Lomitapide for the treatment of pediatric homozygous familial hypercholesterolemia

INTRODUCTION: Homozygous familial hypercholesterolemia (HoFH) is a rare, inherited disorder characterized by severe LDL-hypercholesterolemia and accelerated atherosclerotic cardiovascular disease. It typically presents in childhood or adolescence, and if untreated, may be fatal in the first decades of life. The microsomal triglyceride transfer protein (MTP) is essential for the assembly and secretion of apolipoprotein (apo)B-containing lipoproteins. MTP inhibition with lomitapide effectively lowers plasma LDL-cholesterol as an adjunct therapy in adults with HoFH. AREAS COVERED: We discuss the role of MTP as a therapeutic target for HoFH, describe the pharmacodynamics, pharmacokinetics, and metabolism of lomitapide, and report on the findings of the phase III APH-19 trial in pediatric HoFH. EXPERT OPINION: Lomitapide is an oral small molecule inhibitor of MTP, which reduces LDL-cholesterol by 53.5% in pediatric patients with HoFH on maximal standard lipid-lowering therapy, including lipoprotein apheresis. Moreover, small case series have shown that pediatric HoFH patients on lomitapide were able to cease or reduce the frequency of lipoprotein apheresis. Safety and tolerability studies are consistent with the known mechanism of lomitapide on the gastrointestinal and hepatic systems, and are generally mild and manageable in pediatric HoFH patients. The results of longer-term safety data are awaited.