George Steiner

Safety and tolerability of dalcetrapib

Efficacy and safety data for dalcetrapib (RO4607381/JTT-705) are presented, following a report of increased mortality and cardiac events with another cholesteryl ester transfer protein inhibitor, torcetrapib, associated with off-target adverse effects (hypertension and the activation of the renin-angiotensin-aldosterone system). The efficacy and clinical safety of dalcetrapib 300, 600, and 900 mg or placebo were assessed (n = 838) in 4 pooled 4-week phase IIa trials (1 monotherapy, n = 193; 3 statin combination, n = 353) and 1 12-week phase IIb trial (with pravastatin, n = 292). Nonclinical safety, assessed by the induction of aldosterone production and aldosterone synthase (cytochrome P450 11B2) messenger ribonucleic acid, was measured in human adrenocarcinoma (H295R) cells exposed to dalcetrapib or torcetrapib. Dalcetrapib increased high-density lipoprotein cholesterol by up to 36% and apolipoprotein A-I by up to 16%. The incidence of adverse events (AEs) was similar between placebo (42%) and dalcetrapib 300 mg (50%) and 600 mg (42%), with more events with dalcetrapib 900 mg (58%) (p <0.05, pooled 4-week studies). Six serious AEs (3 with placebo, 1 with dalcetrapib 300 mg, and 2 with dalcetrapib 600 mg) were considered unrelated to treatment. Cardiovascular AEs were similar across treatment groups, with no dose-related trends and no clinically relevant changes in blood pressure or electrocardiographic results. Findings were similar in the 12-week study. In vitro, torcetrapib but not dalcetrapib increased aldosterone production and cytochrome P450 11B2 messenger ribonucleic acid levels. In conclusion, dalcetrapib alone or in combination with statins was effective at increasing high-density lipoprotein cholesterol and was well tolerated, without clinically relevant changes in blood pressure or cardiovascular AEs and no effects on aldosterone production as assessed nonclinically.

Composition of human low density lipoprotein: effects of postprandial triglyceride-rich lipoproteins, lipoprotein lipase, hepatic lipase and cholesteryl ester transfer protein.

A preponderance of small, dense low density lipoprotein (LDL) particles has been linked to increased risk of myocardial infarction, and a dense and protein-rich LDL has proved to be a characteristic of patients with manifest coronary heart disease (CHD). The present study focused on metabolic determinants of the LDL subfraction distribution with the emphasis placed on alimentary lipaemia. The relations of plasma levels and composition of light (1.019 < d < 1.040 kg/l) and dense (1.040 < d < 1.063 kg/l) LDL subfractions to postprandial triglyceride-rich lipoproteins (TGRL), postheparin plasma lipase activities and the activity of cholesteryl ester transfer protein (CETP) were studied in 32 men with angiographically ascertained premature coronary atherosclerosis (age 48.8 +/- 3.2 years) and in 10 age matched healthy control men. LDL subfractions were separated by equilibrium density gradient ultracentrifugation of fasting plasma drawn before participants were subjected to an oral fat tolerance test of a mixed meal type. The response of TGRL to the oral fat load was determined by measuring plasma triglycerides, and the apolipoprotein (apo) B-48 and apo B-100 content of Sf 60-400 and Sf 20-60 lipoprotein fractions. At a second visit plasma samples were taken for determination of postheparin plasma lipoprotein lipase (LPL) and hepatic lipase (HL) activities and for measurement of CETP activity. Hypertriglyceridaemic patients had a preponderance of dense LDL particles compared with normotriglyceridaemic patients and controls. The magnitude of the response of TGRL to the oral fat load showed a positive association with the dense LDL apo B concentration (r = 0.32-0.52, P < 0.05), whereas the LPL activity correlated positively with the free (r = 0.50, P < 0.001) and esterified cholesterol (r = 0.45, P < 0.01) and apo B (r = 0.42, P < 0.01) content of the light LDL fraction. The HL activity was found to be inversely associated with the plasma level of light LDL triglycerides (r = -0.38, P < 0.05). In contrast, no relations were noted between CETP activity and plasma concentrations of LDL constituents. Multiple stepwise linear regression analysis with the proportion of total LDL apo B contained in the dense LDL subfraction (% dense LDL apo B) used as the dependent variable indicated that the combined effect of LPL activity and postprandial plasma levels of TGRL (areas under the curve for plasma triglycerides or Sf 60-400 apo B-48) accounted for around 50% of the variability in the distribution of LDL particles between light and dense subfractions.(ABSTRACT TRUNCATED AT 400 WORDS)

Lipid Profiles in Patients with Rheumatoid Arthritis: Mechanisms and the Impact of Treatment

OBJECTIVEnTo describe the impact of rheumatoid arthritis (RA), and its treatment, on lipoprotein levels with potential implications for atherosclerosis.nnnMETHODSnA PubMed literature search was undertaken for studies published between 1990 and May 2007, using the search terms rheumatoid arthritis AND lipid OR lipoprotein, and including all relevant drug treatment terms for glucocorticoids, disease-modifying antirheumatic drugs, and biologics.nnnRESULTSnPatients with RA face an increased risk of developing premature cardiovascular disease and limited ability to modify risk factors, eg, through exercise. RA is associated with an abnormal lipoprotein pattern, principally low levels of high density lipoprotein (HDL) cholesterol. Most treatments for RA tend to improve the atherogenic index (total/HDL cholesterol ratio), with more evidence for biologics in this regard. The improvement in the lipoprotein profile in RA appears to be associated with suppression of inflammation.nnnCONCLUSIONSnLipid levels should be monitored and managed in patients with RA to minimize the long-term risk of cardiovascular disease. More research is needed to quantify the relationship between systemic inflammation and lipoprotein levels and to determine the impact of specific lipoprotein particles, eg, small dense low-density lipoprotein and subfractions of HDL on long-term risk. Control of inflammation may have an effect on modifying cardiovascular risk.

Glycation of very low density lipoprotein from rat plasma impairs its catabolism

SummaryRat VLDL were glycated in vitro in the presence or absence of a reducing agent. Prior to glycation, the VLDL triglyceride was endogenously radiolabelled with [3H]-oleic acid. Post glycation the VLDL B-apoprotein was exogenously radiolabelled with [131]I. The double labelled VLDL was then injected into normal rats and the decline in plasma radioactivity of the two isotopes was used as a measure of triglyceride and particle clearance. VLDL glycated in either the presence or absence of reducing agent exhibited a significantly slower removal of triglyceride and apoprotein B compared to normal VLDL. The ability of glycated VLDL triglyceride to act as substrate for lipoprotein lipase and hepatic lipase was examined. Increasing concentrations of normal and glycated VLDL triglyceride were incubated with post-heparin plasma. The kinetics of triglyceride hydrolysis were determined in a manner analagous to Michaelis-Menten analysis. Glycated VLDL was found to be poorer than normal VLDL as a substrate for lipoprotein lipase. Glycation of VLDL appears to interfere with the lipolysis of its triglyceride. This may explain the delayed clearance of glycated VLDL triglyceride in vivo. Glycation also extended the mean plasma residence time of the VLDL particle. These factors may, in part, contribute to the hypertriglyceridaemia observed in subjects with diabetes mellitus.

Partial characterization of the fructose-induced defect in very-low-density lipoprotein triglyceride metabolism

Very-low-density lipoprotein triglyceride (VLDL-TG) catabolism was studied in rats receiving either fructose or glucose as a 10% drinking solution. Consumption of either of the hexoses for 16 hours significantly elevated postheparin plasma (PHP) lipoprotein lipase (LPL) activity compared with normal control animals. Prolonged feeding of the carbohydrates for 14 days abolished the higher LPL activities, which were similar to control levels. PHP hepatic lipase (HL) activity was significantly reduced in carbohydrate-fed rats compared with control animals despite the duration of feeding. The kinetic parameters Km and Vmax cannot be obtained with lipoproteins and so the first-order rate constant (k1) of triglyceride hydrolysis was used to assess the effectiveness of VLDL-TG as substrates for endothelial lipases. VLDL-TG from fructose and VLDL-TG from glucose donors was lipolyzed with PHP LPL and HL from normal rats. The k1 (fraction of VLDL-TG lipolyzed) of VLDL-TG was found to be lower when donors had been fed fructose compared with VLDL that had come from glucose-fed donors. Rates of VLDL-TG removal from fructose and glucose donors were determined simultaneously in perfused livers of normal control, fructose-fed, and glucose-fed animals. Livers of fructose-fed animals cleared VLDL-TG at a slower rate than livers from glucose-fed or control rats. VLDL-TG from fructose-fed rats was cleared less effectively than VLDL-TG from glucose-fed rats in livers of both control and glucose-fed animals. We conclude that an impairment in the ability of fructose-fed rats to hydrolyze VLDL-TG, and of their livers to remove VLDL-TG, may in part explain fructose-induced hypertriglyceridemia.

Laboratory standardization of a large international clinical trial: the DAIS experience

OBJECTIVEnTo implement a quality control program for the standardization and harmonization of lipid and lipoprotein analyses as performed at two core laboratories (St. Pauls Hospital, UBC [Vancouver], and NPHI [Helsinki]) for the Diabetes Atherosclerosis Intervention Study (DAIS).nnnDESIGN AND METHODSnA DAISSOFT computer program was designed to minimize the occurrence of data and sample management errors during the course of the study. Fresh human serum was used for the provision of an accuracy based external quality control program that monitored the analytical performance of lipid testing at these two laboratories. A separate program was designed for monitoring hemoglobin A1c (HbA1c). At the outset of the study, allowable total error goals were established for each analyte. Ongoing performance was monitored using bimonthly blinded challenges of fresh human serum. The two EQA programs routinely monitored the analysis of total cholesterol, calculated LDL-cholesterol, HDL-cholesterol, net triglycerides, apoprotein A-1, apoprotein B, and HbA1c.nnnRESULTSnThe EQA precision and accuracy data for the measurement of total cholesterol at the two core laboratories over the last 5 years indicated both laboratories operated with good precision, approximately 1% CV over the time period. The accuracy at both laboratories was similar initially. Part way through the study, the accuracy of the cholesterol method at NHPI tended to drift upward with an operating positive bias (+3%) relative to the Abell Kendall reference method. Triglyceride measurements were the most problematic for the study. By EQA cycle 8, the accuracy of the method at UBC had stabilized and was meeting the accuracy goals of the study. NPHIs method was negatively biased relative to the accuracy base of the DAIS study. In spite of recalibrating their method, NPHI found it difficult to maintain consistent accuracy for the measurement of triglycerides during the study. Both laboratories operated their HDL methods with excellent precision. Accuracy at NHPI was well maintained over the course of the study whereas the accuracy of HDL measurements at UBC was more problematic. There was an inconsistent variation in the accuracy of apoprotein A-1 measurements at both laboratories. In most cases, the bias would be corrected by the time of the next EQA challenge. In the case of apo B, one laboratory was standardized to the CDC while the other laboratory was standardized to IFCC/WHO. The discrepancy between these two accuracy bases was >20%. Recalibration to a common accuracy base rectified the problem. Only minor problems were encountered with the precision and accuracy of the DIAMAT assay for hemoglobin A-1c. The two DAIS core laboratories consistently operated within the 9% total error goals of the study for HbA1c.nnnCONCLUSIONSnThrough the use of this program, the two DAIS core laboratories were able to maintain their lipid analyses within the limits of allowable total error that had been established for the study.

The chromogenicity and quantitation of apoB-100 and apoB-48 of human plasma lipoproteins on analytical SDS gel electrophoresis

ApoB-100 and apoB-48 may be readily resolved in 3.3% sodium dodecyl sulphate-polyacrylamide gels. This study has characterized the relative chromogenicities (staining intensity/micrograms protein) of human apoB-100 and apoB-48 in various lipoprotein classes with Coomassie Brilliant Blue (R250) upon SDS-PAGE. The relation between dye uptake and the mass of each apoB species in any lipoprotein preparation, was linear at least within the concentration range of total apoprotein B which is optimally resolved in these gels (20-50 micrograms total apoprotein B), and was a function of the density of the particular lipoprotein fraction under investigation. There was a constant and characteristic difference between the chromogenicity for apoB-100 and that for apoB-48 as determined from the slopes of their respective chromogenicity curves. The slope of the lines describing staining intensity vs. protein mass for both apoB-100 and apoB-48 decreased as the density of the lipoprotein fraction increased. The slope of the line for apoB-100 was steeper than that for apoB-48 (i.e. chromogenicity apoB-100 greater than apoB-48) in all lipoprotein fractions where both were present. The relationship between the slopes of the lines for apoB-100 and apoB-48 was constant regardless of the density of the lipoprotein fraction. The chromogenicity curves for apoB-100 and for apoB-48 obtained when lipoprotein samples were applied to gels in concentrations conventionally used for this technique (i.e. 20-100 micrograms total apoB/gel) did not extrapolate to the same point on the ordinate, which precludes the use of a simple ratio or chromogenicity factor to describe their relative chromogenicities over this concentration range, Hence, a novel approach was developed to determine the relative mass of apoB-100/apoB-48 in lipoprotein samples, based on their staining characteristics in SDS-PAGE.

Treating lipid abnormalities in patients with type 2 diabetes mellitus

The typical lipid levels in type 2 diabetes mellitus are low high-density lipoprotein cholesterol, normal low-density lipoprotein cholesterol, and high triglycerides. Atherosclerotic cardiovascular disease is the most common problem confronting those with type 2 diabetes mellitus. Some previous large lipid-lowering clinical trials conducted subanalyses of individuals with type 2 diabetes. Although these trials suggested a coronary benefit, questions remained because of (1) the limitations of such subanalyses, (2) the atypical characteristics of the populations, and (3) some inconsistencies in their findings. The Diabetes Atherosclerosis Intervention Study (DAIS), a randomized, double-blind, placebo-controlled study in men and women with type 2 diabetes, has demonstrated by quantitative angiography that treatment with micronized fenofibrate corrected their lipid abnormalities and reduced the progression of coronary disease. Furthermore, this occurred in individuals with lipid levels that many physicians would consider to be normal.

Atherosclerosis in type 2 diabetes: a role for fibrate therapy?

Vascular complications associated with type 2 diabetes confer significant morbidity and mortality. Atherosclerosis develops much earlier and progresses more rapidly than in subjects without diabetes. The clustering of cardiovascular risk factors associated with type 2 diabetes is mainly responsible for accelerated atherosclerotic disease. While statins remain the primary lipid-modifying therapy, the pharmacological profile of the fibrates suggests potential as an alternative or additional treatment for reducing the risk of atherosclerotic vascular complications in type 2 diabetes.

Fenofibrate for Cardiovascular Disease Prevention in Metabolic Syndrome and Type 2 Diabetes Mellitus

Clinical guidelines highlight the importance of managing atherogenic mixed dyslipidemia to reduce the risk of premature cardiovascular disease in type 2 diabetes mellitus and metabolic syndrome. The lipid-modifying activity of fenofibrate, as demonstrated in clinical studies, indicates its effectiveness in treating dyslipidemia characteristic of these conditions. Fenofibrate also has a favorable impact on a number of nonlipid residual risk factors associated with type 2 diabetes and metabolic syndrome, mediated by peroxisome proliferator-activated receptor-alpha. In patients with type 2 diabetes, fenofibrate is effective in reducing the progression of coronary artery disease, as demonstrated by the Diabetes Atherosclerosis Intervention Study (DAIS). In the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study, the primary end point (major coronary events) was not significantly reduced by fenofibrate treatment. However, other findings from this study suggest that fenofibrate reduces cardiovascular risk. Both DAIS and the FIELD study also indicate that fenofibrate may offer additional vascular benefits, specifically affecting the progression of diabetes-related microvascular disease.