Conditions: Obesity Fatty Liver, Nonalcoholic
Keywords: obesity insulin sensitivity statin (HMG-CoA Reductase Inhibitor) fatty liver
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 50
Healthy volunteers: no

Brief summary:
HMG co-A reductase inhibitors, commonly called statins, are an effective treatment for dyslipidemia and atherosclerotic heart disease with proven mortality benefit. While the lipid-lowering effects of statins are well-known, other metabolic effects, including effects on glucose tolerance and ectopic fat distribution, are less completely understood. Recent studies have shown that some statins may increase the risk of diabetes. Further, research has suggested that statins may have some benefit in nonalcoholic fatty liver disease (NAFLD), a condition associated with obesity that includes increased fat in the liver (steatosis) and, in some cases, inflammation and hepatocellular damage (steatohepatitis). Pitavastatin, approved by the United States Food and Drug Administration (FDA) in 2009, is the most recent statin to enter the market. Unlike most statins, pitavastatin is not primarily metabolized through cytochrome P450 (CYP450), and thus has reduced potential for interactions with other medications that are metabolized by CYP450. Previous studies have suggested that pitavastatin may be neutral to glucose homeostasis and may improve hepatic lipid. Neither of these effects has been proven definitively, however, and the current proposal aims to characterize in detail the effects of pitavastatin on glucose homeostasis, hepatic steatosis, and steatohepatitis.

Detailed description:

Arms:
arm 1: pitavastatin 4mg daily by mouth for 6 months arm 2: Identical placebo 4mg by mouth daily for 6 months

Interventions: intervention 1: pitavastatin intervention 2: PLACEBO
Intervention descriptions: intervention 1: None intervention 2: None

Protocol document:
Prot_SAP_000.pdf: 
1 
 
Effects of Pitavastatin on Insulin Sensitivity and Liver Fat 
Massachusetts General Hospital 
Neuroendocrine Unit, Program in Nutritional Metabolism 
PI: Steven Grinspoon, MD, and Takara Stanley, MD  
8/17/17 
 
 
1.  Background and Significance 
 
HMG co-A reductase inhibitors, commonly called statins, are an effective treatment for 
dyslipidemia and atherosclerotic heart disease with proven mortality benefit. Cholesterol 
lowering drugs are currently used by 10.7% of the US population under age 64 years and by 
46.7% of the population 65 years old and above (http://www.cdc.gov/nchs/data/hus/hus13.pdf; 
CDC Health United States Report 2013). Under recently published 2013 American College of 
Cardiology and American Heart Association (ACC-AHA) guidelines for cholesterol 
management1, approximately 56 million US adults will be eligible for use of statins2.  Although 
the lipid-lowering effects of statins are well-known, other metabolic effects, including effects on 
glucose tolerance and ectopic fat distribution, are less completely understood.  It is increasingly 
clear that (i) statins have pleiotropic effects, and may confer metabolic and cardiovascular 
benefit through mechanisms beyond lipid lowering, and (ii) different statins may have dissimilar 
effects on non-lipid metabolic endpoints.  For example, many statins appear to worsen glucose 
homeostasis3, whereas others may be neutral in this regard.  Additionally, some statins may 
have benefit in decreasing hepatic lipid accumulation and associated steatohepatitis4.  Thus 
characterizing the metabolic effects of particular statins is critical to inform prescribers’ choice of 
agent based on clinical context.  Pitavastatin, FDA approved in 2009, is the most recent statin to 
enter the market.  Previous studies have suggested that pitavastatin may be neutral to glucose 
homeostasis5,6 and may improve hepatic lipid7-9.  Neither of these effects has been proven 
definitively, however, and the current proposal aims to characterize in detail the effects of 
pitavastatin on glucose homeostasis, hepatic steatosis, and steatohepatitis.    
 
Although statin use is generally safe, recent studies have demonstrated that statin use is 
associated with increased incidence of diabetes mellitus (DM). This association was first 
reported in The Justification for the Use of Statins in Primary Prevention: An Intervention Trial 
Evaluating Rosuvastatin (JUPITER) trial in 20083, a study of 17,802 subjects in which 
rosuvastatin was found to be associated with an increase in DM incidence compared to 
placebo. Since the publication of the JUPITER trial, several meta-analyses and post-hoc 
analyses have been performed including one large meta-analyses comprising 13 statin trials 
and 91,140 patients without DM, demonstrating an overall 9% increased risk of incident DM 
over 4 years with statin use10. The diabetogenic effect of statins appears to be variable, with 
some statins confering greater risk than others. Generally, atorvastatin11 and rosuvastatin11,12 
appear to confer the greatest risk while pravastatin12,13 and pitavastatin5,13-16 appear to confer 
the least risk for development of DM and may be neutral to glucose homeostasis. While this is 
encouraging for use and development of pitavastatin, the effects of pitavastatin on diabetes risk 
have not been studied in great detail. 
 
In addition to its neutrality with respect to glucose homeostasis, pitavastatin may ameliorate 
hepatic steatosis and steatohepatitis.  Nonalcoholic fatty liver disease (NAFLD) – defined as 
hepatic triglyceride content comprising ≥5% of total liver weight – is highly prevalent among the 
U.S. population and is a significant co-morbidity of obesity.  Data from the Dallas Heart Study 
suggest a prevalence of NAFLD of approximately 33%17.  The disease spectrum of NAFLD 
encompasses not only steatosis but also inflammation, hepatocellular damage, and fibrosis, 
which are hallmarks of non-alcoholic steatohepatitis (NASH).  NASH, in turn, may progress to 
cirrhosis and eventual liver failure. NASH is also a significant risk factor for hepatocellular 
carcinoma 18.  NAFLD is also strongly associated with visceral adiposity and other 


2 
 
cardiometabolic abnormalities, including insulin resistance (IR) and cardiovascular disease 
(CVD) 19,20. Abundant evidence suggests a causal link between NAFLD and IR, and emerging 
data suggest that NAFLD may also be causal in CVD21-23.  Thus amelioration of NAFLD is a 
significant clinical priority both to preserve liver health and improve cardiometabolic risk. 
 
Multiple studies have investigated the use of various statins for NAFLD and NASH, with the 
hypothesis that statins may prove beneficial due to lipid-lowering action as well as other 
pleiotropic effects such as reduction of inflammation4.  These studies have shown mixed results, 
with many having limited validity due to small sample size and/or open-label design4.  For 
pitavastatin in particular, however, animal data7,24-26 and preliminary human studies8,9 
consistently suggest an effect to decrease liver fat content and ameliorate features of NASH.  In 
murine models of NAFLD and NASH, pitavastatin consistently decreases steatosis, reduces 
transaminases, and ameliorates features of steatohepatitis6,21-23.  The mechanisms of these 
effects may include (i) decreased lipogenesis and increased fatty acid oxidation7,25, possibly 
through increased activation of hepatic AMPK-α25,27 and/or PPARα7; (ii) reduced expression of 
inflammatory cytokines, including TNF-α and IL-624-27, and chemokine receptors, including 
CCR226,28 and CCR528; (iii) reduced oxidative stress24; (iv) increased adiponectin25,27; and (v) 
reduced macrophage infiltration26.  In open-label studies in humans, pitavastatin has shown 
some benefit to ameliorate NAFLD and NASH8,9, but a randomized controlled trial has not yet 
been performed. 
 
2.  Specific Aims 
In a randomized, placebo-controlled trial of 50 individuals receiving pitavastatin vs. identical 
placebo for six months, we will test the following hypotheses: 
 
Specific Aim 1:  Pitavastatin will not significantly differ from placebo with respect to changes in 
the following measures of glucose homeostasis: 
a. Insulin-stimulated glucose uptake during standard euglycemic hyperinsulinemic clamp 
b. Insulin suppression of hepatic glucose production during “low-dose” euglycemic 
hyperinsulinemic clamp  
c. Fasting glucose, HOMA-IR, and HbA1c 
 
Specific Aim 2:  Pitavastatin will significantly reduce liver fat and improve markers of NAFLD.   
a. Compared to placebo, pitavastatin will significantly reduce liver fat content as measured 
by 1H-magnetic resonance spectroscopy (MRS). 
b. In the subgroup of patients with ≥5% liver fat by 1H-MRS, compared to placebo, 
pitavastatin will significantly decrease AST and ALT. 
    
3. Subject Selection 
50 men will be recruited from the greater Boston area.  The study is limited to men in order to 
increase the homogeneity of the subject population, particularly with respect to hormonal milieu 
and CVD risk given the substantial variance between men and women in these areas.  Subjects 
will be recruited according to the following inclusion and exclusion criteria: 
 
Inclusion Criteria 
1. Men age 40-65yo 
2. BMI ≥  27 kg/m2 and waist circumference ≥102cm, high probability risk factors for NAFLD 
3. At least one of the following indicating insulin resistance:  Fasting glucose ≥100mg/dL and 
<126mg/dL, HOMA-IR >2.0, and/or 2 hour glucose ≥140mg/dL and <200mg/dL following 
standard glucose tolerance test. 


3 
 
4. 10-year cardiovascular disease risk ≥5% by American Heart Association(AHA)/American 
College of Cardiology (ACC) Pooled Cohort Equations CV Risk Calculator29 or LDL ≥ 
100mg/dL 
5. No use of any statin within 1 year of study entry and not being actively considered for statin 
therapy by a treating provider.   
 
Exclusion Criteria 
1. Diagnosis of diabetes or use of anti-diabetic medications. 
2. Use of erythromycin, rifampin, cyclosporin, colchicine, or gemfibrozil. 
3. Use of statin therapy within 1 year prior to study entry as above.  Use of any other lipid-
modifying therapy (including fish oil, fibrates, niacin, gemfibrozil) within 6 months of study 
entry.   
4. Contraindication to statin therapy. 
5. Creatinine > upper limit of normal or known renal disease 
6. AST or ALT > 3 times the upper limit of normal 
7. Hb < 10g/dL 
8. Contraindication to undergoing a magnetic resonance scan. 
9. Atherosclerotic cardiovascular disease or LDL-C ≥ 190mg/dL. 
10. Triglyceride ≥500mg/dL 
 
4. Subject Enrollment 
 
Methods of Enrollment  
The study will be advertised through ambulatory clinics affiliated with the Massachusetts 
General Hospital, through the MGH Research Study Volunteer Participant database and 
Partners Clinical Trials website, and through flyers and newspaper advertisements.  Craigslist 
will also be utilized, with a link to a REDCap Survey that individuals can fill out. We will also 
place targeted advertisements on Facebook with links to the same REDCap Survey. This 
survey will collect minimal information necessary to see if subjects would potentially be eligible, 
as well as contact information so that we can call them if they are potentially eligible.  We will 
also send targeted mailings to past participants of the SUGAR MGH and SIGMA studies who 
have indicated on written informed consent that they are willing to be contacted for future 
studies. We will also perform a Partners Research Patient Data Registry (RPDR) search to 
identify patients with BMI > 27, who meet our age and sex criteria, who are not currently on 
diabetes or cholesterol medications.  We will subsequently review the resulted medical records 
to hone in on those that meet our inclusion/exclusion criteria.  We will directly contact patients 
with a mailing who have agreed to be approached by research staff as part of the 
Research Opportunities Direct to You (RODY) Program.  Interested subjects will call and 
speak with study staff.  Preliminary eligibility will be determined based on study staff interviews 
of interested subjects over the phone. Eligible subjects will then be scheduled for a screening 
visit. Potential participants who express interest in receiving study related materials and 
communications by e-mail (including a copy of the consent form) will be educated regarding the 
Partners HealthCare e-mail security policy.  If the subject does not want to use encrypted email, 
they can consent to receive unencrypted e-mail, and this will be documented in the subject’s 
record as per the subject’s request. 
 


4 
 
Informed Consent  
Written informed consent will be 
obtained by a licensed physician or 
nurse practitioner investigator prior 
to screening evaluation and testing. 
Subjects will be informed that they 
may withdraw from participation in 
the study at any point.  
 
Randomization 
After signing consent and, prior to 
the baseline visit, eligible subjects 
will be randomized to receive 
pitavastatin 4mg orally daily vs. 
identical placebo for 6 months. Randomization will be performed by the MGH Research 
Pharmacy and will be blinded to study investigators and subjects.   
 
5. Study Procedures 
This double-blind, randomized, placebo-controlled study will include a screening visit and, for 
eligible subjects, 4 additional visits over a 6 month treatment period.  All subjects will receive 
lifestyle and nutrition counseling at the baseline, 12 week, and 24 week visits as per standard 
guidelines, including advice on caloric intake, salt, fiber, cholesterol, fat and exercise, and 
smoking cessation. 
  
All subject encounters will take place at the MGH GCRC.  
 
Screen Visit (to determine eligibility)  
1.  Informed consent  
2.  Detailed medical history and medications (past and current) and physical exam 
3.  Height, weight, waist and hip circumferences.   
4.  Fasting blood samples (CBC, Creatinine, ALT, AST, lipid panel, fasting glucose)  
5.  Standard 75g oral glucose tolerance test 
 
Baseline Visit 
1. Interval H&P 
2. Fasting blood samples (Fasting glucose, insulin, HbA1c, ALT, AST, CPK, lipid panel and 
direct LDL, CoQ10, pro-insulin) 
3. 
1H-MRS/MRI abdomen to quantify liver fat, visceral and subcutaneous adipose tissue (VAT 
and SAT) 
4. Stable isotope infusion to quantify hepatic gluconeogenesis.   
5. Two-step euglycemic hyperinsulinemic clamp to assess insulin sensitivity of liver (“low-dose” 
clamp) and muscle (standard dose clamp)  
6. Whole body DXA scan to quantify total and regional fat and lean mass 
7. 4-day food record and modifiable activity questionnaire 
8. Height, metabolic weight, and anthropometrics 
9. Medication teaching and dispensation 
10. Lifestyle and nutrition counseling 
 
Start of Study Drug 
Pitavastatin 4mg PO QD
Placebo 4mg PO QD
BL
4wk
12wk
24wk
Screen 
Visit
N=50
1:1 Randomization
Baseline and 24wk:  Fasting labs, liver fat by 1H-
MR spectroscopy, isotopes and clamp for hepatic 
and whole body insulin sensitivity.
4wk:  safety visit – H&P
12wk:  safety visit – H&P, labs


5 
 
At the conclusion of the baseline visit, subjects will be instructed to take the study medication – 
pitavastatin 4mg PO QD vs. identical placebo – once nightly by mouth.  At each subsequent 
visit, un-used study drug will be collected and a new supply of study drug will be dispensed. 
 
4 Week Visit 
1. Interval H&P and side-effect assessment 
 
12 Week Visit 
1. Interval H&P and side-effect assessment 
2. Fasting blood samples (Fasting glucose, insulin, HbA1c, ALT, AST, CoQ10, pro-insulin) 
3. Height, weight, and anthropometrics 
4. Lifestyle and nutrition counseling 
 
24 Week Visit – Identical to baseline with added oral glucose tolerance test on additional day.   
. 
 
METHODS 
 
Study Drug 
Pitavastatin (vs. identical placebo) will be administered at a dose of 4mg once daily.  
Pitavastatin is FDA approved for patients with primary hyperlipidemia or mixed dyslipidemia as 
an adjunctive therapy to diet to reduce elevated total cholesterol, low-density lipoprotein 
cholesterol, apolipoprotein B, triglycerides, and to increase high-density lipoprotein cholesterol.  
Exclusion criteria are designed to exclude subjects for whom pitavastatin use may be 
contraindicated, including those with unexplained persistent and significant transaminase 
elevations, and those taking medications with which pitavastatin use is contraindicated or dose-
limited.  An exemption from IND requirement has been granted by the FDA for this protocol.  
Management of possible side effects will be as follows:   
Myopathy:  The risk of myopathy with pitavastatin is low.  For patients complaining of muscle 
aches that are significant and/or persist beyond 1-2 days, a creatine kinase (CK) level will be 
checked.   
• 
CK > 10 times the upper limit of normal (ULN) will prompt immediate discontinuation 
from the study.   
• 
If CK is >5 times ULN but <10 times ULN, subjects will discontinue the study drug.  If 
symptoms do not resolve within 2 weeks, they will be discontinued from the study and 
referred to their provider for evaluation of other possible.  If symptoms resolve in <2 
weeks, subjects will then restart on pitavastatin 1mg.  If symptoms do not return, they 
will increase to 2mg after 1 week and then to 4mg daily after another week.  If symptoms 
return, they will be discontinued from the study.   
• 
For CK < 5 times ULN, a clinical decision will be made based on severity of the muscle 
aches.  If symptoms are mild, subjects may choose to continue in the study.  
Alternatively, subjects may be discontinued with restarting of pitavastatin after resolution 
as above.  For myopathy that is judged to be very severe subjects will be discontinued.   
Other lab abnormalities:  Per guidelines, CK, ALT, and AST will not be sent routinely during 
the study for patients without symptoms.  (ALT and AST at 3 months will be frozen for batched 
analysis.)  If incidental abnormalities in CK, AST, ALT, or creatinine on clinical labs are brought 
to our attention:  (i) CK will be handled as above; (ii) those with Creatinine > ULN confirmed on 
repeat testing will be discontinued from the study; (iii) those with AST or ALT >3 times ULN 
confirmed on repeat testing will be discontinued from the study.  For elevations below this 
threshold, response will be based on the degree of elevation, the degree of rise from screen 


6 
 
visit, and any other possible etiologies and concomitant symptoms, and action will be in 
conjunction with the patient’s primary provider.  
 
1H Magnetic Resonance Spectroscopy(MRS) & MRI 
After a 12-hour overnight fast subjects will undergo 1H -MRS of the liver and MRI of the 
abdomen for quantification of liver fat and VAT and SAT, respectively.  For liver fat, a breath-
hold true fast imaging with steady precession sequence will be obtained.  A voxel measuring 20 
x 20 x 20 mm (8 ml) will be placed within the right lobe of the liver, avoiding vessels or artifact, 
and with position within the liver confirmed by 3 planes of view.  1H -MRS data will be acquired 
using point-resolved spatially localized spectroscopy pulse sequence without water 
suppression. Proton density fat fraction will be calculated from integral lipid and water peak 
areas as previously described30,31.  For abdominal visceral and subcutaneous fat volumes, 
conventional MR images will be acquired and will serve as anatomic reference of 1H-MRS 
overlays. Image series will include Axial T1-weighted localizers.  No intravenous contrast will be 
used.  The total amount of time in the magnet will be approximately 1 hour.   
 
Subjects undergoing MRI/MRS may develop claustrophobia during the scan.  Patients will be 
queried regarding a history of claustrophobia and their ability to tolerate other MRIs during their 
screening visit.  If they report prior claustrophobia or develop distress during the study MRI, they 
will be offered a low-dose benzodiazepine (1 mg lorazepam orally) at the time of their scan.  
Patients who receive anxiolytics will be monitored for a return to baseline mental status 
following the scan, and will be provided with a ride home.   
 
Whole Body DEXA will be performed to determine total body and regional percent fat and lean 
body mass.  The technique has a precision error (1 SD) of 3% for fat and 1.5% for lean body 
mass32. Trunk, extremity and trunk to extremity ratio will also be assessed33,34.  
 
Nutritional Analysis  
Four day food record at baseline and 6 months will be analyzed for protein, carbohydrate, fat, 
micronutrient, dietary supplements and alcohol intake (Nutrition Data Systems).  
 
Anthropometric Measurements  
Measurements of waist and hip circumference, waist to hip ratio, leg circumference, arm 
circumference, and neck circumference will be performed using a standardized technique35. 
 
Activity  
Modifiable Activity Questionnaire (MAQ) will be used to assess physical activity36.   
 
Stable Isotopes and Clamp  Subjects will undergo stable isotope and euglycemic 
hyperinsulinemic clamp studies, in order to assess hepatic insulin sensitivity (stable isotopes 
and low dose clamp to measure insulin suppression of gluconeogenesis) and peripheral insulin 
sensitivity (“full” dose clamp).  Assessment of hepatic gluconeogenesis will utilize 6,6-2H-
glucose.  Starting after IV placement, priming dose (3.0 mg/kg) of 6,6-2H-glucose will be 
administered intravenously, followed by a 4- hour continuous infusion (0.03 mg/kg/min) of 6,6-
2H-glucose.  Baseline fasting samples for isotopic analysis will be collected at 20, 10, and 0 
minutes before the start of the infusion, and samples will be collected at 60, 100, 110, and 120 
minutes after the start of the infusion for 6,6-2H-glucose enrichment for assessment of fasting 
gluconeogenesis.  At 2 hours after the start of the isotope infusion, (time = “0”), a “low dose” 
euglycemic hyperinsulinemic clamp will be performed with an insulin dose of 20 mU/m2/min to 
detect differential suppression of hepatic gluconeogenesis.  At time=120min, a “full dose” insulin 
clamp will commence with an insulin infusion of 80mU/m2/min.  Samples for isotopic enrichment 


7 
 
will be assayed by Metabolic Solutions.   Peripheral insulin sensitivity will be determined during 
the last 20 minutes of the full dose clamp using the DeFronzo method37.  Clamp procedure will 
be as follows.   
• 
Insulin infusate will be prepared by the MGH pharmacy. 
• 
Two intravenous (IV) catheters will be inserted:  (1) one placed in the hand when access 
is available, otherwise in the forearm or antecubital space, to be used for venous 
sampling; (2) one placed in the antecubital space or proximal forearm and used for 
administration of stable isotopes, insulin, and 20% dextrose as below.   
• 
The hand/forearm with the IV that will be used for venous sampling will be placed in a 
warming box for the duration of the clamp procedure, although it may be withdrawn if the 
subject finds the warmth uncomfortable.   
• 
At time “0”, a priming dose of 100mU/m2/min of insulin will be given for 2 minutes 
followed by a continuous infusion of 20mU/m2/min for the next 118 minutes, comprising 
the “low dose” clamp.   
• 
At 120 minutes, the dose of insulin will be increased to a priming dose of 400mU/m2/min 
for 2 minutes followed by a continuous infusion of 80mU/m2/min from 122-240 minutes, 
comprising the “full dose” clamp.   
• 
From 0-240 minutes, a sample (≤ 0.5cc) of venous blood will be drawn every 5 minutes 
for assessment of glucose using a Hemocue glucose analyzer.  Each sample is run 
twice in the Hemocue analyzer, with an additional third run if the difference between the 
first two runs is ≥4mg/dL.  Samples for serum insulin concentration will be drawn at 
times 0, 80, 100, 120, 200, 220, 240. 
• 
Starting at 5 minutes, a variable 20% dextrose infusion will be administered to achieve a 
target glucose of 90mg/dL (range 85-95mg/dL).  The rate will be adjusted by the 
investigator, an MD or NP who is trained in clamp procedure.  The initial infusion rate of 
20% dextrose will be 0-30cc/hr, with the exact rate determined by the investigator based 
on the subject’s fasting glucose, available clinical information, and, if available, data from 
the subject’s previous clamp procedure for the study.  (For example, a subject who is 
known clinically to be insulin resistant and has a fasting glucose of 110mg/dL would be 
started at a rate of 0cc/hr, whereas a lean, muscular subject who exercises regularly and 
has a fasting glucose of 70mg/dL would be started at 30cc/hr.) 
• 
The rate of 20% dextrose infusion will be adjusted up or down for the duration of the 
clamp procedure by the investigator.  Rate changes of 0-40cc/hr will be made by the 
investigator every 5 minutes, based on the subject’s venous glucose and rate of change 
in glucose, to achieve target glucose of 90mg/dL.   
• 
At 240 minutes, the insulin infusion will be discontinued, and the glucose infusion will 
continue for 30 more minutes.  During this time, subjects will be given a meal.  At 270 
minutes, venous glucose will be checked, and the glucose infusion will be discontinued if 
venous glucose ≥80mg/dL.  If glucose is <80mg/dL, the glucose infusion will be 
continued and will be weaned by the investigator at the bedside, with repeat venous 
glucose sampling every 10 minutes until the glucose is ≥80mg/dL and the infusion is 
stopped.   
• 
After the clamp, all subjects are counseled concerning the symptoms of hypoglycemia 
and are asked to report immediately any symptoms.  Subjects are observed on the CRC 
for at least 20 minutes following discontinuation of glucose infusion.   
 
Oral Glucose Tolerance Test  A standard 75g Oral Glucose Tolerance Test will be performed 
with measurement of insulin, c-peptide, and glucose at 0, 30, 60, 90, and 120 minutes.   
 


8 
 
Lifestyle and Nutritional Counseling will be provided by the CRC bionutritionists at baseline, 12, 
and 24 weeks based on the 2010 Dietary Guidelines for Americans (US Departments of 
Agriculture and of Health and Human Services) and the 2008 Physical Activity Guidelines for 
Americans (US Department of Health and Human Services). 
 
6. Biostatistical Analysis 
Data Interpretation:  Co-primary endpoints are (i) change in insulin-stimulated glucose uptake 
during standard euglycemic hyperinsulinemic clamp, reflecting whole-body insulin sensitivity, 
and (ii) change in hepatic fat fraction as measured by 1H-MRS after 6 months of randomized 
treatment.  Secondary endpoints will include changes in the following:  insulin suppression of 
hepatic gluconeogenesis, fasting glucose, QUICKI, HbA1c, pro-insulin, ALT, AST, and lipids.  
The analysis will be based on intention to treat population using all available data, including 
interim data on subjects not completing the study. Wilk-Shapiro test will be used to assess for 
normality of distribution of all variables, and variables that are not normally distributed will be 
appropriately transformed. Baseline variables will be compared between treatment groups, and 
any baseline variable that is statistically different between treatment groups will be adjusted for 
in subsequent analysis. For variables assessed only at baseline and 6 months, including 
changes hepatic fat and insulin-stimulated glucose uptake, the effect of pitavastatin vs. placebo 
will first be assessed first using a two-sample t-test to compare the mean changes. Adjusted 
analyses will then be performed to control for any baseline differences between treatment 
groups, potentially including presence of diet-controlled diabetes.  We will also perform paired t-
testing within the pitavastatin group to assess for any changes in insulin-stimulated glucose 
uptake.  
 
We will also carefully assess changes in physical activity and dietary intake in terms of 
overall caloric intake and macronutrient composition between the groups, and we will determine 
if changes in body weight, physical activity or dietary intake are contributing to the observed 
treatment effect on insulin-stimulated glucose uptake or hepatic fat. If so, we will include these 
variables in the analyses and modeling as adjusted covariates.  If any other variables are 
different between groups, such as medication adherence, these will also be included as co-
variates. For variables measured at baseline, 3 and 6 months in the study, including AST, ALT, 
and fasting measures of glycemia, we will analyze the longitudinal data including 0, 3, and 6 
month data using general linear mixed effects modeling for which the subject level intercept will 
be random, and effects of treatment group, time, time x treatment group will be random, and a 
compound symmetry error covariance structure will be considered. The longitudinal treatment 
effect between pitavastatin and placebo will be examined by testing for time x treatment group 
interaction. If there is evidence that any of the outcomes is not normally distributed, we will 
choose a proper transformation for normalization before the mixed effects model analyses. 
Sample Size and Power Calculations:   
The sample size of 50, allowing for 10% discontinuation rate, has approximately 80% power to 
detect a clinically relevant 0.86 SD change in the endpoints of interest at a two-sided alpha of 
0.05.  Based on preliminary data from study of obese individuals in our group, a 0.86 SD 
change in insulin-stimulated glucose uptake is a change of approximately 1.5mg/kg/min. A 
difference of less than this magnitude in change over time compared to placebo would not be 
viewed as clinically relevant, and consistent with the hypothesis that pitavasatin does not 
significantly affect insulin resistance. Moreover a difference of greater than 0.86 SD in change in 
hepatic fat between the groups would be viewed as clinically relevant, and consistent with the 
hypothesis that pitavastatin will reduce liver fat. Power for within group paired t-testing to assess 
difference in insulin stimulated glucose uptake within the pitavastatin group will depend on the 
correlation between baseline and 6 month measurements, which we estimate will be between r 
= 0.6 to 0.8.  Estimated power for N = 20 to 23 pairs is shown below: 


9 
 
 
r (correlation between 
baseline & 6 month 
measurements) 
Detectable difference 
in means 
N (subjects with both 
baseline & 6 month) 
Power to detect 
difference in means 
0.6 
≥ 0.6 SD 
20 
0.812 
0.6 
≥ 0.6 SD 
21 
0.832 
0.6 
≥ 0.6 SD 
22 
0.851 
0.6 
≥ 0.6 SD 
23 
0.867 
0.7 
≥ 0.5 SD 
20 
0.782 
0.7 
≥ 0.5 SD 
21 
0.803 
0.7 
≥ 0.5 SD 
22 
0.823 
0.7 
≥ 0.5 SD 
23 
0.841 
0.8 
≥ 0.5 SD 
20 
0.918 
0.8 
≥ 0.5 SD 
21 
0.931 
0.8 
≥ 0.5 SD 
22 
0.942 
0.8 
≥ 0.5 SD 
23 
0.952 
 
7. Risks and Discomforts 
 
Radiation:  As a result of participation in this study, subjects will be exposed to 2 DXA scans 
over 6 months, for a total radiation risk for both scans of 0.02mSv.  This radiation exposure 
does not pose excessive risk to subjects.  
 
Blood Drawing:  The total blood drawn for subjects completing the study is equivalent to 
approximately  510cc over a period of 6 months.  The maximum amount of blood drawn at any 
given visit will be approximately 200cc, which will be drawn at the baseline and 6 month visits.  
A total of  510cc (a little more than a blood donation) over 6 months does not pose excessive 
risk to patients, nor does withdrawal of up to 200cc at a single timepoint.  Both of these amounts 
are within Institutional Review Board guidelines.  Patients with a hemoglobin < 10 g/dL will be 
excluded from the study. There will be minimal risk and discomfort associated with blood 
drawing and IV placement. The risks of these procedures are minor bruising or bleeding at the 
site of the blood draw or IV catheter.  
 
Euglycemic Hyperinsulinemic clamp/insulin: Administration of insulin infusion can cause 
hypoglycemia. Blood sugar will be monitored every 5 minutes during the insulin clamp, and 20% 
dextrose is infused per protocol to achieve target blood glucose of 90mg/dL. In the event of 
hypoglycemia, 50% dextrose is available at the bedside, and a physician or nurse practitioner is 
present throughout the insulin clamp procedure.  
 
Medications  
Administration of all medications will be conducted by the appropriate health care professional. 
A physician will be available on-call 24 hours/day, 7 days/week, to all study participants for any 
questions or concerns.  Subjects will be followed closely for symptoms and will be instructed to 
call the study physician with any concerns.  Please see “Study Drug” section above for handling 
of symptoms and adverse events. 
 
Subjects who enter the study may meet criteria for statin treatment based on new guidelines.  
Only subjects who are not currently receiving a statin and who are not under consideration to be 


10 
 
prescribed a statin will be entered into the study.  Half of patients will be randomized to placebo 
for six months, after which they will be referred to their provider.  A potential delay of 6 months 
in initiation of statin for patients not currently being considered for statin does not pose 
excessive risk to subjects.  All subjects will be informed of their ASCVD risk calculation after 
screening results are available, and all subjects will be informed that they can seek immediate 
care from their provider for statin therapy rather than entering the study if they wish. 
 
8. Potential Benefits 
 
Subjects on placebo may not benefit from being in the study.  They will receive detailed medical 
information and will be referred to their physicians at the end of the study for continued care and 
initiation of statin therapy if appropriate.  Subjects on pitavastatin will receive lipid lowering 
therapy that will potentially be of benefit with respect to primary prevention of cardiovascular 
disease, given that subjects will have LDL ≥ 100mg/dL or ASCVD risk of ≥5% over the next 10 
years. 
 
The study is likely to benefit the overall population of individuals needing statin therapy, as it will 
elucidate effects of pitavastatin, on glucose homeostasis and liver fat.   
 
9. Monitoring and Quality Assurance 
 
The study investigators will monitor all data collected for the studies. Data will be stored 
securely, with access restricted to co-investigators and study staff. Binders with subject 
information will be labeled with coded enrollment number to protect confidentiality. Electronic 
databases will be locked, and password-protected, with access available only to study staff.  
Data will not be saved on the hard drive of any laptop or desktop computers or on any 
removable data storage devices such as flash drives or CDs.  
 
Craigslist and Facebook will also be utilized, with a link to a REDCap Survey that individuals 
can fill out.  This survey will collect minimal information necessary to see if subjects would 
potentially be eligible, as well as contact information so that we can call them if they are 
potentially eligible 
 
The PIs (Steven Grinspoon, MD, and Takara Stanley, MD) will monitor the study continuously, 
reviewing all unexpected and possibly related adverse events as they occur, and they will meet 
quarterly to review study progress and ensure quality.   
 
Subjects will be instructed to report immediately any adverse events. A physician or nurse 
practitioner will be available on-call 24 hours/day, 7 days/week, to all study participants for any 
questions or concerns.  
 
Adverse events will be reported to the MGH Institutional Review Board in accordance with AE 
reporting guidelines. 
 
 
10. References 
1. 
Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of 
Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the 
American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J 
Am Coll Cardiol. Jul 1 2014;63(25 Pt B):2889-2934. 


11 
 
2. 
Pencina MJ, Navar-Boggan AM, D'Agostino RB, Sr., et al. Application of new cholesterol 
guidelines to a population-based sample. N Engl J Med. Apr 10 2014;370(15):1422-1431. 
3. 
Ridker PM, Danielson E, Fonseca FA, et al. Rosuvastatin to prevent vascular events in men and 
women with elevated C-reactive protein. N Engl J Med. Nov 20 2008;359(21):2195-2207. 
4. 
Eslami L, Merat S, Malekzadeh R, Nasseri-Moghaddam S, Aramin H. Statins for non-alcoholic 
fatty liver disease and non-alcoholic steatohepatitis. Cochrane Database Syst Rev. 
2013;12:CD008623. 
5. 
Chapman MJ, Orsoni A, Robillard P, Hounslow N, Sponseller CA, Giral P. Effect of high-dose 
pitavastatin on glucose homeostasis in patients at elevated risk of new-onset diabetes: insights 
from the CAPITAIN and PREVAIL-US studies. Curr Med Res Opin. May 2014;30(5):775-784. 
6. 
Sponseller CA, Morgan RE, Kryzhanovski VA, Campbell SE, Davidson MH. Comparison of the 
Lipid-Lowering Effects of Pitavastatin 4 mg Versus Pravastatin 40 mg in Adults With Primary 
Hyperlipidemia or Mixed (Combined) Dyslipidemia: A Phase IV, Prospective, US, Multicenter, 
Randomized, Double-blind, Superiority Trial. Clin Ther. Aug 1 2014;36(8):1211-1222. 
7. 
Egawa T, Toda K, Nemoto Y, et al. Pitavastatin ameliorates severe hepatic steatosis in 
aromatase-deficient (Ar-/-) mice. Lipids. May 2003;38(5):519-523. 
8. 
Han KH, Rha SW, Kang HJ, et al. Evaluation of short-term safety and efficacy of HMG-CoA 
reductase inhibitors in hypercholesterolemic patients with elevated serum alanine transaminase 
concentrations: PITCH study (PITavastatin versus atorvastatin to evaluate the effect on patients 
with hypercholesterolemia and mild to moderate hepatic damage). J Clin Lipidol. Jul-Aug 
2012;6(4):340-351. 
9. 
Hyogo H, Ikegami T, Tokushige K, et al. Efficacy of pitavastatin for the treatment of non-alcoholic 
steatohepatitis with dyslipidemia: An open-label, pilot study. Hepatol Res. Nov 
2011;41(11):1057-1065. 
10. 
Sattar N, Preiss D, Murray HM, et al. Statins and risk of incident diabetes: a collaborative meta-
analysis of randomised statin trials. Lancet. Feb 27 2010;375(9716):735-742. 
11. 
Carter AA, Gomes T, Camacho X, Juurlink DN, Shah BR, Mamdani MM. Risk of incident diabetes 
among patients treated with statins: population based study. BMJ. 2013;346:f2610. 
12. 
Navarese EP, Buffon A, Andreotti F, et al. Meta-analysis of impact of different types and doses of 
statins on new-onset diabetes mellitus. Am J Cardiol. Apr 15 2013;111(8):1123-1130. 
13. 
Yamakawa T, Takano T, Tanaka S, Kadonosono K, Terauchi Y. Influence of pitavastatin on glucose 
tolerance in patients with type 2 diabetes mellitus. J Atheroscler Thromb. Oct 2008;15(5):269-
275. 
14. 
Kawai T, Tokui M, Funae O, et al. Efficacy of pitavastatin, a new HMG-CoA reductase inhibitor, 
on lipid and glucose metabolism in patients with type 2 diabetes. Diabetes Care. Dec 
2005;28(12):2980-2981. 
15. 
Koshiyama H, Taniguchi A, Tanaka K, et al. Effects of pitavastatin on lipid profiles and high-
sensitivity CRP in Japanese subjects with hypercholesterolemia: Kansai Investigation of Statin for 
Hyperlipidemic Intervention in Metabolism and Endocrinology (KISHIMEN) investigatars. J 
Atheroscler Thromb. Dec 2008;15(6):345-350. 
16. 
Gumprecht J, Gosho M, Budinski D, Hounslow N. Comparative long-term efficacy and tolerability 
of pitavastatin 4 mg and atorvastatin 20-40 mg in patients with type 2 diabetes mellitus and 
combined (mixed) dyslipidaemia. Diabetes Obes Metab. Nov 2011;13(11):1047-1055. 
17. 
Szczepaniak LS, Nurenberg P, Leonard D, et al. Magnetic Resonance Spectroscopy to Measure 
Hepatic Triglyceride Content: Prevalence of Hepatic Steatosis in the General Population. Am J 
Physiol Endocrinol Metab. Aug 31 2005;288:E462-E468. 


12 
 
18. 
Ascha MS, Hanouneh IA, Lopez R, Tamimi TA, Feldstein AF, Zein NN. The incidence and risk 
factors of hepatocellular carcinoma in patients with nonalcoholic steatohepatitis. Hepatology. 
Jun 2010;51(6):1972-1978. 
19. 
Guaraldi G, Squillace N, Stentarelli C, et al. Nonalcoholic fatty liver disease in HIV-infected 
patients referred to a metabolic clinic: prevalence, characteristics, and predictors. Clin Infect Dis. 
Jul 15 2008;47(2):250-257. 
20. 
Brown MS, Goldstein JL. Selective versus total insulin resistance: a pathogenic paradox. Cell 
Metab. Feb 2008;7(2):95-96. 
21. 
Kim D, Choi SY, Park EH, et al. Nonalcoholic fatty liver disease is associated with coronary artery 
calcification. Hepatology. Aug 2012;56(2):605-613. 
22. 
Hamaguchi M, Kojima T, Takeda N, et al. Nonalcoholic fatty liver disease is a novel predictor of 
cardiovascular disease. World J Gastroenterol. Mar 14 2007;13(10):1579-1584. 
23. 
Targher G, Bertolini L, Padovani R, et al. Prevalence of nonalcoholic fatty liver disease and its 
association with cardiovascular disease among type 2 diabetic patients. Diabetes Care. May 
2007;30(5):1212-1218. 
24. 
Miyaki T, Nojiri S, Shinkai N, et al. Pitavastatin inhibits hepatic steatosis and fibrosis in non-
alcoholic steatohepatitis model rats. Hepatol Res. Apr 2011;41(4):375-385. 
25. 
Shimizu M, Yasuda Y, Sakai H, et al. Pitavastatin suppresses diethylnitrosamine-induced liver 
preneoplasms in male C57BL/KsJ-db/db obese mice. BMC Cancer. 2011;11:281. 
26. 
Kamada Y, Kiso S, Yoshida Y, et al. Pitavastatin ameliorated the progression of steatohepatitis in 
ovariectomized mice fed a high fat and high cholesterol diet. Hepatol Res. Apr 2013;43(4):401-
412. 
27. 
Yasuda Y, Shimizu M, Shirakami Y, et al. Pitavastatin inhibits azoxymethane-induced colonic 
preneoplastic lesions in C57BL/KsJ-db/db obese mice. Cancer Sci. Jul 2010;101(7):1701-1707. 
28. 
Fujino M, Miura S, Matsuo Y, Tanigawa H, Kawamura A, Saku K. Pitavastatin-induced 
downregulation of CCR2 and CCR5 in monocytes is associated with the arrest of cell-cycle in S 
phase. Atherosclerosis. Aug 2006;187(2):301-308. 
29. 
Goff DC, Jr., Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of 
cardiovascular risk: a report of the American College of Cardiology/American Heart Association 
Task Force on Practice Guidelines. Circulation. Jun 24 2014;129(25 Suppl 2):S49-73. 
30. 
Georgoff P, Thomasson D, Louie A, et al. Hydrogen-1 MR spectroscopy for measurement and 
diagnosis of hepatic steatosis. AJR Am J Roentgenol. Jul 2012;199(1):2-7. 
31. 
Longo R, Pollesello P, Ricci C, et al. Proton MR spectroscopy in quantitative in vivo determination 
of fat content in human liver steatosis. J Magn Reson Imaging. May-Jun 1995;5(3):281-285. 
32. 
Mazess RB, Barden HS, Bisek JP, Hanson J. Dual-energy x-ray absorptiometry for total-body and 
regional bone-mineral and soft-tissue composition. Am J Clin Nutr. Jun 1990;51(6):1106-1112. 
33. 
Hadigan C, Miller K, Corcoran C, Anderson E, Basgoz N, Grinspoon S. Fasting hyperinsulinemia 
and changes in regional body composition in human immunodeficiency virus-infected women. J 
Clin Endocrinol Metab. 1999;84(6):1932-1937. 
34. 
Falutz J, Allas S, Kotler D, et al. A placebo-controlled, dose-ranging study of a growth hormone 
releasing factor in HIV-infected patients with abdominal fat accumulation. AIDS. Aug 12 
2005;19(12):1279-1287. 
35. 
Lohman TG, Roche AF, Martorell R, eds. Anthropometric Standardization Reference Manual. 
Champaign, IL: Human Kinetic Books; 1988. 
36. 
Kriska AM, Knowler WC, LaPorte RE, et al. Development of questionnaire to examine 
relationship of physical activity and diabetes in Pima Indians. Diabetes Care. Apr 1990;13(4):401-
411. 


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37. 
DeFronzo RA, Tobin JD, Andres R. Glucose clamp technique: A method for quantifying insulin 
secretion and resistance. Am J Physiol. 1979;237:E214-223.