Statin buster?

Merck recently reported preliminary results with its drug-in-development, anacetrapib.

After six months of treatment, participants showed:

LDL cholesterol was reduced from 81 mg/dl to 45 mg/dl in those taking anacetrapib, and from 82 mg/dl to 77 mg/dl in the placebo group.

HDL increased from 41 mg/dl to 101 mg/dl in the drug group, from 40 mg/dl to 46 mg/dl in those on placebo.

As you'd expect, the usual line-up of my colleagues gushed over the prospects of the drug, salivating over new speaking opportunities, handsomely-paid clinical "research" trials, and plenty of nice trips to exotic locales.

Anacetrapib is a cholesteryl-ester transfer protein inhibitor, or CETP inhibitor, much like its scrapped predecessor, torcetrapib . . . you know, the one that went down in flames in 2006 after 60% excess mortality occurred in people taking the drug compared to placebo. The hopes of many investors and Pfizer executives were dashed with torcetrapib's demise. The data on torcetrapib's lipid effects were as impressive as Merck's anacetrapib.

These drugs block the effects of the CETP enzyme, an enzyme with complex effects. Among CETP's effects: mediating the "heteroexchange" of triglycerides from triglyceride-rich VLDL particles that first emerge from the liver for cholesterol from LDL particles. This CETP-mediated process enriches LDL particles with triglycerides, which then make LDL a target for action by another enzyme, hepatic lipase, that removes triglycerides. This yields a several nanometer smaller LDL particle, now the number one most common cause of heart disease in the U.S., thanks to conventional advice to cut fat intake and increase consumption of "healthy whole grains."

With effects like this, anacetrapib, should it hold up under the scrutiny of FDA-required trials and not show the same mortality-increasing effects of torcetrapib, will be a huge blockbuster for Merck if release goes as scheduled in 2015. It will likely match or exceed sales of any statin drug. Statin drugs have achieved $27 billion annual sales, some of it deserved. Anacetrapib will likely handily match or exceed Lipitor's $12 billion annual revenue.

More than increasing HDL, CETP inhibition is really a strategy to reduce small LDL particles.

As with many drugs, there are natural means to achieve similar effects with none of the side-effects. In this case, similar effects to CETP inhibition, though with no risk of heightened mortality, is . . . elimination of wheat, in addition to an overall limitation of carbohydrate consumption. Not just low-carb, mind you, but wheat elimination on the background of low-carb. For instance, eliminate wheat products and limit daily carbohydrate intake to 50-100 grams per day, depending on your individual carbohydrate sensitivity, and small LDL drops 50-75%. HDL, too, will increase over time, not as vigorously as with a CETP inhibitor, but a healthy 20-30% increase, more with restoration of vitamin D.

Eliminating wheat and adjusting diet to ratchet down carbs is, of course, cheap, non-prescription, and can be self-administerd, criteria that leave the medical world indifferent. But it's a form of "CETP inhibition" that you can employ today with none of the worries of a new drug, especially one that might share effects with an agent with a dangerous track record.

Comments (20) -

  • Anonymous

    11/19/2010 1:42:54 PM |

    dr. davis whats your take on brown rice? is it a good replacement for wheat? a cup full at mealtimes?

  • steve

    11/19/2010 5:09:16 PM |

    Dr Davis:  As you well know, not all of us can lower small LDL through carb restriction and wheat elimination to a level where small LDL is only say 30% of total LDL, a number low enough to perhaps get plaque regression. I have elimated all wheat, and eat low carb,have achieved HDL of 59, LDL of 45, NMR particle of 609, 57% of which remain small. Take Crestor and Zetia. Vitamin d measures at 60 and no thyroid issues.   My TRG's are only 28.  So, i think i am one that may have a CETP issue not responsive wholly to diet; if this drug works, it would most likely be of help to me and many others. The only way my particle count comes down is with drugs.  Not sure how i can go lower on the carb front given my only carbs now are veggies; no fruit or starch except teaspoon of Metamcuceil.  Any other natural ways to lower small LDL?

  • Jim

    11/19/2010 6:20:15 PM |

    OK, I'm confused.  It sounds like this drug will increase the number of small LDL:

    "This yields a several nanometer smaller LDL particle, now the number one most common cause of heart disease in the U.S."

    But then, maybe not:

    "CETP inhibition is really a strategy to reduce small LDL particles"

  • Anonymous

    11/19/2010 6:30:19 PM |

    Dear Dr Davis,
    what is your commentary about this new investigation which represents decreasing properties of whole grain food to ldl levels
    Thank you in advance for your opinion

  • Anonymous

    11/19/2010 6:36:08 PM |

    Dr. D.

    I love your Blog. Keep up the good work.

    A few years ago I would have been very excited about this new class of drugs. I am however not so sure this drug will be the super star people think it will be (despite being able to raise HDL so much).

    According to Chris Masterjohn @ The Daily Lipid Blog, he believes that much of the benefit of HDL is because HDL transfers vitamin E to the endothelial cells and that CETP inhibitors actually decrease the transfer of vitamin E from other lipoproteins to HDL by about half.   Frown

  • O Primitivo

    11/19/2010 7:49:50 PM |

    Another recent statin study, with null results:

  • j. Carey

    11/20/2010 12:29:06 AM |

    My experience on the Paleo diet plus psyllium plus guar gum equals this drug.  My HDLs went from 35 to 91.

  • Chris

    11/20/2010 12:40:34 AM |

    @ JCarey:

    Paleo diet + psyllium + guar gum raises HDL?
    Glad you hdl's are any references or links for this?

  • Paul

    11/20/2010 3:52:46 AM |

    This is my take Chris.

    Paleo diet = increases HDL as a result of an increase of dietary fats.

    Psyllium husk = lowers LDL by stimulating the conversion of cholesterol into bile acid.  It may also lower small LDL by controlling glucose levels by slowing digestion.

    Guar gum = lowers small LDL by controlling glucose levels by slowing digestion.

  • Anonymous

    11/20/2010 3:54:43 AM |

    It amazes me to no end that people have forgotten what the longest long term study has shown us about LDL.  1998 final Framingham data.  Those with the lowest LDL levels died the soonest and those with the highest levels lived the longest and yet we are still trying to lower LDL small large or medium sized.  Its the oxLDL that matter. Dr. Davis keep fighting the battle.  

    Dr. K

  • Anonymous

    11/20/2010 12:03:14 PM |

    I notice from the Merck statement that this drug did not reduce CRP like most statins.

  • Dr. William Davis

    11/20/2010 12:57:58 PM |

    A few responses:

    Anonymous--It depends on individual carb sensitivity. Most people can tolerate small quantities, e.g., 1/2 per serving. Others (like me) cannot even tolerate this much without triggering a surge in blood glucose and small LDL.

    Steve--You likely have what I call "genetic" small LDL, meaning a CETP variant. Niacin can help. Beyond this, we struggle. I've seen variable effects with more fats, phosphatidylcholine, medium-chain triglycerides, and milk thistle. We also lack endpoint data to tell us what a desirable level is. I believe, however, it is somewhere around 300 nmol/L.

    Jim--In the first paragraph, I was referring to the small LDL-yielding effects of CETP and triglyceride exchange. Blocking CETP prevents this exchange from occurring.

  • Anonymous

    11/20/2010 7:54:02 PM |

    thanks for the response dr. davis.

  • escee

    11/21/2010 6:16:19 AM |

    What I saw from the study was no real difference after 76 weeks in mortality or cardiovascular events. In fact there were 11 deaths in the anacetrapib group and 8 deaths in the control group.

    I don't find that encouraging, but maybe it was too short term.

  • steve

    11/21/2010 6:13:36 PM |

    thank you Dr Davis for your recommendations.  I have tried Slo-Niacin and had great difficulty tolerating it at 1500/1000 mg doses. Felt much better when not on it.  Have tightened up my diet even more, eliminating fruit and cheese and Greek Yogurt.  Will see what next NMR brings.  Might add Niacin at low dose to existing regime.  My small LDL particle size at 20.6 is type A and small particles not to far off from the 300 you suggest despite the proportion of small LDL to total LDL being larger than optimal

  • Randy

    11/22/2010 3:14:45 PM |

    Dr. Davis - can you comment on an article that Shane Ellison has written entitled "Hidden Truth About Cholesterol-Lowering Drugs"?

    Within the article, Mr. Ellison provides the statement that low cholesterol is a bad thing, not a good thing and people with higher cholesterol are living longer.

    Can you place this in context with regard to small LDL particles?

  • Tyson

    11/23/2010 2:26:21 AM |

    I'm not Dr. Davis, but I also have difficulty with Niacin.  I also have high homocysteine.  These 2 things can go hand in hand.  For me, it's a methylation problem.  I'm an undermethylator, which means I have to supplement with TMG and a few other things.  You should get your Homocysteine checked, and if it is elevated, be very careful with Niacin, since Niacin can make it worse unless you supplement with TMG etc...

  • steve

    11/23/2010 3:30:35 PM |

    thanks Tyson:  Homocysteine level is in normal range,but near the high end, ie 10 vs. 12 being top of the range.  My understanding is that it elevates with age and i am pushing 60.  I also hear that a B complex vitamin might make sense.

    Perhaps Dr. Davis may weigh in on the homocysteine issue with regards to treatment and Niacin use.

  • Daniel A. Clinton, RN, BSN

    11/28/2010 6:10:04 PM |

    Don't get your hopes up for anacetrapib. Despite the researchers best attempts to hide it, the anacetrapib group had higher cardiac mortality, and higher overall mortality. So, do you care that some numbers changed, or that the drug increases the risk of death? I wrote an article on the subject on my blog:

  • Sifter

    11/28/2010 11:36:04 PM |

    Considering alledged 400% increase in cardiovascular mortality rate....

    ...I think I'll pass on this new wonder drug.