Effects of PCSK9 Inhibition by Evolocumab on Postprandial Lipid Metabolism in Type 2 Diabetes

Study Overview
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Brief Summary
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Postprandial lipemia is highly prevalent in type 2 diabetes subjects even with normal fasting triglyceride values. Humans are mostly in a postprandial rather than in a fasting state and therefore non-fasting triglyceride values reflect more accurately the continuous exposure of arterial wall to the substantial cholesterol load from remnant particles. Evolocumab lowers blood LDL-cholesterol. This study evaluates the effect of evolocumab on postprandial lipid metabolism in type 2 diabetes. All participants in this study receive evolocumab treatment.

Official Title
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Effects of PCSK9 Inhibition by Evolocumab on Postprandial Lipid Metabolism in Type 2 Diabetes

Conditions
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Type 2 Diabetes Mellitus

Intervention / Treatment
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* Drug: Evolocumab


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Male or female (non-fertile or using a medically approved birth control method) overweight/obese subjects with Type 2 Diabetes Mellitus treated with lifestyle counselling and a stable metformin dose for at least three months age 18-77 yrs. body mass index 25-40 kg/m2 triglycerides between 1.5-4.5 mmol/L and low-density-lipoprotein cholesterol >1.8 but ≤4.0 mmol/L (on Atorvastatin 20 mg/day) glycohemoglobin: ≤9%. Each patient will attend a pre-screening visit (at week -5) where eligibility criteria will be evaluated. If the patient uses another statin than atorvastatin (20 mg) at screening visit the used statin is stopped and atorvastatin 20 mg will be initiated. If the patient is not using any statin, atorvastatin 20 mg will be initiated and the lipid values will be checked after 4 weeks when all inclusion/exclusion criteria will be assessed. Exclusion Criteria: Type 1 diabetes apolipoprotein E2/2 phenotype alanine transaminase / aspartate transaminase > 3× upper limit of normal creatinine kinase>3× upper limit of normal glomerular filtration rate <60 ml/min clinically significant thyroid-stimulating hormone outside the normal range body mass index >40 kg/m2 glycohemoglobin > 9.0 % fasting triglycerides > 4.5 mmol/l total cholesterol > 7.0 mmol/l positive urine or serum pregnancy test untreated or inadequately treated hypertension defined as blood pressure >160 mmHg systolic and/or >105 mmHg diastolic, use of thiazide diuretics at a dose of ≥25 mg/day subject not on a stable dose of atorvastatin (20 mg/ day before randomization) lipid-lowering drugs other than statins within 3 months any other diabetes medication except diet + metformin history/diagnosis of diabetes nephropathy / retinopathy current smoking weekly alcohol use over 24 doses for men and 16 for women history of myocardial infarction, acute coronary syndrome or coronary revascularization (percutaneous coronary intervention or coronary artery bypass grafting) within the last 6 mos. planned revascularization (eg coronary artery bypass grafting, percutaneous coronary intervention, carotid or peripheral revascularization procedures) within 3 months of screening New York Heart Association class III/IV congestive heart failure persisting despite treatment history of hemorrhagic stroke hypersensitivity to (evolocumab or) any of the excipients found in the drug product use of estrogen therapy current use of antithrombotic or anticoagulant therapy known bleeding tendency that would be an contraindication to heparin test history of cancer within the past 5 years (except for adequately treated basal cell skin cancer, squamous cell skin cancer or in situ cervical cancer) women of childbearing potential not protected by effective birth control method and/or not willing to be tested for pregnancy patient considered by the investigator or any sub-investigator as inappropriate for this study for any reason

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 77 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Evolocumab<br>Evolocumab 140 mg subcutaneous injection once every 2 weeks for 12 weeks | Drug: Evolocumab<br> <br> * Other names: Repatha;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Mean ApoB Concentration Before and After Evolocumab | Change in apolipoprotein B concentration in total plasma measured by using turbidimetric immunoassay. | Baseline and after 12 weeks | 
| Mean TRL-C Concentration Before and After Evolocumab | Change in TRL-cholesterol concentration in plasma samples measured by using automated direct assay (Denka Seiken, Tokyo, Japan) | Baseline and after 12 weeks | 
| Mean Total Production of ApoB48 Before and After Evolocumab | Change in ApoB48 total production in plasma measured by using multicompartmental modeling. The power of mathematical modelling to describe the metabolic pathways of lipid and lipoprotein metabolism was demonstrated by Zech L et al (J Clin Invest 1979;63:1262-1273) and have been widely used over 30yrs. So far few studies have focused on the modelling of apo B48 and apo B100 after a meal that is more physiological than the fasting state (Björnson E et al. JIM 2019;285:562-577). Production rates for apo B48, apo B100 and triglycerides in chylomicrons, VLDL1 and VLDL2 were derived from samples taken before and after the tracer injection and after the meal at 0, 30, 45, 60, 75, 90, 120, 150 min and at 3, 4, 5, 6, 8, 10, 24 hrs and averages for 24 hrs. Analysis of tracer/ tracee curves of stable isotopes was used to derived the estimates of kinetic parameters using a new mathematical modeling per day. These figures per day are used to report the data from this study. | Baseline and after 12 weeks | 
| Mean LDL FCR of ApoB100 Before and After Evolocumab | Change in low-density lipoprotein fractional catabolic rate of ApoB100 in LDL from plasma samples measured by multicompartmental modeling. Production rates were derived from samples taken before and after the tracer injection and after the meal at 0, 30, 45, 60, 75, 90, 120, 150 min and at 3, 4, 5, 6, 8, 10, 24 hrs and averages for 24 hrs. More detailed description see Outcome measure 3. | Baseline and after 12 weeks | 
| LDL Pool Size of ApoB100 Before and After Evolocumab | Change in low-density lipoprotein pool size of ApoB100 in LDL fraction prepared from plasma samples using density ultracentrifugation. | Baseline and after 12 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Mean LDL-C Concentration Before and After Evolocumab | Change in LDL-cholesterol concentration in plasma LDL fraction isolated by ultracentrifugation. | Baseline and after 12 weeks | 
| Mean ApoB48 Concentration Before and After Evolocumab | Change in apolipoprotein B48 levels in total plasma measured by enzyme-linked immunosorbent assay. | Baseline and after 12 weeks | 
| Mean CM TG-iAUC Before and After Evolocumab | Change in chylomicron triglyceride incremental area under curve in plasma samples taken at particular time points after the meal. Area under the curve (AUC) was normalized so that 100% corresponds to the AUC before treatment; subsequently the percentage after treatment is in reference to this value. AUC values were calculated using the trapezoidal rule. | 0, 2, 4, 6, 8 hours after the meal at baseline and after 12 weeks | 
| Mean ApoB48 AUC Before and After Evolocumab | Change in apolipoprotein B48 area under curve in plasma samples taken at particular time points after the meal. Area under the curve (AUC) was normalized so that 100% corresponds to the AUC before treatment; subsequently the percentage after treatment is in reference to this value. AUC values were calculated using the trapezoidal rule. | 0, 2, 4, 6, 8 hours after the meal at baseline and after 12 weeks | 
| Mean VLDL1 ApoB100 Production Before and After Evolocumab | Change in VLDL1 ApoB100 production rates measured from isolated VLDL from plasma samples using density ultracentrifugation and the enrichment of tracer was measured in isolated fractions following using mathematical modeling. Production rates were derived from samples taken before and after the tracer injection and after the meal at 0, 30, 45, 60, 75, 90, 120, 150 min and at 3, 4, 5, 6, 8, 10, 24 hrs and averages for 24 hrs. More detailed description see Outcome measure 3. | Baseline and after 12 weeks | 
| Mean VLDL2 ApoB100 Production Before and After Evolocumab | Change in VLDL2 apoB100 production rates measured from isolated VLDL2 from plasma samples by using density ultracentrifugation and the enrichment of tracer was measured in isolated fractions following using mathematical modeling. Production rates were derived from samples taken before and after the tracer injection and after the meal at 0, 30, 45, 60, 75, 90, 120, 150 min and at 3, 4, 5, 6, 8, 10, 24 hrs and averages for 24 hrs. More detailed description see Outcome measure 3. | Baseline and after 12 weeks | 
| IDL Pool Size of ApoB100 Before and After Evolocumab | Change in intermediate-density lipoprotein pool size of ApoB100 in IDL fraction prepared from plasma samples using density ultracentrifugation. | Baseline and after 12 weeks | 
| Mean IDL to LDL Transfer of ApoB100 Before and After Evolocumab | Change in ApoB100 intermediate-density lipoprotein to low-density lipoprotein transfer in isolated samples from plasma by ultracentrifugation and measured using multicompartmental modeling. Production rates were derived from samples taken before and after the tracer injection and after the meal at 0, 30, 45, 60, 75, 90, 120, 150 min and at 3, 4, 5, 6, 8, 10, 24 hrs and averages for 24 hrs. More detailed description see Outcome measure 3. | Baseline and after 12 weeks | 
| Mean VAT Before and After Evolocumab | Change in visceral fat volume measured by magnetic resonance imaging | Baseline and after 12 weeks | 
| Mean Liver Fat Before and After Evolocumab | Change in liver fat content measured by magnetic resonance imaging. | Baseline and after 12 weeks | 
| Mean SAT Before and After Evolocumab | Change in subcutaneous fat volume measured by magnetic resonance imaging | Baseline and after 12 weeks | 
| Mean VLDL1 Triglyceride Production Before and After Evolocumab | Change in VLDL1 triglyceride production measured from isolated VLDL1 from plasma samples by using density gradient ultracentrifugation. Production rates were derived from samples taken before and after the tracer injection and after the meal at 0, 30, 45, 60, 75, 90, 120, 150 min and at 3, 4, 5, 6, 8, 10, 24 hrs and averages for 24 hrs. More detailed description see Outcome measure 3. | Baseline and after 12 weeks | 
| Mean VLDL1 FCR of triglycerideBefore and After Evolocumab | Change in VLDL1 fractional catabolic rate of triglyceride measured in isolated VLDL1 from plasma samples by using density ultracentrifugation and measured by multicompartmental modeling. Production rates were derived from samples taken before and after the tracer injection and after the meal at 0, 30, 45, 60, 75, 90, 120, 150 min and at 3, 4, 5, 6, 8, 10, 24 hrs and averages for 24 hrs. More detailed description see Outcome measure 3. | Baseline and after 12 weeks | 
| Mean VLDL2 Triglyceride Total Production Before and After Evolocumab | Change in VLDL2 triglyceride total production measured in isolated VLDL2 from plasma samples by using density ultracentrifugation and measured by multicompartmental modeling. Production rates were derived from samples taken before and after the tracer injection and after the meal at 0, 30, 45, 60, 75, 90, 120, 150 min and at 3, 4, 5, 6, 8, 10, 24 hrs and averages for 24 hrs. More detailed description see Outcome measure 3. | Baseline and after 12 weeks | 
| Mean VLDL2 FCR of Triglyceride Before and After Evolocumab | Change in VLDL2 fractional catabolic rate of triglyceride measured in isolated VLDL2 from plasma samples by using density ultracentrifugation and measured by multicompartmental modeling. Production rates were derived from samples taken before and after the tracer injection and after the meal at 0, 30, 45, 60, 75, 90, 120, 150 min and at 3, 4, 5, 6, 8, 10, 24 hrs and averages for 24 hrs. More detailed description see Outcome measure 3. | Baseline and after 12 weeks | 
| Mean Postprandial CM of ApoB48 Before and After Evolocumab | Change in Postprandial chylomicron of ApoB48 measured from plasma samples by liquid chromatography-mass spectrometry with multicompartmental modeling assay. Production rates were derived from samples taken before and after the tracer injection and after the meal at 0, 30, 45, 60, 75, 90, 120, 150 min and at 3, 4, 5, 6, 8, 10, 24 hrs and averages for 24 hrs. More detailed description see Outcome measure 3. | Baseline and after 12 weeks | 
| Mean CM-apoB48 FCR of ApoB48 Metabolism Before and After Evolocumab | Change in chylomicron-apoB48 fractional catabolic rate of ApoB48 in isolated chylomicrons from plasma samples measured by multicompartmental modeling assay. Production rates were derived from samples taken before and after the tracer injection and after the meal at 0, 30, 45, 60, 75, 90, 120, 150 min and at 3, 4, 5, 6, 8, 10, 24 hrs and averages for 24 hrs. More detailed description see Outcome measure 3. | Baseline and after 12 weeks | 
| Mean CM-TG Production of ApoB48 Before and After Evolocumab | Change in chylomicron-triglycerides production of ApoB48 in isolated chylomicrons from plasma samples measured by multicompartmental modeling assay. Production rates were derived from samples taken before and after the tracer injection and after the meal at 0, 30, 45, 60, 75, 90, 120, 150 min and at 3, 4, 5, 6, 8, 10, 24 hrs and averages for 24 hrs. More detailed description see Outcome measure 3. | Baseline and after 12 weeks | 
| Mean CM TG-AUC Before and After Evolocumab | Change in chylomicron triglyceride area under curve in plasma at a particular time points after the meal. Area under the curve (AUC) was normalized so that 100% corresponds to the AUC before treatment; subsequently the percentage after treatment is in reference to this value. AUC values were calculated using the trapezoidal rule. | 0, 2, 4, 6, 8 hours after the meal at baseline and after 12 weeks | 
| Mean ApoB48 iAUC Before and After Evolocumab | Change in apolipoprotein B48 incremental area under curve in plasma at a particular time points after the meal. Area under the curve (AUC) was normalized so that 100% corresponds to the AUC before treatment; subsequently the percentage after treatment is in reference to this value. AUC values were calculated using the trapezoidal rule. | 0, 2, 4, 6, 8 hours after the meal at baseline and after 12 weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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apolipoprotein, CVD, chylomicrons, evolocumab, kinetics