Azienda Ospedaliero Universitaria

Trieste S.C. III Medica

NUOVE CLASSI di FARMACI nelle

DISLIPIDEMIE SEVERE

Luigi Cattin

INHERITED MONOGENIC HYPERCHOLESTEROLEMIAS

Genetic disorders due to mutations of a single gene

(monogenic / Mendelian disease) Biochemical phenotype: LDL-C >95th percentile Clinical phenotype: - Tendon and cutaneous xanthomatosis - Premature coronary artery disease

Dominant transmission Heterozygote LDL-C ↑ ↑

(One mutant allele)

Homozygote LDL-C ↑ ↑ ↑ ↑

(Two mutant alleles)

Gene dosage effect

INHERITED MONOGENIC HYPERCHOLESTEROLEMIAS

Recessive transmission

• Heterozygote LDL-C ↔

(One mutant allele)

• Homozygote LDL-C ↑ ↑ ↑

(Two mutant alleles)

The Number of Familial Dyslipidaemias in Italy

Familial hypercholesterolemias 121.000 Familial combined hyperlipidemia > 600.000 Type III hyperlipidemia 10.000 ? Severe hypertriglyceridemias 200 ? Familial hypertriglyceridemias ? Familial hypobetalipoproteinemias 20.000 Combined hypolipidemia ? Abeta & Chylomicron Retention Disease 50-100 Familial hypoalphalipoproteinemias ? Familial hyperalphalipoproteinemias ?

Percentuale di individui con diagnosi di FH in diversi Paesi espressi come frazione dei soggetti previsti *

*Soggetti teoricamente previsti essere affetti da FH sulla base di una frequenza di 1/500 nella popolazione generale

Ipercolesterolemie Familiari AGENDA

Come riconoscerle ? inquadramento genetico-molecolare diagnosi clinica Come curarle ? statine nuovi farmaci - Inibitori di PCSK9 (Evolocumab; Alirocumab) - Lomitapide - Mipomersen

Ipercolesterolemie Familiari AGENDA

Come riconoscerle ? inquadramento genetico-molecolare diagnosi clinica Come curarle ? statine nuovi farmaci - Inibitori di PCSK9 (Evolocumab; Alirocumab) - Lomitapide - Mipomersen

Disease Gene Prevalence

ADH-1 (Classic FH)

Heterozygous

Homozygous

LDL-R

1 per 500

1 per million

ADH-2 (FDB)

Heterozygous

Homozygous

Apo B-100

1 per 1000

>1 per million

ADH-3

Heterozygous

Homozygous

PCSK9

?

?

DOMINANT HYPERCHOLESTEROLEMIAS - ADH (Familial hypercholesterolemia phenotype)

Disease Gene Prevalence

ADH-1 (Classic FH)

Heterozygous

Homozygous

LDL-R

1 per 500

1 per million

ADH-2 (FDB)

Heterozygous

Homozygous

Apo B-100

1 per 1000

>1 per million

ADH-3 (ADH)

Heterozygous

Homozygous

PCSK9

?

?

DOMINANT HYPERCHOLESTEROLEMIAS - ADH (Familial hypercholesterolemia phenotype)

“DOMAINS”

“Ligand binding” 292 aa

“ EGF precursor homology”

400 aa

“O-linked sugars” 58 aa

“Membrane spanning” 22 aa

“Cytoplasmic” 50 aa

321

567

4

NH2

A B

C

COOH

cysteine

FH in Italy

Heterozygotes n. 121.000

LDL chol. 240-450 mg/dl

Homozygotes and Compound Heterozygotes n. 50

LDL chol. 420-950 mg/dl

Disease Gene Prevalence

FH-1 (Classic FH)

Heterozygous

Homozygous

LDL-R

1 per 500

1 per million

FH-2 (FDB)

Heterozygous

Homozygous

Apo B-100

1 per 1000

<1 per million

FH-3 (ADH)

Heterozygous

Homozygous

PCSK9

?

?

DOMINANT HYPERCHOLESTEROLEMIAS - ADH (Familial hypercholesterolemia phenotype)

LDL

SYNTHESIS OF CHOLESTEROL

HMG CoA Reductase

ACAT

CHOLESTEROL ESTERS

MEMBRANES STEROIDS

BILE ACIDS

SYNTHESIS OF LDL RECEPTORS

INHIBITS

ACTIVATES

EXCESS CHOLESTEROL

RNA

DNA

LDL receptors

LDL

B-100

Disease Gene Prevalence

FH-1 (Classic FH)

Heterozygous

Homozygous

LDL-R

1 per 500

1 per million

FH-2 (FDB)

Heterozygous

Homozygous

Apo B-100

1 per 1000

<1 per million

FH-3 (ADH)

Heterozygous

Homozygous

PCSK9

?

?

DOMINANT HYPERCHOLESTEROLEMIAS (Familial hypercholesterolemia phenotype)

PCSK9 gene (1p32) Exon 1 2 3 4 5 6 7 8 9 10 11 12

5’ 3’

mRNA (3636 nt)

PCSK9 protein (692 aa)

N - 1-30 31-152 153-425 426-692

- C SP PRO Catalytic domain CRR

Synthesized by the liver and secreted into the circulation

Proprotein Convertase Subtilisin/hexin type 9 Serine Protease

ER

Golgi

Endosome Coated Pit

3

2 1

SECRETION OF PCSK9

SYNTHESIS OF PCSK9 RNA DNA

Regulation of LDL-R number by PCSK9 activity

LDL-R degradation

LDL

ER

Golgi

Endosome Coated Pit

3

2 1

SECRETION OF PCSK9

SYNTHESIS OF PCSK9 RNA DNA

M

LDL-R degradation

Reduction of LDL-R number induced by increased PCSK9 activity

M

M

M M M M

Ipercolesterolemie Familiari AGENDA

Come riconoscerle ? inquadramento genetico-molecolare diagnosi clinica Come curarle ? statine nuovi farmaci - Inibitori di PCSK9 (Evolocumab; Alirocumab) - Lomitapide - Mipomersen

CLINICAL DIAGNOSIS OF FAMILIAL HYPERCHOLESTEROLEMIA

Plasma LDL-C level

Clinical history

Family history

Clinical diagnosis

30

25

20

15

10

5

0 <80 101-120 141-160 181-200 221-240 261-280 301-320 341-360 381-400

81-100 121-140 161-180 201-220 241-260 281-300 321-340 361-380 >400

non FH FH LDL cholesterol (mg/dl)

Frequency (%) LDL cholesterol distribution in FH families

Approccio clinico al paziente FH 1

Soffio periombelicale

Soffi Carotidei Soffio Aortico

Arco Corneale

Xantomi Tendinei

0,0

10,0

20,0

30,0

40,0

50,0

60,0

30-34 35-39 40-44 45-49 50-54 55-59 >60

Males (n.216) Females (n.354)

CHD in Italian FH heterozygotes (%)

(Years)

Ipercolesterolemie Familiari AGENDA

Come riconoscerle ? inquadramento genetico-molecolare diagnosi clinica Come curarle ? statine nuovi farmaci - Inibitori di PCSK9 (Evolocumab; Alirocumab) - Lomitapide - Mipomersen

Ipercolesterolemie Familiari AGENDA

Come riconoscerle ? inquadramento genetico-molecolare diagnosi clinica Come curarle ? statine nuovi farmaci - Inibitori di PCSK9 (Evolocumab; Alirocumab) - Lomitapide - Mipomersen

PCSK9 gene (1p32) Exon 1 2 3 4 5 6 7 8 9 10 11 12

5’ 3’

mRNA (3636 nt)

PCSK9 protein (692 aa)

N - 1-30 31-152 153-425 426-692

- C SP PRO Catalytic domain CRR

Synthesized by the liver and secreted into the circulation

Proprotein Convertase Subtilisin/hexin type 9 Serine Protease

ER

Golgi

Endosome Coated Pit

3

2 1

SECRETION OF PCSK9

SYNTHESIS OF PCSK9 RNA DNA

M

LDL-R degradation

Reduction of LDL-R number induced by increased PCSK9 activity

M

M

M M M M

Ipercolesterolemie Familiari AGENDA

Come riconoscerle ? inquadramento genetico-molecolare diagnosi clinica Come curarle ? statine nuovi farmaci - Inibitori di PCSK9 (Evolocumab; Alirocumab) - Lomitapide - Mipomersen

Treatment of Drug-Resistant Hypercholesterolemia

In December of 2012, the United States Food and Drug Administration (FDA) the use of lomitapide for patients with homozygous FH

PHASE 3 STUDY RESULTS: changes in LDL-C through week 78 (pazients n. 23)

Ipercolesterolemie Familiari AGENDA

Come riconoscerle ? inquadramento genetico-molecolare diagnosi clinica Come curarle ? statine nuovi farmaci - Inibitori di PCSK9 (Evolocumab; Alirocumab) - Lomitapide - Mipomersen

Antisense Technology

Treatment of Drug-Resistant Hypercholesterolemia

Mipomersen (ISIS 301012) is an antisense oligonucleotide complementary to the coding region for human apolipoprotein B (apo B) mRNA. Through direct binding to apo B mRNA, mipomersen inhibits apo B production.

In January of 2013, the United States Food and Drug Association (FDA) approved the drug for use in patients with homozygous FH.

In clinical trials, many patients stopped taking the drug due to side effects such as flu-like symptoms, injection site reactions, and liver toxicity.

The Role of Apo B in VLDL Synthesis

Dose Dependent Effect of Mipomersen on

Apo B (A) and LDL-C (B) Levels

Dislipidemie Severe AGENDA

Nuovi farmaci?: - Gene Therapy (Glybera)

Glybera®: Mechanism of action

44

The LPL • Lipoprotein lipase

• Expression: heart, muscle, adipose tissue • Functions: triglyceride hydrolase and ligand/bridging

factor for receptor-mediated lipoprotein uptake (VLDL & chylomicrons)

• Stimulated by: Apo-CII, insulin, heparin

Source: John R Burnett & Amanda J Hooper, Alipogene tiparvovec, an adeno-associated virus encoding the Ser447X variant of the human lipoprotein lipase gene for the treatment of patients with lipoprotein lipase deficiency, 2009 11(6):681-691 <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3102144/figure/F3/>

predicted tertiary structure for human LPL

LipoProtein Lipase Deficiency Epidemiology

EU prevalence : 2/106 US prevalence : 1/106 Worldwide prevalence : 1-2/106

Founder effect : Eastern Quebec : 1/10,000

Sources : http://www.ncbi.nlm.nih.gov/books/NBK1308/ http://www.ncbi.nlm.nih.gov/pubmed/20427244 La déficience en lipoprotéine lipase chez les canadiens français-Carole Dionne 1991

46

Plasma TG > 20g/L [1]

–Episodes of abdominal pain –Recurrent acute pancreatitis –Eruptive cutaneous xanthomata [2]

–Hepatosplenomegaly

Plasma TG > 40g/L ‒Lipemia retinalis [3]

‒Complications

Plasma TG< 10g/L –Clinical goal

LPLD natural history

Early in childhood

47

Symptoms

Repeated episodes of abdominal pain

Eruptive cutaneous xanthomatosis (fat accumulation in the skin)

<http://www.healthcentral.com>

How patient receives Glybera®

Source : Glybera® EPAR

LPL gene

rAAV vector

Max total dose : 1x 1012 gc/kg Single treatment only One-time series of IM injections in the legs 1.5 x 1012 gc or 0.5 ml of solution for injection/site

Conclusion of the clinical developement

Good tolerance / No dose limiting toxicity TG levels decrease for 3 months post dosing CM decrease & improve of CM metabolism LPLS447X expression in muscle, 6 months after

administration (1)

Follow up: prevention and reduction of pancreatitis

attacks Source : Sier‐Ferreira et al 2012 in prep 50

Indicazioni dei Nuovi Farmaci

Omozigoti o con eterozigosi doppia (in combinazione con LDL aferesi).

Limitatamente a PCSK9-I: - eterozigoti con ischemia d’organo o

equivalente ischemico, che non tollerano o non rispondono alle statine;

- soggetti a rischio cardiovascolare molto elevato, che non tollerano o non rispondono alle statine.