9 March 2007
VERSION: 1 2 3 4 5 6 7 8 9

Pravafen
A Multi-Center, Prospective, Longitudinal, Randomized, Double-Blind, Phase III Study to Evaluate the Efficacy and Safety of Daily Administration of Pravastatin 40 mgm or Fenofibrate 160mgm or Pravafen (combination of Pravastatin and Fenofibrate 40/160) for 12Weeks Followed by a 52-Week Open-Label Safety Phase of the Pravafen alone in the Treatment of Combined Hyperlipidemia
Sponsor: Sciele Pharma, Inc. + Galephar Pharmaceutical Research
Drug: Pravafen (combo of Pravachol/Pravastatin 40 mgm & Tricor/Fenofibrate 160 mgm)
Site #: 07
CRA: Donica Williams Donica.Williams@Integrium.com
IRB: Sterling
IVRS (Interactive Voice Response System):
CRO: Integrium
Central Lab: Lab Connect
Phase 3
500 Subjects/ Sites = Subjects per Site; R 3 Arms: 1:1:2 ration of: Pravachol 40: TriCor 160: Both
TLC: AHA Step 2 Diet

IC
Age 18-75
GFR more or equals 60
Combined Hyperlipidemia Type IIB
NaÔve or MonoRx: LDL > 130 AND TG more or equals 150 + less or equals 400
ComboRx: LDL > 110 AND TG more or equals 150 + less or equals 400
To Progress to the V3 Baseline Efficacy Phase: -> LDL > 100 AND TG more or equals 150 + less or equals 400

EC
HgbAIC > 8.5 or IDDM
Serious CV Dz
BP 160/100
Hepatic insufficiency
Renal Insufficiency
OSAS
Change in BP med x past month
Steroids
Hyperlipidemia Type: I; IIa; IV; V
Framingham Risk Factors (RF) -> If > 1, Perform 10 Yr. Risk Assessment
1. Smoking
2. BP 140/90 or Rxíed
3. HDL < 40 (subtract one RF if > 60)
4. FH premature CAD in: Men: < 55 or Women < 65
5. Age: Men: at least 45 or Women at least 55

9 March 2007
VERSION: 1 2 3 4 5 6 7 8 9

Pravafen

V1 W -8.5 Lab, ICF, UA, EKG, Selection Phase

V1d W -8 Review labs and Begin open-label Pravachol 40 mgm

V2 W -1 Lab, RTC 1 wk +/- 3 days

V3 D 0 Lab, TLC, R, Baseline Efficacy Phase

V4 W 3 D 21 +/- 3 Lab, TLC

V5 W 6 D 42 +/- 3 Lab, TLC

V6 W 9 D 63 +/- 3 Lab, TLC

V7 W 12 D 84 +/- 3 Lab, TLC, EKG

V8 W 24 D 168 +/- 7 Lab, TLC, Safety Phase Open-Label Pravafen 40/160

V9 W 36 D 252 +/- 7 Lab, TLC; must fulfill NCEP ATP III Lipid levels or flunk-out

V10 W 48 D 336 +/- 7 Lab, TLC, RTC 4 wks +/- 7 days

V11 W 64 D 448 +/- 7 Lab, EKG

Questions

1. GFR 60 or 50? I found it said more than 50 to enter the study & more than 60 to continue study. Is this correct?
2. Indemnification: The sponsor likes to be held harmless for acts of negligence that the PI commits that are solely the error of the treating physician. For example, if a PI treats a subject's UTI during a study and the patient suffers an injury from this, it is squarely the PIís fault and it would not be proper for the sponsor to sustain an injury by being held liable for it. However, we are aware of a BP study where the PI followed the protocol and had the subject wash off their BP medication and suffer a stroke from the lack of the proper BP treatment. The sponsor forced the PI to use his medical malpractice insurance to satisfy the claim for medical malpractice. Clearly, this was an injustice as the PI was following the protocol precisely and even though it is unusual for a stroke to occur during wash out, it certainly does not immunize the subject from having a stroke. When a stroke occurs during wash out it is important that the sponsor take responsibility for the liability. This should be true of any injury ex officio of changing a subjectís treatment while following the protocol.
3. Study Fully Populated Causing Premature Early Termination: As sites advertise for patients to become research volunteers, the people that are good enough to step forward to join, wash off of their existing treatment, come to our site and devote a significant amount of their time with blood draws, signing paperwork and allowing the experimental protocol to progress, should be guaranteed that the sponsor will not prematurely shut down the study because they have obtained the needed number of subjects. That is, it should be the sponsorís responsibility to do the number crunching early enough not to allow subjects to sign consent and undergo early termination just because the study is now considered full enough. This is not ethical or in the patients best interest. All subjects who sign consent must be allowed to continue thru the protocol if they are continuing to fulfill criteria regardless of how many subjects are in the trial.
4. Reimbursement for Screen Failures: Sites are taking finincial risk in the name of enrolling only those subjects who will successfully complete the trial. Sponsors need to recognize that this significantly slows enrollment. When we see a subject who may qualify but then again may not, we would be hesitant to enroll in that study. Since the exclusivity clock starts clicking as soon as the drug is patented it is imperative that the studies are done as quickly as possible. Sites that are rewarded for each piece of work they legitimately perform will have to enroll better. Sites with too high screen failure rates can be turned off to ensure the proper motivation to enroll high quality subjects is present.
5. Initial Fasting Labs and Informed Consent: Many trials have visit one with fasting labs and signing informed consent on the same day. This is less desirable than having a visit one where the subject presents non-fasting for the purpose of signing the informed consent form and having the study discussed with them. The potential problem is with a diabetic. If a diabetic patient answers an ad and presents fasting for visit one, a research related procedure was done prior to signing the ICF (Informed Consent Form). They could get a low sugar reaction while driving to the site and suffer an MVA. They may also feel pressured to sign the ICF quickly as they know when the do so they will finally get something to eat. This can be most safely avoided by allowing subjects to sign the ICF on a pre-visit one or by writing protocols that don't have fasting labs as a visit one procedure.
6. Recruitment: Too often recruitment is an oversight thought to be the sites problem dealt with at a time other than the beginning of the trial. It becomes the sponsorís problem after many sites under enroll. Wise sponsors address recruitment up front at the investigatorís meeting and include recruitment agencies. One budget neutral solution is for the sponsor to push to make available an IRB approved ad for those using the central IRB at the very beginning of the trial. In addition use of centralized recruitment agencies like Pi and Acurian can very useful and cost effective. All our databases could be larger. A small minority of people step forward to become research subject volunteers. Planning for recruitment issues at the beginning is much better than catch up at the end.

Introduction to Cholesterol Metabolism
Cholesterol is an extremely important biological molecule that has roles in membrane structure as well as being a precursor for the synthesis of the steroid hormones and bile acids. Both dietary cholesterol and that synthesized de novo are transported through the circulation in lipoprotein particles. The same is true of cholesteryl esters, the form in which cholesterol is stored in cells. The synthesis and utilization of cholesterol must be tightly regulated in order to prevent over-accumulation and abnormal deposition within the body. Of particular importance clinically is the abnormal deposition of cholesterol and cholesterol-rich lipoproteins in the coronary arteries. Such deposition, eventually leading to atherosclerosis, is the leading contributory factor in diseases of the coronary arteries.
Cholesterol
Biosynthesis of Cholesterol
Slightly less than half of the cholesterol in the body derives from biosynthesis de novo. Biosynthesis in the liver accounts for approximately 10% and in the intestines approximately 15%, of the amount produced each day. Cholesterol synthesis occurs in the cytoplasm and microsomes from the two-carbon acetate group of acetyl-CoA.
The process has five major steps:
∑ 1. Acetyl-CoAs are converted to 3-hydroxy-3-methylglutaryl-CoA (HMG-CoA)
∑ 2. HMG-CoA is converted to mevalonate
∑ 3. Mevalonate is converted to the isoprene based molecule, isopentenyl pyrophosphate (IPP), with the concomitant loss of CO2
∑ 4. IPP is converted to squalene
∑ 5. Squalene is converted to cholesterol.
TAK-475 is a novel SSI (Squalene Synthase Inhibitor) that blocks step # 5.
Statins block step # 2.
Pathway of cholesterol biosynthesis. Synthesis begins with the transport of acetyl-CoA from the mitochondrion to the cytosol. The rate limiting step occurs at the 3-hydroxy-3-methylglutaryl-CoA (HMG-CoA) reductase, HMGR catalyzed step. The phosphorylation reactions are required to solubilize the isoprenoid intermediates in the pathway. Intermediates in the pathway are used for the synthesis of prenylated proteins, dolichol, coenzyme Q and the side chain of heme a.
The acetyl-CoA utilized for cholesterol biosynthesis is derived from an oxidation reaction (eg, fatty acids or pyruvate) in the mitochondria and is transported to the cytoplasm by the same process as that described for fatty acid synthesis (see the Figure below). Acetyl-CoA can also be derived from cytoplasmic oxidation of ethanol by acetyl-CoA synthetase. All the reduction reactions of cholesterol biosynthesis use NADPH as a cofactor. The isoprenoid intermediates of cholesterol biosynthesis can be diverted to other synthesis reactions, such as those for dolichol (used in the synthesis of N-linked glycoproteins, coenzyme Q (of the oxidative phosphorylation) pathway or the side chain of heme a. Additionally, these intermediates are used in the lipid modification of some proteins.
Pathway for the movement of acetyl-CoA units from within the mitochondrion to the cytoplasm for use in lipid and cholesterol biosynthesis. Note that the cytoplasmic malic enzyme catalyzed reaction generates NADPH which can be used for reductive biosynthetic reactions such as those of fatty acid and cholesterol synthesis. Acetyl-CoA units are converted to mevalonate by a series of reactions that begins with the formation of HMG-CoA. Unlike the HMG-CoA formed during ketone body synthesis in the mitochondria, this form is synthesized in the cytoplasm. However, the pathway and the necessary enzymes are the same as those in the mitochondria. Two moles of acetyl-CoA are condensed in a reversal of the thiolase reaction, forming acetoacetyl-CoA. Acetoacetyl-CoA and a third mole of acetyl-CoA are converted to HMG-CoA by the action of HMG-CoA synthase. HMG-CoA is converted to mevalonate by HMG-CoA reductase, HMGR (this enzyme is bound in the endoplasmic reticulum, ER). HMGR absolutely requires NADPH as a cofactor and two moles of NADPH are consumed during the conversion of HMG-CoA to mevalonate. The reaction catalyzed by HMGR is the rate limiting step of cholesterol biosynthesis, and this enzyme is subject to complex regulatory controls. Mevalonate is then activated by three successive phosphorylations, yielding 5-pyrophosphomevalonate. In addition to activating mevalonate, the phosphorylations maintain its solubility, since otherwise it is insoluble in water. After phosphorylation, an ATP-dependent decarboxylation yields isopentenyl pyrophosphate, IPP, an activated isoprenoid molecule. Isopentenyl pyrophosphate is in equilibrium with its isomer, dimethylallyl pyrophosphate, DMPP. One molecule of IPP condenses with one molecule of DMPP to generate geranyl pyrophosphate, GPP. GPP further condenses with another IPP molecule to yield farnesyl pyrophosphate, FPP. Finally, the NADPH-requiring enzyme, squalene synthase catalyzes the head-to-tail condensation of two molecules of FPP, yielding squalene (squalene synthase also is tightly associated with the endoplasmic reticulum). Squalene undergoes a two step cyclization to yield lanosterol. The first reaction is catalyzed by squalene monooxygenase. This enzyme uses NADPH as a cofactor to introduce molecular oxygen as an epoxide at the 2,3 position of squalene. Through a series of 19 additional reactions, lanosterol is converted to cholesterol.
Regulating Cholesterol Synthesis
Normal healthy adults synthesize cholesterol at a rate of approximately 1g/day and consume approximately 0.3g/day. A relatively constant level of cholesterol in the body (150 - 200 mg/dL) is maintained primarily by controlling the level of de novo synthesis. The level of cholesterol synthesis is regulated in part by the dietary intake of cholesterol. Cholesterol from both diet and synthesis is utilized in the formation of membranes and in the synthesis of the steroid hormones and bile acids (see below). The greatest proportion of cholesterol is used in bile acid synthesis.
The cellular supply of cholesterol is maintained at a steady level by three distinct mechanisms:
∑ 1. Regulation of HMGR activity and levels
∑ 2. Regulation of excess intracellular free cholesterol through the activity of acyl-CoA:cholesterol acyltransferase, ACAT
∑ 3. Regulation of plasma cholesterol levels via LDL receptor-mediated uptake and HDL-mediated reverse transport.
Regulation of HMGR activity is the primary means for controlling the level of cholesterol biosynthesis. The enzyme is controlled by four distinct mechanisms: feed-back inhibition, control of gene expression, rate of enzyme degradation and phosphorylation-dephosphorylation.
The first three control mechanisms are exerted by cholesterol itself. Cholesterol acts as a feed-back inhibitor of pre-existing HMGR as well as inducing rapid degradation of the enzyme. The latter is the result of cholesterol-induced polyubiquitination of HMGR and its degradation in the proteosome (see proteolytic degradation below). This ability of cholesterol is a consequence of the sterol sensing domain, SSD of HMGR. In addition, when cholesterol is in excess the amount of mRNA for HMGR is reduced as a result of decreased expression of the gene. The mechanism by which cholesterol (and other sterols) affects the transcription of the HMGR gene is described below under regulation of sterol content.
Regulation of HMGR through covalent modification occurs as a result of phosphorylation and dephosphorylation. The enzyme is most active in its unmodified form. Phosphorylation of the enzyme decreases its activity. HMGR is phosphorylated by AMP-activated protein kinase, AMPK (this is not the same as cAMP-dependent protein kinase, PKA). AMPK itself is activated via phosphorylation. The phosphorylation of AMPK is catalyzed by one or more AMPK kinases (AMPKKs). Visit AMPK: The Master Metabolic Regulator for more detailed information on the role of AMPK in regulating metabolism.
Regulation of HMGR by covalent modification. HMGR is most active in the dephosphorylated state. Phosphorylation is catalyzed by AMP-activated protein kinase, AMPK, (used to be termed HMGR kinase), an enzyme whose activity is also regulated by phosphorylation. Phosphorylation of AMPK is catalyzed by AMPK kinase (AMPKK). Hormones such as glucagon and epinephrine negatively affect cholesterol biosynthesis by increasing the activity of the inhibitor of phosphoprotein phosphatase inhibitor-1, PPI-1. Conversely, insulin stimulates the removal of phosphates and, thereby, activates HMGR activity. Additional regulation of HMGR occurs through an inhibition of its' activity as well as of its' synthesis by elevation in intracellular cholesterol levels. This latter phenomenon involves the transcription factor SREBP described below.
The activity of HMGR is additionally controlled by the cAMP signaling pathway. Increases in cAMP lead to activation of cAMP-dependent protein kinase, PKA. In the context of HMGR regulation, PKA phosphorylates phosphoprotein phosphatase inhibitor-1 (PPI-1) leading to an increase in its' activity. PPI-1 can inhibit the activity of numerous phosphatases including protein phosphatase 2C and HMG-CoA reductase phosphatase which remove phosphates from AMPK and HMGR, respectively. This maintains AMPK in the phosphorylated and active state, and HMGR in the phosphorylated and inactive state. As the stimulus leading to increased cAMP production is removed, the level of phosphorylations decreases and that of dephosphorylations increases. The net result is a return to a higher level of HMGR activity.
Since the intracellular level of cAMP is regulated by hormonal stimuli, regulation of cholesterol biosynthesis is hormonally controlled. Insulin leads to a decrease in cAMP, which in turn activates cholesterol synthesis. Alternatively, glucagon and epinephrine, which increase the level of cAMP, inhibit cholesterol synthesis.
The ability of insulin to stimulate, and glucagon to inhibit, HMGR activity is consistent with the effects of these hormones on other metabolic pathways. The basic function of these two hormones is to control the availability and delivery of energy to all cells of the body. Long-term control of HMGR activity is exerted primarily through control over the synthesis and degradation of the enzyme. When levels of cholesterol are high, the level of expression of the HMGR gene is reduced. Conversely, reduced levels of cholesterol activate expression of the gene. Insulin also brings about long-term regulation of cholesterol metabolism by increasing the level of HMGR synthesis.
Proteolytic Regulation of HMG-CoA Reductase
The stability of HMGR is regulated as the rate of flux through the mevalonate synthesis pathway changes. When the flux is high the rate of HMGR degradation is also high. When the flux is low, degradation of HMGR decreases. This phenomenon can easily be observed in the presence of the statin drugs.
HMGR is localized to the ER and like SREBP (see below) contains a sterol-sensing domain, SSD. When sterol levels increase in cells there is an concomitant increase in the rate of HMGR degradation. The degradation of HMGR occurs within the proteosome, a multiprotein complex dedicated to protein degradation. The primary signal directing proteins to the proteosome is ubiquitination. Ubiquitin is a 7.6kDa protein that is covalently attached to proteins targeted for degradation by ubiquitin ligases. These enzymes attach multiple copies of ubiquitin allowing for recognition by the proteosome. HMGR has been shown to be ubiquitinated prior to its degradation. The primary sterol regulating HMGR degradation is cholesterol itself. As the levels of free cholesterol increase in cells, the rate of HMGR degradation increases.

The Utilization of Cholesterol
Cholesterol is transported in the plasma predominantly as cholesteryl esters associated with lipoproteins. Dietary cholesterol is transported from the small intestine to the liver within chylomicrons. Cholesterol synthesized by the liver, as well as any dietary cholesterol in the liver that exceeds hepatic needs, is transported in the serum within LDLs. The liver synthesizes VLDLs and these are converted to LDLs through the action of endothelial cell-associated lipoprotein lipase. Cholesterol found in plasma membranes can be extracted by HDLs and esterified by the HDL-associated enzyme LCAT. The cholesterol acquired from peripheral tissues by HDLs can then be transferred to VLDLs and LDLs via the action of cholesteryl ester transfer protein (Apo-D) which is associated with HDLs. Reverse cholesterol transport allows peripheral cholesterol to be returned to the liver in LDLs. Ultimately, cholesterol is excreted in the bile as free cholesterol or as bile salts following conversion to bile acids in the liver.
Regulation of Cellular Sterol Content
The continual alteration of the intracellular sterol content occurs through the regulation of key sterol synthetic enzymes as well as by altering the levels of cell-surface LDL receptors. As cells need more sterol they will induce their synthesis and uptake, conversely when the need declines synthesis and uptake are decreased. Regulation of these events is brought about primarily by sterol-regulated transcription of key rate limiting enzymes and by the regulated degradation of HMGR. Activation of transcriptional control occurs through the regulated cleavage of the membrane-bound transcription factor sterol regulated element binding protein, SREBP. As discussed above, degradation of HMGR is controlled by the ubiquitin-mediated pathway for proteolysis.
Sterol control of transcription affects more than 30 genes involved in the biosynthesis of cholesterol, triacylglycerols, phospholipids and fatty acids. Transcriptional control requires the presence of an octamer sequence in the gene termed the sterol regulatory element, SRE-1. It has been shown that SREBP is the transcription factor that binds to SRE-1 elements. It turns out that there are 2 distinct SREBP genes, SREBP-1 and SREBP-2. In addition, the SREBP-1 gene encodes 2 proteins, SREBP-1a and SREBP-1c as a consequence of alternative exon usage. All 3 proteins are proteolytically regulated by sterols. Full-length SREBPs have several domains and are embedded in the membrane of the endoplasmic reticulum (ER). The N-terminal domain contains a transcription factor motif of the basic helix-loop-helix (bHLH) type that is exposed to the cytoplasmic side of the ER. There are 2 transmembrane spanning domains followed by a large C-terminal domain also exposed to the cytosolic side. When sterols are scarce, cleavage of the full-length SREBP takes place with the result being that the N-terminal bHLH motif is released into the cytosol. The bHLH domain then migrates to the nucleus to direct transcription. Conversely, when sterols are abundant, cleavage of SREBP is inhibited. To control the level of SREBP-mediated transcription, the soluble bHLH domain is itself subject to rapid proteolysis.
The cleavage of SREBP is carried out by 2 distinct enzymes, one of which is regulated by sterols. The regulated cleavage occurs in the lumenal loop between the 2 transmembrane domains. This cleavage is catalyzed by site-1 protease, S1P. High sterol content blocks the activity of S1P. The second cleavage, catalyzed by site-2 protease, S2P, occurs in the first transmembrane span, leading to release of active SREBP. In order for S2P to act on SREBP, site-1 must already have been cleaved.
Additional studies on sterol-regulated gene expression demonstrated that cleavage of SREBP by S1P is controlled by the level and action of an additional protein termed, SREBP cleavage-activating protein, SCAP. SCAP is a large protein also found in the ER membrane and contains at least 8 transmembrane spans. The C-terminal portion, which extends into the cytosol, has been shown to interact with the C-terminal domain of SREBP. This C-terminal region of SCAP contains 4 motifs called WD40 repeats. The WD40 repeats are required for interaction of SCAP with SREBP. Interestingly, the N-terminus of SCAP, including membrane spans 2-6, resembles HMGR which itself is subject to sterol-stimulated degradation (see above). This shared motif is called the sterol sensing domain, SSD. Several proteins whose functions involve sterols also contain the SSD. These include patched, an important development regulating receptor whose ligand, hedgehog, is modified by attachment of cholesterol and the Neimann Pick C1 (NPC1) protein which is involved in cholesterol transport in the secretory pathway. NPC1 is one of several genes whose activities, when disrupted, lead to severe neurological dysfunction.
The function of SCAP is to positively stimulate S1P-mediated cleavage of SREBP. The function of sterols is to inhibit this positive action of SCAP. The activity of SCAP involves movement from the ER to the Golgi and back. Because the C-terminus of SCAP interacts with SREBP, movement of SCAP takes SREBP along for the ride. When sterols are low, SCAP and SREBP move to the Golgi. This transit is required for SREBP cleavage as S1P is Golgi-localized. When sterols are high, movement of SCAP is halted. Thus, the overall effect of sterols is to regulate the ability of SCAP to present SREBP to S1P.
Diagrammatic representation of the interactions between SREBP and SCAP in the membrane of the ER CTD = C-terminal domain Bile Acids Synthesis and Utilization The end products of cholesterol utilization are the bile acids, synthesized in the liver. Synthesis of bile acids is one of the predominant mechanisms for the excretion of excess cholesterol. However, the excretion of cholesterol in the form of bile acids is insufficient to compensate for an excess dietary intake of cholesterol. Synthesis of the 2 primary bile acids, cholic acid and chenodeoxycholic acid. The reaction catalyzed by the 7a-hydroxylase is the rate limiting step in bile acid synthesis. Conversion of 7a-hydroxycholesterol to the bile acids requires several steps not shown in detail in this image. Only the relevant co-factors needed for the synthesis steps are shown.
The most abundant bile acids in human bile are chenodeoxycholic acid (45%) and cholic acid (31%). These are referred to as the primary bile acids. Within the intestines the primary bile acids are acted upon by bacteria and converted to the secondary bile acids, identified as deoxycholate (from cholate) and lithocholate (from chenodeoxycholate). Both primary and secondary bile acids are reabsorbed by the intestines and delivered back to the liver via the portal circulation.

Structure of the conjugated cholic acids
Within the liver the carboxyl group of primary and secondary bile acids is conjugated via an amide bond to either glycine or taurine before their being resecreted into the bile canaliculi. These conjugation reactions yield glycoconjugates and tauroconjugates, respectively. The bile canaliculi join with the bile ductules, which then form the bile ducts. Bile acids are carried from the liver through these ducts to the gallbladder, where they are stored for future use. The ultimate fate of bile acids is secretion into the intestine, where they aid in the emulsification of dietary lipids. In the gut the glycine and taurine residues are removed and the bile acids are either excreted (only a small percentage) or reabsorbed by the gut and returned to the liver. This process of secretion from the liver to the gallbladder, to the intestines and finally reabsorbtion is termed the enterohepatic circulation.
Clinical Significance of Bile Acid Synthesis
Bile acids perform four physiologically significant functions:
∑ 1. Their synthesis and subsequent excretion in the feces represent the only significant mechanism for the elimination of excess cholesterol.
∑ 2. Bile acids and phospholipids solubilize cholesterol in the bile, thereby preventing the precipitation of cholesterol in the gallbladder.
∑ 3. They facilitate the digestion of dietary triacylglycerols by acting as emulsifying agents that render fats accessible to pancreatic lipases.
∑ 4. They facilitate the intestinal absorption of fat-soluble vitamins.