Pharmacokinetics and Bioequivalence Comparison of Two Fixed-Dose Combination of Rosuvastatin/Ezetimibe Formulations: A Randomized, Crossover, Open-Label Study in Healthy Volunteers

Objective: To evaluate the bioequivalence (BE) of two fixed-dose combination (FDC) formulations of Rosuvastatin and Ezetimibe: Cresadex® EZE 20/10 mg (Abbott Laboratories) as the reference formulation (R), and Racor® Duo 20/10 mg (Laboratorios Leti, S.A.V.) as the test formulation (T). Method: A randomized, single-dose, two-period, two-sequence, open-label, crossover design was employed. Subjects received a single oral dose of either the Test or Reference formulation under fasting conditions, with a 12-day washout period between treatments. Male subjects aged 18 - 45 years with normal health and laboratory values were included. Exclusion criteria encompassed any medical conditions, recent surgery, drug or alcohol use, and hypersensitivity to the study drugs. Blood samples were collected at pre-dose and multiple post-dose time points and analyzed using a validated LC-MS/MS method to quantify Rosuvastatin and Ezetimibe concentrations in plasma. Descriptive statistics were used to summarize pharmacokinetic (PK) parameters. ANOVA was conducted to compare the ln-transformed values of Cmax, AUC0−t, and AUC0−∞. Schuirmann’s two one-sided t-tests were applied to assess bioequivalence (BE). Results: The 90% Confidence Intervals for the ln-transformed ratios of Cmax, AUC0−t, and AUC0−∞ fell within the acceptance range of 80% to 125%, demonstrating bioequivalence between the Test and Reference formulations. Both formulations were well-tolerated, with no serious adverse events reported. Conclusions: The results of this study confirm the bioequivalence of the two tested FDC Rosuvastatin/Ezetimibe formulations: Cresadex® EZE (Abbott Laboratories) and Racor® Duo (Laboratorios Leti, S.A.V.). These findings endorse the therapeutic interchangeability of these products, providing clinicians with greater flexibility in the treatment of hyperlipidemia.

Lowering of Blood Lipid Levels with a Combination of Pitavastatin and Ezetimibe in Patients with Coronary Heart Disease:A Meta-Analysis

Objectives:According to the findings of randomized controlled trials,blood lipid levels in patients with coronary heart disease(CHD)can be significantly decreased through a combination of pitavastatin and ezetimibe;however,the effects and clinical applications of this treatment remain controversial.This meta-analysis was aimed at objectively assessing the efficacy and safety of pitavastatin and ezetimibe in lowering blood lipid levels.Design:Relevant studies were retrieved from electronic databases,including PubMed,Cochrane Library,Embase,China National Knowledge Infrastructure,VIP,and WanFang Data,from database inception to June 8,2022.The lev-els of low-density lipoprotein cholesterol,total cholesterol,triglycerides,and high-density lipoprotein cholesterol in patients’serum after treatment were the primary endpoint.Results:Nine randomized controlled trials(2586 patients)met the inclusion criteria.The meta-analysis indi-cated that pitavastatin plus ezetimibe resulted in significantly lower levels of LDL-C[standardized mean difference(SMD)=−0.86,95%confidence interval(CI)(−1.15 to−0.58),P<0.01],TC[SMD=−0.84,95%CI(−1.10 to−0.59),P<0.01],and TG[SMD=−0.59,95%CI(−0.89 to−0.28),P<0.01]than pitavastatin alone.Conclusions:Pitavastatin plus ezetimibe significantly decreased serum LDL-C,TC,and TG levels in patients with CHD.

新型调脂药ezetimibe——胆固醇吸收的选择性抑制剂

传统的树脂类、贝特类等药物因为不良反应大,降低胆固醇效果差而不易被病人接受。他汀类药物降低胆固醇效果好,但某些病人单用他汀类药物不能有效降低体内胆固醇水平。因此本文介绍了新近在美国上市的ezetimibe,一种新型胆固醇吸收的选择性抑制剂,在单用或与他汀类药物联用时,都能稳定降低血浆低密度脂蛋白胆固醇(LDL-C)水平,为临床治疗高脂血症提供了新的选择。

新型胆固醇吸收抑制剂Ezetimibe的研究进展

Ezetimibe是一种新型选择性肠胆固醇吸收抑制剂,通过抑制肠上皮细胞的胆固醇吸收蛋白NPC1L1减少胆固醇、植物固醇的吸收以及胆汁胆固醇的再吸收,从而降低血浆固醇水平。Ezetimibe的作用与他汀类药物抑制胆固醇合成的机制互补,在降低血浆低密度脂蛋白胆固醇和总胆固醇水平的同时,升高高密度脂蛋白胆固醇水平,为高胆固醇血症的治疗、动脉粥样硬化和冠心病的防治提供了一种新的有效选择。

降胆固醇新药——贝培多酸(bempedoic acid)及其与依折麦布(ezetimibe)的复方片剂

2004年3月前,美国Esperion制药公司就致力于调节血脂异常药物的研发工作,研制与开发一种先导候选产品:三磷酸腺苷(ATP)-柠檬酸裂合酶(ATP-citrate lyase,ACL)抑制药——bempedoic acid(贝培多酸),用于降低内源性胆固醇,并通过上调LDL受体降低LDL-C水平升高,减轻肌肉相关副作用。除了作为单一疗法的贝培多酸片剂之外,还开发与尼曼-匹克C1型类似蛋白的胆固醇吸收抑制药:贝培多酸与依折麦布(ezetimibe)固定剂量组合的复方制剂可抑制小肠中胆固醇的吸收,降低肝脏细胞里胆固醇的含量,促使循环中胆固醇的吸收增加,从而降低血液中胆固醇含量。用于辅助饮食治疗的原发性高脂血症、混合型高脂血症、纯合子家族性高胆固醇血症和纯合子谷甾醇血症(植物固醇血症)。Esperion公司于2019年5月5日向美国食品药品管理局(FDA)递交贝培多酸薄膜包衣片及其与依折麦布复方片的新药上市申请(NDA),美国FDA分别于2020年2月21日和26日批准贝培多酸薄膜包衣片及其与依折麦布复方片上市,商品名为Nexletol及Nexlizet。2019年1月14日,美国Esperion生物制药公司与日本第一三共制药欧洲分公司签署许可协议,许可该公司在包括瑞士在内的欧洲经济区内对贝培多酸及其与伊折麦布复方片剂进行独家开发、上市、生产和商业化经营权。2020年4月7日欧盟委员会(EC)批准日本第一三共制药欧洲分公司的贝培多酸及其与伊折麦布的复方片剂可临床使用,2020年4月24日欧洲药品管理局(EMA)批准这2种片剂上市,商品名分别为Nilemdo和Nustendi。该文对贝培多酸片薄膜包衣片及其与依折麦布复方片的非临床和临床药理毒理学、临床研究、不良反应、适应证、剂量与用法、用药注意事项及知识产权状态和国内外研究进展等进行介绍。

ezetimibe,高脂血症未来的选择?

大量的随机临床试验(RCT)一致确定了他汀类药物对动脉粥样硬化一级与二级预防中的重要地位.但他汀类在调脂治疗的临床实践中仍有一些局限性.它们降低总胆固醇(TC)和低密度脂蛋白胆固醇(LDL-C)的达标率有限.

新型调脂药Ezetimibe的研究进展

血脂异常与动脉粥样硬化性疾病有着极其紧密的联系,尤其是LDL-c的降低可降低动脉粥样硬化性心脏病的发病率和致死率.他汀类药物自问世以来其强大的调脂作用尤其在降LDL-c方面给动脉粥样硬化性疾病患者带来了希望,在临床上对心血管病的防治产生了前所未有的良好影响和效应.目前虽在开发作用更强且安全的新品种,但其调脂作用仍有限,尤其在遗传性血脂代谢异常、糖尿病等疾病中效果欠佳,且随着他汀类剂量的增加其不良反应亦在增加,这使得一些患者不能耐受,迫切需要新型调脂药的出现,此时ezetimibe应运而生.

Ezetimibe抑制胆固醇结石形成的实验研究

目的 :探讨ezetimibe(Eze)对胆囊胆固醇结石形成的抑制作用。方法 :将30只雄性成年C57BL/6小鼠随机分为普通饲料喂养(chow)组、成石饲料喂养(LD)组和成石饲料加Eze组[Eze 5 mg/(kg·d)灌胃]。饲养8周后收集血清、肝脏、小肠和胆囊。观察胆囊内胆固醇结石形成情况。采用酶法测定血清、胆汁成分、肝组织胆固醇含量。采用实时定量PCR测定肝脏和小肠胆固醇代谢相关基因mRNA相对表达量。结果:chow组小鼠胆囊内未发现结石形成。LD组小鼠胆囊结石形成率为100%。Eze组完全无结石形成。Eze组小鼠小肠胆固醇吸收率(9.29%±4.32%),较LD组(58.62%±3.10%)和chow组(56.42%±2.67%)均显著降低(P<0.01)。LD组血清胆固醇[(4.99±0.50)mmol/L]和肝组织胆固醇含量[(22.92±2.39)mg/g]均较chow组[(2.87±0.06)mmol/L和(2.45±0.08)mg/g]显著增加(P<0.05)。Eze组血清胆固醇[(1.11±0.10)mmol/L]和肝组织胆固醇含量[(2.70±0.07)mg/g]均较LD组显著降低(P<0.05)。LD组小鼠胆汁胆固醇含量[LD组(10.87±1.46)mmol/L比chow组(3.67±0.58)mmol/L]和胆固醇饱和指数[LD组(1.42±0.19)比chow组(0.59±0.02)]显著增加。Eze组胆汁胆固醇含量[(2.72±0.29)mmol/L]和胆固醇饱和指数(0.57±0.07)均较LD组显著降低(P<0.01)。结论:Eze抑制小肠胆固醇肠道摄取,具有预防胆囊胆固醇结石形成的作用。

Effect of insulin-sensitizing agents in combination with ezetimibe, and valsartan in rats with non-alcoholic fatty liver disease

AIM： To assess whether treatment with insulinsensitizing agents （ISAs） in combination with ezetimibe and valsartan have greater effect on hepatic fat content and lipid peroxidation compared to monotherapy in the methionine choline-deficient diet （MCDD） rat model of non-alcoholic fatty liver disease （NAFLD）. METHODS： Rats （n = 6 per group） were treated with different drugs, including MCDD only, MCDD diet with either metformin （200 mg/kg）, rosiglitazone （3 mg/kg）, metformin plus rosiglitazone （M＋R）, ezetimibe （2 mg/ kg）, valsartan （2 mg/kg）, or combination of all drugs for a total of 15 wk. Liver histology, lipids, parameters of oxidative stress and TNF-alpha were measured. RESULTS： Fatty liver （FL） rats demonstrated severe hepatic fatty infiltration （〉 91% fat）, with an increase in hepatic TG （＋1263%, P 〈 0.001）, hepatic cholesterol （＋245%, P 〈 0.03）, hepatic MDA levels （＋225%, P 〈 0.001）, serum TNF-alpha （17.8 ＋ 10 vs 7.8 ＋ 0.0, P 〈 0.001）, but a decrease in hepatic alpha tocopherol （-74%, P 〈 0.001） as compared to the control rats. Combination therapy with all drugs produced a significant decrease in liver steatosis （-54%）, hepatic TG （-64%）, hepatic cholesterol （-31%） and hepatic MDA （-70%）, but increased hepatic alpha tocopherol （＋443%） as compared to FL rats. Combination therapy with ISA alone produced a smaller decrease in liver steatosis （-32% vs -54%, P 〈 0.001） and in hepatic MDA levels （-55% vs -70%, P 〈 0.01）, but a similar decrease in hepatic lipids when compared with the all drugs combination. TNF-alpha levels decreased significantly in all treatment groups except in ISA group. CONCLUSION： Combination therapies have a greater effect on liver fat content as compared to monotherapy. Rosiglitazone appears to improve hepatic steatosis to a greater extent than metformin.

Ezetimibe improves hepatic steatosis in relation to autophagy in obese and diabetic rats

AIM: To investigate whether ezetimibe ameliorates hepatic steatosis and induces autophagy in a rat model of obesity and type 2 diabetes. METHODS: Male age-matched lean control LETO and obese and diabetic OLETF rats were administered either PBS or ezetimibe(10 mg/kg per day) via stomach gavage for 20 wk. Changes in weight gain and energy intake were regularly monitored. Blood and liver tissue were harvested after overnight fasting at the end of study. Histological assessment was performed in liver tissue. The concentrations of glucose, insulin, triglycerides(TG), free fatty acids(FFA), and total cholesterol(TC) in blood and TG, FFA, and TG in livertissue were measured. m RNA and protein abundance involved in autophagy was analyzed in the liver. To investigate the effect of ezetimibe on autophagy and reduction in hepatic fat accumulation, human Huh7 hepatocytes were incubated with ezetimibe(10 μmol/L) together with or without palmitic acid(PA, 0.5 mmol/L, 24 h). Transmission electron microscopy(TEM) was employed to demonstrate effect of ezetimibe on autophagy formation. Autophagic flux was measured with bafilomycin A1, an inhibitor of autophagy and following immunoblotting for autophagy-related protein expression.RESULTS: In the OLETF rats that received ezetimibe(10 mg/kg per day), liver weight were significantly decreased by 20% compared to OLETF control rats without changes in food intake and body weight(P < 0.05). Lipid parameters including TG, FFA, and TC in liver tissue of ezetimibe-administrated OLETF rats were dramatically decreased at least by 30% compared to OLETF controls(P < 0.01). The serum glucose, insulin, HOMA-IR, and lipid profiles were also improved by ezetimibe(P < 0.05). In addition, autophagy-related m RNA expression including ATG5, ATG6, and ATG7 and the protein level of microtubule-associated protein light chain 3(LC3) were significantly increased in the liver in rats that received ezetimibe(P < 0.05). Likewise, for hepatocytes cultured in vitro, ezetimibe treatment significantly decreased PA-induced fat accumulation and increased PA-reduced m RNA and protein expression involved in autophagy(P < 0.05). Ezetimibe-increased autophagosomes was observed in TEM analysis. Immunoblotting analysis of autophagy formation with an inhibitor of autophagy demonstrated that ezetimibe-increased autophagy resulted from increased autophagic flux. CONCLUSION: The present study demonstrates that ezetimibe-mediated improvement in hepatic steatosis might involve the induction of autophagy.

Role of ezetimibe in non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) encompasses a histological spectrum ranging from simple steatosis to steatohepatitis,advanced fibrosis and inflammatory changes.Ezetimibe inhibits cholesterol absorption from the intestinal lumen into enterocytes.The molecular target of ezetimibe is the sterol transporter Niemann-Pick C1-like 1 protein (NPC1L1).Human NPC1L1 is abundantly expressed in the liver and may facilitate the hepatic accumulation of cholesterol.Ezetimibe ex-erts beneficial effects on several metabolic variables.Ezetimibe treatment attenuates hepatic steatosis and is beneficial in terms of NAFLD biochemical markers.The combination of ezetimibe with other interventions may also be beneficial in NAFLD patients.Our group inves-tigated the ezetimibe-orlistat combination treatment in overweight and obese patients with hypercholeste-rolemia,with beneficial effects on NAFLD biochemical markers.These results are promising for patients with NAFLD,who usually have increased cardiovascular disease risk and need a multifactorial treatment.How-ever,it should be mentioned that most results are from animal studies and,although modest elevation of liver function tests may raise the suspicion of NAFLD,none of these tests are sensitive to establish the diagnosis of NAFLD with great accuracy.

Simultaneous determination of ezetimibe and simvastatin in rat plasma by stable-isotope dilution LC-ESI-MS/MS and its application to a pharmacokinetic study

A simple, sensitive and specific liquid chromatography-tandem mass spectrometry method was developed for simultaneous quantification of ezetimibe and simvastatin in rat plasma. The deuterium isotopes： ezetimibe d4 and simvastatin d6 were used as internal standards for ezetimibe and simvastatin, respectively. MS/MS detection involved a switch of electron spray ionization mode from negative to positive at retention time 3.01 rain. Samples were extracted from plasma by liquid-liquid extraction using tertiary butyl methyl ether. Chromatographic separation was achieved with Agilent Eclipse XBD-CIs column using mobile phase that consisted of a mixture of ammonium acetate （pH4.5; 10 mM）-acetonitrile （25：75 v/v）. The method was linear and validated over the concentration range of 0.2--40.0 ng/rnL for simvastatin and 0.05-15.0 ng/mL for ezetimibe. The transitions selected were m/z 408.3→271.1 and m/z 412.0→275.10 for ezetimibe and ezetimibe d4, and m/z 419.30 → 285.20 and rrdz 425.40 →199.20 for simvastatin and simvastatin d6. Intra- and inter-batch precisions for ezetimibe were 1.6-14.8% and 2.1-13.4%; and for simvastatin 0.94-9.56% and 0.79-12%, respectively. The proposed method was sensitive, selective, precise and accurate for the quantification of ezetimibe and simvastatin simultaneously in rat plasma. The method was successfully applied to a pharmacokinetic study by oral co-administration of ezetimibe and simvastatin in SD rats.

高胆固醇血症的双相调节与ezetimibe

目前仍有较多高危患者经他汀类单药治疗后低密度脂蛋白胆固醇 (LDL-C) 不能达到预期的标准,而且以他汀类与其它降脂药物联用常因不良反应增加而受到限制。新型胆固醇吸收抑制剂ezetimibe,与小肠粘膜刷状缘的结构蛋白具极高的亲和力,通过抑制小肠壁对食物及胆汁中的胆固醇吸收而发挥作用。本品口服给药吸收迅速,半衰期长达24小时,且不良反应与安慰剂组相仿。本品与他汀类联合给药具协同效应,且不增加横纹肌溶解等不良反应。据此对高胆固醇血症患者联用上述两类不同作用机制药物的疗效及安全性可予确认。

Serious drug-induced liver disease secondary to ezetimibe

Ezetimibe is the f irst member of a new family of lipid- lowering drugs that inhibits uptake of dietary and bili- ary cholesterol. It was approved by the FDA in 2002 for hypercholesterolemia alone or in combination with statins. Its use has been spreading over the last years. Ezetimibe was considered a safe drug. We report a case of a woman who developed a serious hepatocellular drug-induced liver disease after 4 mo therapy with 10 mg daily of ezetimibe. After withdrawal of the drug, the patient recovered slowly. Ezetimibe may produce seri- ous toxic hepatitis and prompt withdrawal is mandatory in case of a signif icant abnormality in liver testing after beginning or during treatment with ezetimibe.

Effect of ezetimibe on the prevalence of cholelithiasis

AIM： To investigate the prevalence of cholelithiasis among patients treated with ezetimibe. METHODS： A retrospective, case-control study based on computerized medical records from patients of the Clalit Health Services, Sharon-Shomron region, from 2000 to 2009. Patients 20-85 years of age, who had been treated with ezetimibe and statins or statins only for at least 6 too, and who had an abdominal ultrasound were included in the study. Collected data included age, gender, ezetimibe treatment duration, presence of hypothyroidism or diabetes, and existence of cholelithiasis as determined by ultrasound. Ex- cluded were subjects after gallbladder resection, with hemolysis, myeloproliferative or inflammatory bowel diseases, and those treated with ursodeoxycholic acid and fibrates. Patients treated with statins and ezeti- mibe （study group） were compared to patients treated with statins only （control group）. RESULTS： The study group included 25 patients and the control group 168. All patients in the study were treated with statins. The study group included 13 males （52%） and 12 females （48%）, the control group 76 males （45%） and 92 （55%） females （P = 0.544）. The groups did not differ in age （mean age： 68 ± 8 years, range 53-85 years vs mean age： 71±8 years, range 51-85 years; P = 0.153） or in the rate of dia- betic and hypothyroid patients [11 （44%） vs 57 （33%）, P = 0.347 in the study group and 5 （20%） vs 23 （14%）, P = 0.449 in the control group, respectively]. Patients in the study group were treated with ezetimibe for an average of 798±379 d. Cholelithiasis was found in 4 （16%） patients in the study group and in 33 （20%） patients in the control group （P = 0.666）. CONCLUSION： Ezetimibe does not appear to influ- ence the prevalence of gallstones.

A convenient synthesis of ezetimibe analogs as cholesterol ab sorption inhibitors

A convenient method for the synthesis of ezetimibe analogs as cholesterol absorption inhibitors was described.The key step in the synthesis was the intramolecular ring formation through Mitsunobu reaction.Furthermore,a new series of analogs was designed and synthesized.

Isolation and Characterization of R-Enantiomer in Ezetimibe

A simple and rapid Supercritical Fluid Chromatography (SFC) method has been developed to isolate and characterize R-Isomer of Ezetimi be by using normal phase Chiral Cel OD-H with 250 mm × 30 mm, 5 microns column using a mobile phase system containing super critical fluid carbondi oxide (Co2) and the percentage of 2-Propanol as a mobile phase (85:15) and detection at 230 nm. The isolated R-Isomer is characterized by using UV-vis, FT-IR, ESI-MS, HPLC1H and 13C NMR. The purity of isolated R-Isomer is about 98%.

Development and Validation of Chiral HPLC Method for Identification and Quantification of (R)-Enantiomer in Ezetimibe

A normal phase enantioselective high performance liquid chromatographic method was developed for enantiomeric resolution of Ezetimibe it reduces the overall delivery of cholesterol to the liver. The enantiomers of Ezetimibe were resolved on a Chiral Pak AS-H (250 × 4.6 mm, 5 μm) column using a mobile phase system containing n-Hexane, etha-nol, 2-Propanol and Trifloroacetic acid (84:12:4:0.1 v/v). The resolution between enantiomers was found to be more than 2.0. The limit of detection and limit of quantification of (R)-enantiomer were found to be 0.2 μg/mL and 0.5 μg/mL, respectively, for 10 μL injection volume. The sample solution and mobile phase were found to be stable for at least 48 h. The final optimized method was successfully applied to separate (R)-enantiomer from Ezetimibe and was proven to be reproducible and accurate for the quantitative determination of (R)-enantiomer in bulk drugs.