Statins and diabetes: What are the connections?

Protein prenylation in islet β-cell function in health and metabolic stress

Protein prenylation has been implicated in a variety of cellular functions, including cytoskeletal remodeling, trafficking and fusion of secretory vesicles with the plasma membrane. It involves incorporation of either a 15-carbon farnesyl or a 20-carbon geranylgeranyl derivative of mevalonic acid into cysteines at the C-terminus of substrate proteins. At least four types of prenyltransferases, namely farnesyl transferase (FTase) and the geranylgeranyl transferases I-III (GGTase-I, II, and III) have been identified in mammalian cells. Published evidence suggests expression of functionally active forms of these prenyltransferases and their candidate substrate proteins in human islets, rodent islets, and clonal β-cells. Pharmacological and molecular biological evidence implicates requisite roles for protein prenylation in glucose-stimulated insulin secretion. Evidence is also emerging to indicate significant defects in protein prenylome in β-cell models of impaired insulin secretion and diabetes. This review will provide a status update on modulatory roles of protein prenylation, enzymes involved in this signaling pathway, their structural composition and regulation in the context of islet β-cell function in normal health. In addition, experimental evidence on the metabolic fate of protein prenylation pathway in the pancreatic β-cell following chronic exposure to diabetogenic stimuli is reviewed herein. Lastly, crucial gaps in our current understanding, and potential opportunities for future research in this area of islet biology are highlighted.

An update on renal tubular injury as related to glycolipid metabolism in diabetic kidney disease

Diabetic kidney disease (DKD) is a severe microvascular complication of diabetes, which can result in end-stage renal disease (ESRD). As the main site of renal reabsorption and its exposed environment, renal tubules can be damaged by various factors. Recent studies have shown that renal tubular epithelial cells (RTECs) injury plays an important role in the occurrence and progression of DKD. The glycolipid metabolism disorders are a vital factor contributing to RTECs injury, which in turn affects the progression of DKD. Abnormal glucose and lipid metabolism can cause oxidative stress, mitochondrial damage, cell apoptosis and lipid accumulation, which can cause RTECs injury. Therefore, this review describes the main pathological mechanism of the injury caused by glycolipid metabolism and the corresponding therapeutic drugs in the clinical treatment of DKD.

Immediate Versus 5-Year Risk-Guided Initiation of Treatment for Primary Prevention of Cardiovascular Disease for Australians Aged 40 Years: A Health Economic Analysis

BACKGROUND AND OBJECTIVE

Current Australian cardiovascular disease (CVD) prevention guidelines calculate 5-year CVD risk and recommend treatment when risk crosses specific thresholds. This may leave risk factors untreated for people with a low short-term (i.e. 5 years), but high long-term (i.e. lifetime), risk of CVD. We aimed to evaluate the cost effectiveness of intervention for risk factor control at age 40 years (regardless of calculated risk) compared to intervention for risk factor control at the age recommended by contemporary Australian CVD prevention guidelines (when the 5-year CVD risk reaches 10%) across a range of individual risk factor profiles.

METHODS

We used a causal microsimulation model populated with 108 different risk factor profiles, each replicated 10,000 times. Model data were derived from the UK Biobank study and published sources. The primary causal relationships factored in were those of low-density lipoprotein-cholesterol and systolic blood pressure with CVD (defined as myocardial infarction or stroke). The model simulated the ageing of individuals from 40 to 85 years. We calculated years of life lived, quality-adjusted life-years gained, incremental healthcare costs and the incremental cost-effectiveness ratio when low-density lipoprotein-cholesterol and blood pressure were controlled from age 40 years compared to initiation of treatment as recommended by Australian guidelines. The main side effect in the model was an increased risk of type 2 diabetes mellitus from statin use. The trade-off between reduced CVD and increased type 2 diabetes was summarised via quality-adjust life-years. Incremental cost-effectiveness ratios were compared to the Australian willingness-to-pay threshold of AU$28,000 per quality-adjust life-year gained. We adopted a healthcare perspective (2022 AUD) and discounted results at 3% annually.

RESULTS

An earlier intervention meaningfully prevented CVD in all but the lowest risk individuals. Intervention at age 40 years versus age when the 5-year CVD risk reaches 10% led to an increase in quality-adjust life-years for 37/54 female individuals and 44/54 male individuals simulated and an increase in years of life lived (i.e. life expectancy) for 46/54 female individuals and 47/54 male individuals simulated. Earlier intervention was also cost effective in 5/54 female individuals and 17/54 male individuals.

CONCLUSIONS

Current guidelines may result in certain individuals with a lower 5-year, but higher lifetime, risk of CVD being overlooked for earlier cost-effective interventions to prevent CVD.

Lipid-lowering drug therapy for reducing cardiovascular risk in diabetes. A clinical view of the Cardiovascular Disease Working Group of the Spanish Diabetes Society

Patients with type 2 diabetes mellitus (T2DM) managed in both hospital and out-ofhospital settings usually have a high/very high cardiovascular risk, with a high burden of cardiovascular disease. All this justifies that the reduction of low-density lipoprotein cholesterol is the main therapeutic goal in T2DM. However, residual cardiovascular risk is very prevalent in T2DM, and is usually associated with atherogenic dyslipidemia and hyperlipoproteinemia(a); therefore, it is also necessary to reverse these lipoprotein abnormalities to achieve effective cardiovascular prevention. Given the considerable armamentarium of lipid-lowering drugs currently available, the Cardiovascular Disease Working Group of the Spanish Diabetes Society has considered it appropriate to carry out a narrative review and update of the effectiveness of these lipid-lowering drugs in the population with T2DM taking into account their effect on the lipoprotein profile and their potential impact on glycemic control.

Lipoproteins and lipoprotein lipid composition are associated with stages of dysglycemia and subclinical coronary atherosclerosis

BACKGROUND

Dyslipidaemia in patients with diabetes contributes to the risk of atherosclerotic cardiovascular disease. We aimed to identify a dyslipidemic profile associated with both dysglycemia and subclinical coronary atherosclerosis.

METHODS

Study participants (n = 5050) were classified in three groups: normoglycemia, pre-diabetes, and diabetes. A coronary artery calcium score (CACS) > 0 defined subclinical coronary atherosclerosis. Two independent methods were used to identify, among 225 lipid biomarkers, those that were associated with pre-diabetes and diabetes and were further tested for association by zero inflated Poisson regression with CACS and with CACS burden in study participants with CACS>0. Estimates were adjusted for cardiovascular risk factors with an interaction term for dispensed lipid lowering drugs.

RESULTS

Thirty-two biomarkers associated with prediabetes and diabetes were further investigated for association with CACS. HDL diameter [multi-adjusted OR of 0.85 and 95 %CI (0.78-0.92)] as well as free cholesterol, phospholipids and total lipids in extra large HDL were inversely associated with CACS. There was a borderline significant interaction between small HDL and dispensed lipid lowering drugs on the presence of CACS, with and multi-adjusted OR of 0.53 and 95 %CI (0.36-0.77). None of the 32 glycemic profile-related lipid biomarkers associated with the relative increase of CACS in those with CACS>0. No consistent association was observed between non-HDL lipoproteins and CACS.

CONCLUSIONS

Changes in composition and relative concentration of HDL associated with both dysglycemia and subclinical coronary atherosclerosis. Treatment with lipid lowering drugs may contribute to reduce the risk associated with high circulating levels of small HDL.

How to achieve LDL cholesterol goals with the funding criteria for new lipid-lowering drugs?

Given the apparent inconsistency of having potent lipid-lowering drugs and the unacceptable rate of achievement of therapeutic goals in LDL cholesterol, it is imperative to define new strategies. In this regard, it is appropriate to detail the key points in planning to start lipid-lowering therapy, emphasizing relevant clinical aspects such as the considerable individual variability in the response to statin therapy, positioning in relation to high-potency statins versus statin+ezetimibe combination therapy, and the order of choice of lipid-lowering drugs in the therapeutic strategy. An algorithm is then proposed that ensures a personalized approach to lipid-lowering drug treatment in patients with cardiovascular disease and/or familial hypercholesterolemia with the aim of achieving the therapeutic goal in the shortest possible time, taking into account the patient's previous treatment, the funding criteria for new drugs, and the individualized goal of LDL cholesterol reduction.

Statins in the Cause and Prevention of Cancer: Confounding by Indication and Mediation by Rhabdomyolysis and Phosphate Toxicity

Statins are drugs used in cardiovascular pharmacotherapy to decrease hypercholesterolemia and lower the risk of atherosclerosis. Statins also increase the risk of rhabdomyolysis, which is often minimized in comparison with large relative risk reductions of cardiovascular disease reported in clinical trials. By contrast, absolute risk reductions of cardiovascular disease are often clinically insignificant and unreported in statin clinical trials. Additionally, cytotoxic effects of statins inhibit cancer cell proliferation and reduce cancer risk, but other studies found that statins are carcinogenic. Due to an inverse association between incidence of cancer and atherosclerosis, the indication to prescribe statins likely biases the association of statins with cancer prevention. Dietary patterns associated with atherosclerosis and cancer contain inverse amounts of cholesterol and phosphate, an essential mineral that stimulates tumorigenesis. Accordingly, lower cancer risk is associated with high dietary cholesterol intake and increased risk of atherosclerosis. Furthermore, serum is exposed to excessive inorganic phosphate that could increase cancer risk as rhabdomyolysis induced by statins releases phosphate from skeletal muscle breakdown. Increased risk of comorbid conditions associated with statins may share the mediating factor of phosphate toxicity. More research is warranted on statins in the cause and prevention of cancer.

Treating Hypercholesterolemia in Older Adults for Primary Prevention of Cardiovascular Events

As the population ages, the demographic of adults aged 75 years and older in the U.S. is projected to grow to 45 million by 2050. Hypercholesterolemia is directly linked to atherosclerotic cardiovascular disease (ASCVD), which remains the leading cause of death in older adults. However, primary prevention of ASCVD through lipid-lowering agents remains unclear among older adults owing to limited involvement of older adults in current trials, lack of dedicated trials, and evidence primarily derived from secondary and retrospective analyses. Therefore, this article aims to (1) review key updates from the latest guidelines on treatment of hypercholesterolemia in older adults, (2) highlight limitations of the current ASCVD risk scores in the geriatric population, (3) present outcomes from key studies on the use of lipid-lowering agents and associated side effects, including a brief review of novel agents such as bempedoic acid, although very few adults over age 75 were included in these trial, and (4) finally, highlight upcoming dedicated trials of statins in older adults for the primary prevention of important geriatric outcomes as well as ASCVD.

[Rationale for Increasing Doses of Statins in Everyday Clinical Practice]

HMG-CoA reductase inhibitors (statins) were discovered in the early 1970s in Japan and were originally used to treat patients with hereditary hyperlipidemia. In the late 1990s and early 2000s, clinical trials using statins for primary and secondary prevention showed the possibility of reducing cardiovascular (CV) and, in some cases, all-cause mortality. Intensive statin therapy (atorvastatin 80 mg/day and rosuvastatin 40 mg/day) compared to initial doses provides an additional 16% reduction in CV complications. Regression studies with the original rosuvastatin using intracoronary ultrasound and other modern methods have shown the possibility of stabilization and regression of atherosclerosis in the carotid and coronary arteries. High-dose statin therapy is generally well tolerated; the incidence of clinically significant adverse liver reactions does not exceed 2-3 per 100,000 people, and the incidence of myopathies with increased creatine kinase over 10 upper limits of normal is not higher than 1 per 10,000 people per year. Long-term statin treatment does not increase the risk of dementia and, in some studies, reduced the risk of Alzheimer's disease. Achieving target levels of low-density lipoprotein cholesterol (LDL-C) in routine practice does not exceed 5-11%; one of the main reasons for that is the rare (2-3%) prescription of high doses of statins. Increasing statin doses in routine clinical practice will optimize the treatment of patients with high CV risk and will contribute to further reduction of mortality in our country.

A novel chemically engineered multifunctional statin conjugate as self-assembled nanoparticles inhibiting bile acid transporters

Statins are widely used to treat hyperlipidemia; however, their mechanism-inhibiting cholesterol production without promoting its utilization-causes problems, such as inducing diabetes. In our research, we develop, for the first time, a chemically engineered statin conjugate that not only inhibits cholesterol production but also enhances its consumption through its multifunctional properties. The novel rosuvastatin (RO) and ursodeoxycholic acid (UDCA) conjugate (ROUA) is designed to bind to and inhibit the core of the apical sodium-dependent bile acid transporter (ASBT), effectively blocking ASBT's function in the small intestine, maintaining the effect of rosuvastatin. Consequently, ROUA not only preserves the cholesterol-lowering function of statins but also prevents the reabsorption of bile acids, thereby increasing cholesterol consumption. Additionally, ROUA's ability to self-assemble into nanoparticles in saline-attributable to its multiple hydroxyl groups and hydrophobic nature-suggests its potential for a prolonged presence in the body. The oral administration of ROUA nanoparticles in animal models using a high-fat or high-fat/high-fructose diet shows remarkable therapeutic efficacy in fatty liver, with low systemic toxicity. This innovative self-assembling multifunctional molecule design approach, which boosts a variety of therapeutic effects while minimizing toxicity, offers a significant contribution to the advancement of drug development.

Cracking the code of the cardiovascular enigma: hPSC-derived endothelial cells unveil the secrets of endothelial dysfunction

Endothelial dysfunction is a central contributor to the development of most cardiovascular diseases and is characterised by the reduced synthesis or bioavailability of the vasodilator nitric oxide together with other abnormalities such as inflammation, senescence, and oxidative stress. The use of patient-specific and genome-edited human pluripotent stem cell-derived endothelial cells (hPSC-ECs) has shed novel insights into the role of endothelial dysfunction in cardiovascular diseases with strong genetic components such as genetic cardiomyopathies and pulmonary arterial hypertension. However, their utility in studying complex multifactorial diseases such as atherosclerosis, metabolic syndrome and heart failure poses notable challenges. In this review, we provide an overview of the different methods used to generate and characterise hPSC-ECs before comprehensively assessing their effectiveness in cardiovascular disease modelling and high-throughput drug screening. Furthermore, we explore current obstacles that will need to be overcome to unleash the full potential of hPSC-ECs in facilitating patient-specific precision medicine. Addressing these challenges holds great promise in advancing our understanding of intricate cardiovascular diseases and in tailoring personalised therapeutic strategies.

Lipid-lowering in diabetes: An update

Atherosclerotic cardiovascular disease (ASCVD) is accelerated in people with diabetes. Dyslipidemia, hyperglycemia, oxidative stress, and inflammation play a role via a variety of mechanisms operative in the artery wall. In addition, some unique features predispose people with type 1 diabetes to accelerated atherosclerosis. Various organizations have created guidelines that provide advice regarding screening, risk assessment, and roadmaps for treatment to prevent ASCVD in diabetes. Management of dyslipidemia, especially with statins, has proven to be of immense benefit in the prevention of clinical CVD. However, since many patients fail to attain the low levels of low-density lipoproteins (LDL) recommended in these guidelines, supplemental therapy, such as the addition of ezetimibe, bempedoic acid or PCSK9 inhibitors, is often required to reach LDL goals. As a result, the upfront use of combination therapies, particularly a statin plus ezetimibe, is a rational initial approach. The addition to statins of drugs that specifically lower triglyceride levels has not proven beneficial, although the addition of icosapent-ethyl has been shown to be of value, likely by mechanisms independent of triglyceride lowering. Newer treatments in development, including apoC-III and ANGPTL3 inhibitors, seem promising in further reducing apoB-containing lipoproteins.

Atorvastatin ameliorated myocardial fibrosis by inhibiting oxidative stress and modulating macrophage polarization in diabetic cardiomyopathy

In this editorial, we commented on the article published in the recent issue of the World Journal of Diabetes. Diabetic cardiomyopathy (DCM) is characterized by myocardial fibrosis, ventricular hypertrophy and diastolic dysfunction in diabetic patients, which can cause heart failure and threaten the life of patients. The pathogenesis of DCM has not been fully clarified, and it may involve oxidative stress, inflammatory stimulation, apoptosis, and autophagy. There is lack of effective therapies for DCM in the clinical practice. Statins have been widely used in the clinical practice for years mainly to reduce cholesterol and stabilize arterial plaques, and exhibit definite cardiovascular protective effects. Studies have shown that statins also have anti-inflammatory and antioxidant effects. We were particularly concerned about the recent findings that atorvastatin alleviated myocardial fibrosis in db/db mice by regulating the antioxidant stress and anti-inflammatory effects of macrophage polarization on diabetic myocardium, and thereby improving DCM.

Hyperlipidaemia in diabetes: are there particular considerations for next-generation therapies?

Dyslipidaemias are major cardiovascular risk factors, especially in people with diabetes. In this area, next-generation therapies targeting circulating lipoparticle metabolism (LDL, VLDL, chylomicrons, HDL) have recently been approved by the European and US medical agencies, including anti- proprotein convertase subtilisin/kexin 9 (PCSK9) antibodies; an siRNA targeting PCSK9; bempedoic acid, which targets ATP citrate lyase; an antisense oligonucleotide targeting apolipoprotein C-III; an anti-angiopoietin-like 3 antibody; and a purified omega-3 fatty acid, icosapent ethyl. Other therapies are in different phases of development. There are several important considerations concerning the link between these new lipid-lowering therapies and diabetes. First, since concerns were first raised in 2008 about an increased risk of new-onset diabetes mellitus (NODM) with intensive statin treatment, each new lipid-lowering therapy is being evaluated for its associated risk of NODM, particularly in individuals with prediabetes (impaired fasting glucose and/or impaired glucose tolerance). Second, people with diabetes represent a large proportion of those at high or very high cardiovascular risk in whom these lipid-lowering drugs are currently, or will be, prescribed. Thus, the efficacy of these drugs in subgroups with diabetes should also be closely considered, as well as any potential effects on glycaemic control. In this review, we describe the efficacy of next-generation therapies targeting lipoprotein metabolism in subgroups of people with diabetes and their effects on glycaemic control in individuals with diabetes and prediabetes and in normoglycaemic individuals.

A Systematic Review of Statins for the Treatment of Nonalcoholic Steatohepatitis: Safety, Efficacy, and Mechanism of Action

Nonalcoholic fatty liver disease (NAFLD) is the liver component of a cluster of conditions, while its subtype, nonalcoholic steatohepatitis (NASH), emerges as a potentially progressive liver disorder that harbors the risk of evolving into cirrhosis and culminating in hepatocellular carcinoma (HCC). NASH and cardiovascular disease (CVD) have common risk factors, but compared to liver-related causes, the most common cause of death in NASH patients is CVD. Within the pharmacological armamentarium, statins, celebrated for their lipid-modulating prowess, have now garnered attention for their expansive therapeutic potential in NASH. Evidence from a plethora of studies suggests that statins not only manifest anti-inflammatory and antifibrotic properties but also impart a multifaceted beneficial impact on hepatic health. In this review, we used "statin", "NAFLD", "NASH", and "CVD" as the major keywords and conducted a literature search using the PubMed and Web of Science databases to determine the safety and efficacy of statins in patients and animals with NASH and NAFLD, and the mechanism of statin therapy for NASH. Simultaneously, we reviewed the important role of the intestinal microbiota in statin therapy for NASH, as it is hoped that statins will provide new insights into modulating the harmful inflammatory microbiota in the gut and reducing systemic inflammation in NASH patients.

Statin use and incident type 2 diabetes mellitus in women after menopause

Menopause is associated with adverse cardiometabolic changes which increase the risk of new-onset type 2 diabetes (T2DM) and cardiovascular disease (CVD). Statins are widely used for primary and secondary CVD prevention, given their beneficial effects on the lipid profile and the vessel wall. On the other hand, statins increase the risk of T2DM. This association has been evaluated mainly in mixed-gender studies, without gender-specific evaluation. This narrative review evaluates the use of statins and the related risk of new-onset T2DM among postmenopausal women. Studies that incorporated a gender-specific analysis report a higher risk of new-onset T2DM in women than in men on treatment with statins. Fewer studies evaluated female-only samples; these confirm the observed association between statin use and new-onset T2DM. Factors influencing the association between statin use and T2DM include the type and dose of statin and the baseline metabolic status. Women may benefit from stratification of their metabolic risk before initiating a statin for CVD prevention.

Prostate Cancer and the Mevalonate Pathway

Antineoplastic therapies for prostate cancer (PCa) have traditionally centered around the androgen receptor (AR) pathway, which has demonstrated a significant role in oncogenesis. Nevertheless, it is becoming progressively apparent that therapeutic strategies must diversify their focus due to the emergence of resistance mechanisms that the tumor employs when subjected to monomolecular treatments. This review illustrates how the dysregulation of the lipid metabolic pathway constitutes a survival strategy adopted by tumors to evade eradication efforts. Integrating this aspect into oncological management could prove valuable in combating PCa.

Can acetate via FFA receptors contribute to the diabetogenic effect of statins?

Despite the proven effects of statins in preventing cardiovascular disease, their diabetogenic effect has caused concern. The mechanism of this diabetogenic effect is unknown. We suggest a novel mechanism that may contribute to the diabetogenic effect of statins, through an effect of statins that has apparently escaped previous consideration. Briefly, by inhibiting HMG-CoA reductase, statins may cause accumulation of acetate, which through FFA2 and FFA3 stimulation may inhibit insulin secretion.

Statins and risk of type 2 diabetes: mechanism and clinical implications

Statins are widely used to prevent cardiovascular disease events. Cardiovascular diseases and type 2 diabetes are tightly connected since type 2 diabetes is a major risk factor for cardiovascular diseases. Additionally, cardiovascular diseases often precede the development of type 2 diabetes. These two diseases have common genetic and environmental antecedents. Statins are effective in the lowering of cardiovascular disease events. However, they have also important side effects, including an increased risk of type 2 diabetes. The first study reporting an association of statin treatment with the risk of type 2 diabetes was the WOSCOPS trial (West of Scotland Coronary Prevention Study) in 2001. Other primary and secondary cardiovascular disease prevention studies as well as population-based studies have confirmed original findings. The purpose of our review is to examine and summarize the most important findings of these studies as well as to describe the mechanisms how statins increase the risk of type 2 diabetes.

The role of atherogenic lipoproteins in diabetes: Molecular aspects and clinical significance

Dyslipidaemia plays a prominent role in the genesis of atherosclerotic plaque and the increased cardiovascular risk in diabetes. Macrophages readily take up atherogenic lipoproteins, transforming into foam cells and amplifying vascular damage in the presence of endothelial dysfunction. We discuss the importance of distinct lipoprotein subclasses in atherogenic diabetic dyslipidaemia as well as the effects of novel anti-diabetic agents on lipoprotein fractions and ultimately on cardiovascular risk prevention. In patients with diabetes, lipid abnormalities should be aggressively identified and treated in conjunction with therapeutical agents used to prevent cardiovascular disease. The use of drugs that improve diabetic dyslipidaemia plays a prominent role in conferring cardiovascular benefit in individuals with diabetes.