Current Role of Lipoprotein Apheresis in the Treatment of High-Risk Patients

Abstract

Lipoprotein apheresis (LA) is a therapeutic approach to save the lives of patients who are at an extremely high risk of developing cardiovascular events (CVE), especially after all other therapeutic options were not tolerated, or appeared not to be effective enough. Homozygous familial hypercholesterolemia represents a clear indication to start LA therapy. Another recognized indication is a severe hypercholesterolemia, which induced CVE, often in association with other risk factors. In the last years, an expressive elevation of lipoprotein(a) (Lp(a)) emerged as an indication for LA. In Germany, progress of atherosclerosis should have been documented before the permission to start LA therapy is given in these patients. Usually, all LA methods acutely decrease both LDL-C and Lp(a). However, specific columns which reduce only Lp(a) are available. Case reports and prospective observations comparing the situation before and during LA therapy clearly show a high efficiency with respect to the reduction of CVE, especially in patients with high Lp(a) levels. PCSK9 inhibitors may reduce the need for LA in patients with heterozygous or polygenetic hypercholesterolemia, but in some patients, a combination of these drugs with LA will be necessary. In the future, an antisense oligonucleotide against apolipoprotein(a) may offer an alternative therapeutic approach.

Lipoprotein(a)—an interdisciplinary challenge

“…In two studies, cardiovascular events were reduced by about 80% [21][22][23]. This corresponds with the experience of other authors [24][25][26][27]. The Joint Federal Committee defined three conditions before an LA therapy can be started: a. Lp(a) value ≥60 mg/dl (120 nmol/l), b. LDL-C in the optimal range (usually below 1.8 mmol/l [70 mg/dl]), c. A progression of atherosclerosis, either clinically or documented by imaging techniques [19].…”

Lipoprotein(a) apheresis in patients with peripheral arterial disease: rationale and clinical results

“…PAD patients with elevated lipoprotein(a) levels and progressive disease as indicated by recurrent clinical events requiring revascularization or progression of the disease stage from asymptomatic to intermittent claudication or critical limb ischemia or from intermittent claudication to critical K limb ischemia even without the necessity or technical ability for revascularization should be considered candidates for lipoprotein apheresis. In addition patients with elevated lipoprotein(a) levels and clinical overt coronary and cerebrovascular disease that are found to develop PAD should be considered as patients with progressive atherosclerotic vascular disease and considered candidates for lipoprotein apheresis [28].…”

Commentary on rare dyslipidaemia paper

“…1). Treatment of homozygous FH typically comprises the combination of maximally tolerated statin, ezetimibe and a PCSK9 inhibitor, in addi-T tion to diet and lifestyle, as well as lipoprotein apheresis [6,8]. Genetic insights have been a driver for novel adjunctive treatments, including evinacumab (a monoclonal antibody to ANGPTL3) and LDLR gene therapy [9,10].…”