Evolocumab Plus Ezetimibe in Haemodialized Statin-intolerant Patients With Hypercholesterolemia

Evolocumab is a monoclonal antibody that inhibits proprotein convertase subtilisin-kexin type 9 (PCSK9) and lowers low-density lipoprotein (LDL) cholesterol, reducing in turn the risk of cardiovascular events. Whether evolcumab is effective in haemodialized patients is uncertain. The investigators will conduct a randomized, double-blind, placebo-controlled trial to assess the feasibility, safety, and LDL-C-lowering efficacy of evolocumab in high cardiovascular risk haemodialized statin intolerant patients with hypercholesterolemia. Patients will be randomly assigned to receive evolocumab (140 mg subcutaneous every 2 weeks + ezetimibe 10 mg per os daily) or matching placebo (subcutaneous every 2 weeks + ezetimibe 10 mg per os daily) for 24 weeks. The primary efficacy end point will be the proportion of patients that will reduce LDL-C \< 55 mg/dL in the evolocumab group compared to placebo at 24 weeks. The key secondary efficacy end points will be: the reduction of LDL-C from baseline at 4, 6 and 12 weeks; the reduction of HDL-C, non-HDL cholesterol and triglycerides from baseline at 24 weeks. Every adverse event (serious and non-serious) correlated to drug infusion will be recorded (safety end-point).


Eligibility Criteria:
Inclusion Criteria:

* high cardiovascular risk defined as patients with: Documented cardiovascular disease (CVD), clinical or unequivocal on imaging. Documented clinical CVD includes previous acute myocardial infarction, coronary revascularization and other arterial revascularization procedures, stroke and TIA, aortic aneurysm and PAD. Unequivocally documented CVD on imaging includes plaque on coronary angiography or carotid ultrasound; DM with target organ damage or with a major risk factor such as smoking or marked hypercholesterolaemia or marked hypertension.
* History of statin intolerance, demonstrated by: trial of ≥2 statins with intolerance of any dose or to increase statin dose above the total maximum doses because of intolerable: Myopathy or myalgia (muscle pain, ache, or weakness without CK elevation), or Myositis (muscle symptoms with increased CK levels), or Rhabdomyolysis (muscle symptoms with marked CK elevation) and Resolution or improvement of symptoms when the statin dose was decreased or discontinued
* patients with LDL-C \>55 mg/dL
* end-stage renal disease on chronic hemodialysis
* Participant is willing and able to give informed consent for participation in the study.

Exclusion Criteria:

* secondary hypercholesterolemia (i.e. hypothyroidism, Primary biliary cholangitis, etc)
* Use of drugs or dietary supplements that can impact on cholesterol value (i.e. progestinic, red yeast rice, niacin \>200 mg/d, lipid-regulating drugs - eg, ﬁbrates or derivatives, ezetimibe, bile-acid sequestrants, stanols, or stanol esters - )
* Previous treatment with evolocumab or any other anti-PCSK9 therapy
* Inability to provide informed consent or to attend follow-up visits
* Unreliability as a study participant based on judgment of investigator's knowledge of the subject (eg, alcohol or other drug abuse, inability or unwillingness to adhere to the protocol, psychosis)
* Current enrollment in another investigational device or drug study or \<30 d since ending another investigational device or drug study
* serum triglycerides level \> 400 mg/dL at baseline
* Pregnancy, breastfeeding, or inadequate birth control in premenopausal female subjects
* Laboratory values at screening CK \>3 × ULN; AST or ALT \>2 × ULN