Lipoprotein(a)-apheresis in the light of new drug developments

Elevated levels of lipoprotein(a) (Lp(a)) contribute to the risk of early and severe cardiovascular disease (CVD). Recently <50 mg/dl was recommended as the desirable level for clinical use and decision making. All established medical therapies to lower cholesterol levels have no impact on lowering Lp(a) except niacin which is all too often poorly tolerated and not obtainable everywhere. Lipoprotein apheresis is an extracorporeal treatment to lower levels of Lp(a) significantly by > 60%. In some countries it is recommended in very high risk patients with early or progressive CVD. Retrospective data indicate that regular apheresis reduces cardiovascular events, which was substantiated by a recent prospective observational trial. Apheresis is very well tolerated with very few side effects, but it is expensive, time consuming, and offered by specialised centres only. To improve the overall treatment new drug therapies are required. Some of the recently approved lipid modifying drugs lower Lp(a) in addition to LDL-cholesterol: Mipomersen ∼ 25%, CETP-inhibitors ∼ 50%, PCSK9-inhibitors ∼ 30%. If the Lp(a) lowering effect contributes to the expected reduction of CVD events has to be shown in the future. The apo(a) antisense oligonucleotide is the only approach to specifically lower Lp(a). A phase 1 trial showed a decrease in a dose dependant manner (up to 88.8%) in healthy volunteers. Despite the lack of prospective randomised trials apheresis these days remains the standard of care in patients with elevated Lp(a) and severe CVD.