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Relationship Between LowâDensity Lipoprotein Cholesterol, Free Proprotein Convertase Subtilisin/Kexin Type 9, and Alirocumab Levels After Different LipidâLowering Strategies
Background: Alirocumab undergoes targetâmediated clearance via binding of proprotein convertase subtilisin/kexin type 9 (PCSK9). Statins increase PCSK9 levels; the effects of nonstatin lipidâlowering therapies are unclear. Everyâ4âweeks dosing of alirocumab may be appropriate for some patients in absence of background statin but is not yet approved. Methods and Results: Lowâdensity lipoprotein cholesterol (LDLâC), PCSK9, and alirocumab levels were assessed in subjects (LDLâC >130 mg/dL, n=24/group) after a 4âweek runâin taking oral ezetimibe, fenofibrate, or ezetimibe placebo, when alirocumab 150 mg every 4 weeks (days 1, 29, and 57) was added. Maximal mean LDLâC reductions from day â1 baseline (prealirocumab) occurred on day 71 in all groups: alirocumab plus placebo, 47.4%; alirocumab plus ezetimibe, 56.6%; and alirocumab plus fenofibrate, 54.3%. LDLâC reductions were sustained through day 85 with alirocumab plus placebo (47.0%); the duration of effect was slightly diminished at day 85 versus day 71 with ezetimibe (49.6%) or fenofibrate combinations (43.2%). Free PCSK9 concentrations were lowest at day 71 in all groups, then increased over time; by day 85, free PCSK9 concentrations were higher, and alirocumab levels lower, with alirocumab plus fenofibrate, and to a lesser extent alirocumab plus ezetimibe, versus alirocumab plus placebo. Conclusions: Alirocumab 150 mg every 4 weeks produced maximal LDLâC reductions of 47% in combination with placebo and 54% to 57% in combination with ezetimibe or fenofibrate. The oral lipidâlowering therapies appear to increase PCSK9 levels, leading to increased alirocumab clearance. Although the duration of effect was modestly diminished with alirocumab plus ezetimibe/fenofibrate versus placebo, the effect was less than observed in trials with background statins, and it would not preclude the use of alirocumab every 4 weeks in patients taking these nonstatin lipidâlowering therapies concomitantly. Clinical Trial Registration URL: http://www.Clinicaltrials.gov. Unique identifier: NCT01723735