O.D.); The McGill University Health Centre, Montreal, Canada (J.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK (N.S.); Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and
| | - Scott M. Wasserman
- From CGH Medical Center, Sterling, IL, and Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (P.P.T.); Lipid Clinic, Centres Hospitaliers Jolimont, Haine-Saint-Paul, Belgium (O.D.); The McGill University Health Centre, Montreal, Canada (J.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK (N.S.); Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and
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Della Pepa G, Bozzetto L, Annuzzi G, Rivellese AA. Alirocumab for the treatment of hypercholesterolaemia. Expert Rev Clin Pharmacol 2017; 10:571-582. [PMID: 28395555 DOI: 10.1080/17512433.2017.1318063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Prescription of statins for low-density lipoprotein cholesterol (LDL-C) reduction is the standard of care in primary and secondary prevention of cardiovascular disease; nevertheless, a large number of patients treated with statins are unable to reach the recommended LDL-C targets. Therefore, there is need for safe and effective novel therapies for the pharmacological management of hypercholesterolaemia, in addition or as alternative to lipid-lowering therapies (LLT) currently in use. Areas covered: In 2015, the Food and Drug Administration and the European Medicines Agency approved alirocumab (Praluent®; Sanofi), a fully human monoclonal antibody against proprotein convertase subtilisin/kexin type 9 (PCSK9), for the treatment of hypercholesterolaemic patients unable to meet LDL-C targets, as an adjunct to diet in addition/alternative to LLT. The authors review the pharmacological features, clinical efficacy, and safety of alirocumab in lowering LDL-C, and discuss its therapeutic perspectives based on the most recent clinical trials. Expert commentary: Alirocumab causes a marked reduction in LDL-C, presents good safety and tolerability, and represents a promising approach for LDL-C lowering, particularly in patients with intolerance to statin or elevated LDL-C despite maximal statin therapy; nevertheless, further long-term data on safety and efficacy are necessary, such as data on the improvement of cardiovascular outcomes.
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Affiliation(s)
- Giuseppe Della Pepa
- a Department of Clinical Medicine and Surgery , Federico II University , Naples , Italy
| | - Lutgarda Bozzetto
- a Department of Clinical Medicine and Surgery , Federico II University , Naples , Italy
| | - Giovanni Annuzzi
- a Department of Clinical Medicine and Surgery , Federico II University , Naples , Italy
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Giugliano RP, Mach F, Zavitz K, Kurtz C, Schneider J, Wang H, Keech A, Pedersen TR, Sabatine MS, Sever PS, Honarpour N, Wasserman SM, Ott BR. Design and rationale of the EBBINGHAUS trial: A phase 3, double-blind, placebo-controlled, multicenter study to assess the effect of evolocumab on cognitive function in patients with clinically evident cardiovascular disease and receiving statin background lipid-lowering therapy-A cognitive study of patients enrolled in the FOURIER trial. Clin Cardiol 2017; 40:59-65. [PMID: 28207168 PMCID: PMC6490624 DOI: 10.1002/clc.22678] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 01/08/2017] [Accepted: 01/11/2017] [Indexed: 12/13/2022] Open
Abstract
Some observational studies raised concern that statins may cause memory impairment, leading to a US Food and Drug Administration warning. Similar questions were raised regarding proprotein convertase subtilisin/kexin-type 9 inhibitors (PCSK9i) and neurocognitive function. No prospectively designed study has evaluated the relationship between long-term PCSK9i use and cognition changes. Patients with prior cardiovascular disease treated with maximally tolerated statin enrolled in FOURIER (the randomized, double-blind, placebo-controlled cardiovascular outcome study of the PCSK9i evolocumab) could participate in this prospective assessment of cognitive function (EBBINGHAUS). Key additional exclusion criteria for EBBINGHAUS were dementia, cognitive impairment, or other significant mental or neurological disorder. Cognitive testing was performed using the Cambridge Neuropsychological Test Automated Battery, a tablet-based tool assessing executive function, working memory, memory function, and psychomotor speed at baseline, weeks 24 and 48, every 48 weeks thereafter, and study end. The primary endpoint was spatial working memory strategy index of executive function (SWMSI). The primary hypothesis was that evolocumab would be noninferior to placebo in the mean change from baseline over time in SWMSI. Fifteen hundred cognitively normal patients completing the assessments provided approximately 97% power to demonstrate that the upper 95% confidence interval for the treatment difference in mean change from baseline in SWMSI over time is <20% of the SD of the mean change in the placebo group. An exploratory analysis will compare neurocognitive function in patients with post-baseline low-density lipoprotein cholesterol <25 mg/dL. EBBINGHAUS will evaluate whether the addition of evolocumab to statin therapy affects cognitive function over time in patients with stable cardiovascular disease.
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Affiliation(s)
| | - Francois Mach
- Division of Cardiology, Cantonal HospitalGeneva University HospitalsGenevaSwitzerland
| | | | | | | | | | - Anthony Keech
- NHMRC Clinical Trials Centre, Sydney Medical Schoolthe University of SydneyAustralia
| | - Terje R. Pedersen
- Center for Preventive Medicine, Oslo University Hospital, Ullevål; and Medical FacultyUniversity of OsloNorway
| | - Marc S. Sabatine
- TIMI Study Group, Brigham and Women's HospitalBostonMassachusetts
| | - Peter S. Sever
- International Centre for Circulatory Health, Imperial College LondonLondonUnited Kingdom
| | | | | | - Brian R. Ott
- Department of Neurologythe Warren Alpert Medical School of Brown UniversityProvidenceRhode Island
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PCSK9 inhibitors in the current management of atherosclerosis. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2016; 87:43-48. [PMID: 28038950 DOI: 10.1016/j.acmx.2016.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 11/28/2016] [Accepted: 11/29/2016] [Indexed: 11/23/2022] Open
Abstract
The history of proprotein convertase subtilisin/kexin type 9 (PCSK9) in medical science is fascinating and the evolution of knowledge of its function has resulted in new medications of major importance for the cardiovascular (CV) patient. PCSK9 functions as a negative control or feedback for the cell surface receptors for low-density lipoprotein including its component of cholesterol (LDL-C). The initial and key findings were that different abnormalities of PCSK9 can result in an increase or a decrease of LDL-C because of more or less suppression of cell surface receptors. These observations gave hints and awoke interest that it might be possible to prepare monoclonal antibodies to PCSK9 and decrease its activity, after which there should be more active LDL-C cell receptors. The rest is a fascinating story that currently has resulted in two PCSK9 inhibitors, alirocumab and evolocumab, which, on average, decrease LDL-C approximately 50%. Nevertheless, if there are no contraindications, statins remain the standard of prevention for the high-risk CV patient and this includes both secondary and primary prevention. The new inhibitors are for the patient that does not attain the desired target for LDL-C reduction while taking a maximum statin dose or who does not tolerate any statin dose whatsoever. Atherosclerosis can be considered a metabolic disease and the clinician needs to realize this and think more and more of CV prevention. These inhibitors can contribute to both the stabilization and regression of atherosclerotic plaques and thereby avoid or delay major adverse cardiac events. (United States).
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Farnier M. Proprotein convertase subtilisin kexin type 9 inhibitors: update from clinical trials to real-world experience. Curr Opin Lipidol 2016; 27:597-604. [PMID: 27755114 DOI: 10.1097/mol.0000000000000356] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE OF REVIEW After the approval of alirocumab and evolocumab, the first two monoclonal antibodies (mAbs) targeting proprotein convertase subtilisin kexin type 9 (PCSK9), this review provides an update on recent PCSK9 inhibitors data and describes recommendations for the use before the results of the ongoing cardiovascular endpoint trials. RECENT FINDINGS New studies and complementary analysis of phase III trials have consistently shown that alirocumab and evolocumab are highly effective in reducing LDL-cholesterol and to some extent lipoprotein (a). Some preliminary findings coming from exploratory and post-hoc analyses of the longer-term safety phase III trials and meta-analyses suggest that these mAbs can decrease the incidence of cardiovascular events. Whether or not mAbs targeting PCSK9 definitively reduce the incidence of cardiovascular events without safety concerns shall be demonstrated with the ongoing cardiovascular outcome trials. Waiting these outcome trials and given the high cost of these mAbs, groups of experts have proposed as priorities groups of patients with familial hypercholesterolemia and with atherosclerotic cardiovascular disease who have substantially elevated LDL-cholesterol on maximally tolerated statin/ezetimibe therapy. SUMMARY Before the results of large cardiovascular outcome trials, PCSK9 inhibitors should be only used in some categories of patients with familial hypercholesterolemia and/or with atherosclerotic cardiovascular disease.
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Banach M, Stulc T, Dent R, Toth PP. Statin non-adherence and residual cardiovascular risk: There is need for substantial improvement. Int J Cardiol 2016; 225:184-196. [PMID: 27728862 DOI: 10.1016/j.ijcard.2016.09.075] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 09/23/2016] [Indexed: 12/18/2022]
Abstract
Although statin therapy has proven to be the cornerstone for prevention and treatment of cardiovascular disease (CVD), there are many patients for whom long-term therapy remains suboptimal. The aims of this article are to review the current complex issues associated with statin use and to explore when novel treatment approaches should be considered. Statin discontinuation as well as adherence to statin therapy remain two of the greatest challenges for lipidologists. Evidence suggests that between 40 and 75% of patients discontinue their statin therapy within one year after initiation. Furthermore, whilst the reasons for persistence with statin therapy are complex, evidence shows that low-adherence to statins negatively impacts clinical outcomes and residual CV risk remains a major concern. Non-adherence or lack of persistence with long-term statin therapy in real-life may be the main cause of inadequate low density lipoprotein cholesterol lowering with statins. There is a large need for the improvement of the use of statins, which have good safety profiles and are inexpensive. On the other hand, in a non-cost-constrained environment, proprotein convertase subtilisin/kexin type 9 inhibitors should arguably be used more often in those patients in whom treatment with statins remains unsatisfactory.
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Affiliation(s)
- Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Lodz, Poland; Healthy Aging Research Centre, Medical University of Lodz, Lodz, Poland; Polish Mother's Memorial Hospital Research Institute, Lodz, Poland.
| | - Tomas Stulc
- 3rd Department of Internal Medicine, 1st University of Medicine, Prague, Czech Republic
| | | | - Peter P Toth
- CGH Medical Center, Sterling, IL, USA; Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Norata GD, Tavori H, Pirillo A, Fazio S, Catapano AL. Biology of proprotein convertase subtilisin kexin 9: beyond low-density lipoprotein cholesterol lowering. Cardiovasc Res 2016; 112:429-42. [PMID: 27496869 DOI: 10.1093/cvr/cvw194] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 07/06/2016] [Indexed: 12/17/2022] Open
Abstract
Proprotein convertase subtilisin kexin 9 (PCSK9) is a key regulator of low-density lipoprotein receptor levels and LDL-cholesterol levels. Loss-of-function mutations in PCSK9 gene are associated with hypocholesterolaemia and protection against cardiovascular disease, identifying PCSK9 inhibition as a valid therapeutic approach to manage hypercholesterolaemia and related diseases. Although PCSK9 is expressed mainly in the liver, it is present also in other tissues and organs with specific functions, raising the question of whether a pharmacological inhibition of PCSK9 to treat hypercholesterolaemia and associated cardiovascular diseases might be helpful or deleterious in non-hepatic tissues. For example, PCSK9 is expressed in the vascular wall, in the kidneys, and in the brain, where it was proposed to play a role in development, neurocognitive process, and neuronal apoptosis. A link between PCSK9 and immunity was also proposed as both sepsis and viral infections are differentially affected in the presence or absence of PCSK9. Despite the increasing number of observations, the debate on the exact roles of PCSK9 in extrahepatic tissues is still ongoing, and as very effective drugs that inhibit PCSK9 have become available to the clinician, a better understanding of the biological roles of PCSK9 is warranted.
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Affiliation(s)
- Giuseppe Danilo Norata
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Milan, Italy Center for the Study of Atherosclerosis, Ospedale Bassini, Cinisello Balsamo, Italy
| | - Hagai Tavori
- Center for Preventive Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Angela Pirillo
- Center for the Study of Atherosclerosis, Ospedale Bassini, Cinisello Balsamo, Italy IRCCS Multimedica, Milan, Italy
| | - Sergio Fazio
- Center for Preventive Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Alberico L Catapano
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Milan, Italy IRCCS Multimedica, Milan, Italy
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Elbitar S, Khoury PE, Ghaleb Y, Rabès JP, Varret M, Seidah NG, Boileau C, Abifadel M. Proprotein convertase subtilisin / kexin 9 (PCSK9) inhibitors and the future of dyslipidemia therapy: an updated patent review (2011-2015). Expert Opin Ther Pat 2016; 26:1377-1392. [DOI: 10.1080/13543776.2016.1206080] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Sandy Elbitar
- LVTS, INSERM U1148, Hôpital Xavier-Bichat, Paris, France
- Laboratory of Biochemistry and Molecular Therapeutics, Faculty of Pharmacy, Pôle Technologie- Santé, Saint-Joseph University, Beirut, Lebanon
| | - Petra El Khoury
- LVTS, INSERM U1148, Hôpital Xavier-Bichat, Paris, France
- Laboratory of Biochemistry and Molecular Therapeutics, Faculty of Pharmacy, Pôle Technologie- Santé, Saint-Joseph University, Beirut, Lebanon
| | - Youmna Ghaleb
- LVTS, INSERM U1148, Hôpital Xavier-Bichat, Paris, France
- Laboratory of Biochemistry and Molecular Therapeutics, Faculty of Pharmacy, Pôle Technologie- Santé, Saint-Joseph University, Beirut, Lebanon
| | - Jean-Pierre Rabès
- Service de Biochimie et Génétique Moléculaire, AP-HP, Hôpitaux Universitaires Paris Ile-de-France Ouest, Site Ambroise Paré, Boulogne-Billancourt, France
- UFR des Sciences de la Santé Simone Veil, Université Versailles Saint-Quentin-en-Yvelines, Montigny-Le-Bretonneux, France
| | - Mathilde Varret
- LVTS, INSERM U1148, Hôpital Xavier-Bichat, Paris, France
- Faculté de Médecine Paris 7, Université Denis Diderot, Paris, France
| | - Nabil G. Seidah
- Laboratory of Biochemical Neuroendocrinology, Institut de Recherches Cliniques de Montréal, Affiliated to the Université de Montréal, Montréal, Québec, Canada
| | - Catherine Boileau
- LVTS, INSERM U1148, Hôpital Xavier-Bichat, Paris, France
- Faculté de Médecine Paris 7, Université Denis Diderot, Paris, France
- Département de Génétique, AP-HP, CHU Xavier Bichat, Paris, France
| | - Marianne Abifadel
- LVTS, INSERM U1148, Hôpital Xavier-Bichat, Paris, France
- Laboratory of Biochemistry and Molecular Therapeutics, Faculty of Pharmacy, Pôle Technologie- Santé, Saint-Joseph University, Beirut, Lebanon
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Abstract
Proprotein convertase subtilisin/kexin type 9 (PCSK9) is of critical importance in the regulation of the low-density lipoprotein (LDL) receptor-mediated metabolism of cholesterol. The discovery of mutations in the gene encoding PCSK9 in families with an autosomal dominant form of familial hypercholesterolemia (FH), which were later shown to be "gain-of-function" mutations, led to the development of antibodies against PCSK9. The efficacy in markedly reducing levels of LDL-cholesterol and preliminary evidence for benefits in the prevention of cardiovascular diseases indicated that special groups of patients can be more effectively treated. This includes forms of hypercholesterolemia refractory to conventional treatment as well as patients with FH and/or statin intolerance. Further information on long-term efficacy, tolerability and cost-effectiveness of PCSK9 inhibition and possibilities of implementation in the healthcare system are awaited from ongoing clinical outcome trials, such as FOURIER, ODYSSEY OUTCOMES, SPIRE 1 and 2 involving more than 70,000 high-risk patients.
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Inhibition of proprotein convertase subtilisin/kexin type 9 in the treatment of hypercholesterolemia. ACTA ACUST UNITED AC 2016; 63:255-7. [PMID: 27050861 DOI: 10.1016/j.endonu.2016.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 02/08/2016] [Indexed: 11/23/2022]
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Abstract
Statins remain the mainstay of medical cardiovascular risk reduction because of their effectiveness in decreasing low-density lipoprotein cholesterol (LDL-C) as well as some other potentially beneficial effects. The latest US 2013 lipid guidelines essentially recommend only the prescription of a high-dose statin for the high-risk patient. However, both quite old and quite new outcomes evidence, such as reported for ezetimibe, emphasize that LDL-C lowering is, in and of itself, quite important for cardiovascular risk reduction. It appears that the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors represent a major new contribution to this effort, especially for patients with severe familial hypercholesterolemia, proven clinical cardiovascular disease, statin intolerance, or failure to attain an acceptably low LDL-C goal despite maximum available medical management. Very recent clinical trials have proven overwhelmingly the effectiveness and safety of PCSK9 inhibitors for lowering LDL-C. Both alirocumab and evolocumab have now been approved by the US FDA and there are some initial favorable outcomes data. This review is intended to summarize available evidence and emphasize the possible clinical role of these inhibitors following the approval of alirocumab and evolocumab. Understanding the negative receptor feedback of PCSK9 and the mechanism and beneficial effect of PCSK9 inhibitors for cardiovascular risk reduction is essential for the up-to-date practitioner of cardiovascular medicine. There is every reasonable hope for significant cardiovascular benefit from these new additions to our medical cardiovascular armamentarium.
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Update on the molecular biology of dyslipidemias. Clin Chim Acta 2016; 454:143-85. [DOI: 10.1016/j.cca.2015.10.033] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/24/2015] [Accepted: 10/30/2015] [Indexed: 12/20/2022]
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Hassan M. OSLER and ODYSSEY LONG TERM: PCSK9 inhibitors on the right track of reducing cardiovascular events. Glob Cardiol Sci Pract 2015; 2015:20. [PMID: 26566525 PMCID: PMC4625402 DOI: 10.5339/gcsp.2015.20] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 04/30/2015] [Indexed: 01/03/2023] Open
Abstract
Proprotein convertase subtilisin kexin 9 (PCSK9) inhibitors have emerged as a novel treatment option in patients with hypercholesterolemia. Evolocumab and alirocumab have achieved consistent and significant (around 60%) reduction in low-density lipoprotein cholesterol (LDL-C) levels when added to statin therapy in short term studies. The Open-Label Study of Long-term Evaluation Against LDL-C (OSLER), and The Long-term Safety and Tolerability of Alirocumab in High Cardiovascular Risk Patients with Hypercholesterolemia Not Adequately Controlled with Their Lipid Modifying Therapy (ODYSSEY LONG TERM) studies are two phase 3, multicentre, randomized, placebo controlled studies that were conducted to evaluate the long term efficacy and safety of evolocumab and alirocumab respectively in reducing lipids and cardiovascular (CV) events. Both studies demonstrated additional 48–53% reduction of CV events when added to statin therapy. Most adverse events occurred with similar frequency in the two groups; however the rate of neurocognitive adverse events was higher with evolocumab and alirocumab than with placebo. These data provide strong support for the notion that lower LDL-C goal is better, and may confirm the role of PCSK9 inhibitors as a new frontier in lipid management. The results of larger long-term outcome studies are still awaited.
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Affiliation(s)
- Mohamed Hassan
- Division of Cardiology, Aswan Heart Centre, Aswan, Egypt
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Abstract
The proof of concept that proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition affects cholesterol levels was first established after the demonstration that PCSK9 loss-of-function mutations result in a significant drop in circulating LDL cholesterol levels. Subsequent studies revealed that PCSK9 binds the epidermal growth factor precursor homology domain-A on the surface LDL Receptor (LDLR) and directs LDLR and PCSK9 for lysosomal degradation. Alirocumab (also known as SAR236553/REGN727) is a monoclonal antibody that binds circulating PCSK9 and blocks its interactions with surface LDLR. Alirocumab clinical trials with different doses on different administration schedules were shown to significantly reduce LDL cholesterol both as a mono-therapy and in combination with statins or ezetimibe. Although there is great potential for anti-PCSK9 therapies in the management of cholesterol metabolism, there is no clear evidence yet that blocking PCSK9 reduces cardiovascular disease outcome. This is being investigated in ongoing Phase III clinical trials with alirocumab.
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Affiliation(s)
- Hagai Tavori
- Knight Cardiovascular Institute, Center for Preventive Cardiology, Oregon Health and Science University, Portland, OR, USA.
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Swiger KJ, Martin SS. PCSK9 Inhibitors and Neurocognitive Adverse Events: Exploring the FDA Directive and a Proposal for N-of-1 Trials. Drug Saf 2015; 38:519-26. [DOI: 10.1007/s40264-015-0296-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Living the PCSK9 adventure: from the identification of a new gene in familial hypercholesterolemia towards a potential new class of anticholesterol drugs. Curr Atheroscler Rep 2015; 16:439. [PMID: 25052769 DOI: 10.1007/s11883-014-0439-8] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A decade after our discovery of the involvement of proprotein convertase subtilisin/kexin type 9 (PCSK9) in cholesterol metabolism through the identification of the first mutations leading to hypercholesterolemia, PCSK9 has become one of the most promising targets in cholesterol and cardiovascular diseases. This challenging work in the genetics of hypercholesterolemia paved the way for a plethora of studies around the world allowing the characterization of PCSK9, its expression, its impact on reducing the abundance of LDL receptor, and the identification of loss-of-function mutations in hypocholesterolemia. We highlight the different steps of this adventure and review the published clinical trials especially those with the anti-PCSK9 antibodies evolocumab (AMG 145) and alirocumab (SAR236553/REGN727), which are in phase III trials. The promising results in lowering LDL cholesterol levels raise hope that the PCSK9 adventure will lead, after the large and long-term ongoing phase III studies evaluating efficacy and safety, to a new anticholesterol pharmacological class.
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Sabatine MS, Giugliano RP, Wiviott SD, Raal FJ, Blom DJ, Robinson J, Ballantyne CM, Somaratne R, Legg J, Wasserman SM, Scott R, Koren MJ, Stein EA. Efficacy and safety of evolocumab in reducing lipids and cardiovascular events. N Engl J Med 2015; 372:1500-9. [PMID: 25773607 DOI: 10.1056/nejmoa1500858] [Citation(s) in RCA: 1109] [Impact Index Per Article: 123.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Evolocumab, a monoclonal antibody that inhibits proprotein convertase subtilisin-kexin type 9 (PCSK9), significantly reduced low-density lipoprotein (LDL) cholesterol levels in short-term studies. We conducted two extension studies to obtain longer-term data. METHODS In two open-label, randomized trials, we enrolled 4465 patients who had completed 1 of 12 phase 2 or 3 studies ("parent trials") of evolocumab. Regardless of study-group assignments in the parent trials, eligible patients were randomly assigned in a 2:1 ratio to receive either evolocumab (140 mg every 2 weeks or 420 mg monthly) plus standard therapy or standard therapy alone. Patients were followed for a median of 11.1 months with assessment of lipid levels, safety, and (as a prespecified exploratory analysis) adjudicated cardiovascular events including death, myocardial infarction, unstable angina, coronary revascularization, stroke, transient ischemic attack, and heart failure. Data from the two trials were combined. RESULTS As compared with standard therapy alone, evolocumab reduced the level of LDL cholesterol by 61%, from a median of 120 mg per deciliter to 48 mg per deciliter (P<0.001). Most adverse events occurred with similar frequency in the two groups, although neurocognitive events were reported more frequently in the evolocumab group. The risk of adverse events, including neurocognitive events, did not vary significantly according to the achieved level of LDL cholesterol. The rate of cardiovascular events at 1 year was reduced from 2.18% in the standard-therapy group to 0.95% in the evolocumab group (hazard ratio in the evolocumab group, 0.47; 95% confidence interval, 0.28 to 0.78; P=0.003). CONCLUSIONS During approximately 1 year of therapy, the use of evolocumab plus standard therapy, as compared with standard therapy alone, significantly reduced LDL cholesterol levels and reduced the incidence of cardiovascular events in a prespecified but exploratory analysis. (Funded by Amgen; OSLER-1 and OSLER-2 ClinicalTrials.gov numbers, NCT01439880 and NCT01854918.).
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Affiliation(s)
- Marc S Sabatine
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and the Department of Medicine, Harvard Medical School, Boston (M.S.S., R.P.G., S.D.W.); the Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg (F.J.R.), and the Division of Lipidology, Department of Medicine, University of Cape Town, Cape Town (D.J.B.) - both in South Africa; the Departments of Epidemiology and Medicine, College of Public Health, University of Iowa, Iowa City (J.R.); the Sections of Cardiovascular Research and Cardiology, Department of Medicine, Baylor College of Medicine, and the Center for Cardiovascular Disease Prevention, Houston Methodist DeBakey Heart and Vascular Center, Houston (C.M.B.); Amgen, Thousand Oaks, CA (R. Somaratne, J.L., S.M.W., R. Scott); Jacksonville Center for Clinical Research, Jacksonville, FL (M.J.K.); and the Metabolic and Atherosclerosis Research Center, Cincinnati (E.A.S.)
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Tavori H, Giunzioni I, Fazio S. PCSK9 inhibition to reduce cardiovascular disease risk: recent findings from the biology of PCSK9. Curr Opin Endocrinol Diabetes Obes 2015; 22:126-32. [PMID: 25692926 PMCID: PMC4384821 DOI: 10.1097/med.0000000000000137] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Review novel insights into the biology of proprotein convertase subtilisin/kexin 9 (PCSK9) that may explain the extreme efficiency of PCSK9 inhibition and the unexpected metabolic effects resulting from PCSK9 monoclonal antibody therapy, and may identify additional patients as target of therapy. RECENT FINDINGS For over 20 years, the practical knowledge of cholesterol metabolism has centered around cellular mechanisms, and around the idea that statin therapy is the essential step to control metabolic abnormalities for cardiovascular risk management. This view has been embraced by the recent AHA/ACC guidelines, but is being challenged by recent studies including nonstatin medications and by the development of a new class of cholesterol-lowering agents that seems destined to early US Food and Drug Administration approval. The discovery of PCSK9 - a circulating protein that regulates hepatic low-density lipoprotein (LDL) receptor and serum LDL cholesterol levels - has led to a race for its therapeutic inhibition. Recent findings on PCSK9 regulation and pleiotropic effects will help identify additional patient groups likely to benefit from the inhibitory therapy and unravel the full potential of PCSK9 inhibition therapy. SUMMARY Injectable human monoclonal antibodies to block the interaction between PCSK9 and LDL receptor are demonstrating extraordinary efficacy (LDL reductions of up to 70%) and almost the absence of any side-effects. A more moderate effect is seen on other lipoprotein parameters, with the exception of lipoprotein(a) levels. We describe mechanisms that can explain the effect on lipoprotein(a), predict a potential effect on postprandial triglyderides, and suggest a new category of patients for anti-PCSK9 therapy.
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Affiliation(s)
- Hagai Tavori
- The Knight Cardiovascular Institute, Center for Preventive Cardiology, Oregon Health and Sciences University, Portland, Oregon, USA
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Langslet G, Emery M, Wasserman SM. Evolocumab (AMG 145) for primary hypercholesterolemia. Expert Rev Cardiovasc Ther 2015; 13:477-88. [DOI: 10.1586/14779072.2015.1030395] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Schulz R, Schlüter KD, Laufs U. Molecular and cellular function of the proprotein convertase subtilisin/kexin type 9 (PCSK9). Basic Res Cardiol 2015; 110:4. [PMID: 25600226 PMCID: PMC4298671 DOI: 10.1007/s00395-015-0463-z] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 01/04/2015] [Accepted: 01/07/2015] [Indexed: 12/16/2022]
Abstract
The proprotein convertase subtilisin/kexin type 9 (PCSK9) has emerged as a promising treatment target to lower serum cholesterol, a major risk factor of cardiovascular diseases. Gain-of-function mutations of PCSK9 are associated with hypercholesterolemia and increased risk of cardiovascular events. Conversely, loss-of-function mutations cause low-plasma LDL-C levels and a reduction of cardiovascular risk without known unwanted effects on individual health. Experimental studies have revealed that PCSK9 reduces the hepatic uptake of LDL-C by increasing the endosomal and lysosomal degradation of LDL receptors (LDLR). A number of clinical studies have demonstrated that inhibition of PCSK9 alone and in addition to statins potently reduces serum LDL-C concentrations. This review summarizes the current data on the regulation of PCSK9, its molecular function in lipid homeostasis and the emerging evidence on the extra-hepatic effects of PCSK9.
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Affiliation(s)
- Rainer Schulz
- Physiologisches Institut, Justus-Liebig Universität Giessen, Aulweg 129, 35392, Giessen, Germany,
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PCSK9 inhibition in LDL cholesterol reduction: Genetics and therapeutic implications of very low plasma lipoprotein levels. Pharmacol Ther 2015; 145:58-66. [DOI: 10.1016/j.pharmthera.2014.07.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 07/11/2014] [Indexed: 01/15/2023]
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Abstract
PURPOSE OF REVIEW Proprotein convertase subtilisin/kexin type-9 (PCSK9) binds to LDL receptor (LDLR) and targets it for lysosomal degradation in cells. Decreased hepatic clearance of plasma LDL-cholesterol is the primary gauge of PCSK9 activity in humans; however, PCSK9's evolutionary role may extend to other lipoprotein classes and processes. This review highlights studies that are providing novel insights into physiological regulation of PCSK9 transcription and plasma PCSK9 activity. RECENT FINDINGS Recent studies indicate that circulating PCSK9 binds to apolipoprotein B100 on LDL particles, which in turn inhibits PCSK9's ability to bind to cell surface LDLRs. Negative feedback of secreted PCSK9 activity by LDL could serve to increase plasma excursion of triglyceride-rich lipoproteins and monitor lipoprotein remodeling. Recent findings have identified hepatocyte nuclear factor-1α as a key transcriptional regulator that cooperates with sterol regulatory element-binding protein-2 to control PCSK9 expression in hepatocytes in response to nutritional and hormonal inputs, as well as acute inflammation. SUMMARY PCSK9 is an established target for cholesterol-lowering therapies. Further study of PCSK9 regulatory mechanisms may identify additional control points for pharmacological inhibition of PCSK9-mediated LDLR degradation. PCSK9 function could reflect ancient roles in the fasting-feeding cycle and in linking lipoprotein metabolism with innate immunity.
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Affiliation(s)
- Thomas A Lagace
- Department of Pathology and Laboratory Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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Norata GD, Tibolla G, Catapano AL. PCSK9 inhibition for the treatment of hypercholesterolemia: promises and emerging challenges. Vascul Pharmacol 2014; 62:103-11. [PMID: 24924410 DOI: 10.1016/j.vph.2014.05.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 05/31/2014] [Indexed: 10/25/2022]
Abstract
Hypercholesterolemia, is a prominent risk factor for cardiovascular disease (CVD). Undestanding of the biochemical mechanisms that regulate the expression of the low density lipoproteins receptor (LDLR) and the hepatic clearance of LDL cholesterol (LDL-C) paved the way to the statin therapy as the gold standard for CVD prevention. The discovery of proteins that regulate - at a post-translational level - the activity of the LDLR has been a major breakthrough in developing new cholesterol-lowering drugs. Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a key modulator of the LDLR degradation in the liver. Genetic studies confirmed that in humans PCSK9 mutations associate with hypercholesterolemia and hypocholesterolemia (gain-of-function or loss-of-function variants respectively). Moreover, PCSK9 is up-regulated by statin treatment and limits the efficacy of these agents. These findings led to the development of PCSK9 inhibitors. Anti-PCSK9 monoclonal antibodies showed encouraging results and are currently being evaluated in phase III clinical trials. The aim of this short review is to describe the new frontier of PCSK9 inhibition in the treatment of hypercholesterolemia. Emphasis here is given to critical emerging issues linked to PCSK9 physiology and pharmacology, which will require future investigation to definitely address the potential of anti-PCSK9 drugs in clinical practice.
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Affiliation(s)
- Giuseppe Danilo Norata
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Italy; Center for the Study of Atherosclerosis, Società Italiana Studio Aterosclerosi, Bassini Hospital, Cinisello Balsamo, Italy
| | - Gianpaolo Tibolla
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Italy; I.R.C.C.S. Multimedica, Milan, Italy
| | - Alberico Luigi Catapano
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Italy; I.R.C.C.S. Multimedica, Milan, Italy.
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Abstract
Dyslipidemias are a predominant risk factor for cardiovascular disease. Biological and genetic research has led to the identification of several genes and proteins that may be pharmacologically targeted to improve lipoprotein profiles and possibly cardiovascular outcomes in patients with dyslipidemia. The observation that proprotein convertase subtilisin/kexin type 9 (PCSK9) regulates the levels of circulating low-density lipoprotein C (LDL-C) by enhancing the degradation of the hepatic low-density lipoprotein receptor (LDLR) prompted the search for drugs that inhibit PCSK9 activity. Several approaches to inhibiting PCSK9 activity have been proposed; these involve inhibitory antibodies, small molecules, and gene silencing. To date, the most promising and advanced approach relates to monoclonal antibodies, which can decrease LDL cholesterol by 65-70%, even as an add-on therapy to a maximal dose of a statin. Phase III studies and large, event-driven clinical trials are ongoing and will fully address the viability and role of these drugs in clinical practice.
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Affiliation(s)
- Giuseppe Danilo Norata
- Department of Pharmacological and Biomolecular Sciences, University of Milan, 20133 Milan, Italy; , ,
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Abstract
PURPOSE OF REVIEW In the past 10 years, the LDL receptor inhibitor proprotein convertase subtilisin kexin type 9 (PCSK9) has emerged as a validated target for lowering plasma LDL cholesterol levels. Here we review the most recent reports on PCSK9 out of a total of 500 publications published in print or online before March 2013 and indexed on PubMed. RECENT FINDINGS All published in 2012, phase I and II clinical trials demonstrate that fully human monoclonal antibodies targeting PCSK9 dramatically reduce LDL-C and enable patients to reach their target goals, without severe or serious safety issues. SUMMARY This review summarizes the discovery of PCSK9, its original mode of action as a secreted inhibitor of the LDL receptor, as well as its genetic regulation by statins. We then focus on the major results from the 2012 phase I and II PCSK9 inhibitor clinical trials. We also review the recent in-vivo studies demonstrating the potential cardiovascular benefits of long-term PCSK9 inhibition and discuss its potential side-effects.
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Affiliation(s)
- Francine Petrides
- The University of New South Wales, Sydney, New South Wales, Australia
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