C7
`
`Inhibition of microsomal triglyceride transfer protein
`alone or with ezetimibe in patients with moderate
`hypercholesterolemia
`Frederick F Samaha1•2*, James McKenney3, LeAnne T Bloedon4, William J Sasiela5 and Daniel J Rader4
`
`www.nature.com/clinlcalpractice/cardlo
`
`tllJL~ 1~~ t1 ,,$
`
`Background Many patients with coronary heart disease do not achieve
`recommended LDL-cholesterol levels, due to either intolerance or inadequate
`response to available lipid-lowering therapy. Microsomal triglyceride
`transfer protein (MTP) inhibitors might provide an alternative way to lower
`LDL-cholesterol levels. We tested the safety and LDL-cholesterol-lowering
`efficacy of an MTP inhibitor, AEGR-733 (Aegerion Pharmaceuticals Inc.,
`Bridgewater, NJ), alone and in combination with ezetimibe.
`Methods We performed a multicenter, double-blind, 12-week trial, which
`included 84 patients with hypercholesterolemia. Patients were randomly
`assigned ezetimibe 10 mg daily (n = 29); AEGR-733 5.0 mg daily for the
`first 4 weeks, 7.5 mg daily for the second 4 weeks and 10 mg daily for the last
`4 weeks (n = 28); or ezetimibe 10 mg daily and AEGR-733 administered with
`the dose titration described above (n = 28).
`Results Ezetimibe monotherapy led to a 20-22% decrease in LDL(cid:173)
`cholesterol concentrations. AEGR-733 monotherapy led to a dose(cid:173)
`dependent decrease in LDL-cholesterol concentration: 19% at 5.0 mg, 26%
`at 7 .5 mg and 30% at 1 O mg. Combined therapy produced similar but larger
`dose-dependent decreases (35%, 38% and 46%, respectively). The number
`of patients who discontinued study drugs owing to adverse events was five
`with ezetimibe alone, nine with AEGR-733 alone, and four with combined
`ezetimibe and AEGR-733. Discontinuations from AEGR-733 were due
`primarily to mild transaminase elevations.
`Conclusions Inhibition ofLDL production with low-doseAEGR-733, either
`alone or in combination with ezetimibe, could be an effective therapeutic
`option for patients unable to reach target LDL-cholesterol levels.
`KEYWORDS ezetimibe, hypercholesterolemia, microsomal triglyceride
`transfer protein inhibitor
`
`1 Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania
`School of Medicine, Philadelphia, PA, USA
`2Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA
`3School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA
`41nstitute for Translational Medicine and Therapeutics, University of Pennsylvania
`School of Medicine, Philadelphia, PA, USA
`5Aegerion Pharmaceuticals, Bridgewater, NJ, USA
`
`Correspondence
`*University of Pennsylvania Medical Center, Philadelphia VA Medical Center, 81h Floor Cardiology,
`MC 111 C, 3900 Woodland Avenue, Philadelphia, PA 19104, USA
`Tel:+12158236324
`rick.samaha@va.gov
`
`Received 12 November 2007 Accepted 21 February 2008 Published online 27 May 2008
`www.nature.com/clinicalpractice
`doi:10.1038/ncpcardio1250
`
`INTRODUCTION
`Guidelines on the optimum intensity of LDL(cid:173)
`cholesterol lowering have evolved in step with find(cid:173)
`ings from clinical trials. The National Cholesterol
`Education Program (NCEP) guidelines from 2001
`set the target level at below 2.6 mmol/l (100 mg/ dl)
`for high-risk patients with coronary heart disease
`or its risk equivalent. 1 These guidelines were
`updated in 2004 to provide an optional thera(cid:173)
`peutic target of below l.8mmol/l (70mg/dl) for
`very high-risk patients (those with additional risk
`factors, such as diabetes).2 In 2006, the spectrum
`of patients to which the lower value applied was
`broadened to include all patients with athero(cid:173)
`sclerotic disease. Furthermore, a minimum of
`30--40% reduction in LDL was recommended for
`patients at moderate and high risk. 3 Unfortunately,
`at least 20% of high-risk patients do not achieve
`these LDL-cholesterol targets, with those in the
`highest risk group being the least likely to do so.4
`This difficulty might be due partly to statin intol(cid:173)
`erance. The rate of statin discontinuation owing
`to adverse events, observed in clinical trials and
`clinical practice, ranges from 1 % to 7% and is
`mainly caused by myalgias. 5 In a 52-week lipid
`efficacy study of five different statins, the rate of
`discontinuations due to adverse events was even
`higher ( 4--13%).6 Furthermore, there are patients
`for whom high-dose statins are contraindicated,
`such as those taking amiodarone,7 or with clin(cid:173)
`ical factors that raise the risk of rhabdomyolysis. 8
`Because statin-intolerant patients have few other
`options for achieving treatment goals, there is an
`unmet clinical need for additional therapies that
`can lower LDL-cholesterol levels.
`the
`One potential therapeutic target is
`assembly and secretion of apolipoprotein B
`( apoB )-containing lipoproteins. Microsomal
`triglyceride transfer protein (MTP) is an intra(cid:173)
`cellular lipid-transfer protein found in the endo(cid:173)
`plasmic reticulum and which is responsible for
`transferring lipid molecules onto apoB. This
`transfer forms part of the assembly of triglyceride(cid:173)
`rich lipoproteins, such as chylomicrons in the
`
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`intestine and VLDL in the liver.9 Patients with
`the genetic disorder abetalipoproteinemia have
`loss-of-function mutations in the microsomal
`triglyceride transfer protein gene (MTTP), 10
`resulting in extremely low plasma concentrations
`of cholesterol and triglycerides and absense of
`chylomicrons, VLDL and LDL. 11 The elucidation
`of the mechanistic basis for this disease led to the
`concept that small-molecule inhibitors of MTP
`could reduce LDL-cholesterol levels. Indeed,
`preclinical studies in animal models showed that
`inhibition of MTP significantly reduced serum
`cholesterol levels and slowed the formation of
`atherosclerotic plaques. 12,13 Furthermore, MTP
`inhibition significantly reduced LDL-cholesterol
`levels in patients with homozygous familial
`hypercholesterolemia.14
`Clinical applications of MTP inhibitors have
`been focused primarily on high-dose mono(cid:173)
`therapy to produce substantial reductions in
`LDL-cholesterol levels (particularly for patients
`with homozygous familial hypercholesterolemia);
`however, this strategy has been associated with an
`unacceptable rate and severity of gastrointestinal
`and hepatic adverse events, thereby prohibiting
`its use in a broader population of patients with
`hyperlipidemia. Because these side effects are
`thought to be directly linked to the mechanism
`of MTP-inhibition, we hypothesized that much
`lower doses would yield clinically useful LDL(cid:173)
`cholesterol-lowering results but would be better
`tolerated. In addition, we also hypothesized that
`the LDL-cholesterol-lowering effects of the MTP
`inhibitor AEGR-733 (Aegerion Pharmaceuticals
`Inc., Bridgewater, NJ; previously BMS-201038,
`Bristol-Myers Squibb, New York, NY) at these
`reduced doses would be additive to those of
`the cholesterol absorption inhibitor ezetimibe,
`because the two drugs have different mecha(cid:173)
`nisms. To test our hypotheses we evaluated the
`LDL-cholesterol-lowering efficacy of AEGR-733,
`both alone and in combination with ezetimibe, in
`patients with moderate hypercholesterolemia.
`
`METHODS
`This clinical trial is registered on Clinicaltrials.gov
`(registry number NCT00405067 assigned on
`28 November 2006).
`
`Study patients
`This trial was approved by a central investigational
`review board (ASPIRE Institutional Review Board
`LLC, San Diego, CA). Before the 'st~dy started,
`all potential participants signed an informed
`
`consent form approved by the review board.
`Hypercholesterolemic patients of 18-70 years of
`age from six geographically distinct lipid treat(cid:173)
`ment centers within the US were eligible. Patients
`with 0-1 risk factors were required to have an
`LDL-cholesterol concentration between 4.1 and
`6.5 mmol/l (160 and 250 mg/ di), and those with
`more than two risk factors were required to have
`an LDL-cholesterol concentration between 3.4
`and 6.5mmol/l (130 and 250mg/dl). Baseline
`LDL-cholesterol was the mean of measurements
`obtained at the first two clinic screening visits. The
`main exclusion criteria were uncontrolled hyper(cid:173)
`tension, creatinine levels greater than 221 µmo!/!
`(2.5 mg/di), liver disease or transaminase levels
`greater than 1.5 times the upper limit of normal,
`symptomatic congestive heart failure, diabetes,
`plasma triglyceride levels greater than 4.5 mmol/l
`(400mg/dl), or an acute cardiovascular event
`within the prior 6 months. Patients receiving
`concomitant lipid-lowering therapy were required
`to discontinue these medications 4 weeks before
`screening and throughout the trial. AEGR-733
`was manufactured in accordance with current
`Good Manufacturing Practices.
`
`Study design
`This was a phase II, prospective, randomized,
`double-blind study. Participants initially under(cid:173)
`went a 2-6-week eligibility screening process to
`assess their ability to follow a low-fat diet ( <20%
`of energy from total fat and <7% of energy from
`saturated fat) to ensure that lipid values were
`within the range stipulated in the inclusion
`criteria and to wash-out any prior lipid-lowering
`drugs. The active treatment part of the protocol
`was a 12-week treatment period with interim visits
`at weeks 4 and 8. Patients continued to follow
`the low-fat diet and received diet counseling
`throughout the study.
`The patients were randomly assigned one
`of three treatments according to a computer(cid:173)
`generated randomization code issued by the
`central coordinating center. In treatment
`group 1, patients received 10 mg ezetimibe daily
`plus placebo for 12 weeks. In treatment group 2,
`patients received 5.0 mg AEGR-733 for the first
`4 weeks, 7.5 mg for the second 4 weeks, and 10 mg
`for the last 4 weeks, plus placebo for 12 weeks.
`In treatment group 3 patients received AEGR-
`733 (with the same dosing schedule as group 2)
`plus 10 mg ezetimibe daily for 12 weeks. The
`placebos were identical in appearance to either
`the ezetimibe tablets or the AEGR-733 tablets,
`
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`dependent on which they replaced. The patients
`were instructed to take the study medication in
`the morning with breakfast. Patient randomiza(cid:173)
`tion was not stratified by baseline characteristics
`because the small sample size in this study would
`have made such stratification difficult.
`
`Study visit data
`During the study visits at 4, 8 and 12 weeks, data
`were collected from history, physical examinations,
`electrocardiograms, concomitant medications and
`on assessment of study drug adherence, which was
`done by conducting pill counts on the returned
`drug supply from the patients. Blood samples for
`laboratory analyses were obtained after a 12 h fast.
`Plasma was separated from samples, immediately
`frozen at-20°C, and shipped to the core laboratory
`on dry ice.
`
`Laboratory assays
`Total cholesterol, HDL cholesterol, and triglyceride
`levels were measured enzymatically on an auto(cid:173)
`analyzer (Cobas Fara II, Roche Diagnostic
`Systems, Basel, Switzerland). Levels of apoB and
`apolipoprotein A-I (apoA-1) were measured by
`immunonephelometry on a BNII analyzer (Dade
`Behring, Brussels, Belgium), and lipoprotein (a)
`levels were measured by immunoturbidity.
`
`Tracking and recording of adverse events
`In addition to the collection of all clinical adverse
`events, patients also completed the previously vali(cid:173)
`dated Gastrointestinal Symptom Rating Scale, 15•16
`which consists of five symptom clusters: reflux,
`abdominal pain, constipation, diarrhea and
`indigestion. The scale ranges from 1 to 7 (least to
`most severe symptoms).17
`Liver function tests were done at each study
`visit. In any patient who experienced an increase
`in transaminase levels to more than three times
`the upper limit of normal on two consecutive
`occasions the study drug was discontinued, and
`participants were followed up until transaminase
`levels returned to baseline. These patients did not
`enter the study again.
`
`Data analyses
`The primary data analyses were performed by an
`independent statistician employed by the Data
`Coordinating Center (PharmaNet, Princeton,
`NJ). The investigators had complete access to the
`primary data and the data analyses. Normally
`distributed continuous variables are reported as
`mean± SD, and categorical variables as counts
`
`and percentages. Differences in continuous vari(cid:173)
`ables between treatment groups were assessed
`by analysis of variance (ANOVA) and t-tests.
`Within-group differences were assessed with
`paired t-tests. Differences in categorical vari(cid:173)
`ables between treatment groups were assessed by
`x2 tests. All reported P values are two-tailed. All
`patients who received at least one dose of study
`drug or placebo in any group were included in the
`analyses of drug safety and tolerability.
`The efficacy analyses included all randomized
`patients who completed the study. The primary
`outcome of the study was percentage change in
`LDL cholesterol from baseline after each of the
`4-week treatment periods. This time frame was
`based on expected maximum effects of ezetimibe
`within 4 weeks 18·19 and the known LDL(cid:173)
`cholesterol-lowering effects of MTP inhibitors.14
`Secondary outcomes were percentage changes in
`other serum lipoproteins (total cholesterol, non(cid:173)
`HDL, VLDL, triglycerides, HDL cholesterol, lipo(cid:173)
`protein (a), apoB and apoA-1), change in body
`weight and overall safety and tolerability.
`
`Sample size estimates
`The main comparison used for the sample size
`was 10 mg ezetimibe alone versus 10 mg AEGR-
`733 in combination with lOmg ezetimibe. We
`estimated that ezetimibe alone would produce
`an -18% decrease in LDL-cholesterol.19 Based on
`data from an earlier unpublished phase I study; we
`also estimated that the combination with AEGR-
`733 would produce an additional 20% decrease
`in LDL-cholesterol. We calculated, therefore, that
`an enrollment target of 25 patients per group
`with a 20% dropout rate would yield 90% power
`(SD 19%).Significance was set atP=0.05.
`
`RESULTS
`Patients
`A total of 85 patients were enrolled and rando(cid:173)
`mized (28-29 in each treatment group). The
`baseline .characteristics of these patients are
`summa~i~ed in Table 1. Sixty-seven patients
`completed the study, 17 discontinued therapy
`completely owing to adverse events and 1 was
`lost to follow-up before final efficacy data were
`obtained (Figure 1).
`
`Effect of AEGR-733 on apolipoprotein B
`levels
`Patients assigned to the combination of ezetimibe
`plus AEGR-733 experienced dose-dependent
`reductions in LDL ranging from 35% to 46%
`
`AUGUST 2008 VOL 5 NO 8 SAMAHA ET AL.
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`Table 1 Baseline characteristi.cs of ~II randomized patients.
`Characteristic
`Ezetimibe (n=29}
`
`AEGR-733 (10mg)
`(n=28)
`
`AEGR-733 (10mg) plus
`ezetimibe (n=28)
`
`.Mean age (years)
`
`Sex (women, %)
`
`Race (white, %)
`
`Mean (SD) BMI (kg/m2)
`
`Mean (SD) baseline total cholesterol
`leve.1 (mmol/l)a
`
`N with CAD risk factors(%)
`Age >45 years (m) or >55 years (f)
`Hypertension
`Smoking
`Family history of CHD
`HDL-cholesterol level <40 mmol/la
`
`NwithCAD(%)
`
`54.7 ±9.0
`
`57.5±7.2
`
`55.1 ±5.7
`
`62.1
`
`75.9
`
`28.6±5.4
`
`6.3 ±0.8
`
`18 (64.3)
`8(28.6)
`10 (35.7)
`6 (21.4)
`2 (7.2)
`
`0
`
`46.4
`
`78.6
`
`29.6±5.4
`
`6.6±1.0
`
`22 (78.6)
`12 (42.9)
`4 (14.3)
`7 (25.0)
`3 (10.7)
`
`1 (3.6)
`
`50.0
`
`64.3
`
`29.6±7
`
`6 .. 4 ::t;0.9
`
`23 (82.1)
`10 (35.7)
`8(28.6)
`9 (32.1)
`1 (3.6)
`
`0
`
`aro convert to mg/di divide by 0.0259. Abbreviations: CAD, coronary artery disease; CHO, coronary heart disease; f, female;
`m, male; N, number of patients.
`
`168 screened
`
`l
`
`28 assigned AEGR-733
`+ ezetimibe
`
`85 enrolled
`
`l
`
`28assigned AEGR-733
`
`I
`
`29 assigned ezetimibe
`
`4 discontinued
`due to adverse
`events
`
`9 discontinued
`due to adverse
`events
`
`4 discontinued
`due to adverse
`events and 1
`lost to follow~up
`
`24 completed
`and included
`in efficacy analyses
`
`19 completed
`and included
`in efficacy analyses
`
`24 completed
`and included
`in efficacy analyses
`
`Figure 1 Study profile.
`
`(Figure 2 and Table 2; P<0.001 versus ezetimibe
`alone). Patients assigned ezetimibe mono(cid:173)
`therapy experienced a 20-22% decrease in
`LDL-cholesterol levels after 12 weeks of therapy
`(Figure 2 and Table 2). Patients assigned to AEGR-
`733 monotherapy experienced dose-dependent
`reductions in LDL-cholesterol concentrations
`ranging from 19% to 30% (Figure 2 and Table 2;
`P= 0.013 for a greater LDL reduction with 10 mg
`AEGR-733 alone versus lOmg ezetimibe alone).
`Patients receiving AEGR-733 monotherapy also
`
`experienced dose-dependent decreases in concen(cid:173)
`trations of total cholesterol (23% at lOmg), non(cid:173)
`HDL cholesterol (27% at 10 mg) and apoB (24%
`at 10 mg); these reductions were all greater than
`those observed with ezetimibe monotherapy
`(Table 3). Further reductions in total cholesterol,
`non-HDL cholesterol, and apoB levels were
`observed in the group receiving combination
`therapy (Table 3). Triglycerides did not change
`significantly from baseline in any of the three
`groups (Table 3). Patients receiving AEGR-733
`
`500 NATURE CLINICAL PRACTICE CARDIOVASCULAR MEDICINE
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`0
`
`Q)
`.!:
`03 en
`t1l
`.0
`E -10
`,g
`e -20
`
`Q)
`1i)
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`0
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`(.)
`..'.i
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`....J
`.s
`g' -50
`t1l
`.r:
`(.)
`Q)
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`t1l
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`
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`
`Q)
`
`..... c:
`Q)
`~
`Q)
`0..
`
`www.nature.com/cllnicalpractlce/cardlo
`
`Time of study visit
`4-8 weeks
`;
`
`8-12 weeks
`
`;
`
`1·
`
`I~
`
`~-
`
`a
`
`c
`
`a,c
`
`;
`
`; I'
`1;
`
`t:
`,,
`
`~-
`
`a,d
`
`d,e a,e
`
`0-4 weeks
`'
`;: -- .
`
`,]
`
`a
`
`b
`
`'
`
`a,b
`
`U EZ
`DAEGR
`D EZ+AEGR
`
`either alone or in combination with ezetimibe
`experienced a significant decrease in lipoprotein
`(a) compared with those receiving ezetimibe
`alone (Table 3).
`
`Effect of AEGR-733 on apolipoprotein A
`levels
`Patients receiving AEGR-733, alone or with
`ezetimibe, experienced decreases of 7% or more
`in HDL-cholesterol levels, which were signifi(cid:173)
`cantly different from the 6% increase observed
`with ezetimibe monotherapy (P < 0.001 for each
`between-group difference; Table 3). Similar
`changes in apoA-I were seen (Table 3).
`
`Changes in weight
`After 12 weeks, patients assigned ezetimibe
`monotherapy experienced a mean weight loss
`of0.2±1.9kg (0.1 %); those assignedAEGR-733
`monotherapy experienced a mean weight loss of
`0.7 ± 2.0kg (1.0%); and those assigned combined
`AEGR-733 plus ezetimibe experienced a mean
`weight loss of 1.4 ± 2.6 kg ( 1.4% ); only the latter
`change was significant (P=0.013). However,
`the weight loss was not significantly different
`in the combination group from that for the
`group receiving ezetimibe alone.
`
`Safety
`Of the 85 patients enrolled, 18 (20%) either
`stopped or were taken off study medication
`before completion of the study (Table 4), mainly
`owing to mildly elevated transaminase levels.
`This adverse event occurred in 9 of 56 (18%)
`patients who took AEGR-733, either alone or
`in combination with ezetimibe, compared with
`none of the 29 patients assigned to ezetimibe
`alone. Transaminase levels returned to baseline in
`all these patients over the course of the protocol(cid:173)
`specified, 2-week follow-up. One patient in the
`combined AEGR-733 plus ezetimibe group, and
`two patients in each of the AEGR-733-only
`and ezetimibe-only groups, dropped out of the
`study because of gastrointestinal side effects
`(Table 4). The adverse effects were mild (mean
`gastrointestinal symptom rating scores ::;2).
`Patients receiving AEGR-733 alone experienced
`slightly more gastrointestinal symptoms, and
`the severity was greater than in the other groups
`only for constipation (P= 0.007; Table 4).
`
`DISCUSSION
`In this prospective, randomized trial AEGR-
`733 provided a dose-dependent reduction in
`
`Figure 2 Percentage change from baseline in LDL-cholesterol levels at each
`of the study visits, by treatment group. Error bars represent SD of the mean.
`aEz versus EZ+AEGR, P<0.001. bAEGR versus EZ+AEGR, P<0.001. cAEGR
`versus EZ+AEGR, P=0.015. dEz versus AEGR, P=0.016. eAEGR versus
`EZ+ AEGR, P= 0.013. Abbreviations: AEGR, AEGR-733; EZ, ezetimibe.
`
`Tabl~ 2 Changes in LDL-c.holesterol levels after 12 weeks of therapy.
`Mean (SD) values
`Mean (SD) LDL-cholesterol
`
`EZ
`
`AEGR-733
`(10mg)
`
`AEGR-733 (10mg)
`+EZ
`
`Baseline \falue. (mmol/l)a
`
`4.2 ±0.7
`
`4.4 ±0.9
`
`12-week value (mmol/l)a
`. '
`Percentage change (%)
`
`3.3 ±0.5
`
`20±10
`
`3.1 ±0.9
`
`30±15b
`
`4.4±CH
`
`2.3 ±1.1
`
`46±24°•d
`
`"To convert to mg/di divide by 0.0259. bsP =0.015 for AEGR-733 alone versus ezetimibe
`alone. cp =0.013 for AEGR-733 plus ezetimibe versus AEGR-733 alone. dp < 0.001 for
`AEGR-733 plus ezetimibe versus ezetimibe alone.
`
`LDLcholesterol, reaching a 30% reduction with
`10 mg daily monotperapy and a 46% reduction
`when combined with 10 mg ezetimibe daily. Both
`of these regimens provided significantly greater
`lowering effects than ezetimibe monotherapy.
`Concentrations of other apo-B-containing lipo(cid:173)
`proteins, including total cholesterol, non-HDL
`cholesterol and lipoprotein (a), were similarly
`reduced by AEGR-733.
`Patients receiving AEGR-733 experienced
`a 5-9% reduction in HDL-cholesterol levels,
`with corresponding reductions in apoA-1. This
`effect is similar to that observed in two prior
`studies of MTP-inhibitors. 14•20 In a study
`of patients with homozygous familial hyper(cid:173)
`choleste.rolemia AEGR-733 (studied as BMS-
`201038) administered at higher doses than used
`
`AUGUST 2008 VOL 5 NO 8 SAMAHA ET AL.
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`Table 3 Changes .in non-LDL lipids after 12 weeks of therapy.
`
`Lipid a
`
`Baseline valueb
`
`Final 12-week
`valueb
`
`Percentage change
`from baseline (%)
`
`P value between
`Pvalue
`within group groups vs ezetimibe
`
`. Totc:ll chole~terol (m1n0Jfl~C •••
`Ezetimibe
`
`AGER-733
`
`Ezetimibe plus AGER-733
`
`Triglycerides (mmol/l)d
`
`6.3 ±0.8
`
`6.6 ±1.0
`
`6.4 ±0.9
`
`5.5 ±0.6
`
`5.1 ±1.1
`
`4.2 ±1.3
`
`Ezetimibe
`
`AGER~733
`
`1.4 (0.8-3.6)
`
`1.5 (0.6-2.8)
`
`1.8 (0.5-2.7)
`
`1.5 (0.6-3.2)
`
`Ezetimibe plus AGER-733
`
`1.4 (0.5-2.5)
`
`1.0 (0.7-3.4)
`
`HDL cho.1.estei'ol .(mmol/1)0
`
`Ezetimibe
`
`AGERc733
`
`Ezetimibe plus AGER-733
`
`1.4 ±0.3
`
`1.3 ±0.4
`
`1.4 ±0.3
`
`1.5 ±0.3
`
`1.3 ±0.4
`
`1.2 ±0.3
`
`Non-HDL cholesterol (mmol/1)0
`
`-12 ±9
`
`-23 ±12
`
`-34 ±19
`
`-4
`
`-10
`
`-15
`
`6 ±10
`
`-6 ±11
`
`-9 ±14
`
`Ezetimibe
`
`AGER-733
`
`4.9 ±0.8
`
`4.0 ±0.6
`
`-17 ±11
`
`<0.001
`
`<0.001
`
`<0.001
`
`NS
`
`NS
`
`NS
`
`0.006
`
`0.017
`
`0.003
`
`<0.001
`
`<0.001
`
`NA
`
`0.002
`
`<0.001
`
`NA
`
`NS
`
`NS
`
`NA
`
`<0.001
`
`<0.001
`
`NA
`
`0.013
`
`Ezetimibe plus AGER-733
`
`. ApoliP()Pr()tei°' BJ~/I~' ..
`
`Ezetimibe
`
`AGER-733
`
`5.2 ±0.9
`
`5.1 ±0.8
`
`1.5 ±0.2
`
`1.6 ±0.3
`
`Ezetimibe plus AGER-733
`
`1.5 ±0.2
`
`· Apolipoprc>tein A:((gt1)c
`
`Ezetimibe
`
`AGER-733
`
`1.7±0.3
`
`1.7±0.3
`
`Ezetimibe plus AGER-733
`
`1.7 ±0.2
`
`Lipopr()tein (a) (µmol/I)
`
`3.8 ±0.9
`
`3.0 ±1.2
`
`1.3 ±0.2
`
`1.2 ±0.3
`
`1.0 ±0.3
`
`1.8 ±0.3
`
`1.5 ±0.2
`
`1.5 ±0.3
`
`Ezetimibe
`
`AGER-733
`
`0.5 (0.1-2.0)
`
`0.6 (0.1-2.5)
`
`1.0 (0.1-4.6)
`
`Ezetimibe plus AGER-733
`
`0.9 (0.1-3.3)
`
`0.9 (0.1-4.3)
`
`0.8 {0.3-1.3)
`
`-27 ±15
`
`-41 ±23
`
`-15 ±11
`
`-24 ±14
`
`-37 ±22
`
`2 ±10
`
`-8±12
`
`-11 ±16
`
`3
`
`-17
`
`-16
`
`<0.001
`
`<0.001
`
`<0.001
`
`<0.001
`
`<0.001
`
`NS
`
`0.009
`
`0.001
`
`NS
`
`0.045
`
`0.026
`
`NA
`
`0.021
`
`<0.001
`
`NA
`
`0.004
`
`0.001
`
`NA
`
`0.033
`
`0.013
`
`3All AGER:733.values relate tp10mg dose. bvalues are provided as mean±SD, except triglycerides and lipoprotein (a), which were nonparametrically distributed
`and.are thus given as median. (range). Change in non-HDL: AG+ EZ vs AG, P=0.022; Change in apoB: EZ +AG vs AG, P=0.035. c-ro convert to mg/di divide by
`0,0259, ~To corivert.tQ mg/di divide by 0.0133. Abbreviations: NA, not applicable; NS, not significant.
`
`here produced approximately a 10% decrease in
`HDL-cholesterol; however, this effect was only
`observed with the lowest dose ofBMS-201038. 14
`In another study, CP-346086 (30 mg/day; Pfizer,
`Groton, CT), also produced approximately a
`10% decrease in HDL-cholesterol levels after
`14 days of treatment. 20 The decrease in HDL(cid:173)
`cholesterol concentrations caused by MTP(cid:173)
`inhibition might be attributable to at least three
`potential mechanisms: first, low-fat diets are
`known to reduce HDL-cholesterol levels, 21 •22
`
`and MTP inhibition might reduce intestinal
`fat absorption, thus potentially mimicking the
`effects of a low-fat diet; second, MTP inhibition
`could directly reduce the secretion of apoA-1
`from the intestine, liver, or both, through an
`unknown mechanism; and third, patients with
`abetalipoproteinemia have increased catabo(cid:173)
`lism of apoA-I, 23 which suggests that MTP
`inhibition promotes this effect. Further work is
`necessary to define the mechanisms by which
`MTP inhibition reduces HDL-cholesterol,
`
`502 NATURE CLINICAL PRACTICE CARDIOVASCULAR MEDICINE
`
`···········-·····----·--·--·--·-·-----·----· -------·-·--··-··-··--·--·-··--·-····-·-······-·-··-···---
`SAMAHA ET AL. AUGUST 2008 VOL 5 NO 8
`
`© 2008 Macmillan Publishers Limited. All rights reserved
`
`6 of 9
`
`PENN EX. 2265
`CFAD V. UPENN
`IPR2015-01836
`
`

`
`Table 4 System-specific adverse events.
`
`Med ORA system organ class
`
`Ezetimibe only AEGR-733 only
`(n=29)
`(n=28)
`
`www.nature.com/cllnlcalpractice/cardlo
`
`Pvaluefor
`AEGR-733
`vs ezetimibe
`
`AEGR-733 plus
`Pvaluefor
`ezetimibe (n=28) AEGR-733 plus
`ezetimibe
`vs ezetimibe
`
`Transaminase elevation
`
`0
`
`9(32%)
`
`Any adverse event
`
`GI disorders
`
`lnfectionsb
`
`Musculoskeletal
`
`Respiratory, thoracic and mediastinal
`disorders
`
`General disordersc
`
`Nervous system disorders
`
`16(55.2%)
`
`24 (85.7%)
`
`11 (37.9%)
`
`18(64.3%)
`
`4(13.8%)
`
`4(13.8%)
`
`1 (3.4%)
`
`1 (3.4%)
`
`3 (10.3%)
`
`3 (10.7%)
`
`1 (3.6%)
`
`1 (3.6%)
`
`1 (3.6%)
`
`0.001
`
`0.018
`
`NS
`
`NS
`
`NS
`
`NS
`
`NS
`
`NS
`
`9(32%)a
`
`24 (85.7%)
`
`12 (42.9%)
`
`8(28.6%)
`
`3(10.7%)
`
`3 (10.7%)
`
`2(7.1%)
`
`0
`
`0.001
`
`O.Q18
`
`NS
`
`NS
`
`NS
`
`NS
`
`NS
`
`NS
`
`Injury
`
`Cardiac
`
`0
`
`0
`
`Skin & subcutaneous tissue disorders
`
`1 (3.4%)
`
`Psychiatric disorders
`
`Renal and urinary disorders
`
`Vascular disorders
`
`Mean (SD) GSRS (1:-7)
`Diarrhea
`·· · ·
`Indigestion
`Constipation
`Abdominal pain
`
`0
`
`0
`
`0
`
`1.1±0.2
`1.5±0.7
`1.3±0.5
`1.3±0.5
`
`Discontinuations due to adverse events
`Any
`GI
`Transaminase elevation
`Creatinine elevation
`Musculoskeletal
`Nervous system
`Vascular
`
`4 (13.8%)a
`2
`0
`1
`1
`1
`0
`
`1 (3.6%)
`
`2(7.1%)
`
`2(7.1%)
`
`0
`
`0
`
`1 (3.6%)
`
`1 (3.6%)
`
`1.9±1.2
`1.9±1.3
`1.8±1.0d
`1.5±0.8
`
`9 (32.1 %)
`2
`6
`0
`0
`0
`1
`
`NS
`
`NS
`
`NS
`
`NS
`
`NS
`
`NS
`
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`
`1 (3.6%)
`
`0
`
`1 (3.6%)
`
`1 (3.6%)
`
`0
`
`0
`
`1.5±1.3
`1.4±0.6
`1.2 ±0.4
`1.3±0.3
`
`4 (14.3%)e
`1
`3
`0
`1
`0
`0
`
`NS
`
`NS
`
`NS
`
`NS
`
`NS
`
`NS
`
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`
`· "One participant had two adverse events:--nausea (listed under GI disorders) and dizziness (listed under nervous system disorders)-,-identified as leading to
`study drug discontinuation. bJncludes any infection. c1ncludes chest pain, fatigue, and pyrexia. Cardiac disorders were a myocardial infarction and bradycardia.
`The only vascular event was deep vein thrombosis. The only Injury was accidental thermal skin burn; dp=0.007. eone participant had two adverse events-
`. diarrhea (listed under GI disorders) and cramps (listed µnder musculoskeletal)-identified as leading to discontinuation. Abbreviations: GI, gastrointestinal;
`GSRS, Gastrointestinal Symptom Rating Scale; NS, not significant.
`
`and whether this effect has clinical implica(cid:173)
`tions. Given the association between low HDL(cid:173)
`cholesterol and increased risk of cardiovascular
`events, such a decrease as we observed could be a
`serious drawback to MTP-inhibitor therapy. An
`appropriately designed outcomes study would
`be essential to answer the question of whether
`the additional LDL lowering obtained with
`MTP inhibition would outweigh any poten(cid:173)
`tial adverse effect associated with a decrease in
`HDL-cholesterol level.
`The investigators observed a 72% reduc(cid:173)
`tion in LDL-cholesterol and a 75% reduction
`
`in triglyceride levels in patients administered
`CP-346086. 20 This reduction in LDL-cholesterol
`is considerably greater than the one we observed
`with the highest dose of AEGR-733 (30%).
`Moreover, we saw no change in triglyceride
`levels with MTP inhibition. The different effects
`on plasma LDL and triglycerides might relate
`to differences in dose or timing. With regard to
`dose, increases in hepatic and intestinal tri(cid:173)
`glyceride content have been shown to correlate
`with plasma lipid lowering. 20 By using low-dose
`MTP inhibition to minimize intestinal and liver
`fat accumulation, we might also have minimized
`
`- - · · · - - - - - - - - - - · - · · - - · - · · - - - - - · · · - - - - ·
`AUGUST 2008 VOL 5 NO 8 SAMAHA ET AL.
`
`NATURE CLINICAL PRACTICE CARDIOVASCULAR MEDICINE 503
`
`© 2008 Macmillan Publishers Limited. All rights reserved
`
`7 of 9
`
`PENN EX. 2265
`CFAD V. UPENN
`IPR2015-01836
`
`

`
`www.nature.com/cllnicalpractice/cardio
`
`the ability of AEGR-733 to lower triglyceride
`levels. The use of CP-346086 in the previous
`study was associated with a higher incidence of
`
`gastrointestinal side-effects. 2° Furthermore, in
`
`animal models a 2.9-fold increase in intestinal
`triglycerides and a 3.6-fold increase in hepa(cid:173)
`tic triglycerides have been shown at doses of
`CP-346086 equivalent to those in human
`studies.20 With regard to timing, we measured
`fasting triglyceride levels, and, as previously
`demonstrated, the greatest effect seems to occur
`on postprandial triglyceride elevation due to
`intestinal MTP inhibition.20
`Changes in weight observed with combina(cid:173)
`tion therapy could be a result cif reduced fat
`absorption caused by MTP inhibition, which
`is an established mechanism for other weight
`loss drugs. 24 AEGR-733 was fairly well toler(cid:173)
`ated from a gastrointestinal standpoint. MTP is
`required for chylomicron assembly and secre(cid:173)
`tion and, therefore, inhibition of the protein
`could potentially cause steatorrhea. To minimize
`the possibility of gastrointestinal side effects due
`to MTP inhibition, we instructed all patients to
`follow a diet containing less than 20% fat. In
`addition, we used low doses of AEGR-733 and
`titrated the dose, in order to allow the intestine
`to become accustomed to inhibition of MTP.
`In our study, 16% of the patients administered
`AEGR-733, either alone or in combination with
`ezetimibe, and none of the patients administered
`ezetimibe alone discontinued study drugs due
`to rises in aminotransferase levels. We do not
`know whether any of these patients would have
`experienced resolution or further worsening of
`transaminase elevation with continued use of
`AEGR-733, but transaminase levels returned to
`baseline in all these patients. No patients exhib(cid:173)
`ited elevations in bilirubin, a marker of acute
`hepatotoxic effects, or experienced overt hepatic
`dysfunction. Most patients in this study (82%)
`did not experienced transaminase elevation,
`suggesting that at these doses patients might be
`able to use MTP inhibitors without experiencing
`transaminase elevation.
`More of the patients taking AEGR-733 than
`of those given combination therapy experienced
`transaminase elevation. This outcome might
`be spurious and we can only speculate on a
`mechanism by which this could have occurred.
`The primary lipid-lowering effect of ezetimibe
`is thought to be attributable to inhibition of
`the intestinal Niemann-Pick Cl-like 1 lipid
`transporter. This transporter is, however, also
`
`expressed in human liver, where it facilitates
`cholesterol uptake and thus allows the reten(cid:173)
`tion of biliary cholesterol by hepatocytes, 25 and
`ezetimibe disru