• The apolipoprotein AI rate of catabolism and rate of production. [ Time Frame: Experimental visits ] [ Designated as safety issue: No ]
  
• The incremental area under the curve for triglycerides and high-density lipoprotein cholesterol. [ Time Frame: Experimental visits ] [ Designated as safety issue: No ]
  
• Other key outcomes include a. fasting cholesterol efflux, b. HDL cholesterol, apolipoprotein A-I, and enzymes that remodel HDL, c. atherogenic lipoproteins, and d. markers of energy metabolism and e. markers of inflammation. [ Time Frame: experimental visits ] [ Designated as safety issue: No ]
  

Drug: Lipitor
10 mg QD for 22 weeks
Drug: ABT335
135 mg QD for 18 weeks
Drug: Niaspan
2000 mg QD for 10 weeks

Objectives Summary

* To investigate whether the progressive addition of a fibrate and niacin to baseline statin therapy will improve apolipoprotein A-I kinetics, postprandial lipidemia, and postabsorptive lipoproteins and metabolism in adult men and women with atherogenic dyslipidemia.

Major Efficacy Aims

• Objective 1 is to test the hypothesis that the fibrate ABT335 and extended release (ER) niacin progressively improve apolipoprotein A-I kinetics when added sequentially to baseline therapy with atorvastatin. The key outcomes include the apolipoprotein AI rate of catabolism and rate of production.
• Objective 2 is to test the hypothesis that the fibrate ABT335 and ER niacin progressively improve postprandial lipidemia by oral fat challenge when added sequentially to baseline therapy with atorvastatin. Key outcomes include the incremental area under the curve for triglycerides and high-density lipoprotein cholesterol.
• Objective 3 is to test the hypothesis that the fibrate ABT335 and ER niacin progressively improve markers of postabsorptive lipoproteins and metabolism when added sequentially to baseline therapy with atorvastatin. Key outcomes include a. fasting cholesterol efflux, b. HDL cholesterol, apolipoprotein A-I, and enzymes that remodel HDL, c. atherogenic lipoproteins, and d. markers of energy metabolism and e. markers of inflammation.

Additional Aims

* Objective 4 is to assess tolerability and adverse events when ABT335 and ER niacin are added sequentially to atorvastatin. Specifically, we will assess changes in hepatobiliary laboratory tests (including incidence of elevation), incidence of symptomatic myalgia, and incidence of flushing. On an exploratory basis, we will enhance the flushing evaluation with objective and subjective measurements of flushing during inpatient visits.

Study Design:

This is an open-label feasibility study of fixed-sequence addition of lipid-altering medications, in which comparisons are made to the baseline for each subject. Subjects begin a lead-in phase in which they start the study statin (atorvastatin) or switch from previous statin therapy to the study statin. Subjects will wash off other excluded lipid-altering drugs during the lead-in. Subjects return for the first inpatient visit, where they have baseline studies on statin monotherapy. At the end of this visit, subjects are started on fibrate therapy (ABT335). They repeat the studies on dual therapy with statin and fibrate, and then add niacin (ER niacin). To minimize flushing during chronic treatment, they start aspirin 325 mg daily, or titrate to 325 mg if they are taking a lower dose of aspirin (e.g. 81 mg). Finally, they repeat the studies on triple therapy with statin, fibrate, and niacin/aspirin.

Inclusion Criteria:

1. Men and women from the age of 18 to 80 inclusive.

2. Low HDL cholesterol, adjusted for baseline use of statin drugs

   1. Not on statin: Men with HDL <= 40 or women with HDL <= 50 mg/dL
   2. On statin: Men with HDL <= 42 or women with HDL <= 52 mg/dL
3. Triglyceride / HDL ration >= 3.5
4. Ability to understand and agree to informed consent
5. Women of child-bearing potential, that is, women not surgically sterilized and between menarche and 1 year post menopause, must test negative for pregnancy based on a urine pregnancy test and agree to use a reliable method of birth control during the study and for one month following the last dose of the study drugs. Reliable methods include oral contraceptives, a reliable barrier method (diaphragms with contraceptive jelly, cervical caps with contraceptive jelly, condoms with contraceptive foam, intrauterine device), partner with vasectomy, or abstinence.
6. Are reliable and willing to make themselves available for the duration of the study and are willing to follow study procedures

Exclusion Criteria:

1. Subjects with the following lipoprotein disorders:

   1. Patients on a high-potency lipid-lowering regimen are excluded, as defined as chronic therapy with two or more prescription lipid-altering medications (excluding fish oils) where one is a high-dose statin (40 mg/day of rosuvastatin, 80 mg/day of other approved statins). Those on combination therapy with a lower dose of statin may participate, as can those taking high-dose statin monotherapy (excluding fish oils). In that case, patients will switch to atorvastatin 10 mg and/or wash off of other lipid medications to participate
   2. LDL > 190 mg/dL
   3. History of substantial triglyceridemia (TG > 750 mg/dL) or pancreatitis from triglyceridemia, regardless of whether TG is currently controlled
   4. Dysbetalipoproteinemia (VLDL/TG > 0.3 -AND- TG > 200 mg/dL).

2. Use of daily non-statin lipid-altering therapy prior to the initiation of study medication is exclusionary under the following circumstances (n.b. washout of non-statins is permitted):

   1. Niacin > 250 mg/ day within 6 weeks: Advicor, Niaspan, Niacor, Simcor, Slo-Niacin, or supplemental niacin
   2. Fibrates within 12 weeks: fenofibrate (Antara, Lofibra, Tricor, Triglide), gemfibrozil (Lopid), or clofibrate
   3. Enterically active drugs within 4 weeks: colestipol (Colestid), cholestyramine (Questran), colesevelam (Welchol), ezetimibe (Zetia, Vytorin), orlistat (Xenical, Alli)
   4. Red yeast rice during the treatment phase of the study (i.e. must be switched to study statin)
   5. Fish oil > 2 g/day within 4 weeks: Lovaza (née Omacor), numerous supplements
   6. Altered dose of a selective estrogen receptor modulator (SERM) within 4 weeks
3. History of intolerance of a statin, fibrate, aspirin, deuterated leucine, or niacin
4. Contraindications to medications, including chronic muscular disease, history of rhabdomyolysis, moderate to severe gout, severe peptic ulcer disease, bleeding disorders, and aspirin-sensitive asthma.
5. History of Type 1 or Type 2 diabetes, or fasting glucose > 110 mg/dL on two different days obtained for screening purposes, or use of medications indicated for the treatment of diabetes within 6 weeks of the screening visit
6. History of chronic renal insufficiency, nephrotic syndrome, or current serum creatinine > 2.5 mg/dL, or GFR < 60 mL/min/1.73m2 by the MDRD Study equation.
7. Aspartate aminitransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), total bilirubin > 2 X the upper limit of normal (ULN), albumin of < 2.5 mg/dL, prothrombin time (PT) > 1.5 X ULN, partial thromboplastin time (PTT) > 1.5 X ULN, or current active hepatobiliary disease
8. Hemoglobin (Hgb) < 10 mg/dL
9. Weight < 110 pounds
10. Administration of an investigational drug within 6 weeks prior to the screening visit
11. Major surgery within the previous 6 weeks, or anticipated major surgery during the course of the study, or any history of organ transplant
12. History of a non-skin malignancy within the previous 5 years
13. History of drug abuse within the past 3 years, or regular alcohol use of greater than 14 drinks per week
14. Women who are pregnant, plan to conceive, or breast-feed
15. Serious or unstable medical or psychological conditions that, in the opinion of the investigator, would compromise the subject's safety or successful participation in the study.
16. Currently adhering to or planning to adhere to or having used within 3 months prior to screening supplements intended for weight loss or adopt diets with aggressive carbohydrate restrictions for weight loss, such as but not limited to Atkins or South Beach diets.
17. Currently taking Vitamin A supplements (multivitamins allowed)(washouts will be permitted)

18. Excluded concomitant medications

    1. Immunosuppressive therapy within 2 months prior to screening or are likely to require such treatment during the course of the study
    2. Warfarin (coumadin)
19. Significant disinclination to dairy products (e.g. inviolable dietary restrictions or lactose intolerance to an 8 ounce glass of milk despite lactase supplementation) Lactase supplementation is allowed during the study.
20. Regular consumers of grapefruit juice, or currently taking medications known to be metabolized by CYP 3A4 (cyclosporine, itraconazole, ketoconazole, erythromycin, clarithromycin, telithromycin, HIV protease inhibitors, and nefazodone)
21. History of pancreatitis or gallbladder disease
22. History of coronary heart disease
23. Subjects who have a history of intolerance/adverse reaction to heparin or women who have dysfunctional uterine bleeding
24. Thrombocytopenia identified at screening
25. History of intracerebral hemorrhage or significant GI bleed
26. Subjects who engage in regular strenuous activity or who have a CK > 3x ULN at screening