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New, Novel Lipid-Lowering Agents for Reducing Cardiovascular Risk: Beyond Statins
Kyuho Kim, Henry N. Ginsberg, Sung Hee Choi
Diabetes Metab J. 2022;46(4):517-532.   Published online July 27, 2022
DOI: https://doi.org/10.4093/dmj.2022.0198
Correction in: Diabetes Metab J 2022;46(5):817
  • 10,905 View
  • 882 Download
  • 27 Web of Science
  • 28 Crossref
AbstractAbstract PDFPubReader   ePub   
Statins are the cornerstone of the prevention and treatment of atherosclerotic cardiovascular disease (ASCVD). However, even under optimal statin therapy, a significant residual ASCVD risk remains. Therefore, there has been an unmet clinical need for novel lipid-lowering agents that can target low-density lipoprotein cholesterol (LDL-C) and other atherogenic particles. During the past decade, several drugs have been developed for the treatment of dyslipidemia. Inclisiran, a small interfering RNA that targets proprotein convertase subtilisin/kexin type 9 (PCSK9), shows comparable effects to that of PCSK9 monoclonal antibodies. Bempedoic acid, an ATP citrate lyase inhibitor, is a valuable treatment option for the patients with statin intolerance. Pemafibrate, the first selective peroxisome proliferator-activated receptor alpha modulator, showed a favorable benefit-risk balance in phase 2 trial, but the large clinical phase 3 trial (PROMINENT) was recently stopped for futility based on a late interim analysis. High dose icosapent ethyl, a modified eicosapentaenoic acid preparation, shows cardiovascular benefits. Evinacumab, an angiopoietin-like 3 (ANGPTL3) monoclonal antibody, reduces plasma LDL-C levels in patients with refractory hypercholesterolemia. Novel antisense oligonucleotides targeting apolipoprotein C3 (apoC3), ANGPTL3, and lipoprotein(a) have significantly attenuated the levels of their target molecules with beneficial effects on associated dyslipidemias. Apolipoprotein A1 (apoA1) is considered as a potential treatment to exploit the athero-protective effects of high-density lipoprotein cholesterol (HDL-C), but solid clinical evidence is necessary. In this review, we discuss the mode of action and clinical outcomes of these novel lipid-lowering agents beyond statins.

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Original Article
Basic Research
Peroxisomal Fitness: A Potential Protective Mechanism of Fenofibrate against High Fat Diet-Induced Non-Alcoholic Fatty Liver Disease in Mice
Songling Jiang, Md Jamal Uddin, Xiaoying Yu, Lingjuan Piao, Debra Dorotea, Goo Taeg Oh, Hunjoo Ha
Diabetes Metab J. 2022;46(6):829-842.   Published online June 24, 2022
DOI: https://doi.org/10.4093/dmj.2021.0274
  • 5,335 View
  • 297 Download
  • 7 Web of Science
  • 6 Crossref
AbstractAbstract PDFSupplementary MaterialPubReader   ePub   
Background
Non-alcoholic fatty liver disease (NAFLD) has been increasing in association with the epidemic of obesity and diabetes. Peroxisomes are single membrane-enclosed organelles that play a role in the metabolism of lipid and reactive oxygen species. The present study examined the role of peroxisomes in high-fat diet (HFD)-induced NAFLD using fenofibrate, a peroxisome proliferator-activated receptor α (PPARα) agonist.
Methods
Eight-week-old male C57BL/6J mice were fed either a normal diet or HFD for 12 weeks, and fenofibrate (50 mg/kg/day) was orally administered along with the initiation of HFD.
Results
HFD-induced liver injury as measured by increased alanine aminotransferase, inflammation, oxidative stress, and lipid accumulation was effectively prevented by fenofibrate. Fenofibrate significantly increased the expression of peroxisomal genes and proteins involved in peroxisomal biogenesis and function. HFD-induced attenuation of peroxisomal fatty acid oxidation was also significantly restored by fenofibrate, demonstrating the functional significance of peroxisomal fatty acid oxidation. In Ppara deficient mice, fenofibrate failed to maintain peroxisomal biogenesis and function in HFD-induced liver injury.
Conclusion
The present data highlight the importance of PPARα-mediated peroxisomal fitness in the protective effect of fenofibrate against NAFLD.

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Reviews
Drug/Regimen
Fibrates Revisited: Potential Role in Cardiovascular Risk Reduction
Nam Hoon Kim, Sin Gon Kim
Diabetes Metab J. 2020;44(2):213-221.   Published online April 23, 2020
DOI: https://doi.org/10.4093/dmj.2020.0001
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  • 45 Web of Science
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AbstractAbstract PDFPubReader   

Fibrates, peroxisome proliferator-activated receptor-α agonists, are potent lipid-modifying drugs. Their main effects are reduction of triglycerides and increase in high-density lipoprotein levels. Several randomized controlled trials have not demonstrated their benefits on cardiovascular risk reduction, especially as an “add on” to statin therapy. However, subsequent analyses by major clinical trials, meta-analyses, and real-world evidence have proposed their potential in specific patient populations with atherogenic dyslipidemia and metabolic syndrome. Here, we have reviewed and discussed the accumulated data on fibrates to understand their current status in cardiovascular risk management.

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Role of Peroxisome Proliferator-Activated Receptor α in Diabetic Nephropathy
Sungjin Chung, Cheol Whee Park
Diabetes Metab J. 2011;35(4):327-336.   Published online August 31, 2011
DOI: https://doi.org/10.4093/dmj.2011.35.4.327
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AbstractAbstract PDFPubReader   

With a developing worldwide epidemic of diabetes mellitus, the renal complications associated with diabetes have become a serious health concern. Primary therapy for treating diabetic nephropathy is a multifactorial process. Peroxisome proliferator-activated receptor alpha (PPARα) agonists have been used primarily in clinical practice for the treatment of dyslipidemia and insulin resistance. Given that PPARα expression and regulation of metabolic pathways are involved in oxidative stress, inflammation, blood pressure regulation, and the renin-angiotensin aldosterone system, PPARα likely influences the development and pathogenesis of diabetic nephropathy via indirect effects on glucose and lipid homeostasis and also by direct action on the kidneys. These findings suggest that PPARα may become an important therapeutic target for treating diabetic renal complications.

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Original Articles
Prevention of Diabetes by Fenofibrate in OLETF Rats: Hepatic Mechanism for Reducing Visceral Adiposity.
Hye Jeong Lee, Mi Kyoung Park, Kyung Il Lee, Young Jun An, Ji Min Kim, Ja Young Park, Young Han, Sook Hee Hong, Sun Seob Choi, Young Hyun Yoo, Joon Duk Suh, Duk Kyu Kim
Korean Diabetes J. 2007;31(1):63-74.   Published online January 1, 2007
DOI: https://doi.org/10.4093/jkda.2007.31.1.63
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AbstractAbstract PDF
BACKGROUND
The aim of this study is to evaluate the hepatic mechanism of fenofibrate that has the diabetes protective action in rats. METHODS: We chose OLETF rats and divided them into three groups. Fenofibrate (DF) group was fed with diet and fenofibrate (300 mg/kg/day). Paired feeding (Dd) group and free diet (DD) group were fed with diet. After 36 weeks of treatment, all the rats were sacrificed. RESULTS: The fasting blood glucose level of DF group (8.5 +/- 0.9 mmol/L) showed normal. The fasting blood glucose level of Dd group (22.4 +/- 3.0 mmol/L) and DD group (16.9 +/- 3.7 mmol/L) showed significantly increased than that of DF group (P < 0.01, respectively). The body weight, visceral adipose tissue and subcutaneous adipose tissue of DF group were significantly decreased compared to those of Dd and DD groups (P < 0.01, P < 0.05, P < 0.05). DF group showed significantly increased state-3 respiration rate, ATP synthetic activity, state-4 respiration rate and their blood beta-keton body levels than those of control groups (P < 0.01, respectively). DF group showed normal morphology of hepatocytes but DD and Dd groups showed hepatic steatosis with mitochondrial swellings. CONCLUSION: Chronic fenofibrate treatment prevents the development of diabetes in OLETF rats with inhibiting gain of body weight and abdominal adiposity. The hepatic mechanism for reducing visceral adiposity is that fenofibrate leads to increasing oxidative phosphorylation, uncoupling and ketogenesis as well as increasing beta-oxidation of fatty acids. Moreover, fenofibrate treatment prevents the development of hepatic steatosis.

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  • The Differences of Metabolic Syndrome Risk Factors according to Obesity and Abdominal Obesity in Elderly Korean Women
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  • Comparative analysis of fat and muscle proteins in fenofibratefed type II diabetic OLETF rats: the fenofibrate-dependent expression of PEBP or C11orf59 protein
    Jong-Ryeal Hahm, Jin-Sook Ahn, Hae-Sook Noh, Seon-Mi Baek, Ji-Hye Ha, Tae-Sik Jung, Yong-Jun An, Duk-Kyu Kim, Deok-Ryong Kim
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  • Comparative analysis of fat and muscle proteins in fenofibratefed type II diabetic OLETF rats: the fenofibrate-dependent expression of PEBP or C11orf59 protein
    Jong-Ryeal Hahm, Jin-Sook Ahn, Hae-Sook Noh, Seon-Mi Baek, Ji-Hye Ha, Tae-Sik Jung, Yong-Jun An, Duk-Kyu Kim, Deok-Ryong Kim
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Exercise and Fenofibrate Reduces Body Adiposity Synergistically in OLETF Rats.
Young Jun An, Hre Jeong Lee, Mi Kyoung Park, Kyung Il Lee, In Young Koh, Dong Sik Jung, Ah Young Kang, Duk Kyu Kim
Korean Diabetes J. 2004;28(2):131-138.   Published online April 1, 2004
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AbstractAbstract PDF
BACKGROUND
The PPAR alpha activator, Fenofibrate, is a pharmacological ligand, which induces beta-oxidation of long chain fatty acids in the mitochondria of hepatocytes. The beta-oxidation induced by exogenous PPAR alpha activators may be operated maximally when the sustained production of energy substrate in the liver is required by working muscles due to continued exercise. The aim of this study was to determine whether the combination therapy of exercise and Fenofibrate could synergistically reduce body adiposity in OLETF rats. METHODS: Twenty-eight male OLETF rats(13 wk old) were divided into four groups. The diet(n=7) and exercise groups(n=7) were fed with chow for 12 weeks. The Fenofibrate(n=7) and combined treatment(exercise and Fenofibrate) groups (n=7) were fed with Fenofibrate(32mg/kg/day) mixed chow for 12 weeks. The animals in the exercise and combined treatment groups were exercised by running on a treadmill for 12 weeks. At 24 weeks of age, all the rats were sacrificed, and examined by biochemical tests and had their adipose tissue weight measured. RESULTS: There were no significant changes in the retroperitoneal and subcutaneous fats between the diet and Fenofibrate groups, but there were between the diet and combined treatment groups(P<0.05). CONCLUSION: Exercise combined with Fenofibrate synergistically reduces body adiposity in OLETF rats

Diabetes Metab J : Diabetes & Metabolism Journal
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