前蛋白转化酶枯草溶菌素9对胆固醇水平的影响

目的 探讨前蛋白转化酶枯草溶菌素9(PCSK9)水平与血脂等代谢相关指标的关系.方法 采用随机抽样方法收集388名体检人员的空腹血样本388份,并对入选者进行问卷调查、体格检查及代谢相关指标的测定,用ELISA方法检测血清样本PCSK9水平.结果 PCSK9水平为(86.19±32.33)ng/ml,呈偏态分布,女性PCSK9水平显著高于男性(P<0.01).PCSK9水平与总胆固醇(TC)、低密度脂蛋白胆固醇(LDL-C)、高密度脂蛋白胆固醇(HDL-C)呈正相关(P<0.05).他汀类药物治疗组PCSK9水平显著高于未服用他汀类药物组(P<0.01).结论 人群中PCSK9水平呈偏态分布,并且与性别、TC、LDL-C、HDL-C有关.他汀类药物可以升高血PCSK9水平.     

前蛋白转化酶枯草溶菌素9抑制剂的研究进展

低密度脂蛋白胆固醇(low-density lipoprotein cholesterol,LDL-C)升高是心血管疾病危险因素之一。前蛋白转化酶枯草溶菌素9(proprotein convertase subtilisin/kexin type 9,PCSK9)是一种人血清蛋白,通过促进低密度脂蛋白受体(low-density lipoprotein receptor,LDLR)降解,导致LDL-C升高,因此PCSK9已经成为新的调节血脂药物作用靶点。在目前研究中的PCSK9抑制剂中,2种单克隆抗体类抑制剂已完成Ⅱ期临床试验,1种小分子干扰RNA抑制剂正在进行Ⅰ期临床试验,2种反义寡核苷酸类抑制剂Ⅰ期临床试验提前终止。本文对上述PCSK9抑制剂的研究情况作一综述。     

人前蛋白转化酶枯草溶菌素 9抑制剂在治疗高脂血症中的研究进展

动脉粥样硬化是一种贯穿于每个人体生命过程中的慢性疾病,其最终结局以导致动脉粥样硬化性心血管疾病( AS. CVD)最为常见。而促使动脉粥样硬化( AS)发生发展的最主要因素就是高脂血症,他汀类药物是目前临床上应用最广泛、最经典的一线降脂药物,给广大病人带来了获益。但有一部分病人在充分使用他汀类降脂药物时会出现血脂仍不达标或不能耐受的情况。前蛋白转化酶枯草杆菌蛋白酶 / kexin 9型( PCSK9)抑制剂作为临床上另外一类新型降脂药,具有总体降脂效果好、不良反应相对较少、能改善病人预后等优势,是近几年最被看好的新型降脂药物。但也存在比如价格昂贵、病人依从性差、可能出现相关并发症等劣势。该文将系统地阐述 PCSK9抑制剂在治疗高脂血症的研究进展。     

PCSK9抑制剂在动脉粥样硬化性心血管疾病中的临床研究进展

动脉粥样硬化性心血管疾病(ASCVD)现已成为危害人类健康的主要疾病之一。降低胆固醇治疗尤其是低密度脂蛋白-胆固醇(LDL-C),是ASCVD防治的基石,目前指南推荐控制LDL-C水平首选他汀类药物。但在临床实践中,经过他汀治疗的ASCVD患者仍存在较高剩留风险,另仍有部分患者不能耐受他汀类药物或在他汀类药物最大耐受剂量的情况下血脂仍不能达标。人前蛋白转化酶枯草溶菌素9(PCSK9)与LDL-C代谢密切相关,近年来大量基础和临床研究均证实PCSK9抑制剂能够显著降低血LDL-C水平,且耐受性和安全性良好。目前国外已批准PCSK9抑制剂用于临床。本文将系统综述有关PCSK9基因与血脂代谢的关系、PCSK9抑制剂的研发过程,总结其在基础和临床研究的最新进展。     

白藜芦醇对高血脂模型小鼠的预防作用和对模型金黄地鼠的改善作用研究

目的:研究白藜芦醇对高血脂模型小鼠的预防作用和对模型金黄地鼠(以下简称地鼠)的改善作用。方法:以高脂高胆固醇饲料饲养诱导高血脂动物模型。将小鼠和地鼠均分为模型组和白藜芦醇低、中、高剂量组(小鼠给予40、80、160 mg/kg,地鼠给予25、50、100 mg/kg),每组10只,同时设立10只相应动物为正常对照组。除正常对照组动物喂食正常饲料和ig生理盐水外,其余小鼠在喂食高脂高胆固醇饲料的同时ig相应药物;其余地鼠先建模2周,成模后再ig相应药物,给药期间继续喂食高脂高胆固醇饲料。持续给药4周,每周检测各组小鼠和地鼠血清中总胆固醇(TC)和低密度脂蛋白胆固醇(LDL-C)水平,给药4周后检测各组小鼠和地鼠血清中前蛋白转化酶枯草溶菌素9(PCSK9)mRNA及蛋白、微小RNA-27a(miRNA-27a)表达,以及小鼠肝组织中低密度脂蛋白受体(LDLR)蛋白表达。结果:与正常对照组比较,模型组小鼠从给药2周后开始血清中TC、LDL-C、PCSK9 mRNA及蛋白、miRNA-27a水平均明显升高(P<0.05),肝组织中LDLR蛋白水平明显降低(P<0.05);模型组地鼠给药期间血清中TC、LDLC、PCSK9 mRNA及蛋白、miRNA-27a水平均明显升高(P<0.05)。与模型组比较,各给药组小鼠和地鼠上述指标均明显改善(P<0.05),且与剂量呈正相关。结论:白藜芦醇对高血脂模型小鼠有预防作用,对模型地鼠有改善作用。其机制可能是通过下调血清中miRNA-27a表达与PCSK9蛋白表达,进而升高肝组织中LDLR蛋白水平,最终降低血清中LDL-C水平。     

首个新一代靶向降脂药PSCK9抑制药阿里罗单抗概述

摘 要全面介绍首个新一代靶向降脂药——前蛋白转化酶枯草溶菌素9（PSCK9）抑制药阿里罗单抗,其通过与抗肝细胞表面的低密度脂蛋白受体(LDLR)靶向结合,降低低密度脂蛋白胆固醇（LDL-C）,用于治疗原发性高脂血症,为膳食控制和最大耐受量的他汀类药物的辅助治疗,对于患杂合子家族性高胆固醇血症(HeFH)和或合并动脉粥样硬化性心血管病,需要进一步降低LDL C水平的成年患者提供了新的选择。     

芒果苷单钠盐对高胆固醇血症大鼠肝脂质代谢及PCSK9/LDLR途径的影响

目的 观察芒果苷单钠盐对高胆固醇血症大鼠肝脂质代谢及前蛋白转化酶枯草溶菌素9(PCSK9)/低密度脂蛋白受体(LDLR)的作用。方法 选取SD大鼠40只,将其按体质量随机分为对照组、模型组、阿托伐他汀钙片组、芒果苷单钠盐组,每组10只。除对照组外,其余各组采用高脂饲料喂养法建立高胆固醇血症模型。造模成功后,阿托伐他汀钙片组ig阿托伐他汀钙片5 mg/kg,芒果苷单钠盐组ig 80 mg/kg芒果苷单钠盐,给药8周后,观察各组体质量及肝脏指数变化,生化法检测各组血脂指标[三酰甘油(TG)、总胆固醇(TC)、高密度脂蛋白胆固醇(HDL-C)、低密度脂蛋白胆固醇(LDL-C)],肾功能、血清酶指标[肌酐(CRE)、血清尿素(UREA)、肌酸激酶(CK)、乳酸脱氢酶(LDH)]及肝组织游离胆固醇(FC)、总胆汁酸(TBA)的含量,苏木精-伊红染色(HE)观察大鼠肝组织形态学变化,RT-PCR检测肝组织中白细胞介素-1β(IL-1β)和CD68 mRNA表达,Western blotting及RT-PCR检测肝组织中PCSK9、LDLR的蛋白及mRNA表达。结果 与模型组相比,各给药组大鼠体质量和肝脏指数明显降低(P<0.05);血清中TC、LDL-C及CRE、UREA、CK、LDH水平显著降低,HDL-C水平显著升高(P<0.05);肝组织中FC含量降低,TBA含量升高(P<0.05);肝脏脂肪变性改善明显;肝组织I L-1β、CD68 mRNA表达明显减少(P<0.05),同时显著降低了PCSK9的蛋白和mRNA水平,提升了LDLR的蛋白和mRNA水平(P<0.05)。结论 芒果苷单钠盐可有效调节高胆固醇血症大鼠肝胆固醇代谢,减轻高脂造成的心肾功能损害,其作用可能与调节肝脏PCSK9/LDLR信号通路的表达,改善脂质代谢紊乱相关。     

外泌体微小RNA-222预警shRNA-PCSK9诱发 脑Tau蛋白过度磷酸化

目的 PCSK9抑制剂临床不良反应监测数据显示有神经认知不良事件,为尽早预警PCSK9抑制剂在调控脂质稳态过程中对认知障碍的潜在危险, 本研究旨在探究血浆外泌体携带的微小RNA-222（miR-222）作为shRNA-PCSK9 诱发认知障碍提供早期预警标志物。 方法 高脂饲料喂饲法制备高胆固醇血症小鼠模型（high-fat diet,HFD-model group）。再将HFD-model分为shRNA空白对照组（HFD-shRNA-control group）和shRNA PCSK9组（HFD-shRNA-PCSK9 group）。构建shRNA-PCSK9慢病毒,经静脉注入体内,实时荧光定量PCR（RT-PCR）法检测PCSK9 mRNA表达。免疫组织化学（Immunohistochemistry,IHC）观察脑组织Tau蛋白和磷酸化。蛋白免疫印迹（Western blot）检测Tau蛋白和P-Tau蛋白。酶联免疫法（ELISA）法测定血清淀粉样蛋白Aβ1-42Ab水平。试剂盒分步提取血浆外泌体,负染电镜技术对外泌体形态进行鉴定,NTA技术测定外泌体粒径。RT-PCR技术检测血浆外泌体中携带的miR-222表达水平。 结果 高脂饲料喂饲13周制备HFD-model模型,血清总胆固醇（TC）、低密度脂蛋白（LDL-C）含量显著升高,同时,HFD-model小鼠脑组织内PCSK9 mRNA表达明显升高。经shRNA-PCSK9慢病毒干扰后,PCSK9 mRNA表达抑制,同时IHC观察到shRNA-PCSK9诱发了脑组织Tau蛋白的异常表达和过度磷酸化,表明已发生神经纤维缠结的病理改变。然而,此时,血清Aβ1-42Ab尚未明显升高,尚未具备诊断认知障碍的意义。将血浆外泌体中的miRNA提取,RT-PCR结果显示,HFD-shRNA-PCSK9组外泌体中携带的miR-222表达量与HFD-shRNA-control组相比显著降低。 结论 血浆外泌体携带的miR-222（miR-222）作为shRNA-PCSK9 诱发认知障碍提供早期预警标志物。     

荷丹片联合苯扎贝特治疗高脂血症的临床研究

目的探讨荷丹片联合苯扎贝特片治疗高脂血症的临床疗效。方法选取西安市第一医院2016年9月—2017年9月收治的175例高脂血症患者作为研究对象,将患者随机分为对照组(87例)和治疗组(88例)。对照组患者口服苯扎贝特片,1片/次,3次/d;治疗组患者在对照组治疗的基础上口服荷丹片,2片/次,3次/d。两组患者均连续治疗8周。观察两组患者的临床疗效,比较两组治疗前后的血脂、颈动脉内膜中层厚度(IMT)、内皮素-1(ET-1)、人前蛋白转化酶枯草溶菌素-9(PCSK9)水平。结果治疗后,对照组和治疗组的总有效率分别为86.21%、96.59%,两组比较差异具有统计学意义(P0.05)。治疗后,两组患者总胆固醇(TC)、三酰甘油(TG)水平显著降低,载脂蛋白A1(APOA1)水平显著升高,同组治疗前后比较差异具有统计学意义(P0.05);且治疗后治疗组患者TC、TG水平显著低于对照组,APOA1水平显著高于对照组,两组比较差异具有统计学意义(P0.05)。治疗后,两组患者IMT、ET-1水平显著降低,PCSK9水平显著升高,同组治疗前后比较差异具有统计学意义(P0.05);且治疗后治疗组IMT、ET-1水平显著低于对照组,PCSK9水平显著高于对照组,两组比较差异具有统计学意义(P0.05)。结论荷丹片联合苯扎贝特片治疗高脂血症疗效显著,安全性高,具有一定的临床推广应用价值。     

从传统他汀及其联合治疗看调脂治疗的临床获益

摘要： 动脉粥样硬化性心血管疾病 （ASCVD） 是全球范围内主要的疾病负担, 亦是患者死亡的主要原因。既往大量关于他汀类药物调脂治疗的临床试验证实, 他汀类药物可有效降低 ASCVD 患者低密度脂蛋白胆固醇 （LDL-C） 水平、 全因死亡率和心血管病死亡率, 无 ASCVD 的患者亦可获益。然而, 目前无论是 ASCVD 高危患者还是无 ASCVD 的人群, 并未广泛应用降脂治疗。因此, 本文阐述了他汀类及其联合用药所带来的临床获益, 旨在增大受益人群, 改善预后。     

Inclisiran for the treatment of dyslipidemia

Introduction: Dyslipidemia is one of the most important risk factors for cardiovascular disease. Insufficient reduction in LDL-C from existing therapies in patients at high risk of atherogenic cardiovascular disease is an unmet clinical need. Circulating PCSK9 causes hypercholesterolemia by reducing LDL receptors in hepatocytes.

Areas covered: PCSK9 inhibition has emerged as a promising new therapeutic strategy to reduce LDL-C. Inclisiran, a novel, synthetic, siRNA molecule, inhibits PCSK9 synthesis in hepatocytes. Inclisiran targets intracellular PCSK9 synthesis specifically, resulting in a dose-dependent, long-term, significant reduction in LDL-C. Inclisiran has been well tolerated and safe, without severe adverse events so far. This review discusses current PCSK9 inhibitors and the results of phase I and II clinical trials of inclisiran.

Expert opinion: Plasma PCSK9 enhances the degradation of LDL receptor, resulting in accumulation of LDL-C in the circulation. Current approaches with monoclonal antibodies sequester circulating PCSK9 but require frequent injections. Inclisiran inhibits translation of PCSK9 mRNA and thus switches off PCSK9 production and provides advantages over monoclonal antibodies with an infrequent dosing interval of twice a year to reduce LDL-C by over 50%. Ongoing studies will establish the long-term safety of inclisiran in patients with high cardiovascular risk and an elevated LDL-C.     

Berberine inhibits dyslipidemia in C57BL/6 mice with lipopolysaccharide induced inflammation

BackgroundInhibiting the action of proprotein convertase subtilisin/kexin type 9 (PCSK9) on the low-density lipoprotein receptor (LDLR) has emerged as a novel therapeutic target for hypercholesterolemia. Here we investigated the effect of berberine, natural plant extracts, on PCSK9-LDLR pathway in C57BL/6 mice with lipopolysaccharide (LPS) induced inflammation.MethodsForty female mice were divided into four groups (n = 10): control, LPS (5 mg/kg), LPS + berberine 10 (5 mg/kg LPS plus 10 mg/kg berberine), and LPS + berberine 30 (5 mg/kg LPS plus 30 mg/kg berberine). Changes in the levels of blood lipids [total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C)]; pro-inflammatory cytokines [interferon-γ (IFNγ), tumor necrosis factor α (TNFα), and interleukin-1α (IL-1α)], 8-isoprostane, hepatic expressions of PCSK9 and LDLR were determined.ResultsBerberine pretreatment reduced the expression of hepatic PCSK9, decreased the plasma TC, TG, LDL-C, IFNγ, TNFα, IL-1α, and 8-isoprostane concentrations; increased HDL-C level and LDLR expression in mice.ConclusionThe present results suggest that berberine inhibits dyslipidemia in C57BL/6 mice with LPS induced inflammation through regulating PCSK9-LDLR pathway.     

Safety and tolerability of injectable lipid-lowering drugs: a review of available clinical data

Introduction: To answer the need of a better low-density lipoprotein (LDL) cholesterol control in statin-treated patients at high risk for cardiovascular disease, new injectable lipid-lowering drugs with innovative mechanisms of action are in advanced phase of development or have just been approved.

Areas covered: Evolocumab and alirocumab are fully human monoclonal antibodies inhibiting the proprotein convertase subtilisin/kexin type 9 (PCSK9) that binds to hepatic LDL receptor and prevents it from normal recycling by targeting it for degradation. Mipomersen specifically binds to a segment of the human apolipoprotein B100 messenger RNA, blocking the translation of the gene product. Phase II (for evolocumab and alirocumab) and III (for evolocumab) trials show that PCSK9 inhibitors are equally well tolerated, with adverse events mainly limited to mild-to-moderate nasopharyngitis, injection-site pain, arthralgia and back pain. Mipomersen use is mainly associated to hepatosteatosis, increased transaminases (> 3 times the upper limit of normal), mild-to-moderate injection-site reactions and flu-like symptoms.

Expert opinion: PCSK9 inhibitors have demonstrated their good safety and tolerability in a large number of subjects with different clinical conditions, including statin-intolerance, enlarging their potential use in a broader range of patients. Further data on long-term mipomersen safety are required.     

A safety evaluation of evolocumab

Introduction: Evolocumab is an injectable, fully human monoclonal antibody and a member of the newest class of low density lipoprotein cholesterol (LDL-C) lowering agents called proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. The PCSK9 inhibitors are the most significant advance in lipid therapy since the introduction of the first statin 30 years ago.

Areas covered: The PCSK9 monoclonal antibodies have demonstrated a consistently high LDL-C lowering efficacy with and without statins and/or other lipid lowering therapies (LLT). LDL-C levels achieved with these agents are lower than has ever been possible before. This review will focus on the overall safety of evolocumab including cognitive impairment, very low LDL-C levels, new onset diabetes and glucose abnormalities, effect on vitamin E and steroid hormones, liver and muscle abnormalities, and immunogenicity and injection site reactions. The phase II and III clinical trials had relatively low patient-years of exposure, but the open label extension studies and the recently published outcomes trial, FOURIER, will be the focus of this paper. The safety profile of evolocumab to date is remarkable and extremely encouraging as will be demonstrated.

Expert opinion: The PCSK9 inhibitors will be responsible for a new era in lipid therapy that will expand our knowledge of lipid levels and cardiovascular disease (CVD) prevention with an efficacy and safety profile not previously available in clinical practice.     

Novel treatment options for the management of heterozygous familial hypercholesterolemia

Introduction: Even though statins represent the mainstay of treatment of heterozygous familial hypercholesterolemia (FH), their low-density lipoprotein cholesterol (LDL-C) lowering efficacy is finite and most patients with FH will not achieve LDL-C targets with statin monotherapy. Addition of ezetimibe with or without bile acid sequestrants will also not lead to treatment goals in many of these patients, particularly in those with established cardiovascular disease. In this selected subgroup of the FH population, proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors provide substantial reductions in LDL-C levels, reduce cardiovascular morbidity and appear to be safe. Mipomersen, an antisense single-strand oligonucleotide that inhibits the production of apoB by binding to the mRNA that encodes the synthesis of apoB, and lomitapide, an inhibitor of microsomal triglyceride transfer protein, also reduce LDL-C levels but are currently indicated only for the management of homozygous FH.

Areas covered: In the present review, the role of PCSK9 inhibitors, mipomersen and lomitapide in the management of FH is briefly discussed. Other LDL-C-lowering agents under evaluation include inclisiran, a small interference RNA molecule that induces long-term inhibition of PSCK9 synthesis, anacetrapib, a cholesterol ester-transfer protein inhibitor, ETC-1002 (bempedoic acid), an inhibitor of adenosine triphosphate citrate lyase, and gemcabene, which reduces hepatic apolipoprotein C-III mRNA. The safety and efficacy of these agents are also reviewed.

Expert Commentary: Even though several novel treatment options for heterozygous FH are under development, it remains to be shown whether these treatments will also reduce cardiovascular morbidity in these high-risk patients.     

Molecular dynamics insights on the role β‐augmentation of the peptide N‐terminus with binding site β‐hairpin of proprotein convertase subtilisin/kexin 9

PCSK9, a member of the proprotein convertase family, is a key negative regulator of hepatic low‐density lipoprotein receptor (LDLR) concentrations in the blood plasma and is associated with the risk of coronary artery disease (CAD). Peptide inhibitors designed to block PCSK9‐LDLR interactions could reduce the risk of CAD. We present a study of the interaction of a PCSK9 bound peptide and its design through modification by phosphorylation using molecular dynamics simulations. Extensive explicit solvent simulations of PCSK9 and its mutant (Asp374 → Tyr374) with designed peptides provide insights into the mechanism of peptide binding at the protein interface. We establish that β‐augmentation is the key mechanism of peptide association with PCSK9. Position‐specific phosphorylation of threonine residues is observed to have noticeable effect in modulating protein–peptide association. This study provides a handle to explore and improve the design of peptides bound to PCSK9 by incorporating knowledge‐derived functional motifs into designing potent binders.