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“Thinkings” on Lipids:
Genetics, apoB, HDL, and
PCSK9 inhibition
Daniel J Rader, MD
Chair, Department of Genetics
Perelman School of Medicine
University of Pennsylvania
Human genetics is
leading to
identification of new
pathways and to
smarter and faster
development of new
medicines
B
HDL
A-I
TG, CECE
?
LDL
TG-rich
lipoproteins
Lp(a)
Lipoproteins and CAD
ApoB-lipoproteins are biomarkers of CAD risk
LDL cholesterol
Triglycerides
Lipoprotein(a)
Clinical trait Lipoprotein classAssociation with CAD
BTG, CE
ApoB-containing lipoproteins are
causally related to coronary disease
LDL
TG-rich
lipoproteins
Lp(a)
Trait LDL TRLs Lp(a)
Epidemiology ✓ ✓ ✓Human Genetics ✓ ✓ ✓
Randomized Trials ✓ ? ?
Evidence for the causality of apoB-
lipoproteins to CAD risk
Inherited Syndromes of Extremes
of LDL-C: Story of PCSK9F
req
uen
cy (
%)
LDL-C
Gain of function
mutations in PCSK9
Loss of function
mutations in PCSK9
LDL Receptor Function and Life Cycle
8
8
For illustration purposes only
The Role of PCSK9 in the Regulation of LDL Receptor Expression
9
9
For illustration purposes only
Impact of an PCSK9 mAbon LDL Receptor Expression
10
10
For illustration purposes only
mAb
PCSK9 Inhibitors• Alirocumab and Evolocumab• SQ injection biweekly or monthly• Indications:
– Patients with heterozygous familial hypercholesterolemia on maximally tolerated statin therapy with inadequate plasma LDL levels
– Patients with a history of CHD with inadequate plasma LDL levels
• Cardiovascular outcome trials ongoing
Lipoproteins and Coronary Disease
Remaining unmet medical needs in treatment of dyslipidemia
BTG
Triglyceride-rich lipoproteins are
causally related to coronary disease
TG-rich
lipoproteins
B TG
LPL
CE
BCE
ApoC-III inhibits LPL and
TG-rich remnant uptake
apoC-III
B TG
LPL
CE
BCE
ApoC-III as a novel therapeutic target
apoC-III
Inhibitor
X
B TG
LPL
CE
BCE
Lipoprotein lipase is a nodal pathway for
new therapeutic development
apoC-III
ANGPTL4
ANGPTL3
apoA-VANGPTL8
HDL-C does not appear to be causally
associated with CAD
HDL
A-I
X
CE
CETP inhibition raises HDL-C levels…
but doesn’t reduce CV events
A-I
CECE
FCLCATFC
Bile
SR-BI
A-I
Macrophage
FCABCA1
ABCG1FC
SR-BI
CEB
LDLR
VLDL/LDL
CETP
TG
XCETP inhibitor
ApoA-I promotes macrophage cholesterol
efflux and reverse cholesterol transport
A-I
Liver
CECE
FCLCATFC
Bile
SR-BI
A-I
Macrophage
ABCA1
apoA-I
HDL
B
HDL
A-I
TG, CECE
?
LDL
TG-rich
lipoproteins
Lp(a)
Genetics, Lipoproteins and CAD:
Implications for new therapies
Recommended