Antisense inhibition of apoB synthesis with mipomersen reduces plasma apoC-III and apoC-III-containing lipoproteins
2012; Elsevier BV; Volume: 53; Issue: 4 Linguagem: Inglês
10.1194/jlr.p021717
ISSN1539-7262
AutoresJeremy Furtado, Mark K. Wedel, Frank M. Sacks,
Tópico(s)Nuclear Structure and Function
ResumoMipomersen, an antisense oligonucleotide that reduces hepatic production of apoB, has been shown in phase 2 studies to decrease plasma apoB, LDL cholesterol (LDL-C), and triglycerides. ApoC-III inhibits VLDL and LDL clearance, and it stimulates inflammatory responses in vascular cells. Concentrations of VLDL or LDL with apoC-III independently predict cardiovascular disease. We performed an exploratory posthoc analysis on a subset of hypercholesterolemic subjects obtained from a randomized controlled dose-ranging phase 2 study of mipomersen receiving 100, 200, or 300 mg/wk, or placebo for 13 wk (n = 8 each). ApoC-III–containing lipoproteins were isolated by immuno-affinity chromatography and ultracentrifugation. Mipomersen 200 and 300 mg/wk reduced total apoC-III from baseline by 6 mg/dl (38–42%) compared with placebo group (P < 0.01), and it reduced apoC-III in both apoB lipoproteins and HDL. Mipomersen 100, 200, and 300 mg doses reduced apoB concentration of LDL with apoC-III (27%, 38%, and 46%; P < 0.05). Mipomersen reduced apoC-III concentration in HDL. The drug had no effect on apoE concentration in total plasma and in apoB lipoproteins. In summary, antisense inhibition of apoB synthesis reduced plasma concentrations of apoC-III and apoC-III–containing lipoproteins. Lower concentrations of apoC-III and LDL with apoC-III are associated with reduced risk of coronary heart disease (CHD) in epidemiologic studies independent of traditional risk factors. Mipomersen, an antisense oligonucleotide that reduces hepatic production of apoB, has been shown in phase 2 studies to decrease plasma apoB, LDL cholesterol (LDL-C), and triglycerides. ApoC-III inhibits VLDL and LDL clearance, and it stimulates inflammatory responses in vascular cells. Concentrations of VLDL or LDL with apoC-III independently predict cardiovascular disease. We performed an exploratory posthoc analysis on a subset of hypercholesterolemic subjects obtained from a randomized controlled dose-ranging phase 2 study of mipomersen receiving 100, 200, or 300 mg/wk, or placebo for 13 wk (n = 8 each). ApoC-III–containing lipoproteins were isolated by immuno-affinity chromatography and ultracentrifugation. Mipomersen 200 and 300 mg/wk reduced total apoC-III from baseline by 6 mg/dl (38–42%) compared with placebo group (P < 0.01), and it reduced apoC-III in both apoB lipoproteins and HDL. Mipomersen 100, 200, and 300 mg doses reduced apoB concentration of LDL with apoC-III (27%, 38%, and 46%; P < 0.05). Mipomersen reduced apoC-III concentration in HDL. The drug had no effect on apoE concentration in total plasma and in apoB lipoproteins. In summary, antisense inhibition of apoB synthesis reduced plasma concentrations of apoC-III and apoC-III–containing lipoproteins. Lower concentrations of apoC-III and LDL with apoC-III are associated with reduced risk of coronary heart disease (CHD) in epidemiologic studies independent of traditional risk factors. Apolipoprotein (apo)C-III is a protein present on some apoB lipoproteins that is not integral to the lipoprotein structure but that modifies the metabolism in plasma of the lipoprotein particle. Concentration of apoC-III in very low- and low-density lipoproteins (VLDL and LDL) is highly and independently predictive of coronary heart disease (CHD), more so than triglyceride alone (1Sacks F.M. Alaupovic P. Moye L.A. Cole T.G. Sussex B. Stampfer M.J. Pfeffer M.A. Braunwald E. VLDL, apolipoproteins B, CIII, and E, and risk of recurrent coronary events in the Cholesterol and Recurrent Events (CARE) trial.Circulation. 2000; 102: 1886-1892Crossref PubMed Scopus (412) Google Scholar). LDL with apoC-III, a remnant particle produced by partial lipolysis in plasma of VLDL with apoC-III (2Zheng C. Khoo C. Furtado J. Sacks F.M. Apolipoprotein C–III and the metabolic basis for hypertriglyceridemia and the dense low-density lipoprotein phenotype.Circulation. 2010; 121: 1722-1734Crossref PubMed Scopus (181) Google Scholar), is the lipoprotein particle type most predictive for cardiovascular disease in type 2 diabetes (3Lee S.J. Campos H. Moye L.A. Sacks F.M. LDL containing apolipoprotein CIII is an independent risk factor for coronary events in diabetic patients.Arterioscler. Thromb. Vasc. Biol. 2003; 23: 853-858Crossref PubMed Scopus (149) Google Scholar) and in the general population (4Mendivil C.O. Zheng C. Furtado J. Lel J. Sacks F.M. Metabolism of very-low-density lipoprotein and low-density lipoprotein containing apolipoprotein C–III and not other small apolipoproteins.Arterioscler. Thromb. Vasc. Biol. 2010; 30: 239-245Crossref PubMed Scopus (107) Google Scholar). ApoC-III blocks the clearance of VLDL by the liver (5Aalto-Setälä K. Weinstock P.H. Bisgaier C.L. Wu L. Smith J.D. 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Apolipoprotein C–III and the metabolic basis for hypertriglyceridemia and the dense low-density lipoprotein phenotype.Circulation. 2010; 121: 1722-1734Crossref PubMed Scopus (181) Google Scholar, 4Mendivil C.O. Zheng C. Furtado J. Lel J. Sacks F.M. Metabolism of very-low-density lipoprotein and low-density lipoprotein containing apolipoprotein C–III and not other small apolipoproteins.Arterioscler. Thromb. Vasc. Biol. 2010; 30: 239-245Crossref PubMed Scopus (107) Google Scholar, 7Zheng C. Khoo C. Ikewaki K. Sacks F.M. Rapid turnover of apolipoprotein C-III–containing triglyceride-rich lipoproteins contributing to the formation of LDL subfractions.J. Lipid Res. 2007; 48: 1190-1203Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar), increases adhesion of human monocytes to endothelial cells (8Kawakami A. Aikawa M. Alcaide P. Luscinskas F.W. Libby P. Sacks F.M. 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Apolipoprotein CIII-induced THP-1 cell adhesion to endothelial cells involves pertussis toxin-sensitive G protein- and protein kinase C alpha-mediated nuclear factor-kappaB activation.Arterioscler. Thromb. Vasc. Biol. 2007; 27: 219-225Crossref PubMed Scopus (87) Google Scholar). ApoC-III on HDL lipoproteins may result in a dysfunctional subpopulation (8Kawakami A. Aikawa M. Alcaide P. Luscinskas F.W. Libby P. Sacks F.M. Apolipoprotein CIII induces expression of vascular cell adhesion molecule-1 in vascular endothelial cells and increases adhesion of monocytic cells.Circulation. 2006; 114: 681-687Crossref PubMed Scopus (224) Google Scholar) that is associated with increased CHD (1Sacks F.M. Alaupovic P. Moye L.A. Cole T.G. Sussex B. Stampfer M.J. Pfeffer M.A. Braunwald E. VLDL, apolipoproteins B, CIII, and E, and risk of recurrent coronary events in the Cholesterol and Recurrent Events (CARE) trial.Circulation. 2000; 102: 1886-1892Crossref PubMed Scopus (412) Google Scholar, 11Onat A. Hergenc G. Sansoy V. Fobker M. Ceyhan K. Toprak S. Assmann G. Apolipoprotein C–III, a strong discriminant of coronary risk in men and a determinant of the metabolic syndrome in both genders.Atherosclerosis. 2003; 168: 81-89Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar, 12Vaisar T. Mayer P. Nilsson E. Zhao X.Q. Knopp R. Prazen B.J. HDL in humans with cardiovascular disease exhibits a proteomic signature.Clin. Chim. Acta. 2010; 411: 972-979Crossref PubMed Scopus (68) Google Scholar). Mipomersen is a second-generation 20-mer antisense oligonucleotide that reduces hepatic production of apoB-100. Animal models showed its potential for cardiovascular benefits through reduction of VLDL and LDL (13Crooke R.M. Graham M.J. Lemonidis K.M. Whipple C.P. Koo S. Perera R.J. An apolipoprotein B antisense oligonucleotide lowers LDL cholesterol in hyperlipidemic mice without causing hepatic steatosis.J. Lipid Res. 2005; 46: 872-884Abstract Full Text Full Text PDF PubMed Scopus (206) Google Scholar), as well as reduction of lipoprotein (a) and oxidized phospholipids levels (14Merki E. Graham M.J. Mullick A.E. Miller E.R. Crooke R.M. Pitas R.E. Witztum J.L. Tsimikas S. Antisense oligonucleotide directed to human apolipoprotein B-100 reduces lipoprotein(a) levels and oxidized phospholipids on human apolipoprotein B-100 particles in lipoprotein(a) transgenic mice.Circulation. 2008; 118: 743-753Crossref PubMed Scopus (129) Google Scholar). Mipomersen dose-dependently reduces plasma total apoB and LDL cholesterol (LDL-C), and it reduces plasma non-HDL cholesterol (HDL-C) and triglycerides in polygenic and familial hypercholesterolemia (15Kastelein J.J. Wedel M.K. Baker B.F. Su J. Bradley J.D. Yu R.Z. Chuang E. Graham M.J. Crooke R.M. Potent reduction of apolipoprotein B and low-density lipoprotein cholesterol by short-term administration of an antisense inhibitor of apolipoprotein B.Circulation. 2006; 114: 1729-1735Crossref PubMed Scopus (324) Google Scholar, 16Raal F.J. Santos R.D. Blom D.J. Marais A.D. Charng M.J. Cromwell W.C. Lachmann R.H. Gaudet D. Tan J.L. Chasan-Taber S. et al.Mipomersen, an apolipoprotein B synthesis inhibitor, for lowering of LDL cholesterol concentrations in patients with homozygous familial hypercholesterolaemia: a randomised, double-blind, placebo-controlled trial.Lancet. 2010; 375: 998-1006Abstract Full Text Full Text PDF PubMed Scopus (745) Google Scholar) and in subjects with mild to moderate hyperlipidemia (17Akdim F. Tribble D.L. Flaim J.D. Yu R. Su J. Geary R.S. Baker B.F. Fuhr R. Wedel M.K. Kastelein J.J. Efficacy of apolipoprotein B synthesis inhibition in subjects with mild-to-moderate hyperlipidaemia.Eur. Heart J. 2011; 32: 2650-2659Crossref PubMed Scopus (110) Google Scholar). There are no effects on plasma HDL-C concentration. We hypothesize that mipomersen reduces the plasma concentration of apoC-III and the concentration of apoB lipoproteins that contain apoC-III. This could occur if reduced apoB synthesis decreases the amount of VLDL to which apoC-III can attach in the hepatocyte before its secretion into the circulation. It is also possible that reduced hepatic apoB content reduces apoC-III synthesis. This exploratory analysis was performed on a subset of samples from a randomized, double-blind, placebo-controlled dose-escalation Phase II study (registered as NCT00216463 at ClinicalTrials.gov) in which mipomersen was evaluated as a monotherapy in subjects with primary hypercholesterolemia. The primary aim of the parent study was to determine the effects of mipomersen on concentrations of LDL-C and apoB. Recruitment protocol, drug administration, and results have been published (17Akdim F. Tribble D.L. Flaim J.D. Yu R. Su J. Geary R.S. Baker B.F. Fuhr R. Wedel M.K. Kastelein J.J. Efficacy of apolipoprotein B synthesis inhibition in subjects with mild-to-moderate hyperlipidaemia.Eur. Heart J. 2011; 32: 2650-2659Crossref PubMed Scopus (110) Google Scholar). Briefly, the parent study enrolled 50 hypercholesterolemic men and women between the ages of 18 and 65 years. Inclusion criteria were a body mass index (BMI) between 25 and 32 kg/m2 inclusive, fasting LDL-cholesterol greater than or equal to 130 mg/dl (3.36 mmol/l), and triglycerides less than or equal to 400 mg/dl (4.55 mmol/l).Women with childbearing potential were excluded. Subjects were healthy with no medical conditions or clinical abnormalities. Subjects could not take concomitant medications within 14 days of dosing (except hormone replacement therapy), use aspirin or acetaminophen for more than 5 consecutive days, or any lipid-lowering drug within 30 days or five half-lives (of the lipid-lowering drug), whichever was longer, prior to screening. Participation occurred from August 2005 to December 2006. Written informed consent was obtained prior to enrollment. Participants were randomly assigned among five groups, having effective weekly doses of 50, 100, 200, 300, and 400 mg. Each group had 10 subjects, 8 receiving mipomersen and 2 receiving placebo. The duration of administration was 13 weeks. Three of these groups (100, 200 and 300 mg) were included in this substudy on apoC-III. In the 100 mg group, mipomersen or placebo was administered as a 200 mg subcutaneous injection in four loading doses within the first 11 days, followed by a 200 mg subcutaneous injection every other week for 11 weeks. This dosing resulted in an effectual 100 mg/wk dose because of the long plasma terminal elimination half-life of mipomersen of 30 days (18Yu R.Z. Lemonidis K.M. Graham M.J. Matson J.E. Crooke R.M. Tribble D.L. Wedel M.K. Levin A.A. Geary R.S. Cross-species comparison of in vivo PK/PD relationships for second-generation antisense oligonucleotides targeting apolipoprotein B-100.Biochem. Pharmacol. 2009; 77: 910-919Crossref PubMed Scopus (96) Google Scholar). In the 200 mg and 300 mg groups, mipomersen or placebo was administered once per week for 13 weeks. For the purposes of this study, the 2 participants receiving placebo from the mipomersen 400 mg group were also included to produce a balanced analysis of 8 participants, each of whom received placebo, 100 mg/wk, 200 mg/wk, or 300 mg/wk. Baseline blood samples were collected on day 4 for the 100 mg group and on day 8 for the 200 mg and 300 mg groups rather than before the first dose because the predose baseline sample was not available for this study. Previous studies have shown no changes in lipids and lipoproteins within the first week after the first dose (15Kastelein J.J. Wedel M.K. Baker B.F. Su J. Bradley J.D. Yu R.Z. Chuang E. Graham M.J. Crooke R.M. Potent reduction of apolipoprotein B and low-density lipoprotein cholesterol by short-term administration of an antisense inhibitor of apolipoprotein B.Circulation. 2006; 114: 1729-1735Crossref PubMed Scopus (324) Google Scholar). Posttreatment blood samples were collected eight days after the final dose on day 99, except for one participant in the 100 mg group who left the study early at day 50 and one participant in the 300 mg group who terminated at day 22. Both of these participants were mipomersen recipients. Plasma samples were stored at −70°C and shipped to the lab in a single batch on dry ice. The analysis was conducted over the course of two months in June and July 2008 in five analysis batches. To minimize assay bias, batches consisted of 14 or 16 samples arranged to ensure that all treatment arms were present in each analysis batch and that each participant's pre- and posttreatment samples were present in the same batch. All lab staff was blinded to the treatment arm, whether the sample was pre- or posttreatment, and whether the participant was given mipomersen or placebo. The protocol complied with the requirements of the European Clinical Trial Directive 2001/20/EC, applicable German Drug Law, and the revised Declaration of Helsinki (Washington, 2002). The study was reviewed and approved by the local institutional review board at Harvard School of Public Health. Drug safety was monitored with clinical laboratory evaluations, physical examinations, 12-lead electrocardiograms, and vital signs. Follow-up was conducted for six months posttreatment. Samples were removed from cryogenic storage and thawed in the dark at room temperature for 30 min. Samples were filtered and 50 mcl was reserved for whole plasma analysis. The remaining filtered plasma was recorded (volume range 0.151–0.723 ml) and loaded into 20 ml Econo-Pac columns (Bio-Rad Laboratories, Hercules, CA) packed with 2.5 ml anti-apoC-III resin (polyclonal goat anti-human apoC-III antibody bound to Sepharose 4B resin (Academy Biomedical Co., Houston, TX) at a minimum concentration of 5 mg of antibody per 1 ml of resin. The highest concentration of plasma apoC-III found in this study was ∼26 mg/dl (0.26 mg/ml). At a load volume of 0.7 ml, this is a maximum load of 0.18 mg, which is below the minimum theoretical capacity of 0.644 mg of apoC-III based on column specifications. The antibody used in the resin was purified using immuno-affinity chromatography incorporating human apoC-III bound to Sepharose resin. We have tested this antibody for cross-reactivity with other apolipoproteins (apoB, apoE, and apoAI) and found no interaction. Prior to starting this study, we tested the column resin efficiency and found that 99 ± 1% of recovered apoC-III was found in the bound fraction. Lab control samples run in each batch alongside the unknowns showed a column efficiency of 97 ± 2%. Recovery in these lab controls assessed by cholesterol concentration was 96 ± 9%. Samples and resin were incubated for 16 h at 4°C with mixing. The unbound fraction was eluted from the column by gravity followed by washes with phosphate-buffered saline (PBS). The bound fraction was then eluted from the columns with 3M sodium thiocyanate in PBS and was immediately desalted by multiple rinses in Vivaspin 20 ultrafiltration centrifugal device with PES membrane at 50,000 MWCO (Sartorius Stedim Biotech S.A., Aubagne, France), ending with a final sample volume of 700 μl. The bound and unbound fractions were then further separated into density fractions by ultracentrifugation. VLDL was isolated by overlaying the 700 μl of sample with 300 μl of d = 1.006 g/ml PBS solution (OmniPur; EMD, Darmstadt, Germany) and spinning for 16 h at 15°C and 25,000 rpm in the outer-most row of a Beckman 25-Ti rotor with a Beckman L8-70M ultracentrifuge (Beckman Coulter, Inc., Fullerton, CA). The top 200 ± 10 μl from each tube was collected by careful aspiration and briefly stored at 4°C pending same-day analysis of lipids and apolipoproteins while the next ultracentrifugation step for LDL was prepared. LDL was isolated by increasing the density of the plasma remaining after VLDL aspiration with KBr solution to produce a solute density of 1.063 g/ml, and then spinning for 24 h under the same conditions as for VLDL isolation. The top 300 ± 10 μl from each was collected by aspiration. Three density fractions of plasma were thus isolated: d < 1.006 g/ml (VLDL), 1.006 g/ml < d < 1.063 g/ml (LDL), and d > 1.063 g/ml (HDL). The d > 1.063 fraction was treated with dextran sulfate and magnesium chloride to remove any residual apoB lipoproteins, and then was desalted. The products of the combined immuno-affinity chromatography and UC density fractionation were: VLDL without apoC-III, VLDL with apoC-III, LDL without apoC-III, LDL with apoC-III, HDL without apoC-III, and HDL with apoC-III. Sandwich ELISA procedures using affinity purified antibodies (Academy Biomedical Co.) were performed to determine concentrations of apoB, apoC-III, and apoE in whole plasma and the lipoprotein fractions. Cholesterol was determined enzymatically (Thermo Scientific, Waltham, MA). Liquid transfer for 96-well plate loading and ELISA dilutions were handled robotically with a Multiprobe II (PerkinElmer, Waltham, MA). Both ELISA and lipids plates were read with a BioTek ELx808iu 96-well plate reader controlled by KCJunior software (BioTek, Winooski, VT). All assays were completed in triplicate, and any sample with an intra-assay coefficient of variation over 15% was repeated. Final data were exported to Microsoft Excel for analysis and database management. The primary measurements of interest were the concentrations of apoC-III in whole plasma, in apoB lipoproteins, and in HDL; and apoB concentrations in whole plasma and in VLDL and LDL containing apoC-III. Concentrations of apoB in subfractions without apoC-III, as well as apoE and cholesterol concentrations, were also studied. Effect of treatment on these lipids and apolipoproteins was calculated by subtracting baseline concentration from concentration at end of treatment. The placebo-adjusted effects were calculated as changes in participants who received placebo subtracted from the changes in those who received mipomersen in each arm to compute the effective mipomersen treatment. All statistical tests were performed using SAS version 9.1 (SAS Institute Inc., Cary, NC). Differences between baseline and posttreatment concentrations within each treatment group were tested for significance using paired t-test. We used generalized linear models (SAS PROC GLM) to compare changes from baseline in the treatment groups with the changes from baseline in the placebo group, to test whether changes from baseline in the treatment and placebo groups were significantly different from zero, and to test whether placebo-adjusted changes from baseline in the treatment groups were significantly different from zero (defined as P < 0.05). Tests for trend across doses were performed by linear regression (SAS PROC REG), where change in lipoprotein concentration was the dependent variable and dose was the independent variable with values of 100, 200, and 300. We did not adjust P values for multiple comparisons. Sample data were excluded from statistical analysis if laboratory measurements of baseline or posttreatment samples were extreme outliers or too low to be measured accurately. Two participants in the 300 mg dosage group were excluded due to insufficient sample volume available to allow for detection of apoC-III in plasma fractions. The actual sample size for each statistical analysis is indicated in TABLE 1, TABLE 2, TABLE 3, TABLE 4.TABLE 1Effect of mipomersen treatment on apoC-III concentrations (mg/dl)Placebo100 mg/wk200 mg/wk300 mg/wkTotalN8886aObservations were excluded from analysis if either baseline or posttreatment observations were extreme outliers.Mean baseline (SD)16.2 (2.8)11.7 (4.4)13.7 (5.3)16.1 (5.9)Mean change (SD)1.61 (2.16)2.58 (4.93)−4.19 (5.19)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).−4.42 (2.71)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).P valuebP value comparing treatment mean change from baseline to placebo mean change from baseline by generalized linear model (SAS PROC GLM).0.60.01<0.001Placebo-adjusted mean change (SD)0.961 (4.93)−5.81 (5.19)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).−6.03 (2.71)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).In apoB lipoproteinsN85aObservations were excluded from analysis if either baseline or posttreatment observations were extreme outliers.7aObservations were excluded from analysis if either baseline or posttreatment observations were extreme outliers.5aObservations were excluded from analysis if either baseline or posttreatment observations were extreme outliers.Mean baseline (SD)8.17 (3.93)4.38 (1.55)5.86 (3.56)5.87 (1.79)Mean change (SD)−0.239 (2.07)0.029 (3.19)−2.41 (2.93)−2.29 (1.68)P valuebP value comparing treatment mean change from baseline to placebo mean change from baseline by generalized linear model (SAS PROC GLM).0.90.10.09Placebo-adjusted mean change (SD)0.268 (3.19)−2.17 (2.93)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).−2.06 (1.68)In apoAI lipoproteinsN8886aObservations were excluded from analysis if either baseline or posttreatment observations were extreme outliers.Mean baseline (SD)8.06 (3.87)6.93 (2.78)8.21 (4.30)11.1 (6.03)Mean change (SD)1.85 (3.11)1.75 (2.67)−1.88 (4.47)−3.75 (6.91)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).P valuebP value comparing treatment mean change from baseline to placebo mean change from baseline by generalized linear model (SAS PROC GLM).0.90.070.06Placebo-adjusted mean change (SD)−0.106 (2.67)−3.73 (4.47)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).−5.60 (6.9)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).a Observations were excluded from analysis if either baseline or posttreatment observations were extreme outliers.b P value comparing treatment mean change from baseline to placebo mean change from baseline by generalized linear model (SAS PROC GLM).c P value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM). Open table in a new tab TABLE 2Effect of mipomersen treatment on apolipoprotein B concentrations (mg/dl)Placebo100 mg/wk200 mg/wk300 mg/wkTotalN8888Mean baseline (SD)131 (18)131 (28)125 (21)137 (18)Mean change (SD)1.38 (16.6)−28.9 (12.9)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).−55.9 (10.8)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).−83.1 (12.6)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).P valuebP value comparing treatment mean change from baseline to placebo mean change from baseline by generalized linear model (SAS PROC GLM).0.001<0.001<0.001Placebo-adjusted mean change (SD)−30.3 (12.9)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).−57.3 (10.8)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).−84.5 (12.6)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).In VLDL with apoC-IIIN7aObservations were excluded from analysis if either baseline or posttreatment observations were extreme outliers.6aObservations were excluded from analysis if either baseline or posttreatment observations were extreme outliers.6aObservations were excluded from analysis if either baseline or posttreatment observations were extreme outliers.5aObservations were excluded from analysis if either baseline or posttreatment observations were extreme outliers.Mean baseline (SD)0.382 (0.503)0.152 (0.159)0.093 (0.100)0.187 (0.138)Mean change (SD)−0.088 (0.204)0.069 (0.122)−0.022 (0.059)−0.101 (0.096)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).P valuebP value comparing treatment mean change from baseline to placebo mean change from baseline by generalized linear model (SAS PROC GLM).0.050.40.9Placebo-adjusted mean change (SD)0.157 (0.122)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).0.066 (0.059)−0.013 (0.096)In LDL with apoC-IIIN87aObservations were excluded from analysis if either baseline or posttreatment observations were extreme outliers.6aObservations were excluded from analysis if either baseline or posttreatment observations were extreme outliers.8Mean baseline (SD)8.31 (3.92)9.00 (4.14)7.23 (2.50)3.14 (2.13)Mean change (SD)−0.721 (3.15)−3.19 (3.15)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).−3.46 (2.65)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).−2.16 (1.78)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).P valuebP value comparing treatment mean change from baseline to placebo mean change from baseline by generalized linear model (SAS PROC GLM).0.10.10.4Placebo-adjusted mean change (SD)−2.47 (3.15)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).−2.74 (2.65)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).−1.44 (1.78)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).In VLDL without apoC-IIIN87aObservations were excluded from analysis if either baseline or posttreatment observations were extreme outliers.88Mean baseline (SD)2.16 (1.20)1.98 (1.85)1.77 (1.26)2.14 (0.81)Mean change (SD)0.543 (1.15)−1.01 (1.86)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).−0.316 (0.787)−0.953 (1.13)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).P valuebP value comparing treatment mean change from baseline to placebo mean change from baseline by generalized linear model (SAS PROC GLM).0.030.20.03Placebo-adjusted mean change (SD)−1.55 (1.86)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).−0.859 (0.787)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).−1.50 (1.13)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).In LDL without apoC-IIIN8888Mean baseline (SD)120 (14)121 (27)117 (20)131 (17)Mean change (SD)1.568 (15.3)−26.4 (12.4)cP value for change from baseline is <0.05 by generalized linear model (SAS PROC GLM).−53.8 (10.0)cP value for change from baseline is <0.05 by generalized linear model (SAS
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