PCSK9 Inhibitors: Clinical Relevance, Molecular Mechanisms, and Safety in Clinical Practice / Inibidores de PCSK9: Importância Clínica, Mecanismos Moleculares, e Segurança na Prática Clínica

Abstract Coronary artery disease (CAD) is one of the leading causes of mortality. High circulating levels of low-density lipoprotein (LDL) in the blood are associated with cardiovascular mortality, whether through an etiological role or through its association with the progression of CAD per se. Randomized clinical trials have shown that, when LDL levels are reduced, cardiovascular risk is also reduced, which reinforces this association. The first major trial involving a hypolipidemic agent of the statin family, the Scandinavian Simvastatin Survival Study (4S), was published in 1994 and found a significant reduction in mortality in patients at high cardiovascular risk. However, even in subsequent studies with different statins, a residual risk persisted, and this seems not to have changed over time; it is speculated that this risk may be due to statin intolerance. In this scenario, the potential exists for novel hypolipidemic agents to drive a true revolution in the therapy of dyslipidemia. The recent discovery of PCSK9 inhibitors (PCSK9i), a class of hypolipidemic monoclonal antibodies, is extremely promising. PCSK9 inhibition is capable of promoting a mean LDL reduction of up to 60%, with potential for very significant clinical repercussions, as every 38 mg/dL reduction in LDL appears to be associated with a 22% reduction in cardiovascular risk. This review addresses a brief history of PCSK9i, major trials of these drugs, cardiovascular outcomes, and aspects related to their efficacy and safety. Finally, the molecular mechanisms and possible pleiotropic effects of PCSK9i are also discussed.

Resumo A doença arterial coronariana (DAC) é uma das principais causas de mortalidade. Níveis circulantes elevados de lipoproteína de baixa densidade (LDL) no sangue estão associados com mortalidade cardiovascular, seja por um papel etiológico ou por sua associação com a progressão da DAC em si. Estudos clínicos randomizados mostram que, quando os níveis de LDL são reduzidos, o risco cardiovascular também é reduzido, o que reforça tal associação. O primeiro ensaio importante envolvendo um agente hipolipemiante da família da estatina, o estudo Scandinavian Simvastatin Survival Study (4S), foi publicado em 1994 e encontrou uma redução significativa na mortalidade de pacientes com risco cardiovascular elevado. Contudo, mesmo em estudos subsequentes com diferentes estatinas, observou-se um risco residual persistente, o qual aparentemente não mudou ao longo dos anos. Especula-se que esse risco se deve à intolerância às estatinas. Nesse cenário, existe um potencial para novos agentes hipolipemiantes que levem a uma verdadeira revolução no tratamento das dislipidemias. A descoberta recente dos inibidores de PCSK9 (PCSK9i), uma classe de anticorpos monoclonais, é extremamente promissora. A inibição da PCSK9 é capaz de promover uma redução média nos níveis de LDL de até 60%, com potencial para repercussões clínicas muito significativas, já que para cada redução de 38 mg/dL, parece haver uma redução de 22% no risco cardiovascular. Esta revisão aborda uma breve história dos PCSK9i, os principais ensaios envolvendo esses medicamentos, desfechos cardiovasculares, e aspectos relacionados a sua eficácia e segurança. Finalmente, os mecanismos moleculares e possíveis efeitos pleiotrópicos dos PCSK9i são também discutidos.

Lipid profile and statin use in critical care setting: implications for kidney outcome / Perfil lipídico e uso de estatina em terapia intensiva: implicações no desfecho renal

ABSTRACT Objective: To determine whether pre-hospital statin use is associated with lower renal replacement therapy requirement and/or death during intensive care unit stay. Methods: Prospective cohort analysis. We analyzed 670 patients consecutively admitted to the intensive care unit of an academic tertiary-care hospital. Patients with ages ranging from 18 to 80 years admitted to the intensive care unit within the last 48 hours were included in the study. Results: Mean age was 66±16.1 years old, mean body mass index 26.6±4/9kg/m2 and mean abdominal circumference was of 97±22cm. The statin group comprised 18.2% of patients and had lower renal replacement therapy requirement and/or mortality (OR: 0.41; 95%CI: 0.18-0.93; p=0.03). The statin group also had lower risk of developing sepsis during intensive care unit stay (OR: 0.42; 95%CI: 0.22-0.77; p=0.006) and had a reduction in hospital length-of-stay (14.7±17.5 days versus 22.3±48 days; p=0.006). Statin therapy was associated with a protective role in critical care setting independently of confounding variables, such as gender, age, C-reactive protein, need of mechanical ventilation, use of pressor agents and presence of diabetes and/or coronary disease. Conclusion: Statin therapy prior to hospital admission was associated with lower mortality, lower renal replacement therapy requirement and sepsis rates.

RESUMO Objetivo: Determinar se o uso pré-admissão hospitalar de estatina está associado com menor necessidade de diálise e/ou óbito durante internação em unidade de terapia intensiva. Métodos: Análise de coorte prospectiva. Foram incluídos consecutivamente 670 pacientes admitidos na unidade de terapia intensiva de um hospital acadêmico de cuidados terciários. Os pacientes incluídos deveriam ter entre 18 e 80 anos e ter sido admitidos na unidade de terapia intensiva nas últimas 48 horas. Resultados: A média da idade dos pacientes foi de 66±16,1 anos. O índice de massa corporal foi de 26,6±4/9kg/m2 e a circunferência abdominal média foi de 97±22cm. O grupo que fez uso de estatina pré-admissão hospitalar (18,2% dos pacientes) necessitou menos de terapia de substituição renal e/ou evoluiu para óbito (OR: 0,41; IC95%: 0,18-0,93; p=0,03). O grupo que fez uso de estatina também apresentou menor risco de evoluir com sepse durante a internação na unidade de terapia intensiva (OR: 0,42; IC95%: 0,22-0,77; p=0,006) e teve menor duração da hospitalização (14,7±17,5 dias versus 22,3±48 dias; p=0,006). A terapia pré-admissão hospitalar com estatina foi associada a papel protetor no cenário da terapia intensiva independentemente de variáveis confundidoras, como sexo, idade, proteína C-reativa, necessidade de ventilação mecânica, uso de vasopressores e diagnóstico de diabetes e/ou coronariopatia. Conclusão: A terapia com estatina antes da admissão hospitalar foi associada a menor mortalidade, menor necessidade de terapia de substituição renal e taxa de ocorrência de sepse.

Omega-3 fatty acids, inflammatory status and biochemical markers of patients with systemic lupus erythematosus: a pilot study / Ácidos graxos ômega-3, estado inflamatório e marcadores bioquímicos de pacientes com lúpus eritematoso sistêmico: estudo piloto

Abstract Background: Studies have shown that omega-3 fatty acids reduce the concentrations of eicosanoids, cytokines, chemokines, C-reactive protein (CRP) and other inflammatory mediators. Objective: To investigate the effects of omega-3 fatty acids on circulating levels of inflammatory mediators and biochemical markers in women with systemic lupus erythematosus (SLE). Methods: Experimental clinical study (clinical trial: NCT02524795); 49 women with SLE (ACR1982/1997) were randomized: 22 to the omega-3 group (daily intake of 1080 mg EPA + 200 mg DHA, for 12 weeks) and 27 to the control group. The inflammatory mediators and biochemical markers at T0 and T1 in omega-3 group were compared using Wilcoxon test. U-Mann-Whitney test was used to compare variations of measured variables [ΔV = pre-treatment (T0) − post-treatment (T1) concentrations] between groups. p < 0.05 was considered significant. Results: The median (interquartile range - IQR) of age was 37 (29-48) years old, of disease duration was 7 (4-13) years, and of SLEDAI-2K was 1 (0-2). The median (IQR) of variation in CRP levels between the two groups showed a decrease in omega-3 group while there was an increase in control group (p = 0.008). The serum concentrations of IL-6 and IL-10, leptin and adiponectin did not change after a 12 week treatment. Conclusions: Supplementation with omega-3 had no impact on serum concentrations of IL-6, IL-10, leptin and adiponectin in women with SLE and low disease activity. There was a significant decrease of CRP levels as well as evidence that omega-3 may impact total and LDL-cholesterol.

Resumo Introdução: Estudos têm mostrado que os ácidos graxos ômega-3 reduzem as concentrações de eicosanoides, citocinas, quimiocinas, proteína C-reativa (PCR) e outros mediadores inflamatórios. Objetivo: Investigar os efeitos dos ácidos graxos ômega-3 sobre os níveis circulantes de mediadores inflamatórios e marcadores bioquímicos em mulheres com lúpus eritematoso sistêmico (LES). Métodos: Ensaio clínico randomizado (ensaio clínico: NCT02524795); randomizaram-se 49 mulheres com LES (ACR1982/1997): 22 para o grupo ômega-3 (dose diária de 1.080 mg de EPA + 200 mg de DHA durante 12 semanas) e 27 para o grupo controle. Os mediadores inflamatórios e marcadores bioquímicos em T0 e T1 no grupo ômega-3 foram comparados pelo teste de Wilcoxon. O teste U de Mann-Whitney foi usado para comparar variações das variáveis mensuradas [ΔV = concentrações pré-tratamento (T0) menos concentrações pós-tratamento (T1)] entre os grupos. Um p < 0,05 foi considerado significativo. Resultados: A mediana (intervalo interquartil-IIQ) da idade foi de 37 anos (29-48), a duração da doença foi de sete anos (4-13) anos e o Systemic Lupus Disease Activity Index (Sledai-2 K) foi de 1 (0-2). A mediana (IIQ) da variação nos níveis de PCR entre os dois grupos mostrou um decréscimo no grupo ômega-3, enquanto houve um aumento no grupo controle (p = 0,008). As concentrações séricas de IL-6 e IL-10, leptina e adiponectina não se alteraram após um tratamento de 12 semanas. Conclusões: A suplementação de ômega-3 não teve impacto sobre as concentrações séricas de IL-6, IL-10, leptina e adiponectina em mulheres com LES e baixa atividade da doença. Houve uma diminuição significativa nos níveis de PCR, bem como evidências de que o ômega-3 pode impactar sobre o colesterol total e LDL.

Phytosterols in the Treatment of Hypercholesterolemia and Prevention of Cardiovascular Diseases / Fitosteróis no Tratamento da Hipercolesterolemia e Prevenção de Doenças Cardiovasculares

Abstract Phytosterols are bioactive compounds found in foods of plant origin, which can be divided into plant sterols and plant stanols. Clinical studies consistently indicate that the intake of phytosterols (2 g/day) is associated with a significant reduction (8-10%) in levels of low-density lipoprotein cholesterol (LDL-cholesterol). Thus, several guidelines recommend the intake of 2 g/day of plant sterols and/or stanols in order to reduce LDL-cholesterol levels. As the typical western diet contains only about 300 mg/day of phytosterols, foods enriched with phytosterols are usually used to achieve the recommended intake. Although phytosterols decrease LDL-cholesterol levels, there is no evidence that they reduce the risk of cardiovascular diseases; on the contrary, some studies suggest an increased risk of atherosclerosis with increasing serum levels of phytosterols. This review aims to address the evidence available in the literature on the relationship between phytosterols and risk of cardiovascular disease.

Resumo Os fitosteróis são compostos bioativos encontrados em alimentos de origem vegetal e que podem ser divididos em esteróis vegetais e estanóis vegetais. Estudos clínicos indicam de forma consistente que a ingestão de fitosteróis (2 g/dia) está associada a uma redução significativa (8-10%) de níveis de colesterol da lipoproteína de baixa densidade (LDL-C). Desta forma, diversas diretrizes recomendam a ingestão de 2 g/dia de esteróis e/ou estanóis vegetais com o objetivo de reduzir os níveis de LDL-C. Como uma dieta ocidental típica contém apenas cerca de 300 mg/dia de fitosteróis, normalmente são utilizados alimentos enriquecidos com fitosteróis para alcançar a ingestão recomendada. Apesar dos fitosteróis reduzirem os níveis de LDL-C, não há evidências de que reduzam o risco de doenças cardiovasculares. Pelo contrário, alguns estudos sugerem que a elevação na concentração sérica de fitosteróis possa estar associada com aumento no risco de aterosclerose. Esta revisão tem como objetivo abordar as evidências disponíveis na literatura sobre a relação entre fitosteróis e risco de doenças cardiovasculares.

Endothelial Effect of Statin Therapy at a High Dose Versus Low Dose Associated with Ezetimibe / Efeito Endotelial da Terapia com Estatina em Alta Dose versus Baixa Dose Associada à Ezetimiba

Abstract Background: The effect of statins on the endothelial function in humans remains under discussion. Particularly, it is still unclear if the improvement in endothelial function is due to a reduction in LDL-cholesterol or to an arterial pleiotropic effect. Objective: To test the hypothesis that modulation of the endothelial function promoted by statins is primarily mediated by the degree of reduction in LDL-cholesterol, independent of the dose of statin administered. Methods: Randomized clinical trial with two groups of lipid-lowering treatment (16 patients/each) and one placebo group (14 patients). The two active groups were designed to promote a similar degree of reduction in LDL-cholesterol: the first used statin at a high dose (80 mg, simvastatin 80 group) and the second used statin at a low dose (10 mg) associated with ezetimibe (10 mg, simvastatin 10/ezetimibe group) to optimize the hypolipidemic effect. The endothelial function was assessed by flow-mediated vasodilation (FMV) before and 8 weeks after treatment. Results: The decrease in LDL-cholesterol was similar between the groups simvastatin 80 and simvastatin 10/ezetimibe (27% ± 31% and 30% ± 29%, respectively, p = 0.75). The simvastatin 80 group presented an increase in FMV from 8.4% ± 4.3% at baseline to 11% ± 4.2% after 8 weeks (p = 0.02). Similarly, the group simvastatin 10/ezetimibe showed improvement in FMV from 7.3% ± 3.9% to 12% ± 4.4% (p = 0.001). The placebo group showed no variation in LDL-cholesterol level or endothelial function. Conclusion: The improvement in endothelial function with statin seems to depend more on a reduction in LDL-cholesterol levels, independent of the dose of statin administered, than on pleiotropic mechanisms.

Resumo Fundamento: O efeito das estatinas na função endotelial em seres humanos permanece em discussão. Particularmente, ainda carece resposta se a melhora na função endotelial deve-se à redução do LDL-colesterol ou a um efeito pleiotrópico arterial. Objetivo: Testar a hipótese de que a modulação da função endotelial promovida por estatinas é prioritariamente mediada pelo grau de redução do LDL-colesterol, independente da dose de estatina utilizada. Métodos: Ensaio clínico randomizado com dois grupos de tratamento hipolipemiante (16 pacientes/cada) e um grupo placebo (14 pacientes). Os dois grupos ativos foram desenhados para promover graus semelhantes de redução de LDL-colesterol: o primeiro utilizou estatina em alta dose (80 mg, grupo sinvastatina 80) e o segundo em baixa dose (10 mg) associada a ezetimiba (10 mg, grupo sinvastatina 10/ezetimiba) para otimizar o efeito hipolipemiante. A função endotelial foi analisada pela vasodilatação mediada por fluxo (VMF) antes e após 8 semanas de tratamento. Resultados: A redução no LDL-colesterol foi semelhante entre os grupos sinvastatina 80 e sinvastatina 10/ezetimiba (27% ± 31% e 30% ± 29%, respectivamente, p = 0,75). O grupo sinvastatina 80 apresentou incremento da VMF de 8,4% ± 4,3% no basal para 11% ± 4,2% após 8 semanas (p = 0,02). Da mesma forma, o grupo sinvastatina 10/ezetimiba apresentou melhora da VMF de 7,3% ± 3,9% para 12% ± 4,4% (p = 0,001). O grupo placebo não apresentou variação no nível de LDL-colesterol ou da função endotelial. Conclusão: A melhora da função endotelial com uso de estatina parece depender mais da redução do LDL-colesterol, independente da dose de estatina utilizada, do que de mecanismos pleiotrópicos.

Single-nucleotide polymorphisms: a perspective of cardiovascular prevention / Polimorfismos de nucleotídeo único: uma perspectiva de prevenção cardiovascular

Summary Introduction: several studies have evaluated the utilization of lipid biomarkers in an attempt to correlate them with clinical cardiovascular events. Nevertheless, the investigation of clinical conditions under specific plasmatic levels of lipoproteins for long periods presents limitations due to inherent difficulties that are related to the follow-up of individuals throughout their lives. Better understanding of the clinical response and occasional resistance to the action of hypolipidemic drugs in several clinic scenarios is also necessary. Objectives: to determine the role of evaluation of single-nucleotide polymorphisms (SNPs) related to the metabolism of lipids, and its implications in different clinical scenarios. Methods: a search of the literature in English and Spanish languages was performed in Medline, Lilacs via Bireme, IBECS via Bireme, and Cochrane databases. The expected results included information regarding plasmatic lipid profile and SNPs, cardiovascular clinical outcomes and polymorphisms related to the effectiveness of statins in the treatment of hypercholesterolemia. Results: in order to perform this analysis, 19 studies were included from a total of 89 identified citations. The evaluation of the results suggests that low plasmatic levels of LDL-c are associated with a reduction in the risk of heart attacks, although this was not observed for the rise of plasmatic levels of HDL-c. Conclusion: polymorphisms in different populations and clinical perspectives may bring important contributions for a better understanding and adequacy of plasmatic lipoproteins aiming at reducing cardiovascular risk.

Resumo Introdução: muitos estudos tem avaliado a utilização de biomarcadores lipídicos na tentativa de correlacioná-los com eventos clínicos cardiovasculares. Contudo, a investigação de condições clínicas sob níveis plasmáticos específicos de lipoproteínas por longos períodos, apresenta limitações devido às dificuldades inerentes relacionadas ao acompanhamento de indivíduos ao longo de suas vidas. Adicionalmente, há a necessidade de melhor compreensão da resposta clínica e eventual resistência da ação de drogas hipolipemiantes em diversos cenários clínicos. Objetivos: determinar o papel da avaliação de polimorfismos de nucleotídeo único (SNPs) relacionadas com o metabolismo lipídico e suas implicações em diferentes cenários clínicos. Métodos: foi realizada uma pesquisa na literatura de língua inglesa e espanhola nas bases de dados Medline, Lilacas via Bireme, IBECS via Bireme e Cochrane. Os resultados esperados incluíam informações sobre o perfil lipídico plasmático e SNPs, desfechos clínicos cardiovasculares e polimorfismos relacionadas à efetividade de estatinas quanto ao tratamento da hipercolesterolemia. Resultados: para esta análise foram incluídos 19 estudos de um total de 89 citações identificadas. Os dados resultantes e avaliados sugerem que baixos níveis plasmáticos de LDL-c estão associados com redução do risco de infarto do miocárdio o que não foi observado para o aumento nos níveis plasmáticos de HDL-c. Conclusão: os polimorfismos em diferentes populações e perspectivas clínicas podem trazer importantes contribuições para a melhor compreensão e adequação de metas de lipoproteínas plasmáticas que visem a redução de risco cardiovascular.

An Open label, Prospective, Multi-Center, Observational Study to Evaluate the Lipid Lowering Efficacy and Safety of Rosuvastatin in Indian Dyslipidemics in Routine Clinical Practice.

Altered cholesterol levels in the blood or dyslipidemia is a major modifiable risk factor for CVD and is closely associated with the pathophysiology of CVD. Asians, particularly Indians, have a unique pattern of dyslipidemia; with lower HDL cholesterol, increased triglyceride levels and higher proportion of small dense LDL cholesterol, with characteristic centripetal obesity. ‘Statins’ belong to the group of 3-hydroxy-3-methylglutaryl Coenzyme A reductase inhibitors that have been shown to reduce levels of total and LDL cholesterol. Study Objective: To evaluate the lipid lowering efficacy and safety of Rosuvastatin in Indian dyslipidemics in routine clinical practice by measuring the percent change in Total Cholesterol, LDL, TG and HDL over a period of 16 weeks. Methodology : This was a multicentric, open-labeled, post-marketing surveillance study. A committee of key opinion leaders was formed. A total of 1200 doctors were approached of whom 800 provided us with subject data. Each participating doctor was given case report forms and requested to recruit patients according to the inclusion and exclusion criteria. Lipid profile of each recruited patient was done before initiating therapy and at the end of 4 months. Rosuvastatin was given at a dose of either 5mg/ 10mg OD for 4 months. Results : A total of 11, 656 subjects were recruited into this study out of which 10, 410 complete case report forms were considered (n=10410). The study included 65% males and 35% females. Majority of the subjects were in the age group of 46-55years (35.2%) and 56-65 years (29.4%). In this study, the total cholesterol (TC), LDL-C, Triglycerides (TG) has significantly decreased by 46.13%, 53.74% and 41.93% respectively. Also the HDLC levels increased by 26.84%, thereby, indicating a significant change in the levels of all the dyslipidemic indicators. With the reported number of adverse events (n=4) related to Rosuvastatin, it is evident that the drug is safe and tolerable. There were no significant changes observed in the liver and renal function tests with Rosuvastatin reiterating their safety. Conclusion : Rosuvastatin has shown greater efficacy in lowering LDL cholesterol and non-HDL-cholesterol concentrations. It has been shown to enable more patients to reach their LDL cholesterol goals and to do so with an acceptable safety profile.

Hydrochloride pioglitazone protects diabetic rats against podocyte injury through preserving glomerular podocalyxin expression / O cloridrato de pioglitazona protege ratos diabéticos contra a injúria aos podócitos por meio da preservação da expressão de podocalixina glomerular

Objective: We sought to test the effect of different dosages of pioglitazone (PIO) on the glomerular expression of podocalyxin and urinary sediment podocalyxin excretion and to explore the potential renoprotective mechanism. Materials and methods: Type 1 diabetes induced with streptozotocin (65 mg/kg) in 36 male Sprague-Dawley rats were randomly allocated to be treated with vehicle or 10, 20, 30 mg/kg/d PIO respectively for 8 weeks. Eight rats were enrolled in the normal control group. Results: At 8th week, rats were sacrificed for the observation of kidney injury through electron microscope. Glomerular podocalyxin production including mRNA and protein were determined by RT-PCR and immunohistochemistry respectively. Levels of urinary albumin excretion and urinary sediment podocalyxin, kidney injury index were all significantly increased, whereas expression of glomerular podocalyxin protein and mRNA were decreased significantly in diabetic rats compared to normal control. Dosages-dependent analysis revealed that protective effect of PIO ameliorated the physiopathological changes and reached a peak at dosage of 20 mg/kg/d. Conclusion: PIO could alleviate diabetic kidney injury in a dose-dependent pattern and the role may be associated with restraining urinary sediment podocalyxin excretion and preserving the glomerular podocalyxin expression. .

Objetivo: Buscamos testar os efeitos de diferentes doses de pioglitazona (PIO) sobre a expressão glomerular de podocalixina e sobre a excreção de podocalixina em células do sedimento urinário, além de explorar o potencial mecanismo de proteção renal. Materiais e métodos: O diabetes tipo 1 foi induzido em 36 ratos Sprague-Dawley machos com estreptozotocina (65 mg/kg). Os animais foram tratados apenas com o veículo, ou com 10, 20, 30 mg/kg/d de PIO por 8 semanas. Oito ratos foram colocados no grupo controle. Resultados: Na oitava semana, os ratos foram sacrificados para se observar a lesão renal em microscopia eletrônica. A produção de podocalixina glomerular, incluindo mRNA e proteína, foi determinada por RT-PCR e imuno-histoquímica, respectivamente. Os níveis urinários de albumina e podocalixina nas células do sedimento urinário e o índice de lesão renal estavam todos significativamente aumentados, enquanto a expressão glomerular da proteína podocalixina e do mRNA estava significativamente diminuída em ratos diabéticos comparados com o controle normal. A análise dos efeitos dose-dependentes revelou que o efeito protetor da PIO melhorou as mudanças fisiopatológicas e atingiu um pico na dose de 20 mg/kg/dia. Conclusão: A PIO pode melhorar a injúria renal de forma dose-dependente e este papel pode estar associado com a prevenção da excreção de podocalixina nas células do sedimento urinário e com a preservação da expressão glomerular de podocalixina. .

Differences in synthesis and absorption of cholesterol of two effective lipid-lowering therapies

Effective statin therapy is associated with a marked reduction of cardiovascular events. However, the explanation for full benefits obtained for LDL cholesterol targets by combined lipid-lowering therapy is controversial. Our study compared the effects of two equally effective lipid-lowering strategies on markers of cholesterol synthesis and absorption. A prospective, open label, randomized, parallel design study, with blinded endpoints, included 116 subjects. We compared the effects of a 12-week treatment with 40 mg rosuvastatin or the combination of 40 mg simvastatin/10 mg ezetimibe on markers of cholesterol absorption (campesterol and β-sitosterol), synthesis (desmosterol), and their ratios to cholesterol. Both therapies similarly decreased total and LDL cholesterol, triglycerides and apolipoprotein B, and increased apolipoprotein A1 (P < 0.05 vs baseline for all). Simvastatin/ezetimibe increased plasma desmosterol (P = 0.012 vs baseline), and decreased campesterol and β-sitosterol (P < 0.0001 vs baseline for both), with higher desmosterol (P = 0.007) and lower campesterol and β-sitosterol compared to rosuvastatin, (P < 0.0001, for both). In addition, rosuvastatin increased the ratios of these markers to cholesterol (P < 0.002 vs baseline for all), whereas simvastatin/ezetimibe significantly decreased the campesterol/cholesterol ratio (P = 0.008 vs baseline) and tripled the desmosterol/cholesterol ratio (P < 0.0001 vs baseline). The campesterol/cholesterol and β-sitosterol/cholesterol ratios were lower, whereas the desmosterol/cholesterol ratio was higher in patients receiving simvastatin/ezetimibe (P < 0.0001 vs rosuvastatin, for all). Pronounced differences in markers of cholesterol absorption and synthesis were observed between two equally effective lipid-lowering strategies.

Effect of moderate ethanol administration on biochemical indices in streptozotocin-diabetic Wistar rats / Efecto de la administración moderada de etanol sobre los índices bioqumicos en ratas Wistar diabéticas por estreptozotocina

OBJECTIVE: This study was designed to evaluate the effect of moderate ethanol administration on the biochemical indices in streptozotocin (STZ)-diabetic rats. METHODS: Twenty-four male Wistar rats were divided into four groups of six animals each. Groups one and two contained non-diabetic normal rats and normal rats treated with ethanol, respectively. Group three was untreated STZ-diabetic rats and group four was made up of ethanol-treated STZ-diabetic rats. Diabetes was induced by a single intraperitoneal injection of STZ (35 mg/kg), while ethanol (10%v/v) was given at a dose 2 g/kg thrice per week for three weeks. After the last dose of ethanol and an overnight fasting, rats were sacrificed by cervical dislocation. Blood was collected by syringe from the heart into plain centrifuge tubes. RESULTS: Moderate ethanol administration to STZ-diabetic rats caused a significant (p < 0. 05) increase in relative weight of liver relative to normal. Ethanol intake in STZ-diabetic rats produced an insignificant (p > 0. 05) effect on the levels of fasting blood glucose (FBG) and HbA1c rrelative to the untreated-diabetic group. Moderately, ethanol administration to STZ-diabetic rats produced a marked and significant (p < 0. 05) increase in the levels of serum total cholesterol, triglycerides, low-density lipoprotein (LDL)-cholesterol and the activities of alanine aminotransferase relative to untreated diabetic rats. Ethanol-treated diabetic rats had significantly (p < 0. 05) lower high-density lipoprotein (HDL)-cholesterol levels, while the activities of lactate dehydrogenase and α-amylase were insignificantly (p > 0. 05) affected. There were no significant (p > 0. 05) differences in all the biochemical indices in normal rats relative to ethanol-treated normal rats. CONCLUSIONS: Moderate ethanol administration did not affect FBG and HbA1c , but altered the lipid profile of STZ-diabetic rats. Moderate ethanol intake may further increase the risk of complications in diabetes.

OBJETIVO: Este estudio se diseñó con el propósito de evaluar el efecto del uso de etanol moderado sobre los índices bioquímicos en ratas Wistar diabéticas por estreptozotocina (STZ). MÉTODOS: Veinticuatro ratas Wistar machos fueron divididas en cuatro grupos de seis animales cada uno. Dos de los grupos tenían ratas normales no diabéticas y ratas normales tratadas con etanol, respectivamente. El tercer grupo estaba formado por ratas diabéticas por STZ no tratadas, y el cuarto por ratas diabéticas por STZ tratadas con etanol. La diabetes fue inducida mediante una inyección intraperitoneal de STZ (35 mg/kg), mientras que el etanol (10% v/v) fue administrado en dosis de 2 g/kg tres veces por semana durante tres semanas. Tras la última dosis de etanol y un ayuno de una noche, las ratas fueron sacrificadas mediante dislocación cervical. La sangre fue recogida del corazón con jeringuillas e introducida en tubos para centrífuga sin graduación. RESULTADOS: La administración moderada de etanol a ratas diabéticas por STZ, causó un aumento significativo (p < 0.05) en el peso relativo del hígado con relación al normal. La ingestión de etanol en ratas diabéticas por STZ tuvo un efecto insignificante (p > 0.05) en los niveles de glucosa en sangre en ayuno (GSA) y HbA1c en relación con grupos diabéticos no tratados. En medida moderada, la administración de etanol a ratas diabéticas por STZ produjo un aumento marcado y significativo (p < 0.05) en los niveles de colesterol total en suero, triglicéridos, el colesterol asociado con las lipoproteínas de baja densidad, o colesterol LDL, y la actividad de la aminotransferasa alanina en relación con las ratas diabéticas no tratadas. Las ratas diabéticas tratadas con etanol tuvieron niveles significativamente disminuidos de colesterol asociado con las lipoproteínas de alta densidad, o colesterol HDL, en tanto que la actividad del lactato deshidrogenasa y la α-amilasa no fue afectada significativamente (p > 0.05). No hubo diferencias significativas (p > 0.05) en todos los índices bioquímicos en las ratas normales con respecto a las ratas normales tratadas con etanol. CONCLUSIONES: El suministro moderado de etanol no afectó el GSA ni el HbA1c , pero alteró el perfil lípido de las ratas diabéticas por STZ. La ingestión moderada de etanol puede aumentar a un más el riesgo de las complicaciones de la diabetes.

Evaluation of antihyperlipidemic activity of ethanolic extract of Cassia auriculata flowers.

Hyperlipidemia is a major risk factor for development of coronary artery disease. Cassia auriculata is traditionally used in India for medicinal purposes. In this study, effect of ethanolic extract of Cassia auriculata flowers (Et-CAF) was investigated in Triton WR1339-induced hyperlipidemic rats. Treatment with the Et-CAF (450 mg/kg b.wt) significantly reduced the total cholesterol (TC), triglycerides (TG) and low-density lipoprotein-cholesterol (LDL) levels and significantly increased the high-density lipoprotein (HDL) level associated with reduction of atherogenic index in hyperlipidemic rats. However, there was no change in the serum lipid profile of normal rats treated with Et-CAF alone. The results suggest that Et-CAF has a beneficial effect in treating hyperlipidemia and may serve as a potential drug for prevention of hyperlipidemic atherosclerosis.

Statins for progression of aortic valve stenosis and the best evidence for making decisions in health care / Estatinas para a progressão da estenose da valva aórtica e a melhor evidência para tomar decisões em saúde

In the Western world, calcified aortic valve stenosis is the most common form of valvular heart disease, affecting up to 3 percent of adults over the age of 75 years. It is a gradually progressive disease, characterized by a long asymptomatic phase that may last for several decades, followed by a short symptomatic phase associated with severe restriction of the valve orifice. Investigations on treatments for aortic valve stenosis are still in progress. Thus, it is believed that calcification of aortic valve stenosis is similar to the process of atherosclerosis that occurs in coronary artery disease. Recent studies have suggested that cholesterol lowering through the use of statins may have a salutary effect on the progression of aortic valve stenosis.

No mundo ocidental, a estenose da valva aórtica calcificada é a forma mais comum de doença cardíaca valvar, afetando até 3 por cento dos adultos com idade acima de 75 anos. É uma doença gradual e progressiva, caracterizada por uma longa fase assintomática, podendo durar várias décadas, seguida de uma curta fase sintomática associada à restrição grave do orifício da valvar. A investigação sobre o tratamento da estenose da valva aórtica ainda está em curso. Desta forma, acredita-se que a calcificação da estenose da valva aórtica seja semelhante ao processo de aterosclerose que ocorre na doença arterial coronariana. Estudos recentes têm sugerido que a redução do colesterol pelo do uso das estatinas pode ter um efeito salutar sobre a progressão da estenose da valva aórtica.

Atorvastatin improves arterial stiffness in normotensive normolipidaemic persons with type 2 diabetes.

Increased arterial stiffness is an independent predictor of cardiovascular disease and mortality in middle-aged and olderadults. We measured arterial stiffness by pulse wave velocity (PWV)in brachial-ankle segments by automated oscillometry in 71 normotensive and normolipidaemic subjects with type 2 diabetes (40 males and 31 females). 57 patients (whose baPWV was more than 1400 cm/second) were randomised into two groups, group A (n=29) were given 10 mg atorvastatin daily for 6 months and group B (n=28) were given placebo. After 6 months, atorvastatin group had significant improvement in brachial-ankle pulse wave velocity (baPWV) (1712.03 +/- 349.9 cm/second versus 1558.81 +/- 303.26 cm/ second, p< 0.05). Though the placebo group showed some improvement (1692.03 +/- 425.15 cm/second versus 1636.78 +/- 425.1 cm/second) it was not statistically significant. Despite correlation was noted between baPWV and systolic blood pressure (SBP), there was no significant correlation between the mean baPWV and duration of diabetes, body mass index (BMI), waist circumference, waist-hip ratio (WHR), waist to height ratio (WHtR), glycated haemoglobin (HbA1c), LDL, HDL cholesterol and spot urine albumin creatinine ratio (ACR) at the baseline. The decrement of LDL-cholesterol is correlated with the decrement of the baPWV in the atorvastatin group only (p<0.01).

Effect of atorvastatin on LDL & hs-CRP in a selected Thai population.

BACKGROUND: LDL and hs-CRP are risk factors for vascular events and can be modified by Statin. OBJECTIVE: To evaluate the baseline hs-CRP of a certain Thai population who would need Atorvastatin, to evaluate the dose response of Atorvastatin toward LDL and hs-CRP level, and to evaluate the efficacy and safety of different types of Atorvastatin. MATERIAL AND METHOD: Subjects, who needed Statin therapy, were randomized to receive either 20 mg of Berlin(B)-Atorvastatin(R) or Pfizer(P)-Atorvastatin(R). The cross over took place after 8 weeks of therapy and continued for 16 weeks. Baseline blood tests were compared to 8 and 16 weeks. The effect of two brands of 20 mg Atorvastatin toward serum lipid, LFT, muscle enzyme and hs-CRP were compared. RESULTS: One hundred and ten subjects aged between 20-75 years enrolled in the present study. Fifty-four and 56 patients were randomized to group A and B. Baseline total cholesterol, LDL, HDL, and TG were 251, 174, 55, and 160 mg/dl respectively. There was a wide variation of baseline hs-CRP level. One hundred and seven patients completed this 16 weeks study. Atorvastatin 20 mg lowered TC by 32%, LDL 44% and hs-CRP 10% at 16 weeks for the entire study (p < 0.003). The effect of either Atorvastatin the lipid profiles and hs-CRP were different. There was no significant change in LFT or muscle enzyme. CONCLUSION: Atorvastatin 20 mg has a dramatic effect on the lipid but moderate effect on CRP. The two different types of Atorvastatin (group A and B) have similar effect on both safety and efficacy.

Efficacy and safety of combination of extended release niacin and atorvastatin in patients with low levels of high density lipoprotein cholesterol.

OBJECTIVE: We investigated the safety and efficacy of combination therapy of extended release (ER) niacin and atorvastatin in patients with low HDL-C and compared the results with atorvastatin monotherapy. METHODS: This open label study recruited consecutive men and women who had coronary artery disease with HDL-C levels <35 mg/dL. These patients were already on atorvastatin therapy targeted to lower low density lipoprotein cholesterol (LDL-C), for a minimum period of 6 months. Group 1, n = 104 (mean age 52.7 years) received ER niacin in addition to atorvastatin and group 2 (n = 106) continued on atorvastatin (mean age 52.3 years). ER niacin dose was built up to a maximum of 1.5 g and atorvastatin dose titrated according to LDL levels in both the groups. The lipoprotein levels at baseline were similar (p = NS). RESULTS: At 9 +/- 1.8 months of follow-up, the mean dose of ER niacin was 1.3 g and atorvastatin 13.2 mg in group 1. In comparison, group 2 patients had mean atorvastatin dose of 15.9 mg. Patients in group 1 had significant elevation in HDL-C cholesterol (39.5 +/- 5.5 vs 35.7 +/- 4.5 mg/dL), reduction in total cholesterol (156.4 +/- 31 vs 164.5 +/- 39.3 mg/dL) and also LDL-C (88.9 +/- 28.3 vs 99.8 +/- 35.4 mg/dL) compared to group 2 (all p < 0.05). The magnitude of reduction in triglyceride levels was not significant between the groups (140.1 +/- 40.4 vs 145.2 +/- 46.5 mg/dL) (p = NS). No major adverse events or clinical myopathy occurred in either groups. Four patients (4%) discontinued ER niacin (2 due to gastro-intestinal symptoms and 2 due to worsening of diabetes). Flushing occurred in 3% patients, but none felt it to be troublesome. CONCLUSION: Adding ER niacin to atorvastatin exhibited beneficial effects on lipid profile with significant elevation of HDL-C cholesterol and further lowering of LDL-C compared to monotherapy. This treatment offered better targeted therapy and was well tolerated with proper monitoring in Indian patients.

Doses intermitentes de estatina em pacientes em hemodiálise com LDL-colesterol espontaneamente baixo / Intermittent doses of statin in hemodialysis patients with spontaneous low LDL cholesterol levels

FUNDAMENTO: A mortalidade na diálise continua elevada e ocorre principalmente por causas cardiovasculares. A inflamação participa da gênese da aterosclerose acelerada, calcificação vascular, desnutrição e anemia, e tem enorme impacto na sobrevida destes pacientes. As estatinas, através dos seus efeitos pleiotrópicos, podem representar uma opção terapêutica para atenuação do processo inflamatório crônico dos pacientes em hemodiálise. OBJETIVO: Avaliar os efeitos de uma baixa dose de sinvastatina sobre marcadores inflamatórios, parâmetros hematimétricos e nutricionais de pacientes em hemodiálise. MÉTODOS: Pacientes em hemodiálise clinicamente estáveis foram divididos, segundo os níveis basais de LDL-colesterol, em um grupo com níveis abaixo (Grupo 1) e outro com níveis iguais ou superiores a 100 mg/dl (Grupo 2) e tratados com sinvastatina por oito semanas. O Grupo 1 recebeu apenas 20 mg após cada sessão de diálise (dose intermitente), enquanto o Grupo 2 recebeu 20 mg/dia. Dados laboratoriais, índice de resistência a eritropoetina e parâmetros nutricionais foram obtidos antes e após o tratamento. RESULTADOS: Houve redução significativa e equivalente dos níveis de proteína C-reativa em ambos os grupos (35,97±49,23 por cento vs 38,32±32,69 por cento, p=0,86). No Grupo 1 também houve tendência a queda da resistência a eritropoetina (228,6±16,2 vs 208,9±16,2, p=0,058) e melhora dos parâmetros hematimétricos (hematócrito: 33,1±5,9 por cento vs 36,1±4,5 por cento, p=0,021). CONCLUSÃO: A dose intermitente mostrou-se tão eficaz quanto a dose usual em reduzir os níveis de proteína C-reativa e resistência a eritropoetina, além de melhorar os parâmetros hematimétricos, apontando para uma importante redução do risco cardiovascular avaliado por esses parâmetros.

BACKGROUND: Mortality in dialysis patients remains high and is due mainly to cardiovascular causes. Inflammation has a role in the genesis of accelerated atherosclerosis, vascular calcification, malnutrition and anemia, and a huge impact on the survival of these patients. The pleiotropic effects of statins can be a therapeutic option for reducing chronic inflammatory processes of patients undergoing hemodialysis. OBJECTIVE: To evaluate the effects of low doses of simvastatin on inflammatory markers, hematimetric and nutritional parameters of patients undergoing hemodialysis. METHODS: Clinically-stable patients undergoing hemodialysis were classified according to their baseline LDL-cholesterol levels in two groups: those with levels below 100mg/dl (Group 1) and those with levels equal to or greater than 100mg/dl (Group-2), and were treated with simvastatin during eight weeks. Group 1 received 20mg only after each session of hemodialysis (intermittent dose), whereas Group 2 received 20mg/daily. Laboratory data, erythropoietin resistance index and nutritional parameters were obtained before and after treatment. RESULTS: A significant and equivalent reduction in C-reactive protein levels in both groups was observed (35.97±49.23 percent vs 38.32±32.69 percent, p=0.86). In group 1, there was also a tendency towards reduced resistance to erythropoietin (228.6±16.2 vs 208.9±16.2, p=0.058) and improvement of hematimetric parameters (hematocrit: 33.1±5.9 percent vs 36.1±4.5 percent, p=0.021). CONCLUSION: Intermittent doses proved to be as effective as the usual dose in reducing C-reactive protein levels and resistance to erythropoietin, besides improving the hematimetric parameters, indicating an important reduction of the cardiovascular risk evaluated by these parameters.

Glycemic and lipid responses to glucomannan in Thais with type 2 diabetes mellitus.

OBJECTIVE: To evaluate the benefits of glucomannan supplement on glycemic and lipid controls in type 2 diabetic patients. MATERIAL AND METHOD: A single-blind, placebo-controlled, crossover trial with two treatments separated by a 2-week washout period was performed in 10 men and 10 women with type 2 diabetes mellitus. Two separated protocols of experiments were sequentially followed. Initially, purified glucomannan (1 g) or placebo was ingested 30 min before 75-g glucose load to evaluate their effects on glucose absorption and insulin secretion in oral glucose tolerance test (OGTT). Later, the glycemic and lipid changes after 4-week intervention with 3 g/day glucomannan comparing to the placebo were determined. The standard OGTT was performed before and after ending of each intervention. RESULTS: Glucomannan taken before performing the OGTT can lower the rise of blood glucose and insulin from 1 to 2 hour in comparison with the placebo, though a statistically significance of insulin was not achieved. Long-term glucomannan supplement significantly reduced the 120-min glucose area under the curve of OGTT. Glucomannan also decreased the rise of low-density lipoprotein cholesterol (LDL-C). Reductions of HOMA-insulin resistance index and body mass index were detected in glucomannan-treated group though the former was shown only in females. No within- and between-group differences of insulin, fructosamine, and other lipids were observed in glucomannan- nor placebo- treated groups. CONCLUSION: In type 2 diabetes, pre-prandial glucomannan ingestion attenuated a rise of blood glucose without significantly affecting insulin levels. Long-term supplement of glucomannan to the regular diabetic regimen lessened post challenge glucose AUC and impeded the rise of LDL-C. Supplement of glucomannan may be beneficial to the glycemic and lipid controls in type 2 diabetes mellitus.