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Effect of Simvastatin and Fenofibrate on Cytokine Release and Systemic Inflammation in Type 2 Diabetes Mellitus With Mixed Dyslipidemia
Effect of Simvastatin and Fenofibrate on Cytokine Release and Systemic Inflammation in Type 2 Diabetes Mellitus With Mixed Dyslipidemia Robert Krysiak, MD, PhD*, Anna Gdula-Dymek, MD, and Bogusław Okopien, MD, PhD The aim of our study was to compare the effect of simvastatin and fenofibrate treatment on the secretory function of human monocytes and lymphocytes and on systemic inflammation in type 2 diabetes and to assess whether their coadministration is superior to treatment with only 1 of these drugs. One hundred ninety-six adult patients with recently diagnosed and previously untreated type 2 diabetes and mixed dyslipidemia, complying throughout the study with lifestyle intervention and treated with metformin, were randomized in a double-blind fashion to receive simvastatin (40 mg), fenofibrate (200 mg), simvastatin plus fenofibrate, or placebo for 90 days. Main outcome measurements were monocyte and lymphocyte release of proinflammatory cytokines and plasma levels of C-reactive protein. One hundred ninety patients completed the study. Simvastatin and fenofibrate decreased monocyte release of tumor necrosis factor-␣, interleukin-1, interleukin-6, and monocyte chemoattractant protein-1 and lymphocyte release of interleukin-2, interferon-␥, and tumor necrosis factor-␣, which was accompanied by a decrease in plasma C-reactive protein levels. Anti-inflammatory effects of fenofibrate partly correlated with the improvement in insulin sensitivity. Lymphocyte-suppressing, but not monocyte-suppressing, effect was stronger if these 2 agents were administered together. In conclusion, simvastatin and fenofibrate exhibit a similar effect on the secretory function of human monocytes and lymphocytes and on systemic inflammation in type 2 diabetic subjects with mixed dyslipidemia. This effect may be clinically relevant in the prevention of vascular complications in metformin- and diet-treated subjects with newly diagnosed diabetic dyslipidemia. © 2011 Elsevier Inc. All rights reserved. (Am J Cardiol 2011;107:1010 –1018) Recently we found that fenofibrate, particularly administered with metformin, produced pluripotential pleiotropic effects including a decrease in systemic inflammation and monocyte cytokine release and an improvement in insulin sensitivity and hemostasis in type 2 diabetic patients with mixed dyslipidemia.1 In this prospective, double-blind, placebo-controlled randomized study we have compared the effect of fenofibrate and simvastatin, used alone or in combination, on monocyte and lymphocyte secretory functions and systemic inflammation in type 2 diabetic patients with mixed dyslipidemia complying with lifestyle modification and treated with metformin. Monocytes/macrophages and lymphocytes are crucial cells involved in the development and progression of atherosclerosis and are present in large amounts in atherosclerotic plaque.2– 4 Tumor necrosis factor-␣ (TNF-␣), interleukin-1, interleukin-6, monocyte chemoattractant protein-1 (MCP-1), interleukin-2, and interferon-␥ were selected of the many monocyte- and lymphocyte-derived cytokines because these cytokines produce a multidirectional proatherogenic effect5–7 and our team has long-term experience in their assessment.1,8 –13 C-reactive
Department of Internal Medicine and Clinical Pharmacology, Medical University of Silesia, Katowice, Poland. Manuscript received September 14, 2010; revised manuscript received and accepted November 21, 2010. This work was supported by Scientific Grant 2 P05F 036 29 from the Committee of Scientific Research, Warsaw, Poland. *Corresponding author: Tel/fax: 48-32-208-8512. E-mail address: [email protected] (R. Krysiak). 0002-9149/11/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.amjcard.2010.11.023
protein (CRP) has been identified as a sensitive marker of low-grade systemic inflammation of high prognostic value for determining cardiovascular risk and is directly involved in the initiation and progression of atherosclerosis.14,15 Methods Patients (25 to 75 years old) were eligible for the study if they met the following criteria: (1) recently diagnosed and previously untreated type 2 diabetes mellitus (fasting plasma glucose ⱖ126 mg/dl or plasma glucose concentration 2 hours after a glucose load ⱖ200 mg/dl) and (2) mixed dyslipidemia (plasma total cholesterol ⬎200 mg/dl, lowdensity lipoprotein [LDL] cholesterol ⬎130 mg/dl, triglycerides ⬎150 mg/dl). Exclusion criteria are presented in the Supplemental Data (available online). The study was performed in accordance with the Declaration of Helsinki and was approved by the local ethics committee. All patients gave written informed consent after the nature of the study had been explained. All included patients (n ⫽ 196) were given detailed advice about how to achieve the goals of lifestyle modification, which were a decrease in weight ⱖ7% if necessary, total fat intake ⬍30% of total energy intake, saturated fat intake ⬍7% of energy consumed, cholesterol intake ⬍200 mg/day, an increase in fiber intake to 15 g/1,000 kcal, and moderate to vigorous exercise for ⱖ30 minutes/day. Average dietary adherence was assessed by food-frequency questionnaire and analysis of 3-day eating diaries by validated methods at every visit. Apart from dietary recommendations patients were prewww.ajconline.org
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Figure 1. Schematic diagram depicting study protocol.
scribed with metformin, which was administered at a dose of 850 mg 1 times/day for the first week and thereafter 2 times/day for 90 days (Figure 1). After 90 days of lifestyle intervention and metformin treatment, patients were randomized in double-blind fashion to 1 of 4 treatment groups that was treated with simvastatin (40 mg/day), fenofibrate (200 mg/day), simvastatin (40 mg/day) in combination with fenofibrate (200 mg/day), or placebo, respectively. For fenofibrate, a micronized form was used, which is more effective and convenient than its immediate-acting form.16 Simvastatin and fenofibrate were administered for 90 days without any changes in dosage during the entire study period. To minimize the risk of eventual pharmacokinetic interactions between simvastatin and fenofibrate, the 2 drugs were administered in 12-hour intervals (from 8:00 to 9:00 A.M. and from 8:00 to 9:00 P.M.). In the groups treated solely with simvastatin or fenofibrate, 1/2 of patients received a drug in the morning and placebo in the evening, and the other 1/2 was given the drug in the evening and
placebo in the morning. In the combined therapy group, 1/2 of patients were treated with simvastatin in the morning and fenofibrate in the evening, and in the other 1/2 these drugs were administered in reverse order. Placebo-treated patients received placebo 2 times/day. Throughout the study period all patients complied with lifestyle modifications and were treated with metformin. Investigation of possible drug-induced side effects was performed fortnightly. Safety end points were overt myopathy, increase of aminotransferases ⬎3 times the upper limit of normal, and creatine kinase levels ⬎10 times the upper limit of normal. Compliance was assessed during each visit by tablet counts and was considered satisfactory when the number of tablets taken by a patient was 90% to 110%. All measurements were performed 4 times: at baseline, before randomization, and after 30 and 90 days of therapy. Venous blood samples were taken 12 hours after the last meal in a quiet temperature-controlled room (24°C to 25°C) in constant daily hours (from 8:00 to 9:00 A.M.) to avoid
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Table 1 Baseline characteristics of patients* Variable Age (years) Women Smokers Body mass index (kg/m2) Atherogenic dyslipidemia† Total cholesterol (mg/dl) Low-density lipoprotein cholesterol (mg/dl) High-density lipoprotein cholesterol (mg/dl) Triglycerides (mg/dl) Apoprotein A-I (mg/dl) Apoprotein B (mg/dl) Free fatty acids (mol/L) Fasting glucose (mg/dl) Homeostatic model assessment index Glycated hemoglobin (%) High-sensitivity C-reactive protein (mg/dl) Monocyte tumor necrosis factor-␣ release (pg/ml) Monocyte interleukin-1 release (pg/ml) Monocyte interleukin-6 release (ng/ml) Monocyte monocyte chemoattractant protein-1 release (ng/ml) Lymphocyte interleukin-2 release (ng/ml) Lymphocyte interferon-␥ release (ng/ml) Lymphocyte tumor necrosis factor-␣ release (pg/ml)
Placebo (n ⫽ 46)
Simvastatin (n ⫽ 48)
Fenofibrate (n ⫽ 47)
Simvastatin ⫹ Fenofibrate (n ⫽ 49)
52.8 ⫾ 2.0 41% 20% 28.2 ⫾ 1.4 87% (76%) 235 ⫾ 4 155 ⫾ 2 37 ⫾ 1 231 ⫾ 6 121 ⫾ 7 157 ⫾ 5 516 ⫾ 39 173 ⫾ 3 12.1 ⫾ 0.5 8.1 ⫾ 0.2 3.2 ⫾ 0.2 1,720 ⫾ 40 143 ⫾ 5 10.3 ⫾ 0.4 21.3 ⫾ 1.0 7.1 ⫾ 0.2 68.2 ⫾ 3.2 405 ⫾ 19
53.2 ⫾ 1.9 44% 21% 28.8 ⫾ 2.0 83% (73%) 240 ⫾ 5 156 ⫾ 3 37 ⫾ 1 235 ⫾ 6 118 ⫾ 4 159 ⫾ 5 502 ⫾ 26 176 ⫾ 4 11.9 ⫾ 0.5 7.8 ⫾ 0.2 3.4 ⫾ 0.3 1,810 ⫾ 50 139 ⫾ 5 10.7 ⫾ 0.4 21.2 ⫾ 0.8 7.0 ⫾ 0.2 67.6 ⫾ 5.0 413 ⫾ 19
52.6 ⫾ 2.3 43% 23% 29.0 ⫾ 2.2 85% (74%) 238 ⫾ 4 153 ⫾ 4 38 ⫾ 1 226 ⫾ 7 121 ⫾ 5 157 ⫾ 4 512 ⫾ 38 180 ⫾ 3 12.0 ⫾ 0.5 7.9 ⫾ 0.2 3.1 ⫾ 0.3 1,789 ⫾ 48 141 ⫾ 5 10.9 ⫾ 0.3 22.0 ⫾ 1.1 7.2 ⫾ 0.3 67.1 ⫾ 4.1 410 ⫾ 20
53.4 ⫾ 2.0 45% 24% 28.6 ⫾ 1.7 82% (71%) 242 ⫾ 5 159 ⫾ 4 37 ⫾ 1 237 ⫾ 8 117 ⫾ 4 159 ⫾ 4 508 ⫾ 30 172 ⫾ 4 11.6 ⫾ 0.6 8.0 ⫾ 0.1 3.5 ⫾ 0.2 1,825 ⫾ 45 146 ⫾ 6 10.4 ⫾ 0.4 20.9 ⫾ 0.8 7.5 ⫾ 0.4 69.0 ⫾ 6.0 416 ⫾ 17
Data presented as mean ⫾ SEM. * Only data of subjects who completed the study were included in the final analyses. † Based on National Cholesterol Education Program Adult Treatment Panel III criteria17 (criteria proposed by Grundy and Small18).
circadian fluctuations of the parameters studied. Plasma levels of total cholesterol, LDL cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides were assessed colorimetrically using commercially available kits obtained from bioMérieux (Marcy l’Etoile, France). LDL cholesterol levels were measured directly. Plasma glucose concentrations were measured by a glucose oxidase method (Beckman, Palo Alto, California). Total nonesterified free fatty acids were determined by an enzymatic assay using reagents from Alpha Laboratories (Eastleigh, Hants, United Kingdom). Levels of apoproteins A-I and B were assessed by immunoturbidimetry (Incstar, Corp., Stillwater, Minnesota). Glycated hemoglobin was determined using DCA (2000) analyzer (Bayer, Ames Technicon, Tarrytown, New York). Plasma insulin was measured with a commercial radioimmunoassay kit (Linco Research, Inc., St. Charles, Missouri) that does not cross-react with human proinsulin. Homeostatic model assessment index was calculated as the product of fasting plasma insulin level (microunits per milliliter) and fasting plasma glucose level (millimoles per liter) divided by 22.5. Plasma levels of CRP were measured using a high-sensitivity monoclonal antibody assay (highsensitivity CRP [hs-CRP]; MP Biomedicals, Orangeburg, New York). Lower limit of sensitivity of this method was 0.1 mg/L. Cultures of phytohemagglutinin-stimulated T cells and lipopolysaccharide-stimulated monocytes were performed in triplicate as described previously.8 –11 Monocyte release of TNF-␣, interleukin-1, interleukin-6, and MCP-1 and lymphocyte release of interleukin-2, interferon-␥, and TNF-␣ were estimated using commercial enzyme-linked
immunosorbent assay kits (R&D Systems, Minneapolis, Minnesota) according to the manufacturer’s instructions. Minimum detectable levels for assessed cytokines were 8, 15, 4.4, 5.0, 3.9, and 1.0 pg/ml for interleukin-2, interferon-␥, TNF-␣, MCP-1, interleukin-6, TNF-␣, and interleukin-1, respectively. Intra- and interassay coefficients of variation were ⬍6.0% and ⬍8.5%, respectively. All calculations were made using GraphPad Prism 2.01 (GraphPad Software, Inc., San Diego, California) and Statistica 6.1 (StatSoft, Tulsa, Oklahoma). Statistical significance was defined as a p value ⬍0.05. To begin with, distribution of variables was analyzed using Kolmogorov– Smirnov test. Outcomes for insulin, homeostatic model assessment index, hs-CRP, and cytokines were natural logtransformed to satisfy assumptions of normality and equal variance. Because lipid/lipoprotein and carbohydrate and, after logarithmic transformation, other values were normally distributed, parametric statistics were used for analyses. Comparisons between groups were performed using 1-way analysis of variance followed by post hoc Newman– Keuls test. Differences between means of variables within the same treatment group were analyzed with Student’s paired t test. In addition, to verify the correctness of statistical analysis for insulin, homeostatic model assessment index, hs-CRP, and cytokines, their median values on the original scale were recalculated using nonparametric tests (Kruskal–Wallis test followed by Mann–Whitney U test and Wilcoxon matched-pair test). Because the results of nonparametric statistics did not differ from those obtained after using nonparametric tests, these are not shown. Because the results of this analysis are consistent with those obtained
Table 2 Effect of simvastatin and fenofibrate, administered alone or combination on lipid/lipoprotein profile, glucose homeostasis, low-grade inflammation, and monocyte and lymphocyte cytokine release in type 2 diabetic patients with mixed dyslipidemia Treatment Group Placebo (n ⫽ 46)
Fenofibrate (n ⫽ 47)
Simvastatin ⫹ Fenofibrate (n ⫽ 49)
235 ⫾ 4 233 ⫾ 4 (⫺1) 231 ⫾ 4 (⫺2, ⫺1) 230 ⫾ 5 (⫺2, ⫺2)
240 ⫾ 5 235 ⫾ 5 (⫺2) 178 ⫾ 4 (⫺26, ⫺24)‡储‡‡‡ 177 ⫾ 4 (⫺26, ⫺25)‡¶§§§
238 ⫾ 4 229 ⫾ 4 (⫺4) 201 ⫾ 4 (⫺16, ⫺12)*§ 201 ⫾ 3 (⫺16, ⫺12)†§#
242 ⫾ 5 236 ⫾ 5 (⫺3) 168 ⫾ 4 (⫺31, ⫺29)‡¶§§§ 156 ⫾ 5 (⫺36, ⫺34)‡¶#§§§
155 ⫾ 2 151 ⫾ 3 (⫺3) 151 ⫾ 3 (⫺3.0) 148 ⫾ 5 (⫺5, ⫺2)
156 ⫾ 3 152 ⫾ 3 (⫺3)** 104 ⫾ 3 (⫺33, ⫺31)‡††¶††† 100 ⫾ 2 (⫺36, ⫺34)‡††¶†††
153 ⫾ 4 148 ⫾ 3 (⫺4) 122 ⫾ 3 (⫺20, ⫺17)*§ 120 ⫾ 4 (⫺22, ⫺19)*#§
159 ⫾ 4 155 ⫾ 4 (⫺3) 96 ⫾ 3 (⫺39, ⫺38)‡¶††‡‡‡ 92 ⫾ 3 (⫺42, ⫺43)‡¶††‡‡‡
37 ⫾ 1 38 ⫾ 1 (2) 39 ⫾ 2 (5.3) 39 ⫾ 1 (6.4)
37 ⫾ 1 37 ⫾ 1 (1.6) 42 ⫾ 1 (15.13)* 43 ⫾ 1 (16.14)*
38 ⫾ 1 39 ⫾ 1 (2) 46 ⫾ 1 (23.20)†§# 48 ⫾ 1 (27.25)‡储††
37 ⫾ 1 38 ⫾ 1 (2) 47 ⫾ 1 (28.25)†§†† 50 ⫾ 1 (36.33)‡¶††¶¶
231 ⫾ 6 208 ⫾ 5 (⫺10) 192 ⫾ 5 (⫺17, ⫺8)* 191 ⫾ 5 (⫺17, ⫺9)*
235 ⫾ 6 212 ⫾ 6 (⫺10) 179 ⫾ 5 (⫺24, ⫺16)* 178 ⫾ 5 (⫺24, ⫺16)*
226 ⫾ 7 204 ⫾ 7 (⫺10) 144 ⫾ 8 (⫺36, ⫺29)‡¶††## 141 ⫾ 8 (⫺38, ⫺32)‡¶††##
237 ⫾ 8 205 ⫾ 9 (⫺13) 136 ⫾ 6 (⫺43, ⫺34)‡¶††** 123 ⫾ 5 (⫺48, ⫺40)‡¶††***
121 ⫾ 7 130 ⫾ 5 (7) 135 ⫾ 5 (11.3) 136 ⫾ 5 (12.5)
118 ⫾ 4 127 ⫾ 5 (8) 136 ⫾ 4 (15.7) 143 ⫾ 4 (21.13)*
121 ⫾ 5 132 ⫾ 5 (10) 160 ⫾ 5 (32.7, 21.0)‡§††## 161 ⫾ 3 (33.7, 21.8)‡§††¶¶
117 ⫾ 4 128 ⫾ 4 (9) 165 ⫾ 4 (41.29)‡储††## 172 ⫾ 3 (46.34)‡储††##
157 ⫾ 5 150 ⫾ 5 (⫺5) 149 ⫾ 5 (⫺6, ⫺1) 148 ⫾ 3 (⫺6, ⫺1)
159 ⫾ 5 150 ⫾ 4 (⫺6) 110 ⫾ 3 (⫺31, ⫺27)‡††¶††† 108 ⫾ 5 (⫺32, ⫺28)‡¶††‡‡‡
516 ⫾ 39 438 ⫾ 50 (⫺15) 427 ⫾ 40 (⫺17, ⫺3) 420 ⫾ 46 (⫺19, ⫺4)
502 ⫾ 26 426 ⫾ 39 (⫺15) 335 ⫾ 33 (⫺33, ⫺21)‡§# 265 ⫾ 22 (⫺47, ⫺38)‡¶**‡‡
512 ⫾ 38 435 ⫾ 34 (⫺15) 320 ⫾ 37 (⫺38, ⫺26)‡储** 250 ⫾ 29 (⫺51, ⫺43)‡¶††‡‡
508 ⫾ 30 422 ⫾ 42 (⫺17) 301 ⫾ 21 (⫺41, ⫺29)‡¶†† 220 ⫾ 22 (⫺57, ⫺48)‡¶††§§
173 ⫾ 4 144 ⫾ 3 (⫺17)† 140 ⫾ 2 (⫺19, ⫺3)‡ 138 ⫾ 3 (⫺20, ⫺4)‡
176 ⫾ 4 147 ⫾ 4 (⫺16)† 142 ⫾ 3 (⫺18, ⫺3)‡ 141 ⫾ 3 (⫺19, ⫺4)‡
180 ⫾ 3 142 ⫾ 3 (⫺21)‡ 128 ⫾ 2 (⫺29, ⫺10)‡§**## 127 ⫾ 3 (⫺30, ⫺11)‡储**##
172 ⫾ 4 140 ⫾ 2 (⫺18)‡ 126 ⫾ 2 (⫺26, ⫺10)‡储**## 127 ⫾ 3 (⫺26, ⫺10)‡储**##
157 ⫾ 4 152 ⫾ 4 (⫺3) 130 ⫾ 4 (⫺17, ⫺14)†§# 130.2 ⫾ 3 (⫺17, ⫺14)†§#
159 ⫾ 4.3 154 ⫾ 4.0 (⫺3.5) 105 ⫾ 3.5 (⫺33.9, ⫺31.5)‡¶††‡‡‡ 102 ⫾ 3.8 (⫺35.8, ⫺33.5)‡¶††§§§
Preventive Cardiology/Hypolipidemic Agents and Cytokine Release
Total cholesterol (mg/dl) Baseline Before randomization After 30 d of hypolipidemic treatment After 90 days of hypolipidemic treatment Low-density lipoprotein cholesterol (mg/dl) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment High-density lipoprotein cholesterol (mg/dl) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Triglycerides (mg/dl) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Apoprotein A-I (mg/dl) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Apoprotein B (mg/dl) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Free fatty acids (mol/L) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Fasting glucose (mg/dl) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment
Simvastatin (n ⫽ 48)
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Table 2 (continued) Treatment Group Placebo (n ⫽ 46) 12.1 ⫾ 0.5 10.9 ⫾ 0.5 (⫺10)* 10.1 ⫾ 0.6 (⫺17, ⫺7)* 8.7 ⫾ 0.5 (⫺28, ⫺20)‡#
11.9 ⫾ 0.5 10.5 ⫾ 0.4 (⫺12)* 9.8 ⫾ 0.4 (⫺18, ⫺7)† 9.2 ⫾ 0.5 (⫺23, ⫺12)†
Fenofibrate (n ⫽ 47) 12.0 ⫾ 0.5 10.7 ⫾ 0.6 (⫺11)* 8.5 ⫾ 0.4 (⫺29, ⫺21)‡**¶¶ 6.5 ⫾ 0.4 (⫺46, ⫺39)‡储††§§***
Simvastatin ⫹ Fenofibrate (n ⫽ 49) 11.6 ⫾ 0.6 10.2 ⫾ 0.5 (⫺12)* 8.1 ⫾ 0.3 (⫺30, ⫺21)‡储#**## 6.2 ⫾ 0.4 (⫺47, ⫺39)‡储††§§***
8.1 ⫾ 0.2 7.6 ⫾ 0.1 (⫺6)* 7.4 ⫾ 0.2 (⫺9, ⫺3)* 7.4 ⫾ 0.2 (⫺9, ⫺3)*
7.8 ⫾ 0.2 7.0 ⫾ 0.2 (⫺10)* 6.9 ⫾ 0.2 (⫺12, ⫺1)* 6.8 ⫾ 0.1 (⫺13, ⫺3)†
7.9 ⫾ 0.2 7.1 ⫾ 0.2 (⫺10)* 6.3 ⫾ 0.3 (⫺20, ⫺11)‡储# 6.1 ⫾ 0.2 (⫺23, ⫺14)‡储#¶¶
8.0 ⫾ 0.1 7.0 ⫾ 0.2 (⫺13)† 6.3 ⫾ 0.2 (⫺21, ⫺10)‡储# 6.0 ⫾ 0.3 (⫺25, ⫺14)‡¶#¶¶
3.2 ⫾ 0.2 3.0 ⫾ 0.2 (⫺6) 2.9 ⫾ 0.3 (⫺9, ⫺3) 2.8 ⫾ 0.2 (⫺13, ⫺7)
3.4 ⫾ 0.3 3.0 ⫾ 0.3 (⫺12) 2.5 ⫾ 0.2 (⫺27, ⫺17)‡# 1.7 ⫾ 0.2 (⫺50, ⫺43)‡¶††§§
3.1 ⫾ 0.3 2.8 ⫾ 0.2 (⫺10) 2.2 ⫾ 0.2 (⫺29, ⫺21)‡储# 1.6 ⫾ 0.2 (⫺48, ⫺43)‡¶††§§
3.5 ⫾ 0.2 3.1 ⫾ 0.2 (⫺11) 2.1 ⫾ 0.2 (⫺40, ⫺32)‡储†† 1.1 ⫾ 0.1 (⫺69, ⫺65)‡¶††储储¶¶†††
1,720 ⫾ 40 1,580 ⫾ 51 (⫺9) 1,269 ⫾ 40 (⫺26, ⫺20)* 1,250 ⫾ 53 (⫺27, ⫺21)*
1,810 ⫾ 50 1,600 ⫾ 50 (⫺12) 1,213 ⫾ 30 (⫺33, ⫺24)‡** 874 ⫾ 26 (⫺52, ⫺45)‡#储**‡‡
1,789 ⫾ 48 1,586 ⫾ 45 (⫺11) 1,240 ⫾ 9 (⫺31, ⫺22)†# 890 ⫾ 33 (⫺50, ⫺44)‡储#‡‡
1,825 ⫾ 45 1,621 ⫾ 42 (⫺11) 1,185 ⫾ 40 (⫺35, ⫺27)‡** 793 ⫾ 30 (⫺57, ⫺51)‡¶††储储
143 ⫾ 5 140 ⫾ 5 (⫺1.7) 135 ⫾ 6 (⫺5, ⫺4) 134 ⫾ 6 (⫺6, ⫺5)
139 ⫾ 5 130 ⫾ 6 (⫺6) 91 ⫾ 4 (⫺35, ⫺31)‡¶** 73 ⫾ 4 (⫺47, ⫺44)‡¶††‡‡
141 ⫾ 5 132 ⫾ 6 (⫺6) 93.8 ⫾ 5 (⫺33, ⫺29)‡储** 71.2 ⫾ 3 (⫺49, ⫺46)‡¶††§§
146 ⫾ 6 132 ⫾ 6 (⫺9) 94 ⫾ 5 (⫺36, ⫺29)‡¶** 71 ⫾ 4 (⫺51, ⫺46)‡¶††§§
10.3 ⫾ 0.4 9.2 ⫾ 0.3 (⫺11) 8.0 ⫾ 0.3 (⫺22, ⫺13)* 7.9 ⫾ 0.4 (⫺23, ⫺14)*
10.7 ⫾ 0.4 9.5 ⫾ 0.3 (⫺12) 7.6 ⫾ 0.3 (⫺29, ⫺20)*# 5.8 ⫾ 0.3 (⫺46, ⫺39)‡储#**§§
10.9 ⫾ 0.3 9.7 ⫾ 0.4 (⫺11) 7.7 ⫾ 0.3 (⫺29, ⫺21)*# 6.0 ⫾ 0.4 (⫺45, ⫺38)‡储#**‡‡
10.4 ⫾ 0.4 9.8 ⫾ 0.4 (⫺6) 7.3 ⫾ 0.3 (⫺30, ⫺26)†# 5.4 ⫾ 0.4 (⫺48, ⫺45)‡¶††§§
21.3 ⫾ 1.0 19.6 ⫾ 1.1 (⫺8) 19.0 ⫾ 1.4 (⫺11, ⫺3) 19.2 ⫾ 0.8 (⫺10, ⫺2)
21.2 ⫾ 0.8 20.4 ⫾ 0.9 (⫺5) 17.1 ⫾ 0.9 (⫺19, ⫺16)* 13.1 ⫾ 0.6 (⫺38, ⫺36)‡储#‡‡
22.0 ⫾ 1.1 20.3 ⫾ 0.8 (⫺8) 16.9 ⫾ 0.9 (⫺23, ⫺17)*# 12.5 ⫾ 0.7 (⫺43, ⫺38)‡储#‡‡
20.9 ⫾ 0.8 19.4 ⫾ 0.7 (⫺7) 15.4 ⫾ 0.6 (⫺26, ⫺21)*# 11.3 ⫾ 0.7 (⫺46, ⫺42)‡¶††§§
7.1 ⫾ 0.2 6.8 ⫾ 0.2 (⫺4) 6.6 ⫾ 0.1 (⫺7, ⫺3) 6.4 ⫾ 0.1 (⫺10, ⫺6)
7.0 ⫾ 0.2 6.8 ⫾ 0.3 (⫺3) 5.2 ⫾ 0.2 (⫺26, ⫺24)†§# 4.0 ⫾ 0.2 (⫺43, ⫺41)‡¶**‡‡
7.2 ⫾ 0.3 6.7 ⫾ 0.2 (⫺7) 5.0 ⫾ 0.1 (⫺31, ⫺25)†§# 3.8 ⫾ 0.2 (⫺47, ⫺43)‡¶††§§
7.5 ⫾ 0.4 7.1 ⫾ 0.3 (⫺5) 4.6 ⫾ 0.2 (⫺39, ⫺35)‡储†† 2.8 ⫾ 0.2 (⫺63, ⫺61)‡¶††储储***§§§
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Homeostatic model assessment Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Glycated hemoglobin (%) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment High-sensitivity C-reactive protein (mg/dl) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Monocyte tumor necrosis factor-␣ release (pg/ml) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Monocyte interleukin-1 release (pg/ml) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Monocyte interleukin-6 release (ng/ml) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Monocyte monocyte chemoattractant protein-1 release (ng/ml) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Lymphocyte interleukin-2 release (ng/ml) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment
Simvastatin (n ⫽ 48)
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after using parametric tests, these are not discussed in the text. For categorical variables, chi-square test was used. Correlations were calculated using the Kendall test.
416 ⫾ 18 398 ⫾ 18 (⫺4) 298 ⫾ 16 (⫺28, ⫺26)‡§** 179 ⫾ 13 (⫺57, ⫺56)‡¶††储储##§§§
Results
Data represent mean ⫾ SEM (percent change from respective baseline value, percent change from respective value before randomization). * p ⬍0.05;† p ⬍0.01;‡ p ⬍0.001 versus baseline values. § p ⬍0.05;储 p ⬍0.01;¶ p ⬍0.001 versus placebo-treated patients. # p ⬍0.05;** p ⬍0.01;†† p ⬍0.001 versus respective value before randomization. ‡‡ p ⬍0.05;§§ p ⬍0.01;储储 p ⬍0.001 versus respective value after 30 days of treatment. ¶¶ p ⬍0.05;## p ⬍0.01;*** p ⬍0.001 versus effect of simvastatin. ††† p ⬍0.05;‡‡‡ p ⬍0.01;§§§ p ⬍0.001 versus effect of fenofibrate.
413 ⫾ 19 398 ⫾ 21 (⫺3) 310 ⫾ 13 (⫺25, ⫺22)†# 246 ⫾ 12 (⫺41, ⫺38)‡¶††‡‡ 405 ⫾ 12 387 ⫾ 18 (⫺4) 361 ⫾ 18 (⫺11, ⫺7) 359 ⫾ 18 (⫺12, ⫺7)
410 ⫾ 20 393 ⫾ 19 (⫺4) 316 ⫾ 12 (⫺23, ⫺20)†# 251 ⫾ 14 (⫺39, ⫺36)‡¶††‡‡
69.0 ⫾ 6.0 64.2 ⫾ 5.3 (⫺7) 42.8 ⫾ 3.8 (⫺38, ⫺33)‡¶†† 28.6 ⫾ 2.9 (⫺59, ⫺55)‡¶††§§##††† 67.1 ⫾ 4.1 63.2 ⫾ 4.9 (⫺6) 47.9 ⫾ 4.0 (⫺29, ⫺24)†储** 37.5 ⫾ 3.3 (⫺44, ⫺41)‡¶††‡‡ 67.6 ⫾ 5.0 64.8 ⫾ 5.1 (⫺4) 51.1 ⫾ 4.4 (⫺24, ⫺21)†# 38.1 ⫾ 3.5 (⫺44, ⫺41)‡¶††§§ 68.2 ⫾ 3.2 63.7 ⫾ 3.0 (⫺7) 62.1 ⫾ 4.0 (⫺9, ⫺3) 61.9 ⫾ 3.5 (⫺9, ⫺3)
Lymphocyte interferon-␥ release (ng/ml) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Tumor necrosis factor-␣ release (pg/ml) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment
Table 2 (continued)
Placebo (n ⫽ 46)
Simvastatin (n ⫽ 48)
Treatment Group
Fenofibrate (n ⫽ 47)
Simvastatin ⫹ Fenofibrate (n ⫽ 49)
Preventive Cardiology/Hypolipidemic Agents and Cytokine Release
There were no significant differences in age, weight, and gender between treatment groups of diabetic patients with mixed dyslipidemia. All groups were comparable in medical background and clinical and laboratory characteristics (Table 1).17,18 Three patients terminated the study before randomization because of metformin-induced diarrhea, nausea, and increased flatulence. One subject treated with simvastatin was withdrawn from the study because of increased creatine kinase activity. Two subjects dropped out because of noncompliance with the study protocol. Neither significant adverse effects nor any complications were reported throughout the study period in the remaining participants. Baseline characteristics of the 6 subjects who were withdrawn from the study did not differ from the 190 completing the study (data not shown). Thirty days of lifestyle modification and metformin treatment significantly decreased fasting plasma glucose, homeostatic model assessment index, and glycated hemoglobin but produced no effect on plasma lipid/lipoproteins, hs-CRP, and cytokine release (Table 2). Continuation of lifestyle modification and metformin treatment in addition placebo for the next 90 days, apart from changes in plasma glucose, homeostatic model assessment index, and glycated hemoglobin, decreased also triglyceride levels and inhibited monocyte TNF-␣ and interleukin-6 release. However, it did not affect monocyte release of interleukin-1 and MCP-1 and lymphocyte release of interleukin-2, interferon-␥, and TNF-␣. Simvastatin administered to diabetic patients with mixed dyslipidemia complying with lifestyle modification and treated with metformin decreased total cholesterol, LDL cholesterol, triglycerides, apoprotein B, and free fatty acids and increased HDL cholesterol and apoprotein A. Simvastatin did not change fasting glucose levels, glycated hemoglobin, and homeostatic model assessment index. Moreover, simvastatin treatment inhibited plasma hs-CRP, monocyte release of TNF-␣, interleukin-1, interleukin-6, and MCP-1 and lymphocyte release of interleukin-2, interferon-␥, and TNF-␣. Simvastatin action on free fatty acids, hs-CRP, and cytokine release was stronger after 90 than after 30 days of administration. Fenofibrate treatment led to a decrease in total and LDL cholesterol, triglycerides, free fatty acids, fasting plasma glucose, homeostatic model assessment index and glycated hemoglobin, hs-CRP, and monocyte and lymphocyte cytokine release. It also increased HDL cholesterol and apoprotein A-I levels. Effect of fenofibrate on free fatty acids, homeostatic model assessment index, hs-CRP, and cytokine release was more pronounced after 90 than after 30 days of treatment. Combined treatment with simvastatin and fenofibrate decreased total and LDL cholesterol, triglycerides, apoprotein B, fasting plasma glucose, homeostatic model assessment index, and glycated hemoglobin, and increased HDL cholesterol and apoprotein A-I levels. Simvastatin administered with fenofibrate also decreased hs-CRP and inhibited monocyte re-
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lease of TNF-␣, interleukin-1, interleukin-6, and MCP-1 and lymphocyte release of interleukin-2, interferon-␥, and TNF-␣. Effect of simvastatin and fenofibrate on free fatty acids, homeostatic model assessment index, and cytokine release was stronger after 90 than after 30 days of treatment. In type 2 diabetic patients with mixed dyslipidemia complying with lifestyle intervention and treated with placebo, simvastatin alone or in combination with fenofibrate was superior to fenofibrate alone in decreasing plasma levels of total cholesterol, LDL cholesterol, and apoprotein B (Table 2). Fenofibrate alone or administered with simvastatin was superior to simvastatin alone in affecting triglycerides, apoprotein A-I, plasma glucose, homeostatic model assessment index, and glycated hemoglobin. There were no differences between simvastatin and fenofibrate in strength of action on monocyte and lymphocyte cytokine release and on plasma hs-CRP. Simvastatin and fenofibrate administered in combination produced a more pronounced effect on plasma hs-CRP and lymphocyte release of interleukin-2, interferon-␥, and TNF-␣ than treatment with simvastatin or fenofibrate alone. In the group treated with simvastatin and fenofibrate (but not in the remaining treatment groups) degree of decrease in cytokine release and in plasma hs-CRP levels tended to be more pronounced in patients with than in those without atherogenic dyslipidemia (p ⫽ 0.057 to 0.093, data not shown). At baseline, there was a weak correlation between cytokine release and plasma hs-CRP levels and between cytokine release and homeostatic model assessment index. Treatment-induced changes in cytokine release and plasma hs-CRP correlated with degree of decrease in free fatty acids. There was a weak correlation between the effect of fenofibrate alone or simvastatin plus fenofibrate on hs-CRP and cytokine release and on homeostatic model assessment index. There was no correlation between hs-CRP and cytokine release and between hs-CRP and lipid/lipoprotein profile in response to lifestyle intervention plus metformin, simvastatin alone, fenofibrate alone, or simvastatin plus fenofibrate (for more details, see Supplemental Data). Discussion The major finding of the study is that simvastatin and fenofibrate exhibit a similar effect in extent on secretory function of human monocytes and lymphocytes and on systemic inflammation in type 2 diabetic subjects with mixed dyslipidemia, which represents a pleiotropic action of 3-hydroxy-3-methylgluraryl coenzyme A reductase inhibitors and peroxisome proliferator activated receptor-␣ activators. For lymphocytes and systemic inflammation, this effect is stronger when the 2 drugs are administered together. Because low-grade inflammation14,15 and increased production of proatherogenic cytokines are associated with faster development and progression of atherosclerosis,5–7 the anti-inflammatory action of simvastatin and fenofibrate treatment seems to be clinically relevant. In agreement with our previous study,1 an initial period of lifestyle modification and metformin treatment despite improving glycemic control produced only small anti-inflammatory effects. The fact that this effect was potentiated by simvastatin and fenofibrate may suggest the rationale of
adding statin and fibrate therapy to metformin and lifestyle modification in the primary prevention of vascular disorders in subjects with newly diagnosed diabetic dyslipidemia, even if metformin and nonpharmacologic treatment effectively improve glucose homeostasis. Fenofibrate action on monocyte and lymphocyte cytokine release and on systemic inflammation was similar to that of simvastatin, a drug with anti-inflammatory properties observed in carbohydrate and lipid metabolism abnormalities and in end-stage renal failure.10,11,19 This finding is in disagreement with the results of some fibrate trials especially the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD)20 and the Bezafibrate Infarction Prevention (BIP)21 studies, which showed that fibrates only nonsignificantly decreased the primary end point (death plus nonfatal myocardial infarction). Unfortunately, the results of these 2 trials were confounded by other lipid-lowering agents. In the FIELD study, after correction for nonrandomized statin decrease, risk of cardiovascular events in fenofibrate-treated patients decreased significantly by 19% (in patients without ischemic heart disease even by 25%). Similarly, in the BIP trial, after excluding from analysis patients receiving open-label hypolipidemic agents, bezafibrate led to a 17% risk decrease and the risk decrease was particularly pronounced in subjects with metabolic syndrome.22,23 Our results suggest that peroxisome proliferator activated receptor-␣ activators, if administered without other hypolipidemic agents, may bring clinical benefits to subjects with recently diagnosed and previously untreated type 2 diabetes mellitus. Interestingly, no large fibrate trial included only or performed separate analysis of this group of patients (e.g., in the FIELD study diabetes lasted on average 5 years). Interestingly, a recent large clinical study, the Action to Control Cardiovascular Risk in Diabetes Lipid (ACCORD) trial, has shown similar potency of the simvastatin–fenofibrate combination and simvastatin alone in decreasing cardiovascular and cerebrovascular risks in middle-aged and elderly subjects with type 2 diabetes and concomitant coronary artery disease or presence of increased cardiovascular risk.24 Our findings are in some contrast to the results of this study. Combined administration of simvastatin and micronized fenofibrate was superior to monotherapy with these 2 agents in improving lipid profile and decreasing lymphocyte cytokine release, although the 2 treatment strategies were equipotent in affecting monocyte cytokine release. This discrepancy may result from different inclusion criteria for the 2 studies. Our study included subjects with newly diagnosed diabetes who were simultaneously offered lifestyle modification and metformin treatment and were given fixed doses of simvastatin and fenofibrate. In turn, in the ACCORD diabetes lasted on average 10 years, patients were subjected to various hypoglycemic strategies, and doses of hypolipidemic agents depended on plasma lipid levels. Less convincing is the explanation that our study was shorter than ACCORD because the strength of the antiinflammatory action of simvastatin and fenofibrate increased with time. Certainly we cannot fully exclude the hypothesis that monocytes are more important targets for cardiovascular drugs than lymphocytes when determining the decrease of cardiovascular risk. However, a stronger decrease in plasma hs-CRP in the combined treatment group
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than in subjects treated with only 1 hypolipidemic agent contradicts this hypothesis. Because even small differences in levels of the studied markers in the population are associated with various grades of insulin resistance and with various risks of coronary artery disease and its complications,5–7 the additive effect of cotreatment on lymphocyte cytokine release may, in our opinion, bring some cardiovascular and metabolic benefits to the studied population. Most patients included in the study met the criteria of atherogenic dyslipidemia,17,18 which is the most characteristic lipid abnormality in patients with type 2 diabetes.25 As in the entire population, in the subgroup of patients with atherogenic dyslipidemia the 2 drugs decreased cytokine release and plasma hs-CRP levels, and for lymphocytes and systemic inflammation, this effect was more pronounced when simvastatin and fenofibrate were administered together. In the combination treatment group, these anti-inflammatory effects were a bit stronger than in the remaining subjects and this finding agrees with the ACCORD in which patients with HDL cholesterol ⬍34 mg/dl and triglycerides ⬎204 mg/dl gained the greatest clinical benefit from adding fenofibrate to simvastatin.24 Simvastatin and fenofibrate action on cytokine release and systemic inflammation was lipid-independent. The finding that the effect of fenofibrate on monocyte and lymphocyte secretory function and on plasma hs-CRP correlated with its action on free fatty acids, which are the endogenous ligands for peroxisome proliferator activated receptor-␣,16 provides some arguments that nonlipid-related effects of this drug may be mediated by this receptor. That a similar free fatty acid– dependent effect was exhibited also by simvastatin indicates that the favorable anti-inflammatory actions of 3-hydroxy-3-methylgluraryl coenzyme A reductase inhibitors are partly related to their free fatty acid–lowering action and seems to be in line with a hypothesis that molecular mechanisms of action of statins and fibrates may to some extent overlap.26,27 However, the fact that only the action of fenofibrate was related to the improvement in insulin sensitivity suggests, at least for simvastatin, the presence of other mechanisms responsible for pleiotropic actions. Although only fenofibrate treatment improved glycated hemoglobin, homeostatic model assessment index, and plasma glucose levels, simvastatin was devoid of any deteriorating effect on glucose metabolism described previously by other investigators.28,29 This indicates that hypolipidemic agents administered to type 2 diabetic patients not only do not increase the risk of worsening glycemic control but may even (fenofibrate) improve glucose metabolism. Our study has some limitations. First, it included a relatively small number of patients and assessed only surrogates. Second, simvastatin and fenofibrate were used at doses that are not maximal doses. Therefore, it cannot be excluded that the effect of these agents may be stronger when administered at higher doses for a longer period. Third, because we included only diabetic patients with mixed dyslipidemia, whether hypolipidemic agents alter the secretory function of monocytes and lymphocytes in diabetic patients with isolated hypercholesterolemia, isolated hypertriglyceridemia, or without any lipid abnormalities requires further studies.
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1. Pruski M, Krysiak R, Okopien B. Pleiotropic action of short-term metformin and fenofibrate treatment, combined with lifestyle intervention, in type 2 diabetic patients with mixed dyslipidemia. Diabetes Care 2009;32:1421–1424. 2. Hansson GK. Inflammatory mechanisms in atherosclerosis. J Thromb Haemost 2009;7(suppl 1):328 –331. 3. Weyand CM, Younge BR, Goronzy JJ. T cells in arteritis and atherosclerosis. Curr Opin Lipidol 2008;19:469 – 477. 4. Wilson HM, Barker RN, Erwig LP. Macrophages: promising targets for the treatment of atherosclerosis. Curr Vasc Pharmacol 2009;7: 234 –243. 5. Kher N, Marsh JD. Pathobiology of atherosclerosis—a brief review. Semin Thromb Hemost 2004;30:665– 672. 6. Tedgui A, Mallat Z. Cytokines in atherosclerosis: pathogenic and regulatory pathways. Physiol Rev 2006;86:515–581. 7. Schroecksnadel K, Frick B, Winkler C, Fuchs D. Crucial role of interferon-gamma and stimulated macrophages in cardiovascular disease. Curr Vasc Pharmacol 2006;4:205–213. 8. Okopien B, Krysiak R, Haberka M, Herman ZS. Effect of monthly atorvastatin and fenofibrate treatment on monocyte chemoattractant protein-1 release in patients with primary mixed dyslipidemia. J Cardiovasc Pharmacol 2005;45:314 –320. 9. Okopien´ B, Krysiak R, Kowalski J, Madej A, Belowski D, Zielin´ski M, Herman ZS. Monocyte release of tumor necrosis factor-alpha and interleukin-1beta in primary type IIa and IIb dyslipidemic patients treated with statins or fibrates. J Cardiovasc Pharmacol 2005;46: 377–386. 10. Krysiak R, Gdula-Dymek A, Scieszka J, Okopien B. Anti-inflammatory and Monocyte-Suppressing effects of simvastatin in patients with impaired fasting glucose. Basic Clin Pharmacol Toxicol 2011;108: 131–137. 11. Okopien´ B, Krysiak R, Kowalski J, Madej A, Belowski D, Zielin´ski M, Labuzek K, Herman ZS. The effect of statins and fibrates on interferon-gamma and interleukin-2 release in patients with primary type II dyslipidemia. Atherosclerosis 2004;176:327–335. 12. Okopien´ B, Kowalski J, Krysiak R, Łabuzek K, Stachura-Kułach A, Kułach A, Zielin´ski M, Herman ZS. Monocyte suppressing action of fenofibrate. Pharmacol Rep 2005;57:367–372. 13. Okopien B, Krysiak R, Herman ZS. Effects of short-term fenofibrate treatment on circulating markers of inflammation and hemostasis in patients with impaired glucose tolerance. J Clin Endocrinol Metab 2006;91:1770 –1778. 14. Kinlay S, Egido J. Inflammatory biomarkers in stable atherosclerosis. Am J Cardiol 2006;98(suppl):2P– 8P. 15. Ridker PM. Inflammatory biomarkers and risks of myocardial infarction, stroke, diabetes, and total mortality: implications for longevity. Nutr Rev 2007;65(suppl):S253–S259. 16. Keating GM, Omrod D. Micronised fenofibrate. An updated review of its clinical efficacy in the management of dyslipidaemia. Drugs 2002; 62:1909 –1944. 17. National Cholesterol Education Program. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III) final report. Circulation 2002;106:3143–3421. 18. Grundy SM, Small LDL. Atherogenic dyslipidemia, and the metabolic syndrome. Circulation 1997;95:1– 4. 19. Kirmizis D, Papagianni A, Dogrammatzi F, Skoura L, Belechri AM, Alexopoulos E, Efstratiadis G, Memmos D. Effects of simvastatin on markers of inflammation, oxidative stress and endothelial cell apoptosis in patients on chronic hemodialysis. J Atheroscler Thromb 2010; 17:1256 –1265. 20. Keech A, Simes RJ, Barter P, Best J, Scott R, Taskinen MR, Forder P, Pillai A, Davis T, Glasziou P, Drury P, Kesäniemi YA, Sullivan D, Hunt D, Colman P, d’Emden M, Whiting M, Ehnholm C, Laakso M; FIELD Study Investigators. Effects of long-term fenofibrate therapy on cardiovascular events in 9795 people with type 2 diabetes mellitus (the FIELD study): randomised controlled trial. Lancet 2005;366: 1849 –1861. 21. BIP (Bezafibrate Infarction Prevention) Study Group. Secondary prevention by raising HDL cholesterol and reducing triglycerides in patients with coronary artery disease: the Bezafibrate Infarction Prevention (BIP) study. Circulation 2000;102:21–27. 22. Fazio S. More clinical lessons from the FIELD study. Cardiovasc Drugs Ther 2009;23:235–241.
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23. Paumelle R, Staels B. Cross-talk between statins and PPARalpha in cardiovascular diseases: clinical evidence and basic mechanisms. Trends Cardiovasc Med 2008;18:73–78. 24. Ginsberg HN, Elam MB, Lovato LC, Crouse JR III, Leiter LA, Linz P, Friedewald WT, Buse JB, Gerstein HC, Probstfield J, Grimm RH, Ismail-Beigi F, Bigger JT, Goff DC Jr, Cushman WC, Simons-Morton DG, Byington RP; ACCORD Study Group. Effects of combination lipid therapy in type 2 diabetes mellitus. N Engl J Med 2010;362: 1563–1574. 25. Farmer JA. Diabetic dyslipidemia and atherosclerosis: evidence from clinical trials. Curr Diab Rep 2008;8:71–77. 26. Martin G, Duez H, Blanquart C, Berezowski V, Poulain P, Fruchart JC, Najib-Fruchart J, Glineur C, Staels B. Statin-induced inhibition of
the Rho-signaling pathway activates PPARalpha and induces HDL apoA-I. J Clin Invest 2001;107:1423–1432. 27. Staels B, Maes M, Zambon A. Fibrates and future PPARalpha agonists in the treatment of cardiovascular disease. Nat Clin Pract Cardiovasc Med 2008;5:542–553. 28. Ridker PM, Danielson E, Fonseca FA, Genest J, Gotto AM Jr, Kastelein JJ, Koenig W, Libby P, Lorenzatti AJ, MacFadyen JG, Nordestgaard BG, Shepherd J, Willerson JT, Glynn RJ; JUPITER Study Group. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. N Engl J Med 2008;359:2195–2207. 29. Yamakawa T, Takano T, Tanaka S, Kadonosono K, Terauchi Y. Influence of pitavastatin on glucose tolerance in patients with type 2 diabetes mellitus. J Atheroscler Thromb 2008;15:269 –275.
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Supplemental Data Exclusion criteria: Exclusion criteria were (1) primary isolated hypercholesterolemia or hypertriglyceridemia; (2) secondary dyslipidemia in the course of autoimmune disorders, thyroid diseases, chronic pancreatitis, nephrotic syndrome, liver and biliary tract diseases, or alcoholism; (3) body mass index ⬎35 kg/m2; (4) any acute and persistent inflammatory processes; (5) symptomatic congestive heart failure; (6) unstable coronary artery disease, myocardial infarction, or stroke within 6 months before the study; (7) arterial hypertension (European Society of Cardiology/European Society of Hypertension grade 2 or 3); (8) impaired renal or hepatic function; (9) malabsorption syndromes; (10) treatment with other hypolipidemic drugs within 3 months before the study; (11) concomitant treatment with insulin and/or oral antidiabetic drugs; (12) concomitant treatment with other drugs known to affect plasma lipid levels or to interact with statins and fibrates; (13) concomitant treatment with drugs that may affect inflammatory processes in the vascular wall (including nonsteroidal antiinflammatory drugs, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers) within 3 months before the study; (14) ongoing hormonal replacement therapy or oral contraception; and (15) poor patient compliance. Correlations: At baseline, glycated hemoglobin levels correlated with fasting glucose (r ⫽ 0.74, p ⬍001) and homeostatic model assessment index (r ⫽ 0.68, p ⬍0.001). There was a weak correlation between plasma hs-CRP levels and monocyte release of TNF-␣ (r ⫽ 0.46, p ⬍0.001), interleukin-1 (r ⫽ 0.44, p ⬍0.001), interleukin-6 (r ⫽ 0.51, p ⬍0.001), and MCP-1 (r ⫽ 0.50, p ⬍0.001) and between plasma hs-CRP levels and lymphocyte release of interleukin-2 (r ⫽ 0.48, p ⬍0.001), interferon-␥ (r ⫽ 0.53, p ⬍0.001), and TNF-␣ (r ⫽ 0.47, p ⬍0.001). Homeostatic model assessment index correlated with plasma hs-CRP (r ⫽ 0.50, p ⬍0.001), monocyte release of TNF-␣ (r ⫽ 0.43, p ⬍0.001), interleukin-1 (r ⫽ 0.51, p ⬍0.001), interleukin-6 (r ⫽ 0.47, p ⬍0.001), and MCP-1 (r ⫽ 0.49, p ⬍0.001) and lymphocyte release of interleukin-2 (r ⫽ 0.44, p ⬍0.001), interferon-␥ (r ⫽ 0.51, p ⬍0.001), and TNF-␣ (r ⫽ 0.46, p ⬍0.001). No other correlations between baseline values were found. There was no correlation between the studied plasma markers and cytokine release and lipid/lipoprotein profile in response to lifestyle intervention plus metformin (r ⫽ 0.05 to 0.22, all nonsignificant), simvastatin alone (r ⫽ 0.18 to 0.29, all nonsignificant), fenofibrate alone (r ⫽ 0.10 to 0.25, all nonsignificant), or simvastatin plus fenofibrate (r ⫽ 0.08
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to 0.26, all nonsignificant). There was a correlation between decrease of glycated hemoglobin and decrease in fasting plasma glucose (r ⫽ 0.65 to 0.71 depending on group, p ⬍0.001) and homeostatic model assessment index (r ⫽ 0.65 to 0.71 depending on group, p ⬍0.001). Effects of lifestyle intervention plus metformin on cytokine release and on plasma levels of hs-CRP did not correlate with their effects on glucose metabolism markers. Treatment-induced changes in plasma hs-CRP correlated weakly with changes in monocyte cytokine release (simvastatin r ⫽ 0.48, p ⬍0.001, between changes in TNF-␣ and hs-CRP; r ⫽ 0.53, p ⬍0.001, between changes in interleukin-1 and hs-CRP; r ⫽ 0.55, p ⬍0.001, between changes in interleukin-6 and hs-CRP and p ⬍ 0.001 between changes in MCP-1 and hs-CRP; fenofibrate r ⫽ 0.52, p ⬍0.001, between changes in TNF-␣ and hs-CRP; r ⫽ 0.51, p ⬍0.001, between changes in interleukin-1 and hs-CRP; r ⫽ 0.57, p ⬍0.001, between changes in interleukin-6 and hs-CRP; r ⫽ 0.51, p ⬍0.001, between changes in MCP-1 and hs-CRP; simvastatin ⫹ fenofibrate r ⫽ 0.56, p ⬍0.001, between changes in TNF-␣ and hs-CRP; r ⫽ 0.49, p ⬍0.001, between changes in interleukin-1 and hs-CRP; r ⫽ 0.53, p ⬍0.001, between changes in interleukin-6 and hs-CRP; r ⫽ 0.50, p ⬍0.001, between changes in MCP-1 and hs-CRP) and lymphocyte cytokine release (simvastatin r ⫽ 0.51, p ⬍0.001, between changes in interleukin-2 and hs-CRP; r ⫽ 0.44, p ⬍0.001, between changes in interferon-␥ and hs-CRP; r ⫽ 0.42, p ⬍0.001, between changes in TNF-␣ and hs-CRP; fenofibrate r ⫽ 0.49, p ⬍0.001, between changes in interleukin-2 and hs-CRP; r ⫽ 0.52, p ⬍0.001, between changes in interferon-␥ and hs-CRP; r ⫽ 0.49, p ⬍0.001, between changes in TNF-␣ and hs-CRP; simvastatin ⫹ fenofibrate r ⫽ 0.51, p ⬍0.001, between changes in interleukin-2 and hs-CRP; r ⫽ 0.52, p ⬍0.001, between changes in interferon-␥ and hs-CRP; r ⫽ 0.46, p ⬍0.001, between changes in TNF-␣ and hs-CRP). Decrease in plasma hs-CRP and monocyte and lymphocyte cytokine release correlated with changes in free fatty acids (r ⫽ 0.48 to 0.59, p ⬍0.001, for simvastatin; r ⫽ 0.47 to 0.61, p ⬍0.001, for fenofibrate; r ⫽ 0.51 to 0.62 for simvastatin ⫹ fenofibrate). There was a weak correlation between the effect of fenofibrate alone or simvastatin plus fenofibrate, but not simvastatin alone, on hs-CRP and cytokine release and on homeostatic model assessment index (r ⫽ 0.20 to 0.29, all nonsignificant for simvastatin; r ⫽ 0.52 to 0.59, p ⬍0.001, for fenofibrate; and r ⫽ 0.42 to 0.48, p ⬍ 0.001, for simvastatin ⫹ fenofibrate).
Department of Internal Medicine and Clinical Pharmacology, Medical University of Silesia, Katowice, Poland. Manuscript received September 14, 2010; revised manuscript received and accepted November 21, 2010. This work was supported by Scientific Grant 2 P05F 036 29 from the Committee of Scientific Research, Warsaw, Poland. *Corresponding author: Tel/fax: 48-32-208-8512. E-mail address: [email protected] (R. Krysiak). 0002-9149/11/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.amjcard.2010.11.023
protein (CRP) has been identified as a sensitive marker of low-grade systemic inflammation of high prognostic value for determining cardiovascular risk and is directly involved in the initiation and progression of atherosclerosis.14,15 Methods Patients (25 to 75 years old) were eligible for the study if they met the following criteria: (1) recently diagnosed and previously untreated type 2 diabetes mellitus (fasting plasma glucose ⱖ126 mg/dl or plasma glucose concentration 2 hours after a glucose load ⱖ200 mg/dl) and (2) mixed dyslipidemia (plasma total cholesterol ⬎200 mg/dl, lowdensity lipoprotein [LDL] cholesterol ⬎130 mg/dl, triglycerides ⬎150 mg/dl). Exclusion criteria are presented in the Supplemental Data (available online). The study was performed in accordance with the Declaration of Helsinki and was approved by the local ethics committee. All patients gave written informed consent after the nature of the study had been explained. All included patients (n ⫽ 196) were given detailed advice about how to achieve the goals of lifestyle modification, which were a decrease in weight ⱖ7% if necessary, total fat intake ⬍30% of total energy intake, saturated fat intake ⬍7% of energy consumed, cholesterol intake ⬍200 mg/day, an increase in fiber intake to 15 g/1,000 kcal, and moderate to vigorous exercise for ⱖ30 minutes/day. Average dietary adherence was assessed by food-frequency questionnaire and analysis of 3-day eating diaries by validated methods at every visit. Apart from dietary recommendations patients were prewww.ajconline.org
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Figure 1. Schematic diagram depicting study protocol.
scribed with metformin, which was administered at a dose of 850 mg 1 times/day for the first week and thereafter 2 times/day for 90 days (Figure 1). After 90 days of lifestyle intervention and metformin treatment, patients were randomized in double-blind fashion to 1 of 4 treatment groups that was treated with simvastatin (40 mg/day), fenofibrate (200 mg/day), simvastatin (40 mg/day) in combination with fenofibrate (200 mg/day), or placebo, respectively. For fenofibrate, a micronized form was used, which is more effective and convenient than its immediate-acting form.16 Simvastatin and fenofibrate were administered for 90 days without any changes in dosage during the entire study period. To minimize the risk of eventual pharmacokinetic interactions between simvastatin and fenofibrate, the 2 drugs were administered in 12-hour intervals (from 8:00 to 9:00 A.M. and from 8:00 to 9:00 P.M.). In the groups treated solely with simvastatin or fenofibrate, 1/2 of patients received a drug in the morning and placebo in the evening, and the other 1/2 was given the drug in the evening and
placebo in the morning. In the combined therapy group, 1/2 of patients were treated with simvastatin in the morning and fenofibrate in the evening, and in the other 1/2 these drugs were administered in reverse order. Placebo-treated patients received placebo 2 times/day. Throughout the study period all patients complied with lifestyle modifications and were treated with metformin. Investigation of possible drug-induced side effects was performed fortnightly. Safety end points were overt myopathy, increase of aminotransferases ⬎3 times the upper limit of normal, and creatine kinase levels ⬎10 times the upper limit of normal. Compliance was assessed during each visit by tablet counts and was considered satisfactory when the number of tablets taken by a patient was 90% to 110%. All measurements were performed 4 times: at baseline, before randomization, and after 30 and 90 days of therapy. Venous blood samples were taken 12 hours after the last meal in a quiet temperature-controlled room (24°C to 25°C) in constant daily hours (from 8:00 to 9:00 A.M.) to avoid
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Table 1 Baseline characteristics of patients* Variable Age (years) Women Smokers Body mass index (kg/m2) Atherogenic dyslipidemia† Total cholesterol (mg/dl) Low-density lipoprotein cholesterol (mg/dl) High-density lipoprotein cholesterol (mg/dl) Triglycerides (mg/dl) Apoprotein A-I (mg/dl) Apoprotein B (mg/dl) Free fatty acids (mol/L) Fasting glucose (mg/dl) Homeostatic model assessment index Glycated hemoglobin (%) High-sensitivity C-reactive protein (mg/dl) Monocyte tumor necrosis factor-␣ release (pg/ml) Monocyte interleukin-1 release (pg/ml) Monocyte interleukin-6 release (ng/ml) Monocyte monocyte chemoattractant protein-1 release (ng/ml) Lymphocyte interleukin-2 release (ng/ml) Lymphocyte interferon-␥ release (ng/ml) Lymphocyte tumor necrosis factor-␣ release (pg/ml)
Placebo (n ⫽ 46)
Simvastatin (n ⫽ 48)
Fenofibrate (n ⫽ 47)
Simvastatin ⫹ Fenofibrate (n ⫽ 49)
52.8 ⫾ 2.0 41% 20% 28.2 ⫾ 1.4 87% (76%) 235 ⫾ 4 155 ⫾ 2 37 ⫾ 1 231 ⫾ 6 121 ⫾ 7 157 ⫾ 5 516 ⫾ 39 173 ⫾ 3 12.1 ⫾ 0.5 8.1 ⫾ 0.2 3.2 ⫾ 0.2 1,720 ⫾ 40 143 ⫾ 5 10.3 ⫾ 0.4 21.3 ⫾ 1.0 7.1 ⫾ 0.2 68.2 ⫾ 3.2 405 ⫾ 19
53.2 ⫾ 1.9 44% 21% 28.8 ⫾ 2.0 83% (73%) 240 ⫾ 5 156 ⫾ 3 37 ⫾ 1 235 ⫾ 6 118 ⫾ 4 159 ⫾ 5 502 ⫾ 26 176 ⫾ 4 11.9 ⫾ 0.5 7.8 ⫾ 0.2 3.4 ⫾ 0.3 1,810 ⫾ 50 139 ⫾ 5 10.7 ⫾ 0.4 21.2 ⫾ 0.8 7.0 ⫾ 0.2 67.6 ⫾ 5.0 413 ⫾ 19
52.6 ⫾ 2.3 43% 23% 29.0 ⫾ 2.2 85% (74%) 238 ⫾ 4 153 ⫾ 4 38 ⫾ 1 226 ⫾ 7 121 ⫾ 5 157 ⫾ 4 512 ⫾ 38 180 ⫾ 3 12.0 ⫾ 0.5 7.9 ⫾ 0.2 3.1 ⫾ 0.3 1,789 ⫾ 48 141 ⫾ 5 10.9 ⫾ 0.3 22.0 ⫾ 1.1 7.2 ⫾ 0.3 67.1 ⫾ 4.1 410 ⫾ 20
53.4 ⫾ 2.0 45% 24% 28.6 ⫾ 1.7 82% (71%) 242 ⫾ 5 159 ⫾ 4 37 ⫾ 1 237 ⫾ 8 117 ⫾ 4 159 ⫾ 4 508 ⫾ 30 172 ⫾ 4 11.6 ⫾ 0.6 8.0 ⫾ 0.1 3.5 ⫾ 0.2 1,825 ⫾ 45 146 ⫾ 6 10.4 ⫾ 0.4 20.9 ⫾ 0.8 7.5 ⫾ 0.4 69.0 ⫾ 6.0 416 ⫾ 17
Data presented as mean ⫾ SEM. * Only data of subjects who completed the study were included in the final analyses. † Based on National Cholesterol Education Program Adult Treatment Panel III criteria17 (criteria proposed by Grundy and Small18).
circadian fluctuations of the parameters studied. Plasma levels of total cholesterol, LDL cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides were assessed colorimetrically using commercially available kits obtained from bioMérieux (Marcy l’Etoile, France). LDL cholesterol levels were measured directly. Plasma glucose concentrations were measured by a glucose oxidase method (Beckman, Palo Alto, California). Total nonesterified free fatty acids were determined by an enzymatic assay using reagents from Alpha Laboratories (Eastleigh, Hants, United Kingdom). Levels of apoproteins A-I and B were assessed by immunoturbidimetry (Incstar, Corp., Stillwater, Minnesota). Glycated hemoglobin was determined using DCA (2000) analyzer (Bayer, Ames Technicon, Tarrytown, New York). Plasma insulin was measured with a commercial radioimmunoassay kit (Linco Research, Inc., St. Charles, Missouri) that does not cross-react with human proinsulin. Homeostatic model assessment index was calculated as the product of fasting plasma insulin level (microunits per milliliter) and fasting plasma glucose level (millimoles per liter) divided by 22.5. Plasma levels of CRP were measured using a high-sensitivity monoclonal antibody assay (highsensitivity CRP [hs-CRP]; MP Biomedicals, Orangeburg, New York). Lower limit of sensitivity of this method was 0.1 mg/L. Cultures of phytohemagglutinin-stimulated T cells and lipopolysaccharide-stimulated monocytes were performed in triplicate as described previously.8 –11 Monocyte release of TNF-␣, interleukin-1, interleukin-6, and MCP-1 and lymphocyte release of interleukin-2, interferon-␥, and TNF-␣ were estimated using commercial enzyme-linked
immunosorbent assay kits (R&D Systems, Minneapolis, Minnesota) according to the manufacturer’s instructions. Minimum detectable levels for assessed cytokines were 8, 15, 4.4, 5.0, 3.9, and 1.0 pg/ml for interleukin-2, interferon-␥, TNF-␣, MCP-1, interleukin-6, TNF-␣, and interleukin-1, respectively. Intra- and interassay coefficients of variation were ⬍6.0% and ⬍8.5%, respectively. All calculations were made using GraphPad Prism 2.01 (GraphPad Software, Inc., San Diego, California) and Statistica 6.1 (StatSoft, Tulsa, Oklahoma). Statistical significance was defined as a p value ⬍0.05. To begin with, distribution of variables was analyzed using Kolmogorov– Smirnov test. Outcomes for insulin, homeostatic model assessment index, hs-CRP, and cytokines were natural logtransformed to satisfy assumptions of normality and equal variance. Because lipid/lipoprotein and carbohydrate and, after logarithmic transformation, other values were normally distributed, parametric statistics were used for analyses. Comparisons between groups were performed using 1-way analysis of variance followed by post hoc Newman– Keuls test. Differences between means of variables within the same treatment group were analyzed with Student’s paired t test. In addition, to verify the correctness of statistical analysis for insulin, homeostatic model assessment index, hs-CRP, and cytokines, their median values on the original scale were recalculated using nonparametric tests (Kruskal–Wallis test followed by Mann–Whitney U test and Wilcoxon matched-pair test). Because the results of nonparametric statistics did not differ from those obtained after using nonparametric tests, these are not shown. Because the results of this analysis are consistent with those obtained
Table 2 Effect of simvastatin and fenofibrate, administered alone or combination on lipid/lipoprotein profile, glucose homeostasis, low-grade inflammation, and monocyte and lymphocyte cytokine release in type 2 diabetic patients with mixed dyslipidemia Treatment Group Placebo (n ⫽ 46)
Fenofibrate (n ⫽ 47)
Simvastatin ⫹ Fenofibrate (n ⫽ 49)
235 ⫾ 4 233 ⫾ 4 (⫺1) 231 ⫾ 4 (⫺2, ⫺1) 230 ⫾ 5 (⫺2, ⫺2)
240 ⫾ 5 235 ⫾ 5 (⫺2) 178 ⫾ 4 (⫺26, ⫺24)‡储‡‡‡ 177 ⫾ 4 (⫺26, ⫺25)‡¶§§§
238 ⫾ 4 229 ⫾ 4 (⫺4) 201 ⫾ 4 (⫺16, ⫺12)*§ 201 ⫾ 3 (⫺16, ⫺12)†§#
242 ⫾ 5 236 ⫾ 5 (⫺3) 168 ⫾ 4 (⫺31, ⫺29)‡¶§§§ 156 ⫾ 5 (⫺36, ⫺34)‡¶#§§§
155 ⫾ 2 151 ⫾ 3 (⫺3) 151 ⫾ 3 (⫺3.0) 148 ⫾ 5 (⫺5, ⫺2)
156 ⫾ 3 152 ⫾ 3 (⫺3)** 104 ⫾ 3 (⫺33, ⫺31)‡††¶††† 100 ⫾ 2 (⫺36, ⫺34)‡††¶†††
153 ⫾ 4 148 ⫾ 3 (⫺4) 122 ⫾ 3 (⫺20, ⫺17)*§ 120 ⫾ 4 (⫺22, ⫺19)*#§
159 ⫾ 4 155 ⫾ 4 (⫺3) 96 ⫾ 3 (⫺39, ⫺38)‡¶††‡‡‡ 92 ⫾ 3 (⫺42, ⫺43)‡¶††‡‡‡
37 ⫾ 1 38 ⫾ 1 (2) 39 ⫾ 2 (5.3) 39 ⫾ 1 (6.4)
37 ⫾ 1 37 ⫾ 1 (1.6) 42 ⫾ 1 (15.13)* 43 ⫾ 1 (16.14)*
38 ⫾ 1 39 ⫾ 1 (2) 46 ⫾ 1 (23.20)†§# 48 ⫾ 1 (27.25)‡储††
37 ⫾ 1 38 ⫾ 1 (2) 47 ⫾ 1 (28.25)†§†† 50 ⫾ 1 (36.33)‡¶††¶¶
231 ⫾ 6 208 ⫾ 5 (⫺10) 192 ⫾ 5 (⫺17, ⫺8)* 191 ⫾ 5 (⫺17, ⫺9)*
235 ⫾ 6 212 ⫾ 6 (⫺10) 179 ⫾ 5 (⫺24, ⫺16)* 178 ⫾ 5 (⫺24, ⫺16)*
226 ⫾ 7 204 ⫾ 7 (⫺10) 144 ⫾ 8 (⫺36, ⫺29)‡¶††## 141 ⫾ 8 (⫺38, ⫺32)‡¶††##
237 ⫾ 8 205 ⫾ 9 (⫺13) 136 ⫾ 6 (⫺43, ⫺34)‡¶††** 123 ⫾ 5 (⫺48, ⫺40)‡¶††***
121 ⫾ 7 130 ⫾ 5 (7) 135 ⫾ 5 (11.3) 136 ⫾ 5 (12.5)
118 ⫾ 4 127 ⫾ 5 (8) 136 ⫾ 4 (15.7) 143 ⫾ 4 (21.13)*
121 ⫾ 5 132 ⫾ 5 (10) 160 ⫾ 5 (32.7, 21.0)‡§††## 161 ⫾ 3 (33.7, 21.8)‡§††¶¶
117 ⫾ 4 128 ⫾ 4 (9) 165 ⫾ 4 (41.29)‡储††## 172 ⫾ 3 (46.34)‡储††##
157 ⫾ 5 150 ⫾ 5 (⫺5) 149 ⫾ 5 (⫺6, ⫺1) 148 ⫾ 3 (⫺6, ⫺1)
159 ⫾ 5 150 ⫾ 4 (⫺6) 110 ⫾ 3 (⫺31, ⫺27)‡††¶††† 108 ⫾ 5 (⫺32, ⫺28)‡¶††‡‡‡
516 ⫾ 39 438 ⫾ 50 (⫺15) 427 ⫾ 40 (⫺17, ⫺3) 420 ⫾ 46 (⫺19, ⫺4)
502 ⫾ 26 426 ⫾ 39 (⫺15) 335 ⫾ 33 (⫺33, ⫺21)‡§# 265 ⫾ 22 (⫺47, ⫺38)‡¶**‡‡
512 ⫾ 38 435 ⫾ 34 (⫺15) 320 ⫾ 37 (⫺38, ⫺26)‡储** 250 ⫾ 29 (⫺51, ⫺43)‡¶††‡‡
508 ⫾ 30 422 ⫾ 42 (⫺17) 301 ⫾ 21 (⫺41, ⫺29)‡¶†† 220 ⫾ 22 (⫺57, ⫺48)‡¶††§§
173 ⫾ 4 144 ⫾ 3 (⫺17)† 140 ⫾ 2 (⫺19, ⫺3)‡ 138 ⫾ 3 (⫺20, ⫺4)‡
176 ⫾ 4 147 ⫾ 4 (⫺16)† 142 ⫾ 3 (⫺18, ⫺3)‡ 141 ⫾ 3 (⫺19, ⫺4)‡
180 ⫾ 3 142 ⫾ 3 (⫺21)‡ 128 ⫾ 2 (⫺29, ⫺10)‡§**## 127 ⫾ 3 (⫺30, ⫺11)‡储**##
172 ⫾ 4 140 ⫾ 2 (⫺18)‡ 126 ⫾ 2 (⫺26, ⫺10)‡储**## 127 ⫾ 3 (⫺26, ⫺10)‡储**##
157 ⫾ 4 152 ⫾ 4 (⫺3) 130 ⫾ 4 (⫺17, ⫺14)†§# 130.2 ⫾ 3 (⫺17, ⫺14)†§#
159 ⫾ 4.3 154 ⫾ 4.0 (⫺3.5) 105 ⫾ 3.5 (⫺33.9, ⫺31.5)‡¶††‡‡‡ 102 ⫾ 3.8 (⫺35.8, ⫺33.5)‡¶††§§§
Preventive Cardiology/Hypolipidemic Agents and Cytokine Release
Total cholesterol (mg/dl) Baseline Before randomization After 30 d of hypolipidemic treatment After 90 days of hypolipidemic treatment Low-density lipoprotein cholesterol (mg/dl) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment High-density lipoprotein cholesterol (mg/dl) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Triglycerides (mg/dl) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Apoprotein A-I (mg/dl) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Apoprotein B (mg/dl) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Free fatty acids (mol/L) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Fasting glucose (mg/dl) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment
Simvastatin (n ⫽ 48)
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Table 2 (continued) Treatment Group Placebo (n ⫽ 46) 12.1 ⫾ 0.5 10.9 ⫾ 0.5 (⫺10)* 10.1 ⫾ 0.6 (⫺17, ⫺7)* 8.7 ⫾ 0.5 (⫺28, ⫺20)‡#
11.9 ⫾ 0.5 10.5 ⫾ 0.4 (⫺12)* 9.8 ⫾ 0.4 (⫺18, ⫺7)† 9.2 ⫾ 0.5 (⫺23, ⫺12)†
Fenofibrate (n ⫽ 47) 12.0 ⫾ 0.5 10.7 ⫾ 0.6 (⫺11)* 8.5 ⫾ 0.4 (⫺29, ⫺21)‡**¶¶ 6.5 ⫾ 0.4 (⫺46, ⫺39)‡储††§§***
Simvastatin ⫹ Fenofibrate (n ⫽ 49) 11.6 ⫾ 0.6 10.2 ⫾ 0.5 (⫺12)* 8.1 ⫾ 0.3 (⫺30, ⫺21)‡储#**## 6.2 ⫾ 0.4 (⫺47, ⫺39)‡储††§§***
8.1 ⫾ 0.2 7.6 ⫾ 0.1 (⫺6)* 7.4 ⫾ 0.2 (⫺9, ⫺3)* 7.4 ⫾ 0.2 (⫺9, ⫺3)*
7.8 ⫾ 0.2 7.0 ⫾ 0.2 (⫺10)* 6.9 ⫾ 0.2 (⫺12, ⫺1)* 6.8 ⫾ 0.1 (⫺13, ⫺3)†
7.9 ⫾ 0.2 7.1 ⫾ 0.2 (⫺10)* 6.3 ⫾ 0.3 (⫺20, ⫺11)‡储# 6.1 ⫾ 0.2 (⫺23, ⫺14)‡储#¶¶
8.0 ⫾ 0.1 7.0 ⫾ 0.2 (⫺13)† 6.3 ⫾ 0.2 (⫺21, ⫺10)‡储# 6.0 ⫾ 0.3 (⫺25, ⫺14)‡¶#¶¶
3.2 ⫾ 0.2 3.0 ⫾ 0.2 (⫺6) 2.9 ⫾ 0.3 (⫺9, ⫺3) 2.8 ⫾ 0.2 (⫺13, ⫺7)
3.4 ⫾ 0.3 3.0 ⫾ 0.3 (⫺12) 2.5 ⫾ 0.2 (⫺27, ⫺17)‡# 1.7 ⫾ 0.2 (⫺50, ⫺43)‡¶††§§
3.1 ⫾ 0.3 2.8 ⫾ 0.2 (⫺10) 2.2 ⫾ 0.2 (⫺29, ⫺21)‡储# 1.6 ⫾ 0.2 (⫺48, ⫺43)‡¶††§§
3.5 ⫾ 0.2 3.1 ⫾ 0.2 (⫺11) 2.1 ⫾ 0.2 (⫺40, ⫺32)‡储†† 1.1 ⫾ 0.1 (⫺69, ⫺65)‡¶††储储¶¶†††
1,720 ⫾ 40 1,580 ⫾ 51 (⫺9) 1,269 ⫾ 40 (⫺26, ⫺20)* 1,250 ⫾ 53 (⫺27, ⫺21)*
1,810 ⫾ 50 1,600 ⫾ 50 (⫺12) 1,213 ⫾ 30 (⫺33, ⫺24)‡** 874 ⫾ 26 (⫺52, ⫺45)‡#储**‡‡
1,789 ⫾ 48 1,586 ⫾ 45 (⫺11) 1,240 ⫾ 9 (⫺31, ⫺22)†# 890 ⫾ 33 (⫺50, ⫺44)‡储#‡‡
1,825 ⫾ 45 1,621 ⫾ 42 (⫺11) 1,185 ⫾ 40 (⫺35, ⫺27)‡** 793 ⫾ 30 (⫺57, ⫺51)‡¶††储储
143 ⫾ 5 140 ⫾ 5 (⫺1.7) 135 ⫾ 6 (⫺5, ⫺4) 134 ⫾ 6 (⫺6, ⫺5)
139 ⫾ 5 130 ⫾ 6 (⫺6) 91 ⫾ 4 (⫺35, ⫺31)‡¶** 73 ⫾ 4 (⫺47, ⫺44)‡¶††‡‡
141 ⫾ 5 132 ⫾ 6 (⫺6) 93.8 ⫾ 5 (⫺33, ⫺29)‡储** 71.2 ⫾ 3 (⫺49, ⫺46)‡¶††§§
146 ⫾ 6 132 ⫾ 6 (⫺9) 94 ⫾ 5 (⫺36, ⫺29)‡¶** 71 ⫾ 4 (⫺51, ⫺46)‡¶††§§
10.3 ⫾ 0.4 9.2 ⫾ 0.3 (⫺11) 8.0 ⫾ 0.3 (⫺22, ⫺13)* 7.9 ⫾ 0.4 (⫺23, ⫺14)*
10.7 ⫾ 0.4 9.5 ⫾ 0.3 (⫺12) 7.6 ⫾ 0.3 (⫺29, ⫺20)*# 5.8 ⫾ 0.3 (⫺46, ⫺39)‡储#**§§
10.9 ⫾ 0.3 9.7 ⫾ 0.4 (⫺11) 7.7 ⫾ 0.3 (⫺29, ⫺21)*# 6.0 ⫾ 0.4 (⫺45, ⫺38)‡储#**‡‡
10.4 ⫾ 0.4 9.8 ⫾ 0.4 (⫺6) 7.3 ⫾ 0.3 (⫺30, ⫺26)†# 5.4 ⫾ 0.4 (⫺48, ⫺45)‡¶††§§
21.3 ⫾ 1.0 19.6 ⫾ 1.1 (⫺8) 19.0 ⫾ 1.4 (⫺11, ⫺3) 19.2 ⫾ 0.8 (⫺10, ⫺2)
21.2 ⫾ 0.8 20.4 ⫾ 0.9 (⫺5) 17.1 ⫾ 0.9 (⫺19, ⫺16)* 13.1 ⫾ 0.6 (⫺38, ⫺36)‡储#‡‡
22.0 ⫾ 1.1 20.3 ⫾ 0.8 (⫺8) 16.9 ⫾ 0.9 (⫺23, ⫺17)*# 12.5 ⫾ 0.7 (⫺43, ⫺38)‡储#‡‡
20.9 ⫾ 0.8 19.4 ⫾ 0.7 (⫺7) 15.4 ⫾ 0.6 (⫺26, ⫺21)*# 11.3 ⫾ 0.7 (⫺46, ⫺42)‡¶††§§
7.1 ⫾ 0.2 6.8 ⫾ 0.2 (⫺4) 6.6 ⫾ 0.1 (⫺7, ⫺3) 6.4 ⫾ 0.1 (⫺10, ⫺6)
7.0 ⫾ 0.2 6.8 ⫾ 0.3 (⫺3) 5.2 ⫾ 0.2 (⫺26, ⫺24)†§# 4.0 ⫾ 0.2 (⫺43, ⫺41)‡¶**‡‡
7.2 ⫾ 0.3 6.7 ⫾ 0.2 (⫺7) 5.0 ⫾ 0.1 (⫺31, ⫺25)†§# 3.8 ⫾ 0.2 (⫺47, ⫺43)‡¶††§§
7.5 ⫾ 0.4 7.1 ⫾ 0.3 (⫺5) 4.6 ⫾ 0.2 (⫺39, ⫺35)‡储†† 2.8 ⫾ 0.2 (⫺63, ⫺61)‡¶††储储***§§§
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Homeostatic model assessment Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Glycated hemoglobin (%) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment High-sensitivity C-reactive protein (mg/dl) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Monocyte tumor necrosis factor-␣ release (pg/ml) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Monocyte interleukin-1 release (pg/ml) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Monocyte interleukin-6 release (ng/ml) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Monocyte monocyte chemoattractant protein-1 release (ng/ml) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Lymphocyte interleukin-2 release (ng/ml) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment
Simvastatin (n ⫽ 48)
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after using parametric tests, these are not discussed in the text. For categorical variables, chi-square test was used. Correlations were calculated using the Kendall test.
416 ⫾ 18 398 ⫾ 18 (⫺4) 298 ⫾ 16 (⫺28, ⫺26)‡§** 179 ⫾ 13 (⫺57, ⫺56)‡¶††储储##§§§
Results
Data represent mean ⫾ SEM (percent change from respective baseline value, percent change from respective value before randomization). * p ⬍0.05;† p ⬍0.01;‡ p ⬍0.001 versus baseline values. § p ⬍0.05;储 p ⬍0.01;¶ p ⬍0.001 versus placebo-treated patients. # p ⬍0.05;** p ⬍0.01;†† p ⬍0.001 versus respective value before randomization. ‡‡ p ⬍0.05;§§ p ⬍0.01;储储 p ⬍0.001 versus respective value after 30 days of treatment. ¶¶ p ⬍0.05;## p ⬍0.01;*** p ⬍0.001 versus effect of simvastatin. ††† p ⬍0.05;‡‡‡ p ⬍0.01;§§§ p ⬍0.001 versus effect of fenofibrate.
413 ⫾ 19 398 ⫾ 21 (⫺3) 310 ⫾ 13 (⫺25, ⫺22)†# 246 ⫾ 12 (⫺41, ⫺38)‡¶††‡‡ 405 ⫾ 12 387 ⫾ 18 (⫺4) 361 ⫾ 18 (⫺11, ⫺7) 359 ⫾ 18 (⫺12, ⫺7)
410 ⫾ 20 393 ⫾ 19 (⫺4) 316 ⫾ 12 (⫺23, ⫺20)†# 251 ⫾ 14 (⫺39, ⫺36)‡¶††‡‡
69.0 ⫾ 6.0 64.2 ⫾ 5.3 (⫺7) 42.8 ⫾ 3.8 (⫺38, ⫺33)‡¶†† 28.6 ⫾ 2.9 (⫺59, ⫺55)‡¶††§§##††† 67.1 ⫾ 4.1 63.2 ⫾ 4.9 (⫺6) 47.9 ⫾ 4.0 (⫺29, ⫺24)†储** 37.5 ⫾ 3.3 (⫺44, ⫺41)‡¶††‡‡ 67.6 ⫾ 5.0 64.8 ⫾ 5.1 (⫺4) 51.1 ⫾ 4.4 (⫺24, ⫺21)†# 38.1 ⫾ 3.5 (⫺44, ⫺41)‡¶††§§ 68.2 ⫾ 3.2 63.7 ⫾ 3.0 (⫺7) 62.1 ⫾ 4.0 (⫺9, ⫺3) 61.9 ⫾ 3.5 (⫺9, ⫺3)
Lymphocyte interferon-␥ release (ng/ml) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment Tumor necrosis factor-␣ release (pg/ml) Baseline Before randomization After 30 days of hypolipidemic treatment After 90 days of hypolipidemic treatment
Table 2 (continued)
Placebo (n ⫽ 46)
Simvastatin (n ⫽ 48)
Treatment Group
Fenofibrate (n ⫽ 47)
Simvastatin ⫹ Fenofibrate (n ⫽ 49)
Preventive Cardiology/Hypolipidemic Agents and Cytokine Release
There were no significant differences in age, weight, and gender between treatment groups of diabetic patients with mixed dyslipidemia. All groups were comparable in medical background and clinical and laboratory characteristics (Table 1).17,18 Three patients terminated the study before randomization because of metformin-induced diarrhea, nausea, and increased flatulence. One subject treated with simvastatin was withdrawn from the study because of increased creatine kinase activity. Two subjects dropped out because of noncompliance with the study protocol. Neither significant adverse effects nor any complications were reported throughout the study period in the remaining participants. Baseline characteristics of the 6 subjects who were withdrawn from the study did not differ from the 190 completing the study (data not shown). Thirty days of lifestyle modification and metformin treatment significantly decreased fasting plasma glucose, homeostatic model assessment index, and glycated hemoglobin but produced no effect on plasma lipid/lipoproteins, hs-CRP, and cytokine release (Table 2). Continuation of lifestyle modification and metformin treatment in addition placebo for the next 90 days, apart from changes in plasma glucose, homeostatic model assessment index, and glycated hemoglobin, decreased also triglyceride levels and inhibited monocyte TNF-␣ and interleukin-6 release. However, it did not affect monocyte release of interleukin-1 and MCP-1 and lymphocyte release of interleukin-2, interferon-␥, and TNF-␣. Simvastatin administered to diabetic patients with mixed dyslipidemia complying with lifestyle modification and treated with metformin decreased total cholesterol, LDL cholesterol, triglycerides, apoprotein B, and free fatty acids and increased HDL cholesterol and apoprotein A. Simvastatin did not change fasting glucose levels, glycated hemoglobin, and homeostatic model assessment index. Moreover, simvastatin treatment inhibited plasma hs-CRP, monocyte release of TNF-␣, interleukin-1, interleukin-6, and MCP-1 and lymphocyte release of interleukin-2, interferon-␥, and TNF-␣. Simvastatin action on free fatty acids, hs-CRP, and cytokine release was stronger after 90 than after 30 days of administration. Fenofibrate treatment led to a decrease in total and LDL cholesterol, triglycerides, free fatty acids, fasting plasma glucose, homeostatic model assessment index and glycated hemoglobin, hs-CRP, and monocyte and lymphocyte cytokine release. It also increased HDL cholesterol and apoprotein A-I levels. Effect of fenofibrate on free fatty acids, homeostatic model assessment index, hs-CRP, and cytokine release was more pronounced after 90 than after 30 days of treatment. Combined treatment with simvastatin and fenofibrate decreased total and LDL cholesterol, triglycerides, apoprotein B, fasting plasma glucose, homeostatic model assessment index, and glycated hemoglobin, and increased HDL cholesterol and apoprotein A-I levels. Simvastatin administered with fenofibrate also decreased hs-CRP and inhibited monocyte re-
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lease of TNF-␣, interleukin-1, interleukin-6, and MCP-1 and lymphocyte release of interleukin-2, interferon-␥, and TNF-␣. Effect of simvastatin and fenofibrate on free fatty acids, homeostatic model assessment index, and cytokine release was stronger after 90 than after 30 days of treatment. In type 2 diabetic patients with mixed dyslipidemia complying with lifestyle intervention and treated with placebo, simvastatin alone or in combination with fenofibrate was superior to fenofibrate alone in decreasing plasma levels of total cholesterol, LDL cholesterol, and apoprotein B (Table 2). Fenofibrate alone or administered with simvastatin was superior to simvastatin alone in affecting triglycerides, apoprotein A-I, plasma glucose, homeostatic model assessment index, and glycated hemoglobin. There were no differences between simvastatin and fenofibrate in strength of action on monocyte and lymphocyte cytokine release and on plasma hs-CRP. Simvastatin and fenofibrate administered in combination produced a more pronounced effect on plasma hs-CRP and lymphocyte release of interleukin-2, interferon-␥, and TNF-␣ than treatment with simvastatin or fenofibrate alone. In the group treated with simvastatin and fenofibrate (but not in the remaining treatment groups) degree of decrease in cytokine release and in plasma hs-CRP levels tended to be more pronounced in patients with than in those without atherogenic dyslipidemia (p ⫽ 0.057 to 0.093, data not shown). At baseline, there was a weak correlation between cytokine release and plasma hs-CRP levels and between cytokine release and homeostatic model assessment index. Treatment-induced changes in cytokine release and plasma hs-CRP correlated with degree of decrease in free fatty acids. There was a weak correlation between the effect of fenofibrate alone or simvastatin plus fenofibrate on hs-CRP and cytokine release and on homeostatic model assessment index. There was no correlation between hs-CRP and cytokine release and between hs-CRP and lipid/lipoprotein profile in response to lifestyle intervention plus metformin, simvastatin alone, fenofibrate alone, or simvastatin plus fenofibrate (for more details, see Supplemental Data). Discussion The major finding of the study is that simvastatin and fenofibrate exhibit a similar effect in extent on secretory function of human monocytes and lymphocytes and on systemic inflammation in type 2 diabetic subjects with mixed dyslipidemia, which represents a pleiotropic action of 3-hydroxy-3-methylgluraryl coenzyme A reductase inhibitors and peroxisome proliferator activated receptor-␣ activators. For lymphocytes and systemic inflammation, this effect is stronger when the 2 drugs are administered together. Because low-grade inflammation14,15 and increased production of proatherogenic cytokines are associated with faster development and progression of atherosclerosis,5–7 the anti-inflammatory action of simvastatin and fenofibrate treatment seems to be clinically relevant. In agreement with our previous study,1 an initial period of lifestyle modification and metformin treatment despite improving glycemic control produced only small anti-inflammatory effects. The fact that this effect was potentiated by simvastatin and fenofibrate may suggest the rationale of
adding statin and fibrate therapy to metformin and lifestyle modification in the primary prevention of vascular disorders in subjects with newly diagnosed diabetic dyslipidemia, even if metformin and nonpharmacologic treatment effectively improve glucose homeostasis. Fenofibrate action on monocyte and lymphocyte cytokine release and on systemic inflammation was similar to that of simvastatin, a drug with anti-inflammatory properties observed in carbohydrate and lipid metabolism abnormalities and in end-stage renal failure.10,11,19 This finding is in disagreement with the results of some fibrate trials especially the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD)20 and the Bezafibrate Infarction Prevention (BIP)21 studies, which showed that fibrates only nonsignificantly decreased the primary end point (death plus nonfatal myocardial infarction). Unfortunately, the results of these 2 trials were confounded by other lipid-lowering agents. In the FIELD study, after correction for nonrandomized statin decrease, risk of cardiovascular events in fenofibrate-treated patients decreased significantly by 19% (in patients without ischemic heart disease even by 25%). Similarly, in the BIP trial, after excluding from analysis patients receiving open-label hypolipidemic agents, bezafibrate led to a 17% risk decrease and the risk decrease was particularly pronounced in subjects with metabolic syndrome.22,23 Our results suggest that peroxisome proliferator activated receptor-␣ activators, if administered without other hypolipidemic agents, may bring clinical benefits to subjects with recently diagnosed and previously untreated type 2 diabetes mellitus. Interestingly, no large fibrate trial included only or performed separate analysis of this group of patients (e.g., in the FIELD study diabetes lasted on average 5 years). Interestingly, a recent large clinical study, the Action to Control Cardiovascular Risk in Diabetes Lipid (ACCORD) trial, has shown similar potency of the simvastatin–fenofibrate combination and simvastatin alone in decreasing cardiovascular and cerebrovascular risks in middle-aged and elderly subjects with type 2 diabetes and concomitant coronary artery disease or presence of increased cardiovascular risk.24 Our findings are in some contrast to the results of this study. Combined administration of simvastatin and micronized fenofibrate was superior to monotherapy with these 2 agents in improving lipid profile and decreasing lymphocyte cytokine release, although the 2 treatment strategies were equipotent in affecting monocyte cytokine release. This discrepancy may result from different inclusion criteria for the 2 studies. Our study included subjects with newly diagnosed diabetes who were simultaneously offered lifestyle modification and metformin treatment and were given fixed doses of simvastatin and fenofibrate. In turn, in the ACCORD diabetes lasted on average 10 years, patients were subjected to various hypoglycemic strategies, and doses of hypolipidemic agents depended on plasma lipid levels. Less convincing is the explanation that our study was shorter than ACCORD because the strength of the antiinflammatory action of simvastatin and fenofibrate increased with time. Certainly we cannot fully exclude the hypothesis that monocytes are more important targets for cardiovascular drugs than lymphocytes when determining the decrease of cardiovascular risk. However, a stronger decrease in plasma hs-CRP in the combined treatment group
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than in subjects treated with only 1 hypolipidemic agent contradicts this hypothesis. Because even small differences in levels of the studied markers in the population are associated with various grades of insulin resistance and with various risks of coronary artery disease and its complications,5–7 the additive effect of cotreatment on lymphocyte cytokine release may, in our opinion, bring some cardiovascular and metabolic benefits to the studied population. Most patients included in the study met the criteria of atherogenic dyslipidemia,17,18 which is the most characteristic lipid abnormality in patients with type 2 diabetes.25 As in the entire population, in the subgroup of patients with atherogenic dyslipidemia the 2 drugs decreased cytokine release and plasma hs-CRP levels, and for lymphocytes and systemic inflammation, this effect was more pronounced when simvastatin and fenofibrate were administered together. In the combination treatment group, these anti-inflammatory effects were a bit stronger than in the remaining subjects and this finding agrees with the ACCORD in which patients with HDL cholesterol ⬍34 mg/dl and triglycerides ⬎204 mg/dl gained the greatest clinical benefit from adding fenofibrate to simvastatin.24 Simvastatin and fenofibrate action on cytokine release and systemic inflammation was lipid-independent. The finding that the effect of fenofibrate on monocyte and lymphocyte secretory function and on plasma hs-CRP correlated with its action on free fatty acids, which are the endogenous ligands for peroxisome proliferator activated receptor-␣,16 provides some arguments that nonlipid-related effects of this drug may be mediated by this receptor. That a similar free fatty acid– dependent effect was exhibited also by simvastatin indicates that the favorable anti-inflammatory actions of 3-hydroxy-3-methylgluraryl coenzyme A reductase inhibitors are partly related to their free fatty acid–lowering action and seems to be in line with a hypothesis that molecular mechanisms of action of statins and fibrates may to some extent overlap.26,27 However, the fact that only the action of fenofibrate was related to the improvement in insulin sensitivity suggests, at least for simvastatin, the presence of other mechanisms responsible for pleiotropic actions. Although only fenofibrate treatment improved glycated hemoglobin, homeostatic model assessment index, and plasma glucose levels, simvastatin was devoid of any deteriorating effect on glucose metabolism described previously by other investigators.28,29 This indicates that hypolipidemic agents administered to type 2 diabetic patients not only do not increase the risk of worsening glycemic control but may even (fenofibrate) improve glucose metabolism. Our study has some limitations. First, it included a relatively small number of patients and assessed only surrogates. Second, simvastatin and fenofibrate were used at doses that are not maximal doses. Therefore, it cannot be excluded that the effect of these agents may be stronger when administered at higher doses for a longer period. Third, because we included only diabetic patients with mixed dyslipidemia, whether hypolipidemic agents alter the secretory function of monocytes and lymphocytes in diabetic patients with isolated hypercholesterolemia, isolated hypertriglyceridemia, or without any lipid abnormalities requires further studies.
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1. Pruski M, Krysiak R, Okopien B. Pleiotropic action of short-term metformin and fenofibrate treatment, combined with lifestyle intervention, in type 2 diabetic patients with mixed dyslipidemia. Diabetes Care 2009;32:1421–1424. 2. Hansson GK. Inflammatory mechanisms in atherosclerosis. J Thromb Haemost 2009;7(suppl 1):328 –331. 3. Weyand CM, Younge BR, Goronzy JJ. T cells in arteritis and atherosclerosis. Curr Opin Lipidol 2008;19:469 – 477. 4. Wilson HM, Barker RN, Erwig LP. Macrophages: promising targets for the treatment of atherosclerosis. Curr Vasc Pharmacol 2009;7: 234 –243. 5. Kher N, Marsh JD. Pathobiology of atherosclerosis—a brief review. Semin Thromb Hemost 2004;30:665– 672. 6. Tedgui A, Mallat Z. Cytokines in atherosclerosis: pathogenic and regulatory pathways. Physiol Rev 2006;86:515–581. 7. Schroecksnadel K, Frick B, Winkler C, Fuchs D. Crucial role of interferon-gamma and stimulated macrophages in cardiovascular disease. Curr Vasc Pharmacol 2006;4:205–213. 8. Okopien B, Krysiak R, Haberka M, Herman ZS. Effect of monthly atorvastatin and fenofibrate treatment on monocyte chemoattractant protein-1 release in patients with primary mixed dyslipidemia. J Cardiovasc Pharmacol 2005;45:314 –320. 9. Okopien´ B, Krysiak R, Kowalski J, Madej A, Belowski D, Zielin´ski M, Herman ZS. Monocyte release of tumor necrosis factor-alpha and interleukin-1beta in primary type IIa and IIb dyslipidemic patients treated with statins or fibrates. J Cardiovasc Pharmacol 2005;46: 377–386. 10. Krysiak R, Gdula-Dymek A, Scieszka J, Okopien B. Anti-inflammatory and Monocyte-Suppressing effects of simvastatin in patients with impaired fasting glucose. Basic Clin Pharmacol Toxicol 2011;108: 131–137. 11. Okopien´ B, Krysiak R, Kowalski J, Madej A, Belowski D, Zielin´ski M, Labuzek K, Herman ZS. The effect of statins and fibrates on interferon-gamma and interleukin-2 release in patients with primary type II dyslipidemia. Atherosclerosis 2004;176:327–335. 12. Okopien´ B, Kowalski J, Krysiak R, Łabuzek K, Stachura-Kułach A, Kułach A, Zielin´ski M, Herman ZS. Monocyte suppressing action of fenofibrate. Pharmacol Rep 2005;57:367–372. 13. Okopien B, Krysiak R, Herman ZS. Effects of short-term fenofibrate treatment on circulating markers of inflammation and hemostasis in patients with impaired glucose tolerance. J Clin Endocrinol Metab 2006;91:1770 –1778. 14. Kinlay S, Egido J. Inflammatory biomarkers in stable atherosclerosis. Am J Cardiol 2006;98(suppl):2P– 8P. 15. Ridker PM. Inflammatory biomarkers and risks of myocardial infarction, stroke, diabetes, and total mortality: implications for longevity. Nutr Rev 2007;65(suppl):S253–S259. 16. Keating GM, Omrod D. Micronised fenofibrate. An updated review of its clinical efficacy in the management of dyslipidaemia. Drugs 2002; 62:1909 –1944. 17. National Cholesterol Education Program. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III) final report. Circulation 2002;106:3143–3421. 18. Grundy SM, Small LDL. Atherogenic dyslipidemia, and the metabolic syndrome. Circulation 1997;95:1– 4. 19. Kirmizis D, Papagianni A, Dogrammatzi F, Skoura L, Belechri AM, Alexopoulos E, Efstratiadis G, Memmos D. Effects of simvastatin on markers of inflammation, oxidative stress and endothelial cell apoptosis in patients on chronic hemodialysis. J Atheroscler Thromb 2010; 17:1256 –1265. 20. Keech A, Simes RJ, Barter P, Best J, Scott R, Taskinen MR, Forder P, Pillai A, Davis T, Glasziou P, Drury P, Kesäniemi YA, Sullivan D, Hunt D, Colman P, d’Emden M, Whiting M, Ehnholm C, Laakso M; FIELD Study Investigators. Effects of long-term fenofibrate therapy on cardiovascular events in 9795 people with type 2 diabetes mellitus (the FIELD study): randomised controlled trial. Lancet 2005;366: 1849 –1861. 21. BIP (Bezafibrate Infarction Prevention) Study Group. Secondary prevention by raising HDL cholesterol and reducing triglycerides in patients with coronary artery disease: the Bezafibrate Infarction Prevention (BIP) study. Circulation 2000;102:21–27. 22. Fazio S. More clinical lessons from the FIELD study. Cardiovasc Drugs Ther 2009;23:235–241.
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23. Paumelle R, Staels B. Cross-talk between statins and PPARalpha in cardiovascular diseases: clinical evidence and basic mechanisms. Trends Cardiovasc Med 2008;18:73–78. 24. Ginsberg HN, Elam MB, Lovato LC, Crouse JR III, Leiter LA, Linz P, Friedewald WT, Buse JB, Gerstein HC, Probstfield J, Grimm RH, Ismail-Beigi F, Bigger JT, Goff DC Jr, Cushman WC, Simons-Morton DG, Byington RP; ACCORD Study Group. Effects of combination lipid therapy in type 2 diabetes mellitus. N Engl J Med 2010;362: 1563–1574. 25. Farmer JA. Diabetic dyslipidemia and atherosclerosis: evidence from clinical trials. Curr Diab Rep 2008;8:71–77. 26. Martin G, Duez H, Blanquart C, Berezowski V, Poulain P, Fruchart JC, Najib-Fruchart J, Glineur C, Staels B. Statin-induced inhibition of
the Rho-signaling pathway activates PPARalpha and induces HDL apoA-I. J Clin Invest 2001;107:1423–1432. 27. Staels B, Maes M, Zambon A. Fibrates and future PPARalpha agonists in the treatment of cardiovascular disease. Nat Clin Pract Cardiovasc Med 2008;5:542–553. 28. Ridker PM, Danielson E, Fonseca FA, Genest J, Gotto AM Jr, Kastelein JJ, Koenig W, Libby P, Lorenzatti AJ, MacFadyen JG, Nordestgaard BG, Shepherd J, Willerson JT, Glynn RJ; JUPITER Study Group. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. N Engl J Med 2008;359:2195–2207. 29. Yamakawa T, Takano T, Tanaka S, Kadonosono K, Terauchi Y. Influence of pitavastatin on glucose tolerance in patients with type 2 diabetes mellitus. J Atheroscler Thromb 2008;15:269 –275.
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Supplemental Data Exclusion criteria: Exclusion criteria were (1) primary isolated hypercholesterolemia or hypertriglyceridemia; (2) secondary dyslipidemia in the course of autoimmune disorders, thyroid diseases, chronic pancreatitis, nephrotic syndrome, liver and biliary tract diseases, or alcoholism; (3) body mass index ⬎35 kg/m2; (4) any acute and persistent inflammatory processes; (5) symptomatic congestive heart failure; (6) unstable coronary artery disease, myocardial infarction, or stroke within 6 months before the study; (7) arterial hypertension (European Society of Cardiology/European Society of Hypertension grade 2 or 3); (8) impaired renal or hepatic function; (9) malabsorption syndromes; (10) treatment with other hypolipidemic drugs within 3 months before the study; (11) concomitant treatment with insulin and/or oral antidiabetic drugs; (12) concomitant treatment with other drugs known to affect plasma lipid levels or to interact with statins and fibrates; (13) concomitant treatment with drugs that may affect inflammatory processes in the vascular wall (including nonsteroidal antiinflammatory drugs, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers) within 3 months before the study; (14) ongoing hormonal replacement therapy or oral contraception; and (15) poor patient compliance. Correlations: At baseline, glycated hemoglobin levels correlated with fasting glucose (r ⫽ 0.74, p ⬍001) and homeostatic model assessment index (r ⫽ 0.68, p ⬍0.001). There was a weak correlation between plasma hs-CRP levels and monocyte release of TNF-␣ (r ⫽ 0.46, p ⬍0.001), interleukin-1 (r ⫽ 0.44, p ⬍0.001), interleukin-6 (r ⫽ 0.51, p ⬍0.001), and MCP-1 (r ⫽ 0.50, p ⬍0.001) and between plasma hs-CRP levels and lymphocyte release of interleukin-2 (r ⫽ 0.48, p ⬍0.001), interferon-␥ (r ⫽ 0.53, p ⬍0.001), and TNF-␣ (r ⫽ 0.47, p ⬍0.001). Homeostatic model assessment index correlated with plasma hs-CRP (r ⫽ 0.50, p ⬍0.001), monocyte release of TNF-␣ (r ⫽ 0.43, p ⬍0.001), interleukin-1 (r ⫽ 0.51, p ⬍0.001), interleukin-6 (r ⫽ 0.47, p ⬍0.001), and MCP-1 (r ⫽ 0.49, p ⬍0.001) and lymphocyte release of interleukin-2 (r ⫽ 0.44, p ⬍0.001), interferon-␥ (r ⫽ 0.51, p ⬍0.001), and TNF-␣ (r ⫽ 0.46, p ⬍0.001). No other correlations between baseline values were found. There was no correlation between the studied plasma markers and cytokine release and lipid/lipoprotein profile in response to lifestyle intervention plus metformin (r ⫽ 0.05 to 0.22, all nonsignificant), simvastatin alone (r ⫽ 0.18 to 0.29, all nonsignificant), fenofibrate alone (r ⫽ 0.10 to 0.25, all nonsignificant), or simvastatin plus fenofibrate (r ⫽ 0.08
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to 0.26, all nonsignificant). There was a correlation between decrease of glycated hemoglobin and decrease in fasting plasma glucose (r ⫽ 0.65 to 0.71 depending on group, p ⬍0.001) and homeostatic model assessment index (r ⫽ 0.65 to 0.71 depending on group, p ⬍0.001). Effects of lifestyle intervention plus metformin on cytokine release and on plasma levels of hs-CRP did not correlate with their effects on glucose metabolism markers. Treatment-induced changes in plasma hs-CRP correlated weakly with changes in monocyte cytokine release (simvastatin r ⫽ 0.48, p ⬍0.001, between changes in TNF-␣ and hs-CRP; r ⫽ 0.53, p ⬍0.001, between changes in interleukin-1 and hs-CRP; r ⫽ 0.55, p ⬍0.001, between changes in interleukin-6 and hs-CRP and p ⬍ 0.001 between changes in MCP-1 and hs-CRP; fenofibrate r ⫽ 0.52, p ⬍0.001, between changes in TNF-␣ and hs-CRP; r ⫽ 0.51, p ⬍0.001, between changes in interleukin-1 and hs-CRP; r ⫽ 0.57, p ⬍0.001, between changes in interleukin-6 and hs-CRP; r ⫽ 0.51, p ⬍0.001, between changes in MCP-1 and hs-CRP; simvastatin ⫹ fenofibrate r ⫽ 0.56, p ⬍0.001, between changes in TNF-␣ and hs-CRP; r ⫽ 0.49, p ⬍0.001, between changes in interleukin-1 and hs-CRP; r ⫽ 0.53, p ⬍0.001, between changes in interleukin-6 and hs-CRP; r ⫽ 0.50, p ⬍0.001, between changes in MCP-1 and hs-CRP) and lymphocyte cytokine release (simvastatin r ⫽ 0.51, p ⬍0.001, between changes in interleukin-2 and hs-CRP; r ⫽ 0.44, p ⬍0.001, between changes in interferon-␥ and hs-CRP; r ⫽ 0.42, p ⬍0.001, between changes in TNF-␣ and hs-CRP; fenofibrate r ⫽ 0.49, p ⬍0.001, between changes in interleukin-2 and hs-CRP; r ⫽ 0.52, p ⬍0.001, between changes in interferon-␥ and hs-CRP; r ⫽ 0.49, p ⬍0.001, between changes in TNF-␣ and hs-CRP; simvastatin ⫹ fenofibrate r ⫽ 0.51, p ⬍0.001, between changes in interleukin-2 and hs-CRP; r ⫽ 0.52, p ⬍0.001, between changes in interferon-␥ and hs-CRP; r ⫽ 0.46, p ⬍0.001, between changes in TNF-␣ and hs-CRP). Decrease in plasma hs-CRP and monocyte and lymphocyte cytokine release correlated with changes in free fatty acids (r ⫽ 0.48 to 0.59, p ⬍0.001, for simvastatin; r ⫽ 0.47 to 0.61, p ⬍0.001, for fenofibrate; r ⫽ 0.51 to 0.62 for simvastatin ⫹ fenofibrate). There was a weak correlation between the effect of fenofibrate alone or simvastatin plus fenofibrate, but not simvastatin alone, on hs-CRP and cytokine release and on homeostatic model assessment index (r ⫽ 0.20 to 0.29, all nonsignificant for simvastatin; r ⫽ 0.52 to 0.59, p ⬍0.001, for fenofibrate; and r ⫽ 0.42 to 0.48, p ⬍ 0.001, for simvastatin ⫹ fenofibrate).