GLP1-RA associated with PCSK9i as chemosensitizing method and therapy of anthracycline-induced cardiotoxicity under exposure to Ox-LDL: biochemical and preclinical evidences

Background Recent meta analysis have highlighted the key role of oxLDL in cardiovascular risk in patients with/without cancer through the stimulation of pro-inflammatory signaling. GLP-1 receptor agonists, like semaglutide, have shown cardiorenal benefits in patients with/without diabetes, proposing themselves as a new cardioprotective strategy in a broad patient setting. PCSK9i inclisiran exerts cardiovascular benefits through intrahepatic and extrahepatic functions, involving myocardial tissue. High risk patients with hyperlipidemia and treated with anthracyclines need new pharmacological strategies to reduce the magnitude of CTRCD. Purpose We report for the first time the results of the use of combination therapy with a glucagon-like peptide-1 receptor agonist and PCSK9i for the primary prevention of anthracyline-mediated cardiotoxicity. Methods Human cardiomyocytes (HFC cell line) and beast cancer cells (MDA-MB-436) were exposed to subclinical concentration of doxorubicin, (200 nM), alone or in combination with inclisiran (100 nM) and or semaglutide (100 nM) for 48h under exposure to 200 μg/ml oxLDL (hyperlipidemia). After the incubation period, we performed the following tests: determination of cell viability, through analysis of mitochondrial dehydrogenase activity, study of lipid peroxidation (quantifying cellular Malondialdehyde and 4-hydroxynonenal), intracellular Ca2+ homeostasis. Moreover, pro-inflammatory studied were also performed ( NLRP3; expression of TLR4/MyD88; mTORC1 Fox01/3a; activation of p65/NF-κB and expression of cytokines involved in cardiotoxicity (IL-1α, IL-1β, IL-2, IL-4, IL-6, IL-10, IL-12, IL17-α, IFN-γ, TNF-α, G-CSF, GM-CSF). Results Inclisiran and semaglutide co-incubated with doxorubicin exerts synergistic and significant cardioprotective effects,compared to monotherapy regimens, enhancing cell viability of 74,7-88,4 % compared to doxorubicin-oxLDL treated cells (p<0,01 for all). Significant reductions of oxidative stress, ferroptosis and intracellular levels of NLRP-3, MyD88, p65NF-KB, IL-1α, IL-1β, IL-6, IL-12, IL17-α, TNF-α, G-CSF were seen in semaglutide/inclisiran group vs only doxo groups under oxLDL exposure (p<0.05); contrary, IL-10 was significantly increased. Notably, in breast cancer cells, increased cytotoxicity and apoptosis were seen in group Inclisiran+Sema+ doxorubicin vs only doxorubicin alone with significant reductions in NLRP3, MyD88, IL1 and IL-18 expression. Conclusion For the first time, combination therapy with Semaglutide and PCSK9i inclisiran was effective and superior, compared to monotherapy, to reduce anthracycline-mediated cardiotoxicity through different signalling pathways and makes breast cancer tumor cells more vulnerable to anthracycline therapy through cytokine reduction implicated in chemoresistance and metastasis. The overall picture of the study warrent on the use of semaglutide and PCSK9i in primary prevention of CTRCD in cancer patients with hyperlipidemia