1. CHOLESTEROL Amy M. Sharma PHM 142 REM University of Toronto Sept. 27 2012

2. HDL Stage 4 GOOD HDL : Reverse cholesterol transport and function 1. HDL is synthesized and secreted from the liver and the intestine. HDL contains 65% protein + free fatty acids, cholesterol, triacylglyceride and phospholipids. 2 Function: HDL picks up cholesterol released into the plasma from dying cells and from membranes undergoing turnover and returns it to the liver 3. HDL contains cholesterol, cholesterol ester, phospholipid and Lecithin:Cholesterol Acyl Transferase (LCAT) - synthesised in the liver that catalyses : LECITHIN + CHOLESTEROL  LYSOLECITHIN + CHOLESTEROL ESTER LCAT is activated by apo-A1 and deficiency in LCAT means that HDL can’t take up cholesterol from tissue, therefore  cholesterol and lecithin in tissue

3. Increasing HDL to decrease tissue Clt Anacetrapib (Merck drug) NEW Niacin best Fibrate drugs bile acid binding resins Exercise,  -3 fatty acids,red wine,orange juice,beans, soy,oat bran tr.fatty acids, high carbohydrate. decr. HDL

4. Cholesterol Synthesis Essential molecule in many animals including humans However not required from diet – all cells can synthesize it Majority produced in the liver Synthesis occurs in 4 stages: 1. Condensation of 3 acetate units to form 6-carbon intd, Mevalonate 2. Mevalonate to activated isoprene units 3. Polymerization of six 5-carbon isoprene units to form Squalene 4. Squalene cyclization to form four rings of steroid nucleus followed by more changes to form final cholesterol

5. Cholesterol Synthesis: Step 1: Mitochondria Committed and rate- limiting step: Reduction of HMG-CoA to Mevalonate

6. Cholesterol Synthesis: Step 2: Synthesis of isopentenyl pyrophosphate from mevalonate occurs in the PEROXISOMES

7. Cholesterol Synthesis: Step 3: Synthesis of squalene occurs in the peroxisomes then the endoplasmic reticulum peroxisome Squalene synthaseDIMERIZATION e.r. peroxisome CoQ, heme A Dolichol-PP Prenylated proteins

8. Cholesterol Synthesis: Step 4: Synthesis of cholesterol occurs in the ER Dehydrocholesterol Squalene er P450, O 2, NADPH cyclase Squalene epoxide Lanosterol CHOLESTEROL NADPH P450 reductase sunlight diet Unsat. FA acyl CoA Cholesterol ester Vitamin D 3 +cholesterol acyltransferase (ACAT)

9. Drug therapy to decrease plasma Clt Statins (HMG-CoA reductase inhibitors) Inhibit cholesterol biosynthesis in liver to decrease plasma LDL cholesterol and cut the risk of heart attacks and strokes by at least 33% HMG CoA reductase inhibitors can induce rhabdomyolysis (test for muscle/kidney damage) Lipitor, Zocor, Crestor lower risk of heart attack, death and stroke Mevinolin (Fungal), a competitive inhibitor of HMG CoA reductase, resembles 3-hydroxy-3-methyl-glutaryl CoA, the substrate. Mevinolin 3-hydroxy-3-methyl- glutaryl CoA

10.  cholesterol  LDL receptors (induced)  LDL uptake  LDL  risk of atherosclerosis Isopentenyl-PP Dimethylallyl-PP Geranyl-PP Farnesyl-PP Squalene synthase Squalene Cholesterol Decaprenyl-PP TYROSINE 4-OH-benzoate Decaprenyl- 4-OH benzoate transf. Decaprenyl-4-OH-benzoate COENZYME Q trans-prenyltransf. But Statins may also decrease plasma ubiquinone antioxidant Free Rad. Biol. Med. 29, 285-94 (2000) Lancet 356, 391-5 (2000) HMG-CoA Polyprenyl-PP Dolichol N-glycosylates secretory proteins = Export glycoproteins ER, Golgi Peroxisome

11. Drug therapy to decrease plasma Clt Resins (hydrocarbon secretion) Bind bile acids to lower cholesterol Cholesterol is reabsorbed from intestine by forming complexes with bile acids. Liver then replaces bile acids by oxidizing cholesterol (catalysed by CYP7A). Prescription therapeutic resins bind bile acids and prevent cholesterol reabsorption: problem of constipation, ↓absorption of fat sol. vitamin A,D,E,K e.g. colestipol cholestyramine colesevelam Nonprescription bulk forming laxatives (soluble fibres) Psyllium husks (metamucil) Ispaghula husks Oat bran (  -glucan binds bile acids ) Action of bile acid binders  cholesterol excretion  hepatic cholesterol 7  hydroxylase (CYP7A) activity which oxidizes cholesterol to bile acids. (feedback inhibitor is normally bile acids)

12. Drug therapy to decrease plasma Clt Hypolipidemic ie antihyperlipidemic fibrate drugs CLOFIBRATE: 2g/day (also: Gemfibrozil) 1. ↑ lipoprotein lipase activity 2. ↑ fatty acid oxidation by inducing PEROXISOMES  serum triglycerides  serum triglyceride-rich lipoprotein 3.Antioxidant action prevent LDL oxidation

13. Perioxisomes Peroxisomes (microbodies) found in virtually all eukaryotic cells. Involved in the catabolism of very long chain fatty acids, branched chain fatty acids, D-amino acids, polyamines, and biosynthesis of plasmalogens, i.e. ether phospholipids critical for the normal function of mammalian brains and lungs. Major function: breakdown of very long chain fatty acids through beta-oxidation. converted to medium chain fatty acids  to mitochondria  carbon dioxide and water.

14. PEROXISOME (numerous genetic diseases) Peroxisomal fatty acid  -oxidation forms H 2 O 2 which is removed by catalase located in the peroxisomes. Medium-chain fatty acids (C8-18) prefer mitochondrial  -oxidation that doesn’t form H 2 O 2. Acyl carnitine Fatty acyl CoA Synthase Acetyl CoA O2O2 H2O2H2O2 oxidase* heat Shorter-chain fatty acid MITOCHONDRIA  -oxidation NADH + Acetyl CoA Cholesterol CoQ10* Bile acids H 2 O + O 2 catalase H 2 O 2 also formed by peroxisomal glycolate/glyoxylate oxidases, xanthine oxidase, uricase * Peroxisomes induced by peroxisome proliferators via a cytosolic receptor (PPAR) e.g., hypolipidemic drugs, e.g., clofibrate; plasticizers, e.g., phthalate (DEHP); endogenous steroids formed by the adrenal glands e.g., dehydroepiandrosterone. Ann Rev Biochem. 61, 157-97 (1992) Ann Rev Nutr. 14, 343-70 (1994) Long chain or  3 or branched fatty acids

15. Drug therapy to decrease plasma Clt Niacin (Vitamin B 3 ) Deficiency causes pellagra (rough photo-sensitive skin, dementia, etc)  Flour now fortified with niacin; B 1 thiamine; B 2 riboflavin tryptophan  niacin  nicotinamide  NAD  NADP  NADPH derivatives NAD, NADH, NAD +, and NADP play essential roles in energy metabolism and DNA repair. Niacin 1.5-3g/day ↓ plasma LDL cholesterol & triglycerides; best for ↑ HDL But early hot flashes so use slow delivery formula Rare hepatotoxicity or hyperglycemia

16. Drug therapy to decrease plasma Clt Blocking intestinal cholesterol permease Ezetimibe - drug that blocks cholesterol uptake by inhibiting intestinal sterol permease (packaged with a statin).

17. Natural therapy to decrease plasma Clt Plant sterols/stanols Ezetimibe - drug that blocks cholesterol uptake by inhibiting intestinal sterol permease (packaged with a statin). Sitosterol, Sitostanol Clt lowering action of plant sterols on the diet Plant sterol not absorbed by gut (2g/day) so inhibits gut absorption of cholesterol from diet. “functional margarine”) e.g. Becel pro-activ.in Loblaws

18. Natural therapy to decrease plasma Clt Chitosan (shellfish exoskeleton) (LIBRACOL is polychitosamine: amine groups bind cholesterol) Policosanol (sugar cane wax or rice wax alcohol ie. Octacosanol) CH 3 (CH 2 ) 26 CH 2 OH)

19. DIETARY WAYS OF DECREASING THE ATHEROSCLEROSIS RISK: 1.  cholesterol and saturated fatty acids  plant stanols (2g/margarine day) 2.  polyunsaturated fatty acids which  cholesterol oxidation to bile acids  LDL catabolism  cholesterol excretion into intestine 3. smoking, obesity, lack of exercise, low Ca 2+ 4.high HDL in premenopausal women protects but not after menopause. Summary:

20. Summary: Dietary mechanisms to decrease cholesterol are additive (e.g., use in patients resistant or intolerant to statins). 1. Decrease intestinal bile acids by binding them to viscous fibres, e.g., oats (b-glucan), barley, psyllium (metamucil), egg plant,ochra. Glucan is also a soluble fibre & an antioxidant which prev. oxidn of PUFA & cholesterol. Amer.J.Clin.Nutrition 75(2002)834-9. 2. Competitive inhibition of cholesterol absorption from the gut, e.g., plant sterols margarine, almonds, flaxseed. 3. Increase LDL receptor-mediated LDL cholesterol uptake and degradation, e.g., soy proteins, soy milk. 4. Decrease oxidized LDL using antioxidants, e.g., almonds (Vit E), soy proteins (isoflavones).

21. Bile: function & importance Bile (gall) - fluid produced by the liver of most vertebrates Composed of water, bile salts, mucus and pigments, fats, inorganic salts and cholesterol Main functions: Essential in the process of digestion of lipids from the small intestine For protection of small intestines from oxidative damage For excretion of endogenous xenobiotic compounds Also: Aids in absorption of fat-soluble vitamins A, D, E, K Bile salts are also bactericidal (protect from microbial products in foodstuff)

22. Bile: dysfunction & implications Drugs that slow/block bile flow from the liver to the gallbladder & gut may cause liver failure. e.g. chlorpromazine,prochlorperazine, penicillin ampicillin,estradiol, nitrofurantoin, sulindac. Symptoms include dark urine, pale stool, jaundice, fever/rash persistent itching. MUST discontinue the drug.

23. Bile: potential for toxicity Bile acids are cytotoxic to hepatocytes (can cause liver failure via free radical formation). Mechanism: Reduces Fe3+ which reduces H 2 O 2 to form hydroxyl radicals and reactive oxygen species (ROS) Radicals oxidize nucleic acids, proteins, and unsaturated lipids to form other radicals. BUT… Antioxidants & blockers of mitochondrial permeability transition prevent apoptosis

24. Cholestasis defined Cholestasis - any condition in which the flow of bile from the liver is blocked. i.e. where bile cannot flow from the liver to duodenum Obstructive cholestasis - mechanical blockage in the duct system such i.e. as a results of gallstone or malignancy Metabolic cholestasis - disturbance in bile formation due to genetic defects or as an adverse effect of a drug

25. Extra-hepatic cholestasis Cholestasis occurring outside the liver Caused by blockage of bile duct or ducts Possible causes: - bile duct tumors - Pancreatic tumor or pseudocyst - Cysts - Narrowing of the bile duct - Stones - Pancreatitis - Pressure on an organ due to tumor or nearby mass

26. Intra-hepatic cholestasis Cholestasis occurring within the liver Caused by significant blockage of small ducts or by disorders, such as hepatitis, that impair the body's ability to eliminate bile Possible causes: - Alcoholic liver disease - Amyloidosis - Bacterial abscess - Lymphoma Drugs - Primary biliary cirrhosis - Tuberculosis - Sepsis, - Viral hepatitis

27. Biochemistry. 31, 4737-49, (1992) G) BILE ACID SYNTHESIS BY LIVER Endoplasmic reticulum (except CYP27) Hepatocyte death

28. 28 Then efflux into bile and stored in gall bladder. Then released by bile duct into upper-small intestine (ileum). Then metabolised (deconjugation (CO 2 ), dehydroxylation) by anaerobic bacteria of colon to deoxycholate, lithocholate, urodeoxycholate. Then actively reabsorbed and recirculates via liver 8 times / day. Ga) BILE ACID SYNTHESIS BY LIVER (cont)