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Effect of olezarsen targeting APOC-III on lipoprotein size and particle number measured by NMR in patients with hypertriglyceridemia

Open AccessPublished:June 22, 2022DOI:https://doi.org/10.1016/j.jacl.2022.06.005

      Highlights

      • NMR analysis was performed in subjects treated with the ASO olezarsen.
      • Olezarsen reduced triglyceride-rich lipoprotein particle number.
      • Olezarsen induced remodeling to larger LDL particles.
      • Olezarsen resulted in an increase in small HDL particle number.
      • ApoC-III inhibition improves the overall atherogenic risk profile.

      Background

      Olezarsen is a hepatocyte-targeted, GalNAc-modified antisense oligonucleotide that decreases plasma levels of apolipoprotein C-III (apoC-III) and triglyceride-rich lipoproteins (TRLs).

      Objective

      To define the effect of olezarsen on NMR-derived lipoprotein particle size and concentration.

      Methods

      Patients (n=114) with or at risk for atherosclerotic cardiovascular disease and fasting triglycerides ≥200 and <500 mg/dL received olezarsen (10 or 50 mg every 4 weeks, 15 mg every 2 weeks, or 10 mg every week) or saline placebo subcutaneously for 6–12 months. NMR LipoProfile® analysis was performed in frozen EDTA plasma samples collected at baseline and at the primary analysis timepoint (PAT) at 6 months.

      Results

      A dose-dependent relationship was generally noted with increasing cumulative doses of olezarsen in TRL particle (TRLP), LDL particle (LDL-P) and HDL (HDL-P) particle concentrations. In the 50 mg every 4 weeks dose, compared to placebo, olezarsen resulted in a significant reduction in total TRL-P (51%, P<0.0001) with largest reductions in large-size (68%, P<0.0001) and medium-size (63%, P<0.0001) TRL-P. Total LDL-P concentration was not changed, but large LDL-P increased by 186% (p=0.0034), and small LDL-P decreased by 39% (p=0.0713). Total HDL-P concentration increased by 15% (P=0.0006), driven primarily by a 32% increase in small HDL subspecies (diameters <8.3 nm) (P=0.0008).

      Conclusion

      Olezarsen results in favorable changes in lipoprotein concentration and particle size, primarily manifested by reduction in TRLs, remodeling to larger LDL particles, and increase in small HDL-P. These findings suggest that apoC-III inhibition improves the overall atherogenic risk profile.

      Keywords

      Introduction

      Elevated levels of plasma triglycerides are associated with multiple pro-atherogenic and metabolic co-morbidities, including type 2 diabetes mellitus, low high density lipoprotein cholesterol (HDL-C), hypertension, obesity, and measures of subclinical inflammation. Modest elevations of plasma triglycerides in the range of 150-885 mg per deciliter (1.7-10.0 mmol per liter) have been shown to be a risk factor for atherosclerotic cardiovascular disease (ASCVD).
      • Schwartz GG
      • Abt M
      • Bao W
      • et al.
      Fasting triglycerides predict recurrent ischemic events in patients with acute coronary syndrome treated with statins.
      ,
      • Ginsberg HN
      • Packard CJ
      • Chapman MJ
      • et al.
      Triglyceride-rich lipoproteins and their remnants: metabolic insights, role in atherosclerotic cardiovascular disease, and emerging therapeutic strategies-a consensus statement from the European Atherosclerosis Society.
      Moreover, triglyceride levels 500-885 mg per deciliter (>5.6 – 10.0 mmol per liter) are a risk factor for both ASCVD and acute pancreatitis,
      • Ginsberg HN
      • Packard CJ
      • Chapman MJ
      • et al.
      Triglyceride-rich lipoproteins and their remnants: metabolic insights, role in atherosclerotic cardiovascular disease, and emerging therapeutic strategies-a consensus statement from the European Atherosclerosis Society.
      • Nordestgaard BG
      • Varbo A.
      Triglycerides and cardiovascular disease.
      • Laufs U
      • Parhofer KG
      • Ginsberg HN
      • Hegele RA.
      Clinical review on triglycerides.
      Elevated levels of triglycerides reflect dysregulated lipoprotein metabolism with accompanying elevations in triglyceride-rich lipoproteins (TRLs), particularly remnant lipoproteins, which are considered to be highly atherogenic.
      • Varbo A
      • Freiberg JJ
      • Nordestgaard BG.
      Remnant cholesterol and myocardial infarction in normal weight, overweight, and obese individuals from the Copenhagen General Population Study.
      Novel and potent therapeutic agents are in clinical development that reduce triglyceride levels to unprecedented levels.
      • Gaudet D
      • Alexander VJ
      • Baker BF
      • et al.
      Antisense inhibition of apolipoprotein C-III in patients with hypertriglyceridemia.
      • Gaudet D
      • Brisson D
      • Tremblay K
      • et al.
      Targeting APOC3 in the familial chylomicronemia syndrome.
      • Witztum JL
      • Gaudet D
      • Freedman SD
      • et al.
      Volanesorsen and triglyceride levels in familial chylomicronemia syndrome.
      • Alexander VJ
      • Xia S
      • Hurh E
      • et al.
      N-acetyl galactosamine-conjugated antisense drug to APOC3 mRNA, triglycerides and atherogenic lipoprotein levels.
      • Gouni-Berthold I
      • Alexander VJ
      • Yang Q
      • et al.
      Efficacy and safety of volanesorsen in patients with multifactorial chylomicronaemia (COMPASS): a multicentre, double-blind, randomised, placebo-controlled, phase 3 trial.
      • Tardif JC
      • Karwatowska-Prokopczuk E
      • Amour ES
      • et al.
      Apolipoprotein C-III reduction in subjects with moderate hypertriglyceridaemia and at high cardiovascular risk.
      A recent clinical trial evaluated AKCEA-APOCIII-LRx, termed olezarsen henceforth, an N-acetyl-galactosamine-conjugated antisense oligonucleotide targeted to hepatic APOC3 mRNA to inhibit apolipoprotein C-III (apoC-III) production, in lowering triglyceride levels in patients at high risk for or with established cardiovascular disease.
      • Tardif JC
      • Karwatowska-Prokopczuk E
      • Amour ES
      • et al.
      Apolipoprotein C-III reduction in subjects with moderate hypertriglyceridaemia and at high cardiovascular risk.
      Treatment with olezarsen resulted in mean percent triglyceride reductions of 60% with 50 mg every 4 weeks, with significant decreases in apoC-III, very low-density lipoprotein-cholesterol, non-high-density lipoprotein-cholesterol, and apolipoprotein B. Furthermore, 91% of subjects achieved triglyceride levels <150 mg/dL.
      The effect of ApoC-III inhibition beyond the traditional lipid measures, for example on lipoprotein particle size and number, has not been previously reported. In this study we report the effect of olezarsen on a comprehensive set of measurements of lipoprotein particle size and number using nuclear magnetic resonance (NMR) spectroscopy.

      Methods

      Trial Design

      The design of this phase 2, dose-ranging, randomized, double-blind, placebo-controlled trial evaluating olezarsen was previously described.
      • Tardif JC
      • Karwatowska-Prokopczuk E
      • Amour ES
      • et al.
      Apolipoprotein C-III reduction in subjects with moderate hypertriglyceridaemia and at high cardiovascular risk.
      Eligible patients had established ASCVD (documented coronary artery disease, stroke, or peripheral artery disease) or were at high risk for ASCVD defined as having type 2 diabetes mellitus requiring treatment, age ≥50 years, and one additional ASCVD risk factor, and had an elevated screening fasting triglyceride level [triglyceride ≥ 200 mg per deciliter (2.26 mmol per liter) and ≤ 500 mg per deciliter (5.65 mmol per liter)] were eligible for enrollment. Patients had to be on standard-of-care preventive therapy for their CVD risk factors, including stable doses of lipid-lowering medications. Patients were randomized to one of 4 treatment groups (10 mg every 4 weeks, 15 mg every 2 weeks, 10 mg every week, and 50 mg every 4 weeks (equivalent to monthly dose of 10, 30, 40 or 50 mg) or saline placebo. For the current study, plasma samples were evaluated by NMR at baseline and the primary analysis timepoint (PAT). The timing of the primary efficacy endpoint analysis was at week 25 for patients who received every 4-week dosing, and at week 27 for patients who received every 2-week or weekly dosing to achieve 6 months of exposure for each group. The protocol was approved by the relevant health authorities, institutional review boards, and ethics committees. All trial participants provided written informed consent.

      Nuclear magnetic resonance

      Comprehensive NMR LipoProfile® analysis using the LipoProfile-4 algorithm was performed by LabCorp (Morrisville, NC) in frozen EDTA plasma samples collected at baseline and at the primary analysis timepoint at 6 months. Parameters measured included the traditional lipid panel,
      • Garcia E
      • Bennett DW
      • Connelly MA
      • et al.
      The extended lipid panel assay: a clinically-deployed high-throughput nuclear magnetic resonance method for the simultaneous measurement of lipids and Apolipoprotein B.
      concentrations of triglyceride-rich lipoprotein particle (TRL-P) subspecies, low-density lipoprotein particle (LDL-P) subspecies, high-density lipoprotein particle (HDL-P) subspecies, and mean TRL, LDL, and HDL sizes.
      • Jeyarajah EJ
      • Cromwell WC
      • Otvos JD.
      Lipoprotein particle analysis by nuclear magnetic resonance spectroscopy.
      ,
      • Aday AW
      • Lawler PR
      • Cook NR
      • Ridker PM
      • Mora S
      • Pradhan AD.
      Lipoprotein particle profiles, standard lipids, and peripheral artery disease incidence.

      Statistical analyses

      The analyses were performed with the full analysis set, defined as all patients who had undergone randomization and had received at least one dose of olezarsen or placebo. Pairwise comparison of percent change from baseline between each olezarsen group and pooled placebo group was performed using a Mixed-Effect Model Repeated Measures (MMRM) model with treatment group, visit, treatment group by visit interaction as fixed effects and log transformed baseline as a covariate. Due to the exploratory nature of this analysis, the P-values and widths of the 95% CIs were not adjusted for multiplicity. The results are reported as change from baseline to primary analysis timepoint (PAT). The statistical analyses were performed using SAS version 9.4, all p-values were 2-sided.

      Results

      Patient characteristics and baseline lipid variables

      The study population was previously described in detail.
      • Tardif JC
      • Karwatowska-Prokopczuk E
      • Amour ES
      • et al.
      Apolipoprotein C-III reduction in subjects with moderate hypertriglyceridaemia and at high cardiovascular risk.
      By protocol design, all patients had either established ASCVD (79.8%) or were at high risk for ASCVD (20.2%). The demographics and baseline characteristics of patients were generally similar across treatment groups. Depending on group assignment among the 4 olezarsen groups and the placebo group, at trial entry, 74-96% of patients were being treated with statins, 33-46% were on either fibrates or omega-3 fatty acids, 9-17% were on ezetimibe and 4-9% on proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors.
      In general, the groups had elevated triglycerides and relatively well controlled LDL-C (Table 1). NMR derived fasting baseline variables are well balanced across the randomized groups. Relative to the normal levels as previously defined,
      • Garcia E
      • Bennett DW
      • Connelly MA
      • et al.
      The extended lipid panel assay: a clinically-deployed high-throughput nuclear magnetic resonance method for the simultaneous measurement of lipids and Apolipoprotein B.
      ,
      • Jeyarajah EJ
      • Cromwell WC
      • Otvos JD.
      Lipoprotein particle analysis by nuclear magnetic resonance spectroscopy.
      the participants in this study tended to have smaller LDL-P (defined as small LDL-P 18.0-21.2 nm, large LDL-P 21.2-23.0 nm), increased TRL-P and reduced HDL-P (Table 1).
      Table 1Baseline lipid and lipoprotein characteristics measured by NMR LipoProfile of the study group.
      ParameterPlacebopooled N=24Olezarsen
      10 mg N=2230 mg N=2340 mg N=2350 mg N=22Pooled N=90
      Mean (SD)
      Total Cholesterol (mg/dL)153.4 (25.0)149.6 (28.2)163.3 (29.4)158.2 (32.8)174.1 (35.0)161.7 (32.3)
      Triglycerides, (mg/dL) median (IQR)240.5

      (219.5,301.0)
      246.0

      (216.0,337.0)
      278.0

      (222.0,319.0)
      243.0

      (201.0,309.0)
      235.0

      (208.0,310.0)
      245.0

      (208.0,313.0)
      HDL-C (mg/dL)39.9 (7.9)37.7 (7.9)37.1 (8.4)36.5 (7.3)41.3 (9.5)38.3 (8.4)
      LDL-C (mg/dL)70.2 (19.1)68.8 (21.7)80.3 (25.7)75.5 (26.2)88.3 (22.1)78.6 (24.5)
      Total TRLP (nmol/L)

      mean (SD)
      166.6 (57.2)182.4 (63.4)194.2 (56.7)189.1 (55.6)230.9 (126.7)200.3 (84.0)
      Large TRL-P (nmol/L)

      mean (SD)
      9.9 (5.0)12.3 (6.9)11.4 (5.0)12.9 (10.5)10.8 (8.0)11.8 (7.7)
      Medium TRL-P (nmol/L)

      mean (SD)
      39.4 (18.3)51.2 (24.3)49.1 (19.4)36.1 (26.8)48.1 (37.3)46.4 (28.1)
      Small TRL-P (nmol/L)

      mean (SD)
      36.4 (29.5)31.5 (31.4)25.2 (24.3)28.4 (18.9)43.9 (38.2)32.7 (29.9)
      Total LDL-P (nmol/L)

      mean (SD)
      1018 (414)1127 (387)1187 (358)1200 (427)1298 (288)1206 (363)
      Large LDL-P (nmol/L)

      mean (SD)
      341.1 (266.6)221.0 (202.1)398.9 (358.8)293.5 (398.9)328.8 (319.0)311.5 (325.5)
      Small LDL-P (nmol/L)

      mean (SD)
      676.8 (354.9)905.8 (380.9)787.8 (375.1)906.9 (482.1)969.2 (359.1)894.1 (396.3)
      Total HDL-P (μmol/L)

      mean (SD)
      19.8 (3.1)20.2 (3.5)19.8 (3.1)19.3 (3.2)21.2 (3.6)20.2 (3.4)
      Large HDL-P (μmol/L)

      mean (SD)
      0.9 (0.5)0.9 (0.5)0.8 (0.5)0.7 (0.4)0.8 (0.5)0.8 (0.5)
      Medium HDL-P (μmol/L)

      mean (SD)
      3.0 (1.4)1.9 (0.9)2.1 (1.1)2.7 (1.8)3.4 (2.5)2.5 (1.8)
      Small HDL-P (μmol/L)

      mean (SD)
      15.9 (2.7)17.4 (2.9)16.9 (2.7)15.9 (3.7)17.1 (3.3)16.8 (3.2)
      TRL size, nm55.7 (6.8)56.1 (8.2)56.2 (6.7)58.0 (7.4)54.3 (6.8)56.0 (7.3)
      LDL size, nm20.1 (0.5)19.8 (0.5)20.0 (0.6)19.8 (0.5)19.9 (0.5)19.9 (0.1)
      HDL size, nm8.7 (0.2)8.6 (0.2)8.6 (0.2)8.6 (0.2)8.6 (0.3)8.6 (0.2)

      Effect of olezarsen on TRL-P concentrations

      Treatment with olezarsen compared to placebo resulted in significant, dose-dependent, mean percent reductions (range 13.7-48.9%) in total TRL-P concentration (Fig. 1A). The largest reductions were observed for large and medium-size TRL-P subspecies, whereas no significant effect was noted for small TRL-P (Fig. 1B). The highest dose of olezarsen (50 mg/month) compared to placebo resulted in a 51% (95% CI -60% to -41%, P<0.0001) reduction in total TRL-P, 68% (95% CI -79% to -52%, P<0.0001) reduction in large TRL-P, and 63% (95% CI -74% to -47%, P<0.0001) reduction in medium-size TRL-P.
      Fig 1
      Fig. 1Effect of olezarsen on total, large, medium and small TRL-P concentration at the primary analysis timepoint.

      Effect of olezarsen on LDL-P concentrations

      There was minimal effect of olezarsen on total LDL-P concentration, except for a borderline increase in the 40 mg monthly dose (Fig. 2A). Large-size LDL-P were significantly increased in the 40 mg and 50 mg monthly dose by 117% (p=0.0461) and 186% (p= 0.0034), respectively (Fig. 2B), but small-size LDL-P tended to be decreased across all doses (Fig. 2C), with a statistical trend toward the 50 mg dose with a 39% reduction compared to placebo (95% CI -64% to 4%, p=0.0713).
      Fig 2
      Fig. 2Effect of olezarsen on LDL-P concentration at the primary analysis timepoint.

      Effect of olezarsen on HDL-P concentrations

      APOCIII-LRx resulted in an increase in total HDL-P concentration in all doses, ranging from 10-23% compared to placebo, although not in a dose-dependent manner (Fig. 3A). The differences in effect were driven primarily by small HDL-P (Fig. 3B), ranging from 27% to 39% increase compared to placebo (p=value range 0.0047 to 0.0002), whereas no significant changes were noted in medium (Fig. 3C) and large (Fig. 3D) HDL-P. Some of this effect may have been accentuated due to a decline in small HDL-P in the placebo group.
      Fig 3
      Fig. 3Effect of olezarsen on HDL-P concentration at the primary analysis timepoint.

      Effect of olezarsen on particle sizes

      The least squares mean percent change in TRL size decreased across all doses, with significant differences in the 30 mg and 40 mg monthly doses [10 mg monthly = -2.8% (p=0.4762), 30 mg monthly = -8.14% (p=0.0309), 40 mg monthly = -10.24% (p=0.0081) and 50 mg monthly = -5.19% (p=0.1628) versus -0.02% in pooled placebo].
      In contrast, the least squares mean percent change in LDL size increased across all doses, with significant differences in the 40 mg and 50 mg monthly doses [10 mg monthly= 0.70% (p=0.8182), 30 mg monthly = 1.60% (p=0.1514), 40 mg monthly = 2.99% (p=0.0022) and 50 mg monthly = 2.70% (p=0.0039) versus 0.52% in pooled placebo].
      There were no significant changes in HDL particle size in response to olezarsen in any dose cohort (data not shown).

      Additional analyses and NMR measurements of interest

      We evaluated the effect of olezarsen on 3 key subsets in patients with: 1- BMI>=30 2- type 2 diabetes and 3- Age >=65 yrs. The results were similar to the full analysis set (data not shown).
      Glucose, branched chain amino acids, ketone bodies and GlycA were not significantly different at the primary analysis timepoint in any dose cohorts versus placebo (data not shown).

      Discussion

      This study documented that treatment with olezarsen, an antisense oligonucleotide targeting APOC3 mRNA, resulted in significant reductions in the concentration of TRLs, conversion of smaller to larger LDL particle size, and an increase in small HDL-P. These changes in lipoprotein concentration and sizes have previously been associated with lower cardiovascular risk.
      • McGarrah RW
      • Craig DM
      • Haynes C
      • Dowdy ZE
      • Shah SH
      • Kraus WE.
      High-density lipoprotein subclass measurements improve mortality risk prediction, discrimination and reclassification in a cardiac catheterization cohort.
      ,

      Marston NA, Giugliano RP, Melloni GEM, et al. Association of apolipoprotein B-containing lipoproteins and risk of myocardial infarction in individuals with and without atherosclerosis: distinguishing between particle concentration, type, and content. JAMA Cardiol. 2021.

      Overall, these data are consistent with the favorable remodeling of lipoproteins to a less atherogenic risk profile when ApoC-III levels are reduced pharmacologically.
      ApoC-III mediates chylomicronemia and hypertriglyceridemia by inhibiting lipoprotein lipase,
      • Johansen CT
      • Kathiresan S
      • Hegele RA.
      Genetic determinants of plasma triglycerides.
      as well as by delaying hepatic clearance of ApoC-III enriched particles.
      • Gaudet D
      • Alexander VJ
      • Baker BF
      • et al.
      Antisense inhibition of apolipoprotein C-III in patients with hypertriglyceridemia.
      ,
      • Gaudet D
      • Brisson D
      • Tremblay K
      • et al.
      Targeting APOC3 in the familial chylomicronemia syndrome.
      In a prior studies with volanesorsen using immunoassays, it was demonstrated that ApoCIII is present on apoB-100, Lp(a) and apoAI captured on microtiter plates with specific antibodies.
      • Yang X
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      • Choi YS
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      Reduction in lipoprotein-associated apoC-III levels following volanesorsen therapy: phase 2 randomized trial results.
      Volanesorsen, which has the same nucleic acid sequence as olezarsen but lacks the GalNAc moiety,
      • Alexander VJ
      • Xia S
      • Hurh E
      • et al.
      N-acetyl galactosamine-conjugated antisense drug to APOC3 mRNA, triglycerides and atherogenic lipoprotein levels.
      also significantly reduced (>80%) the concertation of apoC-III on all these particles equally, both in patients with familial chylomicronemia syndrome and those with hypertriglyceridemia on no other therapies or on fibrates. Additionally, in isolated lipoprotein fractions using ultracentrifugation, volanesorsen significantly reduced VLDL-, LDL-, and HDL-associated apoC-III levels in similar cohorts (ISA presentation 2014). Finally, the presence of ApoC-III on specific lipoproteins has been linked to both CVD
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      and aortic stenosis.
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      ApoCIII-Lp(a) complexes in conjunction with Lp(a)-OxPL predict rapid progression of aortic stenosis.
      There has been growing evidence from observational and genetic studies that TRLs predict CV events independently of LDL-C, and likely play a causal role in ASCVD.
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      Association of triglyceride-lowering LPL variants and LDL-C-lowering LDLR variants with risk of coronary heart disease.
      Emerging studies in subjects with relatively controlled LDL-C demonstrate that remnant cholesterol within TRLs can impart a higher risk of CV events compared to similar levels of LDL-C, and independent of other risk factors.
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      Remnant cholesterol, not LDL cholesterol, is associated with incident cardiovascular disease.
      ,
      • Balling M
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      VLDL cholesterol accounts for one-half of the risk of myocardial infarction associated with apob-containing lipoproteins.
      Findings from the Copenhagen General Population Study demonstrated that a smaller reduction in remnant cholesterol (32 mg/dL) vs LDL-C and non-HDL-C (37 mg/dL and 50 mg/dL, respectively) was required to achieve an equivalent 20% relative risk reduction in recurrent MACE.
      • Langsted A
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      • Nordestgaard BG.
      Contribution of remnant cholesterol to cardiovascular risk.
      Multiple triglyceride lowering drugs have been evaluated within the context of cardiovascular outcome trials. Studies with fibrates as add-on to statin therapy failed to improve cardiovascular outcomes.
      • Laufs U
      • Parhofer KG
      • Ginsberg HN
      • Hegele RA.
      Clinical review on triglycerides.
      Among omega-3 studies, the REDUCE-IT trial
      • Bhatt DL
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      • Miller M
      • et al.
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      demonstrated significant CV benefit, but the STRENGTH trial did not,
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      although each reduced triglyceride levels similarly by 19%. The PROMINENT trial with pemafibrate was terminated early due to futility in the primary endpoint. A meta-regression analysis of triglyceride lowering trials (excluding REDUCE-IT) to predict the extent of triglyceride lowering required to reduce CV risk suggests that much higher potency compounds are needed, as a 40 mg per deciliter (0.45 mmol per liter) reduction in triglycerides was associated with only 4-5% lower CV risk.
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      With development of techniques allowing for quantification of lipoprotein particles and their size distribution, evidence has accumulated indicating that lipoprotein particles are heterogenous in size and biochemical composition, and different subpopulations might have different functional properties including atherogenic potential. In the current study, the most potent effect of olezarsen on LDL-related measures was to increase large LDL-P, with a strong trend (p=0.0713) was present for a reduction in small LDL-P with olezarsen 50 mg/month. For example, it has been shown that small dense LDL (sdLDL) particles have been associated with higher risk of ASCVD, including MI, after adjustment for all traditional risk factors including LDL-C in prospective studies either in general patient population,
      • Hoogeveen RC
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      • Sun W
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      or in a case-cohort study.
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      These observations suggest that sdLDL particles may have a higher atherogenic potential compared to larger LDL particles, possibly due to its delayed plasma clearance and higher propensity to oxidize, and measurement of total LDL-C may not fully reflect CVD risk. Larger studies are needed of olezarsen on small LDL-P concentrations and to assess whether cholesterol ester transfer protein activity is decreased as a result of olezarsen therapy as a potential mechanism.
      Similarly, changes in total HDL-C do not necessarily reflect the cardioprotective functions of HDL. Although HDL-C has been inversely correlated with CV risk, no benefit of raising HDL-C has been observed in CV outcome studies. The ability to measure HDL-P concentration and size has provided some insight into differences among HDL biomarkers by showing that HDL-P is more strongly related than HDL-C to CV outcomes in primary prevention populations.
      • McGarrah RW
      • Craig DM
      • Haynes C
      • Dowdy ZE
      • Shah SH
      • Kraus WE.
      High-density lipoprotein subclass measurements improve mortality risk prediction, discrimination and reclassification in a cardiac catheterization cohort.
      ,
      • Kontush A.
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      ,
      • Singh K
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      • Sperry T
      • et al.
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      Regarding the potential clinical significance of the 30-40% increase in HDL-C brought about by olezarsen, consideration needs to be given to accompanying changes in levels of HDL particle subspecies, particularly the potentially potent atheroprotective small-size particle subpopulation that appears to mediate (among other functions) the anti-inflammatory and antioxidative activities of HDL. Two pharmacologic approaches to raising HDL-C that failed to exhibit clinical efficacy, treatment with niacin and CETP inhibitors, both increased numbers of large, cholesterol-rich HDL particles at the expense of reduced numbers of small HDL-P.
      • Otvos JD
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      In contrast, the HDL-C raised by a fibrate (gemfibrozil) was due primarily to increased small HDL-P, and on-trial levels of this subclass were independently (inversely) related to CHD events.
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      • et al.
      Low-density lipoprotein and high-density lipoprotein particle subclasses predict coronary events and are favorably changed by gemfibrozil therapy in the veterans affairs high-density lipoprotein intervention trial.
      It is also noted that in the Lancaster Amish study loss of function mutations in apoC-III increased both HDL2 and HDL3.
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      A null mutation in human APOC3 confers a favorable plasma lipid profile and apparent cardioprotection.
      Although speculative, these prior findings are consistent with the possibility that the increase in small HDL-P associated with olezarsen therapy may have some clinical benefit.
      Prior NMR studies with icosapent ethyl 4g/day in participants with triglycerides ≥200 and <500 mg/dL and background statin therapy demonstrated significant reductions in total (12.2%), large (46.4), and medium (12.1%) VLDL, total (7.7%,) and small (13.5%) LDL-P, as well as increases in total (7.4%) and large (31.0%) HDL-C.
      • Ballantyne CM
      • Braeckman RA
      • Bays HE
      • et al.
      Effects of icosapent ethyl on lipoprotein particle concentration and size in statin-treated patients with persistent high triglycerides (the ANCHOR Study).
      The findings of the current analysis with olezarsen demonstrate a more potent effect on VLDL-P, with reductions ranging from 51-68%. Furthermore, although olezarsen did not alter the levels of total LDL-P, it did increase large LDL-P and reduced small LDL-P, the large particles having been associated with less atherogenicity than the small particles.
      • Berneis KK
      • Krauss RM.
      Metabolic origins and clinical significance of LDL heterogeneity.
      Finally, olezarsen led to increases in small rather than large HDL-P that have been suggested to be associated with lower CVD risk.
      • McGarrah RW
      • Craig DM
      • Haynes C
      • Dowdy ZE
      • Shah SH
      • Kraus WE.
      High-density lipoprotein subclass measurements improve mortality risk prediction, discrimination and reclassification in a cardiac catheterization cohort.
      Whether these different effects on atherogenic and anti-atherogenic particles results in differences in clinical outcomes awaits future investigations.
      In conclusion, in patients with or at risk for CVD and triglycerides ≥200 and <500 mg/dL, olezarsen results in an improvement in the overall atherogenic risk profile, manifested by a reduction in TRLs, remodeling to larger LDL particles, and increase in total and small HDL-P.

      Author contributions

      EK-P, VJA, JLW, ST- trial design, data procurement and interpretation, drafting manuscript, critical revision of manuscript; JDO- data procurement and interpretation, J-CT, DG, CMB, MDS, PMM, SJB, AStA- data procurement and interpretation, critical revision of manuscript; SX statistical analysis. All authors have approved the final version.

      Disclosures

      EKP, VJB, SX, and ST are employees of Ionis Pharmaceuticals. J-C T received research grants from Amarin, AstraZeneca, DalCor, Esperion, Ionis, Pfizer and Servier; honoraria from Amarin, DalCor, Pfizer, Sanofi and Servier; minor equity interest in DalCor. DG reports grants and personal fees from Akcea Therapeutics, Ionis Pharmaceuticals during the conduct of the study, Arrowhead and Regeneron, and grants from Kowa and Acasti and grants from Uniqure outside the submitted work. CMB has received grant/research support (to his institution) from Abbott Diagnostic, Akcea, Amgen, Esperion, Ionis, Novartis, Regeneron, and Roche Diagnostic, and has been a consultant for Abbott Diagnostics, Althera, Amarin, Amgen, Arrowhead, AstraZeneca, Corvidia, Denka Seiken, Esperion, Genentech, Gilead, Matinas BioPharma Inc, New Amsterdam, Novartis, Novo Nordisk, Pfizer, Regeneron, Roche Diagnostic, and Sanofi-Synthelabo. MDS serves on scientific advisory boards: Amgen, Esperion, Novartis. PMM is a consultant, speaker, or received Research grants from Amgen, Esperion, Kaneka, Amarin, Stage II Innovations/Renew, Novartis, Ionis, FH Foundation, GB Life Sciences, Aegerion. SJB is consultant on scientific advisory board or speaker for Altimmune, Akcea, Amgen, AstraZeneca, Boehringer Ingelheim, Axcella, Eli Lilly, Esperion, Madrigal, Novartis, Regeneron, Sanofi. JDO is an employee of LabCorp. JLW is a consultant to Ionis. JLW and ST are co-inventors and receive royalties from patents owned by UCSD on oxidation-specific antibodies and of biomarkers related to oxidized lipoproteins and are co-founders and have an equity interest in Oxitope, Inc and its affiliates (“Oxitope”) as well as in Kleanthi Diagnostics, LLC (“Kleanthi”). ST is a co-founder of Covicept Therapeutics. Although these relationships have been identified for conflict of interest management based on the overall scope of the project and its potential benefit to Oxitope and Kleanthi, the research findings included in this particular publication may not necessarily relate to the interests of Oxitope and Kleanthi. The terms of this arrangement have been reviewed and approved by the University of California, San Diego in accordance with its conflict of interest policies. The other authors have no disclosures. All authors have approved the final article should be true and included in the disclosure.

      Acknowledgments

      The authors wish to thank Tracy Reigle from Ionis Pharmaceuticals for generation of the artwork.

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