Omega-3 Fatty Acid Formulation Research Articles

Eicosapentaenoic acid (EPA) reduced expression of neutrophil activation proteins in endothelial cells during challenge with angiotensin II (Ang II) and cytokines

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Amarin Pharmaceutical, Inc. Elucida Research LLC. Background Neutrophil degranulation contributes to atherogenesis and tissue injury in response to cytokine release and activation of the renin-angiotensin system (RAS), along with its effector angiotensin II (Ang II). Mixed omega-3 fatty acid (n3-FA) formulations of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have not shown reduction in CV events compared to EPA-only formulations (REDUCE-IT), but the mechanisms of atheroprotection with EPA are not well understood. Purpose We measured the effects of EPA on expression of proteins related to neutrophil activation in vascular endothelial cells (ECs) under various inflammatory challenges, specifically exposure to Ang II and the cytokine IL-6 in vitro. Methods Human umbilical vein ECs (HUVECs) were challenged with the cytokine IL-6 at (12 ng/mL) and Ang II (100 nM) for 2 h, then treated with EPA (40 µM) for 24 h. Global proteomic analysis was performed using LC/MS to measure relative expression levels of over 2,500 proteins simultaneously. Only significant (p<0.05) changes in expression between treatment groups >1-fold (100%) were analyzed by differential enrichment analysis of proteomics data (DEP) and included in gene set enrichment analyses (GSEA). Results EPA significantly down/up-regulated expression of 507/505 and 544/472 proteins, respectively, compared with Ang II and IL-6 alone. The GSEA revealed EPA treatment significantly modulated expression of 88 and 80 proteins within the neutrophil degranulation pathway (Gene Ontology ID: 0043312), compared to Ang II and IL-6, respectively. Of these proteins, 20 were similarly modulated by EPA relative to each stimulus (13 decreased, 7 increased expression). This included a 110% decrease in expression of heat shock protein 90 (110%) and HSP 86 (110%) and a 140% and 110% increase in junction plakoglobin relative to Ang II and IL-6, respectively, which is also involved in endothelial cell-cell adhesion. Conclusion EPA modulated expression of multiple proteins linked to neutrophil degranulation following challenge with either Ang II or IL-6. The effects of EPA on neutrophil protein expression may lead to reduced inflammation and risk for patients with CV disease as demonstrated in outcome trials.

Recent Updates in Hypertriglyceridemia Management for Cardiovascular Disease Prevention.

Mounting evidence continues to support the causal role of triglyceride-rich lipoproteins (TRL) in the development of atherosclerotic cardiovascular disease (ASCVD). Substantial residual ASCVD risk remains among high-risk patients who have elevated triglycerides despite reduction in low-density lipoprotein cholesterol (LDL-C) with statin therapy. Ongoing research efforts have focused on evaluating triglyceride-lowering therapies among patients with hypertriglyceridemia. The REDUCE-IT trial showed that the addition of icosapent ethyl, a highly purified form of eicosapentaenoic acid (EPA), can reduce vascular events among statin-treated individuals with elevated triglycerides who have either clinical ASCVD or diabetes plus another risk factor. Although additional evidence for EPA has emerged from other trials, conflicting results have been reported by subsequent trials that tested different omega-3 fatty acid formulations. Randomized clinical trials have not demonstrated incremental ASCVD benefit of fibrates on background of statin therapy, but fibrates are used to help prevent pancreatitis in patients with severe hypertriglyceridemia. Selective inhibitors of apolipoprotein C-III (apoC3) and angiopoietin-like protein 3 (ANGPTL3), proteins that are involved in metabolism of TRLs by regulating lipoprotein lipase, have been tested in selected patient populations and showed significant reduction in triglyceride and LDL-C levels. Statin therapy continues to be the cornerstone of pharmacologic reduction of cardiovascular risk. High-dose EPA in the form of icosapent ethyl has been demonstrated to have cardiovascular benefit on top of statins in persons with elevated triglycerides at high ASCVD risk. Ongoing clinical trials are evaluating novel selective therapies such as apoC3 and ANGPTL3 inhibitors.

Omega-3 fatty acids differentially reduced expression of neutrophil degranulation-associated proteins in endothelial cells during IL-6 exposure

Abstract Background Neutrophil degranulation contributes to atherogenesis and tissue injury. Mixed omega-3 fatty acid (n3-FA) formulations of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have failed to reduce CV events compared to EPA only (REDUCE-IT), but the mechanisms are not understood. Purpose The purpose of this study was to compare the effects of EPA and DHA on expression of proteins linked to neutrophil degranulation in the vascular endothelium in vitro. Methods Human umbilical vein endothelial cells (HUVECs) were pretreated with EPA or DHA at equimolar levels (10 μM) for 2 h, then challenged with IL-6 at 12 ng/ml for 24 h. Proteomic analysis was performed using LC/MS to measure relative protein expression. Only significant (p<0.05) changes between treatment groups >1-fold were analyzed. Results In the Reactome “neutrophil degranulation” pathway, EPA and DHA downregulated 27 and 14 proteins, respectively, (p=9.97E-9 and 5.30E-4, respectively) relative to IL-6 alone. There were 12 protein changes common to both n3-FAs, including heme oxygenase-2 and ferritin light chain. EPA downregulated 15 proteins unlike DHA, including peroxiredoxin-6 and mitogen-activated protein kinase-1 (MAPK1). A combined 21 proteins downregulated by EPA and DHA versus IL-6 were upregulated by IL-6 alone relative to vehicle. EPA also increased expression of Rho-associated protein kinase-1 (ROCK-1), a protein downregulated by IL-6 alone and unaffected by DHA. Conclusions EPA and DHA differentially modulated expression of proteins linked to neutrophil degranulation. The distinct effects of EPA on protein expression may contribute to reduced inflammation in vascular injury compared to DHA. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Amarin Pharma Inc., Elucida Research

Meta-analysis of 17 clinical trials using omega-3 fatty acids in patients with cardiovascular disease

Background and Aims: Increased fish oil consumption has been associated with a lower risk of cardiovascular disease (CVD). Fish oils owe their CVD benefits to omega-3 fatty acids which include eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Multiple clinical trials, with the majority of them administering a combination of EPA and DHA, have been conducted in Western and Asian populations with mixed outcomes. This study aimed to determine whether omega-3 fatty acid formulations of EPA alone versus mixed combinations can confer protection in patients with CVD.

The role of icosapent ethyl in cardiovascular risk reduction.

Elevated levels of triglycerides, independent of low-density lipoprotein cholesterol (LDL-C) levels and statin therapy, are associated with heightened cardiovascular risk. Mixed omega-3 fatty acid formulations, which contain varying amounts of docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), lower triglycerides levels but trial results with omega-3 fatty acids combinations have generally been neutral for cardiovascular outcomes. In contrast, the REDUCE-IT trial with icosapent ethyl (IPE), a highly purified ethyl ester of EPA, demonstrated reduced cardiovascular risk in individuals with established atherosclerotic cardiovascular disease or diabetes with at least one additional risk factor, despite having relatively well controlled LDL-C levels but triglycerides at least 135 mg/dl while on statin therapy. IPE offers an important new avenue for cardiovascular risk management in statin-treated individuals with elevated triglycerides. This review summarizes the results from outcome trials conducted with omega-3 fatty acids, differentiating between those with combinations of EPA/DHA and those with pure EPA, as well as imaging and preclinical data that help explain the different cardiovascular efficacy observed. A list of frequently asked questions with evidence-based responses is provided to assist our colleagues and their patients in the shared-decision process when considering if IPE is appropriate for cardiovascular risk reduction.

Effect of High-Dose Omega-3 Fatty Acids vs Corn Oil on Major Adverse Cardiovascular Events in Patients at High Cardiovascular Risk

It remains uncertain whether the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) reduce cardiovascular risk. To determine the effects on cardiovascular outcomes of a carboxylic acid formulation of EPA and DHA (omega-3 CA) with documented favorable effects on lipid and inflammatory markers in patients with atherogenic dyslipidemia and high cardiovascular risk. A double-blind, randomized, multicenter trial (enrollment October 30, 2014, to June 14, 2017; study termination January 8, 2020; last patient visit May 14, 2020) comparing omega-3 CA with corn oil in statin-treated participants with high cardiovascular risk, hypertriglyceridemia, and low levels of high-density lipoprotein cholesterol (HDL-C). A total of 13 078 patients were randomized at 675 academic and community hospitals in 22 countries in North America, Europe, South America, Asia, Australia, New Zealand, and South Africa. Participants were randomized to receive 4 g/d of omega-3 CA (n = 6539) or corn oil, which was intended to serve as an inert comparator (n = 6539), in addition to usual background therapies, including statins. The primary efficacy measure was a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, coronary revascularization, or unstable angina requiring hospitalization. When 1384 patients had experienced a primary end point event (of a planned 1600 events), the trial was prematurely halted based on an interim analysis that indicated a low probability of clinical benefit of omega-3 CA vs the corn oil comparator. Among the 13 078 treated patients (mean [SD] age, 62.5 [9.0] years; 35% women; 70% with diabetes; median low-density lipoprotein [LDL] cholesterol level, 75.0 mg/dL; median triglycerides level, 240 mg/dL; median HDL-C level, 36 mg/dL; and median high-sensitivity C-reactive protein level, 2.1 mg/L), 12 633 (96.6%) completed the trial with ascertainment of primary end point status. The primary end point occurred in 785 patients (12.0%) treated with omega-3 CA vs 795 (12.2%) treated with corn oil (hazard ratio, 0.99 [95% CI, 0.90-1.09]; P = .84). A greater rate of gastrointestinal adverse events was observed in the omega-3 CA group (24.7%) compared with corn oil-treated patients (14.7%). Among statin-treated patients at high cardiovascular risk, the addition of omega-3 CA, compared with corn oil, to usual background therapies resulted in no significant difference in a composite outcome of major adverse cardiovascular events. These findings do not support use of this omega-3 fatty acid formulation to reduce major adverse cardiovascular events in high-risk patients. ClinicalTrials.gov Identifier: NCT02104817.

Development and characterization of stabilized omega-3 fatty acid and micronutrient emulsion formulation for food fortification.

We report a novel stabilized emulsified formulation containing omega-3 fatty acid (ω-3 FA) and micronutrient that can be readily used for food fortification. The emulsification methodology for producing a stabilized formulation containing both ω-3 FA and micronutrients is described. The formulation was developed considering the human requirement of ω-3 FA and recommended daily allowance of important micronutrients. This formulation was characterized for physical appearance, pH, specific gravity, color measurement etc. Fatty acid analysis revealed formulations (2, 4 and 5g/serve) were able to provide 500-1300mg of alpha linoleic acid. Oxidative stability assessment (peroxide value, free fatty acid content) of the formulations showed, stability of the formulation as non-significant alterations were noted in these parameters when the formulations were compared with raw flaxseed oil. Rheological evaluation indicated formulation followed Non-Newtonian system with shear thickening behavior. Particle size was found to be between 673.83 to 798.76nm and poly-dispersity index was between 0.438 to 0.681. Microscopic analysis by Cryo-SEM analysis of the formulation showed stable homogeneous nature of formulation. Stability of the formulations was confirmed by freeze-thawing, dilution test and emulsion stability index. Acute oral toxicity study as per OECD guideline showed safety of the formulations. Most importantly, in vivo bioavailability study of ω-3 FA confirmed better bioavailability of the metabolites of ω-3 FA i.e. eicosapentaenoic and docosahexaenoic acids in formulation treated group as compared to flax oil and comparable bioavailability to that of fish oil.

Intake of omega-3 formulation EPA:DHA 6:1 by old rats for 2 weeks improved endothelium-dependent relaxations and normalized the expression level of ACE/AT1R/NADPH oxidase and the formation of ROS in the mesenteric artery

Omega-3 polyunsaturated fatty acids (PUFAs) including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have been shown to protect the cardiovascular system, in part, by stimulating the endothelial formation of nitric oxide (NO). EPA:DHA 6:1 has been identified as a potent omega 3 PUFA formulation to induce endothelium-dependent vasorelaxation and activation of endothelial NO synthase (eNOS). This study examined whether intake of EPA:DHA 6:1 (500 mg/kg/day) for 2 weeks improves an established endothelial dysfunction in old rats (20 months old), and, if so, the underlying mechanism was subsequently determined.In the main mesenteric artery rings, an endothelial dysfunction characterized by a blunted NO component, an abolished endothelium-dependent hyperpolarization component, and increased endothelium-dependent contractile responses (EDCFs) are observed in old rats compared to young rats. Age-related endothelial dysfunction was associated with increased vascular formation of reactive oxygen species (ROS) and expression of eNOS, components of the local angiotensin system, senescence markers, and cyclooxygenase-2 (COX-2), and the downregulation of COX-1. The EPA:DHA 6:1 treatment improved the NO-mediated relaxation, reduced the EDCF-dependent contractile response and the vascular formation of ROS, and normalized the expression level of all target proteins in the old arterial wall.Thus, the present findings indicate that a 2-week intake of EPA:DHA 6:1 by old rats restored endothelium-dependent NO-mediated relaxations, most likely, by preventing the upregulation of the local angiotensin system and the subsequent formation of ROS.

Ageing enhances the shedding of splenocyte microvesicles with endothelial pro-senescent effect that is prevented by a short-term intake of omega-3 PUFA EPA:DHA 6:1

BackgroundAgeing is associated with progressive endothelial senescence and dysfunction, and cardiovascular risk. Circulating endothelial microvesicles (MVs) are pro-senescent and pro-inflammatory endothelial effectors in acute coronary syndrome. Omega-3 PUFA intake was claimed beneficial in cardiovascular prevention. PurposeTo investigate whether the intake of the omega-3 formulation EPA:DHA 6:1 by middle-aged and old rats reduces the shedding of pro-senescent microvesicles from cultured spleen leukocytes (SMVs) and clarify the underlying mechanisms in target coronary primary endothelial cells (ECs). MethodsMiddle-aged male Wistar rats (M, 48-week old) received 500 mg/kg/d of either EPA:DHA 6:1, EPA:DHA 1:1, or vehicle (CTL) for 7 days, old rats (72-week old) for 14 days. Spleen-derived leukocytes were prepared and cultured for 24 h and MVs collected from supernatants (SMVs). Cultured ECs were prepared from freshly isolated porcine coronary arteries. Senescence-associated β-galactosidase activity (SA-β-gal) was assessed by C12FDG, protein expression by Western blot analysis, oxidative stress by dihydroethidium using confocal microscopy, and procoagulant MVs by prothrombinase assay. The pro-senescent potential of SMVs from middle-aged rats (M−SMVs) was analyzed by comparison with young (Y, 12-week) and old (O) rats. ResultsThe shedding of SMVs significantly increased with age and was inhibited by EPA:DHA 6:1 intake that also prevented ROS accumulation in spleen. Incubation of ECs with 10 nM SMVs from middle-aged and old but not those from young rats induced premature senescence after 48 h. The pro-senescent effect of M−SMVs was prevented by Losartan and associated with endothelial oxidative stress. M−SMVs induced an up-regulation of senescence markers (p16, p21, p53), pro-atherothrombotic (VCAM-1, ICAM-1, tissue factor) and pro-inflammatory markers (pNF-κB, COX-2) and proteins of the angiotensin system (ACE, AT1-R). Conversely, endothelial NO synthase was down-regulated. Intake of EPA:DHA 1:1 and 6:1 by middle-aged rats decreased SMV shedding by 14% and 24%, respectively. Only EPA:DHA 6:1 intake abolished the M−SMVs−induced endothelial senescence and reduced the pro-senescent action of O-SMVs by 45%. Protection of ECs was not observed in response to SMVs from EPA:DHA 1:1 treated rats. ConclusionIngestion of EPA:DHA 6:1 by middle-aged or old rats, respectively abolished or limited both the shedding of SMVs and their pro-senescent, pro-thrombotic and pro-inflammatory effects in ECs, most likely by triggering the local angiotensin system. EPA:DHA 6:1 may help to delay ageing-related endothelial dysfunction.

A Look Beyond Statins and Ezetimibe: a Review of Other Lipid-Lowering Treatments for Cardiovascular Disease Prevention in High-Risk Patients

There has been significant progress made during the last few decades in the management of atherosclerotic cardiovascular disease (ASCVD). Despite this, residual risk remains an unmet need for secondary prevention and high-risk primary prevention patients. First onset and recurrent cardiovascular events remain a major issue despite recommendations for a healthy lifestyle and current optimal medical therapy, which includes the use of maximally tolerated statin therapy plus or minus add-on ezetimibe therapy. These findings have led to the development of new treatments that modulate lipid targets in order to improve prognosis of these patients at highest ASCVD risk. These include inhibitors of proprotein convertase subtilisin/kexin type 9 (evolocumab and alirocumab), an inhibitor of adenosine triphosphate citrate lyase (bempedoic acid), and a high-dose omega-3 formulation (icosapent ethyl), which have been evaluated in large phase III randomized clinical trials and/or currently undergoing continued study. The clinical efficacy of these drugs and their application in cardiovascular prevention are discussed in this review article. Of note, there are other novel lipid-lowering therapeutics with potential cardiovascular benefit, not discussed in this review, that include inhibitors of lipoprotein (a), apolipoprotein CIII, and angiopoietin-like 3. These drugs may also play a future role in reducing residual lipid-mediated ASCVD risk, if efficacy and safety confirmed in cardiovascular outcome trials. In this review, we provide an overview of the current knowledge regarding treatment with several new lipid strategies for high-risk patients, along with suggestions on their use in ASCVD prevention management.

O40 The omega-3 EPA:DHA 6:1 formulation prevents the monocrotaline-induced pulmonary hypertension, pulmonary artery remodelling, endothelial dysfunction, and right ventricular failure in rats

Introduction Omega-3 polyunsaturated fatty acids such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have been shown to protect the cardiovascular system and reduce inflammation. The possibility that the superior omega-3 formulation, EPA:DHA 6:1, prevents cardiopulmonary dysfunction and remodelling was evaluated in an experimental model of pulmonary arterial hypertension (PAH). Methods: Male Wistar rats received 500 mg/kg/day of either EPA:DHA 6:1 or corn oil by daily gavage for 4 weeks before sacrifice. After one week, PAH was induced by a single subcutaneous injection of monocrotaline (MCT, 60 mg/kg). Results MCT treatment was associated with increased systolic pulmonary arterial pressure (PAP) and blunted endothelium-dependent relaxations to acetylcholine in pulmonary artery rings, increased wall thickness and oxidative stress in pulmonary arterioles, and increased right ventricle (RV) systolic pressure and hypertrophy, and reduced cardiac output. The EPA:DHA 6:1 treatment prevented the MCT-induced changes in morphology and pressure in the pulmonary artery and RV. EPA:DHA 6:1 treatment also reduced the MCT-induced pulmonary artery endothelial dysfunction, and the level of oxidative stress in pulmonary arterioles. The protective effect of EPA:DHA 6:1 was associated with the prevention of the MCT-induced upregulation of eNOS, AT1 receptors, endothelin receptors, COX-1 and COX-2, and NADPH oxidase subunits in pulmonary arterioles, and reduced perivascular macrophage and lymphocyte infiltration in lungs. Conclusion The present findings indicate that the EPA:DHA 6:1 has a cardioprotective effect in PAH by preventing right ventricular failure, pulmonary artery and arterioles remodelling and endothelial dysfunction, most likely by preventing vascular oxidative stress.

A novel liquid chromatography/tandem mass spectrometry (LC–MS/MS) based bioanalytical method for quantification of ethyl esters of Eicosapentaenoic acid (EPA) and Docosahexaenoic acid (DHA) and its application in pharmacokinetic study

Omega-3 fatty acids are clinically useful and the two marine omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are prevalent in fish and fish oils. Omega-3 fatty acid formulations should undergo a rigorous regulatory step in order to obtain United States Food and Drug Administration (USFDA) approval as prescription drug. In connection with that, despite quantifying EPA and DHA fatty acids, there is a need for quantifying the level of ethyl esters of them in biological samples. In this study, we make use of reverse phase high performance liquid chromatography coupled with mass spectrometry (RP-HPLC–MS)technique for the method development. Here, we have developed a novel multiple reaction monitoring method along with optimized parameters for quantification of EPA and DHA as ethyl esters. Additionally, we attempted to validate the bio-analytical method by conducting the sensitivity, selectivity, precision accuracy batch, carryover test and matrix stability experiments. Furthermore, we also implemented our validated method for evaluation of pharmacokinetics of omega fatty acid ethyl ester formulations.

Omega-3 Fatty Acid Formulations in Cardiovascular Disease: Dietary Supplements are Not Substitutes for Prescription Products.

Omega-3 fatty acid products are available as prescription formulations (icosapent ethyl, omega-3-acid ethyl esters, omega-3-acid ethyl esters A, omega-3-carboxylic acids) and dietary supplements (predominantly fish oils). Most dietary supplements and all but one prescription formulation contain mixtures of the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Products containing both EPA and DHA may raise low-density lipoprotein cholesterol (LDL-C). In clinical trials, the EPA-only prescription product, icosapent ethyl, did not raise LDL-C compared with placebo. To correct a common misconception, it is important to note that omega-3 fatty acid dietary supplements are not US FDA–approved over-the-counter drugs and are not required to demonstrate safety and efficacy prior to marketing. Conversely, prescription products are supported by extensive clinical safety and efficacy investigations required for FDA approval and have active and ongoing safety monitoring programs. While omega-3 fatty acid dietary supplements may have a place in the supplementation of diet, they generally contain lower levels of EPA and DHA than prescription products and are not approved or intended to treat disease. Perhaps due to the lack of regulation of dietary supplements, EPA and DHA levels may vary widely within and between brands, and products may also contain unwanted cholesterol or fats or potentially harmful components, including toxins and oxidized fatty acids. Accordingly, omega-3 fatty acid dietary supplements should not be substituted for prescription products. Similarly, prescription products containing DHA and EPA should not be substituted for the EPA-only prescription product, as DHA may raise LDL-C and thereby complicate the management of patients with dyslipidemia.

0369 : The optimized omega-3 EPA:DHA 6:1 product prevents the monocrotaline-induced pulmonary arterial hypertension and vascular remodeling in rats

Pulmonary arterial hypertension (PAH) is characterized by an increased pulmonary vascular resistance, right ventricular hypertrophy and increased systolic pressure. Omega-3 polyunsaturated fatty acids such as eicosapentaenoic acid (EPA) and docosahexaenoic acids (DHA) have been shown to protect the cardiovascular system and reduce inflammatory responses. We have investigated the cardiopulmonary protective effects of an optimized omega-3 fatty acid formulation (EPA:DHA 6:1) on the monocrotaline (MCT)-induced PAH in rats. Male Wistar rats received 500 mg/kg/day of either EPA:DHA 6:1 or corn oil by daily gavage. After one week, PAH was induced by a single subcutaneous injection of MCT (60 mg/kg). Three weeks following MCT, echocardiography was used to examine cardiac function, right ventricular (RV) systolic pressure, and pulmonary artery dimension. Endothelial function was assessed in pulmonary artery rings by vascular reactivity, right ventricular hypertrophy and pulmonary vascular morphometry by histology and immunohistochemistry, and oxidative stress using dihydroethidium. MCT induced pulmonary vascular remodeling, RV hypertrophy, endothelial dysfunction, and increased RV pressure and vascular ROS formation. Compared to the MCT group, EPA:DHA 6:1 treatment protected the pulmonary artery acceleration time, cardiac remodeling and prevented the elevation of right ventricular systolic pressure. Moreover, EPA:DHA 6:1 prevented the MCT-induced pulmonary artery endothelial dysfunction and increased wall thickness of pulmonary arterioles. This effect was associated with prevention of the MCT-induced upregulation of eNOS, AT1R, COX-2, COX-1 and the NADPH oxidase subunits (p22phox and p47phox). The present findings indicate that the optimized EPA:DHA 6:1 formulation has a cardioprotective effect in PAH, by preventing right ventricular failure and pulmonary arterial remodeling, endothelial dysfunction and oxidative stress. The author hereby declares no conflict of interest

A Comparison of the Pharmacological and Mechanistic Properties of Therapeutic Long-Chain Omega-3 Fatty Acid Formulations

Dr. Harper is an employee of AstraZeneca.

Abstract P226: Decreasing Cardiovascular Risk via Hypertriglyceridemia Treatment: The Impact of Medical Education on Physician Understanding of the Role of Omega-3 Fatty Acids

Introduction: Triglycerides, although lacking the strong atherogenic potential of LDL-C, are an independent risk factor for cardiovascular disease (CVD), as demonstrated by the correlation between hypertriglyceridemia and cardiovascular (CV) death, CV events, and myocardial infarction. The impact of continuing medical education (CME) on improving the knowledge and competence of cardiologists in treating hypertriglyceridemia with omega-3 fatty acids was measured. Methods: Cardiologists in the US who treat patients with hypertriglyceridemia participated in an online CME activity on the role of omega-3 fatty acids in treating hypertriglyceridemia and the differences between available formulations. The educational impact was assessed using linked pre- and post-assessment questions, and participants were classified into one of 3 learning categories: improved learners (incorrect pre, correct post), reinforced learners (correct pre and post), and unaffected learners (incorrect pre and post). The educational effect size was calculated using Cohen's d formula. Results: A total of 169 cardiologists participated in the CME activity, completed the pre- and post-assessment, and were included in the analysis. Comparison of pre- and post-assessment responses for each individual question demonstrated a statistically significant improvement in knowledge and competence among cardiologists ( P <.05). After completion of the CME activity, correct responses on post-assessment questions increased between 25% to 158% across all questions compared to pre-assessment responses, with an overall large effect size of 1.065 (Small effect ,<0.4; intermediate effect, 0.4-0.8; large effect, >0.8). Between 17% and 51% of participants showed improvement in understanding individual learning concepts; these concepts were reinforced in 18% to 28% of participants. Improvement was demonstrated in understanding recent American College of Cardiology (ACC)/American Heart Association (AHA) guideline recommendations on the treatment of hypertriglyceridemia. There was a need for further education in understanding the mechanism of action of omega-3 fatty acids, the differences between prescription and supplement forms of omega-3 fatty acids, and the pharmacodynamic differences between the different formulations of omega-3 fatty acids. Conclusion: This study demonstrated the success of a targeted educational intervention on improving the knowledge and competence of US cardiologists on the role of omega-3 fatty acids to treat hypertriglyceridemia and reduce CVD. However, the need for additional education was also demonstrated among cardiologists with regard to understanding the different omega-3 fatty acid formulations and their mechanisms of action in order to effectively use these agents.

Efficacy of a unique omega-3 formulation on the correction of nutritional deficiency and its effects on cardiovascular disease risk factors in a randomized controlled VASCAZEN(®) REVEAL Trial.

Low blood levels of long chain omega-3 polyunsaturated fatty acids (LC n-3 PUFA) have been reported to be associated with increased risk for cardiovascular disease (CVD) deaths. Systematic studies measuring LC n-3 PUFA blood levels (pre and post-treatment) in defined subjects, and monitoring the correction of nutritional deficiency with a pure LC n-3 PUFA formulation in sufficient doses, while monitoring CVD risk factors are lacking. We tested the efficacy of a novel LC n-3 PUFA Medical Food formulation (VASCAZEN®, > 90 % pure with a 6:1 eicosapentaenoic acid-(EPA):docosahexaenoic acid-(DHA) ratio; 6:1-OM3), to correct such deficiency and determine the concomitant effects on lipid profiles. Of 655 subjects screened, 89 % were LC n-3 PUFA deficient (Omega-Score, (OS) = blood EPA + DHA + Docosapentaenoic acid < 6.1 %). From these, a study was conducted on 110 ambulatory cardiovascular subjects. Placebo: corn oil. Primary endpoint: change in OS. Secondary endpoint: changes in blood lipid profiles. At 8 weeks of treatment with 6:1-OM3 (4 g/day), placebo-adjusted median OS levels (n = 56) significantly improved (132 %, P < 0.0001) with a decrease in AA (arachidonic acid): EPA ratio (82 %, P < 0.0001). In hypertriglyceridemic subjects (TG 2.26–5.65 mmol/L), HDL-C improved (9 %, P = 0.0069), TG-reduced (48 %, P < 0.0001), and VLDL-C reduced (30 %, P = 0.0023), without significantly affecting LDL-C levels. This study confirms that LC n-3 PUFA deficiency is prevalent in the US population, and its correction with 6:1-OM3 in CVD subjects improves lipid profiles. The purity, EPA:DHA ratio and dose are determinant factors for optimal efficacy of a formulation in reducing CVD risk factors.

Abstract 397: Correlation Between the Whole Blood Omega-Score and Red Blood Cell Membrane Omega-3 Index in a Patient Population with Cardiovascular Disease Risk Factors Treated With a Unique Omega-3 Formulation

Background: Growing evidence supports the value of maintaining a diet rich in omega-3 polyunsaturated fatty acids (PUFA) to achieve longevity of cardiovascular health, and prevent sudden death. Omega-3 deficiency (OM3D) is highly prevalent in the US and contributes to 84,000 deaths/year. To identify patients at risk with OM3D, two laboratory tests are available, including the Omega-Score (OS - whole blood), as well as the Omega-3 Index (OI - red blood cell membrane), that measure omega-3 blood levels. Omega-Score or OI levels &lt;6.1% suggest OM3D. Here we report on the dietary omega-3 status of Canadians, including those with CVD risk factors, through a comparative analysis of the OS vs. OI both pre- and post-treatment with a unique omega-3 formulation. Methods: Open label study of 143 study subjects enrolled for baseline omega-3 deficiency assessment, of which 63 subjects were scheduled to receive a 4 g/day regimen of a highly purified (&gt;90%) omega-3 formulation (2720 mg/day of EPA + 440 mg/day of DHA), a ratio of 6:1 EPA:DHA (6:1 OM-3) for two weeks, and 31 subjects received 6:1 OM-3 for six weeks. Diagnostic evaluation of the OS, and OI was carried out at baseline, and every two weeks until the study completion. Results: The majority (84.5%) of subjects tested at baseline had OS levels &lt;6.1%. The baseline, mean OS and OI levels were 3.4% and 4.4% respectively (N=143). After six weeks of treatment, a significant improvement in the OS (120.6% increase, p&lt;0.0001), and OI (72.7% increase, p&lt;0.0001) was observed (N=31). Comparative analysis of the OS vs. the OI resulted in comparable values, with a greater baseline OI, but with near-identical resultant OS an OI levels after six weeks of treatment (7.5%, vs. 7.6% respectively). Conclusions: This study shows that both the OS and OI provide highly correlative results in the assessment of nutritional omega-3 deficiency, and response to treatment with 6:1 OM-3.

Abstract 589: Correction of Long-Chain Omega-3 Fatty Acid Deficiency With a Unique Omega-3 Formulation is Associated With a Significant Reduction in Atherogenic Index of Plasma in Hypertriglyceridemic Patients: Results of the VASCAZEN-REVEAL Trial

Background: A large number of studies have suggested that the triglyceride/high density lipoprotein cholesterol (TG/HDL-C)) ratio provides useful information about atherogenicity of plasma (AIP) and that a higher ratio has been linked to increased incidence of myocardial infarction. Others have suggested the use of AIP (log ratio of molar concentrations of TG to HDL-C) as a significant predictor of cardiovascular risk and to identify insulin resistant individuals at high cardio-metabolic risk. In this report, we analyzed data from the VASCAZEN-REVEAL trial to investigate if the correction of Omega-3 fatty acid deficiency with a unique Omega-3 formulation (referred to as 6:1 OM-3) in 6:1 ratio of eicosapentaenoic (EPA) and docosahexaenoic (DHA) acids affects TG/HDL-C and AIP indices in hypertriglyceridemic subjects. Methods: A double blind, placebo-controlled study of 42 ambulatory cardiovascular subjects with elevated baseline TG levels (200-500mg/dL) were treated with either placebo (corn oil, 4g/day, n=22) or with 6:1 OM-3 (4g/day; n=20) for 8 weeks. Primary endpoint: Correction of OM-3 deficiency by determining changes in the Omega Score (OS, constituting blood concentration of EPA, DHA and DPA-docosapentaenoic acids). Secondary endpoints: changes in the serum lipid profile including TG and HDL-C. Results: Eight weeks of treatment with 6:1 OM-3 resulted in a significant increase in placebo adjusted median OS (+120.8%, p&lt;0.0001) with concomitant reduction in TG/HDL (-50.3%, p=0.0005), AIP (-46.9%, p&lt; 0.0006) and in AA (arachidonic acid): EPA (-86.6%, p&lt;0.0001) ratios. No significant changes in OS (-2.0% p= 0.5519), TG/HDL (+4.72%, p=0.5233), AIP (+2.43%, p=0.8119) or in AA/EPA (11.3%, p=0.6780) ratios were observed in placebo. Treatment with 6:1 OM-3 also resulted in a significant increase in placebo adjusted median levels of HDL-C (+9.1%, p=0.0069), a significant decrease in VLDL-C (-30.2%, p=0.0023) and with no significant changes in LDL-C (+11.3, p=0.1164). Conclusions: This study shows that 6:1 OM-3 is effective in correcting OM-3 deficiency in hypertriglyceridemic patients and that this correction is strongly associated with significant decreases in TG/HDL ratio and in AIP- an emerging predictor of cardiovascular risk.

A Highly Bioavailable Omega-3 Free Fatty Acid Formulation Improves the Cardiovascular Risk Profile in High-Risk, Statin-Treated Patients With Residual Hypertriglyceridemia (the ESPRIT Trial)

BackgroundA novel omega-3 formulation in free fatty acid form (OM3-FFA) has as much as 4-fold greater bioavailability than ethyl ester forms and reduces triglyceride (TG) levels in patients with severe hypertriglyceridemia. ObjectiveThis study was designed to evaluate the efficacy of adding OM3-FFA (2 or 4 g/d) to statin therapy for lowering non–HDL-C and TG levels in subjects with persistent hypertriglyceridemia and at high risk for cardiovascular disease. MethodsIn this double-blind, parallel-group study, 647 diet-stable patients with fasting TG levels ≥200 mg/dL and <500 mg/dL (treated with a maximally tolerated dose of statin or statin with ezetimibe) and at high risk for cardiovascular disease were randomized to 6 weeks of treatment with capsules of control (olive oil [OO]) 4 g/d, OM3-FFA 2 g/d (plus 2 g/d OO), or OM3-FFA 4 g/d. Assessments included fasting serum levels of lipids and apolipoproteins (apo); plasma concentrations of eicosapentaenoic acid, docosahexaenoic acid, docosapentaenoic acid, and arachidonic acid; and laboratory safety values and adverse events. ResultsIn the 627 subjects in the intention to treat sample, non–HDL-C levels were reduced with OM3-FFA 2 g/d and OM3-FFA 4 g/d (–3.9% and –6.9%, respectively) compared with OO (–0.9%) (both, P < 0.05), as were TG levels (–14.6% and –20.6%, respectively, vs –5.9%; both, P < 0.001). LDL-C levels increased with OM3-FFA 2 g/d (4.6%) compared with OO (1.1%) (P = 0.025) but not with OM3-FFA 4 g/d (1.3%). Total cholesterol and VLDL-C concentrations were reduced compared with OO with both OM3-FFA dosages, and the total cholesterol/HDL-C ratio and apo AI and apo B levels were significantly lowered with OM3-FFA 4 g/d only (all at least P < 0.05). Percent changes from baseline in HDL-C did not differ between OO and either OM3-FFA group. Plasma concentrations of docosahexaenoic acid, eicosapentaenoic acid, and docosapentaenoic acid were significantly increased and arachidonic acid was significantly reduced in both OM3-FFA treatment groups compared with the OO responses (all, P < 0.001). Withdrawals related to treatment-emergent adverse events ranged from 0.9% with OO to 3.2% with OM3-FFA 4 g/d. ConclusionsOM3-FFA was well tolerated and lowered non–HDL-C and TG levels at both 2- and 4-g/d dosages in patients with persistent hypertriglyceridemia taking a statin, with the 4-g/d dosage providing incremental improvements compared with 2 g/d. ClinicalTrials.gov identifier: NCT01408303.