Relationship Between Insulin Resistance and Statin Induced Type 2 Diabetes, and Integrative Personal Omics Profiling

1. Specific Aims There is general agreement that although statin-treatment increases
incidence of type 2 diabetes (T2DM) in patients with elevated plasma low-density
lipoprotein cholesterol (LDL-C) concentrations, the benefits of statin treatment
significantly outweigh this untoward side-effect. During the last few months two
manuscripts have been published that substantially increase understanding of the link
between statin use and incident T2DM. Thus, Swerdlow, et al., based on evidence from
genetic analysis and randomized trials, concluded that the increased risk of T2DM noted
with statins is at least "partially explained by HMG-coenzyme A reductase (HMGCR)
inhibition." They also noted an association of weight gain with HMGCR variants in
statin-treated patients, leading to the notion that decreases in insulin sensitivity
contribute to statin-induced diabetes. In that context, Cederberg, at al. have recently
shown in a large prospective study (n=8749 men) that participants treated with statins
(n=2142) had a 46% increase in incident T2DM, associated with a 24% decrease in insulin
sensitivity and a 12% decrease in insulin secretion.

Since T2DM develops when insulin resistant individuals cannot maintain the degree of
compensatory hyperinsulinemia needed to maintain normal glucose tolerance, the
observations of Cederberg, et al. provide a mechanistic explanation for statin-induced
T2DM at the most general level. However, significant fundamental questions remain. For
example, what is the cellular/molecular link between HMGCR activity and changes in
insulin action and secretion described by Cederberg, et al. ? In that context,
relatively little attention has been given to the role that metabolic heterogeneity in
patients with elevated low-density lipoprotein cholesterol (LDL-C) concentrations might
play in statin-induced T2DM. Specifically, subjects with elevated LDL-C concentrations,
whose plasma triglyceride (TG) concentrations are also elevated, are insulin resistant,
hyperinsulinemic, and glucose intolerant as compared to those with isolated LDL-C levels
. As such, this subset of patients with elevated LDL-C concentrations can be viewed as
being at a "tipping point," and any adverse effect of statins on insulin
action/secretion, irrespective of how mediated, places them at enhanced risk to develop
statin-induced diabetes.

This proposal is based on the premise that identifying such subjects prior to statin
treatment would have substantial clinical benefit, and the investigators primary goal is
to demonstrate that a simple measurement of plasma TG concentration can serve this
purpose. Consequently, the investigators propose to enroll nondiabetic volunteers,
defined as being at high-risk for T2DM, free of known cardiovascular disease (CVD), not
receiving statins, eligible for statin therapy according to ACC/AHA (American College
for Cardiology/American Heart Association) 2013 guidelines [4], subdivided on the basis
of their plasma TG concentration into those whose values are either < 1.7 mmol/L
(↓TG/↑LDL) or ≥ 1.7 mmol/L (↑TG/↑LDL).

Personal Omics Profiling (iPOP) Personalized medicine is expected to benefit from the
combination of genomic information with the global monitoring of molecular components
and physiological states. To further extend Dr. Snyder's previous research of integrated
Personal Omics Profiling (iPOP) by monitoring the genomic, transcriptomic, proteomic,
metabolomic, and autoantibodyomic information, over a 21-month period that included
healthy and two virally infected states, the investigators propose to analyze iPOP of
apparently healthy volunteers with dyslipidemia longitudinally before, during, and after
taking drugs. In this pilot study, by performing unprecedented depth of omics analysis,
analysis will done on the previously-known drug's efficacy but also untargeted drug's
efficacy to obtain a better understanding of how to perform a personal omics profile
when taking drugs, which would lead to develop better use of drugs Hypothesis: The
results will demonstrate that: 1) individuals with ↑TG/↑LDL concentrations are insulin
resistant/hyperinsulinemic and glucose intolerant, with a more adverse cardio-metabolic
risk profile, compared to those with ↓TG/↑LDL concentrations; and 2) that statin
treatment will accentuate the differences in metabolic variables and iPOP profile
between the two experimental groups.

2. Significance, background and Innovation i) Significance: The relationship between statin
treatment and T2DM were initially focused on whether statin treatment increased risk of
T2DM; and what was the clinical impact of this risk. More recently, attention has been
given to understanding why statins increase risk of T2DM, as well as the clinical
characteristics that help identify those at increased risk in order to mount efforts at
minimizing this adverse effect.

a. Statins and risk of T2DM: There is agreement that statin treatment is associated with an
increase in incident diabetes. This adverse outcome seems to be a class effect, although Cho,
et al. showed that the risk of new onset T2DM ranged from 7.8% (pitavastatin) to 3.4%
(simvastatin), with intermediate rates for atorvastatin pravastatin, and rosuvastatin b.
Mechanism of statin-induced T2DM: Swerdlow, et al have demonstrated the importance of reduced
activity of HMGCR in the pathogenesis of statin-induced T2D, in particular the role of
genetic variants enhancing weight gain and decreasing insulin sensitivity. However, given the
pleiotropic effects of statins, a good deal remains to be learned concerning how changes at
the HMGCR gene level modify insulin calorie-restricted diets, action/insulin secretion. Since
Cederberg, et al. showed that both insulin action and insulin secretion are decreased in
patients taking statins, it seems likely that more than one of the multiple mechanisms that
advanced to account for T2DM in statin-treated patients contributes to this adverse effect c.
Identifying those with high LDL-C levels at enhanced risk of stain-induced T2DM: Results of 3
randomized clinical trials with atorvastatin demonstrated that "baseline fasting glucose,
body mass index, hypertension, and fasting triglycerides were independent predictors of
T2DM." These abnormalities form a cluster, initially referred to as Syndrome X and attributed
to insulin-resistance. Since insulin resistance is a predictor of developing T2DM it seems
likely that the more insulin resistant before treatment, the greater the risk to develop
statin-induced diabetes. Individuals with combined elevations of LDL-C and TG concentrations
are insulin resistant and glucose intolerant and thereby at increased risk of T2DM.
Furthermore, the investigators have demonstrated that a plasma TG concentration ≥1.7 mmol/L
identified a subset of nondiabetic persons with elevated LDL-C concentrations, judged at
baseline to be at high risk of T2DM, who were significantly more insulin resistant, glucose
intolerant, and with a more adverse CVD risk profile, than those with a normal TG
concentration.

There are other possible approaches to identify individuals most at risk to develop T2DM when
treated with statins, e.g., a diagnosis of the metabolic syndrome [MetS]. Thus, comparison of
291 apparently healthy individuals in our data base, grouped together on the basis of having
the MetS vs. a plasma TG concentration ≥ 1.7 mmol/L, revealed comparable cardio-metabolic
risk profiles. For example, median fasting plasma insulin concentration, an excellent
surrogate estimate of insulin resistance was almost identical in individuals with the MetS
(13.05 µU/mL) or a plasma TG ≥ 1.7 mmol (12.5 µU/mL). Given this information, it seemed
reasonable to continue evaluating on of the ability of a plasma TG concentration of 1.7
mmol/L to identify those most at risk to develop T2DM when taking statins. More specifically,
to combine our understanding of the phenotypic heterogeneity of individuals with elevated
LDL-C concentrations with quantification of insulin action and secretion to address 2
important unanswered questions:1) does a plasma TG concentration ≥ 1.7 mmol/L identify a
subset at enhanced risk of T2DM and CVD; and 2) what is the impact of statin administration
on insulin action and secretion in individuals whose plasma TG concentration is above or
below that cut-point.

ii) innovation: 1. The investigators believe there is not wide-spread awareness that there
are two disparate phenotypes of individuals with elevated LDL-C concentrations, differing
dramatically in degree of glucose intolerance and insulin resistance; rendering those with
combined elevations of LDL-C and TG concentrations at enhanced risk of statin-induced T2DM.
This proposal is the first prospective study of the impact of statin therapy on glucose
tolerance, insulin action/secretion, and lipid/lipoprotein metabolism comparing these two
phenotypes.

2. The investigators are unaware of any previous evaluation of the adverse effect of statins
on glucose tolerance and insulin action/secretion in individuals enrolled because they
fulfilled predefined criteria to be at high risk of T2DM. This population was chosen because
a retrospective analysis indicated that a plasma TG concentration ≥ 1.7 mmol/L identified
them as glucose intolerant and insulin resistant. Thus, all volunteers enrolled in the study
will be classified as being at high-risk by criteria outlined by ADA (American Diabetes
Association) criteria.

3. As indicated above, the investigators believe the phenotypic heterogeneity in subjects
with elevated LDL-C concentrations is not well-recognized. Not only will the results of our
study emphasize that point, the iPOP profiles obtained before, during and after statin
treatment may give us some potential genetic modulations responsible for these differences,
as well as the impact at the gene expression level of mechanisms potentially involved in the
adverse effects of statin on carbohydrate metabolism.

c) Research Approach

1. Overview: This pilot study will be an open-label, parallel group, 2-arm study, to evaluate
the diabetogenic effect of atorvastatin ( 40 mg/day for 8 weeks) in nondiabetic individuals
with isolated increases in LDL-C concentration (↓TG/↑LDL) vs. combined increases in LDL-C and
TG concentrations (↑TG/↑LDL). The experimental population will consist of 20 apparently
healthy volunteers, selected because they satisfy 2 fundamental criteria: 1) Increased risk
of T2DM by ADA Standards of Care [15], and 2) LDL-C concentration ≥ 3.4 mmol/L. The
experimental population will be further subdivided into groups of 10 each on the basis of a
TG concentration <1.7 mmol/L (↓TG/↑LDL) or ≥ 1.7 mmol/L (↑TG/↑LDL). Following baseline
comparisons of the two groups, participants will be placed on a weight maintenance diet,
treated with 40 mg/day of atorvastatin, and all baseline measurements repeated 8 weeks later
with iPOP measurements done at baseline, week 1, 2, 4, 6 and 8 and one month off
atorvastatin. The goals of this study are to: 1) compare a number of cardio-metabolic
characteristics in the 2 groups before administration of atorvastatin; 2) demonstrate that
significant deterioration of insulin action and/or secretion as well as cardio-metabolic risk
factors following statin treatment will be confined to those with combined ↑TG/↑LDL
concentrations at baseline; and 3) correlate baseline and post-statin changes in
cardio-metabolic characteristics. 4) Perform Personal Omics Profiling (iPOP) in these 2
groups before and after taking statins to compare the two groups in terms of
treatment-associated changes in all baseline variables within each group and across groups
and analyze not only previously-known drug's efficacy but also untargeted drug's efficacy.

Inclusion Criteria:

1. Healthy adults 30- 65 years old,

2. BMI 25-35 kg/m2,

3. nondiabetic as defined by fasting plasma glucose <126 mg/dL

4. Lipids: one group with an LDL =/>130 and Triglycerides < 150 mg/dL The 2nd group will
have and LDL=/>130 mg/dL and Triglycerides =/>150 mg/dL but less than 400 mg/dL.

No one will be on any statin therapy before entering the study. 5. One risk factor for type
2 diabetes as outlined by ADA 2015 guidelines

Exclusion Criteria:

1. Less than 30 yrs of age or > 65 yrs of age

2. Any significant co-morbidities, such as active heart, kidney, or liver diseases,
accelerated or malignant hypertension, heart failure, severe anemia.

3 Cannot be taking any medications intended for weight loss, or those known to influence
insulin sensitivity.

4.Pregnancy/ lactation is an exclusion, as are women unwilling to use an effective birth
control method. 5. History of statin intolerance to all statins