The Promise of Apolipoprotein AI-Based Therapy
Authors: VG Trusca 
Published: November 2021

Apolipoprotein A-I (ApoAI) is an anti-atherosclerotic protein that promotes cholesterol efflux from tissues to the liver for excretion [1]. ApoAI is the main structural and functional protein of High- Density Lipoproteins (HDL), representing ~70% of total HDL proteins [2,3]. Circulating apoAI protein is an amphipathic protein (28kDa) comprising eight alpha-helical domains of 22 amino acids and two repeats of 11 amino acids [4]. Consequently, ApoAI binds avidly to lipids and readily moves between lipoprotein particles; however, ~5-10% of human plasma ApoAI exists in a free state (lipoprotein-unbound) [5]. ApoAI protein is more than a structural scaffold that maintains lipid packaging, as it plays an important role in the transport of cellular cholesterol from the artery wall to the liver for catabolism [6-8]. Antioxidant and anti-inflammatory properties were also attributed to apoAI [9,10]. In addition, a protective role of apoAI against cancer was proposed [11]. ApoAI is synthesized mainly in the liver and small intestine and there are a lot of regulatory elements and transcription factors that control apoAI gene expression, as reviewed in [12]. Treatment with BPA (bisphenol A), one of the most widespread environmental chemicals, downregulates ApoAI gene expression, aggravating the atherosclerotic plaques in LDLR-/- mice [13]. Interestingly, the ratio of HDL-cholesterol to apoAI protein levels is an indicator of the risk of the cardiovascular disorder [14]. Lack of ApoAI augmented atherosclerosis in various hypercholesterolemic mice, such as mice expressing human apoB or ApoAI-/-/LDLR-/- mice [15,16]. In humans, familial ApoAI deficiency is associated with premature coronary heart disease [17]. Interestingly, low levels of apoAI and atherogenic dyslipidemia were found in obese individuals, but increases in apoAI levels and enhancements of cholesterol efflux capacity of HDL were reported at three months after bariatric surgery [18]. Considering the anti-atherogenic properties of apoAI, various apoAI-based therapies were proposed for reduction of atherogenesis: i) overexpression of ApoAI, ii) infusions of ApoAI protein, ApoAI mimetic peptides, or ApoAI-containing HDL [19-21], iii) oral small molecules that stimulate ApoAI production [22]. Overexpression of ApoAI reduced atherogenesis in apoE-/- or LDLR-/- atherosclerotic mice [23-31]. Infusions of ApoAI mimetic peptides led to the regression of aortic valve stenosis in rabbits [32]. Liver-directed adenoviral gene transfer of ApoAI resulted in the regression of preexisting atheroma in LDLR-/- mice [33]. Undoubtedly, local delivery of apoAI protein to the vascular wall represents a more efficient apoAIbased therapy than its systemic delivery. Remarkably, transduction of vascular endothelial cells with ApoAI expressing adenovirus reduced inflammation and protected against atherosclerosis in hyperlipidemic rabbits [34,35]. The oral drug RVX-208 significantly increased apoAI production in monkeys but presented disappointing efficacy in a phase II trial [36]. Notwithstanding there are good results obtained in studies using animal models, several apoAI-based clinical trials failed to regress atherosclerotic plaques in humans [37,38]. Despite tremendous advances regarding the understanding of apoAI, the promise of apoAI-based therapy awaits new studies and trials.