Vascepa to Accelerate Lipoprotein Uptake and Elimination

This is a prospective randomized, controlled pilot/feasibility experiment in a small number
of statin-treated patients with residual triglyceridemia assigned to chronic daily exposure
to icosapent ethyl 4 g daily vs usual care to get preliminary data to ultimately design a
definitive hypothesis-testing experiment to clarify the mechanism of action whereby icosapent
ethyl alters lipoprotein kinetics. The formal statistical aim is to develop statistical
parameters such as central tendency, dispersion, and distributional shape to design a robust
hypothesis-testing study. The primary outcome is based around stable-isotope lipoprotein
kinetics, specifically apolipoprotein B kinetics.

Inclusion Criteria:

- 1. Triglyceridemia, defined as:

1. statin-treated TG > 200 mg/dL -and/or-

2. statin-treated TG > 150 mg/dL -plus- statin-treated HDL < 45 [men] or < 55 [women] 2.
Self-reported Caucasian-majority race, defined as 3 out of 4 grandparents Caucasian 3.
Subjects between the ages of 21 and 75 years of age inclusive 4. Ability to understand
and agree to informed consent 5. Are reliable and willing to make themselves available
for the duration of the study, comply with study procedures, agree not to participate
in other clinical experiments, and agree not to donate blood products during the study

Exclusion Criteria:

- 1. Diagnosis of idiopathic or otherwise active diabetes: History of resolved
gestational or drug-induced diabetes is acceptable, but history Type I or Type II
diabetes are exclusionary.

2. Use of medications indicated for the treatment of diabetes within 6 weeks of
the first experimental visit (see Prohibited Treatments) 3. History of a
myocardial infarction (MI), unstable angina leading to hospitalization, coronary
artery bypass graft surgery (CABG), percutaneous coronary intervention (PCI),
uncontrolled cardiac arrhythmia, carotid surgery or stenting, stroke, transient
ischemic attack, carotid revascularization, endovascular procedure or surgical
intervention within 6 months of baseline.

4. Known inefficacy to TG-lowering doses of fish oils (e.g. >= 4 caps daily of
prescription fish oil or >= 6 caps daily of supplemental fish oil).

5. TG > 500 mg/dL as the average of valid, statin-treated values 6. BMI > 40
kg/m2 7. BMI < 20 kg/m2 8. Evidence of previously undiagnosed diabetes: Average
fasting glucose during screening > 125 mg/dL 9. Known familial lipoprotein lipase
impairment or deficiency (Fredrickson Type I), Apo C II deficiency, or familial
dysbetalipoproteinemia (Fredrickson Type III).

10. Severe allergy to fish, unless non-allergic response to fish oil is
established (n.b. most fish allergies are to the proteins as opposed to the fats,
so with highly-purified oils the risk of a true allergy is remote).

11. Known intolerance or contraindication to Vascepa, and if the former is
unknown, known intolerance or contraindication to fish oil 12. Any surgical or
medical condition that may interfere with absorption, distribution, metabolism,
or excretion of EPA or DHA.

13. History of extreme triglyceridemia (TG > 1000 mg/dL) or pancreatitis from
triglyceridemia, regardless of whether it is currently controlled.

14. Medical condition that would prohibit fasting (e.g. diagnosis of insulinoma
or postabsorptive hypoglycemia).

15. Significant disinclination to dairy products (e.g. lactose intolerance,
inviolable dietary restrictions). All participants will receive a test dose of
the fat challenge during the screening visit, which consists of heavy cream and
lactase enzyme. Many people with lactose intolerance successfully avert symptoms
by correcting their lactase deficiency with lactase supplements. We will allow
these people to participate because we will allow them to take their preferred
brand and dose of lactase supplement beyond the lactase in the fat challenge if
needed. However, we still require that they are able to tolerate the test dose
given during screening.

16. History of a non-skin malignancy within the previous 5 years. 17.
Uncontrolled thyroid disease. 18. Any major active rheumatologic, pulmonary, or
dermatologic disease or inflammatory condition.

19. Major surgery within the previous 6 weeks. 20. Subjects who have undergone
any organ transplant. 21. History of illicit drug use within the past 3 years, or
regular alcohol use of greater than 14 drinks per week. For clarity, illicit
substances are per Federal law or regulations in effect at the time of first
approval of this protocol.

22. Women who are breast-feeding. 23. Women of childbearing potential must have a
negative urine pregnancy test at screening and baseline visits and be willing to
have additional urine pregnancy tests during the study.

24. Sexually active subjects (both women and men) must be willing to use a
medically accepted method of contraception from screening visit until month after
last dose of study drug 25. Significant or unstable medical or psychological
conditions, including known or suspected personality disorders, that could
compromise the subject's safety or successful participation in the study in the
opinion of the investigator.

26. Subject-reported history of HIV and/or use of HIV medications 27. History of
symptomatic gallstone disease unless definitively treated (e.g. condition
successfully treated with cholecystectomy without recurrent or residual biliary
disease).

28. History of bariatric surgery or other major gastrointestinal surgery
associated with major disruptions to drug absorption.

29. Anticipation of major surgery during the screening or treatment periods of
the study 30. Participants with the following conditions will opt out of heparin
exposure for lipase determinations, but will be allowed to participate in the
overall protocol.

31. History of intolerance or adverse reaction to therapeutic or sub-therapeutic
heparin regimens 32. History of intracerebral hemorrhage 33. History of
significant GI bleed, unless definitively treated without recurrence 34. Women
with dysfunctional uterine bleeding 35. Individuals with clinically-significant
coagulopathy at screening 36. Individuals with clinically-significant
thrombocytopenia at screening 37. Hemoglobin < 12 g/dL at screening 38. Mean
corpuscular volume (MCV) < 80 fL or > 100 fL at screening 39. Donation of whole
blood within 8 weeks prior to the first experimental visit. Participation in the
screening phase is permitted.

40. History of inherent unremediable risks for anemia, such as
hemoglobinopathies, hemolytic disorders, and bleeding disorders, regardless of
whether their hemoglobin is currently normal.

41. History of a large-volume gastrointestinal (GI) bleeding, such as a bleed
that required ER evaluation or admission, required acute endoscopic or surgical
management, was managed by blood transfusion, or caused anemia.

42. History of NSAID-mediated peptic ulcer disease is excluded, irrespective of
current medical treatment. A history of peptic ulcer disease from H. pylori does
not exclude participation provided H. pylori was successfully eradicated. Other
causes of peptic ulcer disease may be allowable, especially if definitively
treated or the risk of recurrence is otherwise low.

43. Chronic, untreated conditions that predispose to anemia, such as significant
iron or B vitamin malabsorption, persistent menorrhagia, or other chronic or
intermittent bleeding.

44. Participation in an investigational drug study concurrently; participants who
previously completed an investigational drug study cannot participate in the
first experimental visit until at least 6 weeks after the final dose given during
the previous investigational drug study. For the purposes of this exclusion, an
investigational drug is a new chemical entity or a pharmaceutical investigated to
support an initial new drug application. Furthermore, herbal or other supplements
already deemed "generally regarded as safe" or legally sold in the U.S. would not
be considered an investigational drug.

45. Use of medications indicated for the treatment of diabetes within 6 weeks of
the first experimental visit 46. Daily therapy with non-statin lipid-altering
medications within 6 weeks of the first experimental visit is exclusionary,
including long-term therapy with the agents listed below. Subjects may wash off
these medications so long as the first experimental visit occurs at least 6 weeks
after chronic therapy ceases. Following a washout period, fasting lipids will be
repeated prior to the first experimental visit to assure that these are not
exclusionary as defined above.

1. Niacin > 100 mg/ day: (Niacor®, Slo-Niacin®, Niaspan®, Advicor®, Simcor®,
Inositol Hexanicotinate, or supplemental niacin).

2. Fibrates: gemfibrozil (Lopid®), fenofibrate (Antara®, Lofibra®, Tricor®,
Triglide®), fenofibric acid (Trilipix®, Certriad®).

3. Enterically active lipid altering drugs: colestipol (Colestid®),
cholestyramine (Questran®), colesevelam (Welchol®), ezetimibe (Zetia®,
Vytorin®), orlistat (Xenical®, Ali®).

4. Prescription fish oil: Vascepa®, Epanova®, Lovaza® (nee Omacor®)

5. Supplemental omega-3-enriched oils: flaxseed, fish, or algal oils

6. Foods enriched with omega-3 fatty acids

7. Consumption of up to 2 servings per week of fish is acceptable 47.
Lipid-altering supplements

1. Sterol/stanol products (e.g. CholestOff), policosanols

2. Dietary fiber supplements, including >2 teaspoons of Metamucil® or psyllium
containing supplements per day

3. Garlic supplements or soy isoflavones supplements

4. Supplemental vitamin B5 or related compounds unless part of a multi-vitamin

5. As above, red yeast statin will be switched to a GMP prescription statin

6. Any other medications, herbal products, or dietary supplements with known or
potential lipid-altering effects 48. Anticoagulant therapy (except aspirin)

1. Warfarin

2. Rivaroxiban

3. Apixaba

4. Dabigantran 49. Anti-obesity medications or their components

1. Orlistat (Xenical)

2. Lorcaserin (Belviq)

3. Phentermine plus extended-release topiramate (Qsymia)