Effect of ezetimibe add-on therapy over 52 weeks extension analysis of prospective randomized trial (RESEARCH study) in type 2 diabetes subjects

Abstract Background Lowering cholesterol levels decreases the risk of atherosclerotic diseases. Effective ways to stably reduce LDL-C level are warranted in type 2 diabetic patients, a high-risk population for CVD, with various anti-diabetic therapeutic background. The RESEARCH study focuses on LDL-C reduction in this population along with modifications of the lipid profiles. We evaluated long-term ezetimibe add-on therapy in T2DM patients with hypercholesterolemia. Methods In a randomized, multicenter, open-label, prospective study, a total of 109 T2DM patients not attaining LDL-C target value despite first-line dose statin (10 mg of atorvastatin or 1 mg of pitavastatin) therapy in Japan were recruited. We investigated the difference in cholesterol lowering effect between ezetimibe (10 mg) add-on statin (EAT) group and double-dose statin (DST) group. Changes of parameters related to atherosclerotic event risks were assessed. Results The reduction of LDL-C was larger in the EAT group (28.3%) than in the DST group (9.2%) at 52 weeks as well as the primary endpoint of 12 weeks. EAT achieved significant lower levels of TC and apo B, respectively. Both treatments attained significant reduction in sd-LDL-C or hsCRP on this long-term basis. Notably, sd-LDL-C in EAT reduced as low as 36.1 ± 14.9 mg/dl to reach near the threshold (35.0 mg/dl) for atherosclerosis with significantly higher achievement rate (55.6%) than DST treatment. Simultaneously, hsCRP reduction by EAT attained as low value as 0.52 ± 0.43 mg/l. Conclusions In the present 52-week long-term period, ezetimibe add-on therapy showed a robust advantage in lowering LDL-C and in attaining target LDL-C values compared with the doubling of statin dose. Moreover, it’s meaningful that sd-LDL, powerfully atherogenic lipoprotein, exhibited prominent decrease consistently prominently by ezetimibe add-on therapy. DM patients with hypercholesterolemia are at high risk for CAD, and adding ezetimibe onto usual-dose statin treatment in Japan has been suggested as the first-line therapy for those DM patients who failed to attain the target LDL-C value (UMIN000002593)

Screening for improved activity of a transglutaminase from Streptomyces mobaraensis created by a novel rational mutagenesis and random mutagenesis

Microbial transglutaminase (MTG) has been used extensively in academic research and the food industries through its cross-linking or posttranslational modification of proteins. To improve MTGT, a novel method of rational mutagenesis, called WASH-ROM (Water Accessible Surface Hot-space Region Oriented Mutagenesis), was first attempted. Based on the three-dimensional structure of MTG, 151 point mutations were selected at 40 different residues bearing high solvent accessibility surface area, within a 15 Å of the active center site nucleophile, Cys64. Among them, 32 mutants showed higher specific activity than the wild type enzyme. We found that beneficial mutations are distributed in two regions and with distinctive amino acid substitutions. Next, random mutagenesis was applied to the entire MTG region by developing a new plate assay-based screening system, using Corynebacterium glutamicum as the secretion host strain. This in vivo screening system allowed us to readily distinguish the change in enzymatic activity upon mutation by monitoring the intensity of enzymatic reaction-derived color zones which appeared around the recombinant cell colonies on the plate. From the library of 24,000 clones, 10 mutants were finally selected as beneficial enzymes exhibiting higher specific activity than wild type. Notably, most of the mutations differed from those obtained by WASH-ROM, except for H289Y. Beneficial mutations were distributed in two other regions as well. Furthermore, we found that the FRAP-S199A mutant (FRAP: N-terminal four amino acid residues extension) showed the highest specific activity (45 U/mg: 1.7 times higher than the wild type enzyme). Through these different mutation approaches, various beneficial positions leading to increased specific activity of MTG were surveyed

Effect of Ezetimibe on LDL-C Lowering and Atherogenic Lipoprotein Profiles in Type 2 Diabetic Patients Poorly Controlled by Statins

<div><p>Background</p><p>There exists a subpopulation of T2DM in whom first-line doses of statin are insufficient for optimally reducing LDL-C, representing a major risk of CVD. The RESEARCH study focuses on LDL-C reduction in this population along with modifications of the lipid profiles leading to residual risks.</p><p>Methods</p><p>Lipid changes were assessed in a randomized, multicenter, 12-week, open-label study comparing a high-potency statin (10mg of atorvastatin or 1mg of pitavastatin) plus ezetimibe (EAT: n = 53) with a double dose of statin (20mg of atorvastatin or 2mg of pitavastatin) (DST: n = 56) in DM subjects who had failed to achieve the optimal LDL-C targets. Lipid variables were compared with a primary focus on LDL-C and with secondary focuses on the percentage of patients who reached the LDL-C targets and changes in the levels of RLP-C (remnant like particle cholesterol) and sd-LDL-C, two characteristic atherogenic risks of DM.</p><p>Results</p><p>The reduction of LDL-C (%), the primary endpoint, differed significantly between the two groups (-24.6 in EAT vs. -10.9 in DST). In the analyses of the secondary endpoints, EAT treatment brought about significantly larger reductions in sd-LDL-C (-20.5 vs. -3.7) and RLP-C (-19.7 vs. +5.5). In total, 89.4% of the patients receiving EAT reached the optimized treatment goal compared to 51.0% of the patients receiving DST. The changes in TC (-16.3 vs. -6.3) and non-HDL-C (-20.7 vs. -8.3) differed significantly between the two groups.</p><p>Conclusion</p><p>Ezetimibe added to high-potency statin (10 mg of atorvastatin or 1 mg of pitavastatin) was more effective than the intensified-dose statin (20 mg of atorvastatin or 2 mg of pitavastatin) treatment not only in helping T2DM patients attain more LDL-C reduction, but also in improving their atherogenic lipid profiles, including their levels of sd-LDL-C and RLP-C.</p><p>We thus recommend the addition of ezetimibe to high-potency statin as a first line strategy for T2DM patients with insufficient statin response.</p><p>Trial Registration</p><p>The UMIN Clinical Trials Registry <a href="https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&type=summary&recptno=R000003155&language=E/UMIN000002593" target="_blank">UMIN000002593</a></p></div

The changes in atherogenic lipid profiles (box plots).

<p>A, C: The percent changes in sd-LDL-C and RLP-C, respectively. B, D: sd-LDL-C and RLP-C values before and after the 12 weeks of treatment, respectively. The ‘before treatment’ values are shown as white bars and the ‘after treatment’ values are shown as black bars. n.s., not significant; *, p < 0.05; **, p < 0.01; ***, p < 0.001; ****, p < 0.0001.</p

Flow of Patients in the RESEARCH Study.

<p>One hundred and nine patients were randomized. Fifty-six patients were assigned to the double intensified dose statin therapy (DST) group and 53 patients were assigned to the ezetimibe-add-on therapy (EAT) group. The analysis was performed on 51 patients in the EAT group and 56 patients in the DST group. T2DM: type 2 diabetes mellitus.</p