Clinical trial NCT02437084
Conditions: Hyperlipidemia Insulin Resistance Type 2 Diabetes
Keywords: statin diabetes insulin resistance insulin secretion
Sponsor: Stanford University
Start date: 2015-05-01; Completion date: 2020-04-01
Enrollment: 115 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
Background:

There is general agreement that statin-treatment of patients to lower plasma cholesterol levels can increase the incidence of type 2 diabetes mellitus (T2D) in some individuals1-5. The physiologic mechanism for the increased risk for T2D from statin treatment is unknown but could result from effects on insulin sensitivity or insulin secretion. This study will evaluate how the medication atorvastatin (trade name Lipitor) works in non-diabetic individuals in regards to its effect on insulin sensitivity and insulin secretion to help further understand the possible cause of the increased occurrence of T2D in people who are at risk for T2D. This research study will also examine what metabolic characteristics and variables (for example insulin resistance, high triglycerides, or both) will identify those people at highest risk of statin-induced T2D.

The goals of this study are to:

1. determine the effect of high-intensity atorvastatin (40 mg/day) for \~ 10 weeks on insulin sensitivity and insulin secretion (defined with gold standard methods) (PRIMARY OUTCOMES) as well as other glycemic traits (SECONDARY OUTCOMES);
2. compare a number of cardio-metabolic characteristics (e.g. weight, lipids) before, during, and after administration of atorvastatin;
3. determine if significant deterioration of insulin action and/or secretion following statin treatment will be confined to those with baseline insulin resistance (PRE-SPECIFIED SUBGROUP ANALYSES);
4. perform Personal Omics Profiling (iPOP) 6,7 before and after taking atorvastatin to examine treatment-associated changes in all baseline variables and to analyze not only previously-known drug efficacy but also untargeted drug efficacy (EXPLORATORY ANALYSES).

General approach:

This will be an open-label study to evaluate the diabetogenic effect of atorvastatin (40 mg/day for 10 weeks) on both insulin action and insulin secretion in nondiabetic individuals. To ensure we recruit individuals across a broad range of insulin sensitivity, we will target recruitment to enrich for those with combined increases in LDL-C and TG concentrations (see SIGNIFICANCE and RATIONALE). The experimental population will consist of \~75 apparently healthy, non-diabetic volunteers eligible for statin therapy but without pre-existing atherosclerotic cardiovascular disease. Following baseline assessments of co-primary outcome measures: insulin sensitivity (by insulin suppression test, IST) and insulin secretion (by graded glucose infusion test, GGIT), participants will be placed on a weight maintenance diet and treated with 40 mg/day of atorvastatin. All baseline measurements will be repeated \~10 weeks later with iPOP8 measurements done at baseline, at weeks 2, 4, and 10 on atorvastatin, and at weeks 4 and 8 off atorvastatin.

Detailed description:
1. SIGNIFICANCE

   Statins and the risk of T2D: Statin treatment is associated with an increase in incident T2D.1-4 5

   Mechanism of statin-induced T2D: It is unclear whether statins increase the risk of T2D by decreasing insulin action, secretion, or both. Several manuscripts have been published that substantially increase understanding of the link between statin use and incident T2D. Swerdlow, et al.2 based on evidence from genetic analysis and randomized trials, concluded that the increased risk of T2D 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.9 have shown in a large prospective study (n=8749 men) that participants treated with statins (n=2142) had a 46% increase in incident T2D, associated with a 24% decrease in insulin sensitivity and a 12% decrease in insulin secretion assessed by surrogate measures.

   Identifying those with at enhanced risk of statin-induced T2D: Studies of 3 randomized clinical trials with atorvastatin by David Waters' group 1,3,4 have demonstrated that "baseline fasting glucose, body mass index, hypertension, and fasting triglycerides were independent predictors of T2D." These abnormalities form a cluster attributed to insulin resistance.10 Since insulin resistance is a predictor of developing T2D, it seems likely that the more insulin resistant the individuals are before treatment, the greater is their risk to for statin-induced T2D.

   In that context, relatively little attention has been given to the role that metabolic heterogeneity in patients with elevated LDL-C concentrations might play in statin-induced T2D. 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 and/or secretion, irrespective of how mediated, places them at enhanced risk to develop statin-induced diabetes. Indeed, we have shown (Kohli et al)1 that patients with both insulin resistance (as estimated by high TGs) and prediabetes are at particularly high risk of statin-induced T2D.

   We seek to address 2 important unanswered questions: Do statins primarily affect insulin resistance or insulin secretion?; Are there subsets of individuals at highest risk of statin-induced T2D?
2. RATIONALE, HYPOTHESIS

   Rationale:

   T2D develops when insulin resistant individuals cannot maintain the degree of compensatory hyperinsulinemia needed to maintain normal glucose tolerance. However, significant fundamental questions remain. For example, what is the cellular/molecular link between statin treatment and changes in insulin action and secretion?

   This proposal is based on the premise that studying the effect of statins on insulin action and insulin secretion using "gold standard" methods will help determine if statins adversely affect the risk of T2D by increasing insulin resistance or decreasing insulin secretion. We use the insulin suppression test (with the read-out of steady-state plasma glucose, SSPG) to ascertain insulin sensitivity and the graded glucose infusion test (with the readout of insulin secretion rate, ISR) to ascertain insulin secretion both before and after statin treatment in non-diabetic individuals.

   We hypothesize that treatment with atorvastatin 40 mg/day for approximately 10 weeks will impair insulin sensitivity and/or insulin secretion and that this effect may be exacerbated in those with underlying insulin resistance. Thus, we plan to look at the effect of atorvastatin not only in all participants but also in subsets of individuals with baseline insulin resistance (which will be enriched for by recruiting volunteers with elevated plasma TG levels (≥150 mg/dL) at baseline. The rationale for this is that plasma TGs are a surrogate measure for insulin resistance with a modest correlation with the direct measure of insulin resistance (steady-state plasma glucose) measured by the insulin suppression test. Clinically, subjects with elevated TGs prior to statin treatment would have substantial clinical benefit from statins, and one of investigators' secondary goals is to demonstrate that a simple measurement of plasma TG concentration (as a surrogate for insulin resistance) can help identify those most at risk of statin induced derangements in glycemic control. Consequently, we propose to enroll nondiabetic volunteers at high-risk for T2D, free of known atherosclerotic cardiovascular disease (ASCVD), not receiving statins, eligible for statin therapy according to ACC/AHA (American College for Cardiology/American Heart Association) 2013 guidelines.11 We will also target recruitment efforts to enrich for subjects with plasma TG concentration ≥ 150 mg/dL to ensure that we enroll subjects across the range of insulin sensitivity.

   Hypothesis: We hypothesize that high intensity atorvastatin treatment for approximately 10 weeks will impair insulin sensitivity and/or insulin secretion and that this effect may be exacerbated in those with underlying insulin resistance.
3. STUDY DESIGN

   Sample Size

   • We aim to recruit and retain 75 total participants in this study.

   Study Location

   • Clinical and Translational Research Unit (CTRU) at 800 Welch Road, Palo Alto, CA 94304.

   Duration

   • We anticipate that the entire study will take 4 - 5 years through the end of data analysis. Each eligible candidate who voluntarily consents to participate in the study will be active in the study for a total of 5 months from screening to the end of their last visit.
4. STUDY PROCEDURES

   Recruitment

   Preliminary recruitment strategies will include:

   Volunteers will be recruited from the San Francisco Bay Area through advertisements in newspapers, posted flyers, and the social networking site NextDoor as well as from the Preventive Cardiology Clinics at Stanford Health Care. Our goal is to ensure recruitment across a broad range of insulin sensitivity. Prior work from our group and others has shown that high plasma TG concentrations are associated with increased insulin resistance as assessed by reference measures. Therefore, we will target advertisements to enrich for individuals with high TG levels (\> 150 mg/dL) as a surrogate for increased insulin resistance.

   Participant Visits and Procedures

   Potential participants will be screened initially when they call or email in response to recruitment ads, or a letter from their MD, describing the study as follows:

   Preliminary intake will occur over the phone.

   Visit 1 Screening visit.

   Visit 2: Oral Glucose Tolerance Test (OGTT): This test will take approximately 3 hours.

   i) Glycemic status: Participants will be classified as having normal glucose tolerance (NGT), isolated impaired fasting glucose (IFG), isolated impaired glucose tolerance (IGT), or combined IFG/IGT12. In addition, the total integrated plasma glucose response during the OGTT will be calculated by the trapezoidal method (Glucose-AUC).

   ii) β-cell function: Calculations of the Insulin Secretion- Sensitivity Index-2 (ISSI-2) will be used to quantify insulin secretory function 13, if for some reason a graded glucose infusion study is not done. The ISSI-2 is a validated OGTT- derived method to measure of β-cell function, analogous to the disposition index obtained from the intravenous glucose tolerance test 14. It is calculated by multiplying the insulin secretory response during the OGTT (Insulin-AUC/Glucose-AUC) by insulin resistance (Matsuda index).

   The fasting and 2-hour glucose results will be discussed with the study participant and a copy of the results will be given to them.

   Visit 3. Graded Glucose Infusion, GGIT 15,16: This test will take approximately 6 hours.

   This test is designed to assess the ability of the pancreas to produce insulin in response to a graded glucose infusion. During this test, subjects will have two small IV catheters placed, one in each arm. One IV will be used for drawing samples and the other for the infusion of glucose. During the GGIT, continuous intravenous infusions of glucose will be given at progressively increasing rates: 1, 2, 3, 4, 5, 6, and 8 kg/min in six infusion periods of 40-min duration. Blood samples will be collected for measurements of glucose, insulin, and C-peptide concentrations at fasting and at 30 min and 40 min into each infusion period. The two values during the last 10 min of each infusion period will be averaged. The amount of blood taken for this test will 47.5 ml.

   Visit 4.Insulin Suppression test, IST 17,18: This test will take approximately 6 hours.

   This test is designed to determine whole body insulin sensitivity. Following an overnight fast, subjects will have an IV placed in each arm. One for collection of blood and the other for infusion with octreotide (0.27 μg/m2/min), insulin (32 mU/m2/min), and glucose (267 mg/m2/min) for 180 minutes. During the test, endogenous insulin is suppressed and all individuals are given the same concentration of insulin, based on their body surface area. Blood is drawn every 30 minutes for 150 minutes and then at 10-minute intervals from 150 to 180 minutes of the infusion to measure plasma glucose and insulin concentrations. The mean of the last four values is used as the steady-state plasma insulin (SSPI) and glucose (SSPG) concentrations for each individual. As SSPI concentrations are similar in all subjects during the IST, the SSPG concentration provides a direct measure of the ability of insulin to mediate disposal of an infused glucose load; the higher the SSPG concentration, the more insulin resistant the individual. Labs to check kidney and liver function plus a lipid panel and a urine pregnancy test (if appropriate) will be done at this visit. Blood drawn or IST will be 58.5 ml and 5 ml for SHC labs.

   Labs for iPOP will be drawn at this time and additional samples will be obtained for transcriptome, microbiome, metabolome, and proteome analysis in blood; nasal, tongue, skin surface swabs; urine; and stool.

   The study drug, atorvastatin 40 mg will be given to study participants, once all labs have been reviewed and participant qualifies.

   Visit 5-7: Visits will be every 2 weeks for a total of 10 weeks on study medication (statin). Participants will be assessed for any side effects or adverse events (AE) on the statin. Adherence to study medication will be assessed at each visit.

   Visit 8: Weight, vital signs, and OGTT described above.

   Visit 9: Repeat GGIT as described above.

   Visit 10: Repeat IST and iPOP lab testing and samples as described above. At the end of this visit, the statin will be stopped and the study participant would be scheduled for 4- and 8-week follow up visits.

   Visit 11: One month off statin study visit - weight, vital signs, and iPOP laboratory testing and samples will be done as described above.

   Visit 12: Last study visit - weight, vital signs, and iPOP laboratory testing and samples will be done as described above.

   Participants will be asked to fill out questionnaire about her/his physical activity status, food and eating habits, and stress at the time of each iPOP.
5. STATISTICAL CONSIDERATIONS

Based on our prior work19, we calculated that with 60 subjects, we would be able to detect an 8% change in SSPG concentration and an 8% change in ISRAUC after atorvastatin therapy with 80% power and two-side significance level of 5% using a paired samples t test. Thus, we estimated needing to enroll 75 subjects with an anticipated a dropout rate of 20%.

Summary statistics will be reported as median (interquartile range) or number (percent) of participants unless otherwise specified. Shapiro-Wilk tests will be used to assess normality of data, and variables that are not normally distributed will be log-transformed. Percent changes in variables will be calculated by the formula: \[(end-of study value) - (baseline value) / baseline value\] x 100. Paired samples t tests will be used to compare baseline and end-of-study means. One sample t tests will be employed to evaluate whether percent changes in variables are significantly different from zero (no change). Pearson correlation coefficients will be calculated to determine the strength of association between variables of interest. Prespecified subgroup analyses will be carried out by stratifying for insulin resistant versus insulin sensitive subjects. The SSPG concentration median will be used to define subjects as being insulin resistant or insulin sensitive. Insulin resistant and insulin sensitive group means will be compared by independent sample t tests and proportions by chi-square tests or Fisher's exact tests. Statistical analyses will be performed by using statistical software IBM SPSS version 26.0.

Arms: arm 1: Eligible participants will receive 40 mg of atorvastatin
Interventions: intervention 1: Atorvastatin
Intervention descriptions: intervention 1: Study subjects will receive atorvastatin 40 mg for 10 weeks.

Protocol documents:
ICF_001.pdf: 
 
 
  STANFORD UNIVERSITY Research Consent Form 
 
Protocol Director:  Joshua Knowles, MD 
 
Protocol Title: Relationship Between Insulin Resistance and Statin Induced 
Type 2 Diabetes, and Integrative Personal Omics Profiling 
 
1 
 
IRB USE ONLY 
Approval Date:   April 16, 2019 
Expiration Date: April 16, 2020 
  
INFORMED CONSENT 
 
EXPERIMENTAL SUBJECT’S BILL OF RIGHTS 
Persons who participate in a medical experiment are entitled to certain rights.  These rights 
include but are not limited to the subject's right to be: 
• 
be informed of the nature and purpose of the experiment;  
• 
be given an explanation of the procedures to be followed in the medical experiment, 
and any drug or device to be utilized;  
• 
be given a description of any attendant discomforts and risks reasonably to be 
expected;  
• 
be given an explanation of any benefits to the subject reasonably to be expected, if 
applicable;  
• 
be given a disclosure of any appropriate alternatives, drugs or devices that might be 
advantageous to the subject, their relative risks and benefits;  
• 
be informed of the avenues of medical treatment, if any available to the subject after 
the experiment if complications should rise;  
• 
be given an opportunity to ask questions concerning the experiment or the 
procedures involved;  
• 
be instructed that consent to participate in the medical experiment may be 
withdrawn at any time and the subject may discontinue participation without 
prejudice;  
• 
be given a copy of the signed and dated consent form;  
• 
and be given the opportunity to decide to consent or not to consent to a medical 
experiment without the intervention of any element of force, fraud, deceit, duress, 
coercion or undue influence on the subject's decision. 
 
 
A research study is designed to answer specific questions, sometimes about a drug or 
device’s safety and its effectiveness.  Being in a research study is different from being a 
patient.  When you are a patient, you and your personal doctor have a great deal of 
freedom in making decisions about your health care.  When you are a research subject, 
the Protocol Director and the research staff will follow the rules of the research study 
(protocol) as closely as possible, without compromising your health. 
 
Introduction to Research Studies 


 
 
  STANFORD UNIVERSITY Research Consent Form 
 
Protocol Director:  Joshua Knowles, MD 
 
Protocol Title: Relationship Between Insulin Resistance and Statin Induced 
Type 2 Diabetes, and Integrative Personal Omics Profiling 
 
2 
 
IRB USE ONLY 
Approval Date:   April 16, 2019 
Expiration Date: April 16, 2020 
The Purpose of the Study 
 
You have been asked to participate in a research project at Stanford University Medical 
Center under the direction of Dr. Joshua Knowles and associates because you have 
elevated LDL-C (bad) cholesterol, and/or an elevated inflammatory marker known as high 
sensitivity C reactive protein, (hs-CRP) and/or a cardiovascular risk score of 5% or higher 
and may also have elevated triglycerides (fat in blood) and be at risk for type 2 diabetes.  
There is general agreement that statin-treatment of patients with hypercholesterolemia 
(high cholesterol) can increase the incidence of type 2 diabetes (T2DM) in a small 
percentage of some individuals. This research proposal will study what metabolic 
characteristics and variables (for example high cholesterol or high triglycerides or both) will 
identify those people at highest risk of statin-induced T2DM.  We will evaluate how the 
medication atorvastatin (trade name Lipitor) works in regards to its effect on insulin action, 
insulin sensitivity, and insulin secretion to help us further understand the possible cause of 
the increased occurrences of T2DM in people who are at risk for T2DM. 
 Everyone will receive the same statin, Lipitor, at the same dose, 40 mg which will be taken 
once a day.  We will screen approximately 150-200 people and to complete approximately 
88 people.  . This study is expected to be completed in approximately 3 years.  If you 
qualify to participate, your time involved in this study will be approximately 4-5 months. 
 
Under Dr. Snyder, a Co-director of the study, we will collect samples for integrated 
Personal Omics Profiling (iPOP), a monitoring approach developed by Dr. Snyder and his 
research colleagues. This is described in detail on page 9 under iPOP samples.  The iPOP 
information is for research purposes only and will not be released to you. To further extend 
Dr. Snyder's previous research on iPOP, we propose to analyze iPOP of individuals who 
participate in this study during and after taking the statin. In this study, we will analyze not 
only the previously-known drug's effectiveness but also untargeted drug's effectiveness, 
(other unknown benefits this medication may have) and drug effects such as those seen in 
some participants when given a statin. The hope then is 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. 
You must sign this consent to participant in this study. A screening consent will be signed, 
or verbally agreed to before any screening procedures will be done. 
 
VOLUNTARY PARTICIPATION  
Your participation in this study is voluntary.  Your decision not to participate will not have 
any negative effect on you or your medical care.  You can decide to participate now, but 
withdraw your consent later and stop being in the study without any loss of benefits or 
medical care to which you are entitled. Please let us know or call Dr. Knowles or one of his 
associates at 650-723-7024 if you decide to withdraw from this study, we might ask you to 
come in for a final visit.  


 
 
  STANFORD UNIVERSITY Research Consent Form 
 
Protocol Director:  Joshua Knowles, MD 
 
Protocol Title: Relationship Between Insulin Resistance and Statin Induced 
Type 2 Diabetes, and Integrative Personal Omics Profiling 
 
3 
 
IRB USE ONLY 
Approval Date:   April 16, 2019 
Expiration Date: April 16, 2020 
 
While participating in this study, you should not take part in any other research 
projects without approval from all the investigators.  This is to protect you from 
possible injury arising from such things as extra blood drawing, extra x-rays, 
interactions of research drugs, or similar hazards. 
 
Are you participating in any other research studies?   YES_____   NO____ 
 
Have you donated blood within the last 6 weeks?         YES_____   NO____ 
 
 
Multiple blood samples will be taken throughout the duration of the study for 
measurement of glucose (sugar) levels, lipid levels, kidney and liver function test and 
other chemistries.  Blood sampling will be done by withdrawing blood from a vein/or 
placing an IV catheter (intravenous plastic tubing).  This may cause some discomfort 
and carries a slight risk of infection, or bruising. 
 
All study visits will take place in the Clinical and Translational Research Unit (CTRU) 
at 800 Welch Rd in Palo Alto, CA.  
 
Study Visits 
 
Visit 1 The first visit (screening) will be to determine if you qualify for the study based on 
your age, height, and weight, vital signs (blood pressure and pulse), medical history, 
results of your laboratory test, hematocrit (checking for anemia), glucose (sugar) level, 
cholesterol profile, liver and kidney function. You will not qualify if you have a history of 
severe anemia, kidney or liver disease, diabetes, a recent heart attack, heart procedure, or 
history of heart failure, are pregnant or breast feeding or unwilling to use effective birth 
control methods while you are in the study.  Anyone with a history of allergy to lipitor will 
not qualify.  If you have a history of not being able to tolerate statins in the past we will 
review this with you to see if you would still qualify for the study. 
 
Your responses to questions we ask concerning illicit/illegal drug use could be  
self-incriminating and harmful to you if they became known outside the study.     
As explained in the confidentiality statement on page 13 of the consent, we do    
not intend to disclose this information. 
 
If you qualify at today’s visit, you will be asked to come in for an Oral Glucose 
Tolerance Test which will be described below.  
 
Visit 2 The second visit will be the oral glucose tolerance test (OGTT) described 
below. You will be asked to fast for 12 hours prior to the test and the entire visit will 
take approximately 3 hours.  If you qualify, you will be scheduled for the graded 
glucose infusion test. 


 
 
  STANFORD UNIVERSITY Research Consent Form 
 
Protocol Director:  Joshua Knowles, MD 
 
Protocol Title: Relationship Between Insulin Resistance and Statin Induced 
Type 2 Diabetes, and Integrative Personal Omics Profiling 
 
4 
 
IRB USE ONLY 
Approval Date:   April 16, 2019 
Expiration Date: April 16, 2020 
 
Visit 3 The third test visit will be the glucose infusion test which will evaluate insuln 
clearance and insulin secretion. This test will be 6 hours in length. 
 
Visit 4 The third visit will be the insulin sensitivity test described below.  This test will 
determine if you are insulin sensitive or insulin resistant.  Once you have completed 
this test you will start the study medication Lipitor 40 mg taking it once a day and then 
will be seen for follow up visits over the next 4 months as described below. 
 
Visit 4 -10 You will be seen, every 2 weeks from week zero up to 8 weeks and then 
one and two months later after completing the end of study tests and stopping the 
study medication (statin).  We will check your weight, and blood pressure at each of 
these visits. We will also check a pregnancy test in women who are of childbearing 
age at the beginning, week 4 and week 8.  You will also see Dr. Knowles research 
associates (an MD or nurse practitioner) to review how you are doing on the study 
medication. We will ask you to bring in your study medication at each visit and at the 
end of the study.   At the end of the study we will ask you to stop the statin and not to 
take   any cholesterol lowering medication for two months and will ask you to come in 
at the end of 1 month and 2 months off the study medication for iPOP samples.   
iPOP samples:  Samples for Dr. Snyders’s iPOP research will be taken on day of 
OGTT and week 0 (before starting statin), and then at weeks 2, 4, 8, 12 and 16 We will 
draw 60 ml of blood at each time period (4 Tablespoons) and take other samples of 
body fluids as described on page 9 under iPOP samples.   
 
Questionnaires: 
For the duration of this study you agree to make no changes in your level of physical 
activity, weight or diet. We will ask you to complete several questionnaires, a physical 
activity sheet, food log, eating habits and stress level every time you have blood 
samples drawn for iPOP.  
 
SUBJECT’S RESPONSIBILITIES 
 
If you qualify and agree to participate in this study you will be expected to: 
a) follow the instructions of the Protocol Director and research associates; 
b) answer questions regarding your medical history to the best of your ability; 
c) ask questions as you think of them; 
d) keep your study appointments; 
e) take your study medication as directed and report any side effects; 
f) return your bottle of study medication even if empty at every visit and at the end of 
the study; 
g) complete all baseline and follow-up tests as well as study questionnaires; 
h) tell us if you think you are pregnant 
I) tell us if you can no longer do the study in case we want to complete end of study 
testing. 


 
 
  STANFORD UNIVERSITY Research Consent Form 
 
Protocol Director:  Joshua Knowles, MD 
 
Protocol Title: Relationship Between Insulin Resistance and Statin Induced 
Type 2 Diabetes, and Integrative Personal Omics Profiling 
 
5 
 
IRB USE ONLY 
Approval Date:   April 16, 2019 
Expiration Date: April 16, 2020 
If you decide to participate, all the tests described below will be done at the 
beginning and the completion of the study.   
 
STUDY TESTING PROCEDURES 
 
Oral Glucose Tolerance Test – This test will be done at the beginning and end of 
the study.  You will be asked to fast for 12 hours the night before but will be allowed 
and encouraged to drink water during those 12 hours. 
 
You agree to participate in a procedure called an oral glucose tolerance test (OGTT). The 
OGTT involves a series of blood samples taken before and during the 120 minutes after 
drinking a sweet cola drink which contains 50 -75 grams (5 tablespoons) of glucose (a 
form of sugar).  This test will be done after you have fasted for 12 hours from the previous 
evening.  An IV will be inserted in one of your arms for the purpose of drawing blood 
samples to determine your blood glucose (sugar) level during this procedure.  Blood 
samples will be drawn at time 0, 30, 60, 90 and 120 minutes after drinking the cola drink. 
The total amount of blood taken for this test will be 45 ml (3 tablespoons).  The purpose of 
this procedure is to determine if you have a normal glucose tolerance response, impaired 
glucose tolerance (a mild abnormality of glucose disposal) or if you have diabetes and to 
calculate insulin secretion.   Although not common, some people may experience nausea 
when drinking the cola drink.  
 
The results of this test will be discussed with you, and we will give you a copy. The total 
time for this procedure will take approximately 3 hours. 
 
GRADED GLUCOSE INFUSION TEST This test will be 6 hours in length 
This test is designed to assess the ability of your pancreas gland to produce insulin in 
response to a glucose (sugar) infusion. During this test, you will have two small IV 
catheters (tubing) placed in your veins. One IV will be for blood drawing and the other 
for the infusion of glucose. You will be given glucose in specific amounts based on 
your weight and the glucose rate will be steadily increased over a 4-hour period. The 
amount of blood taken for this test will be equal to approximately 5 tablespoons (47.5 
ml).  On rare occasions, the glucose can be irritating to the vein and may cause an 
achiness or redness in your arm.  If this happens let us know and we will either put a 
warm pack on the IV site or replace the IV to a new site. Although rare a side effect 
associated with having an IV some discomfort and carries a slight risk of infection, or 
bruising 
 
 
INSULIN SENSITIVITY TEST- This test will be done at the beginning and end of 
the study.  You will be asked to fast for 12 hours the night before but will be allowed 
and encouraged to drink water during those 12 hours. 
 


 
 
  STANFORD UNIVERSITY Research Consent Form 
 
Protocol Director:  Joshua Knowles, MD 
 
Protocol Title: Relationship Between Insulin Resistance and Statin Induced 
Type 2 Diabetes, and Integrative Personal Omics Profiling 
 
6 
 
IRB USE ONLY 
Approval Date:   April 16, 2019 
Expiration Date: April 16, 2020 
The insulin sensitivity test is designed to measure how well your cells remove glucose 
(a type of sugar) from your blood in response to insulin. This test will involve the 
infusion of glucose, insulin and octreotide (sandostatin) by vein for three hours.   
During this test you will have two small catheters (tubing) placed in your veins (I.V. 
lines).  One of these will be used for blood drawing and the other for giving the infusion 
of glucose, insulin and sandostatin.  Blood samples will be taken before, during and at 
the end of the infusion study. The total amount of blood that will be drawn from you 
during this study will be 59.5 ml of blood (approximately 4-5 tablespoons).  
 
Insulin is a natural hormone, and sandostatin (a synthetic hormone) is a drug that 
temporarily blocks the secretion of insulin from your pancreas. There are no serious 
adverse effects from the brief use of sandostatin in this study.  However, there may be 
a transient (temporary) decrease in your pulse, and occasionally nausea and 
abdominal cramping can occur in about 5-10% of people.  There may also be a 5-10% 
chance of having abdominal cramping and diarrhea or loose stools, which could occur 
several hours after the completion of the study.   
 
Insulin will cause your cells to remove glucose from your blood. It is possible that your 
blood glucose levels could become too low (hypoglycemia) during and immediately 
after the end of the study. In order to avoid this from occurring, your blood glucose 
levels will be measured during and after the study, and glucose will be given as 
needed to prevent hypoglycemia from occurring. 
 
There is the risk of fever and sudden fall in blood pressure if the infusate solutions 
(substances given in your vein) are contaminated.  However, the solutions are made 
from sterile components or substances tested for sterility before being used in the 
preparation of the solutions, and the risk of contamination is very slight. 
This test will be 6 hours in length 
 
After completing these tests, you will be given the study medication Lipitor 40 mg which 
you will take once a day for 2 months and will stop after completing the end of study tests.  
 
POTENTIAL MEDICATION SIDE EFFECTS and POSSIBLE RISKS, DISCOMFORTS, 
AND INCONVENIENCES 
 
Atorvastatin  
You will receive atorvastatin (Lipitor) 40 mg to be taken once a day.   
 
Side Effects:  Lipitor has been studied over many years and this dose of Lipitor has been 
well tolerated. The most commonly reported adverse reactions (incidence equal to or 
greater than 2%) in patients treated with atorvastatin 40 mg in placebo (no medication) -
controlled trials regardless of causality were: nasopharyngitis, (inflammation of nasal 
passage and sore throat) - 7%, arthralgia (pain in joints) -10.6%, diarrhea -14.1 %, pain in 
extremity - 9.3%, and urinary tract infection 8.0%. 


 
 
  STANFORD UNIVERSITY Research Consent Form 
 
Protocol Director:  Joshua Knowles, MD 
 
Protocol Title: Relationship Between Insulin Resistance and Statin Induced 
Type 2 Diabetes, and Integrative Personal Omics Profiling 
 
7 
 
IRB USE ONLY 
Approval Date:   April 16, 2019 
Expiration Date: April 16, 2020 
 
WARNINGS AND PRECAUTIONS 
Skeletal Muscle 
 
Lipitor, like other statins, occasionally causes myopathy, meaning muscle aches or muscle 
weakness. This can also be associated with muscle breakdown measured by a test called 
CK (creatinine kinase).  
 
Rare cases of rhabdomyolysis (muscle breakdown and kidney failure) have been reported 
with Lipitor and other statins. A history of kidney impairment may be a risk factor for the 
development of rhabdomyolysis.  People with kidney disease will not qualify for this study. 
The risk of myopathy, and in rare cases rhabdomyolysis, during treatment with statins is 
increased when taking certain medications.  These include: cyclosporine, certain 
medications to lower triglycerides (fibric acid derivatives, or niacin), some antibiotics such 
as erythromycin, clarithromycin, certain medications for treating HIV or hepatitis C, or 
strong antifungal medications known as azole antifungals phosphokinase.  It is important 
to let us know all medications you are taking whether prescribed or over the counter and 
any new medications you may be prescribed while you are participating in this study. 
Although very rare, another side effect is elevated liver enzymes which may cause 
symptoms of feeling tired or weak, loss of appetite, stomach pain, dark urine (dark 
brownish orange) or yellowing of the skin or whites of your eyes. 
Individuals who are on the medications listed above or have certain diagnoses as noted 
above will not qualify for this study.  Please let your healthcare provider know you are 
taking Lipitor.  
It can also cause muscle tenderness or weakness, and study participants should be 
advised to report immediately unexplained muscle pain, tenderness, or weakness, 
particularly if in addition you have fatigue or fever or if muscle signs and symptoms persist 
after discontinuing Lipitor.  
 
Other Cholesterol Lowering Medications 
While on the study medication you will not be able to take any other statins or cholesterol 
lowering medications such as niacin, fibrates, ezetimibe, bile acid binding resins or over 
the counter herbs such as red yeast rice which has the similar cholesterol lowering effects.  
It is advised not to drink grapefruit juice when taking a statin.  
 
Contraindications: 
These study medications are not recommended for people with any of the following: a 
known hypersensitive or allergy to statins, previous intolerance to all statins, severe kidney 
or liver disease.  
 
Potential Benefits 
You will know how insulin resistant you are and your risk for type 2 diabetes and risk 
factors for heart disease. You will be given a statin that is known to decrease the risk 
of heart and vascular disease.  At the end of the study we will review all of your risk 


 
 
  STANFORD UNIVERSITY Research Consent Form 
 
Protocol Director:  Joshua Knowles, MD 
 
Protocol Title: Relationship Between Insulin Resistance and Statin Induced 
Type 2 Diabetes, and Integrative Personal Omics Profiling 
 
8 
 
IRB USE ONLY 
Approval Date:   April 16, 2019 
Expiration Date: April 16, 2020 
factors for type 2 diabetes and heart disease and make recommendations to help you 
lower these risks. If appropriate you will have the option to receive dietary counseling 
for a healthier diet and weight loss for 6-8 weeks after completing the study with a 
registered dietitian. Personal benefit to you may or may not result from taking part in 
the iPOP research. However, knowledge may be gained from your participation that 
might eventually benefit you and others. 
 
WE CANNOT AND DO NOT GUARANTEE OR PROMISE THAT YOU WILL RECEIVE 
ANY BENEFITS FROM THIS STUDY 
 
Participant's Rights 
You should not feel obligated to agree to participate.  Your questions should be answered 
clearly and to your satisfaction.  If you decide not to participate, please call Dr. Knowles or 
one of his associates at 650-723-7024. 
You will be told of any important new information that is learned during the course of this 
research study, which might affect your condition or your willingness to continue 
participation in this study.  
 
 
ALTERNATIVES TO STUDY PARTICIPATION 
Lifestyle changes, including dietary changes, regular exercise and weight loss can be 
effective in increasing insulin sensitivity and lowering risk for diabetes and heart 
disease. If you choose not to participate and think you are at risk for type 2 diabetes 
and or heart disease, you can make lifestyle changes including weight loss and 
increased physical activity.  If you have elevated cholesterol and risks for heart 
disease that qualify you for a statin, you may speak to your health care provider about 
being prescribed Lipitor or one of the other recommended statins to lower your risk for 
heart disease.  
 
WOMEN OF CHILDBEARING POTENTIAL 
If you are a woman who is able to become pregnant, it is expected that you will use an 
effective method of birth control, such as a condom, or oral birth control pills to prevent 
exposing a fetus to a potentially dangerous agent with unknown risk. If you are 
pregnant or breast feeding you may not participate in this drug study.  To confirm to 
the extent medically possible that you are not pregnant, you agree to begin the study 
after the onset of your next menstrual period. You must avoid sexual intercourse or 
use a birth control method judged to be effective by the investigator and which will not 
interfere with the proposed investigation. You must accept the risk that pregnancy 
could still result despite the responsible use of reliable method of birth control. You 
agree to notify the investigator as soon as possible of any failure of proper use of your 
birth control method, or if you become pregnant, either of which may result in your 
being withdrawn from the study. 
 


 
 
  STANFORD UNIVERSITY Research Consent Form 
 
Protocol Director:  Joshua Knowles, MD 
 
Protocol Title: Relationship Between Insulin Resistance and Statin Induced 
Type 2 Diabetes, and Integrative Personal Omics Profiling 
 
9 
 
IRB USE ONLY 
Approval Date:   April 16, 2019 
Expiration Date: April 16, 2020 
TISSUE SAMPLING FOR GENETIC TESTING, OTHER TESTING, OR BANKING FOR 
FUTURE RESEARCH 
 
Blood Samples: You have been given a consent form because the investigators want to 
include your blood samples in a research project.  Research using blood samples is an 
important way to try and understand human disease.  Blood samples may be stored for 
future research and testing in the field of insulin resistance and the relationship between 
early events for the development of atherogenesis (blockages in arteries) or type 2 
diabetes. Blood samples are identified by your initials, a number and date of your test; 
otherwise your identity will not be disclosed.   
Because there is no absolute protection against discrimination on the basis of disease or 
genetic information, the investigator will use the results of this study as research only and it 
will not be included in your medical records. Because this is a research study the 
information we learn from this study or any future testing will not be reported directly to 
you.  There is no risk of not knowing this information as you will already be given current 
information regarding insulin resistance and heart disease risks and advised on methods 
to modify insulin resistance and your risk factors for coronary artery disease as it pertains 
to you.  
 
If for some reason you are unable to continue in the study we will keep the blood samples 
obtained from your baseline studies. 
Any tissues you have donated which are used in research may result in new products, 
tests or discoveries. In some instances, these may have potential commercial value and 
may be developed and owned by the Investigators, Stanford University and/or others.  
However, donors of tissues do not retain any property rights to the materials.  Therefore, 
you would not share in any financial benefits from these products, tests or discoveries. 
 
If you do not want to grant permission to save your samples after the completion of 
analysis for this study let us know now or at the completion of your participation. 
You understand you have the right to withdraw your consent to save your blood 
after the completion of analysis now or at any time and this will not affect your 
ability to participate in the research study. 
 
_____Yes:  I consent to my samples being saved for future research 
 
_____No:  I do not consent to my samples being saved for future research 
 
iPOP samples 
 
We will perform iPOP analysis on the samples collected, including genomic (including 
whole genome sequencing, this tells us your DNA sequence and some of your genetic 
disposition to diseases, as well as the DNA sequence of the microbes in your nasal, 
tongue and skin surface swab, saliva, urine and stool samples), epigenomic (this shows 
how genes are regulated at the DNA level), transcriptomic (this informs us how genes are 
expressed at the RNA level), proteomic (this allows us to know the details of all the 


 
 
  STANFORD UNIVERSITY Research Consent Form 
 
Protocol Director:  Joshua Knowles, MD 
 
Protocol Title: Relationship Between Insulin Resistance and Statin Induced 
Type 2 Diabetes, and Integrative Personal Omics Profiling 
 
10 
 
IRB USE ONLY 
Approval Date:   April 16, 2019 
Expiration Date: April 16, 2020 
proteins in your samples), metabolomic (this measures all the metabolites in your samples) 
and autoantibodyomic (this gives us information whether your immune system is attacking 
yourself, and if so, which protein target) profiling, as well as integrative analyses (this will 
enable us to analyze you and your health with all the molecular information above). 
 
As part of this study, we will collect your name, medical history, sample related records, 
results of your physical examinations and answers to questionnaires.  We will also record 
your iPOP profiles (including genomic, epigenomic, transcriptomic, proteomic, 
metabolomics, autoantibodyomic as well as integrative profiles) that we generate in our 
research lab. All participants for this study will be anonymized (unidentified) and assigned 
to a coded ID number and only the core personnel of the study will have access to the key. 
Data may also be looked at by groups who regulate all research, including the Institutional 
Review Board (IRB), the Food and Drug Administration (FDA), or the federal Office for 
Human Research Protections 
  
TISSUE SAMPLING FOR GENETIC TESTING iPOP 
As part of the analysis on your samples, the investigators will do genetic testing. Genetic 
research is research that studies genes, including gene characteristics and gene 
versions that are transmitted by parents to children. Genetic research may include looking 
at information, such as personal appearance and biochemistry, gene sequences, 
genetic landmarks, individual and family medical histories, reactions to medications and 
responses to treatment. Genetic research raises certain questions about informing you of 
any results. Possible risks of knowing results include: anxiety; other psychological distress; 
and the possibility of insurance and job discrimination. A possible risk of not 
knowing includes being unaware of the need for treatment. These risks can change 
depending on the results of the research and whether there is a treatment or cure for a 
particular disease. The iPOP information is for research purposes only and will not be 
released to you.  
 
Your DNA sample and information will be kept in a secured place in Dr. Michael Snyder’s 
laboratory at the Alway Building of the Stanford University School of Medicine, or another 
site until it is used up or destroyed. The banked DNA may be used in future studies of genetic 
factors related to health and disease.  
 
Sometimes patients have been required to furnish information from genetic testing for 
health insurance, life insurance, and/or a job. A Federal law, the Genetic 
Information Nondiscrimination Act of 2008 (GINA), generally makes it illegal for 
health insurance companies, group health plans, and employers with 15 or 
more employees to discriminate against you based on your genetic information. 
 
The National Institutes of Health (NIH) has established a national database of Genotypes 
and Phenotypes (dbGAP) that wasdeveloped to archive and distribute the results of studies 
that have investigated the interaction of genotypes and phenotypes. These studies include 
genome-wide association studies, medical sequencing, molecular diagnostic assays, as well 
as association between genotype and non-clinical traits. dbGaP provides two levels of 


 
 
  STANFORD UNIVERSITY Research Consent Form 
 
Protocol Director:  Joshua Knowles, MD 
 
Protocol Title: Relationship Between Insulin Resistance and Statin Induced 
Type 2 Diabetes, and Integrative Personal Omics Profiling 
 
11 
 
IRB USE ONLY 
Approval Date:   April 16, 2019 
Expiration Date: April 16, 2020 
access - open and controlled - in order to allow broad release of non-sensitive data, while 
providing oversight and investigator accountability for sensitive data sets involving personal 
health information. Controlled-access data can only be obtained with authorization by the 
NIH Data Access Committee (DAC) and includes de-identified genotype and phenotype 
information. Your tissues contain genes which are made of DNA that is unique to you. Coded 
information about you may be sent to this national database. Access will be controlled and 
limited to other researchers.  
 
If you agree we would also like to make your genetic data accessible to the public. In this 
case, your name and personal information would not be posted, but the results of 
sequencing and other biological assays will be available. There is the possibility that you 
could be identified through your genome sequence which means others could have access 
to your genetic information.  
 
Please note that even in the secure database, there is a risk of breach of confidentiality. 
When data are stored electronically, there is also a risk of breach of computer security. Since 
you and your relatives and other members of your ethnic group share some of the same 
genetic make-up, there is a small chance for breach of their privacy, as well.  
 
While we believe that the risks to you and your family are very low, we are unable to tell you 
exactly what all of the risks are. We believe that the benefits of learning more about diseases 
outweigh these potential risks.  
 
Psychological or social risks associated with loss of privacy:  
• Although your genetic information is unique to you, you do share some genetic information 
with your children, parents, brothers, sisters, and other blood relatives. Consequently, it may 
be possible that genetic information from them could be used to help identify you. Similarly, 
it may be possible that genetic information from you could be used to help identify them.  
• While neither the public nor controlled-access databases developed for this project will 
contain information that is traditionally used to identify you, such as your name, address, 
telephone number, or social security number, people may develop ways in the future that 
would allow someone to link your genetic information in our databases with information from 
you (or a blood relative) in another database and be able to identify you (or a blood relative). 
It also is possible that there could be violations to the security of the computer systems used 
to store codes linking your genetic and medical information to you.  
• Since some genetic variations can help to predict the future health problems of you and 
your relatives, this information might be of interest to employers, health providers, insurance 
companies, and others. Patterns of genetic variation can also be used by law enforcement 
agencies to identify a person or his/her blood relatives. Therefore, your genetic information 
potentially could be used in ways that could cause you or your family distress, such as by 
revealing that you (or a blood relative) carry a genetic disease or by leading to the denial of 
employment or insurance for you (or a blood relative).  
• There may be other privacy risks that we have not foreseen.  
 


 
 
  STANFORD UNIVERSITY Research Consent Form 
 
Protocol Director:  Joshua Knowles, MD 
 
Protocol Title: Relationship Between Insulin Resistance and Statin Induced 
Type 2 Diabetes, and Integrative Personal Omics Profiling 
 
12 
 
IRB USE ONLY 
Approval Date:   April 16, 2019 
Expiration Date: April 16, 2020 
Every effort will be made to keep research records private. There may be times when federal 
or state law requires the disclosure of those records, including personal information. This is 
very unlikely. If disclosure is required, we will take all steps allowed by law to protect the 
privacy of your personal information. 
 
If you do not want to grant permission to save your samples after the completion of 
analysis for this study let us know now or at the completion of your participation. You 
understand you have the right to withdraw your consent to save your blood after the 
completion of analysis now or at any time and this will not affect your ability to 
participate in the research study. 
 
_____Yes:  I consent to my samples being saved for future research 
 
_____ No: I do not consent to my samples being saved for future research 
 
 
 
Buffy Coat Genetic Blood Test  
 
In an effort to better understand the relationship of insulin resistance, its relationship with 
metabolic abnormalities and possible genetic links we are asking your permission to collect 
some blood cells known as a buffy coat (part of the white cells). This sample of cells may 
help us to find a gene or genes which may be related to insulin resistance. This sample is 
considered a genetic test and therefore you need to be informed of this test.  Since this is 
purely a research project you will not be notified of the results. Not knowing the results will 
not be harmful as we will tell you the currently known and recommended therapies to reduce 
insulin resistance. 
Sometimes patients have been required to furnish information from genetic testing for health 
insurance, life insurance, and/or a job.  A Federal law, the Genetic Information 
Nondiscrimination Act of 2008 (GINA), generally makes it illegal for health insurance 
companies, group health plans, and employers with 15 or more employees to discriminate 
against you based on your genetic information. 
 
 If we elect to save a buffy coat sample this will be done when you are having a study test 
such as a meal profile or insulin sensitivity test, or glucose infusion study and therefore no 
extra blood will be obtained. Your sample will be identified by initials, a number, and the date 
of the test done. This is done to avoid errors in collection of results. Your identity will not be 
disclosed.  Because there is no absolute protection against discrimination on the basis of 
disease or genetic information the investigator will use the results of this study as research 
only and it will not be included in your medical records.  You have the right to withdraw your 
consent for this test now or at any time and this will not affect your ability to participate in the 
research study. This buffy coat sample will be stored in a minus 80 freezer for as long as but 
not limited to 5 years.  We will not use this sample for any other purpose then described 
above without your specific permission.   


 
 
  STANFORD UNIVERSITY Research Consent Form 
 
Protocol Director:  Joshua Knowles, MD 
 
Protocol Title: Relationship Between Insulin Resistance and Statin Induced 
Type 2 Diabetes, and Integrative Personal Omics Profiling 
 
13 
 
IRB USE ONLY 
Approval Date:   April 16, 2019 
Expiration Date: April 16, 2020 
 
I agree that this sample (buffy coat) may be collected  
for the specific purpose described above.                        YES ____     NO_____ 
 
 
 
 
 
 
 
 
 
Please Initial__________ 
 
Withdrawal From Study 
 
If you first agree to participate and then you change your mind, you are free to withdraw 
your consent and discontinue your participation at any time.  Your decision will not affect 
your ability to receive medical care for your disease and you will not lose any benefits to 
which you would otherwise be entitled.  
Please let us know immediately as we may want to do follow-up testing if you agree.  
 
If you withdraw from the study, or the study medication is stopped for any reason,  
• There will be no harm to you if you withdraw and stop the study medication.  
• You must return all of the unused study medication if you withdraw from the 
study or are asked to stop the study. 
At the discretion of the protocol director subjects may be taken out of this study due to 
unanticipated circumstances. Other reasons why you may be taken out of the study may 
include: failure to follow instructions, the study is cancelled or other administrative reasons.  
If you have any questions, we expect you to ask us.  If you have any additional questions 
please call Dr. Knowles or his associates at 650-723-7024 and they will be happy to 
answer them.    
In the future if there are other studies you 
may qualify for may we contact you?                        YES                         NO   
 
                                                                                       Please Initial__________ 
 
ClinicalTrials.gov 
 
A description of this clinical trial will be available on http://www.ClinicalTrials.gov, as 
required by U.S. Law.  This Web site will not include information that can identify you.  
At most, the Web site will include a summary of the results.  You can search this Web 
site at any time. 
 
CONFIDENTIALITY 
The results of this research study may be presented at scientific or medical meetings or 
published in scientific journals.  Your identity and/or your personal health information will 
not be disclosed except as authorized by you or as required by law.  However, there is 
always some risk that even de-identified information might be re-identified. Patient 
information may be provided to Federal and other regulatory agencies as required.  The 
Food and Drug Administration (FDA), for example, may inspect research records and learn 


 
 
  STANFORD UNIVERSITY Research Consent Form 
 
Protocol Director:  Joshua Knowles, MD 
 
Protocol Title: Relationship Between Insulin Resistance and Statin Induced 
Type 2 Diabetes, and Integrative Personal Omics Profiling 
 
14 
 
IRB USE ONLY 
Approval Date:   April 16, 2019 
Expiration Date: April 16, 2020 
your identity if this study falls within its jurisdiction. The purpose of this research study is to 
compare the effects of taking statins versus placebo (contains no medication) on insulin 
action, insulin secretion, and insulin clearance in overweight/obese, insulin resistant, 
nondiabetic individuals; the results will be provided to the sponsor, the Food and Drug 
Administration and other federal and regulatory agencies as required. 


 
 
  STANFORD UNIVERSITY Research Consent Form 
 
Protocol Director:  Joshua Knowles, MD 
 
Protocol Title: Relationship Between Insulin Resistance and Statin Induced 
Type 2 Diabetes, and Integrative Personal Omics Profiling 
 
15 
 
IRB USE ONLY 
Approval Date:   April 16, 2019 
Expiration Date: April 16, 2020 
Authorization to Use Your Health Information for Research Purposes 
Because information about you and your health is personal and private, it generally 
cannot be used in this research study without your written authorization.  If you sign 
this form, it will provide that authorization.  The form is intended to inform you about 
how your health information will be used or disclosed in the study.  Your information 
will only be used in accordance with this authorization form and the informed 
consent form and as required or allowed by law.  Please read it carefully before 
signing it.   
What is the purpose of this research study and how will my health information 
be utilized in the study? 
The purpose of this study is designed to understand the impact of a statin on insulin 
action, insulin secretion, and insulin clearance in nondiabetic individuals who may be 
at risk for type 2 diabetes.  It is also to analyze iPOP of those individuals who 
participate in this study, before, during, and after taking a statin. Any scientific paper 
written based on the information in this study will not reveal your identity. The 
sponsors will also receive the scientific paper. As required by law the Food and Drug 
Administration (FDA) may also receive your information related to this research 
study. 
Do I have to sign this authorization form? 
You do not have to sign this authorization form but if you do not, you will not be able 
to participate in this research study or receive any of the research related treatments.  
Signing the form is not a condition for receiving any medical care outside the study. 
If I sign, can I revoke it or withdraw from the research later? 
If you decide to participate, you are free to withdraw your authorization regarding the 
use and disclosure of your health information (and to discontinue any other 
participation in the study) at any time. After any revocation, your health information 
will no longer be used or disclosed in the study, except to the extent that the law 
allows us to continue using your information (e.g., necessary to maintain integrity of 
research). If you wish to revoke your authorization for the research use or disclosure 
of your health information in this study, you must write to: Dr. Joshua Knowles, 300 
Pasteur Drive, Falk building, CVRC, Stanford, CA 94305-5406. 
 


 
 
  STANFORD UNIVERSITY Research Consent Form 
 
Protocol Director:  Joshua Knowles, MD 
 
Protocol Title: Relationship Between Insulin Resistance and Statin Induced 
Type 2 Diabetes, and Integrative Personal Omics Profiling 
 
16 
 
IRB USE ONLY 
Approval Date:   April 16, 2019 
Expiration Date: April 16, 2020 
What personal information will be used or disclosed? 
Your health information related to this study includes but is not limited to, the 
following: Name, address, phone number, email address, date of birth, medical record 
number, weight, height, blood pressure and pulse, medical history, current 
medications and over the counter medications, information from your physical exam 
and answers from your questionnaires which may be used or disclosed in connection 
with this research study.  Laboratory tests include hematocrit (blood count), glucose, 
insulin, and lipid levels – fat in the blood-, (cholesterol, triglycerides, (type of fat 
from what we eat and what the liver produces), high density lipoprotein (HDL-C), 
good cholesterol and low density lipoprotein (LDL-C), bad cholesterol), 
inflammatory markers, liver and kidney function tests which may be used or 
disclosed in connection with this research study.  Specimens and information taken 
for Dr. Snyder's lab will be: answers to questionnaires, iPOP profiles, including 
genomic, epigenomic, transcriptomic, proteomic, metabolomic, microbial (sampled 
by nasal, tongue and skin swabs) as well as integrative profiles, that are generated in 
their research lab.  
Who May Use or Disclose the Information? 
The following parties are authorized to use and/or disclose your health information in 
connection with this research study: 
• The Protocol Director Dr. Knowles 
• Research staff  
• The Stanford University Administrative Panel on Human Subjects in Medical 
Research and any other unit of Stanford University as necessary.  
Who May Receive / Use the Information? 
The parties listed in the preceding paragraph may disclose your health information to 
the following persons and organizations for their use in connection with this research 
study: 
• The Office for Human Research Protections in the U.S, Department of Health and 
Human Services 
• The National Institutes of Health 
• The Food and Drug Administration 
• Doris Duke Foundation. 


 
 
  STANFORD UNIVERSITY Research Consent Form 
 
Protocol Director:  Joshua Knowles, MD 
 
Protocol Title: Relationship Between Insulin Resistance and Statin Induced 
Type 2 Diabetes, and Integrative Personal Omics Profiling 
 
17 
 
IRB USE ONLY 
Approval Date:   April 16, 2019 
Expiration Date: April 16, 2020 
• Outside laboratories that may be utilized to analyze samples.  
Your information may be re-disclosed if the recipients described above are not 
required by law to protect the privacy of the information. 
Expiration 
Your authorization for the use and/or disclosure of your health information will 
expire on December 31, 2060 or when the research project ends, whichever is earlier. 
Will Access to my medical records be limited during the study? 
To maintain the integrity of this research study, you may not have access to any 
health information developed as part of this study until it is completed.  At that point, 
you would have access to such health information if it was used to make a medical or 
billing decision about you (e.g., if included in your official medical record).  
 
 
 
 
 
 
 
 
 
 
                                                  
_________________________________                          __________________ 
Signature of Participant  
 
 
 
 
Date 
 
_______________________________                         
Printed Name of Adult Participant 
 
FINANCIAL CONSIDERATIONS 
 
1) Payment – There is no payment for participating in this study  
 
2) Costs - If you participate in this study, the study will pay for those services, supplies, 
procedures, and care associated with the study that are not a part of your routine medical 
care.  However, there may be additional costs to you.  These include basic expenses like 
transportation and the personal time it will take to come to the study visits.  You and/or your 
health insurance must pay for services, supplies, procedures, and care that are required 
during this study for routine medical care.  You will also be responsible for any co-payments 
and/or deductibles as required by your insurance.  Participation in this study is not a 
substitute for health insurance. 
 
3) The Department of Genetics of Stanford University is providing some financial support 
and materials for this study. 
 
4) The National Institutes of Health (NIH) is providing some financial support for the facility 
and staff where part or all of the study is taking place. 
 


 
 
  STANFORD UNIVERSITY Research Consent Form 
 
Protocol Director:  Joshua Knowles, MD 
 
Protocol Title: Relationship Between Insulin Resistance and Statin Induced 
Type 2 Diabetes, and Integrative Personal Omics Profiling 
 
18 
 
IRB USE ONLY 
Approval Date:   April 16, 2019 
Expiration Date: April 16, 2020 
5) A scientific grant from the Doris Duke Charitable Foundation is providing some financial 
support for this study. 
 
6) Dr. Michael Snyder is a paid consultant to, and has stock in Personalis, the company that 
is doing sequencing for this study. 
 
 
COMPENSATION   
 
All forms of medical diagnosis and treatment – whether routine or experimental – involve 
some risk of injury.  In spite of all precautions, you might develop medical complications 
from participating in this study.  If such complications arise, the Protocol Director and the 
research study staff will assist you in obtaining appropriate medical treatment.  In the event 
that you have an injury or illness that is directly caused by your participation in this study, 
reimbursement for all related costs of care first will be sought from your insurer, managed  
care plan, or other benefits program.  You will be responsible for any associated co-
payments or deductibles as required by your insurance. 
If costs of care related to such an injury are not covered by your insurer, managed care 
plan or other benefits program, you may be responsible for these costs.  If you are unable 
to pay for such costs, the Protocol Director will assist you in applying for supplemental 
benefits and explain how to apply for patient financial assistance from the hospital. 
 
You do not waive any liability rights for personal injury by signing this form. 
 
Contact Information  
• Questions, Concerns, or Complaints: If you have any questions, concerns or 
complaints about this research study, its procedures, risks and benefits, or 
alternative courses of treatment, you should ask the Protocol Director.  You may 
contact Dr. Knowles or associates at 650-723-7024.   
• Injury Notification: If you feel you have been hurt by being a part of this study, or 
need immediate assistance please contact the page operator at 650 723-6661 and 
ask them to page Dr. Knowles associates: Dr. Fahim Abbasi, or Cindy Lamendola 
Nurse Practitioner as an alternate contact. 
• Independent Contact: If you are not satisfied with how this study is being conducted, 
or if you have any concerns, complaints, or general questions about the research or 
your rights as a participant, please contact the Stanford Institutional Review Board 
(IRB) to speak to someone independent of the research team at (650)-723-5244 or 
toll free at 1-866-680-2906. You can also write to the Stanford IRB, Stanford 
University, 3000 El Camino Real, Five Palo Alto Square, 4th Floor, Palo Alto, CA 
94306. 


 
 
  STANFORD UNIVERSITY Research Consent Form 
 
Protocol Director:  Joshua Knowles, MD 
 
Protocol Title: Relationship Between Insulin Resistance and Statin Induced 
Type 2 Diabetes, and Integrative Personal Omics Profiling 
 
19 
 
IRB USE ONLY 
Approval Date:   April 16, 2019 
Expiration Date: April 16, 2020 
• Appointment Contact: If you need to change your appointment, please contact Dr. 
Knowles research associates at 650-723-7024 
 
 
 
Signing your name means you agree to be in this study and that you were given a 
copy of this signed and dated consent form  
 
 
 
___________________________________ 
_________________________                                         
Signature of Participant 
 
 
 
 
 
Date 
  
 
___________________________________ 
Printed Name of Adult Participant 
 
 
Person Obtaining Consent 
 
___________________________________           ________________ 
 
     Signature of Person Obtaining Consent            
 
 
Date  
 
 
__________________________________________________ 
Printed Name of Person Obtaining Consent 
 
 
 

Prot_SAP_002.pdf: 
Save Date: 11/1/20 
1 
 
STANFORD UNIVERSITY SCHOOL OF MEDICINE 
DIVISION OF CARDIVASCULAR MEDICINE 
 
 
Relationship Between Insulin Resistance and Statin Induced Type 2 Diabetes, and 
Integrative Personal Omics Profiling 
IRB Protocol Number: 33347 
NCT Number: NCT02437084 
December 20, 2016 
 
STUDY TITLE 
2 
ABBREVIATIONS 
2 
BRIEF DESCRIPTION: BACKGROUND, GOALS, GENERAL APPROACH 
3 
KEY STUDY PERSONNEL 
4 
FUNDING SOURCES 
5 
1. SIGNIFICANCE 
6 
2. RATIONALE, HYPOTHESIS AND OUTCOME MEASURES 
7-8 
3. STUDY DESIGN 
9 
SAMPLE SIZE 
9 
STUDY POPULATION 
9 
STUDY LOCATION 
9 
DURATION 
9 
4. STUDY PROCEDURES 
10 
RECRUITMENT 
10 
PARTICIPANT VISITS AND PROCEDURES 
10 
VISIT 1. SCREENING VISIT 
10 
VISIT 2. ORAL GLUCOSE TOLERANCE TEST 
10-11 
VISIT 3. GRADED GLUCOSE INFUSION TEST 
11 
VISIT 4. INSULIN SUPPRESSION TEST AND INTEGRATED PERSONAL 
OMICS PROFILING, iPOP 
11-12 
VISIT 5-7. BIWEEKLY FOLLOW UP 
12 
VISIT 8: REPEAT ORAL GLUCOSE TOLERANCE TEST 
12 
VISIT 9: REPEAT GRADED GLUCOSE INFUSION 
12 
VISIT 10: REPEAT INSULIN SUPPRESSION TEST AND iPOP 
12 
VISIT 11: ONE-MONTH OFF STATIN: iPOP 
12 
VISIT 12: TWO-MONTH OFF STATIN: iPOP (LAST STUDY VISIT) 
12 
STUDY MEDICATION MONITORING 
12-13 
5. STATISTICAL CONSIDERATIONS 
14 
APPENDIX 
15 
A. INCLUSION/EXCLUSION CRITERIA 
15 
B. PARTICIPANT EXPECTATIONS SCHEDULE EXAMPLE 
16 
C. OUTCOME MEASUREMENT METHODS 
17 
D. REFERENCES 
18 


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STUDY TITLE 
Relationship Between Insulin Resistance and Statin Induced Type 2 Diabetes, and 
Integrative Personal Omics Profiling 
 
 
 
ABBREVIATIONS 
The following abbreviations will be used throughout this protocol: 
Atherosclerotic Cardiovascular Disease: ASCVD 
Type 2 Diabetes Mellitus: T2D 
Metabolic syndrome: MetS 
LDL cholesterol: LDL-C 
HMG-coenzyme A reductase: HMGCR 
High-sensitivity C-reactive protein hs-CRP 
Oral Glucose Tolerance Test: OGTT 
Insulin Suppression Test: IST 
Graded Glucose Infusion Test: GGIT 
Area under the curve: AUC 
Glucose-stimulated Insulin Secretion Rate: ISR 
Integrated Personal Omics Profiling: iPOP 


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Brief Description: 
Background: 
There is general agreement that statin-treatment of patients to lower plasma cholesterol levels 
can increase the incidence of type 2 diabetes mellitus (T2D) in some individuals1-5. The 
physiologic mechanism for the increased risk for T2D from statin treatment is unknown but 
could result from effects on insulin sensitivity or insulin secretion. This study will evaluate how 
the medication atorvastatin (trade name Lipitor) works in non-diabetic individuals in regards to 
its effect on insulin sensitivity and insulin secretion to help further understand the possible cause 
of the increased occurrence of T2D in people who are at risk for T2D. This research study will 
also examine what metabolic characteristics and variables (for example insulin resistance, high 
triglycerides, or both) will identify those people at highest risk of statin-induced T2D. 
 
The goals of this study are to: 
1) determine the effect of high-intensity atorvastatin (40 mg/day) for ~ 10 weeks on 
insulin sensitivity and insulin secretion (defined with gold standard methods) (PRIMARY 
OUTCOMES) as well as other glycemic traits (SECONDARY OUTCOMES); 
2) compare a number of cardio-metabolic characteristics (e.g. weight, lipids) before, 
during, and after administration of atorvastatin; 
3) determine if significant deterioration of insulin action and/or secretion following statin 
treatment will be confined to those with baseline insulin resistance (PRE-SPECIFIED 
SUBGROUP ANALYSES); 
4) perform Personal Omics Profiling (iPOP) 6,7 before and after taking atorvastatin to 
examine treatment-associated changes in all baseline variables and to analyze not only 
previously-known drug efficacy but also untargeted drug efficacy (EXPLORATORY 
ANALYSES). 
General approach: 
This will be an open-label study to evaluate the diabetogenic effect of atorvastatin (40 mg/day 
for 10 weeks) on both insulin action and insulin secretion in nondiabetic individuals. To ensure 
we recruit individuals across a broad range of insulin sensitivity, we will target recruitment to 
enrich for those with combined increases in LDL-C and TG concentrations (see SIGNIFICANCE 
and RATIONALE). The experimental population will consist of ~75 apparently healthy, non- 
diabetic volunteers eligible for statin therapy but without pre-existing atherosclerotic 
cardiovascular disease. Following baseline assessments of co-primary outcome measures: 
insulin sensitivity (by insulin suppression test, IST) and insulin secretion (by graded glucose 
infusion test, GGIT), participants will be placed on a weight maintenance diet and treated with 
40 mg/day of atorvastatin. All baseline measurements will be repeated ~10 weeks later with 
iPOP8 measurements done at baseline, at weeks 2, 4, and 10 on atorvastatin, and at weeks 4 
and 8 off atorvastatin. 


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KEY STUDY PERSONNEL 
Principal Investigator 
Joshua W. Knowles, MD, PhD 
Assistant Professor, Cardiovascular Medicine, Stanford University 
Co-Principal Investigator 
Sun Kim, MD 
Associate Professor, Division of Endocrinology, Stanford University 
Co-Investigator 
Gerald Reaven*, MD 
Professor of Medicine, Stanford University 
* Deceased 
Collaborator 
Michael P. Snyder, PhD 
Stanford W. Ascherman, MD, FACS, Professor in Genetics 
Division of Genetics, Stanford University 
University – Scholar – Postdoctoral Scholar 
Ming-Shian Tsai, PhD 
Division of Genetics, Stanford University 
Senior Research Scientist 
Fahim Abbasi, MD 
Division of Cardiovascular Medicine, Stanford University 
Study Coordinator 
Cindy Lamendola, MSN, ANP 
Nurse Practitioner and Clinical Research Nurse Manager 
Division of Cardiovascular Medicine, Stanford University 
Assistant Clinical Research Coordinator 
Pragya Tripathi, MBBS 
Division of Cardiovascular Medicine, Stanford University 
Assistant Clinical Research Coordinator 
Vander Harris, BA 
Division of Cardiovascular Medicine, Stanford University 
Assistant Clinical Research Coordinator 
Chelsea S. Harris, BA 
Division of Cardiovascular Medicine, Stanford University 
Assistant Clinical Research Coordinator 
Fakhar Abbas, MD 
Research Assistant 
Collaborator 
Peter Reaven, MD 
Professor Division of Endocrinologist 
Carl T Hayden VA Medical Center 


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FUNDING SOURCES 
The Doris Duke Charitable Foundation, grant #2016097 provided major funding for this trial. 
Dr. Knowles is supported by the NIH through grants: P30DK116074 (to the Stanford Diabetes 
Research Center), R01 DK116750, R01 DK120565, R01 DK106236; and by the American 
Diabetes Association (grant #1-19-JDF-108). 
Dr. Kim is supported by the Bose Family Foundation and P30DK116074. 
The Washington University at St. Louis Diabetes Research Center central lab is supported by 
NIH grant P30 DK020579. 
Dr. Snyder is supported by the Metabolic Health Center through Lucille Packard Children’s 
Hospital, the Stanford PHIND Initiative and the NIH R01 AT01023203 


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1. SIGNIFICANCE 
Statins and the risk of T2D: Statin treatment is associated with an increase in incident T2D.1-4 5 
This adverse outcome seems to be a class effect, although there is some evidence for a dose 
dependent relationship. After analyses of large statin clinical trial data showed an increased risk 
of T2D associated with statin use, initial follow-up studies focused on the clinical impact of this 
risk. More recently, attention has been given to understanding why statins increase risk of T2D 
and the clinical characteristics that help identify those at increased risk. 
Mechanism of statin-induced T2D: It is unclear whether statins increase the risk of T2D by 
decreasing insulin action, secretion, or both. Several manuscripts have been published that 
substantially increase understanding of the link between statin use and incident T2D. Swerdlow, 
et al.2 based on evidence from genetic analysis and randomized trials, concluded that the 
increased risk of T2D 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.9 have shown in a large 
prospective study (n=8749 men) that participants treated with statins (n=2142) had a 46% 
increase in incident T2D, associated with a 24% decrease in insulin sensitivity and a 12% 
decrease in insulin secretion assessed by surrogate measures. 
Identifying those with at enhanced risk of statin-induced T2D: Studies of 3 randomized 
clinical trials with atorvastatin by David Waters’ group 1,3,4 have demonstrated that “baseline 
fasting glucose, body mass index, hypertension, and fasting triglycerides were independent 
predictors of T2D.” These abnormalities form a cluster, initially referred to as Syndrome X (or 
sometimes referred to as the Metabolic Syndrome, MetS) and attributed to insulin resistance.10 
Since insulin resistance is a predictor of developing T2D, it seems likely that the more insulin 
resistant the individuals are before treatment, the greater is their risk to for statin-induced T2D. 
In that context, relatively little attention has been given to the role that metabolic heterogeneity 
in patients with elevated LDL-C concentrations might play in statin-induced T2D. 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 and/or secretion, irrespective of how mediated, places them at enhanced risk to 
develop statin-induced diabetes. Indeed, we have shown (Kohli et al)1 that patients with both 
insulin resistance (as estimated by high TGs) and prediabetes are at particularly high risk of 
statin-induced T2D. 
While there are other possible approaches to identify individuals most at risk to develop T2D 
when treated with statins, e.g., a diagnosis of the metabolic syndrome (MetS), a comparison of 
291 apparently healthy individuals in our database, grouped together on the basis of having the 
MetS vs. a plasma TG concentration ≥ 150 mg/dL, revealed comparable cardio-metabolic risk 
profiles. Given this information, it seemed reasonable to continue evaluating the ability of a 
plasma TG concentration of ≥ 150 mg/dL as a surrogate for insulin resistance to identify those 
most at risk to develop T2D when taking statins. 
We seek to combine our understanding of the phenotypic heterogeneity of individuals with 
elevated LDL-C concentrations with quantification of insulin action and secretion with gold 
standard methods to address 2 important unanswered questions: Do statins primarily affect 
insulin resistance or insulin secretion?; Are there subsets of individuals at highest risk of statin- 
induced T2D? 


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2. RATIONALE, HYPOTHESIS AND OUTCOME MEASURES 
Rationale: 
T2D develops when insulin resistant individuals cannot maintain the degree of compensatory 
hyperinsulinemia needed to maintain normal glucose tolerance. However, significant 
fundamental questions remain. For example, what is the cellular/molecular link between statin 
treatment and changes in insulin action and secretion? 
This proposal is based on the premise that studying the effect of statins on insulin action and 
insulin secretion using “gold standard” methods will help determine if statins adversely affect the 
risk of T2D by increasing insulin resistance or decreasing insulin secretion. We use the insulin 
suppression test (with the read-out of steady-state plasma glucose, SSPG) to ascertain insulin 
sensitivity and the graded glucose infusion test (with the readout of insulin secretion rate, ISR) 
to ascertain insulin secretion both before and after statin treatment in non-diabetic individuals. 
We hypothesize that treatment with atorvastatin 40 mg/day for approximately 10 weeks will 
impair insulin sensitivity and/or insulin secretion and that this effect may be exacerbated in 
those with underlying insulin resistance. Thus, we plan to look at the effect of atorvastatin not 
only in all participants but also in subsets of individuals with baseline insulin resistance (which 
will be enriched for by recruiting volunteers with elevated plasma TG levels (≥150 mg/dL) at 
baseline. The rationale for this is that plasma TGs are a surrogate measure for insulin 
resistance with a modest correlation with the direct measure of insulin resistance (steady-state 
plasma glucose) measured by the insulin suppression test. Clinically, subjects with elevated 
TGs prior to statin treatment would have substantial clinical benefit from statins, and one of 
investigators' secondary goals is to demonstrate that a simple measurement of plasma TG 
concentration (as a surrogate for insulin resistance) can help identify those most at risk of statin 
induced derangements in glycemic control. Consequently, we propose to enroll nondiabetic 
volunteers at high-risk for T2D, free of known atherosclerotic cardiovascular disease (ASCVD), 
not receiving statins, eligible for statin therapy according to ACC/AHA (American College for 
Cardiology/American Heart Association) 2013 guidelines.11 We will also target recruitment 
efforts to enrich for subjects with plasma TG concentration ≥ 150 mg/dL to ensure that we enroll 
subjects across the range of insulin sensitivity. 
Hypothesis: We hypothesize that high intensity atorvastatin treatment for approximately 10 
weeks will impair insulin sensitivity and/or insulin secretion and that this effect may be 
exacerbated in those with underlying insulin resistance. 
Primary Outcome Measures: 
• 
Change in insulin sensitivity 
o Insulin Sensitivity: Steady-state plasma glucose concentration (mg/dL) measured 
during the insulin suppression test (IST) 
o Time Frame: Change from baseline to 9 -10 weeks in insulin sensitivity 
• 
Change in insulin secretion 
o Insulin secretion: Insulin secretion rate AUC (pmol/min x 4 h) measured during the 
graded glucose infusion test (GGIT) 
o Time Frame: Change from baseline to 9 -10 weeks in insulin secretion 
Secondary Outcome Measures: 
• 
Change in fasting plasma glucose and fasting plasma insulin 
o Fasting plasma glucose and insulin 
o Time Frame: Change from baseline to 8 - 10 weeks in fasting plasma glucose and 
insulin 


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• 
Change in OGTT glucose AUC and insulin AUC 
o OGTT glucose AUC (mg/dL x 2 h) and OGTT insulin AUC (mU/L x 2h) 
o Time Frame: Change from baseline to 8 weeks in OGTT glucose AUC and insulin 
AUC 
 
Prespecified Subgroup Analyses 
• 
Determine if significant deterioration of insulin action and/or secretion following statin 
treatment will be confined to those with baseline insulin resistance. 
 
Exploratory analyses: 
• 
Personal Omics Profiling Personalized medicine is expected to benefit from the combination 
of genomic information with the global monitoring of molecular components and 
physiological states6,7. To further extend Dr. Snyder's previous research of integrated 
Personal Omics Profiling (iPOP), which monitors genomic, transcriptomic, proteomic, 
metabolomic, and autoantibodyomic information over time, the investigators propose to 
analyze iPOP of apparently healthy volunteers with dyslipidemia longitudinally before, 
during, and after taking atorvastatin. In this pilot substudy, by performing unprecedented 
depth of omics analysis, both previously known and untargeted efficacies of atorvastatin will 
be analyzed. Overall, the endeavor will improve our understanding of how to perform a 
personal omics profile when taking statins and help us develop recommendations for better 
use of statins. 


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3. STUDY DESIGN 
Sample Size 
• 
We aim to recruit and retain 75 total participants in this study. 
Study Population (see Appendix A for detailed inclusion and exclusion criteria) 
• 
Healthy adults 30 - 70 years old. 
• 
BMI: 20 - 37 kg/m2. 
• 
Persons without diabetes as defined by having fasting plasma glucose < 126 mg/dL and 
not taking glucose lowering medications. 
• 
Individuals eligible for statin therapy for primary prevention of ASCVD based on LDL-C ≥ 
130 mg/dL, > 5% ASCVD risk over 10 years, or hs-CRP ≥ 2.0 mg/L. 
Study Location 
• 
Research Participants will be seen and have all study procedures at: Clinical and 
Translational Research Unit (CTRU) at 800 Welch Road, Palo Alto, CA 94304. 
Duration 
• 
We anticipate that the entire study will take 4 - 5 years through the end of data analysis. 
Each eligible candidate who voluntarily consents to participate in the study will be active 
in the study for a total of 5 months from screening to the end of their last visit. 
• 
Month: 1 
o Prepare IRB/Human Subjects materials (2 months total). 
• 
Month: 2-3 
o Prepare all recruitment materials. 
o Prepare all study protocols and materials. 
o Finish IRB protocol approval. 
• 
Months: 4 
o Begin study recruitment. 
o Each patient will be in study for approximately 5 months. 
o Goals is 15 - 20 participant enrollment per year. 
• 
Months: 5-12 
o Begin screening and enrolling study participants. Each participant will complete 
the ~ 5 -month protocol of the study. 
o Data clean-up on an ongoing basis. 
• 
Month: 30 
o Send out OGTT, IST and GGIT blood samples for the first 30 participants for 
measurement of glucose, insulin, and C-peptide. 
• 
Month: 48 
o Last participant completes the study. 
• 
Months: 49-50 
o Finish record update for remaining blood samples and ship out OGTT, IST, and 
GGIT samples for measurement of glucose, insulin, and C-peptide. 
o Start rechecking and clean-up of data and begin data analysis. 
• 
Month: 52 
o Receive the lab analysis results. 
o Continue with study data analysis and prepare manuscript. 


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4. STUDY PROCEDURES 
Recruitment 
Preliminary recruitment strategies will include: 
Volunteers will be recruited from the San Francisco Bay Area through advertisements in 
newspapers, posted flyers, and the social networking site NextDoor as well as from the 
Preventive Cardiology Clinics at Stanford Health Care. Our goal is to ensure recruitment across 
a broad range of insulin sensitivity. Prior work from our group and others has shown that high 
plasma TG concentrations are associated with increased insulin resistance as assessed by 
reference measures. Therefore, we will target advertisements to enrich for individuals with high 
TG levels (³ 150 mg/dL) as a surrogate for increased insulin resistance. 
Participant Visits and Procedures 
Potential participants will be screened initially when they call or email in response to recruitment 
ads, or a letter from their MD, describing the study as follows: 
Preliminary intake will occur over the phone. Potential participants will be asked their height and 
weight, if they have any major health problems, specifically T2D, cardiovascular disease or 
kidney disease, and a list of their current medications. We will also ask potential participants if 
they know their lipid profiles, if they have been on statins in the past, and if they are currently on 
a statin or other lipid lowering medication. Demographic information (name, date of birth and 
address) is required to establish screening appointment in CTRU and a medical record number. 
If they meet preliminary inclusion/exclusion criteria, an appointment will be made for a screening 
visit. The consent will be emailed prior to the visit to allow them to review before the screening 
visit. 
Name, height, weight, and phone number are requested on research line to call back 
appropriate people. That information is written down and is discarded after ~ 6 months. Any 
other information we obtain over the phone is also discarded in confidential bin. 
 
Visit 1 Screening visit. 
For the first visit, potential participants will be invited to the Stanford CTRU for screening. 
Participants must fast (excluding water) for 8 -10 hours prior to the appointment. They will be 
given a copy of the consent to first read on their own. Once they are ready, a member of the 
research group will review and explain the study to the patient and answer any questions. If they 
agree to participate, they will sign the consent form, which will be witnessed and signed by the 
researcher, and a copy of the consent form will be given the participant. 
Once consent is signed, a detailed medical history will be taken to further determine eligibility 
criteria. Participants will undergo measurement of height, weight, blood pressure, and 
calculation of BMI. Blood will be drawn and hematocrit and fasting plasma glucose will be 
analyzed in the CTRU lab and lipid concentrations, hs-CRP, liver function tests and serum 
creatinine will be determined by standard laboratory techniques in Stanford Health Care (SHC) 
laboratory. 
If there are no contraindications to participating based on further data obtained at the screening 
visit including laboratory results noted above, then they will proceed to be scheduled for an oral 
glucose tolerance test. 
 
Visit 2: 
Oral Glucose Tolerance Test (OGTT): This test will take approximately 3 hours. 
The OGTT involves a series of blood samples taken before and during 120 minutes after 
drinking Dexola/Glucola containing 75-gram glucose. This test will be done before and after 


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taking the study medication atorvastatin 40/day. Participants will have fasted for 12 hours from 
the previous evening. One intravenous (IV) catheter will be inserted in their arm for the purpose 
of drawing blood samples to determine blood glucose level during this procedure at zero, 30 
min, 60 min, 90 min, and 120 min. The total amount of blood taken for this test will be 33.5 ml. 
The purpose of this procedure is to define: 
i) 
Glycemic status: Participants will be classified as having normal glucose tolerance 
(NGT), isolated impaired fasting glucose (IFG), isolated impaired glucose tolerance 
(IGT), or combined IFG/IGT12. In addition, the total integrated plasma glucose response 
during the OGTT will be calculated by the trapezoidal method (Glucose-AUC). 
ii) 
β-cell function: Calculations of the Insulin Secretion- Sensitivity Index-2 (ISSI-2) will be 
used to quantify insulin secretory function 13, if for some reason a graded glucose 
infusion study is not done. The ISSI-2 is a validated OGTT- derived method to measure 
of β-cell function, analogous to the disposition index obtained from the intravenous 
glucose tolerance test 14. It is calculated by multiplying the insulin secretory response 
during the OGTT (Insulin-AUC/Glucose-AUC) by insulin resistance (Matsuda index). 
 
The fasting and 2-hour glucose results will be discussed with the study participant and a copy of 
the results will be given to them. 
Visit 3. 
Graded Glucose Infusion, GGIT 15,16: This test will take approximately 6 hours. 
This test is designed to assess the ability of the pancreas to produce insulin in response to a 
graded glucose infusion. During this test, subjects will have two small IV catheters placed, one 
in each arm. One IV will be used for drawing samples and the other for the infusion of glucose. 
During the GGIT, continuous intravenous infusions of glucose will be given at progressively 
increasing rates: 1, 2, 3, 4, 5, 6, and 8 kg/min in six infusion periods of 40-min duration. Blood 
samples will be collected for measurements of glucose, insulin, and C-peptide concentrations at 
fasting and at 30 min and 40 min into each infusion period. The two values during the last 10 
min of each infusion period will be averaged. The amount of blood taken for this test will 47.5 
ml. 
 
Visit 4. 
Insulin Suppression test, IST 17,18: This test will take approximately 6 hours. 
This test is designed to determine whole body insulin sensitivity. Following an overnight fast, 
subjects will have an IV placed in each arm. One for collection of blood and the other for 
infusion with octreotide (0.27 μg/m2/min), insulin (32 mU/m2/min), and glucose (267 mg/m2/min) 
for 180 minutes. During the test, endogenous insulin is suppressed and all individuals are given 
the same concentration of insulin, based on their body surface area. Blood is drawn every 30 
minutes for 150 minutes and then at 10-minute intervals from 150 to 180 minutes of the infusion 
to measure plasma glucose and insulin concentrations. The mean of the last four values is used 
as the steady-state plasma insulin (SSPI) and glucose (SSPG) concentrations for each 
individual. As SSPI concentrations are similar in all subjects during the IST, the SSPG 
concentration provides a direct measure of the ability of insulin to mediate disposal of an infused 
glucose load; the higher the SSPG concentration, the more insulin resistant the individual. Labs 
to check kidney and liver function plus a lipid panel and a urine pregnancy test (if appropriate) 
will be done at this visit. Blood drawn or IST will be 58.5 ml and 5 ml for SHC labs. 
Labs for iPOP will be drawn at this time and additional samples will be obtained for 
transcriptome, microbiome, metabolome, and proteome analysis in blood; nasal, tongue, skin 
surface swabs; urine; and stool. Total blood draw is 54 ml for omics. Participants will fill out 
questionnaires at the time of iPOP samples. The questionnaires will be on physical activity, 


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stress and diet. Laboratory measures will include complete blood count, comprehensive 
metabolic profile, hemoglobin A1c, insulin and IgM levels. 
• 
The study drug, atorvastatin 40 mg will be given to study participants, once all 
labs have been reviewed and participant qualifies. 
Visit 5-7 
Visits will be every 2 weeks for a total of 10 weeks on study medication (statin). Participants will 
be assessed for any side effects or adverse events (AE) on the statin. Adherence to study 
medication will be assessed at each visit. 
At each visit, weight and vital signs will be done as well as iPOP lab testing as described above 
except no iPOP will be done at visit 6. 
Visit 8: 
Weight, vital signs, and OGTT described above. 
Visit 9: 
Repeat GGIT as described above. 
Visit 10: 
Repeat IST and iPOP lab testing and samples as described above. 
At the end of this visit, the statin will be stopped and the study participant would be scheduled 
for 4- and 8-week follow up visits. 
Visit 11: 
One month off statin study visit – weight, vital signs, and iPOP laboratory testing and samples 
will be done as described above. 
Visit 12: 
Last study visit – weight, vital signs, and iPOP laboratory testing and samples will be done as 
described above. 
Participants will be asked to fill out questionnaire about her/his physical activity status, food and 
eating habits, and stress at the time of each iPOP. 
We will not be providing any iPOP results to study participants per protocol. 
 
Study Medication Management of Atorvastatin 40 mg 
Atorvastatin: The most commonly reported adverse reactions (incidence ≥ 2%) in patients 
treated with atorvastatin 40 mg in placebo-controlled trials regardless of causality were: 
nasopharyngitis-7%, arthralgia-10.6%, diarrhea-14.1 %, pain in extremity- 9.3%, and urinary 
tract infection-8.0%. 
WARNINGS AND PRECAUTIONS: Skeletal Muscle 
Rare cases of rhabdomyolysis with acute renal failure secondary to myoglobinuria have been 
reported with LIPITOR and with other drugs in this class. A history of renal (kidney) impairment 
may be a risk factor for the development of rhabdomyolysis. People with kidney disease will not 
qualify for this study. 
Lipitor, like other statins, occasionally causes myopathy, defined as muscle aches or muscle 
weakness in conjunction with increases in creatine phosphokinase (CPK) (enzyme measuring 
muscle breakdown) of values >10 times of upper limits of normal-ULN. The use of higher doses 
of atorvastatin with certain drugs such as cyclosporine and strong CYP3A4 inhibitors (e.g., 
clarithromycin, itraconazole, and HIV protease inhibitors) increases the risk of 
myopathy/rhabdomyolysis. We will only be using 40 mg not the highest dose. 


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Myopathy should be considered in any patient with diffuse myalgias, muscle tenderness or 
weakness, and/or marked elevation of CPK. Patients should be advised to report promptly 
unexplained muscle pain, tenderness, or weakness, particularly if accompanied by malaise or 
fever or if muscle signs and symptoms persist after discontinuing Lipitor. Lipitor therapy should 
be discontinued if markedly elevated CPK levels occur or myopathy is diagnosed or suspected. 
There have been rare reports of immune-mediated necrotizing myopathy (IMNM), an 
autoimmune myopathy, associated with statin use. IMNM is characterized by: proximal muscle 
weakness and elevated serum creatine kinase, which persist despite discontinuation of statin 
treatment; muscle biopsy showing necrotizing myopathy without significant inflammation; and 
improvement with immunosuppressive agents. 
The risk of myopathy during treatment with drugs in this class is increased with concurrent 
administration of cyclosporine, fibric acid derivatives, erythromycin, clarithromycin, certain 
medications for treating HIV or hepatitis C, protease inhibitor telaprevir, niacin, or azole 
antifungals. Creatine phosphokinase (CPK) determinations may be considered in such 
situations, but there is no assurance that such monitoring will prevent the occurrence of severe 
myopathy. Patients with HIV or Hepatitis C will not qualify for this study 
At each visit, we assessed for any sided effects or adverse effects (AE). A lipid panel with 
calculated LDL and comprehensive metabolic profile will be drawn (for iPOP) at weeks 2, 4, and 
10 while on the study drug. If there are any side effects or myalgia, a creatinine kinase will be 
checked, study medication will be stopped until symptoms are resolved and then restarted. If 
symptoms return, with or without laboratory abnormalities, the atorvastatin dose will be 
decreased to 20 mg/day. 


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5. STATISTICAL CONSIDERATIONS 
 
Based on our prior work19, we calculated that with 60 subjects, we would be able to detect an 
8% change in SSPG concentration and an 8% change in ISRAUC after atorvastatin therapy with 
80% power and two-side significance level of 5% using a paired samples t test. Thus, we 
estimated needing to enroll 75 subjects with an anticipated a dropout rate of 20%. 
Summary statistics will be reported as median (interquartile range) or number (percent) of 
participants unless otherwise specified. Shapiro-Wilk tests will be used to assess normality of 
data, and variables that are not normally distributed will be log-transformed. Percent changes in 
variables will be calculated by the formula: [(end-of study value) - (baseline value) / baseline 
value] x 100. Paired samples t tests will be used to compare baseline and end-of-study means. 
One sample t tests will be employed to evaluate whether percent changes in variables are 
significantly different from zero (no change). Pearson correlation coefficients will be calculated 
to determine the strength of association between variables of interest. Prespecified subgroup 
analyses will be carried out by stratifying for insulin resistant versus insulin sensitive subjects. 
The SSPG concentration median will be used to define subjects as being insulin resistant or 
insulin sensitive. Insulin resistant and insulin sensitive group means will be compared by 
independent sample t tests and proportions by chi-square tests or Fisher’s exact tests. 
Statistical analyses will be performed by using statistical software IBM SPSS version 26.0. 


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APPENDIX 
 
A. Inclusion/Exclusion Criteria 
 
Eligibility Criteria 
Inclusion Criteria: 
• 
Healthy adults 30 - 70 years old. 
• 
BMI: 20 - 37 kg/m2. 
• 
Persons without diabetes as defined by having fasting plasma glucose < 126 mg/dL and 
not taking glucose lowering medications. 
• 
Individuals eligible for statin therapy for primary prevention of ASCVD based on LDL-C ≥ 
130 mg/dL, > 5% ASCVD risk over 10 years, or hs-CRP ≥ 2.0 mg/L. 
 
 
Exclusion Criteria: 
• 
Younger than 30 or older than 70 years. 
• 
Persons with any significant co-morbidities, such as diabetes (fasting glucose ≥ 126 
mg/dL or use of glucose lowering medications), active coronary artery disease or heart 
failure, accelerated or malignant hypertension, kidney disease (creatinine ≥ 1.5 mg/dL), 
liver disease (alanine aminotransferase > 2 times upper limit of normal), or severe 
anemia (hematocrit < 30%). 
• 
Individuals taking any medications for weight loss or known to influence insulin 
sensitivity. 
• 
Pregnant or lactating. 
• 
Women unwilling to use an effective birth control method. 
• 
History of statin intolerance. 


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16 
 
B. Participant Expectations Schedule Example 
 
Schedule of Study Visits 
 
Visit 
Visit 
Visit 
Visit 
Visit 
Visit 
Visit 
Visit 
Visit 
Visit 
Visit 
Visit 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
Week 
Week 
Week 
Week 
Week 
Week 
Week 
Week 
Week 
Week 
Week 
Week 
-3 
-2 
-1 
0 
2 
4 
6 
8 
9 
10 
14 
18 
Screening 
X 
Lipids 
X 
X 
X 
X 
X 
OGTT 
X 
X 
GGIT 
X 
X 
IST 
X 
X 
Follow-up 
X 
X 
X 
X 
X 
Atorvastatin 
40 mg 
Start 
Stop 
 
 
 
Individuals on a stain at the screening visit will undergo a 4-week statin washout before the 
baseline metabolic tests. GGIT indicates graded glucose infusion test; IST, insulin suppression 
test; and OGTT, oral glucose tolerance test. 


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17 
 
C. Outcome Measurement Methods 
 
Glucose, Insulin, C-Peptide (Blood): Insulin and C-peptide will be measured by radioimmunoassay 
(Millipore, St. Charles, MO). These will be analyzed by the Core Laboratory for Clinical Studies at the 
Washington University School of Medicine in St Louis, MO. Homeostasis model assessment of insulin 
resistance (HOMA-IR) will be calculated by the following formula: (fasting insulin (mU/L) x fasting glucose 
(mmol/L))/22.5. 
 
Lipids (Blood) LDL-C will be calculated according to Friedewald (1972). 
Anthropometrics. Height will be measured to the nearest mm on a standard wall-mounted stadiometer. Body 
weight will be measured to the nearest 0.1 kg, in duplicate, on a calibrated clinical scale. Body mass index 
(BMI) will be calculated as weight in kg divided by height in m2, and waist circumference will be measured at 
the midpoint between upper iliac crest and lower end of the rib cage in mid respiration while subjects are 
standing. Blood pressure will be measured by using an automated blood pressure monitor with appropriately 
sized arm cuff. Before blood pressure measurement, participants will sit quietly in a chair for 5 minutes with 
arm supported at the heart level. 
Weight and vital signs will be measured at every visit, and waist circumference will be done at baseline and 
post study IST. 


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18 
 
D. References 
 
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Mellitus in Statin-Treated Patients (from the Treating to New Targets and the Stroke Prevention by Aggressive 
Reduction in Cholesterol Levels Trials). Am J Cardiol 2016. 
2. 
Swerdlow DI, Preiss D, Kuchenbaecker KB, et al. HMG-coenzyme A reductase inhibition, type 2 
diabetes, and bodyweight: evidence from genetic analysis and randomised trials. Lancet 2015;385:351-61. 
3. 
Kohli P, Waters DD, Nemr R, et al. Risk of New-Onset Diabetes and Cardiovascular Risk Reduction 
From High-Dose Statin Therapy in Pre-Diabetics and Non-Pre-Diabetics: An Analysis From TNT and IDEAL. 
Journal of the American College of Cardiology 2015;65:402-4. 
4. 
Waters DD, Ho JE, Boekholdt SM, et al. Cardiovascular event reduction versus new-onset diabetes 
during atorvastatin therapy: effect of baseline risk factors for diabetes. Journal of the American College of 
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5. 
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of statin therapy in primary prevention: an analysis from the JUPITER trial. Lancet 2012;380:565-71. 
6. 
Li-Pook-Than J, Snyder M. iPOP goes the world: integrated personalized Omics profiling and the road 
toward improved health care. Chem Biol 2013;20:660-6. 
7. 
Snyder M. iPOP and its role in participatory medicine. Genome Med 2014;6:6. 
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9. 
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10. 
Reaven GM. Banting lecture 1988. Role of insulin resistance in human disease. Diabetes 
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Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood 
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12. 
American Diabetes A. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in 
Diabetes-2020. Diabetes Care 2020;43:S14-S31. 
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insulin secretion and sensitivity on oral glucose tolerance test. Obesity (Silver Spring) 2008;16:1901-7. 
14. 
Weyer C, Bogardus C, Mott DM, Pratley RE. The natural history of insulin secretory dysfunction and 
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15. 
Jones CN, Pei D, Staris P, Polonsky KS, Chen YD, Reaven GM. Alterations in the glucose-stimulated 
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Clin Endocrinol Metab 1997;82:1834-8. 
16. 
Kim SH, Abbasi F, Chu JW, et al. Rosiglitazone reduces glucose-stimulated insulin secretion rate and 
increases insulin clearance in nondiabetic, insulin-resistant individuals. Diabetes 2005;54:2447-52. 
17. 
Shen SW, Reaven GM, Farquhar JW. Comparison of impedance to insulin-mediated glucose uptake in 
normal subjects and in subjects with latent diabetes. J Clin Invest 1970;49:2151-60. 
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Pei D, Jones CN, Bhargava R, Chen YD, Reaven GM. Evaluation of octreotide to assess insulin- 
mediated glucose disposal by the insulin suppression test. Diabetologia 1994;37:843-5. 
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Kim SH, Liu A, Ariel D, et al. Pancreatic beta cell function following liraglutide-augmented weight loss in 
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