Ceramides are decreased after liraglutide treatment in two randomized clinical trials

Background Specific ceramides have been identified as risk markers for cardiovascular disease (CVD) years before onset of disease. Treatment with the glucagon-like peptide-1 receptor agonist (GLP-1RA) liraglutide has been shown to induce beneficial changes in the lipid profile and reduce the risk of CVD. Reducing lipotoxic lipids with an antidiabetic drug therapy could be a path towards precision medicine approaches for the treatment of complications to diabetes. In this post-hoc study, we investigated the effect of liraglutide on CVD-risk associated ceramides in two randomized clinical trials including participants with type 2 diabetes (T2D). Methods This study analyzed plasma samples from two independent randomized placebo-controlled clinical trials. The first trial, Antiproteinuric Effects of Liraglutide Treatment (LirAlbu12) followed a crossover design where 27 participants were treated for 12 weeks with either liraglutide (1.8 mg/d) or placebo, followed by a four-week washout period, and then another 12 weeks of the other treatment. The second clinical trial, Effect of Liraglutide on Vascular Inflammation in Type-2 Diabetes (LiraFlame26), lasted for 26 weeks and followed a parallel design, where 102 participants were randomized 1:1 to either liraglutide or placebo. Here we measured six prespecified plasma ceramides using liquid chromatography mass spectrometry and assessed their changes using linear mixed models and t-tests. Possible confounders were assessed with mediation analyses. Results In the LirAlbu12 trial, C16 Cer and C24 Cer were reduced with liraglutide treatment (p <0.05) compared to placebo. In the LiraFlame26 trial, treatment with liraglutide resulted in a significant reduction of two ceramides associated with CVD risk, C16 Cer and C24:1 Cer (p <0.05) compared to placebo. None of the remaining ceramides showed statistically significant changes in response to liraglutide treatment compared to placebo. Mediation analyses showed that weight loss did not affect ceramide reduction. Conclusions We demonstrated that treatment with liraglutide resulted in a consistent reduction in C16 Cer after both 12 and 26 weeks of treatment and an overall decreasing trend was observed for two other ceramides. Our findings suggest the GLP-1RA can be used also to modulate ceramides. Trial Registration [Clinicaltrial.gov][1] identifier: [NCT02545738][2] and [NCT03449654][3] ### Competing Interest Statement The authors declare no conflict of interest compromising the integrity of this work. Disclosures outside this work: EZ and BJvS are now employees at Novo Nordisk and have shares in Novo Nordisk. RR has served as consultant for Novo Nordisk and has shares in Novo Nordisk. AK has served on advisory boards or as consultant for Novo Nordisk, Curium, Clarity Pharmaceuticals, IPSEN, and Siemens Healthineers. TH own shares in Novo Nordisk. TV has served on scientific advisory panels, been part of speaker's bureaus, served as a consultant to and/or received research support from Amgen, AstraZeneca, Boehringer Ingelheim, Eli Lilly, Gilead, GSK, Mundipharma, Novo Nordisk, Sanofi and Sun Pharmaceuticals. PR has received honoraria for consultancy to Steno Diabetes Center Copenhagen from Astellas, Astra Zeneca, Boehringer Ingelheim, Bayer, Merck, Gilead, Novo Nordisk, Sanofi Aventis. CLQ has served on scientific advisory panels and/or received research support from Pfizer, Novo Nordisk and other companies via the IMI funding scheme. ### Clinical Trial [ClinicalTrials.gov][4] Identifier: [NCT03449654][3] and [NCT02545738][2] ### Funding Statement Liraflame was funded by Novo Nordisk A/S and Skibsreder Per Henriksen, R. og hustrus fund. Steno Diabetes Center Copenhagen and Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet & Cluster for Molecular Imaging, University of Copenhagen, Denmark have provided internal funding (ERC Advanced Grant no. 670261; Research Foundation of Rigshospitalet; Research Council of the Capital Region of Denmark; Lundbeck Foundation; Novo Nordisk Foundation; The John and Birthe Meyer Foundation). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The protocol was approved by the local ethics committee at RegionH Denmark (H-16044546) and the Danish Medicines Agency (2016110109) I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The dataset analyzed here is not publicly available, for the privacy of the participants, in compliance with EU and Danish data protection law. The data can be accessed upon reasonable request; relevant legal permission from the data protection agency is required. Data access request should be directed to PR, peter.rossing{at}regionh.dk. * ADE : Average direct effect ACME : average causal mediation effect Cer : Ceramide CVD : Cardiovascular disease C16 Cer : ceramide(d18:1/16:0) C18 Cer : ceramide(d18:1/18:0) C17 Cer : ceramide(d18:1/17:0) C20 Cer : ceramide(d18:1/20:0) C22 Cer : ceramide(d18:1/22:0) C24 Cer : ceramide(d18:1/24:0) C24:1 Cer : ceramide(d18:1/24:1) eGFR : Estimated glomerular filtration rate HbA1c : Hemoglobin A1C LDL : Low-density lipids RA : Receptor agonist SCD1 : stearoyl-CoA desaturase-1 T2D : Type 2 Diabetes UAER : Urinary albumin excretion rate [1]: http://Clinicaltrial.gov [2]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT02545738&atom=%2Fmedrxiv%2Fearly%2F2023%2F03%2F21%2F2023.03.21.23287536.atom [3]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT03449654&atom=%2Fmedrxiv%2Fearly%2F2023%2F03%2F21%2F2023.03.21.23287536.atom [4]: http://ClinicalTrials.gov