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1. Herbie, we have never accused Amarin of outright fraud. Also, a public service is free to the public, whereas our services are not free. Our research is proprietary, and priced according to its quality and specificity. For example, as this report written by this market research company:
2. We would suggest that ever-searching the motives of others is a poor way to derive information. Also, as policy, we avoid the active trading of securities to help ensure our analysis is tinged with as little bias as possible. During and after the writing of our AMRN report, no member was long or short AMRN securities. This remains true today.
Notice also that even though the rTG form contained less EPA (650 mg) per tab than the ethyl ester form (753 mg), the resultant EPA increase from taken either was similar. Importantly, subjects consumed a well-controlled high fat diet during the study, and always took the supplements with food, which greatly helped the absorption of the EE form supplements. Something that does not happen in the real world, where polypharmacy is common before sleeping.
So, biobillionaire, what do you think would happen if subjects took just two of those Nordic Natural rTG form tabs (half the REDUCE-IT dose)? Would their EPA levels go up to the median seen in REDUCE-IT or higher? Yes, likely.
To answer both of these questions--no. We wrote our report on Amarin of our own volition, and received no compensation on condition of writing it. Neither do any of our members have ties to AZN, nor omega-3 dietary supplement merchants and suppliers.
This isn't quite right. One has to consider bioavailability, and ethyl ester forms are inferior to FFA and rTG forms--unless consumed concurrent with a high fat meal--and even then EE form is still inferior, only less so. It's one thing to strictly enforce dietary habits in a smaller study for 12 weeks, and quite another to instruct and then set free a huge population over numerous years. They just don't do what you tell them to. Actually, seeing a 300 -400% increase in EPA levels (as in REDUCE-IT) is quite easy. It happens when taking simple, cheap, off the shelf "concentrated" (they nearly all are these days) fish oil supplements.
You stated that the EPA:AA ratio was important and related to ASCVD, did you not? Do you contend that taking an off the shelf, high EPA content dietary supplement will raise EPA blood levels? In particular if it is in rTG form and need not be consumed with a moderate to high fat meal to assist with absorption, as is the case with ethyl ester EPA supplements like Vascepa?
We think Amarin is afraid to say anything about that ratio, because obtaining levels seen in REDUCE-IT is in fact very easy for anyone without a prescription in hand.
Sorry, but, we never wrote that. And it would be against our policies; we do not give investment advice, we publish content that may assist as part of a firm's overall due diligence on a company they are contemplating an investment in; short selling their stock; partnering with; or acquiring. Some individual investors may also find our services of use, particularly if they themselves have some expertise in the sector, or have consultants at their disposal that can assist with the material. Our report on Amarin contains no recommendations on what to do with their stock, or any strategies therewith.
It would be a mistake for Amarin to push the EPA:AA ratio idea, especially with the angle that it was this that had anything to do with a reduction in ASCVD, as it is very easy to move the needle of that ratio in EPA's favor by eating a lot of fish, or taking a cheap fish oil supplement with a high percentage of EPA in it. Why do you think they have been silent about that? STRENGTH might even read out with higher EPA levels in its active arm subjects than those treated with Vascepa in REDUCE-IT.
Charming handle. But, you are incorrect. AZN's patents covering Epanova are quite secure, and well written, unlike Amarin's patents covering Vascepa, which are weak and full of redundancies. There is nothing novel about ethyl ester EPA, especially not for the use of lowering trigs.
A line in the supplement to the NEJM paper on REDUCE-IT cites the result of an analysis of log-transformed hs-CRP data, which showed a highly significant 21.8% reduction in IPE group, and no change from baseline in the placebo group. The sponsor’s website provides the following explanation:[1]
However, with a study as large as REDUCE-IT, and with nine separate fasting lipid panels performed on average per subject to ascertain levels,[2] log-transforming biomarker data is unnecessary, and analyses based on such data could be misleading.
The Central Limit Theorem (CLT) states that the sampling distribution of the mean of any independent, random variable will be near normal if the sample size is large enough. Thus, the means of large samples will closely follow a normal distribution, whatever the distribution of the observations themselves.[3] Generally, this is considered true in samples of modest size where skewness and kurtosis are low, but certainly in samples of over 500 subjects when skewness and kurtosis are high.[4]
As the CLT stipulates that for large samples the mean can be approximated by a normal distribution even if the population is non-normal (i.e. data are skewed), then if the sample size is large, it is appropriate to use a t-test.[5] With over 4,000 subjects per arm in REDUCE-IT, and with the added benefit of so many repeat lipid panels performed, untransformed hs-CRP data will follow a normal distribution (mean and median approximately equal). Essentially, REDUCE-IT is over-sized and over-powered when doubling as a biomarker trial, i.e. there were 1,612 major coronary events, but >8,000 biomarker “events.” The percent changes noted in the study are based on median values, which reflect the central tendencies of the robustly sized groups. And because of the large size of each treatment group, the geometric mean and median hs-CRP values will be near equal, and the kurtosis near 3.[6] Skewness will also affect both groups approximately equally, and thus, any subsequent regression to the mean will equally impact both arms.
As the previous citation also enumerates, log-transformation has been shown to have major drawbacks. It can cause right-skewed data to become left-skewed, and may even increase skewness; it can often increase—instead of reduce—the variability of data, whether or not there are outliers; it can lead to inaccurate estimates of the true population mean of the original data; it can cause significant errors in hypothesis testing, and is prone to numerous user errors as well. There is also little value in comparing the variability of original versus log-transformed data because they are on different scales. Log-transformed data therefore cannot usually facilitate inferences concerning the original data, since it shares little in common with the original data.[7] Therefore, an analysis based on classical statistical methods or generalized estimating equations is most appropriate.
Lastly, and as was also seen in JUPITER and CANTOS, hs-CRP values were highly consistent between lipid panel tests over years in both arms of REDUCE-IT (after the initial post-randomization changes had occurred). It has previously been shown that hs-CRP levels are as consistent over time as total cholesterol and blood pressure.[8] This adds to the reliability of interpretations based on observed levels.
The above considerations make drawing conclusions based on log-transformed hs-CRP data from the REDUCE-IT trial potentially misleading. Comparing the percent median change between groups using untransformed hs-CRP data is an accurate and reliable way to analyze these data.[9]
***
1.7 Confirmation of an Adverse Impact of Mineral Oil on Drug Absorption
The elevation of all atherogenic and inflammatory markers measured in MO placebo group in the REDUCE-IT trial was previously observed to a similar degree in a separate study—the ANCHOR trial, also sponsored by Amarin Corp.
In ANCHOR, over 700 subjects (all of whom were on background statin therapy) were randomized 1:1:1 to either 4 g/d MO arm, 2 g/d EPA arm (which included 2 g/d MO in addition to 2 g/d EPA[10]), or 4 g/d EPA arm. The trial was designed with an extensive lead-in period to stabilize lipid and lipoprotein values before randomization. The median percent changes in parameters from baseline to 12 weeks per group were as follows:
An extensive wash-out and stabilization period should help control against errant swings in markers between the three robustly sized groups (approximately 230 randomized per arm). The lead-in period protocol details from the ANCHOR trial are outlined below:
After examining the ANCHOR trial data, an FDA reviewer stated the following in the briefing documents:
In his book Dyslipidemia: Pathophysiology Evaluation and Management, 2015., Dr. Garg writes,
Although the most profound elevations in markers were observed in the 4 g/d MO arm, the 2 g/d arm exhibited a muted effect compared to what might be expected from this dose of concentrated EPA. For example, in the ORD study, comparing TAK-085 (a POM3) with EE-EPA, the 1.8 g/d EPA arm (n=195) showed an 11.2% reduction in triglycerides at the end of 12 weeks of dosing.[11] However, in ANCHOR, 2 g/d EPA combined with 2 g/d MO resulted in a more tepid 5.6% reduction in TG. Importantly, mean TG levels at baseline were similar between the two studies (272 mg/dL in the ORD study and 262 mg/dL in ANCHOR).
In fact, the 5.6% reduction in TG in the 2 g/d arm is similar to the reduction seen in the 4 g/d olive oil placebo arm in the ESPIRIT trial, which enrolled subjects of similar background therapy and baseline TG levels as ANCHOR. There, a 5.9% reduction from baseline in TG level was observed in placebo group.[12]
Was concurrent dosing with MO somehow negatively impacting the efficacy of EPA, or perhaps hindering statin absorption, thus attenuating the overall TG lowering effects observed in the ANCHOR 2 g/d group? The same incongruency is observed in other markers as well, for example non-HDL-C was reduced by 5.7% in ORD (1.8 g/d arm), but increased by 2.4% in ANCHOR (2 g/d arm).
From the MARINE trial data (~25% of whom were on background statin therapy), which also tested 4 g/d EPA against 4 g/d MO or 2 g/d MO+2 g/d EPA in subjects with very high triglycerides (>500 mg/dL), an FDA reviewer commented on the wild fluctuations in mean triglyceride levels in the two arms that received MO, while no fluctuation in the 4 g/d EPA arm that received none. This is consistent with the notion that MO causes some form of interference with drug absorption.[13]
Interestingly, in the ANCHOR and REDUCE-IT placebo groups there was a 4.8% and 4.7% increase in HDL-C respectively, both significant. Counter-intuitively, HDL-C has been shown to increase more from a lower versus higher atorvastatin regimen.[14]
The increase in HDL-C in both placebo groups might therefore be expected if the dose was effectively lowered due to malabsorption. In the MARINE trial, where the vast majority were not on statin therapy, HDL-C was unaffected in either the 4 g/d MO or 2 g/d MO+2 g/d EPA groups.
In the REDUCE-IT trial, highly significant increases in atherogenic markers also appeared in the MO placebo group quickly (at the next blood draw 4 months later) and remained elevated throughout the study. Meanwhile, in those randomized to IPE arm, there was little change (i.e. LDL-C moved down slightly from 85.8 mg/dL at baseline to 83.6 mg/dL at month 4, then back up to 85.3 mg/dL at year 1 and to 85.5 mg/dL at year 2)—except in markers known to be impacted by EPA, such as TG and, to a lesser extent, non-HDL-C.
Regarding the differences in risk reduction seen between subjects on low (HR 1.12), medium (HR 0.76) and high-intensity (HR 0.69; p=0.12, significant for interaction) statins in the REDUCE-IT study, a related phenomenon surfaced in ANCHOR.
However, this was “compared to placebo.” The “decreased hs-CRP” as stated was not due to an observed reduction in hs-CRP levels in IPE group from baseline (-2.4%, p>0.05), but instead due to the highly significant increase in hs-CRP levels in the MO placebo arm. The breakdown is given as follows:
But why would IPE—compared to MO placebo—have such differential effects on CRP, depending on the intensity of the background statin therapy of the subject? We can see that IPE had no measurable impact on CRP levels from baseline in those dosed with it; therefore, whatever impact on CRP is likely coming not from IPE, but from an adverse effect of MO on placebo group subjects.
High-intensity statin regimens produce the largest reductions in CRP levels, followed by moderate and then low-intensity regimens.[16], [17] Therefore, if MO attenuated the efficacy of statin therapy, we would expect those on high-intensity statins to show the largest increase in CRP levels, followed by those on moderate-intensity, with the least change in those on low-intensity regimens. And that is what the ANCHOR trial data show.
Regarding the difference in changes in hs-CRP levels between the ANCHOR (+17% at 12 weeks) and REDUCE-IT (+32.3% at year 2) studies, Bonnet et al. (2008)[18] showed that after an initial sharp decrease in CRP levels from statin therapy, high-dose therapy further lowered levels over a 26-week follow-up period; i.e. atorvastatin 10 mg/d produced a 25% decrease in hs-CRP over a 5-week period, which was maintained at 26 weeks (-24.3%), whereas the 80 mg dose produced a 36.6% decrease over 5-weeks, which then continued on to a 57.1% decrease at 26 weeks. Thus, even in this regard, the ANCHOR and REDUCE-IT studies mirror what might happen at different time points if statin therapy was attenuated in one group of randomized high-risk subjects, but not the other.
Having two clinical trials testing the same therapies (IPE vs MO) in back to back succession, reproducing the findings in one other, adds to the reliability of the evidence presented. In this case, the evidence suggests that MO adversely impacted the efficacy of concomitant therapies.
***
3.2 Critique of Amarin’s U.S. ITC Complaint
Regarding the Complaint brought to the ITC by Amarin against high-purity omega-3 manufacturers (initially dismissed, but being appealed currently[19]), which side-stepped the FDA’s ministerial role on what constitutes a dietary supplement vs. a drug, other authors have previously offered extensive reporting on the issues involved.[20] It is clear to us that high-purity EPA-E was in use as a dietary ingredient well before the Investigational New Drug Application (IND) for Vascepa (no. 102,457 [21]) was granted. Thus, code 21 USC 321(FF)(3)(B) of the FD&C Act[22] does not preclude high-purity EPA-E as a dietary ingredient in that regard. If Amarin had developed and received an IND for a fully synthetic or otherwise unique EPA analogue (vs. the semi-synthetic prodrug EPA-E), which thereafter was made into and sold as a dietary supplement, they would have a case under 21 USC 321. However, Amarin is arguing more broadly that ethyl ester forms (and thus also rTG forms that use an EE step) of EPA and/or DHA are not dietary supplements as defined by the FD&C Act, and further, that their use historically as such only came after these semi-synthetic versions of EPA and DHA were granted INDs.[23]
To reiterate, FDA defines a “dietary supplement” as that containing one or more “dietary ingredients,” further defined as follows:[24]
This includes synthetic or semi-synthetic forms of vitamins, minerals and amino acids. However, synthetically or semi-synthetically produced botanicals, and even esterified omega-3s (as well as other esterified nutrients) at some point may not be deemed to be dietary ingredients (FDA hasn’t issued final guidance on this yet). In their natural forms, EPA and DHA are considered essential fatty acid nutrients, fitting in the category: “a dietary substance for use by man to supplement the diet by increasing the total dietary intake…” But in esterified form, they may not be deemed thus.
From the latest FDA-draft guidance on this topic as of 03-2019:[25]
The language in the above mention seems to suggest that an esterified product is not deemed to be a dietary ingredient, but it is not definitive. It asserts only that the esterified form is a “new substance” and that this “new substance is not considered to be a dietary ingredient merely because it has been altered from a substance that is a dietary ingredient…” It does not explicitly state that this new substance “is not a dietary ingredient,” only that it is a “new substance” that cannot be deemed a dietary ingredient solely (aka “merely”) on the basis that its unaltered form is a dietary ingredient. That does not preclude other rationale for it to potentially be considered a dietary ingredient. As such, some or all esterified products could still fall in line with the requirement to be reported as a New Dietary Ingredient (NDI), which is the main subject matter of this draft guidance document the mention is found in, entitled, “Dietary Supplements: New Dietary Ingredient Notifications and Related Issues: Guidance for Industry.”
As an aside, we wonder here if FDA did not instead mean transesterification [26] when they wrote “esterification” above, as the latter is also a natural process and frequent result of human metabolism[27] (as is “re-esterification”[28]). In fact, any process (metabolic or otherwise) that results in an ester being made is an ‘esterification process.’ This occurs when, for example, a fatty acid is combined with an alcohol (such as ethanol, glycerol, etc.).[29] Trigycerides are thus fatty acid esters of glycerol, formed as a result of esterification.[30]
The “It depends” mention in the draft guidance above relating to metabolites might therefore still be applicable to esterified forms of EPA and DHA, but not ethyl ester forms, which cannot be achieved as a result of human metabolism (no naturally occurring ethanol). However, so called “monoglyceride omega-3s” would appear to fit the excepted clause.[31], [32], [33], [34], [35], [36] Also, “rTG” forms appear to be applicable, as we will elaborate on forthcoming.
The draft guidance clarifies that if a product was in use before Oct. 1994, it may be “grandfathered in,” and not required to be reported as a “New Dietary Ingredient” (NDI). Yet, the guidance also states that an ingredient must first be defined as a “dietary ingredient” to then be either an NDI or not. Thus, the main question (and it is an open question) is whether or not the FD&C Act precludes ethyl ester forms (and potentially rTG forms that first rely upon a transesterification step) of EPA and DHA being deemed “dietary ingredients.”
Another mention by FDA in a letter to AIBMR Life Sciences brought up in Amarin’s appeal is also relevant.
[To AIBMR]:
However, once again we are met with open-ended phrases such as “it is unclear if…” and “FDA cannot determine, at this time, whether your product contains a dietary ingredient (DI)…” FDA clearly acknowledges the ethyl ester forms of EPA and DHA lie outside the statutory definition of a DI, but do not go one step further and outright state they are not DIs. They conclude only it is “unclear” and “cannot be determined at this time.” That at least leaves the door open to a future determination by FDA that EPA-E and DHA-E are DIs.
According to the FD&C Act as interpreted by FDA, synthetic vitamins, minerals, and amino acids are considered dietary ingredients despite their synthetic nature. But that does not mean all other synthetic ingredients are precluded as DIs. For instance, FDA mentions “vanillin” and “cinnamic acid” as synthetic botanical constituents that are considered “dietary ingredients,” due to their long-standing use in food products and very safe track record. The same could possibly be said of ethyl ester omega-3s included in food products for many years now.[37]
In a warning letter to an “ethyl ester creatine” merchant, there is found no mention of the substance itself being deemed as not qualifying as a dietary ingredient, only issues regarding labeling and quality control.[38] If FDA deemed ethyl ester creatine to not be a DI, it would be most straightforward for them to have notified the merchant that they were selling a “drug,” not a “dietary ingredient.” The omission of such is in one respect a concession.
The following from the draft guidance in question may allow reconstituted (aka “re-esterified”) TG (rTG) forms, which return EPA-E/DHA-E to their original TG-form components as found in nature (plus some metabolites) and absent any ethanol, to be considered DIs:
Contrariwise, it could be said that “components that were present in the original plant” that are part of the “new material” are dietary ingredients, despite the semi-synthetic nature of the composition.
A description of rTG is as follows:[39]
Nordic Naturals’ products take advantage of a process that yields an even higher percentage of TG in the final composition:[40]
They also provide helpful graphics to illustrate the components and their metabolism:
Thus, the rTG form is a mixture of what exists in the “original” fish oil, with a lesser percentage of the components that are known metabolites as the body breaks down TGs into free fatty acids and monoglycerides, with some diglycerides also present.[41] Re-esterification is part of this natural metabolism process, with ethanol absent in the final composition.[42] Thus, by our reading of FDA guidance, rTG forms of EPA/DHA should pass muster as dietary ingredients, due to being comprised of 1) mostly TG forms, which are present in the “original” nutrient source (i.e. anchovy, sardines), and 2) metabolites of a dietary ingredient: monoglyceride and diglyceride EPA/DHA. The process also need not take place in the human body.
The only hitch we can see is the last sentence in the above, which might exclude rTG forms in a very strict reading, as an intermediary transesterification process does occur that breaks off the glycerol “backbone” and causes the resultant free fatty acids to cleave to ethanol. This greatly helps concentrate the EPA and/or DHA present in the crude batch via subsequent molecular distillation. But the final rTG product form contains only natural EPA-TG and/or DHA-TG and metabolites of EPA-TG/DHA-TG. This may be enough to convince the ITC (especially given this is an unfinalized draft guidance), even if it might take an eventual citizen petition to persuade the FDA:
Whether ethyl ester forms of EPA and DHA (whereby the free fatty acids remain cleaved to ethanol) are dietary ingredients would not be defensible by this argument, however. Yet by extension, it may be. FDA has stated the following with regard to ethyl alcohol in goods or in the manufacture of foods:[43]
Also, the human body metabolizes the consumption of alcohol and fatty acids to make “fatty acid ethyl esters” (FAEE), which in this case cannot then be considered synthetic.[44]
Beyond these observations, there may also be some room for interpretation of the following mention from the current draft guidance:
For example, a synthetically produced amino acid, i.e. L-carnitine, which is often taken as a weight-loss supplement,[45] is considered a DI based upon its ability to provide L-carnitine to the human body, and the identification of L-carnitine as a “nutrient” itself—as opposed to a synthetic botanical such as echinacea, which cannot in and of itself be considered a “nutrient”—and furthermore, “A substance that has been synthesized in a laboratory or factory has never been part of an herb or other botanical and, therefore, is not a dietary ingredient under section 201(FF)(1)(C) of the FD&C Act.” But EPA-E and DHA-E were “part of” a natural food source, and further, are directly assimilated in and used by the human body as nutrients (essential fatty acids). Therefore, it may be more apt to consider EPA and DHA in a similar category as “vitamins, minerals and amino acids,” or perhaps more succinctly for them all: nutrients. Certainly, the end result is the same—500 mg of EPA-E and 500 mg of NTG EPA will both result in increases in serum EPA levels. It is similar to various forms of vitamin E, in fact, available in natural, synthetic and semi-synthetic forms.[46], [47]
Furthermore, one could argue that since semi-synthetic and synthetic fats of various kinds have long been used as dietary ingredients, such as hydrogenated oil (common fat bound to hydrogen) and “Olestra” (a sucrose polyester), and because EPA/DHA are fatty acids themselves, that a semi-synthetic modification of these falls under the same category of DI.
Amarin’s goal is to get the Federal Circuit to remand the Complaint back to the ITC, charging them to investigate the matter and rule one way or the other. The ITC must then decide whether to infer from the draft guidance or not, and whether it should be concluded that EPA-E is not a dietary ingredient, but rather, a drug, from its interpretation of the FD&C Act. But that is a tall order considering the open-ended nature of the mentions in the draft guidance, and the major changes FDA has historically made to previous drafts to arrive at its final guidance—even omitting entire sections from draft-only versions.[48] Furthermore, FDA is not even legally bound by its own final guidance in making specific decisions that may at times contradict its own guidance.[49] And, most importantly, Congress has solely charged FDA with the ministerial role of interpreting and applying the FD&C Act.[50]
FDA issued a comment to the ITC on the case, stating:[51]
FDA is also working on a master list of those “grandfathered-in dietary ingredients,” including all products that are considered “dietary ingredients” and are exempted from reporting as NDIs by FDA.[52] If ethyl ester forms of omega-3s make it onto the list, then that would absolve manufacturers of the same.
And so, we await the outcome.[53] At worst, supplement manufacturers would be restricted to producing concentrated free fatty acid, natural triglyceride and monoglyceride forms of EPA and DHA (and we think rTG forms would also be allowed), all of which do appear to be better absorbed than ethyl ester forms in any event.[54] Of course, being disallowed to produce EE forms would certainly be a setback to the omega-3 supplement industry, and at least a short-term victory for Amarin. However, we think there is a high likelihood that the Federal Circuit upholds the ITC decision not to take up the case, as the subject matter requiring its ruling lies outside its jurisdiction, and abides only with the FDA.
UPDATE:
The Federal Circuit has issued a ruling against Amarin Corp., 2-1, with the dissenting opinion not disagreeing with the ruling of the majority necessarily, but only in that the dissenting justice viewed the case to be outside the Federal Circuit’s jurisdiction, that the grounds upon which an appeal to the decision by the ITC weren’t even met. The Justice’s view pertains to a subtlety of law, whereby only the ITC’s “final determination” may be appealed, not their decision “not to institute an investigation.”[55] The majority ruled that the ITC was correct in not instituting the investigation as the subject matter lied outside their jurisdiction. And, importantly, they (reiterating the ITC decision) left open the ability for Amarin to try their case again after the FDA issues a determination on whether or not the FD&C Act (FDCA) precludes ethyl ester forms, and forms that use a transesterification step, as drugs and not dietary ingredients. In essence, it was a majority verdict against Amarin.
Amarin may attempt to spend more resources appealing to the Supreme Court, but there is very little chance that their ruling differs.
[3] Douglas G Altman. Statistics notes: The normal distribution. BMJ 1995;310:298.
[4] Thomas Lumley, Paula Diehr, Scott Emerson, and Lu Chen. The Importance of the Normality Assumption in Large Public Health Data Sets. Annual Review of Public Health. 2002 23:1, 151-169
[6] DeCarlo LT. On the Meaning and Use of Kurtosis. APA. 1997.
[7] Feng C, Wang H, Lu N, et al. Log-transformation and its implications for data analysis. Shanghai Arch Psychiatry. 2014.
[8] Robert J. Glynn, Jean G. MacFadyen, Paul M Ridker, et al. Tracking of High-Sensitivity C-Reactive Protein after an Initially Elevated Concentration: The JUPITER Study. Clinical Chemistry. 2009.
[9] Geraci M1, Alston RD, Birch JM. Median percent change: a robust alternative for assessing temporal trends. Cancer Epidemiol. 2013.
[10] Bays HE, Ballantyne CM, Doyle RT, et al. Icosapent ethyl: Eicosapentaenoic acid concentration and triglyceride lowering effects across clinical studies. Elsevier. 2016.
[11] Tatsuno, Ichiro et al. Efficacy and safety of TAK-085 compared with eicosapentaenoic acid in Japanese subjects with hypertriglyceridemia undergoing lifestyle modification: The omega-3 fatty acids randomized double-blind (ORD) study. Journal of Clinical Lipidology. 2013.
[12] Maki KC1, Orloff DG, Nicholls SJ, et al. 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). Clin Ther. 2013.
[14] Agrawal D, Manchanda SC, Sawhney JP, et al. To study the effect of high dose Atorvastatin 40 mg versus 80 mg in patients with dyslipidemia. IHJ. 2018.
[15] Bays HE, Ballantyne CM, Braeckman RA, Stirtan WG, Soni PN. Icosapent ethyl, a pure ethyl ester of eicosapentaenoic acid: effects on circulating markers of inflammation from the MARINE and ANCHOR studies. Am J Cardiovasc Drugs. 2013.
[16] Zamani B, Saatlo BB, Naghavi-Behzad M, Taqizadeh-Jahed M, Alikhah H, Abbasnezhad M. Effects of high versus low-dose atorvastatin on high sensitive C-reactive protein in acute coronary syndrome. Niger Med J. 2014.
[17] Scott Kinlay , Gregory G. Schwartz , Anders G. Olsson, et al. High-Dose Atorvastatin Enhances the Decline in Inflammatory Markers in Patients With Acute Coronary Syndromes in the MIRACL Study. Circulation. 2003.
[18] Bonnet J, McPherson R, Tedgui A, et al. Comparative effects of 10-mg versus 80-mg Atorvastatin on high-sensitivity C-reactive protein in patients with stable coronary artery disease: results of the CAP (Comparative Atorvastatin Pleiotropic effects) study. Clin Ther. 2008.
Bearish AMRN Report: by Medical Research Collaborative, LLC (sample pages)
Following the publication of the REDUCE-IT trial results in November of 2018[1] and the issues that came to light therein, Amarin Corp. (NASDAQ: AMRN) posted a series of apologetics on their website.[2] We found many of these to be lacking in scientific rigor.
For example, the results of a post-hoc subgroup analysis were offered to explain away the observed increase in LDL-C in the placebo group (which was first suggested by the REDUCE-IT trial investigators as possibly due to dosing with mineral oil) and the potential for such to have exacerbated the control event rate.[3]
According to the sponsor (Amarin Corp.), the analysis suggests a lower risk for icosapent ethyl (IPE), aka "Vascepa," group compared with placebo group, regardless of whether or not there was an increase in LDL-C level among patients in the placebo group. The sponsor argues this is proof that statin absorption was either not affected by dosing with mineral oil, or even if it was, had no material impact on the risk of atherosclerotic cardiovascular disease (ASCVD) events, since even those placebo group subjects with no change or a decrease in LDL-C (hence, we assume their statin meds were working just fine) still performed worse than IPE group.
However, the critical drawback to this subgroup analysis is that it was not pre-specified, and therefore fails to take into account the baseline risk of the placebo subgroup that showed “no change/decrease in LDL-C” relative to the baseline risk of the placebo subgroup that showed an “increase in LDL-C” relative to the IPE group. As such, it remains uninterpretable, given that the baseline characteristics (major prognostic factors) between the subgroups explored are not equivalent. An adjusted analysis was not provided either, which might have induced at least some confidence in the finding.[4]
The sponsor was also not forthcoming on the number of subjects in each placebo subgroup (number at risk info is conspicuously absent from both charts). Upon closer inspection, it appears that the “no change/decreased LDL-C” subgroup was much smaller than the “increased LDL-C” subgroup, inflating inter- and intra-group variability (a negative consequence of low statistical power[5]); zooming-in on the original plots that they provide[6] roughly reveals the upticks on the curve:
By our count, it appears to be around 75 key secondary endpoint events for the “no change/decreased LDL-C” placebo subgroup, which leaves about 530 events for the “increased LDL-C” placebo subgroup (in the NEJM paper they enumerate 605 total key secondary endpoint events in placebo group). This is also probably why they avoid any mention of p-values associated with the stated HRs.
Comparing time-to-event rates between these placebo subgroups and the IPE group and drawing conclusions based on such is therefore flawed, due to a lack of equivalent baseline risk between groups and the potential for exaggeration of observed effects from the smaller sample. The fact that the second chart above shows a marked increase in the incidence of “hard” major coronary events (MCE) in the “no change/decreased LDL-C” subgroup beyond 3-years compared to the “increased LDL-C” subgroup (a counter-intuitive observation) infers that the former is much more likely to be a higher risk group than either of the other two (i.e. higher percentage of secondary prevention patients, higher overall BMI, greater prevalence of male subjects and smokers, higher overall levels of atherogenic and inflammatory markers, etc.). The hierarchy of baseline risk by group would then be (from highest to lowest): “no change/decreased LDL-C” group > IPE group > “increased LDL-C” group. It would be expected, then, for the "no change/decreased LDL-C" group to perform worse than the IPE group, as they are a higher baseline risk group (and apparently much smaller in number). We cannot reasonably conclude anything more than this without grossly overinterpreting these data.[7]
Thus, the analysis fails to prove: (a) that statin malabsorption did not occur in placebo group subjects, or (b) if statin malabsorption did occur, it did not meaningfully impact the placebo group’s performance. Post-hoc subgroup analyses such as these—especially when unadjusted—are innately unreliable, and appropriate for hypothesis generating only.[8]
On the second point, regarding the JELIS trial,[9] there are major limitations to the study that make generalizability difficult. It was open-label, and open-label trials are notorious for reporting exaggerated treatment effects;[10],[11] and the only significant individual finding from the trial was a reduction in unstable angina, with well over half of the primary endpoint events comprised of these (193 vs 147 events, p=0.014). Therefore, there is an increased likelihood the results were due to performance bias and/or detection bias, resulting from changes in patients’ behavior, physicians’ treatment, or event ascertainment.[12],[13],[14] It was also comprised of a 100% Japanese population of patients with poorly controlled LDL-C (182 mg/dL at baseline); nearly 70% were women; all were given very low dose statin regimens, even for an all-Asian population (pravastatin 10 mg/day or simvastatin 5 mg/day), and around 27% of the subjects discontinued statin use during the study (whether or not more control group subjects discontinued statin use earlier than ethyl ester EPA (EPA-E) group subjects was not disclosed).
Importantly, in JELIS, the MCE composite endpoint itself was different from that in REDUCE-IT. It included revascularization and hospitalization for unstable angina, but did not include strokes. In order to make an apt comparison with the REDUCE-IT trial—ignoring for a moment the numerous differences in populations and background therapies—the same composite endpoint should be used. When this is done, with strokes included, the RRR in JELIS decreases sharply from 19% to just 11.5%, insignificant from 914 events ([324 vs 262 non-stroke MCE; HR 0.81] + [162 vs 166 stroke events; HR 1.02] = blended HR 0.885). Comparing the reported 19% RRR in JELIS with the 25% RRR in REDUCE-IT is therefore misleading.
Not only this, but there was no perceived effect on coronary death (HR 0.94, p=0.81) in JELIS, and all-cause mortality trended worse for treatment group (265 vs 286 events, HR 1.09, p=0.33).
It can only be said that in this open-label, 100% Japanese, 70% female-gender study, 1.8 g/d EPA-E (aka “IPE”) significantly reduced unstable angina in subjects not optimally treated, with the potential for bias to have overinflated the result. JELIS is not a trial that reliably shows IPE can significantly reduce the risk of ASCVD events, particularly not in a patient population similar to that of REDUCE-IT.
Furthermore, a positive result from one study is often not reproduced in later trials. This is one reason that FDA normally requires at least two adequate and well-controlled studies as proof of efficacy and tolerability.[15]
For example, the GISSI-Prevenzione trial, which tested 1 g/d omega-3 ethyl esters (OM3-E) vs control in over 11,000 Italian post-MI subjects, demonstrated a significant 15% RRR in the primary MCE composite, which included all-cause mortality, MI and stroke. The study showed a 20% reduction in death from any cause and a 30% reduction in CV mortality (each also significant) compared with control. There was also a 44% reduction in sudden death (p<0.01). This led to Omacor 1 g/d (aka “Lovaza”) being indicated for secondary prevention (following MI) in major EU member states. The AHA also began recommending 1 g/d omega-3s for secondary prevention,[16] though there was no formal FDA approval for that indication. However, subsequent placebo-controlled trials did not reproduce the positive findings,[17] and as contrary evidence continued to mount,[18] the EMEA eventually decided to retract their approval.[19]
What happened here? Was the result due to the open-label design? It does not seem possible that that could have affected an endpoint like mortality. Was it due to differences in background therapy between GISSI-P and more modern trials? That could be a plausible explanation, as most of the subjects, especially early on in the study (when much of the benefit in mortality was realized), were not on statin therapy. It is possible that the reduction in sudden death in particular was the result of antiarrhythmic and antifibrillatory properties that have been ascribed to omega-3s.[20] These same properties are also ascribed to statins, particularly at higher doses.[21] There were likely untreated targets present due to lack of statin therapy in GISSI-P subjects. Later trials were conducted in an era where all secondary prevention subjects are given moderate to high-intensity statins following an MI (as well as numerous other treatments and cardiac medications[22]). JELIS enrolled all of its subjects between 1996 and 1999, similar to the GISSI-P trial (1993 – 1997).[23] Would the open-label JELIS trial results involving 1.8 g/d of EPA-E repeat in a placebo-controlled test with optimally treated modern-day subjects of Japanese descent randomized over 20 years after the fact? Perhaps not.
Generalizability of study results is crucial in informing drug regulation.[24] 1 g/d OM3-E offers no additional benefit to secondary or primary prevention patients already on extensive background therapy, even though it proved effective in the GISSI-P trial. The JELIS trial subjects and REDUCE-IT trial subjects are too different and were too differently treated to confer anything from the results of one trial to that of the other.
Another apologetic presented by proponents of icosapent ethyl (IPE), aka “Vascepa,” is in comparing studies such as ODYSSEY and FOURIER that demonstrated a regression to the mean in LDL-C with the REDUCE-IT and ANCHOR trials, arguing that the changes in markers seen in the mineral oil (MO) placebo groups of the latter two trials are also regressions to the mean. However, the regressions seen in other trials often involve one or two parameters only, and impact both treatment and control groups. By contrast, in the REDUCE-IT and ANCHOR trials, we find:
• Highly significant elevations in every atherogenic lipid/ lipoprotein and inflammatory marker tested (11 total in ANCHOR) in MO placebo groups of both trials; • the absence of any of these changes in those randomized to IPE groups in either trial; and • the confirmation of these effects in two robustly sized studies—even to similar degrees.
As elaborated on previously, a lead-in period helps prevent regressions to the mean from impacting data, which the ANCHOR trial had—and yet, all eleven atherogenic/inflammatory markers showed sharp increases in its placebo group. What has so far been reported from the REDUCE-IT trial is a repeat (and thus, confirmation) of the same phenomenon. The baseline characteristics, including background therapies, of subjects in both trials are extremely similar.
In our view, the only potentially relevant comparison in seeking to prove that the highly significant increases in atherogenic and inflammatory markers in the MO placebo groups in ANCHOR and REDUCE-IT could have been a mere regression to the mean would have to be another trial with an extensive lead-in period that also showed abrupt changes in markers in subjects of approximately equal baseline characteristics. The EVOLVE trial was the closest that we could find.
In EVOLVE, which had a similar lead-in stabilization period as ANCHOR, there was noted a 10% increase in median LDL-C in the olive oil placebo group.[25] However, other atherogenic markers were reduced or did not significantly change in this group. Also, the least squares mean value recorded in the study (which reflects changes across the entire arm) showed an insignificant 3% increase in LDL-C in the placebo group.[26] It seems then that the elevations in LDL-C primarily occurred in those placebo group subjects with baseline values near the median, and little change in the rest.
There could also have been some impact on LDL-C from the modest TG and VLDL-C lowering effect of olive oil (-10% and -11% median change, respectively) by mechanisms similar to those by which DHA can cause an increase in LDL-C along with a decrease in TG and VLDL-C—especially in those with very high triglycerides at baseline.[27] An increase in LDL-C from a triglyceride-lowering therapy is much more likely to occur when the baseline TG levels of subjects are very high.[28] In ANCHOR, the median baseline TG level was ~260 mg/dL, and in EVOLVE it was >700 mg/dL, and so an increase in LDL-C from a TG-lowering therapy would be more likely to occur in EVOLVE than in ANCHOR. The discrepancy in changes in median and mean TG values (-10% vs -4.3%, respectively) from baseline in the olive oil placebo group in EVOLVE also lends credence to the possibility that such a phenomenon affected those with values near the median more than the rest of the group. Thus, the comparison between EVOLVE and the ANCHOR/REDUCE-IT trials breaks down on multiple levels.
The adverse impact on all atherogenic/inflammatory markers tested in ANCHOR, and confirmed in a separate study with patients of equivalent background therapy and characteristics (REDUCE-IT), is much more reminiscent of a treatment effect than a regression to the mean.
Lastly, apologists have pointed out the decrease in LDL-C in some of the statin-treated subjects in the placebo arm of the MARINE trial, causing a net reduction in LDL-C in this subgroup, despite being given 4 g/d MO. However, the number of patients in this subgroup analysis is small (n=18 in the 4 g/d MO arm). As one FDA reviewer noted when examining the same data,[29]
Relatively few patients can significantly impact data from a collective small group (especially when considering the median percent change only). Potential reasons for incidental disparities in values from baseline to end of treatment are numerous, such as cessation or reduction in dose of allowed therapies—or the opposite; adding therapies, including supplements, that may affect other prescribed therapies, increasing or decreasing their potency; changes in diet and exercise habits; and/or any of the aforementioned while also taking their statin medication and mineral oil placebo at far removed times of the day. Three or four subjects out of the 18 analyzed that were on statins and in the 4g/d MO placebo group adopting any of the above could completely shift the subgroup’s statistics (the FDA reviewer noted that some of the 18 subjects saw a >30% increase in LDL-C while some saw a >30% decrease in LDL-C). Thus, the subgroup is too small and the variability of data too high to reliably base any conclusions on.
However, later, data were reported on changes in LDL-P and non-HDL-C parameters as determined by analysis of blood samples from all subjects in the MARINE trial, and what was observed appears to confirm, rather than disprove, the adverse MO impact hypothesis:[30]
Increases in LDL-P and non-HDL-C are highly predictive of increased prevalence of ASCVD events, even when LDL-C remains unchanged/low.[31],[32] The above data show that median LDL-P concentration increased by 14.4% and 12.6% (while mean non-HDL-C increased by 19% and 5%) by week 11 in the 4 g/d MO group and 2 g/d IPE group (who concurrently took 2 g/d MO), respectively. Thus, MARINE trial data seem to confirm rather than disprove the adverse MO impact hypothesis.
As an aside, the sponsor chose to report data from the ANCHOR and MARINE studies in the following manner:[33]
Although they do mention “placebo-adjusted,” the clear and obvious message being relayed from the chart (targeting the investment and healthcare communities) is that 4 g/d IPE has a profound impact on atherogenic and inflammatory markers—when in fact, it does not.
For example, hs-CRP levels were lowered insignificantly by ~3 - 4% from baseline in the 4 g/d IPE groups in both studies, yet the slide shows a 36% and 22% reduction in hs-CRP in MARINE and ANCHOR, respectively. This was wholly due to sharp increases in the 4 g/d MO placebo arms, not the result of a CRP-lowering effect of IPE. The graphic also shows that small LDL-P concentration was reduced by 25.6% in MARINE and 13.5% in ANCHOR, but this too was entirely due to increases in the 4 g/d MO placebo arms. In fact, LDL-P actually increased insignificantly in the 4 g/d IPE arms from baseline in both studies. Median apoB was also insignificantly lowered by 3.8% and 2.2% from baseline in the 4 g/d IPE arms of MARINE and ANCHOR, respectively. Yet elsewhere, the sponsor has stated that 4 g/d IPE was shown to significantly reduce apoB by 8.5% (p=0.0019) and 9.3% (p<0.001) in these studies.[34] Once again, this result was predominantly caused by a significant increase in apoB from baseline in the MO-dosed placebo arms, not a significant reduction in IPE arms.
The misleading inference that IPE has a pronounced effect on these biomarkers was further exacerbated by a statement made by the principal investigator of the MARINE trial, quoted in an Amarin Corp. press release:[35]
Investigator bias in industry-sponsored clinical trials has far-reaching implications.[36]
We find the reporting of these data by the sponsor and commentary by the principal investigator to be irresponsible. It seems that the sponsor has been relying on the adverse impact of mineral oil on placebo group subjects to make misleading claims as to the efficacy of IPE therapy. The REDUCE-IT trial results may unfortunately prove to be the culmination of this tendency.
[4] Agoritsas T, Merglen A, Shah N, et al. Adjusted Analyses in Studies Addressing Therapy and Harm
Users’ Guides to the Medical Literature. JAMA. 2017.
[5] Katherine S. Button, John P. A. Ioannidis, Claire Mokrysz, et al. Power failure: why small sample size undermines the reliability of neuroscience. Nature. 2013.
[7] Yusuf S, Wittes J, Probstfield J, Tyroler HA. Analysis and Interpretation of Treatment Effects in Subgroups of Patients in Randomized Clinical Trials. JAMA. 1991.
[8] Sleight P. Debate: Subgroup analyses in clinical trials: fun to look at - but don't believe them!. Curr Control Trials Cardiovasc Med. 2000;1(1):25-27.
[9] Yokoyama M, Origasa H, Matsuzaki M, et al. Effects of eicosapentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS): a randomised open-label, blinded endpoint analysis. The Lancet. 2007.
[10] Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA. 1995.
[11] David Moher, Ba' Pham, Alison Jones, et al. Does quality of reports of randomised trials affect estimates of intervention efficacy reported in meta-analyses? The Lancet. 1998.
[12] J. BEYER-WESTENDORF, H. BÜLLER. External and internal validity of open label or double-blind trials in oral anticoagulation: better, worse or just different? jth. 2011.
[13] Jüni P, Altman DG, Egger M. Systematic reviews in health care: Assessing the quality of controlled clinical trials. BMJ. 2001.
[14] Dariush Moza?arian. JELIS, ?sh oil, and cardiac events. The Lancet. 2007.
[15] Providing Clinical Evidence of Effectiveness for Human Drug and Biolog
[16] JOHN H. LEE, JAMES H. O’KEEFE, CARL J. LAVIE, et al. Omega-3 Fatty Acids for Cardioprotection. Mayo Cin Proc. 2008.
[17] The ORIGIN Trial Investigators. n–3 Fatty Acids and Cardiovascular Outcomes in Patients with Dysglycemia. N Eng J Med. 2012.
[18] Aung T, Halsey J, Kromhout D, et al. Associations of Omega-3 Fatty Acid Supplement Use With Cardiovascular Disease Risks: Meta-analysis of 10 Trials Involving 77 917 Individuals. JAMA Cardiol. 2018.
[20] R. Marchioli. Treatment with n-3 polyunsaturated fatty acids after myocardial infarction: results of GISSI-prevenzione trial. European Heart Journal. 2001.
[21] Rezaei Y, Gholami-Fesharaki M, Dehghani MR et al. Statin Antiarrhythmic Effect on Atrial Fibrillation in Statin-Naive Patients Undergoing Cardiac Surgery: A Meta-Analysis of Randomized Controlled Trials. J Cardiovasc Pharmacol Ther. 2016.
[23] Effects of eicosapentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS): a randomised open-label, blinded endpoint anal... - PubMed - NCBI
[24] Kukull WA, Ganguli M. Generalizability: the trees, the forest, and the low-hanging fruit. Neurology. 2012.
[26] Kastelein, John J.P. et al. Omega-3 free fatty acids for the treatment of severe hypertriglyceridemia: The EpanoVa fOr Lowering Very high triglyceridEs (EVOLVE) trial. Journal of Clinical Lipidology. 2013.
[27] Jan Oscarsson, Eva Hurt-Camejo. Omega-3 fatty acids eicosapentaenoic acid and docosahexaenoic acid and their mechanisms of action on apolipoprotein B-containing lipoproteins in humans: a review. Lipids in Health and Disease. 2017.
[28] Feingold KR, Grunfeld C. Triglyceride Lowering Drugs. Endotext. 2018.
[31] Otvos JD, Mora S, Shalaurova I, Greenland P, Mackey RH, Goff DC. Clinical implications of discordance between low-density lipoprotein cholesterol and particle number. J Clin Lipidol. 2011.
[32] Mora S, Buring JE, Ridker PM. Discordance of low-density lipoprotein (LDL) cholesterol with alternative LDL-related measures and future coronary events. Circulation. 2014.
[34] Christie M.Ballantyne, Rene A.Braeckman, Harold E.Bays, et al. Effects of icosapent ethyl on lipoprotein particle concentration and size in statin-treated patients with persistent high triglycerides (the ANCHOR Study). Journal of Clinical Lipidology. 2014.
[35] Amarin's Phase 3 MARINE Study Results Presented at American Heart Association's Scientific Sessions 2011 | Amarin Corporation plc
[36] Ahn Rosa, Woodbridge Alexandra, Abraham Ann, et al. Financial ties of principal investigators and randomized controlled trial outcomes: cross sectional study. BMJ. 2017.
Experiments in juveniles and infants can garner public praise, lower regulatory hurdles, and mask overspending. It creates a unique and problematic bias. In the US, mores are well established in this regard. One cannot question the utility of such treatments without being vilified.
It is good to see much needed funding come to a company doing this work, but they need to improve on efficiencies. There is a bit of sudden wealth phenomenon going on behind the curtain. Appropriation has gotten more lax.
It is difficult work. However, it is not a problem when merely excising DNA. Cas9 seems to induce activation of p53, which was unexpected. Other enzyme approaches are probably fine. Time, as usual, will tell.