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Original Investigation |

Efficacy and Tolerability of Evolocumab vs Ezetimibe in Patients With Muscle-Related Statin Intolerance The GAUSS-3 Randomized Clinical Trial

Steven E. Nissen, MD1; Erik Stroes, MD, PhD2; Ricardo E. Dent-Acosta, MD3; Robert S. Rosenson, MD4; Sam J. Lehman, MBBS, PhD5; Naveed Sattar, MD, PhD6; David Preiss, MD7,8; Eric Bruckert, MD9; Richard Češka, MD10,11; Norman Lepor, MD12; Christie M. Ballantyne, MD13; Ioanna Gouni-Berthold, MD14; Mary Elliott, MS3; Danielle M. Brennan, MS1; Scott M. Wasserman, MD3; Ransi Somaratne, MD, MBA3; Rob Scott, MD3; Evan A. Stein, MD, PhD15 ; for the GAUSS-3 Investigators
[+] Author Affiliations
1Cleveland Clinic, Cleveland, Ohio
2University of Amsterdam Faculty of Medicine, Amsterdam, the Netherlands
3Amgen Inc, Thousand Oaks, California
4School of Medicine at Mount Sinai, New York, New York
5Flinders University, Bedford Park, SA, Australia
6University of Glasgow, Glasgow, United Kingdom
7Clinical Trial Service Unit, University of Oxford, Oxford, United Kingdom
8Epidemiological Services Unit, University of Oxford, Oxford, United Kingdom
9University Hospital of Paris 6, Paris, France
10Charles University in Prague, Prague, Czech Republic
11General University Hospital in Prague, Prague, Czech Republic
12David Geffen School of Medicine at the University of California, Los Angeles
13Baylor College of Medicine, Houston, Texas
14Center for Endocrinology, Diabetes and Preventive Medicine, University of Cologne, Cologne, Germany
15Metabolic and Atherosclerosis Research Center, Cincinnati, Ohio
JAMA. 2016;315(15):1580-1590. doi:10.1001/jama.2016.3608.
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Importance  Muscle-related statin intolerance is reported by 5% to 20% of patients.

Objective  To identify patients with muscle symptoms confirmed by statin rechallenge and compare lipid-lowering efficacy for 2 nonstatin therapies, ezetimibe and evolocumab.

Design, Setting, and Participants  Two-stage randomized clinical trial including 511 adult patients with uncontrolled low-density lipoprotein cholesterol (LDL-C) levels and history of intolerance to 2 or more statins enrolled in 2013 and 2014 globally. Phase A used a 24-week crossover procedure with atorvastatin or placebo to identify patients having symptoms only with atorvastatin but not placebo. In phase B, after a 2-week washout, patients were randomized to ezetimibe or evolocumab for 24 weeks.

Interventions  Phase A: atorvastatin (20 mg) vs placebo. Phase B: randomization 2:1 to subcutaneous evolocumab (420 mg monthly) or oral ezetimibe (10 mg daily).

Main Outcome and Measures  Coprimary end points were the mean percent change in LDL-C level from baseline to the mean of weeks 22 and 24 levels and from baseline to week 24 levels.

Results  Of the 491 patients who entered phase A (mean age, 60.7 [SD, 10.2] years; 246 women [50.1%]; 170 with coronary heart disease [34.6%]; entry mean LDL-C level, 212.3 [SD, 67.9] mg/dL), muscle symptoms occurred in 209 of 491 (42.6%) while taking atorvastatin but not while taking placebo. Of these, 199 entered phase B, along with 19 who proceeded directly to phase B for elevated creatine kinase (N = 218, with 73 randomized to ezetimibe and 145 to evolocumab; entry mean LDL-C level, 219.9 [SD, 72] mg/dL). For the mean of weeks 22 and 24, LDL-C level with ezetimibe was 183.0 mg/dL; mean percent LDL-C change, −16.7% (95% CI, −20.5% to −12.9%), absolute change, −31.0 mg/dL and with evolocumab was 103.6 mg/dL; mean percent change, −54.5% (95% CI, −57.2% to −51.8%); absolute change, −106.8 mg/dL (P < .001). LDL-C level at week 24 with ezetimibe was 181.5 mg/dL; mean percent change, −16.7% (95% CI, −20.8% to −12.5%); absolute change, −31.2 mg/dL and with evolocumab was 104.1 mg/dL; mean percent change, −52.8% (95% CI, −55.8% to −49.8%); absolute change, −102.9 mg/dL (P < .001). For the mean of weeks 22 and 24, between-group difference in LDL-C was −37.8%; absolute difference, −75.8 mg/dL. For week 24, between-group difference in LDL-C was −36.1%; absolute difference, –71.7 mg/dL. Muscle symptoms were reported in 28.8% of ezetimibe-treated patients and 20.7% of evolocumab-treated patients (log-rank P = .17). Active study drug was stopped for muscle symptoms in 5 of 73 ezetimibe-treated patients (6.8%) and 1 of 145 evolocumab-treated patients (0.7%).

Conclusions and Relevance  Among patients with statin intolerance related to muscle-related adverse effects, the use of evolocumab compared with ezetimibe resulted in a significantly greater reduction in LDL-C levels after 24 weeks. Further studies are needed to assess long-term efficacy and safety.

Trial Registration  clinicaltrials.gov Identifier: NCT01984424

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Figure 1.
Flow of Patients in the GAUSS-3 Trial

GAUSS-3 indicates Goal Achievement After Utilizing an Anti-PCSK9 Antibody in Statin Intolerant Subjects 3.

aAn individual may have been excluded for more than 1 reason.

bSee Methods.

cNineteen patients bypassed phase A because of creatine kinase elevation ≥10× the upper limit of normal.

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Figure 2.
Time to First Occurrence of a Muscle-Related Adverse Effect Resulting in Discontinuation of Study Drug During Period 1 and Period 2 of Phase A, GAUSS-3 Trial

Atorvastatin dose, 20 mg daily; placebo indicates matching placebo. GAUSS-3 indicates Goal Achievement After Utilizing an Anti-PCSK9 Antibody in Statin Intolerant Subjects 3.

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Figure 3.
Mean Percent Change in Low-Density Lipoprotein Cholesterol Level During Randomized Treatment With Ezetimibe or Evolocumab, GAUSS-3 Trial

Ezetimibe dose, 10 mg daily; evolocumab dose, 140 mg 3 times monthly (420 mg total dosage). GAUSS-3 indicates Goal Achievement After Utilizing an Anti-PCSK9 Antibody in Statin Intolerant Subjects 3. Error bars indicate 95% CIs.

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