E-EPA is used in addition to changes in diet to reduce triglyceride levels in adults with severe hypertriglyceridemia. Or it may be used in hypertriglyceridemia ≥ 150 mg/dL in those with risk factors for heart disease. Intake of large doses of long-chain omega-3 fatty acids as prescription drugs or dietary supplements are generally required to achieve significant lowering of triglycerides, and at those doses the effects can be significant. It appears that both eicosapentaenoic acid and docosahexaenoic acid lower triglycerides, however, DHA alone appears to raise low-density lipoprotein and LDL-C values, whilst EPA alone does not and instead lowers the parameters aforementioned.
Other fish-oil based drugs
There are other omega-3 fish-oil based drugs on the market that have similar uses and mechanisms of action:
There are many fish oil dietary supplements on the market. Evidence does not support a beneficial role for n-3 dietary supplements to reduce cardiovascular disease as an addition to contemporary medical therapy including statin therapy. The ingredients of dietary supplements are not as carefully controlled as prescription products and have not been fixed and tested in clinical trials, as prescription drugs have, and the prescription forms are more concentrated, requiring fewer capsules to be taken and increasing the likelihood of compliance.
Side effects
Special caution should be taken with people who have fish and shellfish allergies. In addition, as with other omega-3 fatty acids, taking E-EPA puts people who are on anticoagulants at risk for prolonged bleeding time. The most commonly reported side effect in clinical trials has been joint pain; some people also reported pain in their mouth or throat. E-EPA has not been tested in pregnant women and is rated pregnancy category C; it is excreted in breast milk and the effects on infants are not known.
Pharmacology
After ingestion, E-EPA is metabolized to EPA. EPA is absorbed in the small intestine and enters circulation. Peak plasma concentration occurs about 5 hours after ingestion and the half-life is about 89 hours. EPA is metabolized mostly in the liver like other dietary fatty acids.
Mechanism of action
EPA, the active metabolite of E-EPA, like other omega-3 fatty acid based drugs, appears to reduce production of triglycerides in the liver, and to enhance clearance of triglycerides from circulating very low-density lipoprotein particles; the way it does that is not clear, but potential mechanisms include increased breakdown of fatty acids; inhibition of diglyceride acyltransferase which is involved in biosynthesis of triglycerides in the liver; and increased activity of lipoprotein lipase in blood.
Chemistry
E-EPA is an ethyl ester of eicosapentaenoic acid, which is an omega-3 fatty acid.
History
In July 2012, the US Food and Drug Administration approved E-EPA for severe hypertriglyceridemia as an adjunct to dietary measures; Amarin Corporation had developed the drug. Amarin Corporation, challenged the FDA's authority to limit its ability to market the drug for off-label use and won its case on appeal in 2012, changing the way the FDA regulates the marketing of medication. E-EPA was the second fish-oil drug to be approved, after omega-3 acid ethyl esters and sales were not as robust as Amarin had hoped. The labels for the two drugs were similar, but doctors prescribed Lovaza for people who had triglycerides lower than 500 mg/dL based on some clinical evidence. Amarin wanted to actively market E-EPA for that population as well which would have greatly expanded its revenue, and applied to the FDA for permission to do so in 2013, which the FDA denied. In response, in May 2015 Amarin sued the FDA for infringing its First Amendment rights, and in August 2015, a judge ruled that the FDA could not "prohibit the truthful promotion of a drug for unapproved uses because doing so would violate the protection of free speech." The ruling left open the question of what the FDA would allow Amarin to say about E-EPA, and in March 2016 the FDA and Amarin agreed that Amarin would submit specific marketing material to the FDA for the FDA to review, and if the parties disagreed on whether the material was truthful, they would seek a judge to mediate. In December 2019, the FDA approved the use of icosapent ethyl as an adjunctive therapy to reduce the risk of cardiovascular events among adults with elevated triglyceride levels of 150 milligrams per deciliter or higher. Patients must also have either established cardiovascular disease or diabetes and two or more additional risk factors for cardiovascular disease. Icosapent ethyl is the first FDA approved drug to reduce cardiovascular risk among patients with elevated triglyceride levels as an add-on to maximally tolerated statin therapy. The efficacy and safety of icosapent ethyl were established in a study with 8,179 patients who were either 45 years and older with a documented history of coronary artery, cerebrovascular, carotid artery and peripheral artery disease, or 50 years and older with diabetes and additional risk factors for cardiovascular disease. Patients who received icosapent ethyl were significantly less likely to experience a cardiovascular event, such as a stroke or heart attack. In clinical trials, icosapent ethyl was associated with an increased risk of atrial fibrillation or atrial flutter requiring hospitalization. The incidence of atrial fibrillation was greater among patients with a history of atrial fibrillation or atrial flutter. Icosapent ethyl was also associated with an increased risk of bleeding events. The incidence of bleeding was higher among patients who were also taking other medications that increase the risk of bleeding, such as aspirin, clopidogrel or warfarin at the same time.
