Hyperlipidemia

Fatty liver diseases

Advanced Pharmacology BBMS3014

Connie Woo PhD RPh

Department of Pharmacology and Pharmacy
[email protected]
Hyperlipidemia
What is hyperlipidemia?
What is hypercholesterolemia?
What is hypertriglyceridemia?
What are the differences?

Lipid metabolism and trafficking

Drug Targets
Clinical solution
Lipids

http://physwiki.ucdavis.edu/Wikitexts/UCD_BPH241/Lipid_Headgroup_Types
 Lipids

Fatty Acids Glycerides

Saturated Unsaturated Neutral Phospho

Glycerides Glycerides

Non-glyceride lipids
Complex lipids
Sphingolipids Steroids Waxes

Lipoproteins
Sphingomyelins Glycolipids
Lipid Metabolism
Absorption
Synthesis
Repackaging
Transport
Storage
Utilization
Absorption
 Lipids are not absorbed
in an unchanged form
 They are first broken
down in smaller
molecules in the
intestinal lumen via
different lipases,
followed by the
absorption into
enterocyte
 Lipids then are
repackaged for secretion Nature Reviews Drug Discovery 3, 695-710, 2004
and absorbed through Dietary lipid digestion begins in the stomach, where lipids are subjected to partial digestion by
the lymph. gastric lipase and form large fat globules with hydrophobic triacylglycerol (TAG) cores
surrounded by polar molecules, including phospholipids (PLs), cholesterol (CL), fatty acids (FAs)
and ionized proteins. Bile salts (BS), Monoacylglycerol (MAG), diacylglycerol (DAG),
lysophosphatidic acid (LPA), intestinal FA-binding protein (IFABP), FA-transport protein-4
(FATP4), MAG acyltransferase (MGAT), diacylglycerol acyltransferase (DGAT), 1-acyl-glycerol-3-
phosphate acyltransferase (AGPAT), phosphatidic acid (PA), acyl-CoA:cholesterol acyltransferase
(ACAT), cholesterol esters (CE), microsomal triglyceride transfer protein (MTP), apolipoprotein B
(ApoB), chylomicrons (CM)
Absorption (con’t)
 Lipids are insoluble in water
 In stomach, lipids are in oily phase
 In duodenum and small intestine, lipids are emulsified with
the aid of bile acids
 The emulsion droplets are digested by lipolytic enzymes
 The digested lipids form small molecular aggregates, known
as micelles, with bile acids
 Micelles are absorbed through intestinal brush border
Absorption (con’t)
 Need to breakdown lipids before absorption as micelles
 Stomach (minor):
 preduodenal lipase
 Gastric lipase
 Small Intestine (major):
 Pancreatic lipolytic enzymes
 Glycerol ester hydrolyase (Pancreatic lipase): breakdowns TAG to 2 FA and 1
monoglyceride
 Colipase: relieves the inactivation of lipase by bile salts, displaces bile salt and binds to
pancreatic lipase
 Cholesterol ester hydrolase: yield free cholesterol and FA
 Phospholipase A: breakdown glycerophosphatides, e.g. cleaves phosphatidylcholine to
FA and lysophosphatidylcholine
Absorption (con’t)
 Duodenum and jejunum are the most active sites in fat absorption
 Lipids are uptaken by intestinal epithelial cells
 FA, 2-monoglycerides, cholesterol and lysolecithin easily diffuse
across membrane due to lipid solubility
 Long chain fatty acids, however, need carrier to cross the brush
border
 MVM-FABP: microvillous membrane fatty acid-binding protein
 Cholesterol: only 50% is absorbed
 Can be by simple diffusion or;
 Mediated by ABC transport protein (ATP-binding cassette)

 Cytosolic transporters: I-FABP and L-FABP, SCP-1 and SCP-2 (Sterol

carrier protein)
Absorption (con’t)
• Resynthesis/repackaging of lipids in smooth endoplasmic
reticulum

UC, unesterfied cholesterol

NPC1L1, Niemann-Pick C1–like 1 protein
Sito, Sitosterol J Clin Invest. 2008;118(10):3247-3259.
PC, phosphotidycholine
APOBEC1, APOB mRNA editing complex–1
MTP, microsomal triglyceride transfer protein
ACAT2, acyl-CoA:cholesterol acyltransferase–2
SAR1B, Secretion Associated, Ras Related GTPase 1B
Synthesis: Cholesterol
Liver

Nature Reviews Drug Discovery 2, 517-526, 2003

Synthesis: Fatty acids

ACACA=acetyl-CoA carboxylase, i.e. ACC

Nature Reviews Cancer 7, 763-777, 2007
Transport
Lipid cannot be transported in a aqueous environment, therefore, its transport
requires carrier > Lipoproteins

Nature Reviews Drug Discovery 7, 84-99, 2008

Types of lipoprotein
 Chylomicron
 VLDL, very low density lipoprotein
 LDL, low density lipoprotein
 HDL, high density lipoprotein

Nature Reviews Cardiology 10, 648–661 (2013)

Transport: Apolipoproteins
Transport
Liver/Intestine to peripheral
• Chylomicron (CM) is
responsible for the transport
of lipid from intestine to
peripheral
• In circulation, CM undergoes
digestion of lipases and
majority of TAG breaks down
to FA, CM now is converted to
CM remnant which will be
uptaken by liver via LDLR for
recycling the components
• Liver packages lipids into VLDL
released it into circulation
which provides lipids to the
peripheral
Transport
Molecular repackaging

Physiological Reviews 2012, 92: 1061-1085

Transport
Exogenous
Endogenous

Nature Genetics 40, 129 - 130 (2008)

Transport
Cholesterol Reverse Transport

Nature Reviews Cardiology 6, 455-463 (July 2009)

LCAT, Lecithin cholesterol acyltransferase

CETP, Cholesteryl ester transfer protein
EL, endothelial lipase
Absorption + Transport
Storage:
Adipose tissue

ATGL, Adipose triglyceride lipase Physiology 2013, 28: 117-124

PLIN1, Perilipin-1
HSL, hormone sensitive lipase
 Storage:
Signal to Lipogenesis

PAP: ohydrolase
MGAT: MAG acyltransferase
TIP47: tail-interacting protein of 47 kDa
PER: perilipin
ADRP: Adipose differentiation-related protein
HSL: Hormonal Sensitive lipase
AGPAT: sn-1-acylglycerol-3-phosphate acyltransferase
Nature Reviews Drug Discovery 3, 695-710 , 2004
GPAT: phosphatidic-acid phosphglycerol-3-phosphate acyltransferase
 Utilization
Lipolysis (released from storage)

PDE, Phosphodiesterase
MGL, monoacylglycerol lipase
Utilization
β-oxidation (peripheral use)

© 2010 Nature Education All rights reserved

FACS, Fatty-acyl-CoA Synthase
CPT, Carnitine palmitoyltransferase
CT, Carnitine transporter
UCP, uncoupling protein
Physiological Reviews 2010,90: 207-258 MTE, mitochondrial thioesterase-1
Hyperlipidemia
Hypercholesterolemia
Hyperlipidemia
Hypertriglyceridemia
What is hyperlipoprotemia?
Conditions with abnormally elevated levels of LIPOPROTEINS

• Type I: An inherited condition due to a deficiency of either

LIPOPROTEIN LIPASE or APOLIPOPROTEIN C-II (a lipase-activating
protein). The lack of lipase activities results in inability to remove
CHYLOMICRONS and TRIGLYCERIDES from the blood which has a
creamy top layer after standing.
 Type II: A group of familial disorders characterized by elevated circulating
cholesterol contained in either LOW-DENSITY LIPOPROTEINS alone or also
in VERY-LOW-DENSITY LIPOPROTEINS (pre-beta lipoproteins).
 Type III: An autosomal recessively inherited disorder characterized by the
accumulation of intermediate-density lipoprotein (IDL or broad-beta-
lipoprotein). IDL has a CHOLESTEROL to TRIGLYCERIDES ratio greater than
that of VERY-LOW-DENSITY LIPOPROTEINS. This disorder is due to
mutation of APOLIPOPROTEINS E, a receptor-binding component of VLDL
and CHYLOMICRONS, resulting in their reduced clearance and high plasma
levels of both cholesterol and triglycerides.
 Type IV: A hypertriglyceridemia disorder, often with autosomal dominant
inheritance. It is characterized by the persistent elevations of plasma
TRIGLYCERIDES, endogenously synthesized and contained predominantly in
VERY-LOW-DENSITY LIPOPROTEINS (pre-beta lipoproteins). In contrast, the
plasma CHOLESTEROL and PHOSPHOLIPIDS usually remain within normal
limits.
 Type V: A severe type of hyperlipidemia, sometimes familial, that is
characterized by the elevation of both plasma CHYLOMICRONS and
TRIGLYCERIDES contained in VERY-LOW-DENSITY LIPOPROTEINS. Type
V hyperlipoproteinemia is often associated with DIABETES MELLITUS
and is not caused by reduced LIPOPROTEIN LIPASE activity as in
HYPERLIPOPROTEINEMIA TYPE I.

Q: Is there any therapeutic options to target specific type?

Why?

What are our “off-target” options?

Hypercholesterolemia
1. Statins
2. Bile acid sequentrants
3. Cholesterol
absorption inhibitors

Nature Reviews Genetics 10, 109-121

Hypertriglyceridemia
1. Fibrate
2. Niacin
3. Omega-3 fatty acid

Am J Physiol- Renal 287: F90-F94, 2004

Nature Reviews Drug Discovery 6, 231-248, 2007

Lipid metabolism and sites of action of lipid-modifying drugs

Nature Reviews Cardiology 10, 560-570, 2013

Lomitapide
 microsomal triglyceride transfer protein (MTP) inhibitor used in homozygous
familial hypercholesterolemia patients
 Within the lumen of the endoplasmic reticulum, it inhibits microsomal
triglyceride transfer protein (MTP), which prevents the formation of
apolipoprotein B, and, thus, the formation of VLDL and chylomicrons as well.
Altogether, this leads to a reduction of low-density lipoprotein cholesterol.
 marketed under the name Juxtapid®
 Also a CYP450 3A4 Inhibitor, and P-Glycoprotein Inhibitor

Mipomersan
 was known as the investigational drug, isis-301012, is the salt form of a
synthetic phosphorothioate oligonucleotide
 binds to the mRNA that codes for apoB-100. This binding leads to double-
stranded RNA, which is degraded by RNase H and prevents translation of the
mRNA to form the apo B-100 protein
 Resulting in a decrease in the levels of apolipoprotein B (apo B), low density
lipoprotein (LDL), and total cholesterol.
 indicated in patients with homozygous familial hypercholesterolemia as an
adjunct to diet and other lipid-lowering medications.
 Black box warning of hepatoxicity
 Only available to patients under the restricted program called Kynamro™ Risk
Evaluation and Mitigation Strategy program.
 http://www.athero.org/commentaries/comm1125.asp

What are the future targets?

Fatty Liver/Hepatic Steatosis
 Fatty liver diseases accumulation of lipid in liver
 Non-alcoholic
 Extra energy is stored as lipid and the primary organ to do so is adipose
tissue. In the situation, adipose tissue fails to store all the extra lipid, it
will start accumulation in other places for example, liver etc.
 Hardly diagnosed
 Risk factors
 Gastric bypass surgery
 High cholesterol
 High levels of triglycerides in the blood
 Metabolic syndrome
 Obesity
 Polycystic ovary syndrome
 Sleep apnea
 Type 2 diabetes
 Underactive thyroid (hypothyroidism)
 Underactive pituitary gland (hypopituitarism)
 Alcoholic
 Alcohol consumption
Non-alcoholic Fatty Liver Diseases
Morphology

a | Healthy liver. b | Nonalcoholic fatty liver disease; steatohepatitis is absent but prominent
macrovesicular steatosis can be seen. c | Nonalcoholic steatohepatitis with notable
ballooned hepatocytes, an elevated immune response and collagen deposition indicative of
fibrosis.
Nature Reviews Gastroenterology & Hepatology 8, 35-44, 2011
Types of NAFLD by histology and outcome
Category Histology Outcome
Type 1 steatosis only non-progressive
Type 2 steatosis plus lobular inflammation benign course
steatosis, lobular inflammation and NASH without fibrosis, may
Type 3
ballooning degeneration progress to cirrhosis
steatosis, ballooning degeneration with NASH, may progress to
Type 4
Mallory bodies and/or fibrosis cirrhosis
Watts, G. F. et al. (2013) Demystifying the management of hypertriglyceridaemia
Nat. Rev. Cardiol. doi:10.1038/nrcardio.2013.140
 Nat Clin Pract Endocrino Metabol 2: 335–34, 2006

Approximately 60–80% of hepatocellular lipids derive from the circulation, mainly originating from subcutaneous fat.
Chronic overnutrition and hyperinsulinemia in obesity will increase the contribution of de novo lipogenesis and thereby
augment the cellular pool of activated fatty acids (long-chain fatty acids bound to coenzyme A). According to the
hypothesis of defective mitochondrial function in insulin-resistant states, fatty-acid oxidation would be reduced,
rendering more long-chain fatty acids bound to coenzyme A available for lipoprotein synthesis and secretion, which was
found to be reduced in patients with nonalcoholic steatohepatitis. Subsequently, flux of hepatocellular fatty acids would
be directed into storage of any excess of triglycerides, leading to elevated levels of hepatocellular lipids.
ChREBP, carbohydrate response element binding protein; CM rem, chylomicron remnants; DNL, de novo lipogenesis;
FACoA, long-chain fatty acids bound to coenzyme A; FFA, free fatty acids; SC, subcutaneous; SREBP-1, sterol regulatory
element-binding protein 1; TG, triglycerides; VLDL, very low density lipoproteins.
The ‘integrated response’ hypothesis of nonalcoholic fatty liver disease pathogenesis:
current concepts of tissue crosstalk that can promote hepatic steatosis and
inflammation

Hebbard, L. & George, J. (2010) Animal models of nonalcoholic fatty liver disease
Nat. Rev. Gastroenterol. Hepatol. doi:10.1038/nrgastro.2010.191

2nd Hit: Inflammation

Novel inflammatory factors associated with nonalcoholic fatty liver disease based on
the results of animal models

Hebbard, L. & George, J. (2010) Animal models of nonalcoholic fatty liver disease
Nat. Rev. Gastroenterol. Hepatol. doi:10.1038/nrgastro.2010.191
What is the source of the inflammation?
 Adipose tissue inflammation (Adipocytes)

A high-fat diet is associated with the activation of immune cells, their migration into adipose
tissues and decreased adipocyte production of adiponectin and Sfrp5. The activated immune cells
secrete proinflammatory factors that act on adipocytes, which in turn amplify the inflammatory
response through the release of TNF and IL-6.
IL-6, interleukin 6; SFRP5, secreted frizzled-related protein 5; TNF, tumor necrosis factor.
What is the source of the inflammation?
 Gut microbiota (direct and indirect)

Nature Reviews Gastroenterology & Hepatology 7, 691-701, 2010

“Beer belly” and Metabolic Syndrome

Ther Clin Risk Manag. 2007 Dec; 3(6): 1153–1163.

Treatment for NAFLDs
 No direct treatment
 Indirectly prevent disease progression to fatal
steatoheptitis or cirrhosis (anti-inflammatory and anti-
oxidant approach)
 Risk factors and life-style

Nonconventional therapies
 Vitamin E
 Coffee
 Milk Thistle
 Essential phospholipids
Unknown or inconclusive Effectiveness
Summary of interventions in NAFLD
Against Steatosis and Insulin Resistance
 Weight loss
 Bariatric surgery
 Orilstat
 Pioglitazone
 Metformin
 Statin
Apoptosis
 Ursodiol
Oxidative stress
 Vitamin E
Anti-cytokines
 Pentoxifylline
 Vitamin E
 A daily dose of 800 IU for non-diabetic people
 Antioxidant effect to prevent further damage
 some evidence: benefit children with liver disease
 More evidence is needed
 Coffee
 In one study, people with nonalcoholic fatty liver disease who reported drinking coffee
had less liver damage than those who drank little or no coffee.
 It's not clear how coffee may influence liver damage or how much coffee to drink in
order to benefit
 Milk Thistle
 Silymarin
 Anti-inflammatory effect
 Membrane-stabilizing and antioxidant activity
 Result is controversy
 Essential phospholipids
 Normalized cytochrome oxidase activity
 improved hepatic mitochondrial respiration and potential
 decreased hepatic fat accumulation
 Reduced oxidative stress by the inhibition of free radical generation via CYP2E1 [3, and
products of peroxynitrite hepatotoxicity
 decreased LDL-peroxidation
Milk Thistle (Silybin)
Alcoholic Fatty Liver Disease
Forms of Alcoholic Liver Disease
Parameter Fatty Liver Alcoholic Hepatitis Cirrhosis
Histologic
specificity No No No
for alcoholic cause
Prognosis Excellent Variable Guarded
Reversible? Yes Variable Generally no

• Fatty liver, which occurs after acute alcohol ingestion, is generally reversible with abstinence.
• Alcoholic hepatitis is an acute form of alcohol-induced liver injury that occurs with the consumption of a
large quantity of alcohol over a prolonged period of time; it encompasses a spectrum of severity ranging
from asymptomatic derangement of biochemistries to fulminant liver failure and death.
• Cirrhosis involves replacement of the normal hepatic parenchyma with extensive thick bands of fibrous
tissue and regenerative nodules, which results in the clinical manifestations of portal hypertension and
liver failure
 2 main pathways of alcohol metabolism:
Alcohol dehydrogenase
Cytochrome P-450 (CYP) 2E1.

Schematic representation of lipid biosynthesis from D-glucose metabolism in the procyclic form of T. brucei. Black arrows represent enzymatic steps of D-glucose
metabolism, and excreted end products are boxed. Dashed arrows indicate steps, which are supposed to occur at a background level or not at all. The enzymes
targeted by RNAi are indicated by a boxed number. De novo lipid biosynthesis is schematically represented by double line arrows. The glycosomal compartments, the
mitochondrial compartment and the tricarboxylic acid cycle (TCA) are indicated. Abbreviations: AcCoA, acetyl-CoA; Cit, citrate; DHAP, dihydroxyacetone phosphate;
G3P, glycerol 3-phosphate; KG, 2-ketoglutarate; MAL, malate; PEP, phosphoenolpyruvate; Pyr, pyruvate. Indicated steps are: 1, citrate synthase (CS); 2, citrate
transporter or citrate/malate exchanger; 3, citrate lyase (CL); 4, acetate:succinate CoA-transferase (ASCT); 5, unknown enzyme; 6, passive diffusion or acetate carrier;
7, “AMP-forming” acetyl-CoA synthetase (AceCS).
Rivière L et al. PNAS 2009;106:12694-12699
Alcohol Content of Some Common Beverages

Drink Amount (oz) Absolute Alcohol (g)

Beer 12 12

Wine 5 12

Liquor (80 proof) 1.5 12

• 1 in 5 heavy drinkers develops alcoholic hepatitis, and 1 in 4 develops cirrhosis

(influenced by many factors, including genetic factors e.g. predilection to alcohol
abuse, gender, and environmental factors e.g. availability of alcohol, social
acceptability of alcohol use, concomitant hepatotoxic insults)
• A clear dose-dependent relation between alcohol intake and the incidence of
alcoholic cirrhosis. A daily intake of more than 60 g of alcohol in men and 20 g in
women significantly increases the risk of cirrhosis.
• Liver damage occurs through several interrelated pathways. Alcohol
dehydrogenase and acetaldehyde dehydrogenase cause the reduction of
nicotinamide adenine dinucleotide (NAD) to NADH (reduced form of NAD). The
altered ratio of NAD/NADH promotes fatty liver through the inhibition of
gluconeogenesis and fatty acid oxidation
• CYP2E1, which is upregulated in chronic alcohol use, generates free radicals
through the oxidation of nicotinamide adenine dinucleotide phosphate (NADPH)
to NADP.
• Chronic alcohol exposure also activates hepatic macrophages, which then produce
tumor necrosis factor-alpha (TNF-alpha).
• TNF-alpha induces mitochondria to increase the production of reactive oxygen
species.
• This oxidative stress promotes hepatocyte necrosis and apoptosis, which is
exaggerated in the alcoholic who is deficient in antioxidants such as glutathione and
vitamin E.
• Free radicals initiate lipid peroxidation, which causes inflammation and fibrosis.
Inflammation is also incited by acetaldehyde that, when bound covalently to cellular
proteins, forms adducts that are antigenic.
Physical Examination and Laboratory Findings In Alcoholic Liver Disease
Physical Examination
Constitutional •Fever
•Spider angioma
•Parotid and lacrimal gland enlargement
•Palmer erythema
Skin
•Jaundice
•Decreased body hair
•Gynecomastia
•Dupuytren’s contracture
Musculoskeletal •Clubbing
•Muscle wasting
Genitourinary •Testicular atrophy
•Hepatomegaly or small shrunken liver
•Splenomegaly
Abdomen
•Ascites
•Hepatic tenderness
•Asterixis
Neurologic
•Confusion, stupor
Laboratory Findings
•Hyperbilirubinemia (usually conjugated)
Liver synthetic function •Prolonged prothrombin time
•Hypoalbuminemia
•Aspartate aminotransferase and alanine
Liver enzyme levels aminotransferase levels elevated,
usually < 300 U/L; AST/ALT ratio ~ 2:1
•Anemia
•Leukocytosis or leukopenia
Hematologic
•Thrombocytopenia
•Increased serum globulin levels
•Elevated blood ammonia level
•Hyperglycemia
•Respiratory alkalosis
Metabolic •Hypomagnesemia
•Hypophosphatemia
•Hyponatremia
•Hypokalemia
Treatments for AFLD
Stop Drinking!!
 Supportive care for all patients includes adequate nutrition. Almost
all patients with alcoholic hepatitis have some degree of
malnutrition
 The use of corticosteroids as specific therapy for alcoholic hepatitis
has generated a good deal of interest. The rationale behind this
approach is the possible role of the immune system in initiating and
perpetuating hepatic damage. However, applicability of these study
findings is limited.
 Other therapies that have been investigated in the treatment of
alcoholic hepatitis but not found to be beneficial include
propylthiouracil; infliximab; insulin and glucagon; calcium channel
blockers; antioxidants such as vitamin E, S-adenosyl-L-methionine
(SAMe), or silymarin.

Psychological therapy also helps.

Atherosclerosis vs Fatty Liver Diseases

 Are there any conflict of therapeutic approach these diseases?

 What are the challenge about the drug design?

 Are there any common paths? Is it possible to be a drug target?

 What happens if someone having insulin resistance/metabolic

syndrome/diabetes is also with atherosclerosis and cardiovascular
disease?

Something researchers need to think of….