Current Role of Lipoprotein Apheresis

Abstract

Purpose of Review Lipoprotein apheresis is a very efficient but time-consuming and expensive method of lowering levels of lowdensity lipoprotein cholesterol, lipoprotein(a)) and other apoB containing lipoproteins, including triglyceride-rich lipoproteins. First introduced almost 45 years ago, it has long been a therapy of "last resort" for dyslipidaemias that cannot otherwise be managed. In recent years new, very potent lipid-lowering drugs have been developed and the purpose of this review is to define the role of lipoprotein apheresis in the current setting. Recent Findings Lipoprotein apheresis still plays an important role in managing patients with homozygous FH and some patients with other forms of hypercholesterolaemia and cardiovascular disease. In particular, patients not achieving treatment goals despite modern lipid-lowering drugs, either because these are not tolerated or the response is insufficient. Recently, lipoprotein(a) has emerged as an important cardiovascular risk factor and lipoprotein apheresis has been used to decrease lipoprotein(a) concentrations in patients with marked elevations and cardiovascular disease. However, there is considerable heterogeneity concerning the recommendations by scientific bodies as to which patient groups should be treated with lipoprotein apheresis. Summary Lipoprotein apheresis remains an important tool for the management of patients with severe drug-resistant dyslipidaemias, especially those with homozygous FH.

Lipoprotein(a) Lowering—From Lipoprotein Apheresis to Antisense Oligonucleotide Approach

“…Although LA, within the therapeutic regimen of lipid disorders, is often considered as a therapy of last resort, guidelines differ in defining which patients to treat, and under which circumstances [ 106 ]. Some of these guidelines recommend apheresis as a first-line treatment in patients with HoFH, and after drug therapy failure in patients with heterozygous (He)FH, with differences also in LA treatment frequency (weekly or biweekly) [ 107 , 108 ].…”

“…An inherent drawback of LA is the cyclical rebound of LDL-C within 1 to 2 weeks between apheretic procedures. Lp(a) rebounds at a slower rate than LDL-C, but with a similar monoexponential function [ 106 ]. Thus, despite an acute decrement of 70–75%, regular apheresis can translate into a significant interval mean Lp(a) reduction between 25% and 40% [ 128 ].…”

Therapeutic management of hyperlipoproteinemia (a)

“…LA still plays a significant role in the management of patients with homozygous familial hypercholesterolemia (FH), as well as in the management of some patients with other severe drug-resistant dyslipidemias and established CVD. As it was mentioned earlier, Lp(a) has been recently identified as an important, independent, causative risk factor for CVD and thus LA has been used to reduce plasma Lp(a) levels in patients with marked Lp(a) elevations and CVD 66. It should be noted, however, that LA removes Lp(a) and LDL simultaneously, which makes it hard to distinguish the beneficial effects of Lp(a) and LDL-C lowering 11,67…”

Molecular, Population, and Clinical Aspects of Lipoprotein(a): A Bridge Too Far?

“…Apheresis, however, is limited by high cost and patient burden, and its use is restricted to specific countries and patient populations. Furthermore, its use in specifically reducing risk associated with Lp(a) elevation is unknown due to concomitant reductions in LDL-c [127].…”