State of the Art: Lipoproteinapherese

Abstract

Lipoprotein apheresis (LA) is usually a last resort in cardiovascular high-risk patients in the context of secondary prevention after lifestyle measures and maximal pharmacotherapy have failed to prevent the occurrence of new atherosclerotic cardiovascular events (ASCVDE) or to achieve the internationally accepted target values for LDL cholesterol (LDL-C). Patients with homozygous familial hypercholesterolemia (hoFH), in whom myocardial infarctions can occur even in children < 10 years of age without adequate therapy, often owe their survival to LA (used here in primary prevention). Severe hypercholesterolemia (HCH) can often be well controlled with modern potent lipid-lowering agents, including PCSK9 approaches, so that the need for LA has decreased here over the years. In contrast, the number of patients in whom elevation of lipoprotein(a) (Lp(a)) is relevant to atherogenesis is increasing in applications to the apheresis committees of the associations of panel physicians (KV). For this indication, LA is currently the only therapeutic procedure approved by the Federal Joint Committee (G-BA). LA significantly reduces the new occurrence of ASCVDE (comparison with the situation before the start of LA), especially in Lp(a) patients. There are convincing observational studies and a German LA Registry with now 10-year data, but there is no randomized controlled trial. This had been requested by the G-BA in 2008, and a corresponding concept was designed but not accepted by the ethics committee. In addition to the highly effective reduction of atherogenic lipoproteins, many discussed pleiotropic effects of LA itself, the medical rounds and motivating discussions also with the nursing staff, which take place within the weekly LA, certainly contribute to the success of the therapy (steady adjustment of all cardiovascular risk factors, lifestyle measures including smoking cessation, adherence of medication intake). This review article summarizes and discusses the study situation, clinical practical experience as well as the future of LA against the background of the currently rapid development of new pharmacotherapies.

Triangel oder Mahler-Hammer im Konzert von kardiovaskulären Risikofaktoren

“…verhindert werden sollte, um kardiovaskuläre Ereignisse zu verhindern [19]. Hierbei macht man sich die Antisense-Therapie zunutze, bei der die mRNA als Bauanleitung für Apo(a) spezifisch in der Leber durch den entsprechenden Gegenstrang (Antisense-Strang) abgebaut wird -sie ist aktuell die effektivste medikamentöse Maßnahme in der Lp(a)-Absenkung [20], während die Lipoproteinapherese die bisher einzige zugelassene Methode in der Behandlung von kardiovaskulären Ereignissen durch erhöhtes Lp(a) in Deutschland ist [21]. Die erreichten Absenkungsraten von Lp(a) lagen bei 85-90 % bei der Antisense-Therapie.…”

Therapeutische Apherese

“… Trotz neuer Entwicklungen Low-Density-Lipoprotein-Cholesterin (LDL-C) senkender Medikamente wie Statine, Ezetimib sowie Inhibitoren von Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) wie die PCSK9-Antikörper Alirocumab und Evolocumab oder die PCSK9-Antisense-Therapie mit Inclisiran, besteht weiterhin für bestimmte Patienten die Indikation zur Lipoproteinapherese (LA), wenn alle Lebensstil- und medikamentösen Maßnahmen ausgeschöpft wurden (Ultima-Ratio-Therapie) 1 . Als Entscheidungsgrundlage für die Indikation zur LA gilt die Richtlinie Methoden vertragsärztliche Versorgung, Anlage I Nr.…”