Effects of High Intensity Statin Therapy on Steroid Hormones and Vitamin D in Type 2 Diabetic Men

Study design and setting It is a prospective study carried out at the department of Endocrinology of the University Hospital La Rabta, Tunis, between March 2021 and July 2022. The protocol was approved by La Rabta University Hospital local ethics committee.

Subjects Inclusion criteria were male subjects, aged between 40 and 65 years, with T2D, naive to statin and in whom a high intensity statin therapy was indicated according to the recommendations of the American Diabetes Association 2021 i.e in secondary cardio-vascular prevention or in primary prevention if the patient was aged more than 50 years or if other atherosclerotic cardiovascular disease risk factors were associated.

All patients gave an informed written consent to participate in the study. Exclusion criteria were the use within the last six months of drugs interfering with steroidogenesis (androgens, anti-androgens, Gn-RH analogues, corticosteroids, antiepileptics, barbiturates or other enzyme inducer or inhibitor); history of endocrinopathy (hypogonadism, testicular tumor, pituitary insufficiency, adrenal insufficiency, uncontrolled hypothyroidism); history of severe systemic disease (hepatic insufficiency, cirrhosis, alcoholism, severe or moderate renal insufficiency, symptomatic heart failure, chronic inflammatory disease); myocardial infarction or stroke within the last six months; statin intolerance; withdrawal of consent; loss to follow-up; poor compliance with treatment.

The number of subjects required for the study was calculated. When considering alpha= 0.05, beta= 0.10, and a magnitude of difference in testosterone levels of 0.59 ng/ml according to Dobs AS et al. study with an estimated common standard deviation of 1.0, the number of subjects required is estimated to be 50.

Protocol and data collection Visit 1: inclusion visit. The subjects were included and signed an informed consent to participate in the study. Visits 1 and 2 were performed on the same day in fasting patients.

Visit 2:

Clinical data were determined: age; habits; history; ongoing treatment; signs of adrenal insufficiency (weight loss, anorexia, asthenia, dizziness on standing, signs of hypoglycemia); signs of hypogonadism (decreased libido, presence or absence of nocturnal erections); number of sexual intercourses per month. Patients responded to the androgen deficiency in the aging male questionnaire (ADAM) translated to Tunisian dialect by four physicians from the same department.

Patients underwent a physical examination: measure of weight, height, and lying and standing blood pressure, presence of melanoderma, gynecomastia or myalgia.

A blood sample was collected between 8 a.m. and 9 a.m., after 12 hours of fasting, for the measurement of glucose, HbA1c, total cholesterol, triglycerides, high density lipoprotein cholesterol (HDLc), creatinine, sodium, potassium, transaminases (alanine aminotransferase (ALT) and aspartate aminotransferase (AST)), creatine phosphokinase (CPK), calcium, phosphate, albumin, total testosterone, sex hormone binding globulin (SHBG), estradiol, follicle stimulating hormone (FSH), luteinizing hormone (LH), cortisol, DHEAS (dehydroepiandrosterone sulfate), parathormone (PTH), and 25-hydroxy vitamin D. Blood samples were frozen at -20°c at the laboratory until hormonal measurements.

Treatment with 40 mg atorvastatin a day was initiated in all patients.

Visit 3: after six months of treatment:

The clinical and paraclinical parameters determined at visit 1 were determined again. The dose and the compliance of statin intake were evaluated by Girerd questionnaire. The occurrence of clinical adverse events of statin such as myalgia, arthralgia, digestive symptoms was recorded.