Biomedicine & Pharmacotherapy 58 (2004) 614618 http://france.elsevier.

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Dossier: Diabetes: Basic Research and Clinical Approach

Effects of a statin group drug, pravastatin, on the insulin resistance in patients with metabolic syndrome
Feyzullah Gl a, Bilgin zmen b,*, Zeliha Hekimsoy b, Cengiz Kirmaz a
b

Department of Internal Medicine, Faculty of Medicine, Celal Bayar University, Manisa, Turkey Division of Endocrinology of Internal Medicine, Faculty of Medicine, Celal Bayar University, Manisa, Turkey Received 4 May 2004 Available online 13 October 2004

Abstract Background. In West of Scotland Coronary Prevention Study (WOSCOPS), development of type 2 diabetes mellitus (DM) was found to decrease by 30% in pravastatin-treated patients. In the study, it is suggested that pleiotropic effects of pravastatin may be responsible too as well as its lipid lowering effect. Objective. The aim of this study was to assess the effects of pravastatin treatment on the insulin resistance in patients with metabolic syndrome with impaired glucose tolerance (IGT), by Homeostasis Model Assessment (HOMA) test, insulin sensitivity indices and glucose half activation time (glucose t1/2). Methods. Study population consisted of 25 women who were diagnosed with metabolic syndrome. At baseline and 10 weeks after the 20 mg/daily tablet pravastatin treatment, waist/hip circumference, body weight and arterial blood pressure measurements, plasma glucose, total cholesterol, triglyceride, high density lipoprotein (HDL)-cholesterol, transaminases, glycosylated haemoglobin (A1C) and insulin level measurements were obtained along with HOMA test and insulin tolerance test after 12 h of fasting. Insulin sensitivity indices and glucose t1/2 were assessed. Results. After the treatment, a statistically signicant decrease was observed in arterial blood pressure values (P < 0.0001). While plasma total cholesterol, low density lipoprotein (LDL)-cholesterol, and triglyceride levels were found to decrease signicantly and HDL-cholesterol levels increased signicantly, a decrease in baseline insulin levels, an increase in insulin sensitivity levels were observed along with an decrease in glucose t1/2. Related to the improvement in aforementioned parameters, statistically signicant decreases were noted in HOMA, postprandial and fasting glucose levels and A1C values (P < 0.0001). Conclusion. Our study suggests that using pravastatin in the dyslipidemia treatment of metabolic syndrome with IGT may be an effective approach by its advantageous effects on insulin resistance. Based on this result, it is possible to say that this can be a risk lowering treatment approach for the development of type 2 DM. 2004 Elsevier SAS. All rights reserved.
Keywords: Insulin resistance; Metabolic syndrome; Pravastatin; Hyperlipidemia; HOMA-IR

1. Introduction Metabolic syndrome patients are at increased risk for developing cardiovascular morbidity and mortality [1]. The increasing prevalence of the metabolic syndrome in various asymptomatic populations has been well documented, however, limited information is available about the prevalence in manifest atherosclerotic vascular disease patients [2].
* Corresponding author. Plevne Bulvar No. 14, D. 9, Alsancak, zmir I 35220, Turkey. E-mail address: bilozmen@yahoo.com (B. zmen). 0753-3322/$ - see front matter 2004 Elsevier SAS. All rights reserved. doi:10.1016/j.biopha.2004.09.005

Metabolic syndrome is a disorder in which insulin resistance is the main component of the pathogenetic mechanism. In 1988, Reaven [3], upon observing the more than coincidental existence of obesity, diabetes, hypertension, hyperlipidemia and atherosclerotic coronary diseases concomittantly in a single patient, suggested that these are caused by a single metabolic disorder. On the basis of this conclusion, he dened the insulin resistance syndrome (syndrome X) which consists of insulin resistance, hyperinsulinemia, obesity, glucose intolerance, hypertriglyceridemia, reduced high density lipoprotein (HDL)-cholesterol level, hypertension and coronary arterial diseases, prothrombotic state (e.g., high brinogen or

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plasminogen activator inhibitor [1] (PAI-1) in the blood), proinammatory state (e.g., elevated high-sensitivity C-reactive protein (h-CRP) in the blood) and polcystic ovarian syndrome [35]. Insulin resistance is dened as a decrease in endogenous (native) and/or exogenous insulin action. In other words, an impaired response to a specic insulin dose [3]. Many hereditary and acquired factors lead to an advance decrease in biological response of insulin by preventing the insulin binding to the receptors in target tissues or by impairing the receptor signaling pathways [3,6]. In order to meet the increased action, an excess insulin secretion occurs. Mild-moderate insulin resistance, a common clinical case, leads to impaired glucose tolerance (IGT), type 2 diabetes mellitus (DM), hypertension and early atherosclerosis [7]. All these clinical features that occur related to insulin resistance are signicant mortality and morbidity factors. Given these facts, new approaches in the treatment of insulin resistance may prevent these diseases and also contribute to the treatment of such diseases. In West of Scotland Coronary Prevention Study (WOSCOPS), development of type 2 DM was found to decrease by 30% in pravastatin-treated patients [8]. In this study, it is suggested that anti-inammatory and endothelial effects of pravastatin may be responsible as well as its lipid lowering effect. We aimed to detect the effects of pravastatin treatment on insulin resistance in cases having metabolic syndrome with IGT is assessed by Homeostasis Model Assessment (HOMA) test, insulin sensitivity indices (ISI) and glucose half activation time (glucose t1/2).

being on drugs that may affect insulin resistance; for example, taking an angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker group drugs; cases with acute coronary diseases; patients on hormone replacement treatment (HRT) or those using selective estrogen receptor modulator (SERM); presence of infection, severe physical or psychological trauma on the day of insulin tolerance test or any recent day, as these may affect the result of the test; those who do not comply with the pravastatin treatment. Informed consent for the described investigations was obtained from all patients. Approval for the study was given by the ethics committee of our hospital. 2.2. Study design At the initial visit, waist/hip circumference, body weight and arterial blood pressure measurements and total cholesterol, HDL-cholesterol, LDL-cholesterol, triglyceride, fasting glucose levels, postprandial glucose levels, liver function tests, glycosylated haemoglobin (A1C) and baseline insulin level measurements tests were obtained from the patients chosen according to the metabolic syndrome diagnostic criteria of ATP III [5]. HOMA, ISI and glucose t1/2 of the patients were calculated. Pravastatin treatment (20 mg once daily at bedtime) was initiated in these patients. This treatment was continued until second visit, 10 weeks later. Aforementioned parameters were measured once again. Plasma glucose level, total cholesterol, triglyceride, HDLcholesterol, liver function tests and A1C measurements were analysed at Celal Bayar University, Medical Faculty Biochemistry Laboratory, using an automatic analyzer (Diagnostic Merck-Mega-2000 equipment). LDL-cholesterol levels were calculated by the Friedewald equation [9]. Serum insulin levels were assayed by radioimmunoassay (RIA) method. Commercial kits of DPC (Diagnostic Products Corporation, Los Angeles, USA) were used for the measurements. 2.3. Assessment of insulin tolerance test Following the tension arterial, weight, waist/hip measurements of the patients obtained after 12 h fasting and 3045 min rest, they were instructed to lie in supine position on the examination bed and 22 G needle was used for venous access. Blood glucose measurement was obtained at 5 and 0 min followed by infusion of crystallized insulin IV at a rate of 0.1 unit/kg in the other arm. Blood glucose level measurements were obtained at 1, 2, 3, 5, 7, 10, 15 and 20 min. Hypoglycemic symptoms were monitored closely during the test. During these observations, no serious hypoglycemic symptom was observed except, mild sweat, tachycardia and starvation feeling towards the end of the test. At the end of 20 min, 500 ml 5% dextrose serum was infused at 150 ml/h for 2 or 3 h depending on the condition of the patient. Single dose (before bed time) 10 weeks 20 mg Pravastatin (pravachol-Bristol-Myers Squibb) treatment was initiated.

2. Materials and methods 2.1. Subject Our study consisted of 25 cases that met the ATP III criteria of metabolic syndrome [5] and thus diagnosed with metabolic syndrome between January 2002 and March 2003 in the Department of Endocrinology and General Internal Medicine out-patient clinic of Celal Bayar University Medical Faculty. All the patients were women with an average age of 55.56 8.26 (min: 41, max: 68). Additional exclusion criteria that all selected patients met were: being previously diagnosed with type 2 DM (fasting blood glucose 126/mg/dl or 2 h OGTT plasma glucose 200 mg/dl); having a normal lipid prole (total cholesterol, triglyceride, low density lipoprotein (LDL)-cholesterol); taking obesity treatment within last two months (diet or medical); attending regular physical program or weight loss of more than 3% within the last 6 months; having obesity due to endocrinologic diseases (hypothyroid, cushing syndrome, etc.);

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2.4. Assessment of the results and statistical analysis Baseline insulin values, glucose t1/2 and dG values were taken into account in statistical analysis. dG was calculated by subtracting the 0 min blood glucose value from 20 min blood glucose level. G0 is the 0 min blood glucose level. Insulin sensitivity indices was calculated as (ISI) = dG/G0. Glucose t1/2 of the patients is the value that corresponds to the half of the G1 value in scatterplot graphics SPSS version 10. SPSS Version 10 was used for the assessment of all the statistical analysis. After calculating the average post- and pre-treatment values, paired students t-test was used for the statistical analysis. P values less than 0.05 were accepted as statistically signicant. All data were expressed as SD.

4. Discussion In the last several years, there has been a decided shift in the focus of lipid trials from populations with high LDL cholesterol to populations with a more modest LDL cholesterol and the dyslipidemia that is characteristic of DM and metabolic syndrome [10]. Statins predominantly result in substantial LDL cholesterol lowering but generally also produce favorable, albeit smaller, changes in triglycerides and HDL cholesterol. With statin treatment in either the 4S [11], the CARE [12] or HPS [13], the changes in blood lipids and apoproteins were similar for subgroups with and without diabetes. Today, when factors such as nourishment habits and sedentary life are taken into account, obesity is a serious health problem which threatens life in a growing concern, because serious diseases such as hypertension, stroke, DM, dyslipidemia and atherosclerosis obesity are signicant mortality and morbidity factors [12]. In our study, after a 20 mg tablet 10 weeks pravastatin treatment, an improvement was observed in arterial tension values of the cases of whose majority was stage 1 hypertensive at initial visits. Studies on pravastatin demonstrated a decrease in cardiac reactivity against angiotensin II and norepinephrine after 1012 weeks treatment [14]. As a result, an improvement was observed in tension arterial values by pravastatin treatment. These results are in consistency with our study. In our study, when the post-treatment lipid proles of the patients were evaluated, a decrease was noted in total cholesterol, LDL-cholesterol, triglyceride levels while there was an increase in HDL-cholesterol levels. Thus, pravastatin improved the lipid levels. Previous studies indicated that pravastatin provides an improvement in endothelial dysfunction related to its antioxidant effects while providing a statistically signicant decrease in lipid levels especially in LDLcholesterol levels [15]. Studies have demonstrated that improvement in lipid prole related to using pravastatin, even only the decrease in LDL-cholesterol levels, is efcient for the development of endothelial-dependent vasodilation [16,17]. These events can be explained by an increase in nitric

3. Results Twenty-ve patients that met the inclusion criteria completed the study. When the pre- and post-treatment parameters of the patients were compared, a statistically signicance decrease was found in total cholesterol, LDLcholesterol and triglyceride levels (P < 0.0001), while there was a statistically signicant increase in HDL-cholesterol levels (P < 0.0001) (Table 1). When the seventh report of the Joint National Committee (JNC VII) was taken into account and tension arterial values of the patients were evaluated, it was noted that 28% is prehypertensive, 48% is stage-1 hypertensive and 24% is normotensive. Following the treatment, a statistically signicant decrease was observed in the tension arterial values of the controls (P < 0.0001) (Table 1). Besides an increase in baseline insulin levels (Table 1), a statistically signicant difference was identied between the increase in ISI and decrease in glucose t1/2) (P < 0.0001) (Table 1 and Fig. 1). Related to the improvement in aforementioned parameters, statistically signicant decreases were found in HOMA (Table 1 and Fig. 1), fasting and postprandial glucose and A1C values (P < 0.0001) (Table 1).

Table 1 Pre- and post-treatment parameters of our patients. SBP, systolic blood pressure; DBP, diastolic blood pressure; ISI, insulin sensitivity indices; HOMA, Homeostasis Model Assessment. All data were expressed as SD Total cholesterol Triglyceride HDL-C LDL-C SBP DBP Basaline insulin Glucose t1/2 ISI HOMA Fasting glucose Postprandial glucose A1C Pre-treatment 233.68 20.02 181.92 54.04 45.08 7.93 152.08 25.06 129.88 16.23 76.88 14.58 15.98 4.54 41.10 10.9295 0.3267 7.21E02 4.48 1.47 112.36 8.76 148.24 7.03 5.58 0.44 Post-treatment 196.32 7.50 161.12 46.15 47.04 7.39 117.40 10.46 122.40 15.08 66.80 14.06 8.92 3.23 27.452 5.7048 0.3929 0.00642 2.03 0.78 91.52 6.18 123.04 9.15 5.14 0.39 P <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001

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Fig. 1. Differences in ISI (insulin sensitivity index), HOMA-IR (Homeostasis Model Assessment-Insulin Resistance) and glucose t1/2 (glucose activation half time), respectively, a, b, c.

oxide release related to the improvement in endothelial function [17]. Animal studies demonstrated an increase in endothelial NO release following mevastatin usage [18]. It was shown in similar studies that tissue plasminogen (t-pa), excessive PAI-I and endothelial-I secretion were inhibited as well as an increase in NO secretion due to statin use [19,20]. Vasodilation occurs as a result of these mechanisms. This situation explains the antihypertensive efcacy related to the

improvement in lipid prole, as we have found out in our study too. However, what is ideal for proving the antihypertensive activity adequately is performing the studies by monitoring the ambulatory blood pressure. However, as we did not aim to determine the antihypertensive activity, we did not monitor the ambulatory blood pressures of the patients. In our study, a decrease in baseline insulin levels, an increase in insulin sensitive indices and again a decrease in glucose t1/2 were noted. Signicant increases were identied in HOMA, fasting and proglabin blood glucose and A1C values related to the improvement in these parameters. It has been proved in the literature that high blood lipid and lipoprotein levels increase the risk of diabetes [21,22]. There exist few studies on the usage of the drugs that change the blood lipid prole and have anti-inammatory effects in metabolic syndrome [22,23]. It has been long known that an increase in serum triglyceride levels in metabolic syndrome increases the risk of impaired glucose tolerance [22]. In our study, serum triglyceride levels were found to decrease by pravastatin treatment. The decrease noted in fasting glucose, postprandial glucose, HOMA, A1C levels could have been caused by the alteration in plasma triglyceride levels. However, insulin resistance on its own cannot be seen as an improving factor. It should not be forgotten that bric acid derivatives increase the triglyceride levels more compared to statins [24]. Another point to remember in this regard is that there exist a inverse linear correlation between HDL-cholesterol and insulin resistance in the previous studies [25]. At the end of 10 weeks, controls revealed an increase in HDL-cholesterol levels of the patients in our study too. Moreover, low degree inammatory markers (TNF-a, IL-1, IL-6 and CRP) were shown to reect type 2 DM development risk [22]. Inammatory cytokines secreted by macrophage and T lenfosits modify the endothelial function, smooth muscle cell proliferation, collagen destruction and thrombosis [26,27]. In experimental models, the decrease in cholesterol levels were accompanied by an increase in the number of the inammatory cells in atherosclerotic plaque [28,29]. This incident stops and even regresses the progression of atherosclerosis. Another important point is that statin group drugs (pravastatin) may play an important role in reducing insulin resistance related to their anti-inammatory effects. Studies on pravastatin shows that pravastatin reduces the circulating interleukine-6 and TNF-a levels [30]. TNF-a and IL-6 have been known to inhibit the lipose activity of lipoprotein and stimulate the liposis in adipose tissue [31,32]. TNF-a lymphoid cell, which is a cytokine originates from fat cell and skeletal muscle, is increased in obese cases. TNF-a causes insulin resistance by reducing the insulin signaling and GLUT-4 expression [33]. It is argued that progression from central obesity towards insulin resistance can be interrupted by obtaining a decrease in these cytokines via pravastatin treatment. In our study, the increase in insulin resistance which was obtained by using pravastatin can be attributed to the inhibition of the above mentioned proinammatory cytokines, even though not measured. Given all this information, it has been shown in our study that using statin in dyslipidemia treatment of metabolic syn-

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F. Gl et al. / Biomedicine & Pharmacotherapy 58 (2004) 614618 [16] Tamai O, Matsuoka H, Itabe H, Wada Y, Kohno K, Imaizumi T. Single LDL apheresis improves endothelium-dependent vasodilatation in hypercholesterolemic humans. Circulation 1997;95:7682. [17] Mital S, Zhang X, Zhao G, Bernstein RD, Smith CJ, Fulton DL, et al. Simvastatin upregulates coronary vascular endothelial nitric oxide production in conscious dogs. Am J Physiol Heart Circ Physiol 2000; 279:H2649H2657. [18] Alvarez De Sotomayor M, Herrera MD, Marhuenda E, Andriantsitohaina R. Characterization of endothelial factors involved in the vasodilatory effect of simvastatin in aorta and small mesenteric artery of the rat. Br J Pharmacol 2000;131:117987. [19] Kureishi Y, Luo Z, Shiojima I, Bialik A, Fulton D, Lefer DJ, et al. The HMG-CoA reductase inhibitor activates the protein kinase Akt and promotes angiogenesis in normocholesterolemic animals. Nat Med 2000;6:100410. [20] Feron O, Dessy C, Desager JP, Balligand JL. Hydroxymethylglutaryl-coenzyme A reductase inhibition promotes endothelial nitric oxide synthase activation through a decrease in caveolin abundance. Circulation 2001;103:1138. [21] Reaven GM. Insulin resistance, hyperinsulinemia, hypertriglyceridemia and hypertension: parallels between human disease and rodent models. Diabetes Care 1991;14:195202. [22] Schmidt MI, Duncan BB, Sharrett AR, et al. Markers of inammation and prediction of diabetes mellitus in adults (Atherosclerosis risk in communities study): a cohort study. Lancet 1999;353:164952. [23] Haffner SM, Stern MP, Hazuda HP, et al. Cardiovasculer risk factors in conrmed prediabetic individuals. Dose the clock for coronary heart disease start ticking before the onset of clinical diabetes. JAMA 1990;263:28938. [24] Sane T, Knudsen P, Vuorinen-Markkola H, et al. Decreasing triglyceride by gembrozil therapy does not affect the glucoregulatory or antilipolytic effect of insulin in non-diabetic subjects with mild hypertriglyceridemia. Metabolism 1995;44:58996. [25] Donahue R, Orchard T, Becker D, et al. Physical activity, insulin sensitivity and the lipoprotein prole in young adults. The Beaver County Study. Am J Epidemiol 1988;127:95103. [26] Vallance P, Collier J, Bhagat K. Inection, inammation and infarction: dose acute endothelial dysfunction provide a link? Lancet 1997;349:13912. [27] Neumann FJ, Marx N, Gawaz M, et al. Induction of cytokine expression in leukocytes by binding of thrombin-stimulated platelets. Circulation 1997;95:235894. [28] Shiomi M, Ito T, Tsukada T, et al. Reduction of serum cholesterol levels alters lesional composition of atherosclerotic plaques: effect of pravastatin sodium on atherosclerosis in mature WHHL rabbits. Arterioscler Thromb Vase Biol 1995;15:193844. [29] Williams JK, Sukhova GK, Herrington DM, Libby P. Pravastatin has cholesterol-lowering independent effects on the artery wall of atherosclerotic monkeys. J Am Coll Cardiol 1998;31:68491. [30] Rosenson RS, Tangney CC, Casey LC. Inhibition of proinammatory cytokine production by pravastatin. Lancet 1999;353:9834. [31] Kawakami M, Pekala PH, Lane MD, et al. Lipoprotein lipase suppression in 3T3-L1 cells by an endotoxin-induced mediatr from exudate cells. Proc Natl Acad Sci USA 1982;82:9126. [32] Hardardottir I, Grnfeld C, Feingold KR. Effects of endotoxin and cytokines on lipid metabolism. Curr Opin Lipidol 1994;5:20715. [33] Uysal KT, Wiesbrock SM, Hotamslgil GS. Functional analysis of tumor necrosis factor (TNF) receptors in TNF-alfa mediated insulin resistance in genetic obesity. Endocrinology 1998;139(12):48327.

drome cases is a treatment approach having advantageous effects on insulin resistance. But longer-term clinical studies should be performed with larger numbers of patients to determine the effects of statins on the insulin resistance in the patients with metabolic syndrome.

References
[1] Lakka HM, Laaksonen DE, Lakka TA. The metabolic syndrome and total cardiovascular disease mortality in the middle-aged men. JAMA 2002;288:270916. Meigs JB. Epidemiology of metabolic syndrome. Am J Manag Care 2002;8(Suppl 11):S283S292. Reaven GM. Banting lecture 1988: role of insulin resistance in human disease. Diabetes 1988;37:1595607. Legro RS, Castracane D, Kauffman RP. Detecting insulin resistance in polycistic ovary syndrome: purpose and pitfalls. Obstet Gynecol Surv 2004;59:14151. Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic syndrome among US adults. Findings from Third National Health and Nutrition Examination Survey. JAMA 2002;287:3569. Hollenbeck C, Reaven GM. Variations in inslin stimulated glucose uptake in healthy individuals with normal glucose tolerance. J Clin Endocrinol Metab 1987;64:116973. Bell PM. Clinical signicance of insulin resistance. Diabet Med 1996;13:5049. WOSCOPS Study Group. Screening experience and baseline characteristics in the West of Scotland Study. Am J Cardiol 1995;76:48591. Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem 1972;18:499502. Robins SJ. Cardiovascular disease with diabetes or the metabolic syndrome: should sitatins or brates be rst line lipid therapy? Curr Opin Lipidol 2003;14:57583. Hafner SM, Alexander CM, Cook TJ. Reduced coronary events in simvastatin-treated improves prognosis of diabetic patients with coronary heart disease: a subgroup analysis of Scandinavian Simvastatin Survival Study (4S). Diabetes Care 1997;20:61420. Goldberg RB, Mellies MJ, Sacks FM. Cardiovascular events and their reduction with pravastatin in diabetic and glucose-intolernt myocardial infarction survivors with average cholesterol levels: subgroup analyses in the Cholesterol and Recurrent Events (CARE) trial. Circulation 1998;98:25139. Robins SJ, Targeting LDL. Cholesterol for therapy: lessons from the veterans affairs HDL intervantion trial. Am J Cardiol 2001;88(12A): 19N23N. Straznicky NE, Howes LG, Lam W, Louis WJ. Effects of pravastatin on cardiovascular reactivity to norepinephrine and angiotensin II in patients with hypercholesterolemia and systemic hypertension. Am J Cardiol 1995;75:5826. Anderson TJ, Meredith IT, Yeung AC, Frei B, Selwyn AP, Ganz P. The effect of cholesterol-lowering and antioxidant therapy on endothelium-dependent coronary vasomotion. N Engl J Med 1995; 332:48893.

[2] [3] [4]

[5]

[6]

[7] [8] [9]

[10]

[11]

[12]

[13]

[14]

[15]