Comparative Effects of Emerging Lp(a)‐Lowering Agents and PCSK9 ‐Directed Therapies on Lipoprotein(a): A Network Meta‐Analysis of Randomised Clinical Trials

ABSTRACT Aims Elevated lipoprotein(a) Lp(a) is a genetic ASCVD risk factor that often persists despite intensive LDL‐C lowering. We compared the efficacy and safety of emerging Lp(a)‐targeted therapies (siRNAs, antisense oligonucleotides and an oral assembly inhibitor) with PCSK9‐directed therapies. Materials and Methods We searched PubMed, Embase, Web of Science and Cochrane CENTRAL through December 6, 2025, for randomised trials in adults (≥ 18 years) with ≥ 8‐week follow‐up reporting Lp(a). The primary outcome was placebo‐adjusted mean difference (MD) in percent change from baseline in Lp(a) (percentage points, pp). Secondary outcomes included LDL‐C, other lipid parameters and safety outcomes (injection‐site reactions, serious adverse events (SAEs), discontinuations). We performed a frequentist random‐effects network meta‐analysis in R (netmeta) and ranked interventions using P‐scores. Results Fifty‐one trials (17 810 participants) formed a 16‐node network. Olpasiran 225 mg Q12W was associated with the greatest Lp(a) reduction versus placebo (MD −98.94 pp, 95% CI −114.36 to −83.52); pelacarsen, muvalaplin, zerlasiran and lepodisiran were also associated with large reductions. PCSK9‐directed therapies were associated with more modest Lp(a) reductions (evolocumab 140 mg Q2W: MD −31.58 pp), but greater LDL‐C lowering. The primary Lp(a) network showed high heterogeneity ( I 2 = 90.9%) and funnel plot asymmetry, although treatment rankings remained directionally consistent across sensitivity analyses. No therapy was associated with higher SAEs or discontinuations versus placebo; alirocumab 150 mg was associated with more injection‐site reactions. Conclusions Lp(a)‐targeted therapies were associated with larger Lp(a) reductions than PCSK9‐directed therapies, while PCSK9‐directed therapies had greater LDL‐C lowering. Given high heterogeneity, funnel plot asymmetry and low certainty for several estimates, these findings should be interpreted cautiously pending cardiovascular outcome trials.