Effects of Combination Lipid Therapy on Cardiovascular Events in Type 2 Diabetes Mellitus: The Action to Control Cardiovascular Risk in Diabetes (ACCORD) Lipid Trial

Henry N. Ginsberg, MDCollege of Physicians & Surgeons , Columbia University, New York

For The ACCORD Study Group

Dr. Ginsberg reports receiving ◦ Consulting fees from Merck, Merck Schering Plough,

Bristol-Myers Squibb, AstraZeneca, Abbott, Roche, Isis/Genzyme, GlaxoSmithKline, Novartis, Pfizer, and Regeneron/ SanofiAventis.

◦ Grant support from Merck, ISIS/Genzyme, Roche, and AstraZeneca.

Disclosure

ACCORD Sponsor, Collaborators and Contributors

Collaboration & support◦ National Institute of

Diabetes & Digestive & Kidney Diseases (NIDDK)

◦ National Eye Institute (NEI)

◦ National Institute on Aging (NIA)

◦ Centers for Disease Control and Prevention (CDC)

Contributions◦ Abbott Laboratories (and Fournier

Laboratories)◦ AstraZeneca Pharmaceuticals LP◦ Sanofi-Aventis U.S◦ GlaxoSmithKline Pharmaceuticals◦ King Pharmaceuticals, Inc.◦ MediSense Products (division of

Abbott Laboratories)◦ Merck & Company, Inc.◦ Closer Healthcare Inc.◦ Novartis Pharmaceuticals. Inc.◦ Novo Nordisk Pharmaceuticals., Inc.◦ Omron Healthcare, Inc.◦ Amylin Pharmaceuticals, Inc.◦ Takeda Pharmaceuticals Inc

Sponsor: The National Heart, Lung, and Blood Institute (NHLBI)

ACCORD Study Design

• Designed to independently test three medical strategies to reduce cardiovascular disease in diabetic patients

• Lipid Trial question: whether combination therapy with a statin plus a fibrate would reduce cardiovascular disease compared to statin monotherapy in people with type 2 diabetes mellitus at high risk for cardiovascular disease.

• Randomized, placebo-controlled, double-blind clinical trial conducted in 77 clinical sites in the U.S. and Canada

ACCORD Study Design

• Overall ACCORD Glycemia Trial: 10,251 participants

• Lipid Trial: 5,518 participants • 2765 randomized to fenofibrate• 2753 randomized to placebo

• Primary Outcome: First occurrence of a major cardiovascular event (nonfatal MI, nonfatal stroke, cardiovascular death)

• 87% power to detect a 20% reduction in event rate, assuming placebo rate of 2.4%/yr and 5.6 yrs follow-up in participants without events.

ACCORD Lipid Trial Eligibility• Stable Type 2 Diabetes >3 months• HbA1c 7.5% to 11%• High risk of CVD events = clinical or subclinical disease or

2+ risk factors • Age

• ≥ 40 yrs with history of clinical CVD (secondary prevention)• ≥ 55 yrs otherwise

• Lipids• 60 < LDL-C < 180 mg/dl• HDL-C < 55 mg/dl for women/Blacks; < 50 mg/dl otherwise• Triglycerides < 750 mg/dl if on no therapy; < 400 mg/dl

otherwise

• No contraindication to either fenofibrate or simvastatin

ACCORD Lipid Protocol

All participants on open-labeled simvastatin, 20 to 40 mg/day◦ Simvastatin dose complied with lipid guidelines

Patients randomized to double-blind placebo or fenofibrate, 54 to 160mg/day◦ Dosing based upon eGFR level

Only blinded ACCORD trial

Observed Follow-up: 4 to 8 years (mean 4.7 years)

Characteristic Mean or % CharacteristicMean or

%Age (yrs) 62 Total Cholesterol

(mg/dl)175

Women % 31 LDL-C (mg/dl) 101Race / Ethnicity HDL-C (mg/dl) 38 White % 68 Triglyceride (mg/dl)* 162 Black % 15 Blood pressure (mm

Hg)134/74

Hispanic % 7 Serum creatinine (mg/dl)

0.9

Secondary prevent %

37 Current smoking % 15

DM duration (yrs)* 9 On a statin % 60A1c (%) * 8.3 On another LLA % 8BMI (kg/m2) 32

Baseline Characteristics

* Median values

Plasma Lipid Levels During Trial

Adverse Experiences During Follow-upFenofibrate Placebo

Adverse events (no. (%)) (N=2765) (N=2753) P value

Out of the ordinary severe muscle aches/pains:

regardless of CK 1110 (40.1%) 1115 (40.5%) 0.81plus CK > 5 X ULN 7 (0.3%) 8 (0.3%) 0.79

plus CK > 10 X ULN 1 (0.04%) 2 (0.07%) 0.56

Any nonhypoglycemic SAE 54 (2.0%) 43 (1.6%) 0.27

Any Myopathy/Myositis/ Rhabdomyolysis SAE

4 (0.1%) 4 (0.1%) 1.00

Any Hepatitis SAE 3 (0.1%) 0 (0.0%) 0.18

Any SAE attributed to lipid meds 27 (1.0%) 19 (0.7%) 0.24

Lab Measures During Follow-upFenofibrate Placebo

Laboratory Measures (no. (%)) (N=2765) (N=2753) P value

ALT ever > 3X ULN 52 (1.9%) 40 (1.5%) 0.21

ALT ever > 5X ULN 16 (0.6%) 6 (0.2%) 0.03

CK ever > 5X ULN 51 (1.9%) 59 (2.2%) 0.43

CK ever > 10X ULN 10 (0.4%) 9 (0.3%) 0.83

Lab Measures During Follow-upFenofibrate Placebo

Laboratory Measures (no. (%)) (N=2765) (N=2753) P value

ALT ever > 3X ULN 52 (1.9%) 40 (1.5%) 0.21

ALT ever > 5X ULN 16 (0.6%) 6 (0.2%) 0.03

CK ever > 5X ULN 51 (1.9%) 59 (2.2%) 0.43

CK ever > 10X ULN 10 (0.4%) 9 (0.3%) 0.83

Serum creatinine elevation Women ever > 1.5 mg/dl Men ever > 1.3 mg/dl

235 (27.9%) 157 (18.7%) <0.001698 (36.7%) 350 (18.5%) <0.001

Post-randomization incidence ofmicroalbuminuria (> 30 to < 300 mg/g*) 1050 (38.2%) 1137 (41.6%) 0.01

Post-randomization incidence ofmacroalbuminuria (> 300 mg/g*) 289 (10.5%) 337 (12.3%) 0.03

Primary Outcome

Rate(%/yr)

Primary Outcome: Major Fatal or Nonfatal Cardiovascular Event

310 2.41

Placebo(N=2753)

N of Events

Primary Outcome

Rate Rate(%/yr) (%/yr)

Primary Outcome: Major Fatal or Nonfatal Cardiovascular Event

291 2.24 310 2.41

Fenofibrate Placebo(N=2765) (N=2753)

N of Events

N of Events

Primary Outcome

Rate Rate(%/yr) (%/yr) HR (95% CI) P Value

Primary Outcome: Major Fatal or Nonfatal Cardiovascular Event

291 2.24 310 2.41 0.92 (0.79 - 1.08)

0.32

Fenofibrate Placebo(N=2765) (N=2753)

N of Events

N of Events

Prespecified Secondary Outcomes

Rate Rate(%/yr) (%/yr) HR (95% CI) P Value

Primary + Revasc + hospitalized CHF 641 5.35 667 5.64 0.94 (0.85-1.05) 0.30

Major Coronary Event 332 2.58 353 2.79 0.92 (0.79-1.07) 0.26

Nonfatal MI 173 1.32 186 1.44 0.91 (0.74 - 1.12) 0.39

Total Stroke 51 0.38 48 0.36 1.05 (0.71 - 1.56) 0.80

Nonfatal Stroke 47 0.35 40 0.30 1.17 (0.76 - 1.78) 0.48

Total Mortality 203 1.47 221 1.61 0.91 (0.75 - 1.10) 0.33

Cardiovascular Death 99 0.72 114 0.83 0.86 (0.66 - 1.12) 0.26

Fatal/Nonfatal CHF 120 0.90 143 1.09 0.82 (0.65 - 1.05) 0.10

Fenofibrate Placebo

Outcome

(N=2765) (N=2753)N of

EventsN of

Events

Primary Outcome By Treatment Group and Baseline Subgroups

Primary Outcome By Treatment Group and Baseline Subgroups

Comparison of ACCORD subgroup results with those from prior fibrate studies

Trial(Drug)

Primary Endpoint: Entire Cohort (P-value)

Lipid Subgroup Criterion

Primary Endpoint: Subgroup

HHS (Gemfibrozil) -34% (0.02)

TG > 200 mg/dlLDL-C/HDL-C > 5.0

-71% (0.005)

BIP (Bezafibrate) -7.3% (0.24)

TG > 200 mg/dl -39.5% (0.02)

FIELD(Fenofibrate) -11% (0.16)

TG > 204 mg/dlHDL-C < 42 mg/dl

-27% (0.005)

ACCORD(Fenofibrate) -8% (0.32)

TG > 204 mg/dlHDL-C < 34 mg/dl

-31%

Conclusion (1)

• ACCORD Lipid does not support use of the

combination of fenofibrate and simvastatin,

compared to simvastatin alone, to reduce CVD

events in the majority of patients with T2DM who are

at high risk for CVD

Conclusion (2)

• Subgroup analyses suggesting heterogeneity in

response to combination therapy by gender or by

the presence of significant dyslipidemia require

further investigation