Addition of omega-3 carboxylic acids to statin therapy in patients with persistent hypertriglyceridemia

Abstract

The incidence of hypertriglyceridemia has grown alongside that of obesity. Statin therapy has been widely recommended for the treatment of dyslipidemias. Omega-3 (OM3) fatty acid concentrates are commonly prescribed concurrently with statins in patients with persistent hypertriglyceridemia for additional lowering of triglyceride and non-HDL cholesterol. The bioavailability of currently available OM3 ethyl ester drugs is limited by their need for hydrolysis by pancreatic lipases, largely stimulated by dietary fat, prior to intestinal absorption. This review will discuss the chemistry, pharmacokinetics and clinical efficacy of a novel OM3 carboxylic acid drug that provides polyunsaturated docosahexaenoic and eicosapentaenoic acids in the free fatty acid form, which is readily absorbed by the intestine. This drug was approved in May 2014 as an adjunct to diet to reduce triglyceride levels in adults with severe (≥500 mg/dl) hypertriglyceridemia.

Keywords::

• cholesterol-lowering drug
• fish oil
• hyperlipidemia
• lipids
• omega-3 carboxylic acid
• triglycerides

Financial & competing interests disclosure

This work was supported by a grant from AstraZeneca. MH Davidson is an employee of AstraZeneca and has received consulting fees from AbbVie, Merck, Amgen, Sanofi and Aegerion. AK Phillips is an employee of the Midwest Center for Metabolic and Cardiovascular Research, which has received consulting fees from AstraZeneca. D Kling is an employee of Omthera Pharmaceuticals, Inc., a subsidiary of AstraZeneca. KC Maki has received research grant support and consulting fees from AstraZeneca, GlaxoSmithKline, AbbVie, Amarin and Trygg Pharmaceuticals.

No writing assistance was utilized in the production of this manuscript.

Key issues

Mechanisms of action

The active ingredient of Epanova^® is a naturally derived mixture comprising omega-3 (OM3) in free fatty acid form (OM3 carboxylic acids [OM3-CA]), with eicosapentaenoic acid and docosahexaenoic acid being the most prevalent OM3 species that lower triglyceride (TG) through:

• Reduced synthesis and release of hepatic very-low-density lipoprotein (VLDL) particles.

• Enhanced clearance of TG from VLDL particles in circulation.

• Reduction of hepatic lipogenesis.

• Enhanced β-oxidation of fatty acids.

Pharmacokinetic properties

• OM3-CA has enhanced bioavailability over currently available OM3-EE drugs.

• The OM3-CA drug delivers eicosapentaenoic acid + docosahexaenoic acid free fatty acids, the form readily absorbed by the intestine, and thus does not require hydrolysis by pancreatic lipases prior to absorption, as do the OM3-EE drugs.

• Thus, the improved bioavailability of OM3-CA over OM3-EE drugs is particularly pronounced under conditions of low dietary fat.

Clinical efficacy

• OM3-CA significantly reduced TG concentrations over OO control in subjects with elevated TG in the EpanoVa fOr Lowering Very high triglyceridEs and ESPRIT Phase III trials.

• Non-high-density lipoprotein cholesterol, total cholesterol and VLDL-C were also significantly reduced versus control in the two key Phase III trials.

• The lipid-altering effects are apparent at doses of 2 and 4 g/day.

• Efficacy tends to be greater when used in combination with high- versus low-potency statins.

Safety & tolerability

• Most common adverse events related to gastrointestinal disturbances (diarrhea, nausea, abdominal pain or discomfort and eructation) were mild to moderate in severity.

• These adverse events were not sufficient to cause greater study discontinuation compared with trials of other OM3 drugs.

Regulatory affairs

• OM3-CA was approved by the US FDA in May 2014 for the indication as an adjunct to diet to reduce TG in persons with severe hypertriglyceridemia (≥500 mg/dl).

Conclusion

• OM3-CA appears to be generally well tolerated and effective for the reduction of TG at doses of 2 and 4 g/day in statin-treated patients with persistent hypertriglyceridemia.

Notes