15289-s-bos

7 105 | Latest developments in the treatment of lipoprotein (a) antagonist, had influence on outcome and safety. Neither the AIMHIGH or the HPS- Thrive analysed whether the subgroup of patients with high Lp(a) at baseline did have a particular benefit of niacin therapy. In 2010 the European Atherosclerosis Society Consensus Panel recommended the use of niacin in high risk patients with elevated Lp(a) (>0,5g/L)[2]. However given the outcome of the recent RCT’s it is questionable if this recommendation is correct [25, 28]. In conclusion, niacin can significantly reduce Lp(a) and effects on the lipoprotein profile are beneficial, but RCT’s have not shown a decrease in CVD outcome when added to statins, although specific subgroup analysis of patients with high Lp(a) has not been performed. Ezetimibe Previously it was shown that ezetimibe (MSD, Whitehouse Station, NJ, USA) does not influence Lp(a) levels, which is not surprising since the mechanism of inhibiting intestinal cholesterol uptake by blocking Nieman-Pick C1-like protein, is not involved in Lp(a) metabolism as far as we know. In the recent PROBE (Prospective, Randomized, Open-label, Blinded Endpoint) study Lp(a) was not reduced in dyslipidaemic patients after addition of ezetimibe to statins [29]. Anti-sense Apo-B Mipomersen (Carlsbad, CA, USA) is an antisense nucleotide that binds to the mRNA encoding the Apo-B protein and thereby inhibit its synthesis. Apo-B synthesis is essential for the formation of lipoprotein particles, and its inhibition reduces TG levels (25-33%), very low dense lipoprotein-cholesterol (VLDL-C) (33-37%), LDL-C (28-37%) as well as Lp(a) (21-28%) [30, 31]. Although mipomersen reduces plasma levels of these atherogenic lipoproteins, no outcome study has been performed. Mipomersen is not very well tolerated. It was discontinued in 43% of patients after 26 weeks follow up, due to side effects such as injection site reactions (up to 92%), flu-like symptoms, and elevated liver enzymes [30, 31]. In January 2013, the FDA approved mipomersen for the treatment of homozygous FH. However the EMA did not follow, and mipomersen is therefore not approved in Europe [http://www.medscape.com/viewarticle/781317 ]. Due to the approval for an orphan disease, the Lp(a) lowering will merely be a beneficial side effect. It is improbable that mipomersen will be used specifically to lower Lp(a). Microsomal triglyceride transport protein (MTP) inhibition MTP is an enzyme that facilitates the transport of TG into VLDL-C in the liver, and the