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Honda S, Puri R, Anderson T, Kastelein JJP, Brennan DM, Kassahun H, Somaratne R, Wasserman SM, Nissen SE, Nicholls SJ. Determinants of Plaque Progression Despite Very Low Low-Density Lipoprotein-Cholesterol Levels With the PCSK9 Inhibitor, Evolocumab. JACC Cardiovasc Imaging 2021; 15:709-711. [PMID: 34922870 DOI: 10.1016/j.jcmg.2021.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 10/25/2021] [Accepted: 11/10/2021] [Indexed: 11/29/2022]
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2
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Stiekema LCA, Stroes ESG, Verweij SL, Kassahun H, Chen L, Wasserman SM, Sabatine MS, Mani V, Fayad ZA. Persistent arterial wall inflammation in patients with elevated lipoprotein(a) despite strong low-density lipoprotein cholesterol reduction by proprotein convertase subtilisin/kexin type 9 antibody treatment. Eur Heart J 2020; 40:2775-2781. [PMID: 30561610 DOI: 10.1093/eurheartj/ehy862] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 10/25/2018] [Accepted: 12/04/2018] [Indexed: 12/24/2022] Open
Abstract
AIMS Subjects with lipoprotein(a) [Lp(a)] elevation have increased arterial wall inflammation and cardiovascular risk. In patients at increased cardiovascular risk, arterial wall inflammation is reduced following lipid-lowering therapy by statin treatment or lipoprotein apheresis. However, it is unknown whether lipid-lowering treatment in elevated Lp(a) subjects alters arterial wall inflammation. We evaluated whether evolocumab, which lowers both low-density lipoprotein cholesterol (LDL-C) and Lp(a), attenuates arterial wall inflammation in patients with elevated Lp(a). METHODS AND RESULTS In this multicentre, randomized, double-blind, placebo-controlled study, 129 patients {median [interquartile range (IQR)]: age 60.0 [54.0-67.0] years, Lp(a) 200.0 [155.5-301.5] nmol/L [80.0 (62.5-121.0) mg/dL]; mean [standard deviation (SD)] LDL-C 3.7 [1.0] mmol/L [144.0 (39.7) mg/dL]; National Cholesterol Education Program high risk, 25.6%} were randomized to monthly subcutaneous evolocumab 420 mg or placebo. Compared with placebo, evolocumab reduced LDL-C by 60.7% [95% confidence interval (CI) 65.8-55.5] and Lp(a) by 13.9% (95% CI 19.3-8.5). Among evolocumab-treated patients, the Week 16 mean (SD) LDL-C level was 1.6 (0.7) mmol/L [60.1 (28.1) mg/dL], and the median (IQR) Lp(a) level was 188.0 (140.0-268.0) nmol/L [75.2 (56.0-107.2) mg/dL]. Arterial wall inflammation [most diseased segment target-to-background ratio (MDS TBR)] in the index vessel (left carotid, right carotid, or thoracic aorta) was assessed by 18F-fluoro-deoxyglucose positron-emission tomography/computed tomography. Week 16 index vessel MDS TBR was not significantly altered with evolocumab (-8.3%) vs. placebo (-5.3%) [treatment difference -3.0% (95% CI -7.4% to 1.4%); P = 0.18]. CONCLUSION Evolocumab treatment in patients with median baseline Lp(a) 200.0 nmol/L led to a large reduction in LDL-C and a small reduction in Lp(a), resulting in persistent elevated Lp(a) levels. The latter may have contributed to the unaltered arterial wall inflammation.
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Affiliation(s)
- Lotte C A Stiekema
- Department of Vascular Medicine, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, AZ Amsterdam, The Netherlands
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, AZ Amsterdam, The Netherlands
| | - Simone L Verweij
- Department of Vascular Medicine, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, AZ Amsterdam, The Netherlands
| | - Helina Kassahun
- Department of Clinical Development, Amgen Inc., One Amgen Center Drive Thousand Oaks, CA, USA
| | - Lisa Chen
- Department of Biostatistics, Amgen Inc., One Amgen Center Drive Thousand Oaks, CA, USA
| | - Scott M Wasserman
- Department of Clinical Development, Amgen Inc., One Amgen Center Drive Thousand Oaks, CA, USA
| | - Marc S Sabatine
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Fenwood Road, Boston, MA, USA
| | - Venkatesh Mani
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Pl, New York, NY, USA
| | - Zahi A Fayad
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Pl, New York, NY, USA
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3
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Chan DC, Watts GF, Coll B, Wasserman SM, Marcovina SM, Barrett PHR. Lipoprotein(a) Particle Production as a Determinant of Plasma Lipoprotein(a) Concentration Across Varying Apolipoprotein(a) Isoform Sizes and Background Cholesterol-Lowering Therapy. J Am Heart Assoc 2020; 8:e011781. [PMID: 30897995 PMCID: PMC6509712 DOI: 10.1161/jaha.118.011781] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Elevated lipoprotein(a) (Lp(a)), a low‐density lipoprotein‐like particle bound to the polymorphic apolipoprotein(a) (apo(a)), may be causal for cardiovascular disease. However, the metabolism of Lp(a) in humans is poorly understood. Methods and Results We investigated the kinetics of Lp(a)‐apo(a) and low‐density lipoprotein‐apoB‐100 in 63 normolipidemic men. The fractional catabolic rate (FCR) and production rate PR) were studied. Plasma apo(a) concentration was significantly and inversely associated with apo(a) isoform size (r=−0.536, P<0.001) and apo(a) FCR (r=−0.363, P<0.01), and positively with apo(a) PR (r=0.877, P<0.001). There were no significant associations between the FCRs of apo(a) and low‐density lipoprotein‐apoB‐100. Subjects with smaller apo(a) isoform sizes (≤22 kringle IV repeats) had significantly higher apo(a) PR (P<0.05) and lower apo(a) FCR (P<0.01) than those with larger sizes. Plasma apo(a) concentration was significantly associated with apo(a) PR (r=0.930, P<0.001), but not with FCR (r=−0.012, P>0.05) in subjects with smaller apo(a) isoform size. In contrast, both apo(a) PR and FCR were significantly associated with plasma apo(a) concentrations (r=0.744 and −0.389, respectively, P<0.05) in subjects with larger isoforms. In multiple regression analysis, apo(a) PR and apo(a) isoform size were significant predictors of plasma apo(a) concentration independent of low‐density lipoprotein‐apoB‐100 FCR and background therapy with atorvastatin and evolocumab. Conclusions In normolipidemic men, the plasma Lp(a) concentration is predominantly determined by the rate of production of Lp(a) particles, irrespective of apo(a) isoform size and background therapy with a statin and a proprotein convertase subtilisin‐kexin type 9 inhibitor. Our findings underscore the importance of therapeutic targeting of the hepatic synthesis and secretion of Lp(a) particles. Lp(a) particle catabolism may only play a modest role in determining Lp(a) concentration in subjects with larger apo(a) isoform size. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02189837.
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Affiliation(s)
- Dick C Chan
- 1 School of Medicine University of Western Australia Perth Australia.,2 School of Biomedical Science University of Western Australia Perth Australia
| | - Gerald F Watts
- 1 School of Medicine University of Western Australia Perth Australia.,3 The Lipid Disorders Clinic Department of Cardiology Royal Perth Hospital Perth Australia
| | | | | | - Santica M Marcovina
- 5 Northwest Lipid Metabolism and Diabetes Research Laboratories Division of Metabolism, Endocrinology, and Nutrition Department of Medicine University of Washington Seattle WA
| | - P Hugh R Barrett
- 2 School of Biomedical Science University of Western Australia Perth Australia.,6 Faculty of Medicine and Health University of New England Armidale New South Wales Australia
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4
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Koren MJ, Sabatine MS, Giugliano RP, Langslet G, Wiviott SD, Ruzza A, Ma Y, Hamer AW, Wasserman SM, Raal FJ. Long-Term Efficacy and Safety of Evolocumab in Patients With Hypercholesterolemia. J Am Coll Cardiol 2020; 74:2132-2146. [PMID: 31648705 DOI: 10.1016/j.jacc.2019.08.1024] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 07/16/2019] [Accepted: 08/04/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Evolocumab and other anti-PCSK9 antibodies reduced adverse cardiovascular outcomes in clinical trials of high-risk patients over <3 years median treatment duration. OBJECTIVES The OSLER-1 trial (Open Label Study of Long Term Evaluation Against LDL-C Trial) evaluated longer-term effects of evolocumab during open-label hypercholesterolemia treatment for up to 5 years. METHODS Patients randomized to standard of care (SOC) or evolocumab 420 mg monthly (evolocumab + SOC) for year 1. After year 1, patients could enter the all-evolocumab period and receive evolocumab + SOC for an additional 4 years. The authors analyzed the persistence of lipid effects and exposure-dependent safety focusing on yearly rates of adverse events (AEs) and anti-drug antibodies over 4.951 patient-years of observation. RESULTS A total of 1,255 patients (safety analysis population) randomized into the year 1 SOC-controlled period and received ≥1 evolocumab dose (mean ± SD age 57 ± 12 years; 53% female). A total of 1,151 patients (efficacy analysis population) progressed to the all-evolocumab period (year 2 and beyond). Evolocumab + SOC persistently lowered mean ± SE low-density lipoprotein cholesterol (LDL-C) by 56% ± 0.6% (n = 1,071), 57% ± 0.8% (n = 1,001), 56% ± 0.8% (n = 943), and 56% ± 0.8% (n = 803) after approximately 2, 3, 4, and 5 years, respectively, from randomization. Mean baseline LDL-C decreased from 140 to 61 mg/dl on treatment. Yearly serious AE rates during evolocumab + SOC ranged from 6.9% to 7.9%, comparable to the 6.8% rate in SOC patients during year 1. Evolocumab discontinuation due to AEs occurred in 5.7% of patients. Two SOC and 2 evolocumab + SOC patients developed new, transient, binding anti-drug antibodies; no neutralizing antibodies were observed. CONCLUSIONS The OSLER-1 trial demonstrated consistently excellent LDL-C-lowering efficacy, tolerance, and safety of evolocumab, with no neutralizing antibodies detected, throughout the longest-duration study of a PCSK9 inhibitor reported to date. (Open Label Study of Long Term Evaluation Against LDL-C Trial [OSLER-1]; NCT01439880).
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Affiliation(s)
- Michael J Koren
- Jacksonville Center for Clinical Research, Jacksonville, Florida.
| | - Marc S Sabatine
- Thrombolysis In Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert P Giugliano
- Thrombolysis In Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Stephen D Wiviott
- Thrombolysis In Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrea Ruzza
- Amgen, One Amgen Center Drive, Thousand Oaks, California
| | - Yuhui Ma
- Amgen, One Amgen Center Drive, Thousand Oaks, California
| | - Andrew W Hamer
- Amgen, One Amgen Center Drive, Thousand Oaks, California
| | | | - Frederick J Raal
- The Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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5
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Giugliano RP, Pedersen TR, Saver JL, Sever PS, Keech AC, Bohula EA, Murphy SA, Wasserman SM, Honarpour N, Wang H, Lira Pineda A, Sabatine MS. Stroke Prevention With the PCSK9 (Proprotein Convertase Subtilisin-Kexin Type 9) Inhibitor Evolocumab Added to Statin in High-Risk Patients With Stable Atherosclerosis. Stroke 2020; 51:1546-1554. [DOI: 10.1161/strokeaha.119.027759] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background and Purpose—
The PCSK9 (proprotein convertase subtilisin-kexin type 9) monoclonal antibody evolocumab lowered LDL (low-density lipoprotein) cholesterol by 59% to 0.8 (0.5–1.2) mmol/L and significantly reduced major vascular events in the FOURIER trial (Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk). Herein, we report the results of a prespecified analysis of cerebrovascular events in the overall trial population and in patients stratified by prior stroke.
Methods—
FOURIER was a randomized, double-blind trial comparing evolocumab versus placebo in patients with established atherosclerosis, additional risk factors, and LDL cholesterol levels ≥1.8 (or non-HDL [high-density lipoprotein] ≥2.6 mmol/L) on statin therapy. The median follow-up was 2.2 years. We analyzed the efficacy of evolocumab to reduce overall stroke and stroke subtypes, as well as the primary cardiovascular composite end point by subgroups according to a history of stroke.
Results—
Among the 27 564 patients, 469 (1.7%) experienced a total of 503 strokes of which 421 (84%) were ischemic. Prior ischemic stroke, diabetes mellitus, elevated CRP (C-reactive protein), history of heart failure, older age, nonwhite race, peripheral arterial disease, and renal insufficiency were independent predictors of stroke. Evolocumab significantly reduced all stroke (1.5% versus 1.9%; hazard ratio, 0.79 [95% CI, 0.66–0.95];
P
=0.01) and ischemic stroke (1.2% versus 1.6%; hazard ratio, 0.75 [95% CI, 0.62–0.92];
P
=0.005), with no difference in hemorrhagic stroke (0.21% versus 0.18%; hazard ratio, 1.16 [95% CI, 0.68–1.98];
P
=0.59). These findings were consistent across subgroups, including among the 5337 patients (19%) with prior ischemic stroke in whom the hazard ratios (95% CIs) were 0.85 (0.72–1.00) for the cardiovascular composite, 0.90 (0.68–1.19) for all stroke, and 0.92 (0.68–1.25) for ischemic stroke (
P
interactions, 0.91, 0.22, and 0.09, respectively, compared with patients without a prior ischemic stroke).
Conclusions—
Inhibition of PCSK9 with evolocumab added to statin in patients with established atherosclerosis reduced ischemic stroke and cardiovascular events in the total population and in key subgroups, including those with prior ischemic stroke.
Registration—
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT01764633.
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Affiliation(s)
- Robert P. Giugliano
- From the TIMI (Thrombolysis in Myocardial Infarction) Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (R.P.G., E.A.B., S.A.M., M.S.S.)
| | - Terje R. Pedersen
- Oslo Universitetssykehus HF, Endocrinology–Morbid Obesity and Preventive Medicine, Norway (T.R.P.)
| | - Jeffrey L. Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at UCLA, Los Angeles, CA (J.L.S.)
| | - Peter S. Sever
- National Heart and Lung Institute, Imperial College London, United Kingdom (P.S.S.)
| | - Anthony C. Keech
- Sydney Medical School, National Health and Medical Research Council Clinical Trials Centre, Australia (A.C.K.)
| | - Erin A. Bohula
- From the TIMI (Thrombolysis in Myocardial Infarction) Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (R.P.G., E.A.B., S.A.M., M.S.S.)
| | - Sabina A. Murphy
- From the TIMI (Thrombolysis in Myocardial Infarction) Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (R.P.G., E.A.B., S.A.M., M.S.S.)
| | - Scott M. Wasserman
- Amgen, Inc, Global Development, Thousand Oaks, CA (S.M.W., N.H., H.W., A.L.P.)
| | - Narimon Honarpour
- Amgen, Inc, Global Development, Thousand Oaks, CA (S.M.W., N.H., H.W., A.L.P.)
| | - Huei Wang
- Amgen, Inc, Global Development, Thousand Oaks, CA (S.M.W., N.H., H.W., A.L.P.)
| | - Armando Lira Pineda
- Amgen, Inc, Global Development, Thousand Oaks, CA (S.M.W., N.H., H.W., A.L.P.)
| | - Marc S. Sabatine
- From the TIMI (Thrombolysis in Myocardial Infarction) Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (R.P.G., E.A.B., S.A.M., M.S.S.)
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6
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Qamar A, Giugliano RP, Keech AC, Kuder JF, Murphy SA, Kurtz CE, Wasserman SM, Sever PS, Pedersen TR, Sabatine MS. Interindividual Variation in Low-Density Lipoprotein Cholesterol Level Reduction With Evolocumab: An Analysis of FOURIER Trial Data. JAMA Cardiol 2020; 4:59-63. [PMID: 30540337 DOI: 10.1001/jamacardio.2018.4178] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Little is known about the heterogeneity in low-density lipoprotein cholesterol levels (LDL-C) lowering with proprotein convertase subtilisin kexin 9 (PCSK9) inhibitor medications. Objective To evaluate the interindividual variability in LDL-C reduction with the PCSK9 inhibitor drug evolocumab. Design, Setting, and Participants We examined the percentage change in LDL-C levels from baseline in the Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk (FOURIER) trial, a placebo-controlled randomized clinical trial of the PCSK9 inhibitor evolocumab in patients with stable atherosclerotic cardiovascular disease who were taking statin medications. Patients in either treatment arm who had high baseline LDL-C variability during screening and either did not receive the study drug, altered their background lipid-lowering therapy regimen, or had no LDL-C level sample in week 4 were excluded from the primary analysis. Analyses in the patients were stratified by treatment arm. Data was collected from 2013 to 2016, and data were analyzed from January 2018 to November 2018. Main Outcomes and Measures Interindividual variation in percent reduction in LDL-C with evolocumab. Results There were 27 564 individuals in the cohort; after exclusions for baseline variability (n = 3524) or alterations in background lipid therapy and other causes (n = 2272), 21 768 patients remained. At week 4, the median percent reduction in LDL-C levels from baseline was 66% (interquartile range, 54%-76%; median [interquartile range] baseline value, 90 [79-105] mg/dL; postchange value, 31 [21-44] mg/dL) with evolocumab. During the first year, a total of 10 325 of 10902 patients in the evolocumab group (94.7%) had a reduction 50% or greater in LDL-C levels, 10 669 of 10 902 (97.9%) had a reduction 30% or more, and 10 849 of 10 902 (99.5%) had any reduction in LDL-C levels. Fifty-three patients (0.5%) had no apparent reduction in LDL-C levels. In the placebo arm, the median LDL-C reduction was 4% (interquartile range, 6% increase to 13% reduction; baseline median [IQR] value, 90 [79-106] mg/dL; postchange value, 87 [74-103] mg/dL) at 4 weeks. Waterfall plots showed notable variability in the top and bottom 5% of patients for both evolocumab and placebo groups, with large changes in LDL-C levels in the placebo group (increases of ≥25%, 531 patients [4.9%]; decreases of ≥25%, 985 patients [9.1%]). At 4 weeks, the placebo-adjusted reductions in LDL-C levels with evolocumab were 50% or greater in 9839 of 10 866 patients (90.5%) and 30% or greater in 10 846 of 10 866 patients (99.8%). Results were consistent across clinically relevant subgroups. Conclusions and Relevance There appears to be a highly consistent robust reduction in LDL-C levels with evolocumab use. Trial Registration ClinicalTrials.gov identifier: NCT01764633.
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Affiliation(s)
- Arman Qamar
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert P Giugliano
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anthony C Keech
- Sydney Medical School, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Julia F Kuder
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sabina A Murphy
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Peter S Sever
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Terje R Pedersen
- Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Oslo, Norway
| | - Marc S Sabatine
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Deputy Editor
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7
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Martin SS, Giugliano RP, Murphy SA, Wasserman SM, Stein EA, Ceška R, López-Miranda J, Georgiev B, Lorenzatti AJ, Tikkanen MJ, Sever PS, Keech AC, Pedersen TR, Sabatine MS. Comparison of Low-Density Lipoprotein Cholesterol Assessment by Martin/Hopkins Estimation, Friedewald Estimation, and Preparative Ultracentrifugation: Insights From the FOURIER Trial. JAMA Cardiol 2019; 3:749-753. [PMID: 29898218 DOI: 10.1001/jamacardio.2018.1533] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Importance Recent studies have shown that Friedewald underestimates low-density lipoprotein cholesterol (LDL-C) at lower levels, which could result in undertreatment of high-risk patients. A novel method (Martin/Hopkins) using a patient-specific conversion factor provides more accurate LDL-C levels. However, this method has not been tested in proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor-treated patients. Objective To investigate accuracy of 2 different methods for estimating LDL-C levels (Martin/Hopkins and Friedewald) compared with gold standard preparative ultracentrifugation (PUC) in patients with low LDL-C levels in the Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Patients With Elevated Risk (FOURIER) trial. Design, Setting, and Participants The FOURIER trial was a randomized clinical trial of evolocumab vs placebo added to statin therapy in 27 564 patients with stable atherosclerotic cardiovascular disease. The patients' LDL-C levels were assessed at baseline, 4 weeks, 12 weeks, 24 weeks, and every 24 weeks thereafter, and measured directly by PUC when the level was less than 40 mg/dL per the Friedewald method (calculated as non-HDL-C level - triglycerides/5). In the Martin/Hopkins method, patient-specific ratios of triglycerides to very low-density lipoprotein cholesterol (VLDL-C) ratios were determined and used to estimate VLDL-C, which was subtracted from the non-HDL-C level to obtain the LDL-C level. Main Outcomes and Measures Low-density lipoprotein cholesterol calculated by the Friedewald and Martin/Hopkins methods, with PUC as the reference method. Results For this analysis, the mean (SD) age was 62.7 (9.0) years; 2885 of the 12 742 patients were women (22.6%). A total of 56 624 observations from 12 742 patients had Friedewald, Martin/Hopkins, and PUC LDL-C measurements. The median difference from PUC LDL-C levels for Martin/Hopkins LDL-C levels was -2 mg/dL (interquartile range [IQR], -4 to 1 mg/dL) and for Friedewald LDL-C levels was -4 mg/dL (IQR, -8 to -1 mg/dL; P < .001). Overall, 22.9% of Martin/Hopkins LDL-C values were more than 5 mg/dL different than PUC values, and 2.6% were more than 10 mg/dL different than PUC levels. These were significantly less than respective proportions with Friedewald estimation (40.1% and 13.3%; P < .001), mainly because of underestimation by the Friedewald method. The correlation with PUC LDL-C was significantly higher for Martin/Hopkins vs Friedewald (ρ, 0.918 [95% CI 0.916-0.919] vs ρ, 0.867 [0.865-0.869], P < .001). Conclusions and Relevance In patients achieving low LDL-C with PCSK9 inhibition, the Martin/Hopkins method for LDL-C estimation more closely approximates gold standard PUC than Friedewald estimation does. The Martin/Hopkins method may prevent undertreatment because of LDL-C underestimation by the Friedewald method. Trial Registration ClinicalTrials.gov Identifier: NCT01764633.
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Affiliation(s)
- Seth S Martin
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert P Giugliano
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Sabina A Murphy
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | | | - Evan A Stein
- Metabolic and Atherosclerosis Research Center, Cincinnati, Ohio
| | - Richard Ceška
- Center of Preventive Cardiology, 3rd Department Internal Medicine, University General Hospital and First Medical Faculty, Prague, Czech Republic
| | - José López-Miranda
- Lipids and Atherosclerosis Unit, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofía University Hospital, University of Cordoba, Cordoba, Spain.,CIBER Fisiopatología de la Obesidad y Nutrición (CIBERObN), Cordoba, Spain
| | | | | | - Matti J Tikkanen
- Folkhälsan Research Center, University of Helsinki, Helsinki, Finland
| | - Peter S Sever
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, England
| | - Anthony C Keech
- Sydney Medical School, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Terje R Pedersen
- Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Oslo, Norway
| | - Marc S Sabatine
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Deputy Editor
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8
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Desai NR, Giugliano RP, Wasserman SM, Gibbs JP, Liu T, Scott R, Sabatine MS. Association Between Circulating Baseline Proprotein Convertase Subtilisin Kexin Type 9 Levels and Efficacy of Evolocumab. JAMA Cardiol 2019; 2:556-560. [PMID: 28122070 DOI: 10.1001/jamacardio.2016.5395] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Importance Levels of proprotein convertase subtilisin kexin type 9 (PCSK9) vary markedly across the population and are influenced by genetic and nongenetic factors. Evolocumab is a fully human, monoclonal antibody against PCSK9 that reduces low-density lipoprotein cholesterol (LDL-C) levels by 55% to 75%. Whether the efficacy of evolocumab varies based on an individual's baseline PCSK9 level remains unknown. Objective To characterize variability in PCSK9 levels and determine whether the LDL-C level reduction achieved with evolocumab differs based on PCSK9 levels. Design, Setting, and Participants This study included pooled data from 3016 patients from 4 phase 3 randomized clinical trials of evolocumab as part of the Program to Reduce LDL-C and Cardiovascular Outcomes Following Inhibition of PCSK9 in Different Populations. Circulating PCSK9 levels were measured at baseline using quantitative enzyme-linked immunosorbent assays and used to stratify patients into quartiles, and LDL-C level was measured at baseline and weeks 10 and 12. In an additional 138 patients enrolled in a pharmacokinetic and pharmacodynamic substudy from 4 phase 2 trials, circulating PCSK9 levels were measured at baseline and then weekly at weeks 8 through 12. Main Outcomes and Measures Placebo-controlled percentage change in LDL-C level with evolocumab, 140 mg every 2 weeks and 420 mg once monthly, across quartiles of baseline PCSK9 levels. Results Of the 3016 patients, 1492 (49.5%) were female and 2758 (91.4%) were white. The median baseline circulating PCSK9 level was 323 ng/mL (interquartile range, 258-406 ng/mL). Patients with higher levels of PCSK9 were more likely to be receiving intensive statin therapy (56%, 36%, 25%, and 13% in the fourth through first quartiles; P < .001) and had significantly lower baseline LDL-C level (123 mg/dL, 124 mg/dL, 128 mg/dL, and 137 mg/dL in the fourth through first quartiles; P < .001). After stratifying by statin use, there was no correlation between PCSK9 levels and LDL-C levels (ρ = 0.03 [95% CI, -0.04 to 0.10] for nonstatin users, P = .39, and ρ = 0.03 [95% CI, -0.01 to 0.08] for statin users, P = .12). Across all quartiles of baseline PCSK9 levels, both evolocumab 140 mg every 2 weeks and 420 mg once monthly suppressed circulating PCSK9 levels by 90% to 100% within 1 week of administration. Both evolocumab 140 mg every 2 weeks and 420 mg once monthly were associated with significant reductions in LDL-C levels between 64% and 71% (P < .001), regardless of PCSK9 levels (P for interaction = .76 and .21, respectively). Conclusions and Relevance Regardless of baseline PCSK9 levels, the doses of evolocumab being studied in a large cardiovascular outcomes trial suppress PCSK9 levels and consistently and substantially reduce LDL-C levels.
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Affiliation(s)
- Nihar R Desai
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut2Center for Outcomes Research and Evaluation, Yale-New Haven Health Services Corporation, New Haven, Connecticut
| | - Robert P Giugliano
- Thrombolysis in Myocardial Infarction Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Rob Scott
- Amgen Inc, Thousand Oaks, California5currently with AbbVie Inc, North Chicago, Illinois
| | - Marc S Sabatine
- Thrombolysis in Myocardial Infarction Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Charytan DM, Sabatine MS, Pedersen TR, Im K, Park JG, Pineda AL, Wasserman SM, Deedwania P, Olsson AG, Sever PS, Keech AC, Giugliano RP. Efficacy and Safety of Evolocumab in Chronic Kidney Disease in the FOURIER Trial. J Am Coll Cardiol 2019; 73:2961-2970. [DOI: 10.1016/j.jacc.2019.03.513] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 03/10/2019] [Accepted: 03/19/2019] [Indexed: 10/26/2022]
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10
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O’Donoghue ML, Fazio S, Giugliano RP, Stroes ES, Kanevsky E, Gouni-Berthold I, Im K, Lira Pineda A, Wasserman SM, Češka R, Ezhov MV, Jukema JW, Jensen HK, Tokgözoğlu SL, Mach F, Huber K, Sever PS, Keech AC, Pedersen TR, Sabatine MS. Lipoprotein(a), PCSK9 Inhibition, and Cardiovascular Risk. Circulation 2019; 139:1483-1492. [DOI: 10.1161/circulationaha.118.037184] [Citation(s) in RCA: 354] [Impact Index Per Article: 70.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Michelle L. O’Donoghue
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (M.L.O., R.P.G., E.K., K.A.I., M.S.S.)
| | - Sergio Fazio
- Center for Preventive Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland (S.F.)
| | - Robert P. Giugliano
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (M.L.O., R.P.G., E.K., K.A.I., M.S.S.)
| | - Erik S.G. Stroes
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands (E.S.G.S.)
| | - Estella Kanevsky
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (M.L.O., R.P.G., E.K., K.A.I., M.S.S.)
| | - Ioanna Gouni-Berthold
- Polyclinic for Endocrinology, Diabetes and Preventive Medicine, University of Cologne, Germany (I.G.-B.)
| | - KyungAh Im
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (M.L.O., R.P.G., E.K., K.A.I., M.S.S.)
| | | | | | - Richard Češka
- Center for Preventive Cardiology, 3rd Internal Medicine Clinic, University General Hospital and Charles University 1st Medical Faculty, Prague, Czech Republic (R.C.)
| | - Marat V. Ezhov
- National Cardiology Research Center, Moscow, Russia (M.V.E.)
| | - J. Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, The Netherlands (J.W.J.)
| | - Henrik K. Jensen
- Department of Cardiology, Aarhus University Hospital and Department of Clinical Medicine, Health, Aarhus University, Denmark (H.K.J.)
| | | | - François Mach
- Cardiology Division, University of Geneva, Switzerland (F.M.)
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital and Sigmund Freud University, Medical Faculty, Vienna, Austria (K.H.)
| | | | - Anthony C. Keech
- Sydney Medical School, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Australia (A.C.K.)
| | - Terje R. Pedersen
- Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Norway (T.R.P.)
| | - Marc S. Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (M.L.O., R.P.G., E.K., K.A.I., M.S.S.)
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11
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Graham I, Shear C, De Graeff P, Boulton C, Catapano AL, Stough WG, Carlsson SC, De Backer G, Emmerich J, Greenfeder S, Kim AM, Lautsch D, Nguyen T, Nissen SE, Prasad K, Ray KK, Robinson JG, Sasiela WJ, Bruins Slot K, Stroes E, Thuren T, Van der Schueren B, Velkovski-Rouyer M, Wasserman SM, Wiklund O, Zouridakis E. New strategies for the development of lipid-lowering therapies to reduce cardiovascular risk. Eur Heart J Cardiovasc Pharmacother 2019; 4:119-127. [PMID: 29194462 DOI: 10.1093/ehjcvp/pvx031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 11/27/2017] [Indexed: 12/29/2022]
Abstract
The very high occurrence of cardiovascular events presents a major public health issue, because treatment remains suboptimal. Lowering LDL cholesterol (LDL-C) with statins or ezetimibe in combination with a statin reduces major adverse cardiovascular events. The cardiovascular risk reduction in relation to the absolute LDL-C reduction is linear for most interventions without evidence of attenuation or increase in risk at low LDL-C levels. Opportunities for innovation in dyslipidaemia treatment should address the substantial risk of lipid-associated cardiovascular events among patients optimally treated per guidelines but who cannot achieve LDL-C goals and who could benefit from additional LDL-C-lowering therapy or experience side effects of statins. Fresh approaches are needed to identify promising drug targets early and develop them efficiently. The Cardiovascular Round Table of the European Society of Cardiology (ESC) convened a workshop to discuss new lipid-lowering strategies for cardiovascular risk reduction. Opportunities to improve treatment approaches and the efficient study of new therapies were explored. Circulating biomarkers may not be fully reliable proxy indicators of the relationship between treatment effect and clinical outcome. Mendelian randomization studies may better inform development strategies and refine treatment targets before Phase 3. Trials should match the drug to appropriate lipid and patient profile, and guidelines may move towards a precision-based approach to individual patient management. Stakeholder collaboration is needed to ensure continued innovation and better international coordination of both regulatory aspects and guidelines. It should be noted that risk may also be addressed through increased attention to other risk factors such as smoking, hypertension, overweight, and inactivity.
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Affiliation(s)
- Ian Graham
- Trinity College, Adelaide Health Foundation, Tallaght Hospital, Dublin 24, Ireland
| | - Chuck Shear
- Global Product Development/Internal Medicine, Pfizer, Inc., 235 E. 42nd Street, New York, New York 10017, NY, USA
| | - Pieter De Graeff
- Dutch Medicines Evaluation Board (CBG-MEB), Graadt Van Roggenweg 500, 3531 AH Utrecht, The Netherlands.,Department of Pharmacy and Clinical Pharmacology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | | | - Alberico L Catapano
- Department of Pharmacological and Biomolecular Sciences and Multimedica IRCCS, University of Milan, via Balzaretti 9, 20133 Milano, Italy
| | - Wendy Gattis Stough
- Departments of Clinical Research and Pharmacy Practice, Campbell University College of Pharmacy and Health Sciences, 217 Main St., Buies Creek, NC 27506, USA
| | - Stefan C Carlsson
- Cardiovascular Pharmacology, AstraZeneca, Pepparredsleden 1, SE-431 83 Mölndal, Sweden
| | - Guy De Backer
- Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, University Hospital, K3, 4th floor, De Pintelaan 185, B9000 Ghent, Belgium
| | - Joseph Emmerich
- Université Paris-Descartes, Cochin-Hôtel Dieu Hospital, French National Agency for Medicines and Health Products Safety, 143/147, Boulevard, Anatole France 93285, Saint-Denis, France
| | - Scott Greenfeder
- Regulatory Affairs, Daiichi-Sankyo, 211 Mt. Airy Road, Basking Ridge, NJ 07920, USA
| | - Albert M Kim
- Internal Medicine Research Unit, Pfizer, Inc., 1 Portland St., 4th floor, Cambridge, MA 02139, USA
| | - Dominik Lautsch
- Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ 07033, USA
| | - Tu Nguyen
- Sanofi, 55 Corporate Drive, Bridgewater, NJ, USA
| | - Steven E Nissen
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Krishna Prasad
- Licensing Division, United Kingdom Medicines and Healthcare Products Regulatory Agency, 151 Buckingham Palace Road, London SW1W 9SZ, UK
| | - Kausik K Ray
- Department of Primary Care and Public Health, Imperial College, 323 Reynolds Building, Room 320, Charing Cross Hospital, London W68RF, UK
| | - Jennifer G Robinson
- Department of Epidemiology, College of Public Health, University of Iowa, 145 N. Riverside Dr S455 CPHB, Iowa City, IA 52242, USA
| | - William J Sasiela
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Karsten Bruins Slot
- Oslo University Hospital, Ullevål, Medical Department, Postboks 4956 Nydalen, 0424 Oslo, Norway
| | - Erik Stroes
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Tom Thuren
- Novartis Pharma AG, Asklepios 8, 4056 Basel, Switzerland
| | - Bart Van der Schueren
- Laboratory of Experimental Medicine and Endocrinology, University of Leuven, Herestraat 49, 3000 Leuven, Belgium
| | | | - Scott M Wasserman
- Amgen, One Amgen Center Drive, MS 38.2.C, Thousand Oaks, CA 91320, USA
| | - Olov Wiklund
- Wallenberg Laboratory, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
| | - Emmanouil Zouridakis
- Licensing Division, United Kingdom Medicines and Healthcare Products Regulatory Agency, 151 Buckingham Palace Road, London SW1W 9SZ, UK
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12
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Lee E, Gibbs JP, Emery MG, Block G, Wasserman SM, Hamilton L, Kasichayanula S, Hanafin P, Somaratne R, Egbuna O. Influence of Renal Function on Evolocumab Exposure, Pharmacodynamics, and Safety. Clin Pharmacol Drug Dev 2019; 8:281-289. [PMID: 30676701 PMCID: PMC6590207 DOI: 10.1002/cpdd.650] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/03/2018] [Indexed: 12/31/2022]
Abstract
We evaluated the pharmacokinetics, pharmacodynamics, and safety of evolocumab, a fully human monoclonal antibody against proprotein convertase subtilisin kexin type 9 (PCSK9), in an open‐label, parallel‐design study in participants with normal renal function (n = 6), severe renal impairment (RI; n = 6), or end‐stage renal disease (ESRD) receiving hemodialysis (n = 6) who received a single 140‐mg dose of evolocumab. The effects of evolocumab treatment on low‐density lipoprotein cholesterol (LDL‐C) lowering and unbound PCSK9 concentrations were similar in the normal renal function group and the renally impaired groups. Geometric mean Cmax and AUClast values in the severe RI and ESRD hemodialysis groups compared with the normal renal function group were lower but within 37% of the normal renal function group (Jonckheere‐Terpstra trend test; Cmax, P = .23; AUClast, P = .22) and within 26% after adjusting for body weight (mean body weight was approximately 9% higher in the renally impaired groups compared with the normal renal function group). No correlations were observed between exposure and baseline creatinine clearance. No adverse event was determined by the investigators to be related to evolocumab, and there were no trends indicative of clinically important effects on laboratory variables or vital signs. Overall, there were no meaningful differences in evolocumab exposure, as assessed by Cmax and AUClast, in patients with severe RI and ESRD hemodialysis compared with patients with normal renal function, and LDL‐C‐lowering effects were similar across groups. These results support the use of evolocumab without dose adjustment in patients who have severe RI or ESRD.
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13
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Stroes E, Robinson JG, Raal FJ, Dufour R, Sullivan D, Kassahun H, Ma Y, Wasserman SM, Koren MJ. Consistent LDL-C response with evolocumab among patient subgroups in PROFICIO: A pooled analysis of 3146 patients from phase 3 studies. Clin Cardiol 2018; 41:1328-1335. [PMID: 30120772 PMCID: PMC6489970 DOI: 10.1002/clc.23049] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 08/09/2018] [Accepted: 08/13/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Evolocumab significantly lowers low-density lipoprotein cholesterol (LDL-C) when dosed 140 mg every 2 weeks (Q2W) or 420 mg monthly (QM) subcutaneously. HYPOTHESIS LDL-C changes are comparable among different patient subgroups in a pooled analysis of data from phase 3 trials. METHODS A total of 3146 patients received ≥1 dose of evolocumab or control in four 12-week phase 3 studies. Percent change from baseline in LDL-C for evolocumab 140 mg Q2W or 420 mg QM vs control was reported as the average of week 10 and 12 values. Quantitative and qualitative interactions between treatment group and subgroup by dose regimen were tested. RESULTS In the pooled analysis, treatment differences vs placebo or ezetimibe were similar for both 140 mg Q2W and 420 mg QM doses across ages (<65 years, ≥65 years); gender; race (Asian, black, white, other); ethnicity (Hispanic, non-Hispanic); region (Europe, North America, Asia Pacific); glucose tolerance status (type 2 diabetes mellitus, metabolic syndrome, neither); National Cholesterol Education Program risk categories (high, moderately high, moderate, low); and European Society of Cardiology/European Atherosclerosis Society risk categories (very high, high, moderate, or low). Certain low-magnitude variations in LDL-C lowering among subgroups led to significant quantitative interaction P values that, when tested by qualitative interaction, were not significant. The incidences of adverse events were similar across groups treated with each evolocumab dosing regimen or control. CONCLUSIONS Consistent reductions in LDL-C were observed in the evolocumab group regardless of demographic and disease characteristics.
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Affiliation(s)
- Erik Stroes
- Department of Vascular Medicine, Academic Medical Center of Amsterdam, Amsterdam, Netherlands
| | - Jennifer G Robinson
- Departments of Epidemiology and Medicine, University of Iowa, Iowa City, Iowa
| | - Frederick J Raal
- Department of Medicine, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Robert Dufour
- Institut de recherches cliniques de Montréal, Université de Montréal, Montreal, Canada
| | - David Sullivan
- Department of Clinical Biochemistry, Prince Alfred Hospital, Camperdown, Australia
| | | | - Yuhui Ma
- Amgen Inc., Thousand Oaks, California
| | | | - Michael J Koren
- Jacksonville Center for Clinical Research, Jacksonville, Florida
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14
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Raman SR, Curtis LH, Temple R, Andersson T, Ezekowitz J, Ford I, James S, Marsolo K, Mirhaji P, Rocca M, Rothman RL, Sethuraman B, Stockbridge N, Terry S, Wasserman SM, Peterson ED, Hernandez AF. Leveraging electronic health records for clinical research. Am Heart J 2018; 202:13-19. [PMID: 29802975 DOI: 10.1016/j.ahj.2018.04.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 04/23/2018] [Indexed: 12/11/2022]
Abstract
Electronic health records (EHRs) can be a major tool in the quest to decrease costs and timelines of clinical trial research, generate better evidence for clinical decision making, and advance health care. Over the past decade, EHRs have increasingly offered opportunities to speed up, streamline, and enhance clinical research. EHRs offer a wide range of possible uses in clinical trials, including assisting with prestudy feasibility assessment, patient recruitment, and data capture in care delivery. To fully appreciate these opportunities, health care stakeholders must come together to face critical challenges in leveraging EHR data, including data quality/completeness, information security, stakeholder engagement, and increasing the scale of research infrastructure and related governance. Leaders from academia, government, industry, and professional societies representing patient, provider, researcher, industry, and regulator perspectives convened the Leveraging EHR for Clinical Research Now! Think Tank in Washington, DC (February 18-19, 2016), to identify barriers to using EHRs in clinical research and to generate potential solutions. Think tank members identified a broad range of issues surrounding the use of EHRs in research and proposed a variety of solutions. Recognizing the challenges, the participants identified the urgent need to look more deeply at previous efforts to use these data, share lessons learned, and develop a multidisciplinary agenda for best practices for using EHRs in clinical research. We report the proceedings from this think tank meeting in the following paper.
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Affiliation(s)
| | | | | | | | - Justin Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, United Kingdom
| | - Stefan James
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Keith Marsolo
- Cinncinatti Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cinncinatti, OH
| | | | - Mitra Rocca
- Food and Drug Administration, Silver Spring, MD
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15
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Povsic TJ, Scott R, Mahaffey KW, Blaustein R, Edelberg JM, Lefkowitz MP, Solomon SD, Fox JC, Healy KE, Khakoo AY, Losordo DW, Malik FI, Monia BP, Montgomery RL, Riesmeyer J, Schwartz GG, Zelenkofske SL, Wu JC, Wasserman SM, Roe MT. Navigating the Future of Cardiovascular Drug Development-Leveraging Novel Approaches to Drive Innovation and Drug Discovery: Summary of Findings from the Novel Cardiovascular Therapeutics Conference. Cardiovasc Drugs Ther 2018; 31:445-458. [PMID: 28735360 DOI: 10.1007/s10557-017-6739-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE The need for novel approaches to cardiovascular drug development served as the impetus to convene an open meeting of experts from the pharmaceutical industry and academia to assess the challenges and develop solutions for drug discovery in cardiovascular disease. METHODS The Novel Cardiovascular Therapeutics Summit first reviewed recent examples of ongoing or recently completed programs translating basic science observations to targeted drug development, highlighting successes (protein convertase sutilisin/kexin type 9 [PCSK9] and neprilysin inhibition) and targets still under evaluation (cholesteryl ester transfer protein [CETP] inhibition), with the hope of gleaning key lessons to successful drug development in the current era. Participants then reviewed the use of innovative approaches being explored to facilitate rapid and more cost-efficient evaluations of drug candidates in a short timeframe. RESULTS We summarize observations gleaned from this summit and offer insight into future cardiovascular drug development. CONCLUSIONS The rapid development in genetic and high-throughput drug evaluation technologies, coupled with new approaches to rapidly evaluate potential cardiovascular therapies with in vitro techniques, offer opportunities to identify new drug targets for cardiovascular disease, study new therapies with better efficiency and higher throughput in the preclinical setting, and more rapidly bring the most promising therapies to human testing. However, there must be a critical interface between industry and academia to guide the future of cardiovascular drug development. The shared interest among academic institutions and pharmaceutical companies in developing promising therapies to address unmet clinical needs for patients with cardiovascular disease underlies and guides innovation and discovery platforms that are significantly altering the landscape of cardiovascular drug development.
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Affiliation(s)
- Thomas J Povsic
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt Street, Duke Medicine, Durham, NC, 27705, USA.
| | - Rob Scott
- AbbVie Pharmaceuticals, Chicago, IL, USA
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research (SCCR), Stanford University School of Medicine, Stanford, CA, USA
| | - Robert Blaustein
- Merck Research Laboratories, Merck & Co., Inc, Kenilworth, NJ, USA
| | | | | | | | | | - Kevin E Healy
- University of California, Berkeley, Berkeley, CA, USA
| | | | | | | | | | | | | | | | | | - Joseph C Wu
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Matthew T Roe
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt Street, Duke Medicine, Durham, NC, 27705, USA
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16
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Chan DC, Watts GF, Somaratne R, Wasserman SM, Scott R, Barrett PHR. Comparative Effects of PCSK9 (Proprotein Convertase Subtilisin/Kexin Type 9) Inhibition and Statins on Postprandial Triglyceride-Rich Lipoprotein Metabolism. Arterioscler Thromb Vasc Biol 2018; 38:1644-1655. [PMID: 29880491 PMCID: PMC6039422 DOI: 10.1161/atvbaha.118.310882] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 05/09/2018] [Indexed: 11/20/2022]
Abstract
Supplemental Digital Content is available in the text. Objective— Inhibition of PCSK9 (proprotein convertase subtilisin/kexin type 9) and statins are known to lower plasma LDL (low-density lipoprotein)-cholesterol concentrations. However, the comparative effects of these treatments on the postprandial metabolism of TRLs (triglyceride-rich lipoproteins) remain to be investigated. Approach and Results— We performed a 2-by-2 factorial trial of the effects of 8 weeks of subcutaneous evolocumab (420 mg every 2 weeks) and atorvastatin (80 mg daily) on postprandial TRL metabolism in 80 healthy, normolipidemic men after ingestion of an oral fat load. We evaluated plasma total and incremental area under the curves for triglycerides, apo (apolipoprotein)B-48, and VLDL (very-LDL)-apoB-100. We also examined the kinetics of apoB-48 using intravenous D3-leucine administration, mass spectrometry, and multicompartmental modeling. Atorvastatin and evolocumab independently lowered postprandial VLDL-apoB-100 total area under the curves (P<0.001). Atorvastatin, but not evolocumab, reduced fasting plasma apoB-48, apoC-III, and angiopoietin-like 3 concentrations (P<0.01), as well as postprandial triglyceride and apoB-48 total area under the curves (P<0.001) and the incremental area under the curves for plasma triglycerides, apoB-48, and VLDL-apoB-100 (P<0.01). Atorvastatin also independently increased TRL apoB-48 fractional catabolic rate (P<0.001) and reduced the number of apoB-48–containing particles secreted in response to the fat load (P<0.01). In contrast, evolocumab did not significantly alter the kinetics of apoB-48. Conclusions— In healthy, normolipidemic men, atorvastatin decreased fasting and postprandial apoB-48 concentration by accelerating the catabolism of apoB-48 particles and reducing apoB-48 particle secretion in response to a fat load. Inhibition of PCSK9 with evolocumab had no significant effect on apoB-48 metabolism.
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Affiliation(s)
- Dick C Chan
- From Schools of Medicine (D.C.C., G.F.W.).,Biomedical Science (D.C.C., P.H.R.B.)
| | - Gerald F Watts
- From Schools of Medicine (D.C.C., G.F.W.) .,the Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, University of Western Australia (G.F.W.)
| | - Ransi Somaratne
- Amgen Inc, Thousand Oaks, CA (S.M.W., R. Somaratne, R. Scott)
| | | | - Rob Scott
- Amgen Inc, Thousand Oaks, CA (S.M.W., R. Somaratne, R. Scott)
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17
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Wasserman SM, Sabatine MS, Koren MJ, Giugliano RP, Legg JC, Emery MG, Doshi S, Liu T, Somaratne R, Gibbs JP. Comparison of LDL-C Reduction Using Different Evolocumab Doses and Intervals. J Cardiovasc Pharmacol Ther 2018; 23:423-432. [DOI: 10.1177/1074248418774043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background: The proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor evolocumab reduces low-density lipoprotein cholesterol (LDL-C) and the risk of cardiovascular events. Objectives: To compare LDL-C reduction using evolocumab 140 mg once every 2 weeks (Q2W) or 420 mg monthly (QM) versus lower doses (70 mg Q2W or 280 mg QM) or placebo. Methods: Patients received evolocumab 70 or 140 mg Q2W, 280 or 420 mg QM, or placebo Q2W or QM in two 12-week phase 2 studies: one with and one without statins. Changes from baseline in LDL-C were compared across Q2W doses and across QM doses. Results: The analysis included 741 patients. Mean (95% confidence interval [CI]) reduction in LDL-C across Q2W visits through week 12 was 63.0% (60.3% to 65.7%) for evolocumab 140 mg Q2W, compared to 41.3% (38.6% to 44.0%) for 70 mg Q2W and 1.9% (4.6% reduction to 0.8% increase) for placebo Q2W (each P < .001 vs 140 mg Q2W), and 62.7% (60.1% to 65.3%) for 420 mg QM, compared to 55.5% (52.9% to 58.0%) for 280 mg QM and 2.5% (5.1% reduction to 0.1% increase) for placebo QM (each P < .001 vs 420 mg QM). Similar results were observed at the mean of weeks 10 and 12. In a subgroup (n = 151) with weekly assessments from weeks 8 to 12, mean (95% CI) peak effect on LDL-C reduction was 72.8% (67.7% to 77.9%) for 140 mg Q2W and 69.0% (63.6% to 74.3%) for 420 mg QM. Trough effect at week 12 underestimated LDL-C reduction. Median peak–trough variability was 20.5%, 21.1%, 31.9%, and 35.1% for evolocumab 140 mg Q2W, 420 mg QM, 70 mg Q2W, and 280 mg QM, respectively. Conclusion: Evolocumab 140 mg Q2W and 420 mg QM yielded similar LDL-C reduction. These doses sustained maximal LDL-C reduction, resulting in greater stability in LDL-C reduction over the dosing interval compared to lower doses. These results support evolocumab doses of either 140 mg Q2W or 420 mg QM.
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Affiliation(s)
| | - Marc S. Sabatine
- Division of Cardiovascular Medicine, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael J. Koren
- Jacksonville Center for Clinical Research, Jacksonville, FL, USA
| | - Robert P. Giugliano
- Division of Cardiovascular Medicine, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Jason C. Legg
- Global Biostatistical Science, Amgen Inc, Thousand Oaks, CA, USA
| | | | - Sameer Doshi
- Clinical Pharmacology, Amgen Inc, Thousand Oaks, CA, USA
| | - Thomas Liu
- Global Biostatistical Science, Amgen Inc, Thousand Oaks, CA, USA
| | | | - John P. Gibbs
- Clinical Pharmacology, Amgen Inc, Thousand Oaks, CA, USA
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Kuchimanchi M, Grover A, Emery MG, Somaratne R, Wasserman SM, Gibbs JP, Doshi S. Population pharmacokinetics and exposure-response modeling and simulation for evolocumab in healthy volunteers and patients with hypercholesterolemia. J Pharmacokinet Pharmacodyn 2018; 45:505-522. [PMID: 29736889 PMCID: PMC5953983 DOI: 10.1007/s10928-018-9592-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 04/24/2018] [Indexed: 12/27/2022]
Abstract
Evolocumab, a novel human monoclonal antibody, inhibits proprotein convertase subtilisin/kexin type 9, a protein that targets low-density lipoprotein-cholesterol (LDL-C) receptors for the treatment of hyperlipidemia. The primary objective of this analysis was to characterize the population pharmacokinetics (popPK) and exposure-response relationship of evolocumab to assess if dose adjustment is needed across differing patient populations. Data were pooled for 5474 patients in 11 clinical studies who received evolocumab doses of 7-420 mg at various frequencies, either intravenously or subcutaneously. Evolocumab area under concentration-time curve from 8 to 12 weeks (AUCwk8-12) was simulated for individuals using the popPK model and was used to predict the LDL-C response in relation to AUCwk8-12. Evolocumab was eliminated through nonspecific (linear) and target-mediated (nonlinear) clearance. PopPK parameters and associated variabilities of evolocumab were similar to those of other monoclonal antibodies. The exposure-response model predicted a maximal 66% reduction in LDL-C from baseline to the mean of weeks 10 and 12 for doses of evolocumab 140 mg subcutaneously every 2 weeks or 420 mg subcutaneously once monthly. After inclusion of statistically significant covariates in an uncertainty-based simulation, LDL-C reduction from baseline at the mean of weeks 10 and 12 was predicted to be within 74% to 126% of the reference patient for all simulated patient groups. Evolocumab had nonlinear pharmacokinetics. The range of responses based on intrinsic and extrinsic factors was not predicted to be sufficiently different from the reference patient to warrant evolocumab dose adjustment.
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Affiliation(s)
| | - Anita Grover
- Amgen Inc., One Amgen Center Dr, Thousand Oaks, CA, USA
| | | | | | | | - John P Gibbs
- Amgen Inc., One Amgen Center Dr, Thousand Oaks, CA, USA
| | - Sameer Doshi
- Amgen Inc., One Amgen Center Dr, Thousand Oaks, CA, USA.
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19
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Watts GF, Chan DC, Somaratne R, Wasserman SM, Scott R, Marcovina SM, Barrett PHR. Controlled study of the effect of proprotein convertase subtilisin-kexin type 9 inhibition with evolocumab on lipoprotein(a) particle kinetics. Eur Heart J 2018; 39:2577-2585. [DOI: 10.1093/eurheartj/ehy122] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 03/02/2018] [Indexed: 12/24/2022] Open
Affiliation(s)
- Gerald F Watts
- Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth, WA, Australia
- Schools of Medicine and Biomedical Science, University of Western Australia, Perth, WA, Australia
| | - Dick C Chan
- Schools of Medicine and Biomedical Science, University of Western Australia, Perth, WA, Australia
| | | | | | - Rob Scott
- Formerly of Amgen, Inc., Thousand Oaks, CA, USA
| | - Santica M Marcovina
- Northwest Lipid Metabolism and Diabetes Research Laboratories, Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA, USA
| | - P Hugh R Barrett
- Schools of Medicine and Biomedical Science, University of Western Australia, Perth, WA, Australia
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20
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Qamar A, Giugliano RP, Keech AC, Kuder JF, Murphy SA, Liu T, Kurtz C, Wasserman SM, Sever PS, Pedersen TR, Sabatine MS. CONSISTENCY OF LDL-C REDUCTION WITH EVOLOCUMAB: AN ANALYSIS FROM FOURIER. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)32268-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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21
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Giugliano RP, Pedersen TR, Park JG, De Ferrari GM, Gaciong ZA, Ceska R, Toth K, Gouni-Berthold I, Lopez-Miranda J, Schiele F, Mach F, Ott BR, Kanevsky E, Pineda AL, Somaratne R, Wasserman SM, Keech AC, Sever PS, Sabatine MS. Clinical efficacy and safety of achieving very low LDL-cholesterol concentrations with the PCSK9 inhibitor evolocumab: a prespecified secondary analysis of the FOURIER trial. Lancet 2017; 390:1962-1971. [PMID: 28859947 DOI: 10.1016/s0140-6736(17)32290-0] [Citation(s) in RCA: 405] [Impact Index Per Article: 57.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 08/11/2017] [Accepted: 08/14/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND LDL cholesterol is a well established risk factor for atherosclerotic cardiovascular disease. How much one should or safely can lower this risk factor remains debated. We aimed to explore the relationship between progressively lower LDL-cholesterol concentrations achieved at 4 weeks and clinical efficacy and safety in the FOURIER trial of evolocumab, a monoclonal antibody to proprotein convertase subtilisin-kexin type 9 (PCSK9). METHODS In this prespecified secondary analysis of 25 982 patients from the randomised FOURIER trial, the relationship between achieved LDL-cholesterol concentration at 4 weeks and subsequent cardiovascular outcomes (primary endpoint was the composite of cardiovascular death, myocardial infarction, stroke, coronary revascularisation, or unstable angina; key secondary endpoint was the composite of cardiovascular death, myocardial infarction, or stroke) and ten prespecified safety events of interest was examined over a median of 2·2 years of follow-up. We used multivariable modelling to adjust for baseline factors associated with achieved LDL cholesterol. This trial is registered with ClinicalTrials.gov, number NCT01764633. FINDINGS Between Feb 8, 2013, and June 5, 2015, 27 564 patients were randomly assigned a treatment in the FOURIER study. 1025 (4%) patients did not have an LDL cholesterol measured at 4 weeks and 557 (2%) had already had a primary endpoint event or one of the ten prespecified safety events before the week-4 visit. From the remaining 25 982 patients (94% of those randomly assigned) 13 013 were assigned evolocumab and 12 969 were assigned placebo. 2669 (10%) of 25 982 patients achieved LDL-cholesterol concentrations of less than 0·5 mmol/L, 8003 (31%) patients achieved concentrations between 0·5 and less than 1·3 mmol/L, 3444 (13%) patients achieved concentrations between 1·3 and less than 1·8 mmol/L, 7471 (29%) patients achieved concentrations between 1·8 to less than 2·6 mmol/L, and 4395 (17%) patients achieved concentrations of 2·6 mmol/L or higher. There was a highly significant monotonic relationship between low LDL-cholesterol concentrations and lower risk of the primary and secondary efficacy composite endpoints extending to the bottom first percentile (LDL-cholesterol concentrations of less than 0·2 mmol/L; p=0·0012 for the primary endpoint, p=0·0001 for the secondary endpoint). Conversely, no significant association was observed between achieved LDL cholesterol and safety outcomes, either for all serious adverse events or any of the other nine prespecified safety events. INTERPRETATION There was a monotonic relationship between achieved LDL cholesterol and major cardiovascular outcomes down to LDL-cholesterol concentrations of less than 0·2 mmol/L. Conversely, there were no safety concerns with very low LDL-cholesterol concentrations over a median of 2·2 years. These data support further LDL-cholesterol lowering in patients with cardiovascular disease to well below current recommendations. FUNDING Amgen.
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Affiliation(s)
- Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Terje R Pedersen
- Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Oslo, Norway
| | - Jeong-Gun Park
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Gaetano M De Ferrari
- Department of Molecular Medicine, University of Pavia and Cardiac Intensive Care Unit and Laboratories for Experimental Cardiology, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Zbigniew A Gaciong
- Department of Internal Medicine, Hypertension and Vascular Diseases, The Medical University of Warsaw, Warsaw, Poland
| | - Richard Ceska
- Center of Preventive Cardiology, 3rd Department Internal Medicine, University General Hospital and 1st Medical Faculty, Prague, Czech Republic
| | - Kalman Toth
- 1st Department of Medicine, University of Pécs, Pécs, Hungary
| | - Ioanna Gouni-Berthold
- Polyclinic for Endocrinology, Diabetes, and Preventive Medicine, University of Cologne, Cologne, Germany
| | - Jose Lopez-Miranda
- Lipids and Atherosclerosis Unit, Maimonides Biomedical Research Institute of Cordoba, Reina Sofia University Hospital, University of Cordoba, CIBEROBN, Cordoba, Spain
| | | | - François Mach
- Hopital Cantonal, Hopitaux Universitaires de Geneva, Geneva, Switzerland
| | - Brian R Ott
- Rhode Island Hospital, Department of Neurology, Alpert Medical School of Brown University, Providence, RI, USA
| | - Estella Kanevsky
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | | | - Anthony C Keech
- Sydney Medical School, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Peter S Sever
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, UK
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
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22
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Giugliano RP, Mach F, Zavitz K, Kurtz C, Im K, Kanevsky E, Schneider J, Wang H, Keech A, Pedersen TR, Sabatine MS, Sever PS, Robinson JG, Honarpour N, Wasserman SM, Ott BR. Cognitive Function in a Randomized Trial of Evolocumab. N Engl J Med 2017; 377:633-643. [PMID: 28813214 DOI: 10.1056/nejmoa1701131] [Citation(s) in RCA: 311] [Impact Index Per Article: 44.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background Findings from clinical trials of proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors have led to concern that these drugs or the low levels of low-density lipoprotein (LDL) cholesterol that result from their use are associated with cognitive deficits. Methods In a subgroup of patients from a randomized, placebo-controlled trial of evolocumab added to statin therapy, we prospectively assessed cognitive function using the Cambridge Neuropsychological Test Automated Battery. The primary end point was the score on the spatial working memory strategy index of executive function (scores range from 4 to 28, with lower scores indicating a more efficient use of strategy and planning). Secondary end points were the scores for working memory (scores range from 0 to 279, with lower scores indicating fewer errors), episodic memory (scores range from 0 to 70, with lower scores indicating fewer errors), and psychomotor speed (scores range from 100 to 5100 msec, with faster times representing better performance). Assessments of cognitive function were performed at baseline, week 24, yearly, and at the end of the trial. The primary analysis was a noninferiority comparison of the mean change from baseline in the score on the spatial working memory strategy index of executive function between the patients who received evolocumab and those who received placebo; the noninferiority margin was set at 20% of the standard deviation of the score in the placebo group. Results A total of 1204 patients were followed for a median of 19 months; the mean (±SD) change from baseline over time in the raw score for the spatial working memory strategy index of executive function (primary end point) was -0.21±2.62 in the evolocumab group and -0.29±2.81 in the placebo group (P<0.001 for noninferiority; P=0.85 for superiority). There were no significant between-group differences in the secondary end points of scores for working memory (change in raw score, -0.52 in the evolocumab group and -0.93 in the placebo group), episodic memory (change in raw score, -1.53 and -1.53, respectively), or psychomotor speed (change in raw score, 5.2 msec and 0.9 msec, respectively). In an exploratory analysis, there were no associations between LDL cholesterol levels and cognitive changes. Conclusions In a randomized trial involving patients who received either evolocumab or placebo in addition to statin therapy, no significant between-group difference in cognitive function was observed over a median of 19 months. (Funded by Amgen; EBBINGHAUS ClinicalTrials.gov number, NCT02207634 .).
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Affiliation(s)
- Robert P Giugliano
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Boston (R.P.G., K.I., E.K., M.S.S.); Hôpital Cantonal, Hopitaux Universitaires de Genève, Geneva (F.M.); Cambridge Cognition, Cambridge (K.Z.), and International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.) - both in the United Kingdom; Amgen, Thousand Oaks, CA (C.K., J.S., H.W., N.H., S.M.W.); Sydney Medical School, NHMRC Clinical Trials Centre, University of Sydney, Sydney (A.K.); Oslo University Hospital, Ullevål, and Medical Faculty, University of Oslo - both in Oslo (T.R.P.); University of Iowa, Iowa City (J.G.R.); and Rhode Island Hospital, Department of Neurology, Alpert Medical School of Brown University, Providence (B.R.O.)
| | - François Mach
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Boston (R.P.G., K.I., E.K., M.S.S.); Hôpital Cantonal, Hopitaux Universitaires de Genève, Geneva (F.M.); Cambridge Cognition, Cambridge (K.Z.), and International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.) - both in the United Kingdom; Amgen, Thousand Oaks, CA (C.K., J.S., H.W., N.H., S.M.W.); Sydney Medical School, NHMRC Clinical Trials Centre, University of Sydney, Sydney (A.K.); Oslo University Hospital, Ullevål, and Medical Faculty, University of Oslo - both in Oslo (T.R.P.); University of Iowa, Iowa City (J.G.R.); and Rhode Island Hospital, Department of Neurology, Alpert Medical School of Brown University, Providence (B.R.O.)
| | - Kenton Zavitz
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Boston (R.P.G., K.I., E.K., M.S.S.); Hôpital Cantonal, Hopitaux Universitaires de Genève, Geneva (F.M.); Cambridge Cognition, Cambridge (K.Z.), and International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.) - both in the United Kingdom; Amgen, Thousand Oaks, CA (C.K., J.S., H.W., N.H., S.M.W.); Sydney Medical School, NHMRC Clinical Trials Centre, University of Sydney, Sydney (A.K.); Oslo University Hospital, Ullevål, and Medical Faculty, University of Oslo - both in Oslo (T.R.P.); University of Iowa, Iowa City (J.G.R.); and Rhode Island Hospital, Department of Neurology, Alpert Medical School of Brown University, Providence (B.R.O.)
| | - Christopher Kurtz
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Boston (R.P.G., K.I., E.K., M.S.S.); Hôpital Cantonal, Hopitaux Universitaires de Genève, Geneva (F.M.); Cambridge Cognition, Cambridge (K.Z.), and International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.) - both in the United Kingdom; Amgen, Thousand Oaks, CA (C.K., J.S., H.W., N.H., S.M.W.); Sydney Medical School, NHMRC Clinical Trials Centre, University of Sydney, Sydney (A.K.); Oslo University Hospital, Ullevål, and Medical Faculty, University of Oslo - both in Oslo (T.R.P.); University of Iowa, Iowa City (J.G.R.); and Rhode Island Hospital, Department of Neurology, Alpert Medical School of Brown University, Providence (B.R.O.)
| | - Kyungah Im
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Boston (R.P.G., K.I., E.K., M.S.S.); Hôpital Cantonal, Hopitaux Universitaires de Genève, Geneva (F.M.); Cambridge Cognition, Cambridge (K.Z.), and International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.) - both in the United Kingdom; Amgen, Thousand Oaks, CA (C.K., J.S., H.W., N.H., S.M.W.); Sydney Medical School, NHMRC Clinical Trials Centre, University of Sydney, Sydney (A.K.); Oslo University Hospital, Ullevål, and Medical Faculty, University of Oslo - both in Oslo (T.R.P.); University of Iowa, Iowa City (J.G.R.); and Rhode Island Hospital, Department of Neurology, Alpert Medical School of Brown University, Providence (B.R.O.)
| | - Estella Kanevsky
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Boston (R.P.G., K.I., E.K., M.S.S.); Hôpital Cantonal, Hopitaux Universitaires de Genève, Geneva (F.M.); Cambridge Cognition, Cambridge (K.Z.), and International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.) - both in the United Kingdom; Amgen, Thousand Oaks, CA (C.K., J.S., H.W., N.H., S.M.W.); Sydney Medical School, NHMRC Clinical Trials Centre, University of Sydney, Sydney (A.K.); Oslo University Hospital, Ullevål, and Medical Faculty, University of Oslo - both in Oslo (T.R.P.); University of Iowa, Iowa City (J.G.R.); and Rhode Island Hospital, Department of Neurology, Alpert Medical School of Brown University, Providence (B.R.O.)
| | - Jingjing Schneider
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Boston (R.P.G., K.I., E.K., M.S.S.); Hôpital Cantonal, Hopitaux Universitaires de Genève, Geneva (F.M.); Cambridge Cognition, Cambridge (K.Z.), and International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.) - both in the United Kingdom; Amgen, Thousand Oaks, CA (C.K., J.S., H.W., N.H., S.M.W.); Sydney Medical School, NHMRC Clinical Trials Centre, University of Sydney, Sydney (A.K.); Oslo University Hospital, Ullevål, and Medical Faculty, University of Oslo - both in Oslo (T.R.P.); University of Iowa, Iowa City (J.G.R.); and Rhode Island Hospital, Department of Neurology, Alpert Medical School of Brown University, Providence (B.R.O.)
| | - Huei Wang
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Boston (R.P.G., K.I., E.K., M.S.S.); Hôpital Cantonal, Hopitaux Universitaires de Genève, Geneva (F.M.); Cambridge Cognition, Cambridge (K.Z.), and International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.) - both in the United Kingdom; Amgen, Thousand Oaks, CA (C.K., J.S., H.W., N.H., S.M.W.); Sydney Medical School, NHMRC Clinical Trials Centre, University of Sydney, Sydney (A.K.); Oslo University Hospital, Ullevål, and Medical Faculty, University of Oslo - both in Oslo (T.R.P.); University of Iowa, Iowa City (J.G.R.); and Rhode Island Hospital, Department of Neurology, Alpert Medical School of Brown University, Providence (B.R.O.)
| | - Anthony Keech
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Boston (R.P.G., K.I., E.K., M.S.S.); Hôpital Cantonal, Hopitaux Universitaires de Genève, Geneva (F.M.); Cambridge Cognition, Cambridge (K.Z.), and International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.) - both in the United Kingdom; Amgen, Thousand Oaks, CA (C.K., J.S., H.W., N.H., S.M.W.); Sydney Medical School, NHMRC Clinical Trials Centre, University of Sydney, Sydney (A.K.); Oslo University Hospital, Ullevål, and Medical Faculty, University of Oslo - both in Oslo (T.R.P.); University of Iowa, Iowa City (J.G.R.); and Rhode Island Hospital, Department of Neurology, Alpert Medical School of Brown University, Providence (B.R.O.)
| | - Terje R Pedersen
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Boston (R.P.G., K.I., E.K., M.S.S.); Hôpital Cantonal, Hopitaux Universitaires de Genève, Geneva (F.M.); Cambridge Cognition, Cambridge (K.Z.), and International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.) - both in the United Kingdom; Amgen, Thousand Oaks, CA (C.K., J.S., H.W., N.H., S.M.W.); Sydney Medical School, NHMRC Clinical Trials Centre, University of Sydney, Sydney (A.K.); Oslo University Hospital, Ullevål, and Medical Faculty, University of Oslo - both in Oslo (T.R.P.); University of Iowa, Iowa City (J.G.R.); and Rhode Island Hospital, Department of Neurology, Alpert Medical School of Brown University, Providence (B.R.O.)
| | - Marc S Sabatine
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Boston (R.P.G., K.I., E.K., M.S.S.); Hôpital Cantonal, Hopitaux Universitaires de Genève, Geneva (F.M.); Cambridge Cognition, Cambridge (K.Z.), and International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.) - both in the United Kingdom; Amgen, Thousand Oaks, CA (C.K., J.S., H.W., N.H., S.M.W.); Sydney Medical School, NHMRC Clinical Trials Centre, University of Sydney, Sydney (A.K.); Oslo University Hospital, Ullevål, and Medical Faculty, University of Oslo - both in Oslo (T.R.P.); University of Iowa, Iowa City (J.G.R.); and Rhode Island Hospital, Department of Neurology, Alpert Medical School of Brown University, Providence (B.R.O.)
| | - Peter S Sever
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Boston (R.P.G., K.I., E.K., M.S.S.); Hôpital Cantonal, Hopitaux Universitaires de Genève, Geneva (F.M.); Cambridge Cognition, Cambridge (K.Z.), and International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.) - both in the United Kingdom; Amgen, Thousand Oaks, CA (C.K., J.S., H.W., N.H., S.M.W.); Sydney Medical School, NHMRC Clinical Trials Centre, University of Sydney, Sydney (A.K.); Oslo University Hospital, Ullevål, and Medical Faculty, University of Oslo - both in Oslo (T.R.P.); University of Iowa, Iowa City (J.G.R.); and Rhode Island Hospital, Department of Neurology, Alpert Medical School of Brown University, Providence (B.R.O.)
| | - Jennifer G Robinson
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Boston (R.P.G., K.I., E.K., M.S.S.); Hôpital Cantonal, Hopitaux Universitaires de Genève, Geneva (F.M.); Cambridge Cognition, Cambridge (K.Z.), and International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.) - both in the United Kingdom; Amgen, Thousand Oaks, CA (C.K., J.S., H.W., N.H., S.M.W.); Sydney Medical School, NHMRC Clinical Trials Centre, University of Sydney, Sydney (A.K.); Oslo University Hospital, Ullevål, and Medical Faculty, University of Oslo - both in Oslo (T.R.P.); University of Iowa, Iowa City (J.G.R.); and Rhode Island Hospital, Department of Neurology, Alpert Medical School of Brown University, Providence (B.R.O.)
| | - Narimon Honarpour
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Boston (R.P.G., K.I., E.K., M.S.S.); Hôpital Cantonal, Hopitaux Universitaires de Genève, Geneva (F.M.); Cambridge Cognition, Cambridge (K.Z.), and International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.) - both in the United Kingdom; Amgen, Thousand Oaks, CA (C.K., J.S., H.W., N.H., S.M.W.); Sydney Medical School, NHMRC Clinical Trials Centre, University of Sydney, Sydney (A.K.); Oslo University Hospital, Ullevål, and Medical Faculty, University of Oslo - both in Oslo (T.R.P.); University of Iowa, Iowa City (J.G.R.); and Rhode Island Hospital, Department of Neurology, Alpert Medical School of Brown University, Providence (B.R.O.)
| | - Scott M Wasserman
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Boston (R.P.G., K.I., E.K., M.S.S.); Hôpital Cantonal, Hopitaux Universitaires de Genève, Geneva (F.M.); Cambridge Cognition, Cambridge (K.Z.), and International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.) - both in the United Kingdom; Amgen, Thousand Oaks, CA (C.K., J.S., H.W., N.H., S.M.W.); Sydney Medical School, NHMRC Clinical Trials Centre, University of Sydney, Sydney (A.K.); Oslo University Hospital, Ullevål, and Medical Faculty, University of Oslo - both in Oslo (T.R.P.); University of Iowa, Iowa City (J.G.R.); and Rhode Island Hospital, Department of Neurology, Alpert Medical School of Brown University, Providence (B.R.O.)
| | - Brian R Ott
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Boston (R.P.G., K.I., E.K., M.S.S.); Hôpital Cantonal, Hopitaux Universitaires de Genève, Geneva (F.M.); Cambridge Cognition, Cambridge (K.Z.), and International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.) - both in the United Kingdom; Amgen, Thousand Oaks, CA (C.K., J.S., H.W., N.H., S.M.W.); Sydney Medical School, NHMRC Clinical Trials Centre, University of Sydney, Sydney (A.K.); Oslo University Hospital, Ullevål, and Medical Faculty, University of Oslo - both in Oslo (T.R.P.); University of Iowa, Iowa City (J.G.R.); and Rhode Island Hospital, Department of Neurology, Alpert Medical School of Brown University, Providence (B.R.O.)
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Sabatine MS, Giugliano RP, Keech AC, Honarpour N, Wiviott SD, Murphy SA, Kuder JF, Wang H, Liu T, Wasserman SM, Sever PS, Pedersen TR. Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease. N Engl J Med 2017; 376:1713-1722. [PMID: 28304224 DOI: 10.1056/nejmoa1615664] [Citation(s) in RCA: 3433] [Impact Index Per Article: 490.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Evolocumab is a monoclonal antibody that inhibits proprotein convertase subtilisin-kexin type 9 (PCSK9) and lowers low-density lipoprotein (LDL) cholesterol levels by approximately 60%. Whether it prevents cardiovascular events is uncertain. METHODS We conducted a randomized, double-blind, placebo-controlled trial involving 27,564 patients with atherosclerotic cardiovascular disease and LDL cholesterol levels of 70 mg per deciliter (1.8 mmol per liter) or higher who were receiving statin therapy. Patients were randomly assigned to receive evolocumab (either 140 mg every 2 weeks or 420 mg monthly) or matching placebo as subcutaneous injections. The primary efficacy end point was the composite of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary revascularization. The key secondary efficacy end point was the composite of cardiovascular death, myocardial infarction, or stroke. The median duration of follow-up was 2.2 years. RESULTS At 48 weeks, the least-squares mean percentage reduction in LDL cholesterol levels with evolocumab, as compared with placebo, was 59%, from a median baseline value of 92 mg per deciliter (2.4 mmol per liter) to 30 mg per deciliter (0.78 mmol per liter) (P<0.001). Relative to placebo, evolocumab treatment significantly reduced the risk of the primary end point (1344 patients [9.8%] vs. 1563 patients [11.3%]; hazard ratio, 0.85; 95% confidence interval [CI], 0.79 to 0.92; P<0.001) and the key secondary end point (816 [5.9%] vs. 1013 [7.4%]; hazard ratio, 0.80; 95% CI, 0.73 to 0.88; P<0.001). The results were consistent across key subgroups, including the subgroup of patients in the lowest quartile for baseline LDL cholesterol levels (median, 74 mg per deciliter [1.9 mmol per liter]). There was no significant difference between the study groups with regard to adverse events (including new-onset diabetes and neurocognitive events), with the exception of injection-site reactions, which were more common with evolocumab (2.1% vs. 1.6%). CONCLUSIONS In our trial, inhibition of PCSK9 with evolocumab on a background of statin therapy lowered LDL cholesterol levels to a median of 30 mg per deciliter (0.78 mmol per liter) and reduced the risk of cardiovascular events. These findings show that patients with atherosclerotic cardiovascular disease benefit from lowering of LDL cholesterol levels below current targets. (Funded by Amgen; FOURIER ClinicalTrials.gov number, NCT01764633 .).
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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 Harvard Medical School, Boston (M.S.S., R.P.G., S.D.W., S.A.M., J.F.K.); Sydney Medical School, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney (A.C.K.); Amgen, Thousand Oaks, CA (N.H., H.W., T.L., S.M.W.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.); and Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Oslo (T.R.P.)
| | - Robert P Giugliano
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.S.S., R.P.G., S.D.W., S.A.M., J.F.K.); Sydney Medical School, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney (A.C.K.); Amgen, Thousand Oaks, CA (N.H., H.W., T.L., S.M.W.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.); and Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Oslo (T.R.P.)
| | - Anthony C Keech
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.S.S., R.P.G., S.D.W., S.A.M., J.F.K.); Sydney Medical School, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney (A.C.K.); Amgen, Thousand Oaks, CA (N.H., H.W., T.L., S.M.W.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.); and Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Oslo (T.R.P.)
| | - Narimon Honarpour
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.S.S., R.P.G., S.D.W., S.A.M., J.F.K.); Sydney Medical School, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney (A.C.K.); Amgen, Thousand Oaks, CA (N.H., H.W., T.L., S.M.W.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.); and Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Oslo (T.R.P.)
| | - Stephen D Wiviott
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.S.S., R.P.G., S.D.W., S.A.M., J.F.K.); Sydney Medical School, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney (A.C.K.); Amgen, Thousand Oaks, CA (N.H., H.W., T.L., S.M.W.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.); and Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Oslo (T.R.P.)
| | - Sabina A Murphy
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.S.S., R.P.G., S.D.W., S.A.M., J.F.K.); Sydney Medical School, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney (A.C.K.); Amgen, Thousand Oaks, CA (N.H., H.W., T.L., S.M.W.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.); and Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Oslo (T.R.P.)
| | - Julia F Kuder
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.S.S., R.P.G., S.D.W., S.A.M., J.F.K.); Sydney Medical School, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney (A.C.K.); Amgen, Thousand Oaks, CA (N.H., H.W., T.L., S.M.W.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.); and Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Oslo (T.R.P.)
| | - Huei Wang
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.S.S., R.P.G., S.D.W., S.A.M., J.F.K.); Sydney Medical School, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney (A.C.K.); Amgen, Thousand Oaks, CA (N.H., H.W., T.L., S.M.W.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.); and Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Oslo (T.R.P.)
| | - Thomas Liu
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.S.S., R.P.G., S.D.W., S.A.M., J.F.K.); Sydney Medical School, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney (A.C.K.); Amgen, Thousand Oaks, CA (N.H., H.W., T.L., S.M.W.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.); and Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Oslo (T.R.P.)
| | - Scott M Wasserman
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.S.S., R.P.G., S.D.W., S.A.M., J.F.K.); Sydney Medical School, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney (A.C.K.); Amgen, Thousand Oaks, CA (N.H., H.W., T.L., S.M.W.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.); and Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Oslo (T.R.P.)
| | - Peter S Sever
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.S.S., R.P.G., S.D.W., S.A.M., J.F.K.); Sydney Medical School, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney (A.C.K.); Amgen, Thousand Oaks, CA (N.H., H.W., T.L., S.M.W.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.); and Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Oslo (T.R.P.)
| | - Terje R Pedersen
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.S.S., R.P.G., S.D.W., S.A.M., J.F.K.); Sydney Medical School, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney (A.C.K.); Amgen, Thousand Oaks, CA (N.H., H.W., T.L., S.M.W.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London (P.S.S.); and Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Oslo (T.R.P.)
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Raal FJ, Hovingh GK, Blom D, Santos RD, Harada-Shiba M, Bruckert E, Couture P, Soran H, Watts GF, Kurtz C, Honarpour N, Tang L, Kasichayanula S, Wasserman SM, Stein EA. Long-term treatment with evolocumab added to conventional drug therapy, with or without apheresis, in patients with homozygous familial hypercholesterolaemia: an interim subset analysis of the open-label TAUSSIG study. Lancet Diabetes Endocrinol 2017; 5:280-290. [PMID: 28215937 DOI: 10.1016/s2213-8587(17)30044-x] [Citation(s) in RCA: 163] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 12/02/2016] [Accepted: 12/05/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Homozygous familial hypercholesterolaemia is a genetic disorder characterised by substantially raised LDL cholesterol, reduced LDL receptor function, xanthomas, and cardiovascular disease before age 20 years. Conventional therapy is with statins, ezetimibe, and apheresis. We aimed to assess the long-term safety and efficacy of the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor evolocumab in a subset of patients with homozygous familial hypercholesterolaemia enrolled in an open-label, non-randomised phase 3 trial. METHODS In this interim subset analysis of the TAUSSIG study, which was undertaken at 35 sites in 17 countries, we included patients aged 12 years or older with homozygous familial hypercholesterolaemia who were on stable LDL cholesterol-lowering therapy for at least 4 weeks; all patients received evolocumab 420 mg subcutaneously monthly, or if on apheresis every 2 weeks. Dosing could be increased to every 2 weeks after 12 weeks in patients not on apheresis. The primary outcome of the TAUSSIG study was treatment-emergent adverse events; secondary outcomes were the effects of evolocumab on LDL cholesterol and other lipids. We analysed patients on an intention-to-treat basis, and all statistical comparisons were done post hoc in this interim analysis. The TAUSSIG study is registered with ClinicalTrials.gov, number NCT01624142, and is ongoing. FINDINGS 106 patients were included in this analysis, 34 receiving apheresis at study entry and 14 younger than 18 years. The first patient was enrolled on June 28, 2012, and the cutoff date for the analysis was Aug 13, 2015; mean follow-up was 1·7 years (SD 0·63). After 12 weeks, mean LDL cholesterol decreased from baseline by 20·6% (SD 24·4; mean absolute decrease 1·50 mmol/L [SD 1·92]); these reductions were maintained at week 48. 47 of 72 patients not on apheresis at study entry increased evolocumab dosing to every 2 weeks, with an additional mean reduction in LDL cholesterol of 8·3% (SD 13·0; mean absolute decrease 0·77 mmol/L [SD 1·38]; p=0·0001). In a post-hoc analysis, mean reductions in LDL cholesterol in patients on apheresis were significant at week 12 (p=0·0012) and week 48 (p=0·0032), and did not differ from reductions achieved in patients not on apheresis (p=0·38 at week 12 and p=0·09 at week 48). We noted a small reduction (median -7·7% [IQR -21·6 to 6·8]) in lipoprotein(a) at week 12 (p=0·0015), with some additional reduction at week 48 (-11·9% [-28·0 to 0·0]; p<0·0001). HDL cholesterol was increased by a mean of 7·6% (SD 18·1) at week 12 (p<0·0001) and 7·6% (SD 20·6) at week 48 (p=0·0007). Evolocumab was well tolerated; 82 (77%) patients reported treatment-emergent adverse events, which were mostly minor. The most common were nasopharyngitis (14 patients [13%]), influenza (13 [12%]), headache (11 [10%]), and upper respiratory tract infection (11 [10%]). Serious adverse events occurred in 18 (17%) patients, with the most common being cardiovascular events (four patients [4%]). There were no deaths and four positively adjudicated cardiovascular events, one (3%) among patients on apheresis and three (4%) among patients who did not receive apheresis. INTERPRETATION Our interim results suggest that evolocumab is an effective additional option to reduce LDL cholesterol in patients with homozygous familial hypercholesterolaemia, with or without apheresis. FUNDING Amgen.
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Affiliation(s)
- Frederick J Raal
- Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - G Kees Hovingh
- Department of Vascular Medicine, Academisch Medisch Centrum, Amsterdam, Netherlands
| | - Dirk Blom
- Division of Lipidology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Raul D Santos
- Lipid Clinic Heart Institute (InCor), University of Sao Paulo Medical School Hospital and Preventive Medicine Center and Cardiology Program, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Mariko Harada-Shiba
- Department of Molecular Innovation in Lipidology, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Eric Bruckert
- Hôspital Pitié Salpêtrière, Assistance-Publique Hôpitaux de Paris, Paris, France
| | - Patrick Couture
- Centre Hospitalier Universitaire de Québec, Quebec City, QC, Canada
| | - Handrean Soran
- Cardiovascular Trials Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Gerald F Watts
- Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
| | | | | | | | | | | | - Evan A Stein
- Metabolic and Atherosclerosis Research Center, Cincinnati, OH, USA.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Blom DJ, Koren MJ, Roth E, Monsalvo ML, Djedjos CS, Nelson P, Elliott M, Wasserman SM, Ballantyne CM, Holman RR. Evaluation of the efficacy, safety and glycaemic effects of evolocumab (AMG 145) in hypercholesterolaemic patients stratified by glycaemic status and metabolic syndrome. Diabetes Obes Metab 2017; 19:98-107. [PMID: 27619750 DOI: 10.1111/dom.12788] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 09/07/2016] [Accepted: 09/09/2016] [Indexed: 01/24/2023]
Abstract
AIM To examine the lipid and glycaemic effects of 52 weeks of treatment with evolocumab. MATERIALS AND METHODS The Durable Effect of PCSK9 Antibody Compared with Placebo Study (DESCARTES) was a 52-week placebo-controlled trial of evolocumab that randomized 905 patients from 88 study centres in 9 countries, with 901 receiving at least one dose of study drug. For this post-hoc analysis, DESCARTES patients were categorized by baseline glycaemic status: type 2 diabetes, impaired fasting glucose (IFG), metabolic syndrome (MetS) or none of these. Monthly subcutaneous evolocumab (420 mg) or placebo was administered. The main outcomes measured were percentage change in LDL-cholesterol (LDL-C) at week 52 and safety. RESULTS A total of 413 patients had dysglycaemia (120, type 2 diabetes; 293, IFG), 289 had MetS (194 also had IFG) and 393 had none of these conditions. At week 52, evolocumab reduced LDL-C by >50% in all subgroups, with favourable effects on other lipids. No significant differences in fasting plasma glucose, HbA1c, insulin, C-peptide or HOMA indices were seen in any subgroup between evolocumab and placebo at week 52. The overall incidence of new-onset diabetes mellitus did not differ between placebo (6.6%) and evolocumab (5.6%); in those with baseline normoglycaemia, the incidences were 1.9% and 2.7%, respectively. Incidences of AEs were similar in evolocumab- and placebo-treated patients. CONCLUSIONS Evolocumab showed encouraging safety and efficacy at 52 weeks in patients with or without dysglycaemia or MetS. Changes in glycaemic parameters did not differ between evolocumab- and placebo-treated patients within the glycaemic subgroups examined.
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Affiliation(s)
- Dirk J Blom
- Division of Lipidology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Michael J Koren
- Jacksonville Center for Clinical Research, Jacksonville, Florida
| | - Eli Roth
- Sterling Research Group, Cincinnati, Ohio
| | | | | | | | | | | | - Christie M Ballantyne
- Baylor College of Medicine, Houston, Texas
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Rury R Holman
- Diabetes Trials Unit, OCDEM, University of Oxford, Oxford, UK
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28
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Nicholls SJ, Puri R, Anderson T, Ballantyne CM, Cho L, Kastelein JJP, Koenig W, Somaratne R, Kassahun H, Yang J, Wasserman SM, Scott R, Ungi I, Podolec J, Ophuis AO, Cornel JH, Borgman M, Brennan DM, Nissen SE. Effect of Evolocumab on Progression of Coronary Disease in Statin-Treated Patients: The GLAGOV Randomized Clinical Trial. JAMA 2016; 316:2373-2384. [PMID: 27846344 DOI: 10.1001/jama.2016.16951] [Citation(s) in RCA: 700] [Impact Index Per Article: 87.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Reducing levels of low-density lipoprotein cholesterol (LDL-C) with intensive statin therapy reduces progression of coronary atherosclerosis in proportion to achieved LDL-C levels. Proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors produce incremental LDL-C lowering in statin-treated patients; however, the effects of these drugs on coronary atherosclerosis have not been evaluated. OBJECTIVE To determine the effects of PCSK9 inhibition with evolocumab on progression of coronary atherosclerosis in statin-treated patients. DESIGN, SETTING, AND PARTICIPANTS The GLAGOV multicenter, double-blind, placebo-controlled, randomized clinical trial (enrollment May 3, 2013, to January 12, 2015) conducted at 197 academic and community hospitals in North America, Europe, South America, Asia, Australia, and South Africa and enrolling 968 patients presenting for coronary angiography. INTERVENTIONS Participants with angiographic coronary disease were randomized to receive monthly evolocumab (420 mg) (n = 484) or placebo (n = 484) via subcutaneous injection for 76 weeks, in addition to statins. MAIN OUTCOMES AND MEASURES The primary efficacy measure was the nominal change in percent atheroma volume (PAV) from baseline to week 78, measured by serial intravascular ultrasonography (IVUS) imaging. Secondary efficacy measures were nominal change in normalized total atheroma volume (TAV) and percentage of patients demonstrating plaque regression. Safety and tolerability were also evaluated. RESULTS Among the 968 treated patients (mean age, 59.8 years [SD, 9.2]; 269 [27.8%] women; mean LDL-C level, 92.5 mg/dL [SD, 27.2]), 846 had evaluable imaging at follow-up. Compared with placebo, the evolocumab group achieved lower mean, time-weighted LDL-C levels (93.0 vs 36.6 mg/dL; difference, -56.5 mg/dL [95% CI, -59.7 to -53.4]; P < .001). The primary efficacy parameter, PAV, increased 0.05% with placebo and decreased 0.95% with evolocumab (difference, -1.0% [95% CI, -1.8% to -0.64%]; P < .001). The secondary efficacy parameter, normalized TAV, decreased 0.9 mm3 with placebo and 5.8 mm3 with evolocumab (difference, -4.9 mm3 [95% CI, -7.3 to -2.5]; P < .001). Evolocumab induced plaque regression in a greater percentage of patients than placebo (64.3% vs 47.3%; difference, 17.0% [95% CI, 10.4% to 23.6%]; P < .001 for PAV and 61.5% vs 48.9%; difference, 12.5% [95% CI, 5.9% to 19.2%]; P < .001 for TAV). CONCLUSIONS AND RELEVANCE Among patients with angiographic coronary disease treated with statins, addition of evolocumab, compared with placebo, resulted in a greater decrease in PAV after 76 weeks of treatment. Further studies are needed to assess the effects of PCSK9 inhibition on clinical outcomes. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01813422.
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Affiliation(s)
- Stephen J Nicholls
- South Australian Health and Medical Research Institute, University of Adelaide, Adelaide, Australia2Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
| | - Rishi Puri
- Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
| | - Todd Anderson
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Christie M Ballantyne
- The Methodist DeBakey Heart and Vascular Center, Section of Cardiovascular Research, Baylor College of Medicine, Houston, Texas
| | - Leslie Cho
- Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
| | - John J P Kastelein
- Academic Medical Center, Department of Vascular Medicine, University of Amsterdam, Amsterdam, the Netherlands
| | - Wolfgang Koenig
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany7DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany8Department of Internal Medicine, University of Ulm Medical Center, Ulm, Germany
| | | | | | | | | | | | - Imre Ungi
- Department of Cardiology, University of Szeged, Hungary
| | - Jakub Podolec
- Department of Interventional Cardiology, Cardiology Institute, Jagiellonian University, College of Medicine and the John Paul II Hospital, Krakow, Poland
| | - Antonius Oude Ophuis
- Department of Cardiology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Jan H Cornel
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands
| | - Marilyn Borgman
- Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
| | - Danielle M Brennan
- Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
| | - Steven E Nissen
- Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
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29
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Gibbs JP, Doshi S, Kuchimanchi M, Grover A, Emery MG, Dodds MG, Gibbs MA, Somaratne R, Wasserman SM, Blom D. Impact of Target-Mediated Elimination on the Dose and Regimen of Evolocumab, a Human Monoclonal Antibody Against Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9). J Clin Pharmacol 2016; 57:616-626. [PMID: 27861991 PMCID: PMC5412926 DOI: 10.1002/jcph.840] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 10/11/2016] [Indexed: 01/14/2023]
Abstract
Understanding the pharmacokinetic (PK) and pharmacodynamic (PD) relationship of a therapeutic monoclonal antibody against proprotein convertase subtilisin/kexin type 9 (PCSK9) exhibiting target-mediated drug disposition (TMDD) is critical for selecting optimal dosing regimens. We describe the PK/PD relationship of evolocumab using a mathematical model that captures evolocumab binding and removal of unbound PCSK9 as well as reduction in circulating low-density lipoprotein cholesterol (LDL-C). Data were pooled from 2 clinical studies: a single-dose escalation study in healthy subjects (7-420 mg SC; n = 44) and a multiple-dose escalation study in statin-treated hypercholesterolemic patients (14 mg weekly to 420 mg monthly [QM] SC; n = 57). A TMDD model described the time course of unbound evolocumab concentrations and removal of unbound PCSK9. The estimated linear clearance and volume of evolocumab were 0.256 L/day and 2.66 L, respectively, consistent with other monoclonal antibodies. The time course of LDL-C reduction was described by an indirect response model with the elimination rate of LDL-C being modulated by unbound PCSK9. The concentration of unbound PCSK9 associated with half-maximal inhibition (IC50 ) of LDL-C elimination was 1.46 nM. Based on simulations, 140 mg every 2 weeks (Q2W) and 420 mg QM were predicted to achieve a similar time-averaged effect of 69% reduction in LDL-C in patients on statin therapy, suggesting that an approximate 3-fold dose increase is required for a 2-fold extension in the dosing interval. Evolocumab dosing regimens of 140 mg Q2W or 420 mg QM were predicted to result in comparable reductions in LDL-C over a monthly period, consistent with results from recently completed phase 3 studies.
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Affiliation(s)
- John P Gibbs
- Amgen Inc, Thousand Oaks, CA, USA.,Current affiliation: AbbVie, North Chicago, IL, USA
| | | | | | - Anita Grover
- Amgen Inc, Thousand Oaks, CA, USA.,Current affiliation: BioMarin Pharmaceuticals, Novato, CA, USA
| | | | - Michael G Dodds
- Amgen Inc, Thousand Oaks, CA, USA.,Current affiliation: Quantitative Solutions, a Certara Company, Seattle, WA, USA
| | - Megan A Gibbs
- Amgen Inc, Thousand Oaks, CA, USA.,Current affiliation: BioMarin Pharmaceuticals, Novato, CA, USA
| | | | | | - Dirk Blom
- Division of Lipidology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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30
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Gibbs JP, Slatter JG, Egbuna O, Geller M, Hamilton L, Dias CS, Xu RY, Johnson J, Wasserman SM, Emery MG. Evaluation of Evolocumab (AMG 145), a Fully Human Anti-PCSK9 IgG2 Monoclonal Antibody, in Subjects With Hepatic Impairment. J Clin Pharmacol 2016; 57:513-523. [PMID: 27667740 PMCID: PMC5363371 DOI: 10.1002/jcph.832] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 09/22/2016] [Indexed: 11/11/2022]
Abstract
Evolocumab binds PCSK9, increasing low-density lipoprotein cholesterol (LDL-C) receptors and lowering LDL-C. Target-mediated evolocumab elimination is attributable to PCSK9 binding. As circulating PCSK9 and LDL-C levels are primarily regulated by the liver, we compared evolocumab pharmacokinetics, pharmacodynamics, and safety in individuals with and without hepatic impairment. An open-label, parallel-group study evaluated the pharmacokinetics of evolocumab in hepatic-impaired (Child-Pugh Class A or B) or healthy adults. Participants were classified as having no, mild, or moderate hepatic impairment (n = 8/group) and received a single 140-mg evolocumab dose. Assessments of unbound evolocumab and PCSK9 were made predose and postdose. Adverse events were monitored throughout the study. No significant association was observed between baseline PCSK9 and increasing level of hepatic impairment. No difference in extent and time course of PCSK9 or LDL-C reduction was observed despite an apparent decrease in mean unbound evolocumab exposure with increasing hepatic impairment (Jonckheere-Terpstra trend test; maximum serum concentration P = .18; area under the curve P = .09). Maximum reductions were observed in moderately impaired subjects vs healthy individuals: mean maximum serum concentration -34%; mean area under the concentration-time curve (AUC) -47%. On average, unbound PCSK9 serum concentrations fell by >80% at 4 hours after a single evolocumab dose. Mean (95% confidence interval) maximum LDL-C reductions in the healthy, mild, and moderate groups were -57% (-64% to -48%), -70% (-75% to -63%), and -53% (-61% to -43%), respectively. No safety risks were identified. These results support evolocumab use without dose adjustment in patients with active liver disease and mild or moderate hepatic impairment.
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Affiliation(s)
- John P Gibbs
- Medical Sciences, Amgen, Inc., Thousand Oaks, CA, USA.,AbbVie, North Chicago, IL, USA
| | - J Greg Slatter
- Medical Sciences, Amgen, Inc., Thousand Oaks, CA, USA.,Acerta Pharma, Bellevue, WA, USA
| | - Ogo Egbuna
- Medical Sciences, Amgen, Inc., Thousand Oaks, CA, USA
| | | | - Lisa Hamilton
- Biostatistics-Internationals, Amgen, Inc., Uxbridge, UK
| | - Clapton S Dias
- Medical Sciences, Amgen, Inc., Thousand Oaks, CA, USA.,BioMarin Pharmaceutical Inc., San Rafael, CA, USA
| | - Ren Y Xu
- Medical Sciences, Amgen, Inc., Thousand Oaks, CA, USA.,Gilead Science Inc., Foster City, CA, USA
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31
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Peach M, Xu R, Fitzpatrick D, Hamilton L, Somaratne R, Scott R, Wasserman SM, Djedjos CS. Effect of evolocumab on cholesterol synthesis and absorption. J Lipid Res 2016; 57:2217-2224. [PMID: 27707817 DOI: 10.1194/jlr.p071704] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 09/28/2016] [Indexed: 11/20/2022] Open
Abstract
The effects of cholesterol-lowering drugs, including those that reduce cholesterol synthesis (statins) and those that reduce cholesterol absorption (ezetimibe), on cholesterol absorption and synthesis are well understood. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are a novel class of cholesterol-lowering drugs that robustly reduce LDL-cholesterol (LDL-C), but little is known about their effects on cholesterol absorption and synthesis. We evaluated how treatment with evolocumab, a fully human monoclonal IgG2 antibody to PCSK9, affects markers of cholesterol synthesis and absorption by measuring these markers in patients from an evolocumab clinical trial. At 2 weeks, changes in β-sitosterol/total cholesterol (TC) from baseline were 4% for placebo, 10% for evolocumab 140 mg (nonsignificant vs. placebo), and 26% for evolocumab 420 mg (P < 0.001 vs. placebo). Changes in campesterol/TC at week 2, relative to baseline between placebo and evolocumab, were all nonsignificant. Evolocumab had a modest effect on markers of cholesterol synthesis. At 2 weeks, changes in desmosterol/TC were 1% for placebo, 7% for evolocumab 140 mg (nonsignificant vs. placebo), and 15% for evolocumab 420 mg (P < 0.01 vs. placebo). Changes from baseline in lathosterol/TC at week 2 between placebo and evolocumab were nonsignificant. These results suggest that evolocumab has a modest effect on cholesterol synthesis and absorption despite significant LDL-C lowering.
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Affiliation(s)
| | - Ren Xu
- Amgen Inc., Thousand Oaks, CA
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32
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Teerlink JR, Felker GM, McMurray JJV, Ponikowski P, Metra M, Filippatos GS, Ezekowitz JA, Dickstein K, Cleland JGF, Kim JB, Lei L, Knusel B, Wolff AA, Malik FI, Wasserman SM. Acute Treatment With Omecamtiv Mecarbil to Increase Contractility in Acute Heart Failure: The ATOMIC-AHF Study. J Am Coll Cardiol 2016; 67:1444-1455. [PMID: 27012405 DOI: 10.1016/j.jacc.2016.01.031] [Citation(s) in RCA: 163] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/04/2016] [Accepted: 01/05/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Omecamtiv mecarbil (OM) is a selective cardiac myosin activator that increases myocardial function in healthy volunteers and in patients with chronic heart failure. OBJECTIVES This study evaluated the pharmacokinetics, pharmacodynamics, tolerability, safety, and efficacy of OM in patients with acute heart failure (AHF). METHODS Patients admitted for AHF with left ventricular ejection fraction ≤40%, dyspnea, and elevated plasma concentrations of natriuretic peptides were randomized to receive a double-blind, 48-h intravenous infusion of placebo or OM in 3 sequential, escalating-dose cohorts. RESULTS In 606 patients, OM did not improve the primary endpoint of dyspnea relief (3 OM dose groups and pooled placebo: placebo, 41%; OM cohort 1, 42%; cohort 2, 47%; cohort 3, 51%; p = 0.33) or any of the secondary outcomes studied. In supplemental, pre-specified analyses, OM resulted in greater dyspnea relief at 48 h (placebo, 37% vs. OM, 51%; p = 0.034) and through 5 days (p = 0.038) in the high-dose cohort. OM exerted plasma concentration-related increases in left ventricular systolic ejection time (p < 0.0001) and decreases in end-systolic dimension (p < 0.05). The adverse event profile and tolerability of OM were similar to those of placebo, without increases in ventricular or supraventricular tachyarrhythmias. Plasma troponin concentrations were higher in OM-treated patients compared with placebo (median difference at 48 h, 0.004 ng/ml), but with no obvious relationship with OM concentration (p = 0.95). CONCLUSIONS In patients with AHF, intravenous OM did not meet the primary endpoint of dyspnea improvement, but it was generally well tolerated, it increased systolic ejection time, and it may have improved dyspnea in the high-dose group. (Acute Treatment with Omecamtiv Mecarbil to Increase Contractility in Acute Heart Failure [ATOMIC-AHF]; NCT01300013).
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Affiliation(s)
- John R Teerlink
- School of Medicine, University of California San Francisco, San Francisco, California; Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, California.
| | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Piotr Ponikowski
- Department of Heart Diseases, Medical University, Clinical Military Hospital, Wroclaw, Poland
| | - Marco Metra
- Division of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | | | - Kenneth Dickstein
- Cardiology Division, University of Bergen, Bergen, Norway; Cardiology Division, Stavanger University Hospital, Stavanger, Norway
| | - John G F Cleland
- National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, United Kingdom
| | - Jae B Kim
- Amgen, Inc., Thousand Oaks, California
| | - Lei Lei
- Amgen, Inc., Thousand Oaks, California
| | | | | | - Fady I Malik
- Cytokinetics, Inc., South San Francisco, California
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Puri R, Nissen SE, Somaratne R, Cho L, Kastelein JJ, Ballantyne CM, Koenig W, Anderson TJ, Yang J, Kassahun H, Wasserman SM, Scott R, Borgman M, Nicholls SJ. Impact of PCSK9 inhibition on coronary atheroma progression: Rationale and design of Global Assessment of Plaque Regression with a PCSK9 Antibody as Measured by Intravascular Ultrasound (GLAGOV). Am Heart J 2016; 176:83-92. [PMID: 27264224 DOI: 10.1016/j.ahj.2016.01.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 01/29/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Statin-mediated low-density lipoprotein cholesterol (LDL-C) lowering fails to prevent more than half of cardiovascular events in clinical trials. Serial plaque imaging studies have highlighted the benefits of aggressive LDL-C lowering, with plaque regression evident in up to two-thirds of patients with achieved LDL-C levels <70 mg/dL. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors permit LDL-C-lowering by a further 54% to 75% in statin-treated patients. The impact of achieving very low LDL-C levels with PCSK9 inhibitors on coronary atherosclerosis has not been investigated. AIMS To test the hypothesis that incremental LDL-C lowering with the PCSK9 inhibitor, evolocumab, will result in a significantly greater change from baseline in coronary atheroma volume than placebo in subjects receiving maximally tolerated statin therapy. METHODS A phase 3, multicenter, double-blind, randomized, placebo-controlled trial evaluating the impact of evolocumab on coronary atheroma volume as assessed by serial coronary intravascular ultrasound at baseline in patients undergoing a clinically indicated coronary angiogram with angiographic evidence of coronary atheroma, and after 78 weeks of treatment. Subjects (n = 968) were randomized 1:1 into 2 groups to receive monthly either evolocumab 420 mg or placebo subcutaneous injections. CONCLUSIONS The GLAGOV trial will explore whether greater degrees of plaque regression are achievable with ultrahigh-intensity LDL-C lowering after combination statin-PCSK9 inhibitor therapy. GLAGOV will provide important mechanistic, safety, and efficacy data prior to the eagerly anticipated clinical outcomes trials testing the PCSK9 inhibitor hypothesis (www.clinicaltrials.gov identifier NCT01813422).
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34
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Sattar N, Preiss D, Robinson JG, Djedjos CS, Elliott M, Somaratne R, Wasserman SM, Raal FJ. Lipid-lowering efficacy of the PCSK9 inhibitor evolocumab (AMG 145) in patients with type 2 diabetes: a meta-analysis of individual patient data. Lancet Diabetes Endocrinol 2016; 4:403-10. [PMID: 26868195 DOI: 10.1016/s2213-8587(16)00003-6] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 12/15/2015] [Accepted: 12/22/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Patients with type 2 diabetes have increased cardiovascular risk. PCSK9 monoclonal antibodies have been shown to reduce LDL cholesterol and other lipids, but specific efficacy for patients with diabetes is unknown. We compared the effect of the PCSK9 inhibitor evolocumab on lipid parameters in patients with and without type 2 diabetes. METHODS We did a random-effects meta-analysis of randomised clinical trials comparing the efficacy of evolocumab, placebo, and ezetimibe to improve lipid parameters in adult patients (age 18-80 years) with or without type 2 diabetes. We searched MEDLINE and Embase to identify eligible 12-week, phase 3 trials published between Jan 1, 2012, and Feb 28, 2015. We excluded trials that included patients who had homozygous familial hypercholesterolaemia. All analyses were based on individual participant data. We used DerSimonian and Laird random-effects meta-analyses to compare the mean changes from baseline in concentrations of LDL cholesterol, non-HDL cholesterol, total cholesterol, triglycerides, lipoprotein(a), and HDL cholesterol at 12 weeks for evolocumab, placebo, and ezetimibe. We also assessed the effect of evolocumab therapy compared with placebo across subgroups of patients based on glycaemia, insulin use, renal function, and cardiovascular disease status at baseline. RESULTS Three trials met our inclusion criteria, and included 413 patients with type 2 diabetes and 2119 patients without type 2 diabetes. In patients with type 2 diabetes evolocumab caused mean reductions in LDL cholesterol concentration that were 60% (95% CI 51-69) versus placebo and 39% (32-47) versus ezetimibe. In patients without type 2 diabetes, evolocumab caused mean reductions in LDL cholesterol that were 66% (62-70) versus placebo and 40% (36-45) versus ezetimibe. In patients with type 2 diabetes, evolocumab was associated with reductions in non-HDL cholesterol (55% [47-63] vs placebo and 34% [26-41] vs ezetimibe), total cholesterol (38% [32-44] vs placebo and 24% [16-31] vs ezetimibe), and lipoprotein(a) (31% [25-37] vs placebo and 26% [16-35] vs ezetimibe), and an increase in HDL cholesterol (7% [4-11] vs placebo and 8% [4-13] vs ezetimibe). Findings were similar across diabetes subgroups based on glycaemia, insulin use, renal function, and cardiovascular disease status. INTERPRETATION Evolocumab markedly reduces atherogenic lipoproteins in patients with type 2 diabetes, an effect that is consistent across subgroups and similar to that seen in patients without type 2 diabetes. Results from ongoing cardiovascular outcome trials of PCSK9 inhibitors will provide additional data to inform the use of these drugs in patients with type 2 diabetes. FUNDING Amgen.
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Affiliation(s)
- Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
| | - David Preiss
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jennifer G Robinson
- Departments of Epidemiology and Medicine, College of Public Health, University of Iowa, Iowa City, IA, USA
| | | | | | | | | | - Frederick J Raal
- Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Raal FJ, Giugliano RP, Sabatine MS, Koren MJ, Blom D, Seidah NG, Honarpour N, Lira A, Xue A, Chiruvolu P, Jackson S, Di M, Peach M, Somaratne R, Wasserman SM, Scott R, Stein EA. PCSK9 inhibition-mediated reduction in Lp(a) with evolocumab: an analysis of 10 clinical trials and the LDL receptor's role. J Lipid Res 2016; 57:1086-96. [PMID: 27102113 DOI: 10.1194/jlr.p065334] [Citation(s) in RCA: 157] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Indexed: 12/12/2022] Open
Abstract
Lipoprotein (a) [Lp(a)] is independently associated with CVD risk. Evolocumab, a monoclonal antibody (mAb) to proprotein convertase subtilisin/kexin type 9 (PCSK9), decreases Lp(a). The potential mechanisms were assessed. A pooled analysis of Lp(a) and LDL cholesterol (LDL-C) in 3,278 patients from 10 clinical trials (eight phase 2/3; two extensions) was conducted. Within each parent study, biweekly and monthly doses of evolocumab statistically significantly reduced Lp(a) at week 12 versus control (P < 0.001 within each study); pooled median (quartile 1, quartile 3) percent reductions were 24.7% (40.0, 3.6) and 21.7% (39.9, 4.2), respectively. Reductions were maintained through week 52 of the open-label extension, and correlated with LDL-C reductions [with and without correction for Lp(a)-cholesterol] at both time points (P < 0.0001). The effect of LDL and LDL receptor (LDLR) availability on Lp(a) cell-association was measured in HepG2 cells: cell-associated LDL fluorescence was reversed by unlabeled LDL and Lp(a). Lp(a) cell-association was reduced by coincubation with LDL and PCSK9 and reversed by adding PCSK9 mAb. These studies support that reductions in Lp(a) with PCSK9 inhibition are partly due to increased LDLR-mediated uptake. In most situations, Lp(a) appears to compete poorly with LDL for LDLR binding and internalization, but when LDLR expression is increased with evolocumab, particularly in the setting of low circulating LDL, Lp(a) is reduced.
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Affiliation(s)
- Frederick J Raal
- Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | | | - Dirk Blom
- Division of Lipidology, University of Cape Town, Cape Town, South Africa
| | | | | | | | | | | | | | - Mei Di
- Amgen Inc., San Francisco, CA
| | | | | | | | | | - Evan A Stein
- Metabolic and Atherosclerosis Research Center, Cincinnati, OH
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Nissen SE, Stroes E, Dent-Acosta RE, Rosenson RS, Lehman SJ, Sattar N, Preiss D, Bruckert E, Ceška R, Lepor N, Ballantyne CM, Gouni-Berthold I, Elliott M, Brennan DM, Wasserman SM, Somaratne R, Scott R, Stein EA. Efficacy and Tolerability of Evolocumab vs Ezetimibe in Patients With Muscle-Related Statin Intolerance: The GAUSS-3 Randomized Clinical Trial. JAMA 2016; 315:1580-90. [PMID: 27039291 DOI: 10.1001/jama.2016.3608] [Citation(s) in RCA: 352] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
IMPORTANCE Muscle-related statin intolerance is reported by 5% to 20% of patients. OBJECTIVE To identify patients with muscle symptoms confirmed by statin rechallenge and compare lipid-lowering efficacy for 2 nonstatin therapies, ezetimibe and evolocumab. DESIGN, SETTING, AND PARTICIPANTS Two-stage randomized clinical trial including 511 adult patients with uncontrolled low-density lipoprotein cholesterol (LDL-C) levels and history of intolerance to 2 or more statins enrolled in 2013 and 2014 globally. Phase A used a 24-week crossover procedure with atorvastatin or placebo to identify patients having symptoms only with atorvastatin but not placebo. In phase B, after a 2-week washout, patients were randomized to ezetimibe or evolocumab for 24 weeks. INTERVENTIONS Phase A: atorvastatin (20 mg) vs placebo. Phase B: randomization 2:1 to subcutaneous evolocumab (420 mg monthly) or oral ezetimibe (10 mg daily). MAIN OUTCOME AND MEASURES Coprimary end points were the mean percent change in LDL-C level from baseline to the mean of weeks 22 and 24 levels and from baseline to week 24 levels. RESULTS Of the 491 patients who entered phase A (mean age, 60.7 [SD, 10.2] years; 246 women [50.1%]; 170 with coronary heart disease [34.6%]; entry mean LDL-C level, 212.3 [SD, 67.9] mg/dL), muscle symptoms occurred in 209 of 491 (42.6%) while taking atorvastatin but not while taking placebo. Of these, 199 entered phase B, along with 19 who proceeded directly to phase B for elevated creatine kinase (N = 218, with 73 randomized to ezetimibe and 145 to evolocumab; entry mean LDL-C level, 219.9 [SD, 72] mg/dL). For the mean of weeks 22 and 24, LDL-C level with ezetimibe was 183.0 mg/dL; mean percent LDL-C change, -16.7% (95% CI, -20.5% to -12.9%), absolute change, -31.0 mg/dL and with evolocumab was 103.6 mg/dL; mean percent change, -54.5% (95% CI, -57.2% to -51.8%); absolute change, -106.8 mg/dL (P < .001). LDL-C level at week 24 with ezetimibe was 181.5 mg/dL; mean percent change, -16.7% (95% CI, -20.8% to -12.5%); absolute change, -31.2 mg/dL and with evolocumab was 104.1 mg/dL; mean percent change, -52.8% (95% CI, -55.8% to -49.8%); absolute change, -102.9 mg/dL (P < .001). For the mean of weeks 22 and 24, between-group difference in LDL-C was -37.8%; absolute difference, -75.8 mg/dL. For week 24, between-group difference in LDL-C was -36.1%; absolute difference, -71.7 mg/dL. Muscle symptoms were reported in 28.8% of ezetimibe-treated patients and 20.7% of evolocumab-treated patients (log-rank P = .17). Active study drug was stopped for muscle symptoms in 5 of 73 ezetimibe-treated patients (6.8%) and 1 of 145 evolocumab-treated patients (0.7%). CONCLUSIONS AND RELEVANCE Among patients with statin intolerance related to muscle-related adverse effects, the use of evolocumab compared with ezetimibe resulted in a significantly greater reduction in LDL-C levels after 24 weeks. Further studies are needed to assess long-term efficacy and safety. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01984424.
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Affiliation(s)
| | - Erik Stroes
- University of Amsterdam Faculty of Medicine, Amsterdam, the Netherlands
| | | | | | - Sam J Lehman
- Flinders University, Bedford Park, SA, Australia
| | | | - David Preiss
- Clinical Trial Service Unit, University of Oxford, Oxford, United Kingdom8Epidemiological Services Unit, University of Oxford, Oxford, United Kingdom
| | | | - Richard Ceška
- Charles University in Prague, Prague, Czech Republic11General University Hospital in Prague, Prague, Czech Republic
| | - Norman Lepor
- David Geffen School of Medicine at the University of California, Los Angeles
| | | | - Ioanna Gouni-Berthold
- Center for Endocrinology, Diabetes and Preventive Medicine, University of Cologne, Cologne, Germany
| | | | | | | | | | - Rob Scott
- Amgen Inc, Thousand Oaks, California
| | - Evan A Stein
- Metabolic and Atherosclerosis Research Center, Cincinnati, Ohio
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Nissen SE, Dent-Acosta RE, Rosenson RS, Stroes E, Sattar N, Preiss D, Mancini GBJ, Ballantyne CM, Catapano A, Gouni-Berthold I, Stein EA, Xue A, Wasserman SM, Scott R, Thompson PD. Comparison of PCSK9 Inhibitor Evolocumab vs Ezetimibe in Statin-Intolerant Patients: Design of the Goal Achievement After Utilizing an Anti-PCSK9 Antibody in Statin-Intolerant Subjects 3 (GAUSS-3) Trial. Clin Cardiol 2016; 39:137-44. [PMID: 26946077 DOI: 10.1002/clc.22518] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 12/30/2015] [Indexed: 11/09/2022] Open
Abstract
Statins are the accepted standard for lowering low-density lipoprotein cholesterol (LDL-C). However, 5% to 10% of statin-treated patients report intolerance, mostly due to muscle-related adverse effects. Challenges exist to objective identification of statin-intolerant patients. Evolocumab is a monoclonal antibody that binds proprotein convertase subtilisin/kexin type 9 (PCSK9), resulting in marked LDL-C reduction. We report the design of Goal Achievement After Utilizing an Anti-PCSK9 Antibody in Statin-Intolerant Subjects 3 (GAUSS-3), a phase 3, multicenter, randomized, double-blind, ezetimibe-controlled study to compare effectiveness of 24 weeks of evolocumab 420 mg monthly vs ezetimibe 10 mg daily in hypercholesterolemic patients unable to tolerate an effective statin dose. The study incorporates a novel atorvastatin-controlled, double-blind, crossover phase to objectively identify statin intolerance. Eligible patients had LDL-C above the National Cholesterol Education Project Adult Treatment Panel III target level for the appropriate coronary heart disease risk category and were unable to tolerate ≥3 statins or 2 statins (one of which was atorvastatin ≤10 mg/d) or had a history of marked creatine kinase elevation accompanied by muscle symptoms while on 1 statin. This trial has 2 co-primary endpoints: mean percent change from baseline in LDL-C at weeks 22 and 24 and percent change from baseline in LDL-C at week 24. Key secondary efficacy endpoints include change from baseline in LDL-C, percent of patients attaining LDL-C <70 mg/dL (1.81 mmol/L), and percent change from baseline in total cholesterol, non-high-density lipoprotein cholesterol, and apolipoprotein B. Recruitment of 511 patients was completed on November 28, 2014.
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Affiliation(s)
- Steven E Nissen
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ricardo E Dent-Acosta
- Department of Clinical Development, and Biostatistics, Amgen Inc., Thousand Oaks, California
| | - Robert S Rosenson
- The Cardiometabolic Disorders Unit, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Erik Stroes
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, Netherlands
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - David Preiss
- Clinical Trial Service Unit and Epidemiological Services Unit, University of Oxford, Oxford, United Kingdom
| | - G B John Mancini
- Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christie M Ballantyne
- Department of Medicine, Baylor College of Medicine and Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Alberico Catapano
- Department of Pharmacological Sciences, University of Milan, and IRCCS Multimedica, Milan, Italy
| | - Ioanna Gouni-Berthold
- Center for Endocrinology, Diabetes and Preventive Medicine, University of Cologne, Cologne, Germany
| | - Evan A Stein
- Metabolic and Atherosclerosis Research Center, Cincinnati, Ohio
| | - Allen Xue
- Department of Clinical Development, and Biostatistics, Amgen Inc., Thousand Oaks, California
| | - Scott M Wasserman
- Department of Clinical Development, and Biostatistics, Amgen Inc., Thousand Oaks, California
| | - Rob Scott
- Department of Clinical Development, and Biostatistics, Amgen Inc., Thousand Oaks, California
| | - Paul D Thompson
- Department of Cardiology, Hartford Hospital, Hartford, Connecticut
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Sabatine MS, Giugliano RP, Keech A, Honarpour N, Wang H, Liu T, Wasserman SM, Scott R, Sever PS, Pedersen TR. Rationale and design of the Further cardiovascular OUtcomes Research with PCSK9 Inhibition in subjects with Elevated Risk trial. Am Heart J 2016; 173:94-101. [PMID: 26920601 DOI: 10.1016/j.ahj.2015.11.015] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 11/25/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Despite current therapies, patients with vascular disease remain at high risk for major adverse cardiovascular events. Low-density lipoprotein cholesterol is a well-established modifiable cardiovascular risk factor. Evolocumab is a fully human monoclonal antibody inhibitor of proprotein convertase subtilisin/kexin type 9 that reduces low-density lipoprotein cholesterol by approximately 60% across various populations. STUDY DESIGN FOURIER is a randomized, placebo-controlled, double-blind, parallel-group, multinational trial testing the hypothesis that adding evolocumab to statin therapy will reduce the incidence of major adverse cardiovascular events in patients with clinically evident vascular disease. The study population consists of 27,564 patients who have had a myocardial infarction (MI), an ischemic stroke, or symptomatic peripheral artery disease and have a low-density lipoprotein ≥70 mg/dL or a non-high-density lipoprotein cholesterol ≥100 mg/dL on an optimized statin regimen. Patients were randomized in a 1:1 ratio to receive either evolocumab (either 140 mg subcutaneously every 2 weeks or 420 mg subcutaneously every month, according to patient preference) or matching placebo injections. The primary end point is major cardiovascular events defined as the composite of cardiovascular death, MI, stroke, hospitalization for unstable angina, or coronary revascularization. The key secondary end point is the composite of cardiovascular death, MI, or stroke. The trial is planned to continue until at least 1,630 patients experience the secondary end point, thereby providing 90% power to detect a relative reduction of ≥15% in this end point. CONCLUSIONS FOURIER will determine whether the addition of evolocumab to statin therapy reduces cardiovascular morbidity and mortality in patients with vascular disease.
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Kiyosue A, Honarpour N, Kurtz C, Xue A, Wasserman SM, Hirayama A. A Phase 3 Study of Evolocumab (AMG 145) in Statin-Treated Japanese Patients at High Cardiovascular Risk. Am J Cardiol 2016; 117:40-7. [PMID: 26547291 DOI: 10.1016/j.amjcard.2015.10.021] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 10/09/2015] [Accepted: 10/09/2015] [Indexed: 12/14/2022]
Abstract
Evolocumab (AMG 145), a fully human monoclonal antibody against PCSK9, significantly reduced low-density lipoprotein cholesterol (LDL-C) levels in phase 2 and 3 studies. This phase 3 study evaluated the efficacy and safety of evolocumab plus atorvastatin in Japanese patients with hyperlipidemia or mixed dyslipidemia and high cardiovascular risk. Patients were randomized to atorvastatin 5 or 20 mg/day for 4 weeks. Subsequently, patients underwent second randomization to evolocumab 140 mg biweekly (Q2W) or 420 mg monthly (QM) or placebo Q2W or QM. Coprimary end points were % change from baseline in LDL-C at week 12 and mean of weeks 10 and 12. Secondary end points included change and % change in other lipids and proportion of patients reaching LDL-C <70 mg/dl. Adverse events and laboratory values were recorded. Four hundred four patients were randomized to study drug. At baseline, the mean (SD) age was 61 (10) years (placebo) and 62 (11) years (evolocumab); 39% and 40% were women; 14% and 12% had cerebrovascular or peripheral arterial disease; and 51% and 47% had diabetes. At entry, mean (SD) calculated LDL-C was 128 (23) mg/dL; after stabilization on atorvastatin 5 and 20 mg/day, baseline LDL-C levels were 118 (35) and 94 (24) mg/dL, respectively. Mean LDL-C reductions at week 12 for evolocumab versus placebo ranged from 67% to 76%. No imbalances were observed in adverse events between treatment groups. Efficacy and safety for Q2W or QM evolocumab dosing were similar. In conclusion, in high-risk Japanese patients receiving stable statin therapy, evolocumab markedly reduced LDL-C and was well tolerated.
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Blom DJ, Djedjos CS, Monsalvo ML, Bridges I, Wasserman SM, Scott R, Roth E. Effects of Evolocumab on Vitamin E and Steroid Hormone Levels. Circ Res 2015; 117:731-41. [DOI: 10.1161/circresaha.115.307071] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 07/30/2015] [Indexed: 11/16/2022]
Abstract
Rationale
:
Vitamin E transport and steroidogenesis are closely associated with low-density lipoproteins (LDLs) metabolism, and evolocumab can lower LDL cholesterol (LDL-C) to low levels.
Objective:
To determine the effects of evolocumab on vitamin E and steroid hormone levels.
Methods and Results:
After titration of background lipid-lowering therapy per cardiovascular risk, 901 patients with an LDL-C ≥2.0 mmol/L were randomized to 52 weeks of monthly, subcutaneous evolocumab, or placebo. Vitamin E, cortisol, adrenocorticotropic hormone, and gonadal hormones were analyzed at baseline and week 52. In a substudy (n=100), vitamin E levels were also measured in serum, LDL, high-density lipoprotein, and red blood cell membranes at baseline and week 52. Absolute vitamin E decreased in evolocumab-treated patients from baseline to week 52 by 16% but increased by 19% when normalized for cholesterol. In the substudy, vitamin E level changes from baseline to week 52 mirrored the changes in the lipid fraction, and red blood cell membrane vitamin E levels did not change. Cortisol in evolocumab-treated patients increased slightly from baseline to week 52, but adrenocorticotropic hormone and the cortisol:adrenocorticotropic hormone ratio did not change. No patient had a cortisol:adrenocorticotropic hormone ratio <3.0 (nmol/pmol). Among evolocumab-treated patients, gonadal hormones did not change from baseline to week 52. Vitamin E and steroid changes were consistent across subgroups by minimum postbaseline LDL-C <0.4 and <0.6 mmol/L.
Conclusions:
As expected, vitamin E levels changed similarly to lipids among patients treated for 52 weeks with evolocumab. No adverse effects were observed in steroid or gonadal hormones, even at very low LDL-C levels.
Clinical Trial Registration:
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT01516879.
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Affiliation(s)
- Dirk J. Blom
- From the Division of Lipidology, Department of Medicine, University of Cape Town, Cape Town, South Africa (D.J.B.); Cardiovascular Therapeutic Area, Amgen Inc, Thousand Oaks, CA (C.S.D., M.L.M., S.M.W., R.S.); Biostatistics-International, Amgen Ltd, Uxbridge, United Kingdom (I.B.); and President, Sterling Research Group, Cincinnati, OH (E.R.)
| | - C. Stephen Djedjos
- From the Division of Lipidology, Department of Medicine, University of Cape Town, Cape Town, South Africa (D.J.B.); Cardiovascular Therapeutic Area, Amgen Inc, Thousand Oaks, CA (C.S.D., M.L.M., S.M.W., R.S.); Biostatistics-International, Amgen Ltd, Uxbridge, United Kingdom (I.B.); and President, Sterling Research Group, Cincinnati, OH (E.R.)
| | - Maria Laura Monsalvo
- From the Division of Lipidology, Department of Medicine, University of Cape Town, Cape Town, South Africa (D.J.B.); Cardiovascular Therapeutic Area, Amgen Inc, Thousand Oaks, CA (C.S.D., M.L.M., S.M.W., R.S.); Biostatistics-International, Amgen Ltd, Uxbridge, United Kingdom (I.B.); and President, Sterling Research Group, Cincinnati, OH (E.R.)
| | - Ian Bridges
- From the Division of Lipidology, Department of Medicine, University of Cape Town, Cape Town, South Africa (D.J.B.); Cardiovascular Therapeutic Area, Amgen Inc, Thousand Oaks, CA (C.S.D., M.L.M., S.M.W., R.S.); Biostatistics-International, Amgen Ltd, Uxbridge, United Kingdom (I.B.); and President, Sterling Research Group, Cincinnati, OH (E.R.)
| | - Scott M. Wasserman
- From the Division of Lipidology, Department of Medicine, University of Cape Town, Cape Town, South Africa (D.J.B.); Cardiovascular Therapeutic Area, Amgen Inc, Thousand Oaks, CA (C.S.D., M.L.M., S.M.W., R.S.); Biostatistics-International, Amgen Ltd, Uxbridge, United Kingdom (I.B.); and President, Sterling Research Group, Cincinnati, OH (E.R.)
| | - Rob Scott
- From the Division of Lipidology, Department of Medicine, University of Cape Town, Cape Town, South Africa (D.J.B.); Cardiovascular Therapeutic Area, Amgen Inc, Thousand Oaks, CA (C.S.D., M.L.M., S.M.W., R.S.); Biostatistics-International, Amgen Ltd, Uxbridge, United Kingdom (I.B.); and President, Sterling Research Group, Cincinnati, OH (E.R.)
| | - Eli Roth
- From the Division of Lipidology, Department of Medicine, University of Cape Town, Cape Town, South Africa (D.J.B.); Cardiovascular Therapeutic Area, Amgen Inc, Thousand Oaks, CA (C.S.D., M.L.M., S.M.W., R.S.); Biostatistics-International, Amgen Ltd, Uxbridge, United Kingdom (I.B.); and President, Sterling Research Group, Cincinnati, OH (E.R.)
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Fordyce CB, Roe MT, Ahmad T, Libby P, Borer JS, Hiatt WR, Bristow MR, Packer M, Wasserman SM, Braunstein N, Pitt B, DeMets DL, Cooper-Arnold K, Armstrong PW, Berkowitz SD, Scott R, Prats J, Galis ZS, Stockbridge N, Peterson ED, Califf RM. Cardiovascular drug development: is it dead or just hibernating? J Am Coll Cardiol 2015; 65:1567-82. [PMID: 25881939 DOI: 10.1016/j.jacc.2015.03.016] [Citation(s) in RCA: 136] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 03/03/2015] [Accepted: 03/03/2015] [Indexed: 12/19/2022]
Abstract
Despite the global burden of cardiovascular disease, investment in cardiovascular drug development has stagnated over the past 2 decades, with relative underinvestment compared with other therapeutic areas. The reasons for this trend are multifactorial, but of primary concern is the high cost of conducting cardiovascular outcome trials in the current regulatory environment that demands a direct assessment of risks and benefits, using clinically-evident cardiovascular endpoints. To work toward consensus on improving the environment for cardiovascular drug development, stakeholders from academia, industry, regulatory bodies, and government agencies convened for a think tank meeting in July 2014 in Washington, DC. This paper summarizes the proceedings of the meeting and aims to delineate the current adverse trends in cardiovascular drug development, understand the key issues that underlie these trends within the context of a recognized need for a rigorous regulatory review process, and provide potential solutions to the problems identified.
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Affiliation(s)
| | - Matthew T Roe
- Duke Clinical Research Institute, Durham, North Carolina
| | - Tariq Ahmad
- Duke Clinical Research Institute, Durham, North Carolina
| | - Peter Libby
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey S Borer
- State University of New York Downstate Medical Center, Brooklyn, New York
| | | | | | - Milton Packer
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, Michigan
| | - David L DeMets
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Katharine Cooper-Arnold
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | | | - Rob Scott
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jayne Prats
- The Medicines Company, Parsippany, New Jersey
| | - Zorina S Galis
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Norman Stockbridge
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Raal FJ, Stein EA, Dufour R, Turner T, Civeira F, Burgess L, Langslet G, Scott R, Olsson AG, Sullivan D, Hovingh GK, Cariou B, Gouni-Berthold I, Somaratne R, Bridges I, Scott R, Wasserman SM, Gaudet D. PCSK9 inhibition with evolocumab (AMG 145) in heterozygous familial hypercholesterolaemia (RUTHERFORD-2): a randomised, double-blind, placebo-controlled trial. Lancet 2015; 385:331-40. [PMID: 25282519 DOI: 10.1016/s0140-6736(14)61399-4] [Citation(s) in RCA: 503] [Impact Index Per Article: 55.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Heterozygous familial hypercholesterolaemia is characterised by low cellular uptake of LDL cholesterol, increased plasma LDL cholesterol concentrations, and premature cardiovascular disease. Despite intensive statin therapy, with or without ezetimibe, many patients are unable to achieve recommended target levels of LDL cholesterol. We investigated the effect of PCSK9 inhibition with evolocumab (AMG 145) on LDL cholesterol in patients with this disorder. METHODS This multicentre, randomised, double-blind, placebo-controlled trial was undertaken at 39 sites (most of which were specialised lipid clinics, mainly attached to academic institutions) in Australia, Asia, Europe, New Zealand, North America, and South Africa between Feb 7 and Dec 19, 2013. 331 eligible patients (18-80 years of age), who met clinical criteria for heterozygous familial hypercholesterolaemia and were on stable lipid-lowering therapy for at least 4 weeks, with a fasting LDL cholesterol concentration of 2·6 mmol/L or higher, were randomly allocated in a 2:2:1:1 ratio to receive subcutaneous evolocumab 140 mg every 2 weeks, evolocumab 420 mg monthly, or subcutaneous placebo every 2 weeks or monthly for 12 weeks. Randomisation was computer generated by the study sponsor, implemented by a computerised voice interactive system, and stratified by LDL cholesterol concentration at screening (higher or lower than 4·1 mmol/L) and by baseline ezetimibe use (yes/no). Patients, study personnel, investigators, and Amgen study staff were masked to treatment assignments within dosing frequency groups. The coprimary endpoints were percentage change from baseline in LDL cholesterol at week 12 and at the mean of weeks 10 and 12, analysed by intention-to-treat. This trial is registered with ClinicalTrials.gov, number NCT01763918. FINDINGS Of 415 screened patients, 331 were eligible and were randomly assigned to the four treatment groups: evolocumab 140 mg every 2 weeks (n=111), evolocumab 420 mg monthly (n=110), placebo every 2 weeks (n=55), or placebo monthly (n=55). 329 patients received at least one dose of study drug. Compared with placebo, evolocumab at both dosing schedules led to a significant reduction in mean LDL cholesterol at week 12 (every-2-weeks dose: 59·2% reduction [95% CI 53·4-65·1], monthly dose: 61·3% reduction [53·6-69·0]; both p<0·0001) and at the mean of weeks 10 and 12 (60·2% reduction [95% CI 54·5-65·8] and 65·6% reduction [59·8-71·3]; both p<0·0001). Evolocumab was well tolerated, with rates of adverse events similar to placebo. The most common adverse events occurring more frequently in the evolocumab-treated patients than in the placebo groups were nasopharyngitis (in 19 patients [9%] vs five [5%] in the placebo group) and muscle-related adverse events (ten patients [5%] vs 1 [1%]). INTERPRETATION In patients with heterozygous familial hypercholesterolaemia, evolocumab administered either 140 mg every 2 weeks or 420 mg monthly was well tolerated and yielded similar and rapid 60% reductions in LDL cholesterol compared with placebo. FUNDING Amgen Inc.
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Affiliation(s)
- Frederick J Raal
- Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
| | - Evan A Stein
- Metabolic and Atherosclerosis Research Center, Cincinnati, OH, USA
| | - Robert Dufour
- Institut de Recherches Cliniques de Montreal, University of Montreal, Montreal, QC, Canada
| | - Traci Turner
- Metabolic and Atherosclerosis Research Center, Cincinnati, OH, USA
| | | | - Lesley Burgess
- TREAD Research, Department of Internal Medicine, Tygerberg Hospital, Cape Town, South Africa
| | | | - Russell Scott
- Lipid and Diabetes Research Group, University of Otago, Christchurch, New Zealand
| | - Anders G Olsson
- Linkoping University and Stockholm Heart Centre, Stockholm, Sweden
| | - David Sullivan
- Department of Clinical Biochemistry, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - G Kees Hovingh
- Vascular Medicine, Academic Medical Centre, Amsterdam, Netherlands
| | - Bertrand Cariou
- Institut du Thorax, Nantes University Hospital, Nantes, France
| | - Ioanna Gouni-Berthold
- Center for Endocrinology, Diabetes and Preventive Medicine, University of Cologne, Cologne, Germany
| | | | - Ian Bridges
- Amgen Ltd, Cambridge Science Park, Milton, Cambridge, UK
| | | | | | - Daniel Gaudet
- ECOGENE-21, Dyslipidemia, Diabetes and Atherosclerosis Research Group, Department of Medicine, University of Montreal, Montreal, QC, Canada
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Raal FJ, Honarpour N, Blom DJ, Hovingh GK, Xu F, Scott R, Wasserman SM, Stein EA. Inhibition of PCSK9 with evolocumab in homozygous familial hypercholesterolaemia (TESLA Part B): a randomised, double-blind, placebo-controlled trial. Lancet 2015; 385:341-50. [PMID: 25282520 DOI: 10.1016/s0140-6736(14)61374-x] [Citation(s) in RCA: 507] [Impact Index Per Article: 56.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Homozygous familial hypercholesterolaemia is a rare, serious disorder caused by very low or absent plasma clearance of LDL, substantially raised LDL cholesterol, and accelerated development of cardiovascular disease. Conventional lipid-lowering treatments are modestly effective. Evolocumab, a monoclonal antibody to proprotein convertase subtilisin/kexin type 9 (PCSK9), reduced LDL cholesterol by 16% in a pilot study. We now report results with evolocumab in a randomised, double-blind, placebo-controlled phase 3 trial. METHODS This randomised, double-blind, placebo-controlled phase 3 trial was undertaken at 17 sites in ten countries in North America, Europe, the Middle East, and South Africa. 50 eligible patients (aged ≥12 years) with homozygous familial hypercholesterolaemia, on stable lipid-regulating therapy for at least 4 weeks, and not receiving lipoprotein apheresis, were randomly allocated by a computer-generated randomisation sequence in a 2:1 ratio to receive subcutaneous evolocumab 420 mg or placebo every 4 weeks for 12 weeks. Randomisation was stratified by LDL cholesterol at screening (<11 mmol/L or ≥11 mmol/L) and implemented by a computerised interactive voice-response system. Patients, study personnel, and the funder were masked to treatment and to the efficacy results by the central laboratory not returning LDL cholesterol or any lipid results to the clinical sites after the baseline visit. The primary endpoint was percentage change in ultracentrifugation LDL cholesterol from baseline at week 12 compared with placebo, analysed by intention-to-treat. This trial is registered with ClinicalTrials.gov, number NCT01588496. FINDINGS Of the 50 eligible patients randomly assigned to the two treatment groups, 49 actually received the study drug and completed the study (16 in the placebo group and 33 in the evolocumab group). Compared with placebo, evolocumab significantly reduced ultracentrifugation LDL cholesterol at 12 weeks by 30·9% (95% CI -43·9% to -18·0%; p<0·0001). Treatment-emergent adverse events occurred in ten (63%) of 16 patients in the placebo group and 12 (36%) of 33 in the evolocumab group. No serious clinical or laboratory adverse events occurred, and no anti-evolocumab antibody development was detected during the study. INTERPRETATION In patients with homozygous familial hypercholesterolaemia receiving stable background lipid-lowering treatment and not on apheresis, evolocumab 420 mg administered every 4 weeks was well tolerated and significantly reduced LDL cholesterol compared with placebo. FUNDING Amgen Inc.
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Affiliation(s)
- Frederick J Raal
- Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | | | - Dirk J Blom
- Division of Lipidology, Department of Medicine, University of Cape Town, UCT Faculty Health Sciences, Cape Town, South Africa
| | - G Kees Hovingh
- Vascular Medicine, Academic Medical Centre, Amsterdam, Netherlands
| | - Feng Xu
- Amgen Inc, One Amgen Center Drive, Thousand Oaks, CA, USA
| | - Rob Scott
- Amgen Inc, One Amgen Center Drive, Thousand Oaks, CA, USA
| | | | - Evan A Stein
- Metabolic and Atherosclerosis Research Center, Cincinnati, OH, USA.
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Greenberg BH, Chou W, Saikali KG, Escandón R, Lee JH, Chen MM, Treshkur T, Megreladze I, Wasserman SM, Eisenberg P, Malik FI, Wolff AA, Shaburishvili T. Safety and tolerability of omecamtiv mecarbil during exercise in patients with ischemic cardiomyopathy and angina. JACC Heart Fail 2014; 3:22-29. [PMID: 25453536 DOI: 10.1016/j.jchf.2014.07.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 07/22/2014] [Accepted: 07/28/2014] [Indexed: 01/10/2023]
Abstract
OBJECTIVES The goal of this study was to assess the safety and tolerability of omecamtiv mecarbil treatment during symptom-limited exercise in patients with ischemic cardiomyopathy and angina. These patients may have increased vulnerability to prolongation of the systolic ejection time. BACKGROUND Omecamtiv mecarbil is a selective cardiac myosin activator that augments cardiac contractility in patients with systolic heart failure through a dose-dependent increase in systolic ejection time. METHODS In this double-blind, placebo-controlled study, patients with chronic heart failure were randomized 2:1 to receive omecamtiv mecarbil or placebo in 2 sequential cohorts of escalating doses designed to achieve plasma concentrations previously shown to increase systolic function. Patients underwent 2 symptom-limited exercise treadmill tests (ETTs) at baseline (ETT1 and ETT2) and again before the end of a 20-h infusion of omecamtiv mecarbil (ETT3). RESULTS The primary pre-defined safety endpoint (i.e., the proportion of patients who stopped ETT3 because of angina at a stage earlier than baseline) was observed in 1 patient receiving placebo and none receiving omecamtiv mecarbil. No dose-dependent differences emerged in the proportion of patients stopping ETT3 for any reason or in the pattern of adverse events. CONCLUSIONS Doses of omecamtiv mecarbil producing plasma concentrations previously shown to increase systolic function were well tolerated during exercise in these study patients with ischemic cardiomyopathy and angina. There was no indication that treatment increased the likelihood of myocardial ischemia in this high-risk population. (Pharmacokinetics [PK] and Tolerability of Intravenous [IV] and Oral CK-1827452 in Patients With Ischemic Cardiomyopathy and Angina; NCT00682565).
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Affiliation(s)
| | - Willis Chou
- Cytokinetics, Inc., South San Francisco, California
| | | | | | | | | | - Tatyana Treshkur
- Almazov Federal Heart Blood and Endocrinology Centre, St. Petersburg, Russia
| | | | | | | | - Fady I Malik
- Cytokinetics, Inc., South San Francisco, California
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Henry RR, Holman RR, Giugliano RP, Raal FJ, Sullivan D, Honarpour N, Nelson P, Elliott M, LIU T, Wasserman SM, Koren MJ. Effects of Long-Term, Monthly Administration of the PCSK9 Inhibitor Evolocumab in Patients with Dysglycemia or Metabolic Syndrome. Can J Diabetes 2014. [DOI: 10.1016/j.jcjd.2014.07.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ason B, van der Hoorn JWA, Chan J, Lee E, Pieterman EJ, Nguyen KK, Di M, Shetterly S, Tang J, Yeh WC, Schwarz M, Jukema JW, Scott R, Wasserman SM, Princen HMG, Jackson S. PCSK9 inhibition fails to alter hepatic LDLR, circulating cholesterol, and atherosclerosis in the absence of ApoE. J Lipid Res 2014; 55:2370-9. [PMID: 25258384 DOI: 10.1194/jlr.m053207] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
LDL cholesterol (LDL-C) contributes to coronary heart disease. Proprotein convertase subtilisin/kexin type 9 (PCSK9) increases LDL-C by inhibiting LDL-C clearance. The therapeutic potential for PCSK9 inhibitors is highlighted by the fact that PCSK9 loss-of-function carriers exhibit 15-30% lower circulating LDL-C and a disproportionately lower risk (47-88%) of experiencing a cardiovascular event. Here, we utilized pcsk9(-/-) mice and an anti-PCSK9 antibody to study the role of the LDL receptor (LDLR) and ApoE in PCSK9-mediated regulation of plasma cholesterol and atherosclerotic lesion development. We found that circulating cholesterol and atherosclerotic lesions were minimally modified in pcsk9(-/-) mice on either an LDLR- or ApoE-deficient background. Acute administration of an anti-PCSK9 antibody did not reduce circulating cholesterol in an ApoE-deficient background, but did reduce circulating cholesterol (-45%) and TGs (-36%) in APOE*3Leiden.cholesteryl ester transfer protein (CETP) mice, which contain mouse ApoE, human mutant APOE3*Leiden, and a functional LDLR. Chronic anti-PCSK9 antibody treatment in APOE*3Leiden.CETP mice resulted in a significant reduction in atherosclerotic lesion area (-91%) and reduced lesion complexity. Taken together, these results indicate that both LDLR and ApoE are required for PCSK9 inhibitor-mediated reductions in atherosclerosis, as both are needed to increase hepatic LDLR expression.
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Affiliation(s)
- Brandon Ason
- Metabolic Disorders Amgen, Inc., South San Francisco, CA
| | | | - Joyce Chan
- Metabolic Disorders Amgen, Inc., South San Francisco, CA
| | - Edward Lee
- Metabolic Disorders Amgen, Inc., South San Francisco, CA
| | - Elsbet J Pieterman
- TNO-Metabolic Health Research, Gaubius Laboratory, Leiden, The Netherlands
| | | | - Mei Di
- Metabolic Disorders Amgen, Inc., South San Francisco, CA
| | | | - Jie Tang
- Protein Technologies, Amgen, Inc., South San Francisco, CA
| | - Wen-Chen Yeh
- Metabolic Disorders Amgen, Inc., South San Francisco, CA
| | | | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Rob Scott
- Cardiovascular, Amgen Inc., Thousand Oaks, CA
| | | | - Hans M G Princen
- TNO-Metabolic Health Research, Gaubius Laboratory, Leiden, The Netherlands
| | - Simon Jackson
- Metabolic Disorders Amgen, Inc., South San Francisco, CA
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50
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Robinson JG, Nedergaard BS, Rogers WJ, Fialkow J, Neutel JM, Ramstad D, Somaratne R, Legg JC, Nelson P, Scott R, Wasserman SM, Weiss R. Effect of evolocumab or ezetimibe added to moderate- or high-intensity statin therapy on LDL-C lowering in patients with hypercholesterolemia: the LAPLACE-2 randomized clinical trial. JAMA 2014; 311:1870-82. [PMID: 24825642 DOI: 10.1001/jama.2014.4030] [Citation(s) in RCA: 367] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
IMPORTANCE In phase 2 studies, evolocumab, a fully human monoclonal antibody to PCSK9, reduced LDL-C levels in patients receiving statin therapy. OBJECTIVE To evaluate the efficacy and tolerability of evolocumab when used in combination with a moderate- vs high-intensity statin. DESIGN, SETTING, AND PATIENTS Phase 3, 12-week, randomized, double-blind, placebo- and ezetimibe-controlled study conducted between January and December of 2013 in patients with primary hypercholesterolemia and mixed dyslipidemia at 198 sites in 17 countries. INTERVENTIONS Patients (n = 2067) were randomized to 1 of 24 treatment groups in 2 steps. Patients were initially randomized to a daily, moderate-intensity (atorvastatin [10 mg], simvastatin [40 mg], or rosuvastatin [5 mg]) or high-intensity (atorvastatin [80 mg], rosuvastatin [40 mg]) statin. After a 4-week lipid-stabilization period, patients (n = 1899) were randomized to compare evolocumab (140 mg every 2 weeks or 420 mg monthly) with placebo (every 2 weeks or monthly) or ezetimibe (10 mg or placebo daily; atorvastatin patients only) when added to statin therapies. MAIN OUTCOMES AND MEASURES Percent change from baseline in low-density lipoprotein cholesterol (LDL-C) level at the mean of weeks 10 and 12 and at week 12. RESULTS Evolocumab reduced LDL-C levels by 66% (95% CI, 58% to 73%) to 75% (95% CI, 65% to 84%) (every 2 weeks) and by 63% (95% CI, 54% to 71%) to 75% (95% CI, 67% to 83%) (monthly) vs placebo at the mean of weeks 10 and 12 in the moderate- and high-intensity statin-treated groups; the LDL-C reductions at week 12 were comparable. For moderate-intensity statin groups, evolocumab every 2 weeks reduced LDL-C from a baseline mean of 115 to 124 mg/dL to an on-treatment mean of 39 to 49 mg/dL; monthly evolocumab reduced LDL-C from a baseline mean of 123 to 126 mg/dL to an on-treatment mean of 43 to 48 mg/dL. For high-intensity statin groups, evolocumab every 2 weeks reduced LDL-C from a baseline mean of 89 to 94 mg/dL to an on-treatment mean of 35 to 38 mg/dL; monthly evolocumab reduced LDL-C from a baseline mean of 89 to 94 mg/dL to an on-treatment mean of 33 to 35 mg/dL. Adverse events were reported in 36%, 40%, and 39% of evolocumab-, ezetimibe-, and placebo-treated patients, respectively. The most common adverse events in evolocumab-treated patients were back pain, arthralgia, headache, muscle spasms, and pain in extremity (all <2%). CONCLUSIONS AND RELEVANCE In this 12-week trial conducted among patients with primary hypercholesterolemia and mixed dyslipidemia, evolocumab added to moderate- or high-intensity statin therapy resulted in additional LDL-C lowering. Further studies are needed to evaluate the longer-term clinical outcomes and safety of this approach for LDL-C lowering. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01763866.
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Affiliation(s)
- Jennifer G Robinson
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City2Department of Medicine, College of Public Health, University of Iowa, Iowa City
| | | | - William J Rogers
- Division of Cardiovascular Disease, University of Alabama Medical Center, Birmingham
| | - Jonathan Fialkow
- Department of Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami
| | | | - David Ramstad
- Hampton Roads Center for Clinical Research, Suffolk, Virginia
| | | | | | | | - Rob Scott
- Amgen Inc, Thousand Oaks, California
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