> This is a case sent by Andy Waxler, an excellent clinical cardiologist in Pennsylvania, who was also a great medical resident when I was at Pitt. It’s worth a quick read to remember that allergic vasculitis can occur with PCSK9 inhibitors. We have not seen it and have about 300 patients on these drugs but it can occur.
FROM ANDY — “69-year-old patient who has CAD… intolerant to multiple statins even at very low dose… he and I embraced Praluent in 12/2017 — he initially tolerated it extremely well and had fantastic lipids panel. Unbeknownst to me, until he told me two days ago, over the past three months he’s noticed a pattern in which about five days after each injection(75mg Q2w) he’s had a predictable pattern of 2–3 days of myalgias/fatigue/dry cough… He tried to be stoic and didn’t tell me; once he tried himself on brief steroids and once he tried antibiotics. Last week, he had a very odd lipid panel in which his HDL dropped from 55 (six months ago) down to 5!!! (total cholest 49, trigs around 110, HDL 5). His most recent injection was one week ago and approximately 3–4 days later he developed severe fever/chills, headache, malaise, exertional dyspnea and dry cough. After a few days he came to the ER and was admitted; he had a fever, rigors, low WBCs, bilat. ground glass opacities on chest CT, blood cultures negative so far, urine negative, CK normal, ESR>140!!! Seen by multiple consultants; we all believe he has hypersensitivity vasculitis. He has responded beautifully to IV steroids.
Yes, I have discussed the case in detail with Regeneron/Sanofi, it has been officially reported.
MY REPLY — Luckily I have not seen this, but allergic vasculitis with these drugs has been reported. A couple of points:
1. Extremely low HDLs can be seen with monoclonal gammopathies and with extremely high antibody levels to anything. Serum amyloid A, which goes up in inflammation, is carried in the HDL particle and this may also hasten the HDL clearance.
2. Anytime the lipids get lower than expected, be a little worried about a drug side effect. This was most often seen with hepatitis from niacin where the LDL plummeted when they were getting hepatitis.
Paul
Paul D. Thompson, MD
Chief of Cardiology — Emeritus, Hartford Hospital
Professor of Medicine, University of Connecticut
Telephone: 860–972–1793
