From the University of Pennsylvania School
`of Medicine, Philadelphia (M.C., L.T.B.,
`P.O.S., D.M.K., M.L.W.,J.S.M., E.S.S., DJ.R.);
`H6tel Dieu de France Hospital, St. joseph
`University, Beirut, Lebanon (A.S.);Jikei Uni(cid:173)
`versity School of Medicine, Tokyo (K.I.);
`and Bristol-Myers Squibb Pharmaceuti(cid:173)
`cal Research Institute, Lawrenceville, NJ
`(R.E.G.). Address reprint requests to Dr.
`Rader at the University of Pennsylvania
`Medical Center, 654 BRBII/111 Labs, 421
`Curie Blvd., Philadelphia, PA 19104, or at
`rader@mail.med.upenn.edu.
`
`N Englj Med 2007;356:148-56.
`Copyright © 2001 Massachusetts Medical Society.
`
`Tht NEW ENGLAND JOURNAL of MEDICINE
`
`~~~--------------o_R_r_G_r_N_A_L_A_R_T_rc_L_E ____________ ~II
`
`Inhibition of Microsomal Triglyceride Transfer
`Protein in Familial Hypercholesterolemia
`
`Marina Cuche!, M.D., Ph.D., LeAnne T. Bloedon, M.S., R.D.,
`Philippe 0. Szapary, M.D., Daniel M. Kolansky, M.D., Megan L. Wolfe, B.S.,
`Antoine Sarkis, M.D., johnS. Millar, Ph.D., Katsunori lkewaki, M.D.,
`EvanS. Siegelman, M.D., Richard E. Gregg, M.D., and DanieiJ. Rader, M.D.
`
`ABSTRACT
`
`BACKGROUND
`Patients with homozygous familial hypercholesterolemia have markedly elevated
`cholesterol levels, which respond poorly to drug therapy, and a very high risk of
`premature cardiovascular disease. Inhibition of the microsomal triglyceride trans(cid:173)
`fer protein may be effective in reducing cholesterol levels in these patients.
`
`METHODS
`We conducted a dose-escalation study to examine the safety, tolerability, and effects
`on lipid levels of BMS-201038, an inhibitor of the microsomal triglyceride transfer
`protein, in six patients with homozygous familial hypercholesterolemia. All lipid(cid:173)
`lowering therapies were suspended 4 weeks before treatment. The patients received
`BMS-201038 at four different doses (0.03, 0.1, 0.3, and 1.0 mg per kilogram of body
`weight per day), each for 4 weeks, and returned for a final visit after a 4-week drug
`washout period. Analysis oflipid levels, safety laboratory analyses, and magnetic reso(cid:173)
`nance imaging of the liver for fat content were performed throughout the study.
`
`RESULTS
`All patients tolerated titration to the highest dose, 1.0 mg per kilogram per day.
`Treatment at this dose decreased low-density lipoprotein (LDL) cholesterol levels by
`50.9% and apolipoprotein B levels by 55.6% from baseline (P<O.OOl for both com(cid:173)
`parisons). Kinetic studies showed a marked reduction in the production of apolipo(cid:173)
`protein B. The most serious adverse events were elevation ofliver aminotransferase
`levels and accumulation of hepatic fat, which at the highest dose ranged from less
`than 10% to more than 40%.
`
`CONCLUSIONS
`Inhibition of the microsomal triglyceride transfer protein by BMS-201038 resulted
`in the reduction of LDL cholesterol levels in patients with homozygous familial
`hypercholesterolemia, owing to reduced production of apolipoprotein B. However,
`the therapy was associated with elevated liver aminotransferase levels and hepatic
`fat accumulation.
`
`148
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`JANUARY 11, 2007
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`
`INHIBITION OF MTTP IN FAMILIAL HYPERCHOLESTEROLEMIA
`
`H OMOZYGOUS FAMILIAL HYPERCHOLES(cid:173)
`
`terolemia is caused by loss-of-function
`mutations in both alleles of the low-den(cid:173)
`sity lipoprotein (LDL) receptor gene.1-3 Patients
`with the disease have plasma cholesterol levels
`of more than 500 mg per deciliter (12.9 mmol per
`liter); if untreated, patients have cardiovascular
`disease before 20 years of age and generally do
`not survive past 30 years of age.l-3 Patients with
`homozygous familial hypercholesterolemia also
`have a poor response to conventional drug ther(cid:173)
`apy, 1"3 which generally lowers LDL cholesterol
`levels through up-regulation of the hepatic LDL
`receptor. The current standard of care for these
`patients is LDL apheresis. This procedure can
`transiently reduce LDL cholesterol levels by more
`than 50%4 •5 and may delay the onset of athero(cid:173)
`sclerosis, 6 "8 but it must be repeated frequently
`(every 1 to 2 weeks) and is not widely available.
`Thus, new therapies are needed for patients with
`homozygous familial hypercholesterolemia, as
`well as for other patients with severe refractory
`hypercholesterolemia who are candidates for LDL
`apheresis.
`A potentially effective therapy for homozy(cid:173)
`gous familial hypercholesterolemia would be to
`reduce LDL production. The microsomal triglyc(cid:173)
`eride transfer protein is responsible for transfer(cid:173)
`ring triglycerides onto apolipoprotein B within
`the liver in the assembly of very-low-density lipo(cid:173)
`protein (VLDL), the precursor to LDL.9 In the
`absence of functional microsomal triglyceride
`transfer protein, as in the rare recessive genetic
`disorder abetalipoproteinemia, the liver cannot
`secrete VLDL, leading to the absence of all lipo(cid:173)
`proteins containing apolipoprotein B in the
`
`Table 1. Baseline Characteristics of the Study Patients.
`
`plasma.10"12 Thus, the pharmacologic inhibition
`of microsomal triglyceride transfer protein might
`be a strategy for reducing LDL production and
`plasma LDL cholesterol levels.
`Preclinical studies in animal models lacking
`LDL receptors have shown that the inhibition of
`microsomal triglyceride transfer protein signifi(cid:173)
`cantly reduces serum cholesterol levels.13•14 We
`evaluated the cholesterol-lowering efficacy of the
`microsomal triglyceride transfer protein inhibi(cid:173)
`tor BMS-201038 in patients with homozygous fa(cid:173)
`milial hypercholesterolemia and determined the
`mechanism of cholesterol reduction, the tolerabil~
`ity, and the effects on hepatic fat, using magnetic
`resonance imaging (MRI).
`
`METHODS
`
`STUDY PATIENTS
`Six patients with homozygous familial hypercho(cid:173)
`lesterolemia (three men and three women), 18 to
`40 years of age, were enrolled in and completed
`the study. A diagnosis of homozygous familial
`hypercholesterolemia was suspected on clinical
`grounds and was confirmed by genetic analysis.
`Exclusion criteria were major surgery in the pre(cid:173)
`vious 3 months, congestive heart failure, history
`ofliver disease or aminotransferase levels of more
`than three times the upper limit of the normal
`range, a serum creatinine level of more than 2.5 mg
`per deciliter (221~-tmol per liter), cancer within
`the past 5 years, or history of alcohol abuse or
`drug abuse. 1\vo patients had known, clinically
`significant cardiovascular disease; both had un(cid:173)
`dergone prosthetic-valve replacement and were
`receiving anticoagulation therapy. Our study was
`
`Patient
`No.
`
`Sex
`
`1
`
`2
`
`3
`
`4
`
`5
`
`6
`
`F
`
`F
`
`M
`
`F
`
`M
`M
`
`Age
`yr
`18
`
`18
`
`35
`
`40
`22
`
`21
`
`Weight
`kg
`56.1
`
`59.0
`
`85.4
`
`77.3
`
`60.1
`
`64.0
`
`Body-Mass
`Index*
`
`Cardiovascular
`Diseaset
`
`LDL·Receplor
`Gene Mutations
`
`24.3
`
`25.3
`
`27.7
`
`30.1
`
`18.5
`
`23.2
`
`Absent
`
`Absent
`
`Present
`
`Present
`
`Absent
`
`Absent
`
`deiEx3-6fdeiEx3-6
`
`1877deiAJ?
`
`652deiGGT /652deiGGT
`
`Serl56leu/Serl56Leu
`
`Cys660XaaJCys660Xaa
`
`Cys660XaafCys660Xaa
`
`*The body-mass index is the weight in kilograms divided by the square of the height in meters.
`t Patients 3 and 4 had symptomatic coronary artery disease that was confirmed by coronary angiography. Patients 1, 2, 5,
`and 6 had no symptoms of cardiovascular disease and were regularly evaluated with the use of noninvasive testing
`(and, if appropriate, coronoary angiography), without evidence of obstructive coronary disease.
`
`N ENGLJ MED 356;2 WWW.NEJM.ORG JANUARY 11, 2007
`
`149
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`The NEW ENGLAND JOURNAL of MEDICINE
`
`Table 2. Upid and Upoproteln Levels at Baseline, after Receipt of One of four Doses ofBMS-201038 for 4 Weeks, and after the 4-Week
`Washout Period.*
`
`Measure
`
`Total cholesterol (mgfdl)
`
`1
`
`2
`
`Patient No.
`4
`
`3
`
`5
`
`6
`
`Baseline
`0.03 mg
`0.1 mg
`
`0.3 mg
`
`l.Omg
`
`Washout
`
`LDL cholesterol (mgfdl)
`
`Baseline
`0.03 mg
`
`0.1 mg
`0.3 mg
`1.0 mg
`
`Washout
`
`VLDL cholesterol (mgfdl)
`
`756
`660
`627
`
`482
`284
`
`993
`
`480
`505
`
`558
`348
`224
`804
`
`837
`840
`
`858
`
`714
`410
`1053
`
`789
`748
`
`753
`642
`383
`883
`
`903
`717
`
`585
`
`591
`443
`
`1023
`
`609
`585
`
`483
`498
`403
`858
`
`684
`717
`
`774
`
`504
`340
`
`714
`
`637
`668
`718
`436
`301
`518
`
`711
`684
`
`648
`424
`236
`714
`
`534
`442
`
`481
`387
`201
`559
`
`1212
`1248
`
`1086
`
`891
`379
`738
`
`636
`597
`
`403
`478
`306
`478
`
`Percent Change
`from Baseline
`
`PValue
`
`-4.8±9.9
`
`-9.3±16.6
`
`-29.8±9.2
`-58.4±8.6
`6.0±25.1
`
`-3.7±8.3
`-7.1±20.1
`-24.7±5.3
`-50.9±9.3
`13.6±35.4
`
`0.29
`
`0.23
`
`<0.001
`<0.001
`
`0.58
`
`0.32
`
`0.42
`<0.001
`<0.001
`0.39
`
`Baseline
`
`0.03 mg
`
`0.1 mg
`0.3 mg
`1.0 mg
`
`Washout
`
`Triglycerides (mgjdl)
`
`Baseline
`
`0.03 mg
`0.1 mg
`0.3 mg
`
`l.Omg
`
`Washout
`
`256
`135
`48
`108
`34
`
`153
`
`285
`
`248
`194
`
`200
`
`51
`226
`
`21
`69
`84
`
`48
`5
`138
`
`130
`84
`
`68
`87
`
`56
`119
`
`270
`114
`
`75
`57
`18
`
`138
`
`362
`
`279
`
`139
`148
`
`102
`210
`
`12
`15
`
`24
`29
`8
`
`162
`
`82
`
`110
`
`113
`88
`46
`234
`
`153
`220
`
`138
`28
`14
`
`129
`
`233
`
`416
`
`105
`126
`
`69
`135
`
`549
`627
`642
`
`372
`44
`
`216
`
`605
`
`502
`
`658
`340
`206
`288
`
`34.4±103.3
`
`42.3±142.4
`3.3±103.7
`-78.7±23.1
`273.6±535.1
`
`4.1±43.5
`
`-24.9±39.7
`-34.1±22.8
`
`-65.2±13.3
`3.3±90.6
`
`0.45
`
`0.50
`0.94
`<0.001
`
`0.27
`
`0.83
`0.19
`0.02
`
`<0.001
`0.93
`
`This was an open-label study to evaluate the
`approved by the institutional review board and
`the General Clinical Research Center of the Uni-
`safety, tolerability, and efficacy of BMS-201038
`for the treatment of patients with homozygous
`versity of Pennsylvania and was monitored by the
`Office of Human Research of the University of familial hypercholesterolemia. During an initial
`Pennsylvania. The study protocol was fully ex-
`screening visit, the eligibility of the six patients
`plained to all six patients, each of whom provid- was verified, their health status was evaluated,
`ed written, informed consent.
`and a very-low-fat diet was initiated. All lipid-
`lowering treatments, including apheresis, were
`suspended at least 4 weeks before the baseline
`STUDY PROTOCOL
`The authors designed the study and generated, visit and continued to be suspended until the
`held, and analyzed the data. The study drug, EMS-
`study was completed. No other drug treatment
`201038, was provided by Bristol-Myers Squibb.
`was suspended. BMS-201038 was administered,
`
`150
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`JANUARY 11, 2007
`
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`INHIBITION OF MTTP IN FAMILIAL HYPERCHOLESTEROLEMIA
`
`Table 2. (Continued.)
`
`Measure
`
`Patient No.
`
`Percent Change
`from Baseline
`
`PValue
`
`Apolipoprotein B (mgfdl)
`
`Baseline
`
`0.03 mg
`
`0.1 mg
`
`0.3 mg
`
`1.0 mg
`
`Washout
`
`HDL cholesterol (mgfdl)
`
`Baseline
`
`O.Q3 mg
`
`315
`
`306
`
`276
`
`228
`
`112
`
`324
`
`20
`
`20
`
`2
`
`3
`
`4
`
`5
`
`6
`
`273
`
`354
`
`336
`
`312
`
`149
`
`345
`
`27
`
`23
`
`21
`
`342
`
`336
`
`288
`
`273
`
`216
`
`432
`
`24
`
`18
`
`27
`
`240
`
`300
`
`276
`
`216
`
`121
`
`324
`
`35
`
`34
`
`303
`
`330
`
`225
`
`213
`
`91
`
`282
`
`24
`
`22
`
`29
`
`387
`
`396
`
`375
`
`330
`
`127
`
`312
`
`27
`
`24
`
`41
`
`10.2±14.0
`
`-3.2±18.8
`
`-14.7±16.0
`
`-55.6±13.5
`
`10.7±21.7
`
`0.13
`
`0.70
`
`0.08
`
`<0.001
`
`0.28
`
`-10.4±9.0
`
`9.9±25.6
`
`0.04
`
`0.39
`
`0.1 mg
`
`0.3 mg
`
`1.0 mg
`
`Washout
`
`Apolipoprotein A-1 (mgfdl)
`
`Baseline
`
`0.03 mg
`
`0.1 mg
`
`0.3 mg
`
`1.0 mg
`
`Washout
`
`21
`
`26
`
`26
`
`36
`
`68
`
`67
`
`69
`
`78
`
`62
`
`100
`
`24
`
`22
`
`32
`
`79
`
`67
`
`64
`
`70
`
`64
`
`81
`
`36
`
`22
`
`27
`
`83
`
`63
`
`79
`
`80
`
`64
`
`82
`
`32
`
`39
`
`31
`
`34
`
`76
`
`80
`
`80
`
`88
`
`67
`
`96
`
`9
`
`21
`
`26
`
`62
`
`77
`
`65
`
`64
`
`49
`
`76
`
`41
`
`29
`
`44
`
`30
`
`95
`
`74
`
`94
`
`44
`
`104
`
`11.6±43.5
`
`-2.2±18.0
`
`29.9±33.4
`
`34.2±90.9
`
`22.4±61.5
`
`38.7±86.2
`
`-6.1±26.4
`
`57.3±94.4
`
`0.54
`
`0.77
`
`0.08
`
`0.40
`
`0.41
`
`0.32
`
`0.59
`
`0.20
`
`*Plus-minus values are means ±SD. To convert values for cholesterol to millimoles per liter, multiply by 0.02586. To convert values for
`triglycerides to millimoles per liter, multiply by 0.01129. P values are for the levels during the study versus those at baseline.
`
`est dose and treatment proceeded per protocol.
`beginning at the baseline visit, at four increas-
`ing doses -
`0.03, 0.1, 0.3, and 1.0 mg per kilo- Adverse events were judged by one of the inves(cid:173)
`gram of body weight per day- each for 4 weeks.
`tigators as not related to treatment with the study
`The patients returned to the General Clinical Re- drug, unlikely to be related, possibly related, prob(cid:173)
`search Center every 7, 14, and 28 days after the ably related, or definitely related, and these judg(cid:173)
`start of a new dose, and 28 days after the last ments were reviewed by a data and safety moni(cid:173)
`dose of the study drug, for safety and pharmaco-
`to ring board.
`dynamic evaluations.
`The most recent Common Terminology Crite- DIET
`ria for Adverse Events of the National Cancer In- All patients received detailed dietary counseling
`by a registered dietitian at the screening visit and
`stitute (initially version 2 and subsequently ver-
`sion 3) were used to assign a severity grade to all at all subsequent visits until after the study drug
`adverse events. According to protocol, if a patient was discontinued. The patients were advised to
`had a confirmed grade 3 (severe) adverse event, consume a diet containing less than 10% of en(cid:173)
`the dose was decreased to 1.5 times the previous ergy from total dietary fat while consuming ad(cid:173)
`dose for 4 weeks (with visits at 7, 14, and 28 days equate calories to maintain weight or promote
`during that period). If there was no evidence of growth. All patients received a standard multi(cid:173)
`adverse events of grade 3 or higher during that vitamin that supplied 100% of the reference di(cid:173)
`period, the dose was increased to the next-high-
`etary intake for all vitamins and minerals.
`
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`The NEW ENGLAND JOURNAL of MEDICINE
`
`MRI OF THE LIVER
`MRI of the liver was conducted at baseline, after
`4 weeks at each dose, and at 4 weeks after drug
`withdrawal, with the use of chemical-shift MRI
`techniques that have been shown to evaluate fat
`content of the liver accurately.15•16 All quantita(cid:173)
`tive MRI measurements of hepatic fat content
`were performed by a single radiologist, who was
`unaware of the patients' clinical status and liver(cid:173)
`function results.
`
`LABORATORY ANALYSIS
`Blood was drawn at each visit, after a 12-hour
`fast. A standard metabolic panel, complete blood
`count, and standard urinalysis were also per(cid:173)
`formed at each visit. Plasma lipid and lipoprotein
`analyses were performed in a lipid laboratory stan(cid:173)
`dardized by the Centers for Disease Control and
`Prevention. Total cholesterol, high-density lipo(cid:173)
`protein (HDL) cholesterol, and triglyceride levels
`were measured enzymatically on an autoanalyzer
`(Cobas Fara II, Roche Diagnostic Systems) with
`reagents from Sigma Chemical Co. VLDL and LDL
`cholesterol levels were determined with the use
`ofbeta-quantification and the standard Lipid Re(cid:173)
`search Clinics protocol as modified by Cole et
`al.17 Levels of apolipoproteins B and A-I were mea(cid:173)
`sured with the use of reagents from Wako Chem(cid:173)
`icals USA, and Lp(a) lipoprotein levels were mea(cid:173)
`sured with reagents from Diasorin on a Cobas
`Fara II autoanalyzer. Levels of lipoprotein sub(cid:173)
`classes were determined with the use of proton
`nuclear magnetic resonance spectroscopy, as pre(cid:173)
`viously described.18
`
`KINETICS STUDIES
`Before the study began, three patients (Patients
`4, 5, and 6) had participated in a kinetics study to
`investigate the metabolism oflipoproteins contain(cid:173)
`ing apolipoprotein B in patients with homozygous
`familial hypercholesterolemia.19 To investigate in
`vivo the mechanism of action ofBMS-201038, we
`repeated the kinetic study in these patients at
`the end of the 4-week period at the highest dose
`(1.0 mg per kilogram per day), using identical
`methods (endogenous labeling with deuterated
`leucine).
`
`STATISTICAL ANALYSIS
`Statistical comparisons were performed with SAS
`software (version 8.2, SAS Institute). Continuous
`variables that were not normally distributed, such
`
`as fasting triglyceride levels, were appropriately
`transformed to meet the assumptions of subse(cid:173)
`quent statistical tests. Continuous variables were
`analyzed using paired t-tests for changes over
`time or the Wilcoxon signed-rank test, as appro(cid:173)
`priate. Percentages were analyzed using the chi(cid:173)
`square test or Fisher's exact test when expected cell
`counts were less than 5. For within-patient com(cid:173)
`parisons over time, we used McNemar's test, along
`with matched odds ratios and 95% confidence
`intervals. All P values were calculated from two(cid:173)
`tailed tests, and P values less than 0.05 were con(cid:173)
`sidered to indicate statistical significance.
`
`RESULTS
`
`STUDY PATIENTS
`The characteristics of the six study patients at
`screening are shown in Table 1. Four patients
`(Patients 1, 3, 5, and 6) were found to be negative
`for the LDL receptor on the basis of homozygos(cid:173)
`ity for known loss-of..function LDL-receptor mu(cid:173)
`tations.1•2 A fifth (Patient 2) was found to be re(cid:173)
`ceptor-negative on the basis of phenotype and
`LDL-receptor activity in skin fibroblasts. The sixth
`patient (Patient 4) was found to have a defective
`LDL receptor on the basis of her LDL-receptor mu(cid:173)
`tation.
`
`EFFECTS OF BMS-201038 ON PLASMA LIPID
`AND LIPOPROTEIN LEVELS
`The mean doses of BMS-201038 at each of the
`four titration steps were 2.0, 6.7, 20.1, and 67.0
`mg per day. Table 2 shows the changes in lipid
`and lipoprotein levels during the study (addition(cid:173)
`al lipoprotein results are available in Table A in
`the Supplementary Appendix, available with the
`full text of this article at www.nejm.org). The mean
`total cholesterol level was 851 mg per deciliter
`(22.0 mmol per liter) at baseline. After 4 weeks
`of receiving the 0.3-mg-per-kilogram dose, the
`mean level was reduced to 601 mg per deciliter
`(15.5 mmol per liter), a 29.8% reduction from the
`baseline level (P<0.001). After 4 weeks of receiving
`the 1.0-mg-per-kilogram dose, the mean level was
`reduced to 349 mg per deciliter (9.0 mmol per li(cid:173)
`ter), a 58.4% reduction from baseline (P<0.001).
`The mean LDL cholesterol level was 614 mg
`per deciliter (15.9 mmol per liter) at baseline.
`After 4 weeks at the 0.3-mg-per-kilogram dose, the
`mean level was reduced to 465 mg per deciliter
`(12.0 mmol per liter), a 24.7% reduction from the
`
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`INHIBITION OF MTTP IN FAMILIAL HYPERCHOLESTEROLEMIA
`
`12S
`
`100
`
`7S
`
`so
`
`2S
`
`:ai
`
`.. c:
`[
`.. .. Gl
`E
`.g
`.. .c:
`~ c:
`u
`
`• Total cholesterol
`0 LDL cholesterol
`Y Apolipoprotein B
`
`0+------r-----,------~----~
`0.00
`0.03
`0.10
`0.30
`1.00
`
`Dose of BM5-201038 (mgfkgfday)
`
`Figure 1. Mean Percent Change from Baseline Levels
`ofTotal Cholesterol, LDL Cholesterol, and Apolipopro·
`tein B after Receipt of Four Doses of BMS-201038,
`Each for 4 Weeks.
`I bars indicate standard deviations.
`
`baseline level (P<0.001). At the 1.0-mg-per-kilo(cid:173)
`gram dose, the mean level was further reduced to
`303 mg per deciliter (7.8 mmol per liter), a 50.9%
`reduction from the baseline level (P<0.001).
`The me.an triglyceride level was 283 mg per
`deciliter (3.2 mmol per liter) at baseline and was
`reduced to 165 mg per deciliter (1.9 mmol per liter)
`after 4 weeks at the 0.3-mg-per-kilogram dose,
`a 34.1% reduction from the baseline level (P=0.02).
`After 4 weeks at the 1.0-mg-per-kilogram dose, the
`mean level was further reduced to 88 mg per deci(cid:173)
`liter (1.0 mmol per liter), a 65.2% reduction from
`the baseline level (P<0.001).
`The mean apolipoprotein B level was 310 mg
`per deciliter at baseline and, after 4 weeks at the
`0.3-mg-per-kilogram dose, was reduced to 262 mg
`per deciliter, a 14.7% reduction from the baseline
`level (P=0.08). After 4 weeks at the 1.0-mg-per(cid:173)
`kilogram dose, the mean level was further reduced
`to 136 mg per deciliter, a 55.6% reduction from the
`baseline level (P<O.OOl).
`Despite a range of lipid levels at baseline,
`similar percent reductions were observed during
`the study in all the patients (Fig. 1). There were
`no clinically significant changes in the plasma
`levels ofHDL cholesterol, apolipoprotein A-1, or
`Lp(a) lipoprotein. Lipoprotein subclass levels,
`measured by nuclear magnetic resonance spec(cid:173)
`troscopy, were consistent with the plasma lipid
`and apolipoprotein levels (see Table A in the Sup(cid:173)
`plementary Appendix). Thus, inhibition of the
`
`20
`
`A Patient 4
`j
`i .:!. 1S
`! ·g
`
`10
`
`.5 i
`
`B Patient 5
`
`-:::::..
`0
`E
`
`1S
`
`~ .. .~ 20
`.:!. .. c:
`'0 10
`.3
`l s
`
`After 4 wk of BMS-201038
`(1.0 mgfkgfday)
`
`25
`
`so
`Hours
`
`7S
`
`100
`
`Baseline
`
`After 4 wk of BMS-201038
`(1.0 mgfkgfday)
`
`~ 0
`
`0
`
`25
`
`50
`Hours
`
`75
`
`100
`
`C Patient 6
`~
`
`Baseline
`
`-~ 20
`-:::::..
`0
`E
`
`.:!. .. c: ·o
`
`:s
`.5
`]
`£
`'!2
`~
`
`15
`
`10
`
`After 4 wk of BMS-201038
`(1.0 mgfkgfday)
`
`so
`Hours
`
`75
`
`100
`
`Figure 2. Levels of Newly Produced LDL Apolipoprotein B,
`Represented by the Deuterated Leucine Tracer, at Base(cid:173)
`line and after Receipt ofBMS-201038 in Patients 4, 5,
`and 6.
`
`microsomal triglyceride transfer protein markedly
`reduced plasma levels of apolipoprotein B-con(cid:173)
`taining lipoproteins across the spectrum.
`Lipoprotein kinetics studies, using endogenous
`labeling with deuterated leucine, were performed
`in three of the six patients before the trial began
`and again during the 4 weeks at the highest dose
`of BMS-201038 (1.0 mg per kilogram). As com(cid:173)
`pared with the pretreatment (baseline) kinetic data,
`the rate of production ofillL apolipoprotein B dur(cid:173)
`ing those 4 weeks at LO mg per kilogram was re(cid:173)
`duced by approximately 70% (Fig. 2). This finding
`
`N ENGLJ MED 356;2 WWW.NEJM.ORG JANUARY 11,2007
`
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`
`The NEW ENGLAND JOURNAL of MEDICINE
`
`.. Patient 1
`• Patient 2
`• Patient 3
`• Patient 4
`• Patient 5
`o Patient 6
`
`A
`
`800
`
`700
`
`-.:-
`-~
`-::::.
`iii 600
`5:
`500
`l.!
`'!l
`c
`I!
`0 c
`·e
`< .. 200
`c ·;:
`'" < 100
`
`400
`
`300
`
`0
`
`0 1 2 3 4
`
`I
`
`2 3
`
`4 1 2 3 4 1
`Week
`
`2 3 4
`
`1 2 3
`
`4
`
`0.03
`
`0.10
`
`0.30
`
`1.00
`
`Washout
`
`Dose (mgfkgfday)
`
`B
`
`[
`~ .. >
`~
`LL
`
`::;
`
`50
`
`40
`
`30
`
`20
`
`10
`
`0
`
`O.Q3
`
`0.10
`
`0.30
`Dose (mgfkgfday)
`
`1.00
`
`Washout
`
`Figure 3. Serum Levels of Alanine Aminotransferase (Panel A) and Percent(cid:173)
`age of Fat in the Liver (Panel B), as Measured by MRI at Baseline, after Re(cid:173)
`ceipt of Four Doses of BMS-201038 and after the 4-Week Washout Period.
`
`shows that the mechanism of the reduction in LDL
`cholesterol levels induced by the microsomal tri(cid:173)
`glyceride transfer protein is reduced production
`of apolipoprotein B.
`
`tients reported one or more episodes of increased
`stool frequency of mild or moderate intensity. All
`episodes were transient and in many cases were
`temporally linked to consumption of a relatively
`high-fat meal. The average caloric intake from fat
`during the entire study was 16.7%, but the range
`was less than 10% to approximately 30%, and fat
`intake may have influenced the gastrointestinal
`tolerability of the drug. By the end of the 4 weeks
`at 1.0 mg per kilogram of BMS-201038 per day,
`there was a trend toward a decrease in body weight
`as compared with baseline {mean [±SD] decrease,
`4.4±2.9%; P=0.06). Weight rebounded to base(cid:173)
`line values after the 4-week washout period.
`We observed elevated liver aminotransferase
`levels {Fig. 3A, and Table C in the Supplementary
`Appendix) in four of the six patients. In addition,
`hepatic fat {Fig. 3B) increased substantially in four
`patients in response to treatment with BMS-
`201038. 1\vo patients {Patients 1 and 4) did not
`have elevated aminotransferase levels and had only
`minimal increases in hepatic fat {less than 10%).
`In two other patients (Patients 2 and 5), the eleva(cid:173)
`tion in aminotransferase levels was dose-depen(cid:173)
`dent, and the hepatic fat content was 18 to 24%.
`In Patients 3 and 6, aminotransferase levels were
`elevated substantially, and the hepatic fat content
`increased to more than 30% at the highest dose.
`In particular, Patient 3 had a confirmed grade 3
`elevation in aminotransferase level 1 week after
`titration to the 0.3-mg-per-kilogram dose. As per
`protocol, the dose was reduced to 0.15 mg per ki(cid:173)
`logram for 4 weeks, with a consequent decrease
`in aminotransferase levels, and was then titrated
`back up to 0.3 mg per kilogram. The patient then
`completed 4 weeks of treatment at both the
`0.3-mg-per-kilogram and 1.0-mg-per-kilogram
`doses. Aminotransferase and hepatic fat levels re(cid:173)
`turned to baseline levels 4 weeks after the therapy
`was ceased in all the patients except Patient 3, in
`whom they did not return to the normal range
`until 14 weeks after cessation of therapy.
`
`DISCUSSION
`
`SAFETY AND TOLERABILITY
`In this study, we showed that treating patients
`A list of all adverse events reported during the
`study is given in Table B in the Supplementary who have homozygous familial hypercholesterol(cid:173)
`Appendix. No patients withdrew from the study emia with the microsomal triglyceride transfer
`owing to an adverse event. Adverse events judged protein inhibitor BMS-201038 was highly effective
`in reducing plasma LDL cholesterol levels, with a
`to be possibly or probably drug-related included
`primarily gastrointestinal adverse events, partie-
`reduction of more than 50% at the highest dose.
`ularly increased stool frequency. Five of the six pa- Plasma levels of all other apolipoprotein B-con-
`
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`INHIBITION OF MTTP IN FAMILIAL HYPERCHOLESTEROLEMIA
`
`taining lipoproteins were similarly reduced by in(cid:173)
`hibition of the microsomal triglyceride transfer
`protein. We also established that the mechanism
`of this reduction in LDL cholesterol is a markedly
`reduced rate of production of LDL apolipopro(cid:173)
`tein B. Thus, inhibition of microsomal triglycer(cid:173)
`ide transfer protein is effective in lowering plasma
`levels of atherogenic apolipoprotein B-contain(cid:173)
`ing lipoproteins in patients lacking functional
`LDL receptors.
`Because the microsomal triglyceride transfer
`protein is expressed in the intestine and is required
`for chylomicron assembly and secretion,9 inhibi(cid:173)
`tion of the protein could cause steatorrhea. For
`this reason, we instructed patients in this study
`to follow a diet containing less than 10% of en(cid:173)
`ergy from fat In addition, we devised a dose-titra(cid:173)
`tion strategy that might allow the intestine to
`accommodate the increasing inhibition of micro(cid:173)
`somal triglyceride transfer protein. Under these
`conditions, all six patients tolerated the drug
`up to the highest dose (1.0 mg per kilogram per
`day), with relatively minor gastrointestinal side
`effects. The few episodes of frequent stools were
`dose-related, transient, and temporally associ(cid:173)
`ated with consumption of a relatively high-fat
`meal. Patients with abetalipoproteinemia, who
`completely lack microsomal triglyceride trans(cid:173)
`fer protein, learn early in life to consume a fat(cid:173)
`restricted diet in order to avert steatorrhea. 10•20-
`22
`Thus, it may be possible to minimize the gastro(cid:173)
`intestinal side effects of microsomal triglyceride
`transfer protein inhibition through dietary fat
`restriction, dose titration and, when necessary,
`reduction of the dose.
`Accumulation ofliver fat is likely to be intrin(cid:173)
`sically linked to the mechanism of action of mi(cid:173)
`crosomal triglyceride transfer protein inhibitors,
`and such accumulation could present a serious
`barrier to the clinical use of this class of agents.
`In our small study, we noted substantial variabil(cid:173)
`ity among the six patients, in whom responses
`ranged from no elevation of aminotransferase lev(cid:173)
`els and minimal changes in hepatic fat content in
`two patients to substantial elevation of amino(cid:173)
`transferase levels and increases in hepatic fat con(cid:173)
`tent to more than 30% in two others. Of the latter
`patients, one had marked hypertriglyceridemia,
`and the other revealed that he had been drinking
`a substantial amount of alcohol during the study.
`
`Thus, these patients had metabolic perturbations
`associated with increased hepatic triglyceride syn(cid:173)
`thesis that might have predisposed them to great(cid:173)
`er increases in hepatic fat. In five of the six pa(cid:173)
`tients, hepatic fat content returned to baseline
`levels 4 weeks after the drug was withdrawn, but
`it did persist in the sixth patient.
`The clinical significance of hepatic fat accu(cid:173)
`mulation and the probability of its evolution to
`fibrotic liver disease are still debated, but substan(cid:173)
`tial elevation of aminotransferase levels and hepa(cid:173)
`tic steatosis are potentially serious adverse events
`that should not be underestimated. Studies of
`long-term therapy with microsomal triglyceride
`transfer protein inhibitors, under carefully mon(cid:173)
`itored conditions, will be required to fully deter(cid:173)
`mine the safety of this approach.
`In summary, the microsomal triglyceride trans(cid:173)
`fer protein inhibitor BMS-201038 was effective
`in reducing the levels of atherogenic apolipo(cid:173)
`protein B-containing lipoproteins by reducing
`their production in patients with homozygous
`familial hypercholesterolemia. These results es(cid:173)
`tablish proof of concept for microsomal triglyc(cid:173)
`eride transfer protein inhibition in such patients
`and provide support for further clinical investi(cid:173)
`gation of this therapy. However, our small study
`showed major effects on aminotransferase and
`hepatic fat levels. The effects of long-term inhibi(cid:173)
`tion of the microsomal triglyceride transfer pro(cid:173)
`tein on the liver will need to be carefully studied
`to determine the safety of this approach.
`
`Supported by a Distinguished Clinical Scientist Award from
`the Doris Duke Charitable Foundation (to Dr. Rader) and grants
`(Kl2-RR017625 and M01·RR00040) from the National Center
`for Research Resources.
`Dr. Szapary reports being an employee of and having equity
`interest in Wyeth; Dr. Gregg, being an employee of and having
`equity interest in Bristol-Myers Squibb and holding patents on
`microsomal triglyceride transfer protein inhibitors (including
`BMS"it01038) and the use of microsomal triglyceride transfer
`protein inhibitors to lower plasma lipid and lipoprotein levels;
`Dr. Rader, receiving lecture fees, consulting fees, and grant sup·
`port from Bristol-Myers Squibb, as well as from other companies
`that manufacture lipid-lowering drugs, and having equity inter(cid:173)
`est in Aegerion Pharmaceuticals, which holds the license to de(cid:173)
`velop BMS-201038; and Ms. Bloedon, serving as a consultant for
`Aegerion Pharmaceuticals. No other potential conflict of inter(cid:173)
`est relevant to this article was reported.
`We thank ]essie Chittams and Qing Liu for statistical analy(cid:173)
`sis, Kathleen Yerger for recruiting and following the srudy pa(cid:173)
`tients, Anna DiFlorio and Linda Morrell for technical support,
`the nurses and registered dietitians at the General Clinical Re(cid:173)
`search Center for their help with patient care, and, especially, the
`six patients for their participation in this study.
`
`N ENGLJ MED 356;2 WWW.NEJM.ORG
`
`JANUARY 11, 2007
`
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`INHIBITION OF MTTP IN FAMILIAL HYPERCHOLESTEROLEMIA
`
`REFERENCES
`
`1. Goldstein }L, Hobbs HH, Brown MS.
`Familial hypercholesterolemia. In: Scriver
`CR, Beaudet AL, Sly WS, Valle D, eds. The
`metabolic and molecular bases of inher(cid:173)
`ited disease. 8th ed. New York: McGraw(cid:173)
`Hill, 2001:2863-913.
`2. Hobbs HH, Brown MS, Goldstein JL.
`Molecular genetics of the LDL receptor
`gene in familial hypercholesterolemia.
`Hum Mutat 1992;1:445-6.
`3. Rader D}, Cohen J, Hobbs HH. Mono(cid:173)
`genic hypercholesterolemia: new insights
`in pathogenesis and tr