The differences of the effects on lipid-lowering actions and glucose metabolisms between Rosuvastatin and Atorvastatin in Japanese diabetic patients with hyperlipidemia. - LIpid lowering with highly potent Statins in hyperlipidemia with Type 2 diabetes patiENts – Hisao Ogawa, Yoshihiko Saito, Hideaki Jinnouchi, Masahiro Sugawara, Seigo Sugiyama, Izuru. Masuda, Kunihiko Matsui, Hisao Mori, Masako Waki, Hirotaka Watada, Minoru Yoshiyama on behalf of the LISTEN Study investigators ESC Congress 2014 August 31, 2014 Barcelona – Spain Conflict of interest disclosure LISTEN study was funded by the Non-Profit Organization, Hokkaido Kenkoukagaku Institute and the Investigator Sponsored Study Program of AstraZeneca K.K. Hisao Ogawa, MD, PhD has received research supports or honoraria or both from Astellas Pharma Inc., AstraZeneca K.K., Bayer Yakuhin, Ltd., Boehringer Ingelheim Japan, Inc., Bristol-Myers Squibb Company, Chugai Pharmaceutical Co., Ltd., Daiichi-Sankyo Company, Limited, Dainippon Sumitomo Pharma Co., Ltd., Kowa Company, Ltd., MSD K.K., Novartis Pharma K.K., Otsuka Pharmaceutical Co., Ltd., Pfizer Japan Inc., Sanofi K.K., and Takeda Pharmaceutical Company Limited. Conflict of interest disclosure Yoshihiko Saito, MD, PhD is an adviser at Ono Pharmaceutical Co., Ltd. YS has a clinical commission for an advisor from Ono Pharmaceutical Co., Ltd. YS has received research supports or honoraria or both from Astellas Pharma Inc., AstraZeneca K.K., Daiichi Sankyo Company, Limited, Kyowa Hakko Kirin Co., Ltd., Mitsubishi Tanabe Pharma Corporation, MSD K.K., Novartis Pharma K.K., Otsuka Pharmaceutical Co., Ltd., Pfizer Japan Inc., Shionogi & Co., Ltd., St. Jude Medical Japan Co., Ltd., and Takeda Pharmaceutical Company Limited. YS has endowed departments by MSD Co., Ltd. Hiroyuki Watada, MD, PhD has received research supports or honoraria or both from Astellas Pharma Inc., AstraZeneca K.K., Boehringer Ingelheim Japan, Inc., Bristol-Myers Squibb Company, Daiichi Sankyo Company, Limited, Dainippon Sumitomo Pharma Co., Ltd., Eli Lilly Japan K.K., Johnson & Johnson K.K., Kissei Pharmaceutical Co., Ltd., Kowa Company, Ltd., Kyowa Hakko Kirin Co., Ltd., Mitsubishi Tanabe Pharma Corporation, Mochida Pharmaceutical Co., Ltd., MSD K.K., Novartis Pharma K.K., Novo Nordisk Pharma Ltd., Ono Pharmaceutical Co., Ltd., Pfizer Japan Inc., Sanofi K.K., Sanwa Kagaku Kenkyusho Co., Ltd., and Takeda Pharmaceutical Company Limited. Minoru Yoshiyama, MD, PhD has received research supports or honoraria or both from Astellas Pharma Inc., Boehringer Ingelheim Japan, Inc., Bristol-Myers Squibb Company, Daiichi Sankyo Company, Limited, Dainippon Sumitomo Pharma Co., Ltd., Eisai Co., Ltd., GlaxoSmithKline K.K., Kissei Pharmaceutical Co., Ltd., Kyowa Hakko Kirin Co., Ltd., Mochida Pharmaceutical Co., Ltd., MSD K.K., Otsuka Pharmaceutical Co., Ltd., Pfizer Japan Inc., Sanofi K.K., and Teijn Pharma Limited. Background The clinical benefit to prevent cardiovascular events by using statins in hypercholesterolemic patients with diabetes has been demonstrated in several randomized trials. Recent data showed that statins were associated with an increased dose-dependent risk of new-onset diabetes. However, few prospective, randomized, controlled trials have been conducted to investigate the impact of statin on glucose levels in patients with diabetes. Purpose The LISTEN study was conducted to examine the effects of statins on both lipids and glucose control in Japanese patients with diabetes. Endpoints Primary endpoints ・Percent Change in non-HDL-C level ・Change in HbA1c level Secondary endpoints ・Changes in other lipids, and glucose metabolism parameters ・Any intensification in diabetic treatment status Study design Target population 1. Type 2 diabetes 2. 6.5% ≤ HbA1c ≤ 7.4% 3. Hyper-LDLcholesterolemia (LDL-C ≥ 120 mg/dL without ASCVD [atherosclerotic cardiovascular disease], ≥ 100 mg/dL with ASCVD) Randomized Rosuvastatin 5 mg/day as starting dose (n=500) Atorvastatin 10 mg/day as starting dose (n=500) 4. ≥ 20 years of age Informed consent /eligibility 0M 3M 6M Multicenter, open-label, randomized, parallel-group study Primary endpoints : Percent Change in non-HDL-C level Change of HbA1c level Number of study sites : 132 sites in Japan 12M Participants Flow Enrolled and randomized (n = 1049) Allocated to Rosuvastatin group (n = 525) Not administered study treatment (n = 9) Participant’s request (n = 7) Investigator’s decision (n = 1) Other reasons (n = 1) Administered study treatment (n = 516) Allocated to Atorvastatin group (n = 524) Not administered study treatment (n = 18) Participant’s request (n = 12) Investigator’s decision (n = 4) Other reasons (n = 2) Administered study treatment (n = 506) Excluded from Full analysis set (n = 2) Excluded from Full analysis set (n = 2) Not performed pre-dose examination (n = 2) Administered prohibit prior medication (n = 0) Not performed pre-dose examination (n = 1) Administered prohibit prior medication (n = 1) Analyzed as Full analysis set (n = 514) Analyzed as Full analysis set (n = 504) Baseline characteristics (1) All participants Rosuvastatin Atorvastatin (n = 1018) (n = 514) (n = 504) Male 466 (45.8%) 235 (45.7%) 231 (45.8%) 1.00 Age (years) Mean ± SD 66.4 ± 11.1 66.3 ±11.6 66.6 ±10.6 0.99 Statin administration before entry 241 (23.7%) 121 (23.5%) 120 (23.8%) 0.94 Cardiovascular and Cerebrovascular events before entry 206 (20.2%) 103 (20.0%) 103 (20.4%) 0.88 P value Myocardial infarction 14 (1.4%) 7 (1.4%) 7 (1.4%) 1.00 Angina pectoris 62 (6.1%) 31 (6.0%) 31 (6.2%) 1.00 Heart failure 18 (1.8%) 8 (1.6%) 10 (2.0%) 0.64 Revascularization 12 (1.2%) 9 (1.8%) 3 (0.6%) 0.14 Cardiac arrhythmias 57 (5.6%) 26 (5.1%) 31 (6.2%) 0.50 Cerebral haemorrhage 9 (0.9%) 6 (1.2%) 3 (0.6%) 0.51 Cerebral infarction 51 (5.0%) 30 (5.8%) 21 (4.2%) 0.25 Transient ischaemic attack 9 (0.9%) 4 (0.8%) 5 (1.0%) 0.75 Baseline characteristics (2) All Rosuvastatin Atorvastatin participants P value (n = 1018) Complications related to diabetes 116 (11.4%) (n = 514) (n = 504) 67 (13.0%) 49 (9.7%) 0.11 Diabetic retinopathy 13 (1.3%) 9 (1.8%) 4 (0.8%) 0.26 Diabetic nephropathy 34 (3.3%) 21 (4.1%) 13 (2.6%) 0.22 Diabetic neuropathy 46 (4.5%) 23 (4.5%) 23 (4.6%) 1.00 Diabetic foot 1 (0.1%) 1 (0.2%) 0 (0.0%) 1.00 Hypertension 645 (63.4%) 338 (65.8%) 307 (60.9%) 0.12 Baseline characteristics (3) All participants (n = 1018) Rosuvastatin (n = 514) Atorvastatin (n = 504) P value Non-HDL-C (mg/dL) 168.9 ± 33.3 168.9 ± 35.8 169.0 ± 30.6 0.41 LDL-C (mg/dL) 139.4 ± 30.0 139.2 ± 31.9 139.6 ± 27.9 0.45 HDL-C (mg/dL) 54.9 ± 14.1 54.1 ± 13.6 55.8 ± 14.6 0.08 TC (mg/dL) 223.9 ± 34.0 223.0 ± 36.0 224.8 ± 31.8 0.15 TG (mg/dL) 152.1 ± 115.8 154.5 ± 137.1 149.6 ± 89.1 0.73 3.30 ± 1.20 2.69 ± 0.86 3.36 ± 1.31 2.73 ± 0.91 3.25 ± 1.07 2.66 ± 0.81 0.43 0.36 0.584 ± 0.298 0.584 ± 0.299 0.585 ± 0.297 0.91 HbA1c (%) (NGSP value) 6.39 ± 0.63 6.40 ± 0.66 6.38 ± 0.59 0.80 Blood glucose (mg/dL) 118.9 ± 29.2 119.1 ± 31.2 118.8 ± 27.0 0.54 Insulin (μU/mL) 11.77 ± 19.39 12.57 ± 20.07 10.95 ± 18.66 0.13 1,5-AG (μg/mL) 15.40 ± 8.01 15.39 ± 8.10 15.40 ± 7.91 0.97 Lipid parameters Non-HDL-C/HDL-C ratio LDL-C/HDL-C ratio FFA (mEq/L) Glucose metabolism parameters Mean ± SD Lipid parameters (1) Non-HDL-C -25 -30 111.0 111.3 110.2 Value (mg/dL) 106.8 Percent change (%) Percent change (%) 113.6 -35 LDL-C Overall: P = 0.0399 90.6 P = 0.0780 P = 0.5374 109.6 Rosuvastatin -30 Overall: P = 0.0922 P = 0.0475 Atorvastatin 87.7 85.9 -35 88.1 85.8 -40 Value (mg/dL) 82.0 P = 0.0106 -40 P = 0.3205 P = 0.0896 -45 0 3 3 6 9 12 (months) 12 0 3 3 6 No. of participants 0 month 3 months 6 months 12 months Atorvastatin 504 494 482 472 Rosuvastatin 514 493 485 468 9 12 12(months) Lipid parameters (2) Atorvastatin Rosuvastatin HDL-C 15 TC -15 P = 0.3039 P = 0.4272 P = 0.0112 10 57.7 57.4 56.5 59.0 5 0 0 33 P = 0.0419 P = 0.4313 P = 0.1703 -20 TG: Triglyceride 171.4 170.0 167.1 -25 57.8 Value (mg/dL) 57.5 TC: Total Cholesterol Overall: P = 0.1023 Percent change (%) Percent change (%) Overall: P = 0.0764 167.8 168.7 Value (mg/dL) 163.2 -30 6 9 12 (months) 12 0 3 3 6 9 12 (months) 12 TG -5 Overall: P = 0.8555 Percent change (%) 126.7 Value (mg/dL) 123.9 117.8 -10 -15 119.1 118.8 116.6 P = 0.5063 P = 0.8397 P = 0.2005 -20 0 3 3 6 9 12 (months) 12 No. of participants 0 month 3 months 6 months 12 months Atorvastatin 504 494 482 472 Rosuvastatin 514 493 485 468 Glucose metabolism parameters (1) Atorvastatin Rosuvastatin HbA1c 0.3 15.0 Overall: P = 0.0846 0.2 6.52 6.50 6.44 0.1 6.50 0.0 P = 0.1492 10.0 0 126.0 122.8 121.4 5.0 122.9 3 3 6 9 12 (months) 12 120.1 Value(mg/dL) 118.8 Value(%) -0.1 P = 0.1882 P = 0.1259 0.0 6.44 6.40 Overall: P = 0.0683 P = 0.6695 P = 0.0104 Change (mg/dL) P = 0.1661 Change (%) Blood glucose -5.0 0 3 3 9 12 (months) 12 6 No. of participants 0 month 3 months 6 months 12 months No. of participants 0 month 3 months 6 months 12 months Atorvastatin 504 494 482 472 Atorvastatin 503 493 481 471 Rosuvastatin 514 493 485 468 Rosuvastatin 514 492 485 468 Glucose metabolism parameters (2) Atorvastatin Rosuvastatin 1,5-AG Insulin 3.0 Overall: P = 0.4962 2.0 P = 0.2205 2.0 P = 0.7543 Overall: P = 0.3283 P = 0.9722 P = 0.2130 P = 0.1016 P = 0.6957 12.23 12.15 1.0 Change (µg/mL) Change (μU/mL) 1.0 Value(μU/mL) 0.0 -1.0 11.66 9.81 15.24 0.0 Value(μg/mL) 14.53 14.88 -1.0 10.98 -2.0 14.08 9.63 -3.0 14.40 14.37 -2.0 0 3 3 6 9 12 (months) 12 0 3 3 6 No. of participants 0 month 3 months 6 months 12 months Atorvastatin 503 493 481 471 Rosuvastatin 514 493 485 468 9 12 (months) 12 Change in diabetes therapies Change in diabetes therapies Addition of new drug DPP-4 inhibitor Biguanide Sulfonylurea α-glucosidase inhibitor Insulin sensitizer Insulin analogue GLP-1 analogue Insulin secretagogue Increase in dosage Sulfonylurea Biguanide DPP-4 inhibitor Insulin sensitizer Drug changes (judged as therapy intensification) DPP-4 inhibitor change +Metformin hydrochloride Subtotal of therapy intensification Rosuvastatin (n = 514) 61 (11.9%) 29 (5.6%) 13 (2.5%) 11 (2.1%) 4 (0.8%) 0 (0.0%) 2 (0.4%) 0 (0.0%) 1 (0.2%) 0 (0.0%) 15 (2.9%) 7 (1.4%) 5 (1.0%) 4 (0.8%) 1 (0.2%) 1 (0.2%) Atorvastatin P value (n = 504) 83 (16.5%) 0.04 54 (10.7%) 35 (6.9%) 7 (1.4%) 6 (1.2%) 5 (1.0%) 2 (0.4%) 2 (0.4%) 0 (0.0%) 1 (0.2%) 10 (2.0%) 4 (0.8%) 4 (0.8%) 2 (0.4%) 0 (0.0%) 0 (0.0%) 1 (0.2%) 0 (0.0%) 45 (8.8%) 64 (12.7%) 0.04 Change of therapies on diabetes Rosuvastatin Atorvastatin P value (n = 514) Change in diabetes therapies (n = 504) 61 (11.9%) 83 (16.5%) Drug Changes (other than the intensification) 4 (0.8%) 8 (1.6%) Decreased dosage 5 (1.0%) 6 (1.2%) Drug withdrawal 7 (1.4%) 5 (1.0%) Change timing after the first dose in this study therapy intensification other than the above 0 to 3 months 14 (2.7%) 20 (4.0%) 3 to 6 months 8 (1.6%) 12 (2.4%) 6 to 12 months 23 (4.5%) 32 (6.3%) 0 to 3 months 5 (1.0%) 6 (1.2%) 3 to 6 months 5 (1.0%) 5 (1.0%) 6 to 12 months 6 (1.2%) 8 (1.6%) 0.04 Intensification of diabetes treatment (%) The cumulative incidence of diabetes treatment intensification No. at Risk Atorvastatin Rosuvastatin 20% 20 Hazard ratio: 1.46 (95%CI, 1.00-2.14) P = 0.05 15% 15 10% 10 5% 5 0% 0 0 3 6 504 514 471 480 451 466 9 12 (months) 182 190 Limitations This was an open-label study, and changing or intensifying the treatment for diabetes was left to the judgment of the investigator, possible bias cannot be excluded. This was a rather small size study and compared laboratory data mainly as the outcome, in addition to short-term observation period. We used low doses based on the Japanese regulation compared to those in U.S. and European countries. Conclusions Rosuvastatin did not reduce non-HDL-C compared with Atorvastatin, but overall did reduce LDL-C significantly. The intensification of diabetic treatments was significantly less frequent in the Rosuvastatin group than in the Atorvastatin group. Further prospective studies are required to confirm the differences in the effects on diabetes among statins. LISTEN Study investigators Hisao Mori Takao Nagasu Kazuo Maeda Kumio Iroden Kazuaki Uchiyama Toshibumi Hogi Fumiaki Ono Hideki Kikuchi Masahiko Kuroda Eiichi Tokutake Tsutomu Hayashi Keiichi Chin Hareaki Yamamoto Yoshihisa Takada Nobuaki Oka Masako Waki Shuji Kagawa Masaru Murakami Toshihiro Arizumi Hifumi Atsuko Akira Maki Hiroo Miyagi Kentarou Yata Shinsuke Takei Masami Kogure Masayuki Nakano Youichi Ehara Akira Ota Hideo Ayame Masahiro Sugawara Tetsuo Munakata Koichi Hasegawa Shoshi Matsuda Takashi Fujimoto Shinichi Matsumoto Osame Tanaka Akira Soejima Tomoyuki Shibuya Soichi Honda Shuji Mizumachi Yutaka Wakasa Hirokuni Etsuda Toshifumi Matsuno Tetsuya Tsurumachi Nobushige Ote Hisataka Tegoshi Masaki Matsuoka Kengo Matsumoto Nobuyuki Enomoto Masayuki Yanagi Katsumi Yoshida Koji Oida Masahiro Fukuda Koji Takaki Tomohiro Katsuya Takuma Eto Hiroki Kamata Kohsuke Minamisawa Hiroaki Seino Ichitaro Takada Hideto Ishii Yoshiko Kubota Hidetaka Kanazawa Shinya Hiramitsu Yoshihiro Fujii Yuichiro Nakamura Yasuhiro Hashiguchi Shinya Okamoto Kazuo Ikeda Hiroshi Nishimura Takahiko Kawagishi Kazuya Shigenobu Masaaki Arima Kenichi Yamamoto Yasushi Suzuki Naomi Yoshimura Takahiro Hayashi Satoru Hasegawa Ken-ichi Doniwa Masatoshi Yanagisawa Toshiki Tatsumura Kimikazu Sawai Hiroto Moriyasu Masaru Matsuda Shuichi Kawano Kazuo Sakabe Akiyo Shinoda Ken Takenaka Ichiro Kanamori Toshiyuki Kashiwagi Arata Iwasaki Naoto Yokota Kou Arakawa Masanori Inoue Masahiro Ueno Yuji Nakatani Takayuki Higashi Kiyohito Takahashi Shuichi Matsuo Yoshiyuki Ishii Shoichi Kitano Hiroshi Tanaka Hideaki Jinnouchi Naotaka Kusunose Toshimitsu Jikuhara Hiroshi Kobayashi Yasuhiko Kawade Yasuhiko Kawade Junpei Iinuma Kuniyuki Takai Takao Yasue Tsuguo Niimi Yukinori Kawase Reiki Yoshida Koji Ishimura Hatsumi Masaki Joji Koike Naoto Ishikawa Jun Arao Toru Kinugawa Haruyoshi Nakao Mikio Yamaguchi Shinichiro Otake Michio Tamatani Yumiko Ide Haruyuki Taguchi Nobuyuki Azuma Izuru Masuda Harunori Oda Kazuhiko Takano Ren Horibe Junichiro Kondo Appendices Details of therapy intensifications on diabetes (1) Change of therapies on diabetes Addition of new drug gliclazide glimepiride metformin hydrochloride Rosuvastatin Atorvastatin (n = 514) (n = 504) 61 (11.9%) 83 (16.5%) 29 0 4 11 (5.6%) (0.0%) (0.8%) (2.1%) 54 2 4 7 (10.7%) (0.4%) (0.8%) (1.4%) pioglitazone hydrochloride 2 (0.4%) 2 (0.4%) sitagliptin phosphate hydrate 6 (1.2%) 14 (2.8%) alogliptin benzoate 4 (0.8%) 7 (1.4%) vildagliptin 3 (0.6%) 10 (2.0%) linagliptin 0 (0.0%) 3 (0.6%) teneligliptin hydrobromide hydrate 0 (0.0%) 1 (0.2%) voglibose 0 (0.0%) 2 (0.4%) miglitol 0 (0.0%) 3 (0.6%) mitiglinide calcium hydrate 0 (0.0%) 1 (0.2%) liraglutide 1 (0.2%) 0 (0.0%) insulin glargine 0 (0.0%) 2 (0.4%) P value 0.0386 Details of therapy intensifications on diabetes (2) Rosuvastatin Atorvastatin P value (n = 514) Change of therapies on diabetes Increase of dosage 61 (11.9%) (n = 504 83 (16.5%) 15 (2.9%) 10 (2.0%) gliclazide 0 (0.0%) 1 (0.2%) glimepiride 7 (1.4%) 3 (0.6%) metformin hydrochloride 5 (1.0%) 4 (0.8%) pioglitazone hydrochloride 1 (0.2%) 0 (0.0%) sitagliptin phosphate hydrate 3 (0.6%) 2 (0.4%) vildagliptin 1 (0.2%) 0 (0.0%) Drug Changes (judged as therapy intensification) 1 (0.2%) 0 0.0386 (0.0%) DPP-4 inhibitor change+metformin hydrochloride 1 (0.2%) 0 (0.0%) Subtotal of therapy intensification 45 (8.8%) 64 (12.7%) 0.0432