Key result
Emerging therapies for homozygous familial hypercholesterolemia, including PCSK9 inhibitors and evinacumab, offer additional average LDL-C reductions of 24% and 49%, respectively.
Why the study?
Current treatment options have limited success in bringing patients with homozygous familial hypercholesterolemia to LDL-C targets, leaving morbidity and mortality high.
Novel therapies such as evinacumab, RNA interference, and gene therapy offer promising avenues for further LDL-C reduction in patients with homozygous familial hypercholesterolemia who are difficult to treat with standard therapies.
May support additional LDL-C lowering options in HoFH; leaves open need for outcome trials before practice change.
PURPOSE OF REVIEW: Homozygous familial hypercholesterolemia (HoFH) is a rare disorder associated with early atherosclerotic disease due to impairment of the LDL receptor (LDLR) pathway. Because of their molecular defect, current treatment options have limited success in bringing HoFH patient to LDL-C target and morbidity and mortality remain high. We review current and upcoming therapies directed at HoFH, including gene therapy. RECENT FINDINGS: Recent real-world studies have confirmed the strength in lomitapide as a treatment adjunct to statins and other lipid-lowering therapies in HoFH patients. The approval of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor monoclonal antibodies has also been a welcome addition to the treatment armamentarium offering an additional average reduction in LDL-C levels of 24% when added to background lipid-lowering therapies in this population. Although achieving adequate LDL-C levels in this population is difficult, there are several therapies on the horizon that may help more patients reach goal. Evinacumab, a monoclonal antibody against ANGPTL3, has been shown to substantially reduce LDL-C of an average of 49%, independently of residual LDLR activity. RNA interference targeting PCSK9 and ANGPTL3 shows promise in clinical trials. Adeno-associated virus-mediated gene transfer and gene editing techniques are in early clinical and preclinical development. SUMMARY: LDL-C lowering in HoFH patients remains very challenging. However, novel treatment options are emerging. Upcoming therapies directed at PCSK9 and ANPTL3 may offer additional LDL-C reduction, to help patients achieve adequate LDL-C levels. Gene therapy and gene editing techniques, if proven effective, may offer a unique opportunity to treat patients with a one-time treatment.
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Bajaj et al. (2020) conducted a review in Homozygous familial hypercholesterolemia. Novel lipid-lowering therapies (PCSK9 inhibitors, evinacumab, gene therapy) was evaluated on LDL-C reduction. Emerging therapies for homozygous familial hypercholesterolemia, including PCSK9 inhibitors and evinacumab, offer additional average LDL-C reductions of 24% and 49%, respectively.