effects of atorvastatin on apelin, visfatin (nampt), ghrelin and early carotid atherosclerosis in...

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Acta Diabetologica ISSN 0940-5429Volume 49Number 4 Acta Diabetol (2012) 49:269-276DOI 10.1007/s00592-011-0310-0

Effects of atorvastatin on apelin, visfatin(nampt), ghrelin and early carotidatherosclerosis in patients with type 2diabetes

Nikolaos P. E. Kadoglou, NikolaosSailer, Alkistis Kapelouzou, StylianosLampropoulos, Ioulia Vitta, AlkiviadisKostakis, et al.

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ORIGINAL ARTICLE

Effects of atorvastatin on apelin, visfatin (nampt), ghrelinand early carotid atherosclerosis in patients with type 2 diabetes

Nikolaos P. E. Kadoglou • Nikolaos Sailer •

Alkistis Kapelouzou • Stylianos Lampropoulos •

Ioulia Vitta • Alkiviadis Kostakis • Christos D. Liapis

Received: 29 March 2011 / Accepted: 27 June 2011 / Published online: 12 July 2011

� Springer-Verlag 2011

Abstract To investigate the influence of atrovastatin

treatment on carotid intima-media thickness (CIMT) and

serum levels of novel adipokines, like apelin, visfatin (nampt),

and ghrelin, in patients with type 2 diabetes mellitus (T2DM).

87 statin-free patients (50 males) with T2DM, aged 55–70, but

without carotid atherosclerotic plaques were initially enrolled.

CIMT was assayed in all participants by ultrasound. Patients

were then treated with atorvastatin (10–80 mg) to target

LDL \100 mg/dl. Anthropometric parameters, blood pres-

sure, glycemic and lipid profile, high-sensitivity CRP

(hsCRP), insulin resistance (HOMA-IR), apelin, visfatin and

ghrelin were measured at baseline and after 12 months.

Atorvastatin treatment significantly improved lipid profile

across with increased apelin (from 0.307 ± 0.130 pg/ml to

1.537 ± 0.427 pg/ml; P \ 0.001) and suppressed visfatin

(from 21.54 ± 10.14 ng/ml to 15.13 ± 7.61 ng/ml; P =

0.002) serum levels in our diabetic patients. Standard multiple

regression analysis showed that the atorvastatin-induced

increment in apelin was independently associated with

changes in total cholesterol (b = –0.510, P = 0.030) and

LDL-cholesterol (b = –0.590, P \ 0.001) (R2 = 0.449,

P = 0.014), while the reduction of visfatin concentration

was independently associated with the change in hsCRP

(b = 0.589, P \ 0.001; R2 = 0.256, P = 0.006), after

adjustment for age, sex and BMI. CIMT and ghrelin did not

alter significantly after 12 months of atorvastatin treatment

(NS). Among participants, high-dose (80 mg) rather than low-

dose (10 mg) of atorvastatin treatment yielded greater

(P \ 0.05) changes in apelin, visfatin and CIMT levels

despite the final equivalent levels of LDL. Atorvastatin

administration increased apelin and decreased visfatin serum

levels significantly, without change of CIMT, in patients with

T2DM. However, high-dose of atorvastatin exerted more

favourable impact on adipokines and CIMT than low-dose.

Our results implicate another important link between adi-

posity and atherosclerosis.

Keywords Statins � Visfatin (nampt) � Ghrelin � Apelin �Carotid intima-media thickness � Type 2 diabetes

Introduction

Cholesterol-lowering therapy with 3-hydroxy-3-methyl-

glutaryl coenzyme A reductase inhibitors (statins) has been

widely-documented to suppress early atherosclerosis, as

expressed by carotid intima-media thickness (CIMT) [1],

and reduce the risk of cardiovascular events in patients

with type 2 diabetes mellitus (T2DM) [2]. Besides the

inhibition of cholesterol synthesis, the beneficial effects of

statins have been attributed in part to ‘‘pleiotropic mech-

anisms’’ as well as the attenuation of the pro-inflammatory/

pro-thrombotic pathways involved in atherothrombosis [3].

N. P. E. Kadoglou (&) � N. Sailer � I. Vitta

First Department of Internal Medicine,

‘‘Hippokratio’’ General Hospital of Thessaloniki,

Thessaloniki, Greece

e-mail: [email protected]; [email protected]

A. Kapelouzou � A. Kostakis

Foundation of Biomedical Research,

Center of Experimental Surgery,

Academy of Athens, Athens, Greece

S. Lampropoulos

Department of Cardiology,

‘‘Mpodosakio’’ General Hospital of Ptolemaida,

Ptolemaida, Greece

C. D. Liapis

Department of Vascular Surgery, Medical School,

University of Athens, Athens, Greece

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Acta Diabetol (2012) 49:269–276

DOI 10.1007/s00592-011-0310-0

Author's personal copy

Recent data suggest that adipose tissue may be a target of

statins’ ‘‘pleiotropic’’ anti-inflammatory effect, while adi-

pose-tissue derivatives, adipokines, may be a mediator of

the latter mechanisms of statins [4]. Inflammatory path-

ways are closely related with the metabolic syndrome,

prediabetes and T2DM, by increasing the cardiovascular

risk [5]. Therefore, adipokines may link adiposity,

inflammation and cardiovascular disease, providing a novel

therapeutic target of statins [6].

Apelin, a novel adipokine, has recently emerged as

regulatory factor of glucose homeostasis and insulin

resistance [7]. We and other investigators have previously

documented the link of low plasma apelin levels with

plaque vulnerability and coronary atherosclerosis severity

[8, 9]. However, the contribution of apelin to carotid ath-

erosclerosis is still elucidated. Regarding pharmaceutical

modulation, a sole study has shown positive effects of

statins and lipid-lowering on apelin levels [10].

Visfatin, nicotinamide phosphoribosyltransferase

(Nampt), has been initially recognized as a pre-B-cell col-

ony enhancing factor (PBEF), which enhances differentia-

tion of B cell precursors [11]. Most, but not all, studies

suggest this novel adipokine to trigger inflammation and

promote atherosclerosis associated with metabolic disorders

[12, 13]. Up to now, the anti-atherosclerotic impact of statins

on visfatin’s levels is subject of controversy [14, 15].

Ghrelin is a brain-gut peptide, involved in numerous

physiological processes (e.g. increased food intake, glucose

regulation, fat deposition), and metabolic abnormalities

(e.g. obesity, T2DM) [16]. A limited number of clinical

trials support the counter-regulatory effect of grhelin on

CIMT [12]. Despite the promising, anti-atherogenic role of

ghrelin, a sole study has demonstrated the absence of

changes after short-term atorvastatin therapy in T2DM

[17].

Taken together, we hypothesized that a 12 month,

intensive lipid-lowering treatment with atorvastatin would

favorably change serum concentration of novel adipokines

across with significant suppression of CIMT.

Materials and methods

Patients

Eighty-seven subjects with T2DM (21 men and 66

women), aged 64.1 ± 7.2 years, were selected for the

present study from patients who attend our outpatient

diabetes centre. The diagnosis of diabetes was based on a

previous history of diabetes or on the American Diabetes

Association criteria. All patients were under hypoglycemic

regimen (metformin, sulfonylureas, DPP-4 inhibitors,

insulin or their combination). Subjects with renal (serum

creatinine [2 mg/dl) or liver (Alanine Aminotransfer-

ase [3 times higher than the upper normal limit)

dysfunction, diagnosed coronary artery disease or overt

cardiac-origin symptoms, autoimmune diseases, malig-

nancy, ongoing use or contraindications to the use of lipid-

lowering medications and acute infection were excluded.

Subjects with carotid plaques identified at ultrasound

examination, thiazolidinediones treatment and LDL-C

\100 mg/dl were not considered eligible for our study.

Study design and methods

According to NCEP ATP III recommendations, diabetes

constitutes a coronary heart disease (CHD) equivalent and

elevated LDL-C levels ([100 mg/dl) is recommended to

be treated with statins, which have been demonstrated to

substantially improve outcomes [18]. Thus, it was deemed

unethical to randomize diabetic patients, even in the

absence of obvious CHD, to placebo. Accordingly, all

diabetic participants, after initial carotid ultrasound exam-

ination, were assigned to active treatment with atorvastatin.

The dose was gradually titrated (10 to 80 mg/day) at

6 weeks intervals to target LDL-C \ 100 mg/dl. Con-

comitant anti-hypertensive or hypoglycaemic medications

were maintained unaltered during this study, unless it was

considered medically necessary. We further explored the

differential response of normal-weight (BMI \ 25 kg/m2)

(group A) and overweight (BMI [ 25 kg/m2) (group B)

patients to atorvastatin regimen.

Blood sampling, ultrasound images of both carotids and

clinical parameters assessment, such as body mass index

(BMI), waist-hip ratio (WHR) and blood pressure (BP)

were obtained at baseline and at the end of the study. BMI

was calculated as body weight in kilograms divided by the

square of the height in meters (kg/m2). Waist circumfer-

ence was assessed at the level midway between the lower

rib margin and the iliac crest. The hips were measured at

the level of the greater femoral trochanters. Thus, WHR

expressed waist circumference divided by hip girth. BP

was measured twice, after keeping all participants in a

sitting position for 15 min. There was a 5 min interval

between the two measurements and the mean value was

estimated for study purposes. Constructed recommenda-

tions for smoking ceasing were provided to all smokers.

This study was approved by the Committees on Research

Ethics at our hospitals, in compliance with the ethical

guidelines of the Declaration of Helsinki. All participants

gave written informed consent prior to study entry.

Ultrasound

A diagnostic high-resolution B-mode ultrasound (General

Electric Logiq700, Riverside, USA) with a 7.5 MHz linear

270 Acta Diabetol (2012) 49:269–276

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array transducer of both carotids was performed in all

participants at baseline and at the end of the study. A single

ultrasound operator performed blinded to patients’ history

performed all ultrasound examinations and measurements.

The CIMT was calculated using an automated system

employing an edge detection algorithm with manual

override capacity defined. Two parallel echogenic lines

(double line pattern), which correspond to the lumen-

intima and the media-adventitia interfaces defined IMT

[19]. End-diastolic B-mode images of the distal right and

left common carotid artery (CCA) were acquired in real

time at longitudinal axis. Segments of each CCA at 1 cm

distance from the bifurcation on the far wall were allocated

for IMT measurement. We averaged six IMT measure-

ments made over six cardiac cycles of each carotid. Final

CIMT of each patient was calculated as the mean of left

and right CCA IMT. Focal thickening at least 50% greater

than that of the surrounding vessel wall was defined as a

discrete plaque. Moreover, extended locally thickened IMT

of [1.3 mm was considered as carotid atherosclerosis [20].

The reproducibility of the IMT measurements was verified

by a second ultrasonographer within 3 months in 20 dia-

betic subjects. The within-coefficient of variation was

4.9%. Carotid ultrasound examination in our laboratory has

been previously validated [12].

Blood analyses

Blood sampling took place in the morning (8.00–10.00 am)

after an overnight fast. Fasting plasma glucose (FPG) and

lipid parameters were measured in an automatic enzymatic

analyzer (Olympus AU560, Hamburg, Germany). Low

density lipoprotein cholesterol (LDL-C) was calculated by

Friedewald formula. We quantified HbA1c and serum

insulin using high-performance liquid chromatography

(Menarini Diagnostics, Florence, Italy) and ELISA method

(DRG Diagnostics, Marburg, Germany), respectively.

Insulin assessment had inter- and intra-assay coefficients of

variance (CVs) 3 and 3.4%, respectively. The insulin

resistance was estimated by homeostasis model assessment

(HOMA-IR) index with the following formula: HOMA-

IR = fasting insulin (mU/L) x fasting glucose (mg/dl)/405.

For visfatin, ghrelin and apelin (human apelin-12) mea-

surements, we used commercially available enzyme

immunoassay (EIA) kits (Phoenix Pharmaceuticals,

Belmont, CA, USA). The intra-assay CVs were: 5% for

apelin, \5% for visfatin and \14% for ghrelin, while the

inter-assay CVs for the latter adipocytokines were 14, 4,

and 7.5%, respectively. High-sensitivity CRP (hsCRP) was

assessed by nephelometric assay (Dade Behrin, BNII,

Marburg, Germany). Serum samples collected from cen-

trifuged blood samples had been frozen and stored (–80�C)

until ELISA analysis in duplicate.

Statistical analysis

Normality of distribution was assessed by Kolmogorov–

Smirnov test, while values were expressed as

mean ± standard deviation (SD). Data after atorvastatin

treatment were compared with baseline values using the

paired-samples Student’s t-test. Between groups differ-

ences were assessed by Student’s independent t-test and

chi-square test for parametric and non-parametric data,

respectively. The relationships were determined by Pearson

correlation coefficient. The correlations of CIMT, apelin,

visfatin (nampt) and ghrelin with a number of independent

variables were further explored using standard multiple

regression analysis after adjustment for age, sex and BMI.

A two-tailed value of P \ 0.05 was considered statistically

significant. All statistical analyses were performed with

the statistical software package SPSS-16.0 (SPSS Inc,

Chicago, IL, USA).

Results

Clinical and biochemical characteristics are presented in

Tables 1 and 2. Two patients died within the study period

for reasons not related to cardiovascular diseases. Four

patients dropped out (one by withdrawing informed con-

sent, two because of liver enzymes and/or creatinophos-

phokinase elevation and one because of a newly diagnosed

autoimmune disease) and so they were excluded from the

analyses. No other serious adverse events were observed.

In six patients, concomitant anti-hypertensive medica-

tions dosage was increased, while 8 patients had their

anti-diabetic medications modified during study-period.

Compliance, defined as acceptable if at least 85% of

atorvastatin medication was consumed.

Table 1 Baseline clinical and demographic characteristics

Characteristic Value

Number (males/females) 81 (18/63)

Age (y) 64.1 ± 7.2

Smokers (%) 21 (25.93)

Anti-hypertensive regimen (%) 63 (77.78)

Metformin (%) 21 (25.93)

Sulphonylureas (%) 8 (9.88)

DPP4 inhibitors (%) 6 (7.41)

Combinations (%) 39 (48.15)

Insulin (%) 7 (8.64)

Diabetes duration (y) 6.8 ± 2.22

Data are expressed as means ± SD. Y years; DPP4 dipeptidyl-pep-

tidase 4

Acta Diabetol (2012) 49:269–276 271

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Follow-up

As expected, atorvastatin induced a significant and optimal

reduction in total-cholesterol, LDL-Cholesterol and tri-

glycerides and a non-significant increase in HDL-choles-

terol. In parallel, body weight, blood pressure, glycemic

control and insulin resistance did not change throughout

the study (NS) (Table 2).

We observed a considerable upregulation of apelin

serum levels (from 0.307 ± 0.130 pg/ml to 1.537 ±

0.427 pg/ml; P \ 0.001) after 12 months of atorvastatin

treatment. On the other hand, atorvastatin treatment sig-

nificantly reduced serum concentrations of visfatin (from

21.54 ± 10.14 ng/ml to 15.13 ± 7.61 ng/ml; P = 0.002)

and hsCRP (from 5.03 ± 2.12 ml/L to 1.83 ± 0.72 mg/L;

P \ 0.001). Non-significant changes in either ghrelin lev-

els (from 3.11 ± 0.93 ng/ml to 4.70 ± 1.84 ng/ml;

P = 0.128) or mean CIMT (from 0.96 ± 0.13 mm to

0.94 ± 0.19 mm; P = 0.929) were detected (Fig. 1).

High-dose versus low-dose of atorvastatin treatment

We further searched whether the aforementioned changes

in lipids, adipokines and mean CIMT were dose-dependent.

At the end of the study, 19 patients had received high-dose

of atorvastatin (80 mg), while 29 were treated with

low-dose of atorvastatin (10 mg) (Table 3). Since the

target-to-treat in our study was identical to all patients

(LDL-C \ 100 mg/dl), the selected dose was mainly

determined by the baseline LDL-Cholesterol levels. As

expected, the high-dose subgroup showed higher baseline

levels of lipids and so the amount of lipids amelioration

was greater compared to low-dose subgroup (P \ 0.05).

We did not detect differences in the changes of inflam-

matory markers between subgroups. The rest of variables at

baseline and their changes during the study did not differ

between subgroups (data not shown). Notably, high-dose of

atorvastatin treatment yielded greater changes (P \ 0.05)

in apelin, visfatin and CIMT levels compared to low-dose

treatment. We must underline that patients receiving the

Table 2 Baseline and end values after atorvastatin treatment in the

whole study group

Variables Baseline End P

BMI (kg/m2) 29.76 ± 4.87 29.68 ± 4.92 0.567

Waist circumference (cm) 102.2 ± 11.8 101.7 ± 11.6 0.228

WHR 0.93 ± 0.08 0.92 ± 0.08 0.319

Systolic BP (mmHg) 130 ± 21 127 ± 41 0.199

Diastolic BP (mmHg) 77 ± 11 74 ± 10 0.054

Total cholesterol (mg/dl) 232 ± 51 179 ± 47 \0.001

HDL-C (mg/dl) 44 ± 12 45 ± 14 0.442

LDL-C (mg/dl) 157 ± 38 97 ± 22 \0.001

Triglycerides (mg/dl) 157 ± 72 136 ± 71 0.015

FPG (mg/dl) 142 ± 41 135 ± 34 0.256

HbA1c (%) 6.57 ± 1.12 6.36 ± 1.04 0.101

HOMA-IR 3.66 ± 0.63 3.25 ± 1.16 0.315

hsCRP (mg/L) 4.04 ± 2.12 1.83 ± 0.72 \0.001

WBC (cells/lL) 7,370 ± 2,197 6,945 ± 2,331 0.043

Data are expressed as means ± SD. BMI Body-mass index, BP Blood

pressure, FPG Fasting plasma glucose, HOMA-IR Homeostasis model

assessment, hsCRP High sensitivity C-Reactive protein, WBC White

blood cells

0

0.4

0.8

1.2

1.6

2

2.4

Baseline End

Apelin (ng/ml)

0

5

10

15

20

25

30

35

Baseline End

Visfatin (ng/ml)

p<0.001

p=0.002

0

2

4

6

8

Baseline End

Ghrelin (ng/ml)

0.7

0.75

0.8

0.85

0.9

0.95

1

1.05

1.1

Baseline End

CIMT (mm)p=0.929

p=0.128

Fig. 1 The effects of

atorvastatin on apelin, visfatin,

ghrelin, carotid intima-media-

thickness (CIMT). P values of

changes of variables from

baseline to the end

272 Acta Diabetol (2012) 49:269–276

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intermediate doses of atorvastatin achieved scores in all

variables between high and low dose groups.

Correlations at baseline

Apelin, at baseline, correlated with visfatin (r = –0.324,

P = 0.024), total cholesterol (r = –0.412, P = 0.040),

LDL-cholesterol (r = –0.327, P = 0.011), and triglycer-

ides (r = –0.487, P = 0.013). Besides to apelin, visfatin

was associated with ghrelin (r = -0.342, P = 0.027),

BMI (r = 0.336, P = 0.032) and WHR (r = 0.334,

P = 0.042). Furthermore, we observed a significant cor-

relation of ghrelin with visfatin and WHR (r = -0.344,

P = 0.009), while mean CIMT significantly correlated

with age (r = 0.425, P \ 0.001), visfatin (r = 0.282,

P = 0.003) and ghrelin (r = –0.311, P = 0.011) at

baseline.

Correlations of changes of variables

In our diabetic population, the atorvastatin-induced incre-

ment of apelin was significantly associated in univariate

and multivariate analysis with the alterations in total cho-

lesterol (b = –0.510, P = 0.030) and LDL-cholesterol

(b = –0.590, P \ 0.001) (R2 = 0.449, P = 0.014). Simi-

larly, the atorvastatin-related reduction of visfatin consid-

erably correlated with hsCRP change in univariate and

multivariate analysis after adjustment for age, sex and BMI

(b = 0.696, P = 0.026; R2 = 0.256, P = 0.006).

In the high-dose subgroup the observed reduction in

mean CIMT was significantly related to the visfatin

reduction (r = 0.612, P \ 0.001).

Discussion

In the present study, the 12 month atorvastatin (10–80 mg)

therapy, targeting at LDL-C \ 100 mg/dl, yielded a con-

siderable amelioration of apelin and visfatin serum levels

in patients with T2DM. We did not observed significant

alterations in CIMT in the whole cohort. However, a small

subgroup of patients treated with high-dose of atorvastatin

(80 mg) considerably suppressed CIMT after 12 months

compared to low-dose subgroup accompanied with greater

changes in the above adipokines.

Apelin has gained a lot of attention after the first notion

that it is involved in metabolic disorders [21], cardiac

function [22] and vascular pathophysiology [9, 11]. To our

knowledge this is the first study demonstrating a statin-

induced increment of apelin circulating levels in the dia-

betic population. Recently, Tasci et al. [10] reported a

significant upregulation of apelin plasma levels after either

life-style change or statin treatment in patients with iso-

lated hypercholesterolemia. In consistent to that study, the

atorvastatin-induced upregulation of apelin was predomi-

nantly determined by the dose-dependent lowering of total

cholesterol and LDL-C in our study. Further investigation

will clarify whether those statin-related changes in apelin

are ascribed to the lipid-lowering or to the ‘‘pleiotropic’’

properties of statins [23, 24].

Despite indications of the emerging atheroprotective

role of apelin, our study failed to find any relationship

between apelin and the valid marker of early atheroscle-

rosis, CIMT, either at baseline or after atorvastatin

administration. Those findings raises question about the

‘‘beneficial’’ role, which apelin displays in atherosclerosis.

Perhaps, apelin has modest impact on early atherosclerosis

compared to advanced stages [12, 25]. Another plausible

Table 3 Baseline and end

values of biochemical

parameters and mean CIMT

after atorvastatin treatment in

low-dose and high dose

subgroups

Data are expressed as

means ± SD. hsCRP High

sensitivity C-Reactive protein,

WBC White blood cells, CIMT

carotid intima-media thickness.

P value of changes of variables

* P \ 0.05 changes of variables

within groups

Variables High-dose atorvastatin (80 mg)

(N = 19)

Low-dose atorvastatin (10 mg)

(N = 29)

Baseline End Baseline End P

Age (y) 65.2 ± 8.2 64 ± 5.9

Total cholesterol (mg/dl) 245 ± 46 175 ± 48* 199 ± 44 185 ± 44* \0.001

HDL-C (mg/dl) 44 ± 12 46 ± 12 42 ± 15 42 ± 11 0.089

LDL-C (mg/dl) 167 ± 35 93 ± 21* 123 ± 27 97 ± 25* \0.001

Triglycerides (mg/dl) 157 ± 70 132 ± 75* 169 ± 79 145 ± 60* 0.067

hsCRP (mg/L) 4.02 ± 1.52 1.82 ± 0.93* 4.49 ± 2.5 2.5 ± 1.3* 0.447

WBC (cells/lL) 7,512 ± 1,999 6,815 ± 2,521* 7,098 ± 2,112 6,165 ± ±2,432* 0.652

Apelin (pg/ml) 0.308 ± 0.143 1.941 ± 0.411* 0.298 ± 0.101 1.422 ± 0.647* 0.035

Visfatin (ng/ml) 21.62 ± 9.32 12.67 ± 7.41* 20.80 ± 10.25 15.78 ± 5.91* 0.048

Ghrelin (ng/ml) 3.43 ± 1.14 6 ± 2.02* 2.69 ± 1.07 3.37 ± 1.03 0.110

Mean CIMT (mm) 0.97 ± 0.18 0.93 ± 0.21* 0.96 ± 0.22 0.96 ± 0.17 0.021

Acta Diabetol (2012) 49:269–276 273

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explanation is that greater changes in apelin are required in

order to affect atherosclerosis progression. However, the

greater changes in apelin levels observed in the high-dose

of atorvastatin-treated subgroup did not correlate with the

CIMT reduction. Unambiguously, our findings should be

interpreted with caution due to the limited number of

participants.

Visfatin participates in cardiovascular diseases in addi-

tion to energy homeostasis [26]. In consistent to previous

clinical trials, we demonstrated an independent association

of visfatin with early atherosclerosis measured by CIMT

[12, 27, 28], independent of well-known cardiovascular

risk factors. Although statins are the mainstay of the

pharmaceutical therapy of atherosclerosis, their impact on

visfatin serum levels is subject of debate. Recent studies

have demonstrated either no change [15, 29] or significant

downregulation of visfatin after statins treatment [14]. The

latter discrepant results may be firstly attributed to the

different members and doses of used statins. The second

was true in our study, since we observed a dose-dependent

suppression of visfatin within our diabetic population.

Moreover, all published trials enrolled small number of

patients, which might have biased the final results.

Importantly, previous studies did not examine the interplay

between statins and visfatin in the diabetic population.

Diabetic patients show higher levels of visfatin compared

to their non-diabetic counterparts and changes in visfatin’s

concentrations are therefore more likely to be found [30].

Looking for the underlying mechanisms of visfatin’s

regulation, accumulating data strongly support the pro-

inflammatory function of visfatin [31], leading to the ath-

erosclerotic plaque destabilization [32]. In our study, the

atorvastatin-induced hsCRP decrease was independently

associated with the visfatin reduction. Although we cannot

rule-out additional mechanisms, the anti-inflammatory

effect of atorvastatin seems to predominantly explain its

effect on visfatin levels, since T2DM is per se a low-grade

inflammatory condition. Notably, a small subgroup treated

with high-dose of atorvastatin yielded a greater reduction

in visfatin across with CIMT regression compared to low-

dose subgroup. This is of clinical relevance. However,

further studies will confirm the pleiotropic effects of statins

on visfatin and whether those effects are mirrored into

clinical manifestations of atherosclerosis.

Growing body of evidence supports the interaction

between ghrelin and atherogenesis. Nevertheless, it is still

unknown whether ghrelin constitutes a counterregulatory

factor [33] or a bystander of atherosclerosis development

[34]. In the present study, we attempted to shed more light

on the underlying mechanisms of ghrelin involvement in

the atherosclerotic process. This is the second study

investigating the effects of a well-established anti-athero-

genic pharmaceutical agent, atorvastatin, on ghrelin levels,

concomitantly with changes in CIMT. In agreement with

previous investigators, we observed a non-significant

change in ghrelin levels after atorvastatin treatment [17].

Moreover, we did not find any significant correlation

between ghrelin and CIMT changes, despite the indepen-

dent association of their baseline values [12].

Previous researchers have suggested potential compen-

satory mechanisms of ghrelin on atherosclerosis evolution,

as well as the improvement of endothelial dysfunction [35],

the attenuation of insulin resistance [36], the suppression of

oxidative stress [37] and the anti-inflammatory actions

[38]. Although our study was not designed to unravel the

molecular mechanisms, we did not document any rela-

tionship of ghrelin changes with atorvastatin-induced anti-

inflammatory effects. Future studies using more sensitive

inflammatory markers (e.g. IL-6, TNFa) might have exer-

ted different results [39]. On the other hand, we cannot

rule-out the possibility that other mechanisms, irrelevant to

statins, modulate the function of ghrelin within the diabetic

population. Perhaps, pharmaceutical agents targeting at

insulin resistance, rather than lipid homeostasis, could be

more effective in altering ghrelin levels [40]. Finally, one

could hypothesize that ghrelin levels reflect the progression

of atherosclerosis. Therefore, our results might have been

different in diabetic patients with advanced atherosclerotic

lesions.

The most important limitation of the present study was

the absence, for ethical reasons, of a diabetic control group

not receiving statins, in order to assess the progression of

CIMT. Since it is well known that CIMT progresses, and

we maintained the concomitant treatments mostly

unmodified throughout the study, the observed CIMT

change is unlikely to have been spontaneous. In parallel,

our study cohort was relatively small. Nevertheless, we

used numerous exclusion criteria in order to create an

homogeneous study-group. However, our subgroups of

high- and low-dose were extremely small and so the

comparative results need further consideration. Finally, the

changes in circulating levels of biomarkers should be

always interpreted with caution, since adipokines have

usually multifactorial regulation.

In conclusion, atorvastatin administration for 12 months

increased apelin and decreased visfatin serum levels in a

dose dependent manner, in patients with T2DM. We did

not observed any change of CIMT in the whole cohort

compared to baseline values. However, patients treated

with high-dose of atorvastatin (80 mg) reduced CIMT in

comparison with low-dose (10 mg) treatment group,

despite the achievement of equivalent LDL-C levels at the

end. The latter effect was associated with visfatin reduc-

tion. Future studies are needed to shed more light on the

underlying link between adiposity and atherosclerosis and

the regulatory role of statins.

274 Acta Diabetol (2012) 49:269–276

123


Acknowledgments The project was co-funded by the European

Social Fund and National Resources—(EPEAEK II) ‘‘PYTHAGO-

RAS II’’. Nikolaos P. E. Kadoglou was awarded a grant by the

Alexander S. Onassis Public Benefit Foundation.

Conflict of interest None.

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