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Long-term efficacy and safety of inclisiran in patients with high cardiovascular risk and elevated LDL cholesterol (ORION-3): results from the 4-year open-label extension of the ORION-1 trial
Open accessAbstract
INTRODUCTION: Whether long-term treatment with the twice-yearly, siRNA therapeutic inclisiran, which reduces hepatic production of proprotein convertase subtilisin/kexin type 9 (PCSK9), results in sustained reductions in LDL cholesterol with an acceptable safety profile is not known. The aim of this study was to assess the effect of long-term dosing of inclisiran in patients with high cardiovascular risk and elevated LDL cholesterol. METHODS: ORION-3 was a 4-year open-label extension study of the placebo-controlled, phase 2 ORION-1 trial, conducted at 52 sites across five countries. Patients with prevalent atherosclerotic cardiovascular disease or high-risk primary prevention and elevated LDL cholesterol despite maximally tolerated statins or other LDL-lowering treatments, or with documented statin intolerance, who had completed the ORION-1 trial were eligible. Patients receiving inclisiran in ORION-1 received twice-yearly 300 mg subcutaneous inclisiran sodium throughout ORION-3 (inclisiran-only arm), whereas patients receiving placebo in ORION-1 first received subcutaneous evolocumab 140 mg every 2 weeks until day 360 thereafter transitioning to inclisiran twice-yearly for the remainder of ORION-3 study (switching arm). The primary efficacy endpoint was the percentage change in LDL cholesterol with inclisiran from the start of ORION-1 through to day 210 of the open label extension phase in the inclisiran-only arm (approximately 570 days of total inclisiran exposure in the modified intention-to-treat population). Secondary and exploratory endpoints included changes in LDL-C cholesterol and PCSK9 concentrations levels up to day 1440 (4 years) in each arm, and safety. ORION-3 is registered with ClinicalTrials.gov, NCT03060577. FINDINGS: Of the original ORION-1 cohort of 497 patients, 290 of 370 patients allocated to drug continued into the inclisiran-only arm and 92 of 127 patients allocated to placebo entered the switching-arm in the ORION-3 extension study conducted between March 24, 2017, and Dec 17, 2021. In the inclisiran-only arm, LDL cholesterol was reduced by 47·5% (95% CI 50·7-44·3) at day 210 and sustained over 1440 days. The 4-year averaged mean reduction of LDL-C cholesterol was 44·2% (95% CI: 47·1-41·4), with reductions in PCSK9 ranging from 62·2% to 77·8%. Adverse events at the injection site were reported in 39 (14%) of 284 patients in the inclisiran-only arm and 12 (14%) of 87 patients in the switching arm. The incidence of treatment-emergent serious adverse events possibly related to the study drug was 1% (three of 284) in the inclisiran-only arm and 1% (one of 87) in the switching arm. INTERPRETATION: Twice-yearly inclisiran provided sustained reductions in LDL cholesterol and PCSK9 concentrations and was well tolerated over 4 years in the extension study. This is the first prospective long-term study to assess repeat hepatic exposure to inclisiran. FUNDING: Novartis Pharma.
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“The research findings demonstrate that Inclisiran functions as a safe and effective treatment for lipid reduction among diverse patient groups [70].”
From Inclisiran SiRNA therapy for durable LDL-C reduction: a systematic review and meta-analysis highlighting a breakthrough in long-term cardiovascular risk management (2026) · cites this paper as [70]
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“The studies presented demonstrated sustained maximum LDL-C reduction levels that persisted throughout six months following the last administered dose [25, 42, 70].”
From Inclisiran SiRNA therapy for durable LDL-C reduction: a systematic review and meta-analysis highlighting a breakthrough in long-term cardiovascular risk management (2026) · cites this paper as [70]
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“It is important to note that of the ORION-3 participants, 23% had diabetes and 33% were not taking statin therapy.”
From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2026 (2026) · cites this paper as [133]
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“Extension Trial of Inclisiran in Participants With Cardiovascular Disease and High Cholesterol [ORION-3]), where an LDL cholesterol reduction of ∼45% was maintained through the end of year 4 (133).”
From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2026 (2026) · cites this paper as [133]
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Zou, D., Hu, Q., Liu, Y., & Yu, L. (2024) · International Journal of Clinical Pharmacy · doi:10.1007/s11096-024-01784-0 · Cited by 5
A retrospective study of people with familial hypercholesterolaemia in a Belgian lipid clinic
Ide, V., Cock, D. D., Pazmiño, S., Vangoitsenhoven, R., der Schueren, B. V., & Mertens, A. C. (2023) · Acta cardiologica. Supplementum · doi:10.1080/00015385.2023.2266647 · Cited by 5
Pang, J., Sanfilippo, F. M., Chan, D. C., & Watts, G. F. (2023) · Current Opinion in Endocrinology Diabetes and Obesity · doi:10.1097/med.0000000000000842 · Cited by 5
Expanding therapeutic options: overview of novel pharmacotherapies for dyslipidemia
ALGhasab, N. S., Fogacci, F., Арманович, А. А., & Cicero, A. F. G. (2024) · Expert Opinion on Pharmacotherapy · doi:10.1080/14656566.2024.2406270 · Cited by 5
Khattak, S., Ochoa-Ferraro, A. F., Khan, N., George, S., Khan, S. Q., Townend, J., Dawson, C., & Thomas, M. R. (2025) · Journal of Clinical Medicine · doi:10.3390/jcm14227946 · Cited by 4
Dyslipidemia management in stroke prevention: An individualized approach
Stefanou, M., Panagiotopoulos, E., Liberopoulos, E. N., Milionis, H. J., Theodorou, A., Mira, K., de Sousa, D. A., Palaiodimou, L., Vlachopoulos, C., Siasos, G., et al. (2026) · International Journal of Stroke · doi:10.1177/17474930261418388 · Cited by 4
Taha, H., Kandil, H., Badran, H. M., Farag, N. M., Khamis, H., Nasr, G. M., Samy, M., Abdrabou, M., Abuelezz, M., & Shaker, M. M. (2024) · The Egyptian Heart Journal · doi:10.1186/s43044-024-00562-7 · Cited by 5
Cicero, A. F. G., Mahjoubin-Tehran, M., Reiner, Ž., Eid, A. H., Jamialahmadi, T., & Sahebkar, A. (2025) · Pharmacological Reviews · doi:10.1016/j.pharmr.2025.100110 · Cited by 5
Enea, I., & Martelli, E. (2023) · Journal of Clinical Medicine · doi:10.3390/jcm12113652 · Cited by 5
Tsamoulis, D., Rallidis, L. S., & Kosmas, C. E. (2024) · Expert Opinion on Drug Discovery · doi:10.1080/17460441.2024.2360415 · Cited by 4
Li, H., Zhao, S., Wu, J., Han, J., Xu, Y., Shi, S., & Zhang, Y. (2024) · Lipids in Health and Disease · doi:10.1186/s12944-024-02294-8 · Cited by 5
Varughese, M. S., Nayak, A., & Jacob, S. (2024) · Eye · doi:10.1038/s41433-024-03523-1 · Cited by 4
Efficacy, benefit and safety of inclisiran
López-Miranda, J. (2024) · Clínica e Investigación en Arteriosclerosis (English Edition) · doi:10.1016/j.artere.2025.100730 · Cited by 4
A novel lncRNA FLJ promotes castration resistance in prostate cancer through AR mediated autophagy
Wu, Y., Cheng, S., Zhang, T., Wang, L., Li, T., Zheng, Y., Yang, G., Wu, X., Luo, C., Chen, T., et al. (2025) · Journal of Translational Medicine · doi:10.1186/s12967-025-06294-9 · Cited by 4
Targeting PCSK9 beyond the liver: evidence from experimental and clinical studies
Dalt, L. D., Baragetti, A., & Norata, G. D. (2025) · Expert Opinion on Therapeutic Targets · doi:10.1080/14728222.2025.2482545 · Cited by 4
2024 KSoLA Update on New Lipid-Lowering Agents: Inclisiran and Bempedoic Acid
Kim, H., Cha, J., & Lee, S. (2025) · Journal of Lipid and Atherosclerosis · doi:10.12997/jla.2025.14.2.135 · Cited by 6
25 years of lipid-lowering therapy: secular trends in therapy of coronary patients
Ratz, M., Vogel, J. B., Kuehrer, H., Säly, C., Mündlein, A., Vonbank, A., MADER, A., Fraunberger, P., Leiherer, A., & Drexel, H. (2024) · Wiener klinische Wochenschrift · doi:10.1007/s00508-024-02365-x · Cited by 4
Small interfering RNA (siRNA) in dyslipidemia: a systematic review on safety and efficacy of siRNA
Alla, S. S. M., Shah, D. J., Meyur, S., Agarwal, P., Alla, D., Moraboina, S. L., Ghadvaje, G. V., Bayeh, R. G., Malireddi, A., Shajan, T., et al. (2025) · Journal of Experimental Pharmacology · doi:10.2147/jep.s521579 · Cited by 4
Proprotein convertase subtilisin/kexin type 9-inhibition across different patient populations
Stürzebecher, P. E., & Laufs, U. (2024) · Current Opinion in Lipidology · doi:10.1097/mol.0000000000000935 · Cited by 3
Farhan, M., Hussein, G. A., Alom, T., Das, A., Durrani, T., Hayani, Z. M., Alkassar, A., Oweis, H. A., Nazir, M. H., Dhillon, D. K., et al. (2025) · Annals of Medicine and Surgery · doi:10.1097/ms9.0000000000002927 · Cited by 3
Inhibition of PCSK9 with polypurine reverse hoogsteen hairpins: A novel gene therapy approach
López-Aguilar, E., Pacheco-Velázquez, S. C., Busquets, M.-A., Hay, J., Mueller, P. A., Fazio, S., Ciudad, C. J., Noé, V., & Pamir, N. (2025) · Biochemical Pharmacology · doi:10.1016/j.bcp.2025.116976 · Cited by 3
PCSK9 in vascular smooth muscle cells: biology, pathology, and inhibition to fight atherosclerosis
Amorosi, A., & Varret, M. (2026) · Atherosclerosis Plus · doi:10.1016/j.athplu.2025.12.001 · Cited by 5
Knowlton, K. U., Návar, A. M., Anderson, J. L., Brown, A. S., Muhlestein, J. B., Kleeman, K., Sarwat, S., Abbas, C. A., Ramirez, M. A., Grines, C. L., et al. (2026) · Journal of the American Heart Association · doi:10.1161/jaha.125.043655 · Cited by 3
Inclisiran in patients with acute ischemic stroke: first data
Cherepianskii, M. S., Ponomareva, G. M., Skiba, I. B., Abakarov, R. M., Дудайте, В. В., & Cherepianskaia, A. A. (2023) · Kardiologiia · doi:10.18087/cardio.2023.10.n2560 · Cited by 3
Mining of adverse event signals associated with inclisiran: a post-marketing analysis based on FAERS
Shi, X., Qiao, Y., Yang, Y., Wang, N., Zhang, Y., Shi, S., Shen, G., & Jia, X. (2024) · Expert Opinion on Drug Safety · doi:10.1080/14740338.2024.2409707 · Cited by 3
Wilson, P. M., Elvey, R., Mathieson, A., Bower, P., Gibson, M., Vell, T., & Dixon, S. (2025) · BMJ Open · doi:10.1136/bmjopen-2023-083441 · Cited by 4
Maligłówka, M., Dec, A., Bułdak, Ł., & Okopień, B. (2025) · Pharmaceuticals · doi:10.3390/ph18060832 · Cited by 3
Muscoli, S., Cimmino, G., Canonico, M. E., Cesaro, A., Rosa, G. D., Rosa, S. D., Coronelli, M. M., Natale, F., Perrone, M. A., Sticchi, A., et al. (2025) · Journal of Cardiovascular Medicine · doi:10.2459/jcm.0000000000001740 · Cited by 4
Emerging therapies targeting lipoprotein(a): Pharmacologic advances and future directions
Perez, A. D., Simpson, R. J., Komé, A. M., & Lopez, S. T. (2025) · Journal of Pharmacology and Experimental Therapeutics · doi:10.1016/j.jpet.2025.103695 · Cited by 3
Small Interfering Ribonucleic Acid as Lipid-Lowering Therapy: Inclisiran in Focus
Rakočević, J., Dobric, M. R., Vučić, R. M., Furtula, M., Zaletel, I. V., Milutinović, K., Ilijevski, A., Labudović‐Borović, M., Tomasevic, M. V., & Bajčetić, M. (2023) · International Journal of Molecular Sciences · doi:10.3390/ijms24066012 · Cited by 5
PCSK9 siRNA INHIBITOR INCLISIRAN AS A TREATMENT OPTION IN HYPERCHOLESTEROLEMIA: A BRIEF REVIEW
Kılıç, M. E. (2023) · TURKISH MEDICAL STUDENT JOURNAL · doi:10.4274/tmsj.galenos.2023.2023-5-1 · Cited by 3
Li, W., Sun, L., & Yan, S. (2024) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2024.1375040 · Cited by 4
Pirillo, A., Casula, M., Baragetti, A., & Catapano, A. L. (2024) · Elsevier eBooks · doi:10.1016/b978-0-443-15734-9.00001-7 · Cited by 3
Lis, P., Lis, A. E., Kaźmierski, W., Jurek, J., Ziomek, M., Kocur, K., Ziobro, A., & Camlet, K. (2024) · Prospects in Pharmaceutical Sciences · doi:10.56782/pps.241 · Cited by 3
Metadata
- Authors
- Ray, K. K., Troquay, R. P. T., Visseren, F. L. J., Leiter, L. A., Scott Wright, R., Vikarunnessa, S., Talloczy, Z., Zang, X., Maheux, P., Lesogor, A., & Landmesser, U.
- Affiliations
- Imperial College London (GB)
- VieCuri Medisch Centrum (NL)
- University Medical Center Utrecht (NL)
- St. Michael's Hospital (CA)
- Novartis (Switzerland) (CH)
- German Centre for Cardiovascular Research (DE)
- Corresponding author
- Ray, Kausik K
- Venue
- The Lancet Diabetes & Endocrinology
- Publisher
- Elsevier BV
- Published
- 2023-02
- Volume
- 11
- Issue
- 2
- Pages
- 109-119
- ISSN
- 2213-8587 (ISSN-L)
- OpenAlex
- W4313554841
- Cited by
- 328
- References
- 28
- Citations by year
- 2026: 55 · 2025: 102 · 2024: 103 · 2023: 67
- FWCI
- 87.61
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- The Lancet Diabetes & Endocrinology (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Utrecht University Repository (Utrecht University) (submittedVersion, cc-by)
- Funders
- Novartis
- NIHR Imperial Biomedical Research Centre
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Lipoproteins and Cardiovascular Health
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Biochemistry › Cholesterol and Lipid Metabolism
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Lipid metabolism and disorders
- Keywords
- inclisiran, PCSK9 inhibition, siRNA therapeutics, LDL cholesterol lowering, high cardiovascular risk, atherosclerotic cardiovascular disease, statin intolerance, long-term efficacy, safety
- MeSH terms
- Proprotein Convertase 9, Heart Disease Risk Factors, Anticholesteremic Agents, Cardiovascular Diseases, Humans, Cholesterol, LDL, Prospective Studies, Risk Factors, Hydroxymethylglutaryl-CoA Reductase Inhibitors, RNA, Small Interfering
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