ZDRAVILA, KI VPLIVAJO NA METABOLIZEM LIPIDOV
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1 ZDRAVILA, KI VPLIVAJO NA METABOLIZEM LIPIDOV Prof. Lovro Stanovnik Inštitut za farmakologijo in eksperimentalno toksikologijo, Medicinska fakulteta, Univerza v Ljubljani
2 Pregled Nastanek aterosklerotičnega plaka Metabolizem lipidov v plazmi (lipoproteinov) Zdravila, s katerimi lahko vplivamo na te procese
3 Nastanek aterosklerotičnega plaka vdor lipidov skozi endotel oksidacija lipidov fagocitoza (makrofagi) penaste celice (foam cells) adhezija trombocitov
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5 Leukocyte Endothelial Adhesion Molecules Mono T B PMN
6 Faktorji, ki sodelujejo v vnetnih dogajanjih v ateromu Vascular Cell Adhesion Molecule 1 (VCAM-1) Monocyte Chemoattractant Protein 1 (MCP-1) Scavenger receptors Macrophage Colony-Stimulating Factor (M-CSF) Tumor necrosis factor receptor (TNFR = CD40)
7 Molecular Mediators of Atherogenesis VCAM-1 MCP-1 M-CSF
8 Schematic Time Course of Human Atherogenesis Ischemic Heart Disease Cerebrovascular Disease Lesion initiation No symptoms + Symptoms Peripheral Vascular Disease Symptoms Time (y)
9 Anatomy of the Atherosclerotic Plaque Fibrous cap Lumen Intima Lipid Core Shoulder Media Elastic laminæ Internal External
10 Matrix Metabolism and Integrity of the Plaque s Fibrous Cap IFN-g Collagen-degrading Proteinases Fibrous cap Lipid core CD-40L IL-1 TNF-a MCP-1 M-CSF Tissue Factor Procoagulant Libby P. Circulation 1995;91:
11 Inflammation Can Promote Thrombosis Tissue Factor Fibrinogen Via gp llb/llla CD40L Fibrin Platelet Platelet- Fibrin Thrombus Platelet Fibrinopeptides
12 Metabolizem lipidov Transport lipidov po telesu Lipoproteini CE (estri holesterola) TG (trigliceridi) proteini (apolipoproteini) ligandi za receptorje, kofaktorji encimov
13 Lipoproteini (LP) Več vrst glede na sestavo in gostoto (centrifugiranje na osmotskem gradientu): hilomikroni VLDL LP zelo majhne gostote IDL LP srednje gostote LDL LP majhne gostote HDL LP velike gostote Razlike v vsebnosti in vrsti lipidov in v vrstah apolipoproteinov (ApoA, ApoB, ApoC, ApoE, Apo(a)
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15 Transport in metabolizem lipidov Pot za endogene lipide Pot za eksogene lipide
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18 VLOGA HDL Transport CE in TG med različnimi lipoproteini in jetri Prenos apolipoproteinov CII, CIII, apo E Povratni transport holesterola Antiaterogeno delovanje
19 Structure of HDL Particle A-I CE TG A-I A-II A-I, A-II = apolipoprotein A-I, A-II; CE = cholesteryl ester; TG = triglycerides
20 Production of HDL by Liver and Intestine Liver Intestine A-I A-I A-II HDL HDL A-I, A-II = apolipoprotein A-I, A-II
21 HDL Metabolism and Reverse Cholesterol Transport Bile FC Liver CE SR-BI A-I CE Mature HDL LCAT A-I FC Nascent HDL FC ABC1 CE Macrophage ABC1 = ATP-binding cassette protein 1; A-I = apolipoprotein A-I; CE = cholesteryl ester; FC = free cholesterol; LCAT = lecithin:cholesterol acyltransferase; SR-BI = scavenger receptor class BI
22 Role of CETP in HDL Metabolism F C Liver Bile CE LDLR SR-BI Mature HDL Macrophage A-I Nascent HDL A-I LCAT CE FC CE FC ABC1 SRA CETP CE B VLDL/LDL CETP = cholesteryl ester transfer protein LDL = low-density lipoprotein LDLR = low-density lipoprotein receptor VLDL = very-low-density lipoprotein
23 Role of Hepatic Lipase and Lipoprotein Endothelium CMR/IDL Lipase in HDL Metabolism HL B PL LPL A-I CE TG HDL 2 PL Kidney CM = chylomicron; CMR = chylomicron remnant; HDL = high-density lipoprotein; HL = hepatic lipase; IDL = intermediate-density lipoprotein; LPL = lipoprotein lipase; PL = phospholipase; TG = triglyceride B TG CM/VLDL A-I CE HDL 3 C-II
24 Pregled lipoproteinov (LP) VRSTA LP GLAVNE SESTAVINE APOPROT. MESTO SINTEZE POTI KATABOLIZMA Hilomikroni (CH) in ostanki CH) Trigliceridi (TG) in holesterol (C) v hrani, 10:1 B-48, E, A-I, A-IV, C-I, C- II, C-III Črevo Hidroliza TG z LPL. Privzem ostankov CH v jetrih preko ApoE VLDL Endogeni ali jetrni TG, 5:1 B-100, E, C-I, C-II, C-III Jetra Hidroliza TG z LPL IDL Holesterilni estri (CE) in endogeni TG B-100, E, C- II, C-III Katabolni produkt VLDL 50% v LDL, posredovana z jetrno lipazo (HL), 50% privzem v jetra z ApoE
25 Pregled LP VRSTA LP GLAVNE SESTAVINE APOPROTEINI LDL CE B-100 HDL Fosfolipidi, CE A-I, A-II, E, C-I, C-II, C-III MESTO SINTEZE Katabolni produkt VLDL Črevo, jetra, plazma POTI KATABOLIZMA Privzem z LDL-R (~75% v jetrih), posredovan z ApoB-100 Prenos CE v VLDL in LDL. Privzem HDL C v hepatocite Lp(a) CE B-100, apo(a) Jetra Neznano
26 LASTNOSTI APOLIPOPROTEINOV I APOLIPOPROTEIN MESTO SINT. VLOGA ApoA-I ApoA-II ApoB-100 Jetra, črevo Jetra Jetra Sestavina HDL, kofaktor LCAT, ligand za HDL-R, reverzni transport C Tvori -S-S- kompleks z apoe-2 in E-3, kar prepreči vezavo apoe-2 in apoe-3 na LP-R Strukturni protein VLDL, IDL, LDL, ligand LDL-R ApoB-48 Črevo Strukturni protein hilomikronov (CM)
27 LASTNOSTI APOLIPOPROTEINOV II APOLIPOPROTEIN MESTO SINT. VLOGA ApoC-I Jetra Aktivator LCAT. Modulira vezavo ostankov CM na R ApoC-II Jetra Kofaktor LPL ApoC-III ApoE Apo(a) Jetra Jetra, možgani, koža, gonade, vranica Jetra Modulira vezavo ostankov CM na R Ligand za LDL-R in receptorje za ostanke hilomikronov; reverzni transport holesterola (HDL z apoe) Modulator fibrinolize (inhibitor tpa)
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29 Age Risk Factors for Coronary Heart Disease Male > 45 years or female > 55 years Family history of premature CHD A first-degree relative (male below 55 years or female below 65 years when the first CHD clinical event occurs) Current cigarette smoking Hypertension Blood pressure 140/90 or use of antihypertensive medication, irrespective of blood pressure Low HDL-C < 1.04 mmol/l (consider < 1.3 mmol/l as "low" for women) Obesity Body mass index > 25 kg/m 2 and waist circumference above 100 cm (men ) or 90 cm (women )
30 Pregled Nastanek aterosklerotičnega plaka Metabolizem lipidov v plazmi (lipoproteinov) Zdravila, s katerimi lahko vplivamo na te procese
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32 Pregled zdravil za zdravljenje hiperlipidemij Inhibitorji HMG-CoA reduktaze Smole, ki vežejo žolčne kisline Ezetimib Derivati fibrične kisline (fibrati) Nikotinska kislina (niacin) Probukol Kombinacije zdravil Druga zdravila
33 HMG-CoA reduktazni inhibitorji Hidroksi-metil-glutaril-CoA reduktaza ključni (rate limiting) encim pri sintezi holesterola HMG-CoA mevalonska kislina Posledica: koncentracija holesterola Povečana ekspresija gena za HMG-CoA reduktazo Povečana ekspresija gena za LDL-R Povečano odstranjevanje LDL koncentracija LDL
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36 Farmakokinetika Dobra obsorpcija iz prebavil Ekstrakcija v jetrih (mesto delovanja) Izločanje preko jeter (metabolizem) Vezava na plaz. belj. ( > 90% )
37 Klinična uporabnost Zmanjšajo morbiditeto in mortaliteto pri izbranih bolnikih Indicirani pri bolnikih z manifestno aterosklerozo in tistih z večjim tveganjem za koronarno bolezen Neučinkoviti (razen atorvastatina) pri homozigotni družinski hiperholesterolemiji
38 New cardiovascular prevention guidelines released in November 2013 by the American College of Cardiology (ACC) and the American Heart Association (AHA) People without cardiovascular disease who are aged 40 to 75 years and have a > 7.5% risk for MI or stroke within 10 years. People with a history of MI, stroke, stable or unstable angina, peripheral artery disease, transient ischemic attack, or coronary or other arterial revascularisation. People aged 21 years and older who have a very high level of LDL-C (> 190 mg/dl (>= 4.92 mmol/l)). People with type 1 or type 2 diabetes who are aged 40 to 75 years. Obesity Should Be Managed and Treated Like a Disease
39 Stranski učinki Relativno skromni jetrne transaminaze previdnost pri jetrnih boleznih Miopatija ( rabdomioliza ) kontrola kreatin fosfokinaze ( CPK ) 0,1% pacientov z blažjim miozitisom verjetnost večja pri sočasni uporabi fibratov in nikotinske kisline
40 Survival in patients with coronary heart disease and serum cholesterol mmol/l treated either with placebo or with simvastatin. The relative risk of death in the simvastatin group was 0.70 (95% confidence intervals ). (Based on 4S study 1994 Lancet 344: ) Downloaded from: StudentConsult (on 29 November :21 PM) 2005 Elsevier
41 Povzetek Inhibitorji HMG-CoA reduktaze (statini): celokupni holesterol, LDL in trigliceride HDL razlike v učinkovitosti med predstavniki Primarna in sekundarna prevencija koronarne bolezni Skupna huda neželena učinka: hepatotoksičnost, miopatija tveganje za miopatijo izogibanje visokim koncentracijam statinov (posledica visokih doz, zmanjšane eliminacije in/ali interakcij med zdravili)
42 Smole, ki vežejo žolčne kisline Delovanje v črevesu ni sistemskih učinkov Preprečevanje enterohepatične cirkulacije žolčnih kislin ( 97 % ) izločanje iz telesa Holesterol konc. Holesterola žolčne kisline koncentracija HMG-CoA reduktaze sinteza cholesterola in TG sinteza LDL-R
43 Predstavniki
44 Klinična uporabnost Uporabne v kombinaciji s statini (ob nezadostnem učinku) Kot monoterapija pri bolnikih s povečanim holesterolom in normalnimi trigliceridi, če so statini kontraindicirani
45 Stranski učinki Napihnjenost v trebuhu Zaprtje alkalne fosfataze (jetra) - zmerno Hipertrigliceridemija Interakcije s številnimi zdravili na nivoju absorpcije: tiroksin kardiotonični glikozidi antikoagulansi nekateri tiazidi nekatera antilipemična zdravila: nekateri statini gemfibrozil
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47 EZETIMIB Relativno novo zdravilo (ZDA 2002, SLO 2005) Selektivna inhibicija absorpcije holesterola in fitosterolov v črevesu. Ezetimib se veže v luminalni membrani epitelnih celic (brush border) v črevesu. Molekularna tarča ezetimiba je prenašalec za sterole (sterol transporter).
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49 Ezetimib - učinki Znižanje LDL mehanizem podoben kot pri smolah Povečan nivo HDL Farmakokinetika Biološka uporabnost variabilna Razpolovni čas okrog 22 ur Metabolizem: ezetimib-glukuronid
50 Ezetimib stranski učinki Relativno skromni Bolečine v trebuhu Mialgija (pogostejša ob kombinaciji s statini)
51 Derivati fibrične kisline (fibrati) Delovanje preko PPARα (peroxisome proliferator activated receptor) (jedrni receptorji regulacija transkripcije različnih genov LPL, ApoA, ApoC ) VLDL HDL ( ekspresija ApoA I in II ) aktivnost LPL VLDL IDL sintezo ApoC-III (ki je inhibitor LPL) sintezo VLDL v jetrih aktivnost in agregacijo trombocitov CRP Fenofibrat urikozurično delovanje
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54 Farmakoinetika: Hitra in skoraj popolna absorpcija t 1/2 različen pri različnih predstavnikih: gemfibrozil 1 h fenofibrat 20 h Izločajo se kot glukuronidi
55 Stranski učinki: Od strani GIT Redko: alergični pojavi spremenjeni jetrni encimi Miozitis Nagnjenost k holelitiazi
56 Varfarin Interakcije fibratov Fibrati æučinek varfarina (zmanjšana sinteza koagul. faktorjev, odvisnih od vit. K) Fibrati in varfarin vezava na plazemske beljakovine spodrivanje Substrati za CYP2C9 in CYP2C8 Fibrati inhibitorji CYP2C8, 2C9, 2A6, 2C19 Statini večja nevarnost rabdomiolize Antidiabetiki fibrati æ občutljivost na inzulin in sekrecija glukagona Nekateri oralni antidiabetiki (glitazoni) metabolizem preko CYP2C8
57 Nikotinska kislina (niacin) Vitamin produkcija VLDL sinteza TG dotok FFA do jeter ( lipoliza v maščevju) HDL ( privzem ApoA v jetra) ABC1 in SR (CD36) v makrofagih obratni transport holesterola
58 Farmakokinetika in stranski učinki Dobra absorpcija Kratek t 1/2 1 ura ) Naval krvi v zgornji del telesa (flushing) udeleženost PG (NSAID zmanjšajo ta učinek ) dodan laropiprant (blokator DP 1 R) Tredaptive Pruritus (povezan s prejšnjim) Motena funkcija jeter transaminaze toleranca glukoze Palpitacije (pogosto spremljajo navale krvi)
59 Vasodilatation caused by nicotinic acid (1.5 g, extended-release preparation) is attenuated by aspirin or by laropiprant, an antagonist of prostaglandin D2 (PGD2). Blood flow in the cheeks of human subjects was measured by laser Doppler perfusion imaging after either placebo or nicotinic acid. Aspirin (325 mg 30 min before nicotinic acid) or laropiprant (300 mg with nicotinic acid) reduced the increase in malar blood flow caused by nicotinic acid. (Redrawn from Lai E et al Suppression of niacin-induced vasodilation with an antagonist to prostaglandin D2 receptor subtype 1. Clin Pharmacol Therap 81: ) Downloaded from: StudentConsult (on 12 November :44 PM) 2005 Elsevier
60 Lomitapid za zdravljenje homozigotne družinske hiperholesterolemije znižuje LDL holesterol, celokupni holesterol, apolipoprotein B inhibira mikrosomni protein za prenos trigliceridov (microsomal triglyceride transfer protein MTP), potreben za nastanek VLDL kombinacija z dieto in drugimi zdravili
61 Lomitapid farmakokinetika Peroralna absorpcija Biol. uporabnost 7% Metabolizem s CYP 3A4 (v manjši meri tudi CYP 1A2, 2B6, 2C8 in 2C19) Metaboliti neaktivni t - 40 ur (eliminacijski) 1/2
62 Stranski učinki Težave GIT (diareja, bruhanje, napetost v trebuhu, GERB) æ jetrnih maščob absorpcija v maščobi topnih vitaminov
63 Schematic diagram of cholesterol transport in the tissues, with sites of action of the main drugs affecting lipoprotein metabolism. ACoA, acetyl-coenzyme A; C, cholesterol; CE, cholesteryl ester; HDL, high-density lipoprotein; HMG-CoA reductase, 3-hydroxy-3- methylglutarylcoenzyme A reductase; LDL, low-density lipoprotein; MVA, mevalonate; TG, triglyceride; VLDL, very low-density lipoprotein. Downloaded from: StudentConsult (on 29 November :21 PM) 2005 Elsevier
64 Effects of Lipid-Modifying Drugs on HDL-C Levels Niacin 15 35% Fibrates 10 15% Estrogens 10 15% Statins 5 10% Belalcazar LM et al. Progr Cardiovasc Dis 1998;41:
65 Mehanizmi povečevanja HDL Niacin: serumskega Apo A-I in lipoproteina A-I, serumskega apo-b. Fibrati: ekspresija gena za Apo A-I in ApoA-II Statini: produkcija Apo A-I, Inhibicija aktivnosti hepatične lipaze
66 Drugi faktorji z vplivom na lipide oz. na tveganje za CVI Ribje olje Homocistein Antioksidanti Vitamin E Vitamin C Koencim Q10 Česen (alicin) Karotenoidi Beta karoten Licopen
67 Ribje olje Vsebuje w-3 trigliceride TG holesterol (LDL) Mehanizem ni znan Zmanjša obolevnost za koronarno boleznijo Vpliv na hemostazo: eikozipentaenoična kislina zamenja arahidonsko kislino manj učinkoviti eikozanoidi (TXA 2 )
68 Alipogen tiparvovek Pri pomanjkanju lipoproteinske lipaze (multipli napadi pankreatitisa) Gensko zdravljenje (prvo tako zdravilo) Alipogen tiparvovek vsebuje humano varianto gena LPLS447X (gen za LPL) v vektorju z adeno-asociiranim virusnim serotipom 1(AAV1), ki je usmerjen na mišico. I.m. aplikacija ob imunosupresiji
69 Zdravila v fazi preizkušanja I Inhibitorji acil-koencim A holesterol aciltransferaze (ACAT) paktimib Preprečevanje kopičenja holesterola v makrofagih Inhibicija nastajanja penastih celic Živalski modeli in vivo zmanjšanje volumna intravaskularnega ateroma Klinične študije ni bilo pričakovanega učinka
70 Zdravila v fazi preizkušanja II Kandidat za zdravilo Small interfering ribonucleic acid (sirna) ALN-PCS Zniža LDL pri zdravih prostovoljcih do 57% (Lancet) Blokira produkcijo proteina PCSK9 (cholesterol regulator proprotein convertase subtilisin/kexin type 9), ki razgrajuje receptorje za LDL V kliničnih poskusih prve faze DocGuide.com Doctor's Guide Publishing ( )
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