New and Emerging Therapeutic Targets for ApoB-Containing Particles Lowering

ApoB is the structural protein of all atherogenic lipoproteins, including VLDLs (very-low-density lipoproteins), IDLs (intermediate-density lipoproteins), LDLs (low-density lipoproteins), chylomicron remnants, as well as Lp(a) (lipoprotein[a]). Because each lipoprotein particle contains a single apoB molecule, plasma apoB concentration reflects the number of circulating atherogenic particles. Genetic, epidemiological, and randomized clinical trial evidence consistently demonstrate that, on a per-particle basis, apoB is a more accurate causal determinant of atherosclerotic cardiovascular disease risk than LDL cholesterol alone. Beyond atherosclerosis, apo B₄₈-containing chylomicrons play a central role in severe hypertriglyceridemia and, importantly, contribute to the risk of triglyceride-mediated acute pancreatitis. Most established therapies that reduce major cardiovascular events, including statins, ezetimibe, PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors, and bempedoic acid, act primarily by enhancing LDL receptor-mediated clearance of apoB-containing particles. Other currently available therapies reduce LDL cholesterol as well as apoB through LDL receptor-independent mechanisms. Lomitapide, an inhibitor of MTP (microsomal triglyceride transfer protein), and evinacumab, a monoclonal antibody targeting ANGPTL3 (angiopoietin-like protein 3), reduce LDL cholesterol in homozygous familial hypercholesterolemia by decreasing triglyceride-rich apoB-containing lipoproteins upstream of LDL particle formation. Emerging therapeutic strategies targeting the angiopoietin-like protein axis, apo CIII, Lp(a), CETP (cholesteryl ester transfer protein), hepatic lipid flux, and incretin signaling expand the therapeutic landscape for modulating apoB-containing lipoproteins. Gene-targeted approaches, including gene editing, epigenome editing, small interfering RNA, and antisense oligonucleotides, as well as novel oral or injectable agents and combination therapies, further broaden opportunities for durable apoB modulation. Transitioning from an LDL cholesterol-centric to an apoB-centric framework may represent a biologically integrated strategy to reduce both atherosclerotic cardiovascular disease and triglyceride-mediated pancreatitis risk.