Annals of Internal Medicine: Mortality reduction with PCSK9 Antibodies

Effects of Proprotein Convertase Subtilisin/Kexin Type 9 Antibodies in Adults With Hypercholesterolemia: A Systematic Review and Meta-analysis

Eliano Pio Navarese, Michalina Kołodziejczak, Volker Schulze, Paul A. Gurbel, Udaya Tantry, Yingfeng Lin, Maximilian Brockmeyer, David E. Kandzari, Julia M. Kubica, Ralph B. D’Agostino Sr., Jacek Kubica, Massimo Volpe, Stefan Agewall, Dean J. Kereiakes, and Malte Kelm

Ann Intern Med. Published online 28 April 2015 doi:10.7326/M14-2957

Background: Guidelines recommend statins as first-line therapy for dyslipidemia. Monoclonal antibodies targeting proprotein convertase subtilisin/kexin type 9 (PCSK9) are a new lipid-lowering approach.

Purpose: To assess the efficacy and safety of PCSK9 antibodies in adults with hypercholesterolemia.

Data Sources: MEDLINE, PubMed Central, and Google Scholar; conference proceedings; and the ClinicalTrials.gov registry through 4 April 2015.

Study Selection: Phase 2 or 3 randomized, controlled trials (RCTs) comparing treatment using PCSK9 antibodies with no anti-PCSK9 therapy in adults with hypercholesterolemia.

Data Extraction: Two investigators independently extracted data on study characteristics and lipid and clinical outcomes, and rated risk of bias of trials. Prespecified primary end points were all-cause and cardiovascular mortality.

Data Synthesis: Twenty-four RCTs comprising 10 159 patients were included. Compared with no antibody, treatment with PCSK9 antibodies led to marked reductions in low-density lipoprotein cholesterol levels (mean difference, −47.49% [95% CI, −69.64% to −25.35%]; P  < 0.001] and other atherogenic lipid fractions, and it reduced all-cause mortality (odds ratio [OR], 0.45 [CI, 0.23 to 0.86]; P = 0.015; heterogeneity P = 0.63; I2 = 0%) and cardiovascular mortality (OR, 0.50 [CI, 0.23 to 1.10]; P = 0.084; heterogeneity P = 0.78; I2 = 0%). The rate of myocardial infarction was significantly reduced with use of PCSK9 antibodies (OR, 0.49 [CI, 0.26 to 0.93]; P = 0.030; heterogeneity P = 0.45; I2 = 0%), and increases in the serum creatine kinase level were reduced (OR, 0.72 [CI, 0.54 to 0.96]; P = 0.026; heterogeneity P = 0.65; I2 = 0%). Serious adverse events did not increase with administration of PCSK9 antibodies.

Limitations: Results were derived from study-level data rather than patient-level data, and clinical outcome data are rare.

Conclusion: PCSK9 antibodies seem to be safe and effective for adults with dyslipidemia.

Primary Funding Source: CRC 1116 Masterswitches in Myocardial Ischemia, German Research Council DFG.

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