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Inhibition of microsomal triglyceride transfer protein

alone or with ezetimibe in patients with moderate
hypercholesterolemia
Frederick F Samaha1,2*, James McKenney3, LeAnne T Bloedon4, William J Sasiela5 and Daniel J Rader4

S U M M ARY INTRODUCTION
Guidelines on the optimum intensity of LDL-
Background Many patients with coronary heart disease do not achieve
cholesterol lowering have evolved in step with find-
recommended LDL-cholesterol levels, due to either intolerance or inadequate
ings from clinical trials. The National Cholesterol
response to available lipid-lowering therapy. Microsomal triglyceride
Education Program (NCEP) guidelines from 2001
transfer protein (MTP) inhibitors might provide an alternative way to lower
set the target level at below 2.6 mmol/l (100 mg/dl)
LDL-cholesterol levels. We tested the safety and LDL-cholesterol-lowering
for high-risk patients with coronary heart disease
efficacy of an MTP inhibitor, AEGR-733 (Aegerion Pharmaceuticals Inc.,
Bridgewater, NJ), alone and in combination with ezetimibe. or its risk equi­valent.1 These guidelines were
updated in 2004 to provide an optional thera-
Methods We performed a multicenter, double-blind, 12-week trial, which
peutic target of below 1.8 mmol/l (70 mg/dl) for
included 84 patients with hypercholesterolemia. Patients were randomly very high-risk patients (those with additional risk
assigned ezetimibe 10 mg daily (n = 29); AEGR-733 5.0 mg daily for the factors, such as diabetes).2 In 2006, the spectrum
first 4 weeks, 7.5 mg daily for the second 4 weeks and 10 mg daily for the last
of patients to which the lower value applied was
4 weeks (n = 28); or ezetimibe 10 mg daily and AEGR-733 administered with
broadened to include all patients with athero­
the dose titration described above (n = 28).
sclerotic disease. Furthermore, a minimum of
Results Ezetimibe monotherapy led to a 20–22% decrease in LDL- 30–40% reduction in LDL was recommended for
cholesterol concentrations. AEGR-733 monotherapy led to a dose- patients at moderate and high risk.3 Unfortunately,
dependent decrease in LDL-cholesterol concentration: 19% at 5.0 mg, 26% at least 20% of high-risk patients do not achieve
at 7.5 mg and 30% at 10 mg. Combined therapy produced similar but larger these LDL-cholesterol targets, with those in the
dose-dependent decreases (35%, 38% and 46%, respectively). The number highest risk group being the least likely to do so.4
of patients who discontinued study drugs owing to adverse events was five This difficulty might be due partly to statin intol-
with ezetimibe alone, nine with AEGR-733 alone, and four with combined erance. The rate of statin discontinuation owing
ezetimibe and AEGR-733. Discontinuations from AEGR-733 were due to adverse events, observed in clinical trials and
primarily to mild transaminase elevations. clinical practice, ranges from 1% to 7% and is
Conclusions Inhibition of LDL production with low-dose AEGR-733, either mainly caused by myalgias.5 In a 52-week lipid
alone or in combination with ezetimibe, could be an effective therapeutic efficacy study of five different statins, the rate of
option for patients unable to reach target LDL-cholesterol levels. discontinuations due to adverse events was even
Keywords ezetimibe, hypercholesterolemia, microsomal triglyceride higher (4–13%).6 Furthermore, there are patients
transfer protein inhibitor for whom high-dose statins are contraindicated,
such as those taking amiodarone,7 or with clin-
ical factors that raise the risk of rhabdomyolysis.8
1Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania Because statin-intolerant patients have few other
School of Medicine, Philadelphia, PA, USA
2Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA options for achieving treatment goals, there is an
3School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA unmet clinical need for additional therapies that
4Institute for Translational Medicine and Therapeutics, University of Pennsylvania
can lower LDL-cholesterol levels.
School of Medicine, Philadelphia, PA, USA
5Aegerion Pharmaceuticals, Bridgewater, NJ, USA One potential therapeutic target is the
assembly and secretion of apolipoprotein B
Correspondence (apoB)-containing lipoproteins. Microsomal
*University of Pennsylvania Medical Center, Philadelphia VA Medical Center, 8th Floor Cardiology,
MC 111C, 3900 Woodland Avenue, Philadelphia, PA 19104, USA
tri­glyceride transfer protein (MTP) is an intra­
Tel: +1 215 823 6324 cellular lipid-transfer protein found in the endo-
rick.samaha@va.gov plasmic reticulum and which is responsible for
transferring lipid molecules onto apoB. This
Received 12 November 2007 Accepted 21 February 2008 Published online 27 May 2008
www.nature.com/clinicalpractice
transfer forms part of the assembly of triglyceride-
doi:10.1038/ncpcardio1250 rich lipoproteins, such as chylo­microns in the

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intestine and VLDL in the liver.9 Patients with
the genetic disorder abetalipoproteinemia have
loss-of-function mutations in the microsomal
triglyceride transfer protein gene (MTTP),10
resulting in extremely low plasma concentrations
of cholesterol and triglycerides and absense of
chylomicrons, VLDL and LDL.11 The elucidation
of the mechanistic basis for this disease led to the
concept that small-molecule inhibitors of MTP
could reduce LDL-cholesterol levels. Indeed,
preclinical studies in animal models showed that
inhibition of MTP significantly reduced serum
cholesterol levels and slowed the formation of
atherosclerotic plaques.12,13 Furthermore, MTP
inhibition significantly reduced LDL-cholesterol
levels in patients with homozygous familial
hypercholesterolemia.14
Clinical applications of MTP inhibitors have
been focused primarily on high-dose mono-
therapy to produce substantial reductions in
LDL-cholesterol levels (particularly for patients
with homozygous familial hypercholesterolemia);
however, this strategy has been associated with an
unacceptable rate and severity of gastrointestinal
and hepatic adverse events, thereby prohibiting
its use in a broader population of patients with
hyperlipidemia. Because these side effects are
thought to be directly linked to the mechanism
of MTP-inhibition, we hypothesized that much
lower doses would yield clinically useful LDL-
cholesterol-lowering results but would be better
tolerated. In addition, we also hypothesized that
the LDL-cholesterol-lowering effects of the MTP
inhibitor AEGR-733 (Aegerion Pharmaceuticals
Inc., Bridgewater, NJ; previously BMS-201038,
Bristol-Myers Squibb, New York, NY) at these
reduced doses would be additive to those of
the cholesterol absorption inhibitor ezetimibe,
because the two drugs have different mecha-
nisms. To test our hypotheses we evaluated the
LDL-cholesterol-lowering efficacy of AEGR-733,
both alone and in combination with ezetimibe, in
patients with moderate hypercholesterolemia.
METHODS
This clinical trial is registered on Clinicaltrials.gov
(registry number NCT00405067 assigned on
28 November 2006).
Study patients
This trial was approved by a central investigational
review board (ASPIRE Institutional Review Board
LLC, San Diego, CA). Before the study started,
all potential participants signed an informed
498 nature clinical practice cardiovascular medicine
consent form approved by the review board.
Hypercholesterolemic patients of 18–70 years of
age from six geographically distinct lipid treat-
ment centers within the US were eligible. Patients
with 0–1 risk factors were required to have an
LDL-­cholesterol concentration between 4.1 and
6.5 mmol/l (160 and 250 mg/dl), and those with
more than two risk factors were required to have
an LDL-cholesterol concentration between 3.4
and 6.5 mmol/l (130 and 250 mg/dl). Baseline
LDL-cholesterol was the mean of measurements
obtained at the first two clinic screening visits. The
main exclusion criteria were uncontrolled hyper-
tension, creatinine levels greater than 221 μmol/l
(2.5 mg/dl), liver disease or transaminase levels
greater than 1.5 times the upper limit of normal,
symptomatic congestive heart failure, diabetes,
plasma triglyceride levels greater than 4.5 mmol/l
(400 mg/dl), or an acute cardiovascular event
within the prior 6 months. Patients receiving
concomitant lipid-lowering therapy were required
to discontinue these medications 4 weeks before
screening and throughout the trial. AEGR-733
was manufactured in accordance with current
Good Manufacturing Practices.
Study design
This was a phase II, prospective, randomized,
double-blind study. Participants initially under-
went a 2–6-week eligibility screening process to
assess their ability to follow a low-fat diet (<20%
of energy from total fat and <7% of energy from
saturated fat) to ensure that lipid values were
within the range stipulated in the inclusion
criteria and to wash-out any prior lipid-lowering
drugs. The active treatment part of the protocol
was a 12-week treatment period with interim visits
at weeks 4 and 8. Patients continued to follow
the low-fat diet and received diet counseling
throughout the study.
The patients were randomly assigned one
of three treatments according to a computer-
­generated randomization code issued by the
central coordinating center. In treatment
group 1, patients received 10 mg ezetimibe daily
plus placebo for 12 weeks. In treatment group 2,
patients received 5.0 mg AEGR-733 for the first
4 weeks, 7.5 mg for the second 4 weeks, and 10 mg
for the last 4 weeks, plus placebo for 12 weeks.
In treatment group 3 patients received AEGR-
733 (with the same dosing schedule as group 2)
plus 10 mg ezetimibe daily for 12 weeks. The
placebos were identical in appearance to either
the ezetimibe tablets or the AEGR-733 tablets,
samaha et al. august 2008 vol 5 no 8

dependent on which they replaced. The patients
were instructed to take the study medication in
the morning with breakfast. Patient randomiza-
tion was not stratified by baseline characteristics
because the small sample size in this study would
have made such stratification difficult.
Study visit data
During the study visits at 4, 8 and 12 weeks, data
were collected from history, physical examinations,
electrocardiograms, concomitant medications and
on assessment of study drug adherence, which was
done by conducting pill counts on the returned
drug supply from the patients. Blood samples for
laboratory analyses were obtained after a 12 h fast.
Plasma was separated from samples, immediately
frozen at –20°C, and shipped to the core laboratory
on dry ice.
Laboratory assays
Total cholesterol, HDL cholesterol, and tri­glyceride
levels were measured enzymatically on an auto­
analyzer (Cobas Fara II, Roche Diagnostic
Systems, Basel, Switzerland). Levels of apoB and
apolipoprotein A-I (apoA-I) were measured by
immunonephelometry on a BNII analyzer (Dade
Behring, Brussels, Belgium), and lipoprotein (a)
levels were measured by immunoturbidity.
Tracking and recording of adverse events
In addition to the collection of all clinical adverse
events, patients also completed the previously vali-
dated Gastrointestinal Symptom Rating Scale,15,16
which consists of five symptom clusters: reflux,
abdominal pain, constipation, diarrhea and
in­digestion. The scale ranges from 1 to 7 (least to
most severe symptoms).17
Liver function tests were done at each study
visit. In any patient who experienced an increase
in transaminase levels to more than three times
the upper limit of normal on two consecutive
occasions the study drug was discontinued, and
participants were followed up until trans­aminase
levels returned to baseline. These patients did not
enter the study again.
Data analyses
The primary data analyses were performed by an
independent statistician employed by the Data
Coordinating Center (PharmaNet, Princeton,
NJ). The investigators had complete access to the
primary data and the data analyses. Normally
distributed continuous variables are reported as
mean ± SD, and categorical variables as counts
august 2008 vol 5 no 8 samaha et al. 
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and percentages. Differences in continuous vari-
ables between treatment groups were assessed
by analysis of variance (ANOVA) and t-tests.
Within-group differences were assessed with
paired t-tests. Differences in categorical vari-
ables between treatment groups were assessed by
χ2 tests. All reported P values are two-tailed. All
patients who received at least one dose of study
drug or placebo in any group were included in the
analyses of drug safety and tolerability.
The efficacy analyses included all randomized
patients who completed the study. The primary
outcome of the study was percentage change in
LDL cholesterol from baseline after each of the
4-week treatment periods. This time frame was
based on expected maximum effects of ezetimibe
within 4 weeks18,19 and the known LDL-
­cholesterol-lowering effects of MTP inhibitors.14
Secondary outcomes were percentage changes in
other serum lipoproteins (total chol­­esterol, non-
HDL, VLDL, triglycerides, HDL cholesterol, lipo-
protein (a), apoB and apoA-I), change in body
weight and overall safety and tolerability.
Sample size estimates
The main comparison used for the sample size
was 10 mg ezetimibe alone versus 10 mg AEGR-
733 in combination with 10 mg ezetimibe. We
estimated that ezetimibe alone would produce
an ~18% decrease in LDL-cholesterol.19 Based on
data from an earlier unpublished phase I study; we
also estimated that the combination with AEGR-
733 would produce an additional 20% decrease
in LDL-cholesterol. We calculated, therefore, that
an enrollment target of 25 patients per group
with a 20% dropout rate would yield 90% power
(SD 19%). Significance was set at P = 0.05.
RESULTS
Patients
A total of 85 patients were enrolled and rando­
mized (28–29 in each treatment group). The
baseline characteristics of these patients are
summarized in Table 1. Sixty-seven patients
completed the study, 17 discontinued therapy
completely owing to adverse events and 1 was
lost to follow-up before final efficacy data were
obtained (Figure 1).
Effect of AEGR-733 on apolipoprotein B
levels
Patients assigned to the combination of ezetimibe
plus AEGR-733 experienced dose-dependent
reductions in LDL ranging from 35% to 46%
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Table 1 Baseline characteristics of all randomized patients.

Characteristic Ezetimibe (n = 29) AEGR-733 (10 mg) AEGR-733 (10 mg) plus
(n = 28) ezetimibe (n = 28)
Mean age (years) 54.7 ± 9.0 57.5 ± 7.2 55.1 ± 5.7
Sex (women, %) 62.1 46.4 50.0
Race (white, %) 75.9 78.6 64.3
Mean (SD) BMI (kg/m2) 28.6 ± 5.4 29.6 ± 5.4 29.6 ± 7
Mean (SD) baseline total cholesterol 6.3 ± 0.8 6.6 ± 1.0 6.4 ± 0.9
level (mmol/l)a
N with CAD risk factors (%)
Age >45 years (m) or >55 years (f) 18 (64.3) 22 (78.6) 23 (82.1)
Hypertension 8 (28.6) 12 (42.9) 10 (35.7)
Smoking 10 (35.7) 4 (14.3) 8 (28.6)
Family history of CHD 6 (21.4) 7 (25.0) 9 (32.1)
HDL-cholesterol level <40 mmol/la 2 (7.2) 3 (10.7) 1 (3.6)
N with CAD (%) 0 1 ( 3.6) 0
aToconvert to mg/dl divide by 0.0259. Abbreviations: CAD, coronary artery disease; CHD, coronary heart disease; f, female;
m, male; N, number of patients.

168 screened

85 enrolled

28 assigned AEGR-733 28 assigned AEGR-733 29 assigned ezetimibe

+ ezetimibe

4 discontinued 9 discontinued 4 discontinued

due to adverse due to adverse due to adverse
events events events and 1
lost to follow-up

24 completed 19 completed 24 completed

and included and included and included
in efficacy analyses in efficacy analyses in efficacy analyses

Figure 1 Study profile.

(Figure 2 and Table 2; P <0.001 versus ezetimibe
alone). Patients assigned ezetimibe mono-
therapy experienced a 20–22% decrease in
LDL-­cholesterol levels after 12 weeks of therapy
(Figure 2 and Table 2). Patients assigned to AEGR-
733 monotherapy experienced dose-dependent
reductions in LDL-cholesterol concentrations
ranging from 19% to 30% (Figure 2 and Table 2;
P = 0.013 for a greater LDL reduction with 10 mg
AEGR-733 alone versus 10 mg ezetimibe alone).
Patients receiving AEGR-733 monotherapy also
experi­enced dose-dependent decreases in concen-
trations of total cholesterol (23% at 10 mg), non-
HDL cholesterol (27% at 10 mg) and apoB (24%
at 10 mg); these reductions were all greater than
those observed with ezetimibe monotherapy
(Table 3). Further reductions in total cholesterol,
non-HDL cholesterol, and apoB levels were
observed in the group receiving combination
therapy (Table 3). Triglycerides did not change
significantly from baseline in any of the three
groups (Table 3). Patients receiving AEGR-733

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either alone or in combination with ezetimibe Time of study visit

0–4 weeks 4–8 weeks 8–12 weeks

Percentage change in LDL-cholesterol from baseline

experienced a significant decrease in lipoprotein 0–
(a) compared with those receiving ezetimibe
alone (Table 3). –10 –

Effect of AEGR-733 on apolipoprotein A –20 –

levels
Patients receiving AEGR-733, alone or with –30 –
ezetimibe, experienced decreases of 7% or more a
b
in HDL-cholesterol levels, which were signifi- –40 – a
cantly different from the 6% increase observed a,b c
a,d
with ezetimibe monotherapy (P < 0.001 for each –50 – a,c
between-group difference; Table 3). Similar d,e a,e
–60 –
changes in apoA-I were seen (Table 3).
EZ
–70 – AEGR
Changes in weight
EZ + AEGR
After 12 weeks, patients assigned ezetimibe
monotherapy experienced a mean weight loss Figure 2 Percentage change from baseline in LDL-cholesterol levels at each
of 0.2 ± 1.9 kg (0.1%); those assigned AEGR-733 of the study visits, by treatment group. Error bars represent SD of the mean.
aEZ versus EZ + AEGR, P<0.001. bAEGR versus EZ + AEGR, P<0.001. cAEGR
monotherapy experienced a mean weight loss of
versus EZ + AEGR, P = 0.015. dEZ versus AEGR, P = 0.016. eAEGR versus
0.7 ± 2.0 kg (1.0%); and those assigned combined EZ + AEGR, P = 0.013. Abbreviations: AEGR, AEGR-733; EZ, ezetimibe.
AEGR-733 plus ezetimibe experienced a mean
weight loss of 1.4 ± 2.6 kg (1.4%); only the latter
change was significant (P = 0.013). However,
the weight loss was not significantly different Table 2 Changes in LDL-cholesterol levels after 12 weeks of therapy.
in the combination group from that for the Mean (SD) LDL-cholesterol Mean (SD) values
group receiving ezetimibe alone. EZ AEGR-733 AEGR-733 (10 mg)
(10 mg) + EZ
Safety Baseline value (mmol/l)a 4.2 ± 0.7 4.4 ± 0.9 4.4 ±0.7
Of the 85 patients enrolled, 18 (20%) either 12-week value (mmol/l)a 3.3 ± 0.5 3.1 ± 0.9 2.3 ± 1.1
stopped or were taken off study medication
Percentage change (%) 20 ± 10 30 ± 15b 46 ± 24c,d
before completion of the study (Table 4), mainly
aTo convert to mg/dl divide by 0.0259. bsP = 0.015
for AEGR-733 alone versus ezetimibe
owing to mildly elevated transaminase levels. alone. cP = 0.013 for AEGR-733 plus ezetimibe versus AEGR-733 alone. dP < 0.001 for
This adverse event occurred in 9 of 56 (18%) AEGR-733 plus ezetimibe versus ezetimibe alone.
patients who took AEGR-733, either alone or
in combination with ezetimibe, compared with
none of the 29 patients assigned to ezetimibe
alone. Transaminase levels returned to baseline in LDL cholesterol, reaching a 30% reduction with
all these patients over the course of the protocol- 10 mg daily monotherapy and a 46% reduction
specified, 2-week follow-up. One patient in the when combined with 10 mg ezetimibe daily. Both
combined AEGR-733 plus ezetimibe group, and of these regimens provided significantly greater
two patients in each of the AEGR-733-only lowering effects than ezetimibe monotherapy.
and ezetimibe-only groups, dropped out of the Concentrations of other apo-B-containing lipo-
study because of gastrointestinal side effects proteins, including total cholesterol, non-HDL
(Table 4). The adverse effects were mild (mean cholesterol and lipoprotein (a), were similarly
gastro­intestinal symptom rating scores ≤2). reduced by AEGR-733.
Patients receiving AEGR-733 alone experienced Patients receiving AEGR-733 experienced
slightly more gastrointestinal symptoms, and a 5–9% reduction in HDL-cholesterol levels,
the severity was greater than in the other groups with corresponding reductions in apoA-I. This
only for constipation (P = 0.007; Table 4). effect is similar to that observed in two prior
studies of MTP-inhibitors.14,20 In a study
DISCUSSION of patients with homozygous familial hyper­
In this prospective, randomized trial AEGR- cholesterolemia AEGR-733 (studied as BMS-
733 provided a dose-dependent reduction in 201038) administered at higher doses than used
ncpcm_2007_294f2.eps
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Table 3 Changes in non-LDL lipids after 12 weeks of therapy.

Lipida Baseline valueb Final 12-week Percentage change P value P value between
valueb from baseline (%) within group groups vs ezetimibe
Total cholesterol (mmol/l)c
Ezetimibe 6.3 ± 0.8 5.5 ± 0.6 –12 ± 9 <0.001 NA
AGER-733 6.6 ± 1.0 5.1 ± 1.1 –23 ± 12 <0.001 0.002
Ezetimibe plus AGER-733 6.4 ± 0.9 4.2 ± 1.3 –34 ± 19 <0.001 <0.001
Triglycerides (mmol/l)d
Ezetimibe 1.4 (0.8–3.6) 1.5 (0.6–2.8) –4 NS NA
AGER-733 1.8 (0.5–2.7) 1.5 (0.6–3.2) –10 NS NS
Ezetimibe plus AGER-733 1.4 (0.5–2.5) 1.0 (0.7–3.4) –15 NS NS
HDL cholesterol (mmol/l)c
Ezetimibe 1.4 ± 0.3 1.5 ± 0.3 6 ± 10 0.006 NA
AGER-733 1.3 ± 0.4 1.3 ± 0.4 –6 ± 11 0.017 <0.001
Ezetimibe plus AGER-733 1.4 ± 0.3 1.2 ± 0.3 –9 ± 14 0.003 <0.001
Non-HDL cholesterol (mmol/l)c
Ezetimibe 4.9 ± 0.8 4.0 ± 0.6 –17 ± 11 <0.001 NA
AGER-733 5.2 ± 0.9 3.8 ± 0.9 –27 ± 15 <0.001 0.013
Ezetimibe plus AGER-733 5.1 ± 0.8 3.0 ± 1.2 –41 ± 23 <0.001 <0.001
Apolipoprotein B (g/l)
Ezetimibe 1.5 ± 0.2 1.3 ± 0.2 –15 ± 11 <0.001 NA
AGER-733 1.6 ± 0.3 1.2 ± 0.3 –24 ± 14 <0.001 0.021
Ezetimibe plus AGER-733 1.5 ± 0.2 1.0 ± 0.3 –37 ± 22 <0.001 <0.001
Apolipoprotein A-I (g/l)c
Ezetimibe 1.7 ± 0.3 1.8 ± 0.3 2 ± 10 NS NA
AGER-733 1.7 ± 0.3 1.5 ± 0.2 –8 ± 12 0.009 0.004
Ezetimibe plus AGER-733 1.7 ± 0.2 1.5 ± 0.3 –11 ± 16 0.001 0.001
Lipoprotein (a) (μmol/l)
Ezetimibe 0.5 (0.1–2.0) 0.6 (0.1–2.5) 3 NS NA
AGER-733 1.0 (0.1–4.6) 0.9 (0.1–4.3) –17 0.045 0.033
Ezetimibe plus AGER-733 0.9 (0.1–3.3) 0.8 (0.3–1.3) –16 0.026 0.013
aAllAGER-733 values relate to 10 mg dose. bValues are provided as mean ± SD, except triglycerides and lipoprotein (a), which were nonparametrically distributed
and are thus given as median (range). Change in non-HDL: AG + EZ vs AG, P = 0.022; Change in apoB: EZ + AG vs AG, P = 0.035. cTo convert to mg/dl divide by
d
0.0259. To convert to mg/dl divide by 0.0133. Abbreviations: NA, not applicable; NS, not significant.

here produced approximately a 10% decrease in
HDL-­cholesterol; however, this effect was only
observed with the lowest dose of BMS-201038.14
In another study, CP-346086 (30 mg/day; Pfizer,
Groton, CT), also produced approximately a
10% decrease in HDL-cholesterol levels after
14 days of treatment.20 The decrease in HDL-
cholesterol concentrations caused by MTP-
inhibition might be attributable to at least three
potential mechanisms: first, low-fat diets are
known to reduce HDL-­cholesterol levels,21,22
and MTP inhibition might reduce intestinal
fat absorption, thus potentially mimicking the
effects of a low-fat diet; second, MTP inhibition
could directly reduce the secretion of apoA-I
from the intestine, liver, or both, through an
unknown mechanism; and third, patients with
abetalipo­proteinemia have increased catabo-
lism of apoA-I,23 which suggests that MTP
inhibition promotes this effect. Further work is
necessary to define the mechanisms by which
MTP inhibi­­tion reduces HDL-cholesterol,

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Table 4 System-specific adverse events.

MedDRA system organ class Ezetimibe only AEGR-733 only P value for AEGR-733 plus P value for
(n= 29) (n = 28) AEGR-733 ezetimibe (n = 28) AEGR-733 plus
vs ezetimibe ezetimibe
vs ezetimibe
Transaminase elevation 0 9 (32%) 0.001 9 (32%)a 0.001
Any adverse event 16 (55.2%) 24 (85.7%) 0.018 24 (85.7%) 0.018
GI disorders 11 (37.9%) 18 (64.3%) NS 12 (42.9%) NS
Infectionsb 4 (13.8%) 3 (10.7%) NS 8 (28.6%) NS
Musculoskeletal 4 (13.8%) 1 (3.6%) NS 3 (10.7%) NS
Respiratory, thoracic and mediastinal 1 (3.4%) 1 (3.6%) NS 3 (10.7%) NS
disorders
General disordersc 1 (3.4%) 1 (3.6%) NS 2 (7.1%) NS
Nervous system disorders 3 (10.3%) 1 (3.6%) NS 0 NS
Injury 0 2 (7.1%) NS 1 (3.6%) NS
Cardiac 0 2 (7.1%) NS 0 NS
Skin & subcutaneous tissue disorders 1 (3.4%) 0 NS 1 (3.6%) NS
Psychiatric disorders 0 0 NS 1 (3.6%) NS
Renal and urinary disorders 0 1 (3.6%) NS 0 NS
Vascular disorders 0 1 (3.6%) NS 0 NS
Mean (SD) GSRS (1–7)
Diarrhea 1.1 ± 0.2 1.9 ± 1.2 – 1.5 ± 1.3 –
Indigestion 1.5 ± 0.7 1.9 ± 1.3 – 1.4 ± 0.6 –
Constipation 1.3 ± 0.5 1.8 ± 1.0d – 1.2 ± 0.4 –
Abdominal pain 1.3 ± 0.5 1.5 ± 0.8 – 1.3 ± 0.3 –
Discontinuations due to adverse events
Any 4 (13.8%)a 9 (32.1%) NS 4 (14.3%)e NS
GI 2 2 NS 1 NS
Transaminase elevation 0 6 NS 3 NS
Creatinine elevation 1 0 NS 0 NS
Musculoskeletal 1 0 NS 1 NS
Nervous system 1 0 NS 0 NS
Vascular 0 1 NS 0 NS
aOne participant had two adverse events—nausea (listed under GI disorders) and dizziness (listed under nervous system disorders)—identified as leading to
study drug discontinuation. bIncludes any infection. cIncludes chest pain, fatigue, and pyrexia. Cardiac disorders were a myocardial infarction and bradycardia.
The only vascular event was deep vein thrombosis. The only injury was accidental thermal skin burn. dP = 0.007. eOne participant had two adverse events—
diarrhea (listed under GI disorders) and cramps (listed under musculoskeletal)—identified as leading to discontinuation. Abbreviations: GI, gastrointestinal;
GSRS, Gastrointestinal Symptom Rating Scale; NS, not significant.

and whether this effect has clinical implica-
tions. Given the association between low HDL-
cholesterol and increased risk of cardiovascular
events, such a decrease as we observed could be a
serious drawback to MTP-inhibitor therapy. An
appropriately designed outcomes study would
be essential to answer the question of whether
the additional LDL lowering obtained with
MTP inhibition would outweigh any poten-
tial adverse effect associated with a decrease in
HDL-cholesterol level.
The investigators observed a 72% reduc-
tion in LDL-cholesterol and a 75% reduction
in triglyceride levels in patients administered
CP-346086.20 This reduction in LDL-cholesterol
is considerably greater than the one we observed
with the highest dose of AEGR-733 (30%).
Moreover, we saw no change in triglyceride
levels with MTP inhibition. The different effects
on plasma LDL and triglycerides might relate
to differences in dose or timing. With regard to
dose, increases in hepatic and intestinal tri­­
glyceride content have been shown to correlate
with plasma lipid lowering.20 By using low-dose
MTP inhibition to minimize intestinal and liver
fat accumulation, we might also have minimized

august 2008 vol 5 no 8 samaha et al.  nature clinical practice cardiovascular medicine 503
CLINICAL r e s e a r c h
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the ability of AEGR-733 to lower triglyceride
levels. The use of CP-346086 in the previous
study was associated with a higher incidence of
gastrointestinal side-effects.20 Furthermore, in
animal models a 2.9-fold increase in intestinal
triglycerides and a 3.6-fold increase in hepa­
­tic triglycerides have been shown at doses of
CP-346086 equivalent to those in human
studies.20 With regard to timing, we measured
fasting triglyceride levels, and, as previously
demonstrated, the greatest effect seems to occur
on postprandial triglyceride elevation due to
intestinal MTP inhibition.20
Changes in weight observed with combina-
tion therapy could be a result of reduced fat
absorption caused by MTP inhibition, which
is an established mechanism for other weight
loss drugs.24 AEGR-733 was fairly well toler-
ated from a gastrointestinal standpoint. MTP is
required for chylomicron assembly and secre-
tion and, therefore, inhibition of the protein
could potentially cause steatorrhea. To minimize
the possibility of gastrointestinal side effects due
to MTP inhibition, we instructed all patients to
follow a diet containing less than 20% fat. In
addition, we used low doses of AEGR-733 and
titrated the dose, in order to allow the intestine
to become accustomed to inhibition of MTP.
In our study, 16% of the patients administered
AEGR-733, either alone or in combination with
ezetimibe, and none of the patients administered
ezetimibe alone discontinued study drugs due
to rises in aminotransferase levels. We do not
know whether any of these patients would have
experienced resolution or further worsening of
transaminase elevation with continued use of
AEGR-733, but transaminase levels returned to
baseline in all these patients. No patients exhib-
ited elevations in bilirubin, a marker of acute
hepatotoxic effects, or experienced overt hepatic
dysfunction. Most patients in this study (82%)
did not experienced transaminase elevation,
suggesting that at these doses patients might be
able to use MTP inhibitors without experiencing
transaminase elevation.
More of the patients taking AEGR-733 than
of those given combination therapy experienced
transaminase elevation. This outcome might
be spurious and we can only speculate on a
mechanism by which this could have occurred.
The primary lipid-lowering effect of ezetimibe
is thought to be attributable to inhibition of
the intestinal Niemann-Pick C1–like 1 lipid
transporter. This transporter is, however, also
504 nature clinical practice cardiovascular medicine
expressed in human liver, where it facilitates
cholesterol uptake and thus allows the reten-
tion of biliary cholesterol by hepatocytes,25 and
ezetimibe disrupts this process.25 This effect
could, theoretically protect against hepatic lipid
accumulation when ezetimibe is combined with
an MTP inhibitor. Further studies that measure
hepatic lipid accumulation would be required
to test this.
Our study has some limitations. First, it was
relatively short, and longer-term trials will be
needed to fully address the durability of the
LDL-cholesterol-lowering effect, the ability of
patients to maintain drug adherence over time,
and the safety profile with longer term use.
Second, the patients in our study followed a low-
fat diet; the efficacy and tolerability of the MTP
inhibition could differ in patients following
higher-fat diets. Although several animal studies
have shown that MTP inhibition protects
against atherosclerosis,26–28 a beneficial effect of
LDL-cholesterol-lowering, by MTP inhibition,
on atherosclerotic cardiovascular disease has not
yet been demonstrated in humans. Assessment
of the risk-to-benefit ratio for MTP inhibitors,
in patients at different levels of cardiovascular
disease risk, will be needed before clinical use of
this class of drugs can be recommended.
Nevertheless, based on our findings, we envi-
sion a potential role for MTP inhibition alone
or in combination with other lipid-lowering
therapies (e.g. ezetimibe) for patients who
are statin intolerant. Furthermore, trials are
underway to investigate a potential role for MTP
inhibition in patients who have been unable to
achieve LDL-cholesterol target levels on statin
therapy alone. The use of MTP inhibition in
statin-intolerant patients with insulin resist-
ance, type 2 diabetes mellitus, or both, might
also be appropriate. Given the neutral effect
on triglyceride levels and the small decrease in
HDL-­cholesterol levels we observed, however,
we suggest caution in these patients. The higher
incidence of transaminase elevation and the
potential mechanism by which this might occur
(e.g. hepatic fat accumulation) suggest that
patients with nonalcoholic fatty liver disease
should not be treated with MTP inhibitors
unless data from future studies show that this
can be done safely. In summary, MTP inhibition
with AEGR-733 might offer a treatment option
for patients who cannot tolerate statin therapy
or who experience insufficient LDL lowering
with currently available therapies.
samaha et al. august 2008 vol 5 no 8

KEY POINTS
■ Many patients with coronary heart disease
cannot achieve current target levels for LDL-
cholesterol owing to either intolerance or
inadequate response to conventional lipid-
lowering therapy; new treatment strategies are
required
■ A possible therapeutic approach is inhibition of
microsomal triglyceride transfer protein, which
is essential for the assembly and secretion of
apolipoprotein-B-containing lipoproteins
■ AEGR-733, alone and in combination with
ezetimibe, had notable LDL-cholesterol-
lowering effects in patients with hyperlipidemia
■ The main side effect associated with AEGR-733
was elevation in transaminase concentrations,
which returned to baseline values after
cessation of therapy; gastrointestinal side
effects were minor
■ Low-dose microsomal triglyceride transfer
protein inhibitors, alone or in combination with
ezetimibe, could be an effective therapeutic
option for patients unable to reach target LDL
levels with conventional therapy
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Clinical context
See the accompanying Clinical Context article by
Joy and Hegele. [doi:10.1038/ncpcardio1251]
nature clinical practice cardiovascular medicine 505