Effects of CETP inhibition with anacetrapib on metabolism of VLDL-TG and plasma apolipoproteins C-II, C-III, and E[S]

Cholesteryl ester transfer protein (CETP) mediates the transfer of HDL cholesteryl esters for triglyceride (TG) in VLDL/LDL. CETP inhibition, with anacetrapib, increases HDL-cholesterol, reduces LDL-cholesterol, and lowers TG levels. This study describes the mechanisms responsible for TG lowering by examining the kinetics of VLDL-TG, apoC-II, apoC-III, and apoE. Mildly hypercholesterolemic subjects were randomized to either placebo (N = 10) or atorvastatin 20 mg/qd (N = 29) for 4 weeks (period 1) followed by 8 weeks of anacetrapib, 100 mg/qd (period 2). Following each period, subjects underwent stable isotope metabolic studies to determine the fractional catabolic rates (FCRs) and production rates (PRs) of VLDL-TG and plasma apoC-II, apoC-III, and apoE. Anacetrapib reduced the VLDL-TG pool on a statin background due to an increased VLDL-TG FCR (29%; P = 0.002). Despite an increased VLDL-TG FCR following anacetrapib monotherapy (41%; P = 0.11), the VLDL-TG pool was unchanged due to an increase in the VLDL-TG PR (39%; P = 0.014). apoC-II, apoC-III, and apoE pool sizes increased following anacetrapib; however, the mechanisms responsible for these changes differed by treatment group. Anacetrapib increased the VLDL-TG FCR by enhancing the lipolytic potential of VLDL, which lowered the VLDL-TG pool on atorvastatin background. There was no change in the VLDL-TG pool in subjects treated with anacetrapib monotherapy due to an accompanying increase in the VLDL-TG PR.


SAMPLE
Approximately, forty (40) dyslipidemic male or female patients between the ages of 18 and 75 years of age (inclusive) who fulfill the entry criteria outlined in Section 2.2 and 2.3 will be enrolled in the study.
All patients who participate in the study will have a TG level of ≤ 400 mg/dL at the screening visit. All patients will have an LDL-C level of ≥ 100 mg/dL and ≤ 190 mg/dL (if they have no or 1 cardiac risk factor according to NCEP guidelines) or ≤ 160 mg/dL (if they have 2 or more cardiac risk factors according to NCEP guidelines) at the screening visit for statin-naïve patients, or at Visit 2 for patients that are undergoing the 2-3 week washout period for statins.

DOSAGE/DOSAGE FORM, ROUTE, AND DOSE REGIMEN
In Period 1, Panel A will receive atorvastatin 20 mg (1 x 20 mg tablet) co-administered with PBO to MK-0859 (1 x PBO to MK-0859 tablet) and Panel B will receive PBO to atorvastatin (1 x PBO to atorvastatin tablet) and PBO to MK-0859 (1 x PBO to MK-0859 tablet) daily for 4 to 5 weeks followed by a lipoprotein kinetic assay. Patients will continue to receive the study drug regimen during the lipoprotein kinetic assay (total dosing days in Period 1 will be 30 to 37 days).
In Period 2, Panel A will receive 100 mg MK-0859 (1 x 100 mg tablet) co-administered with atorvastatin 20 mg (1 x 20 mg tablet) for 8 to 9 weeks, followed by a lipoprotein kinetic assay. Panel B will receive 100 mg MK-0859 (1 x 100 mg tablet) coadministered with PBO to atorvastatin (1 x PBO to atorvastatin tablet) for 8 to 9 weeks, followed by a kinetics assay. Patients will continue to receive the study drug regimen during the kinetic assay (total dosing days in Period 2 will be 57 to 64 days). A sample treatment plan is provided in Table 1-1.
In both periods oral doses will be taken at home with the main meal of the day (dose in the evening with dinner), with the exception of the doses given during the kinetics assays, which will be given in the clinical research center (CRC). Compliance will be monitored by pill counts and random phone calls by the research staff. In Period 2, the exact time of dosing on the day prior to Visit 8 (Day 55, Period 2) and for the doses given in the CRC will be recorded on the case report forms (CRF).  In-house stay X X X X Meals ‡ ‡ X X X X Study Drug Compliance X X X Dispense study medication X X 24-hour diet recall X Dispense 3-day food record X X Evaluation of adverse experiences Tests to be done include: apoA-I, apoA-II, apoB100, apoC-II, apoC-III, apoE and Lp(a) concentrations; samples will be archived for possible determination of lipoprotein size by NMR. # Tests to be done include: TC, HDL-C, TG and LDL-C [LDL-C will be a calculated value (TC-HDL-C minus 20% TG)], per the automated standard in-house methods in all visits. If TG are >400 mg/dl, procedures for the measurement of fasting LDL-C and HDL-C as described in Appendix 6.10 will be employed.

Objective:
To determine the effect of treatment with MK-0859 100 mg added to background statin therapy on the turnover [production rate (PR) and/or fractional catabolic rate (FCR)] of apolipoprotein (apo) B100 in low-density lipoprotein (LDL) in dyslipidemic patients.
Hypothesis: The addition of MK-0859 to background atorvastatin therapy is associated with a decrease in PR of LDL apoB100. A true difference in LDL apoB100 PR obtained following Panel A, Period 2 compared to the LDL apoB100 PR obtained following Panel A, Period 1 (MK-0859 + atorvastatin versus atorvastatin) is expected.
Hypothesis: The addition of MK-0859 to background atorvastatin therapy is associated with an increase in FCR of LDL apoB100. A true difference in LDL apoB100 FCR obtained following Panel A, Period 2 compared to the LDL apoB100 PR obtained following Panel A, Period 1 (MK-0859 + atorvastatin versus atorvastatin) is expected.

Objective:
To determine the effect of treatment with MK-0859 100 mg (compared with PBO) on the FCR of apolipoprotein (apo) B100 in low-density lipoprotein (LDL) in dyslipidemic patients.

Hypothesis:
The administration of MK-0859 is associated with an increase in FCR of LDL apoB100. A true difference in LDL apoB100 FCR obtained following Panel B, Period 2 compared to the LDL apoB100 FCR obtained following Panel B, Period 1 (MK-0859 versus PBO) is expected.

Objective:
To determine the effect of treatment with MK-0859 100 mg per day on the FCR of apoA-I in high-density lipoprotein (HDL) in dyslipidemic patients.

Hypothesis:
The administration of MK-0859 is associated with a decrease in FCR of HDL apoA-I. A true difference in HDL apoA-I FCR obtained following Panel B, Period 2 compared to the HDL apoA-I FCR obtained following Panel B, Period 1 (MK-0859 versus PBO) is expected. h. percent conversion of VLDL apoB100 to IDL apoB100, VLDL apoB100 to LDL apoB100, and IDL apoB100 to LDL apoB100

PATIENT INCLUSION CRITERIA Demographics
1. Patient is a male or female between 18 to 75 years of age.
Note: Women who are postmenopausal or status post hysterectomy, oophorectomy (patient recall) or tubal ligation (patient recall) are eligible for participation in the study.
Postmenopausal is defined as no menses for > than 1 year and an FSH value in the postmenopausal range upon prestudy (screening) evaluation.
Note: Female subjects of reproductive potential must demonstrate a serum β-hCG level consistent with the nongravid state at the prestudy (screening) visit and agree to use (and/or have their partner use) two acceptable methods of birth control beginning at least 2 weeks prior to administration of the first dose of study drug, throughout the study and until at least 2 weeks after administration of the last dose of study drug in the last treatment period. Acceptable methods of birth control are abstinence, or 2 of the following: intrauterine device (IUD-with or without local hormone release), diaphragm, spermicides, cervical cap, contraceptive sponge, and condoms.
2. Patient has a stable weight (± 3 kg) for >6 weeks prior to screening (based on patient recall). 3. The patient has a Body Mass Index (BMI) of 18.5 ≤ BMI ≤ 40 kg/m 2 at the prestudy (screening) visit. BMI is calculated by taking the patient's weight in kg and dividing by the patient's height in meters, squared (Appendix 6.1). Protocol/Amendment No.: 026-03 0859_026-03_ProtCore APPROVED 29-Jul-2010 U.S. IND, U.S. Study Restricted Confidential -Limited Access

Medical history, physical examinations, laboratory safety tests and ECG measurement
4. Patient is judged to be in good health based on medical history, physical examination, vital sign measurements, and laboratory safety tests (see Appendices 6.2 and 6.3) performed at the pre-study (screening) visit and/or prior to administration of the initial dose of study drug.
5. Patient has a TG level of ≤ 400 mg/dL at the screening visit. All patients will have an LDL-C level of ≥ 100 mg/dL and ≤ 190 mg/dL (if they have no or 1 cardiac risk factor according to NCEP guidelines) or ≤ 160 mg/dL (if they have 2 or more cardiac risk factors according to NCEP guidelines) at the screening visit for statin-naïve patients, or at Visit 2 for patients that are undergoing the 2-3 week washout period for statins.
Note: TC, HDL-C, TG and LDL-C [LDL-C will be a calculated value (TC-HDL-C minus 20% TG)] will be determined per the automated standard in-house methods in all visits. If TG are >400 mg/dl, procedures for the measurement of fasting LDL-C and HDL-C as described in Appendix 6.10 will be employed.
6. Patient has no clinically significant abnormality on electrocardiogram (ECG) performed at the pre-study (screening) visit and/or prior to administration of the initial dose of study drug.

Diet/Activity/Other
7. Patient has been a nonsmoker and/or has not used nicotine or nicotine-containing products for at least approximately 6 months and does not plan to begin smoking during the conduct of the study; patients who have discontinued smoking or the use of nicotine/nicotine containing products for at least approximately 3 months may be enrolled in the study at the discretion of the investigator. Non-daily or social smokers who have consumed no greater than approximately 5 cigarettes or equivalent over the 3 month period prior to screening also may be enrolled at the discretion of the investigator.
8. Patient understands the study procedures and agrees to participate in the study by giving written informed consent. 9. Patient is willing to comply with the study restrictions (see Section 3.2. for a complete summary of study restrictions). 10. Patient is able to follow the American Heart Association NCEP diet. An actual creatinine clearance, as determined by a 24-hour urine collection, may be used in place of, or in conjunction with, the Cockcroft-Gault equation; patients who have an actual or estimated creatinine clearance up to 10% below 60 mL/min may be enrolled at the discretion of the investigator.
4. Patient has a history of stroke, chronic seizures, or major neurological disorder.
Note: Patients with controlled hypertension (≤ 150/100 mmHg), if they are on a stable medical regimen (for at least 4 weeks) may be allowed at the discretion of the investigator.
Note: For patients on thyroid hormone replacement treatment at the time of screening, there is no lower TSH threshold for entry. The patient must have been on a stable dose of thyroid hormone therapy for ≥ 6 weeks prior to the screening. If TSH levels are undetectable and the patient requires a change in thyroid hormone therapy or this represents a new diagnosis, then the patient will be excluded.
Note: Hypothyroidism is defined as having a TSH >20% above the local laboratory's upper limit of the normal reference range.
One redraw will be allowed if the original TSH value is equal to or less than 40% above the normal reference range at the local laboratory. The patient must meet the criterion upon redraw. (2) Patients with other malignancies which have been successfully treated ≥10 years prior to the pre-study (screening) visit where, in the judgment of both the investigator and treating physician, appropriate follow-up has revealed no evidence of recurrence from the time of treatment through the time of the pre-study (screening) visit; or, (3) Patients, who, in the opinion of the study investigator, are highly unlikely to sustain a recurrence for the duration of the study.
7. Patient has a history of any illness that, in the opinion of the study investigator, might confound the results of the study or poses an additional risk to the patient by their participation in the study.
8. Patient is a nursing mother.
Note: Hormone replacement therapy may be allowed at the discretion of the investigator, if the patient is on a stable dose for at least 6 weeks.
Note: Low dose thiazide diuretics (12.5 mg hydrochlorothiazide or equivalent) may be allowed at the discretion of the investigator.
Note: Stable doses (for at least 4 weeks) of beta-blockers may be allowed at the discretion of the investigator.
Note: Stable doses of thyroid replacement treatment are allowed; for more details, please refer to Section 2.3, item #5 above.
10. Patient is currently taking fiber-based laxatives, phytosterol margarines, and/or over the counter (OTC) therapies that are known to affect serum lipids or anticipates use during the study.
Note: Psyllium may be allowed at the discretion of the investigator.
11. Patient has taken lipid-lowering agents (except for statins) including fish oils, fibrates, C e (Pharmanex, Inc.; also known as red yeast rice, or Monascus purpureus extract), or niacin (vitamin B 3 ) (>200 mg/day) within 6 weeks prior to screening or anticipates use during the study.
Note: If a patient has taken lipid-lowering agents (except for statins) including fish oils, fibrates, C (Pharmanex, Inc.; also known as red yeast rice, or Note: Patients who consume greater than 6 servings of caffeine may be enrolled at the discretion of the investigator. 16. Patient has had major surgery, donated or lost 1 unit of blood (approximately 500 mL) or participated in another investigational study within 4 weeks prior to the prestudy (screening).
17. Patient has a history of significant multiple and/or severe allergies (including latex), or has had an anaphylactic reaction or significant intolerability to prescription or nonprescription drugs or food.
Note: Patients with a history of minor allergies may be enrolled at the discretion of the investigator.
18. Patient is currently a regular user of any illicit drugs or has a history of drug (including alcohol) abuse within approximately 2 years. Protocol/Amendment No.: 026-03 0859_026-03_ProtCore APPROVED 29-Jul-2010 U.S. IND, U.S. Study Restricted Confidential -Limited Access Blood samples will also be collected to determine the concentrations of lipoprotein lipase (LPL), hepatic lipase (HL) and apolipoproteins, as well as activities of LPL, HL and lecithin-cholesterol acyltransferase (LCAT). Archive samples will also be obtained for possible determination of PCSK9, lathosterol, and prebeta HDL concentrations and lipoprotein size by NMR. Samples for determination of CETP activity and mass will also be archived. Plasma samples for MK-0859 concentrations will be obtained and archived during period 1 and period 2 at the time points specified in the Study Flow Chart.
Safety will be monitored throughout the study by repeated clinical and laboratory evaluation.
The duration of the study for an individual patient will be approximately 22 weeks (including the prestudy and poststudy visits).

Treatment Plan
In Period 1, Panel A will receive atorvastatin 20 mg (1 x 20 mg tablet) co-administered with PBO to MK-0859 (1 x PBO to MK-0859 tablet) and Panel B will receive PBO to atorvastatin (1 x PBO to atorvastatin tablet) and PBO to MK-0859 (1 x PBO to MK-0859 tablet) daily for 4 to 5 weeks prior to the first lipoprotein kinetic assay. Patients will continue to receive study drug during the lipoprotein kinetic assay (total dosing days in Period 1 will be 30 to 37 days).
In Period 2, Panel A will receive 100 mg MK-0859 (1 x 100 mg tablet) co-administered with atorvastatin 20 mg (1 x 20 mg tablet) for 8 to 9 weeks, followed by a lipoprotein kinetic assay. Panel B will receive 100 mg MK-0859 (1 x 100 mg tablet) coadministered with PBO to atorvastatin (1 x PBO to atorvastatin tablet) for 8 to 9 weeks, followed by a kinetics assay. Patients will continue to receive study drug during the kinetics assay (total dosing days in Period 2 will be 57 to 64 days).
Study drugs will be administered orally with the main meal of the day (dose in the evening with dinner). Dosing will be done at home with the exception of doses administered during Visit 5 (Period 1) and Visit 8 (Period 2) which will be at the CRC. Compliance will be monitored by pill count and random phone calls by the research staff. In Period 2, the exact time of dosing on the day prior to Visit 8 (Day 55, Period 2) and for the doses given in the CRC will be recorded on the case report forms (CRF).
Patients will be randomized to Panel A or Panel B according to an allocation schedule. Patients with LDL-C levels at randomization of <160 mg/dL will receive the next lowest allocation number, and patients with LDL-C levels at randomization of ≥160 mg/dL will receive the next highest allocation number, to be sure that the patients are allocated to each panel at a 3:1 ratio according to LDL-C level.
The investigator and patient will be blinded to treatment. A sample allocation schedule is in Table 2 For specific time points please refer to the Study Flow Chart. See Appendix 6.5 for sample handling and processing procedures.

LIST OF SAFETY MEASUREMENTS
Safety will be monitored throughout the study by repeated clinical and laboratory evaluation including vital signs, physical exam, 12-lead ECG, laboratory safety parameters (hematology, chemistry, and urinalysis), plasma lipids (total cholesterol, HDL, LDL and triglycerides) and serum/urine β-hCG. Patients will be monitored for adverse experiences throughout the study.

DATA ANALYSIS SUMMARY
Method: The primary hypotheses will be addressed by analyzing both the production rate (PR) and the fractional catabolic rate (FCR) of LDL apoB100 with separate linear mixed effects models containing fixed effects for panel and treatment within panel, and a random effect for subject within panel. Summary statistics including point estimates, 95% confidence intervals (CIs) and between-treatment p-values (two-tailed) for the true mean differences (MK-0859 w/atorvastatin -atorvastatin) in LDL apoB100 PR and LDL apoB100 FCR will be calculated based on their respective models. The 4A multiple testing procedure of Li and Mehrotra (2008) [1] will be followed in order to account for the disparity in statistical power for the two primary endpoints. If the p-value for the true mean difference (MK-0859 w/atorvastatin versus atorvastatin) in LDL apoB100 PR is statistically significant at the α 1 =0.04 level, the corresponding true mean difference for LDL apoB100 FCR will be tested at the full α 2 =0.05 level. However, if the true mean difference for LDL apoB100 PR is not significant at α 1 =0.04, the true mean difference for LDL apoB100 FCR will be tested at an adjusted α 2 level based on both the observed p-value for PR and the correlation among the two endpoints. The primary hypothesis will be supported if the test for either endpoint is significant at their respective α level. That is, administration of MK-0859 on a background of atorvastatin therapy is associated with a significant change in LDL apoB100 turnover.
The secondary hypothesis will be addressed by an analyzing the fractional catabolic rate of LDL apoB100 with a linear mixed effects model containing fixed effects for panel and treatment within panel, and a random effect for subject within panel. Summary statistics including point estimates, 95% CIs and between-treatment p-values (two-tailed) for the true mean differences (MK-0859 -placebo; atorvastatin -placebo) in LDL apoB100 FCR will be calculated based on this model.
The tertiary hypotheses and exploratory objectives will each be addressed by analyzing each tertiary/exploratory endpoint with a similar linear mixed effects model as described above. Point estimates, 95% CIs and between-treatment p-values (two-tailed) will be calculated for all of the treatment differences in these endpoints. Restricted Confidential -Limited Access rich lipoproteins (TRL), such as VLDL and IDL, and net transfer of triglyceride from TRL to HDL. Thus, CETP provides a link between the metabolism of apoB-containing lipoproteins and HDL. Expression of CETP in mice, which normally lack CETP, or manipulation of CETP activity in other animals that express CETP, changes the plasma concentration of apoB-containing lipoproteins as well as the HDL-C concentration. In humans, CETP inhibitors raise HDL-C and lower LDL-C levels.
Recently, Millar and co-workers [2] reported the effects of the CETP inhibitor, torcetrapib, on plasma lipoproteins in patients selected for low HDL-C (<40 mg • dL -1 ). In these patients, torcetrapib treatment resulted in a dose-dependent increase in HDL-C and reductions in triglyceride and LDL-C levels. Kinetic studies were performed to define the mechanism(s) by which torcetrapib, alone or on a background with the HMG-CoA reductase inhibitor, atorvastatin, influenced lipoprotein and apolipoprotein metabolism. Data from these studies form the bases on which predictions of the effects of MK-0859 on lipoprotein kinetics were formulated.
Our primary objective in this study is to investigate whether CETP inhibition by MK-0859 on a statin background reduces LDL-C plasma levels by altering the turnover (production rate and/or fractional catabolic rate) of LDL apoB100. This objective is based on the observation in the Millar et al torcetrapib studies that, in the setting of background therapy with atorvastatin 20 mg, the addition of torcetrapib 120 mg daily resulted in a -10 ± 19% change in LDL apoB100 production rate, while the LDL apoB100 catabolic rate was unchanged. This trend suggests that in statin-treated dyslipidemic patients LDL apoB100 production rate is decreased with CETP inhibition, which in turn leads to further reductions in LDL-C plasma levels. On background statin therapy, the proposed 100 mg dose of MK-0859 for this study is roughly equipotent in terms of effects on apoB100 abundance to 120 mg of torcetrapib daily [2; 3]. As a result, we are predicting that MK-0859 will have an effect on the production rate of apoB100 in LDL that is similar to that which was observed with torcetrapib. Specifically, we are hypothesizing that the addition of MK-0859 to background statin therapy will result in a decrease in PR of LDL apoB100. We anticipate a decrease in LDL apoB100 PR of 10%, or an absolute reduction of 1.4 mg·kg/d (from a predicted baseline of ~13.5 mg·kg/d).
The power to detect an expected absolute difference of 1.4 mg·kg/d in LDL apoB100 PR, assuming an intrasubject SD of 1.94 mg·kg/d (derived from experimental data from the laboratories of the co-investigators) is 96% with a cohort size of 30.
However, after Millar et al added CETP inhibition with torcetrapib to a statin background, the change in LDL apoB100 PR was not statistically significant [2]. Thus, due to a relatively small sample size, the evidence is not conclusive that reduced PR may account for the additional decrease in the LDL apoB100 pool size which was observed after the addition of torcetrapib to atorvastatin. Since decreased LDL apoB pool size may also result from an increase in the LDL apoB100 fractional catabolic rate, we have included a hypothesis that the addition of CETP inhibition with MK-0859 to a statin background is associated with increased LDL apoB100 FCR. With a cohort size of 30, there will be 80% power to detect a 6% change in LDL apoB100 FCR (or an absolute change of 0.026 pools/d from a predicted baseline of 0.44 pools/d). In order to fulfill the Protocol/Amendment No.: 026-03 0859_026-03_ProtDet APPROVED 29-Jul-2010 U.S. IND, U.S. Study Restricted Confidential -Limited Access primary objective of this trial, either or both of the primary hypotheses must be proven.
A multiplicity adjustment will be employed for the primary endpoints to control the overall Type I error of the primary hypothesis 5%.
The secondary objective of this study focuses on the effect of MK-0859 monotherapy on LDL apoB100 kinetics. Data from the Millar et al study suggested that torcetrapib monotherapy (at a dose of 120 mg BID) increased the rate of LDL apoB100 catabolism by 26 ± 28%. As a result, the LDL apoB100 pool size decreased significantly by 19%. Thus, CETP inhibition appears to have a catabolic effect on LDL apoB100 in statin-naïve patients. As a result, we are hypothesizing that treatment with 100 mg of MK-0859 (in the absence of statin therapy) will increase the FCR of LDL apoB100. In statin-naïve patients, MK-0859 100 mg and torcetrapib 120 mg BID are roughly equipotent in their effects on apoB100 abundance. Thus, we are anticipating that treatment with 100 mg of MK-0859 will increase the FCR of LDL apoB100 by 26%, corresponding to an absolute increase of 0.065 pools/d (from a predicted baseline of ~0.25 pools/d). The power to detect an expected absolute difference of 0.065 pools/d in LDL apoB100 FCR, assuming an intrasubject SD of 0.05 pools/d (derived from experimental data from the laboratories of the co-investigators) is 95% with a cohort size of 10.
The effects of MK-0859 on HDL apoA-I metabolism in statin-naïve and statin-treated patients will be the focus of two of the tertiary objectives. Based on the torcetrapib experience [4], we hypothesize that CETP inhibition with MK-0859 in the absence of statin background therapy (tertiary hypothesis #1) or in the presence of statin co-therapy (tertiary hypothesis #2) is associated with a decrease in the FCR of HDL apoA-I. In statin-naïve patients, MK-0859 100 mg and torcetrapib 120 mg BID are roughly equipotent in their effects on apoA-I abundance. As a result, we anticipate that treatment with 100 mg of MK-0859 as monotherapy (as per tertiary hypothesis #1) will decrease the FCR of HDL apoA-I by 21%, corresponding to an absolute decrease of 0.048 pools/d (from a predicted baseline of 0.228 pools/d). The power to detect an expected absolute difference of 0.048 pools/d in HDL apoA-I FCR, assuming an intrasubject SD of 0.030 pools/d (derived from experimental data from the laboratories of the coinvestigators) is 99.4% with a cohort size of 10. In statin-treated patients, MK-0859 100 mg has a > two-fold greater potency on apoA-I abundance compared to torcetrapib 120 mg QD. As a result, we anticipate that treatment with 100 mg of MK-0859 on a statin background (as per tertiary hypothesis #2) will decrease the FCR of HDL apoA-I by 14%, corresponding to an absolute decrease of 0.033 pools/d (from a predicted baseline of 0.237 pools/d). The power to detect an expected absolute difference of 0.033 pools/d in HDL apoA-I FCR, assuming an intrasubject SD of 0.030 pools/d (derived from experimental data from the laboratories of the co-investigators) is >99.9% with a cohort size of 10.
The third of the tertiary objectives is to investigate whether the previously described effect of atorvastatin on LDL apoB100 FCR [5] can be detected in the present study. We hypothesize that treatment with atorvastatin 20 mg will result in an increase in LDL apoB100 FCR. We anticipate that treatment with atorvastatin 20 mg will increase the FCR of LDL apoB100 by 81%, corresponding to an absolute increase of 0.20 pools/d Restricted Confidential -Limited Access (from a predicted baseline of 0.25 pools/d). The power to detect an expected absolute difference of 0.20 pools/d in LDL apoB100 FCR, assuming an intersubject SD of 0.11 pools/d [5] is 99.9% with the proposed cohort sizes.
Additionally, because CETP transfers triglycerides from TRL to LDL in exchange for CE, inhibition of CETP with MK-0859 could have significant effects on the metabolism of apoB-containing lipoproteins that may not be directly related to exchange of lipids with HDL. Thus, the kinetics of apoB100 in VLDL and IDL will be investigated as exploratory objectives. Further assessment of the possible or anticipated effects on lipid kinetics in this study is provided in Appendix 6.9.
Interestingly, CETP inhibition (with either MK-0859 or torcetrapib) results in a dosedependent increase in plasma CETP concentration over time. The mechanism responsible for the increased CETP plasma abundance is currently unknown. Possible mechanisms include: 1) reduced clearance from plasma due to association with HDL particles which are significantly increased in plasma following CETP inhibition; or 2) increased CETP production. We will archive serum in the current study to support potential future experiments to determine how treatment with MK-0859 influences CETP kinetics, mass and activity. Furthermore, we will archive serum to support possible investigations into how CETP inhibition affects the abundance of the regulatory molecule PCSK9.
In this study, randomized, double-blind, double-dummy, placebo-controlled, 2-period, fixed-sequence design will be used. Patients will be randomized into either Panel A or Panel B (in a 3:1 ratio). Panel A (N=30) will receive atorvastatin 20 mg co-administered with PBO to MK-0859 for 4 to 5 weeks (Period 1) followed by MK-0859 100 mg coadministered with atorvastatin 20 mg once daily for 8 to 9 weeks (Period 2). Panel B (N=10) will receive placebo to atorvastatin 20 mg (PBO to atorvastatin) co-administered with PBO to MK-0859 for 4 to 5 weeks (Period 1) followed by MK-0859 100 mg coadministered with PBO to atorvastatin once daily for 8 to 9 weeks (Period 2).
Blood will be drawn at multiple time points during and after cessation of the infusion. An 8-week duration for Period 2 in both Panels of this study was selected to insure that MK-0859 pharmacodynamics are at steady state, particularly with respect to changes in Lp(a). Incremental reductions in Lp(a) were observed in the previous Phase IIb MK-0859 study between 4 and 8 weeks of dosing. Patients will be stabilized on 20 mg of atorvastatin for approximately 4 weeks in Period 1, which in the case of statins is predicted to be a sufficient amount of time to allow for achievement of pharmacodynamic steady state.
A dyslipidemic patient population (with TG ≤ 400 mg/dL, LDL-C level of ≥ 100 mg/dL and ≤ 190 mg/dL, if they have no or 1 cardiac risk factor according to NCEP guidelines, or ≤ 160 mg/dL, if they have 2 or more cardiac risk factors according to NCEP Protocol/Amendment No.: 026-03 0859_026-03_ProtDet APPROVED 29-Jul-2010 U.S. IND, U.S. Study Restricted Confidential -Limited Access guidelines) under statin-treated conditions has been selected for this investigation, so that MK-0859 may be assessed in a paradigm that will most closely approximate its anticipated clinical use.
The intent of the frequently administered meals is to raise and maintain triglyceride levels and keep diet induced fluctuations in lipid levels to a minimum.

MK-0859
A dose of 100 mg of MK-0859, administered once-daily with the main meal of the day has been chosen for this study. The rationale for dosing with the main meal of the day is to improve subject compliance for this study and to reduce pharmacokinetic variability associated with meals.

Atorvastatin
Atorvastatin calcium (LIPITOR ® ) is a lipid-lowering agent that acts as an inhibitor of 3-hydroxy-3-methlglutaryl-coenzyme A (HMG-CoA) reductase, which catalyzes an early and rate-limiting step in the biosynthesis of cholesterol. LIPITOR ® administration is associated with reductions in total cholesterol and LDL cholesterol and with increases in HDL cholesterol, all of which have been associated with reductions in cardiovascular morbidity and mortality.
A dose of 20 mg of atorvastatin has been selected for background statin therapy for several reasons. Atorvastatin is a commonly used and well-tolerated statin drug that is indicated for the treatment of dyslipidemia and the most frequently prescribed dose is 20 mg daily. Atorvastatin was used at this dose in the studies of CETP inhibition with torcetrapib that form the basis for our power assumptions for this study. In addition, Atorvastatin was used at a dose of 20 mg in Phase IIb studies of MK-0859 and therefore a great deal of clinical experience has been accrued already with this specific combination.
Atorvastatin is generally well tolerated however, like other HMG-CoA reductase inhibitors, has been associated with liver chemistry abnormalities such as increases in Restricted Confidential -Limited Access transaminase levels which typically manifests following administration over the first 3 months of treatment rather than after single-dose administration. In addition, rare cases of rhabdomyolysis and associated sequelae have been reported with atorvastatin and other HMG-CoA reductase inhibitors during the initial months of therapy.
Refer to LIPITOR ® package insert in protocol Attachments for detailed information.

Endpoints
It is anticipated that the administration of MK-0859 in combination with atorvastatin to dyslipidemic patients will be associated with a mean change in at least one of our primary endpoints, the production rate or fractional catabolic rate of apoB100 in LDL-C. We further predict that MK-0859 monotherapy will result in a significant increase in our secondary endpoint, the fractional catabolic rate of LDL apoB100. Tertiary endpoints include changes in the fractional catabolic rate of apoA-I in HDL-C after treatment with MK-0859 in combination with atorvastatin, as well as MK-0859 monotherapy.
Additionally, we will investigate the effect of atorvastatin alone on the fractional catabolic rate of LDL apoB100 in comparison to placebo as a tertiary objective. We will also explore the effect of treatment with MK-0859 monotherapy and MK-0859 in combination with atorvastatin on the kinetics of apoB100 in VLDL and IDL, apoA-II in HDL-C, and apo(a) in Lp(a). Additional samples will be archived for possible determination of VLDL TG production rate and PCSK9 and CETP kinetics. Effects on concentrations and/or activities of LCAT, LPL and HL, as well as lipoprotein size will also be studied. Additional samples will be archived for possible determination of PCSK9, lathosterol and prebeta HDL concentrations, as well as CETP mass and activity.
ApoB100 and apoA-I will be isolated from lipoprotein fractions after ultracentrifugation using SDS PAGE.
Additional samples will be archived for possible determination of lipoprotein size by proton NMR.

Rationale for Subject/Patient Genetic Sample Collection
As part of this study, pharmacogenomic analysis may be performed on samples from appropriately consented patients/patients. The objective of collecting genetic samples in this study is to investigate the relationship between genetic make-up, and the way investigational therapies are absorbed, broken down and eliminated from the body, how they affect the body and how DNA relates to human disease.

Concomitant Medication
Patients currently being treated with a statin at the prestudy (screening) visit will be washed-off their treatment beginning up to 3 weeks prior to study drug administration in Restricted Confidential -Limited Access Period 1 of the study until the poststudy visit. After the poststudy visit has been completed, patients can resume treatment with their previously prescribed statin medication according to instructions provided by the study investigator.
Use of any other prescription or nonprescription medication (including herbal remedies such as St. John's Wort) within approximately 14 days prior to administration of the initial dose in Period 1 of the study (or 5 half lives, whichever is longer) and throughout the study or the anticipated use of any prescription or nonprescription medications are prohibited, unless the study investigator can rationalize that the specific use of a prior medication is not clinically relevant within the context of the study.
Medications of particular concern are prescription and non prescription lipid modifying therapies including fibrates, niacin, ezetimibe, bile acid-sequestrants, fish oils, hormonal contraceptives, and glucocorticoids; and potent inhibitors or inducers of CYP3A4.
Certain concomitant medications (e.g., stable doses of beta-blockers; low dose thiazide diuretics; hormone replacement therapy; psyllium and thyroid hormone replacement therapy) will be allowed to treat comorbid conditions (e.g., hypertension, hypothyroidism, and menopause), at the discretion of the investigator. Refer to Section 2.3 for details. Acetaminophen and over-the-counter non-steroidal anti-inflammatory drugs will be permitted for minor ailments with the permission of the study investigator.
Concurrent therapy with any medication during the course of the protocol (after randomization) including both prescription and nonprescription drugs must first be discussed with the investigator and Sponsor Medical Monitor prior to administration, unless appropriate medical care necessitates that therapy should begin before the investigator and Sponsor Medical Monitor can be consulted.
Paracetamol/acetaminophen and over-the-counter non-steroidal anti-inflammatory drugs may be used for minor ailments without prior consultation with the Merck clinical monitor.

Diet
Patients will be asked to provide a 24 hour food recall at the prestudy (screening) visit. Study participants will be asked to follow the American Heart Association NCEP or similar diet throughout the study. If deemed necessary by the clinical investigator the subject will meet with a dietician who will provide guidelines for following the American Heart Association NCEP diet or a similar diet. Patients will be asked to follow these guidelines throughout the study and not make any major changes to their diet during the study. Prior to Visit 5 (Day 28; Period 1) and Visit 8 (Day 56; Period 2) patients will be asked to complete a 3 day food record provided by the investigator. Three day food records should be reviewed upon receipt for accuracy and completion. Analysis of the 3-day food record will be conducted on an individual basis at the discretion of the investigator. Protocol/Amendment No.: 026-03 Restricted Confidential -Limited Access Patients must fast from all food and drink, except water, for 12 hours prior to laboratory safety tests and blood samples for the lipid panel, plasma lipoproteins, LCAT activity, HL and LPL analysis, and archive samples for: lipoprotein size, PCSK9, lathosterol and prebeta HDL concentration, and CETP mass and activity. All witnessed oral doses will be administered with approximately 240 mL of water.
During Visit 5 (Day 28, Period 1) and Visit 8 (Day 56, Period 2) patients will receive a standard meal in the evening. Patients will then fast, except from water until the administration of small iso-caloric meals (~ 18% fat) every 2 hours for 30 hours.

Fruit Juice Restrictions
Patients will refrain from consumption of grapefruit juice, grapefruits and grapefruit products beginning approximately 2 weeks prior to administration of the initial dose of study drug, throughout the study (including the washout interval between treatment periods) and until the poststudy visit.

Alcohol/Caffeine/Smoking/Activity
Alcohol Patients will refrain from consumption of alcohol for 24 hours prior to Visit 5 (Day 28, Period 1) and Visit 8 (Day 56, Period 2) [prior to the beginning of the kinetic assay in each period] through the completion of the visit; and for 24 hours prior to Visit 2 (Day -2; Period 1), Visit 4 (Day 21; Period 1) and Visit 7 (Day 28; Period 2) and the pre-and poststudy visits.
At all other times, alcohol consumption is limited to no more than approximately 2 alcoholic beverages or equivalent (beer [12 oz.], wine [5 oz] or distilled spirits [1.5 oz]) per day. Patients should be encouraged not to make major changes in their alcohol consumption for the duration of the study.

Caffeine
Patients will be allowed to consume up to two caffeinated beverages per day during Visit 5 (Day 28, Period 1) and Visit 8 (Day 56, Period 2) [prior to the beginning of the kinetic assay in each period] through the completion of the visit; and for 24 hours prior to Visit 2 (Day -2; Period 1), Visit 4 (Day 21; Period 1), Visit 7 (Day 28; Period 2) and the pre-and post-study visits.
At all other times, caffeinated beverages will be limited to no more than 6 units per day amounts (>6 units: 1 unit=120 mg of caffeine).

Activity
Patients should continue any activity he/she was accustomed to prior to entering the study. The subject must avoid all unusual, unaccustomed, or strenuous exercise or activity for the duration of the study and follow-up period. Activities to avoid include but Protocol/Amendment No.: 026-03 Restricted Confidential -Limited Access are not restricted to strenuous or unaccustomed exercise such as body building training, marathon training, and intense bicycling.

Smoking
Smoking is not permitted during the study.

Pregnancy and Contraception
Women of childbearing potential can be enrolled. However, 2 acceptable methods of barrier contraception must be used beginning at least 2 weeks prior to administration of the initial dose of study drug in Period 1, throughout the study until the poststudy visit. Acceptable methods of birth control are abstinence, or 2 of the following: intrauterine device (IUD-with or without local hormone release), diaphragm, spermicides, cervical cap, contraceptive sponge, and condoms.
Patients must be completely informed of the unknown risks of pregnancy and agree not to become pregnant during the time they are participating in this study.
Hormonal based contraceptives are not allowed as a method of birth control in this study.

Pregnancy Testing
Female patients of childbearing potential will be tested for serum β-human chorionic gonadotropin (hCG) at prestudy and poststudy visits, and for urine β-human chorionic gonadotropin (hCG) in Visit 4, Visit 5, Visit 7 and Visit 8. In the case of a positive or borderline serum β-hCG pregnancy test at the prestudy visit, the subject must not enter the study; in the case of a positive or borderline urine β-hCG pregnancy test during the study, the pregnancy test should be repeated and confirmed positive. If the pregnancy has been confirmed the subject must be discontinued from the study immediately and the Merck clinical monitor must be contacted within 24 hours. The site will contact the subject for SPONSOR updates until the pregnancy has been terminated or completed. The outcome of the pregnancy will be reported to the SPONSOR without delay and within 24 hours if the outcome is a serious adverse experience (e.g., death, abortion [spontaneous or elective], congenital anomaly, birth defect, or other disabling or lifethreatening complication to the mother or newborn).

Procedures
Study procedures should be completed as close to the prescribed/scheduled time as possible.
The exact time at which a procedure is performed must be recorded on the case report forms. Any nonscheduled procedures required for urgent evaluation of safety concerns take precedence over all routine scheduled procedures.
See the Study Flow Chart in the Synopsis section for a complete outline of all study procedures. Protocol/Amendment No.: 026-03 Restricted Confidential -Limited Access

Weight
Body weight will be measured using a standardized scale, with regular calibration. The same scale should be used for the duration of the study. Weight must be measured after an overnight fast, after voiding, with shoes and jacket off.

Vital Sign Measurements
Patients should be resting in a semi-recumbent position for at least 10 minutes prior to having vital sign measurements obtained. Semi-recumbent vital signs will include heart rate, blood pressure, respiratory rate, and temperature.

12-Lead ECG
Special Care must be taken for proper lead placement. Men should be shaved as necessary for proper lead placement. Women must remove their bras prior to lead placement.
Patients should be resting in a semi-recumbent position for at least 10 minutes prior to having ECG readings obtained.

Laboratory Safety Tests, Lipid Panel and Plasma Lipoproteins (Appendix 6.2)
Samples for the laboratory safety tests, lipid panel and plasma lipoproteins will be obtained after a 12-hour fast.

LCAT Activity Assay
LCAT activity will be measured on plasma by thin layer chromatography measuring the rate of cholesteryl ester formation. The site will follow the site SOP for conduction of assay. A copy of the site SOP for the LCAT activity assay will be maintained in the Investigator Trial files for this study.

Hepatic Lipase (HL) and Lipoprotein Lipase (LPL)
Blood samples will be obtained at the end of each kinetic assay (48 hours post start of the kinetic assay). Heparin (60 units/kg body weight) will be injected in the patient. Ten minutes after heparin infusion, 5 mL of blood will be collected and processed for the measurement of HL and LPL concentration and activity. Detailed procedures are provided in site SOPs. A copy of the site SOP for the conduct of the assay will be maintained in the Investigator Trial files for the study.

Lipoprotein Kinetic Assays
A brief summary of the procedures is in Appendix 6.8. The lipoprotein kinetic assays will be conducted per site specific SOPs. A copy of the site SOP for the lipoprotein kinetic assays will be maintained in the Investigator Trial files for this study. Protocol/Amendment No.: 026-03 Restricted Confidential -Limited Access

Genetic Samples
Laboratory supplies and instructions for the labeling, packaging and overnight shipment of samples for genetic analysis will be provided by the central laboratory. The blood samples will be shipped the same day, at ambient temperature, to the central laboratory, according to the instructions provided by the central laboratory.

Archive Samples
Lipoprotein Size by NMR Archive samples will be obtained after a 12 hour fast for possible determination of lipoprotein size by NMR. Procedures for sample preparation, storage and shipment are provided in an operations manual to the investigators.

Lathosterol Concentration and CETP Mass
Archive samples for possible determination of lathosterol concentration and CETP mass will be obtained after a 12 hour fast. Procedures for sample preparation, storage and shipment are provided in an operations manual to the investigators.

Prebeta HDL
Archive samples for possible determination of prebeta HDL will be obtained after a 12-hour fast Procedures for sample preparation, storage and shipment will be per site specific SOP and will be maintained in the Investigator Trial files for this study.

PCSK9 Concentration and CETP Activity
Archive samples for possible determination of PCSK9 concentration and CETP activity will be obtained after a 12-hour fast. Procedures for sample preparation, storage and shipment are in Appendices 6.5 and 6.6, respectively.

PCSK9 and CETP Kinetics
Archive samples will be obtained at each time point during the kinetics assay to support possible future investigations of PCSK9 and CETP kinetics. Storage and shipment procedures will be provided in an operations manual to the investigators.

Plasma for MK-0859 Concentration
Archive plasma samples for MK-0859 concentration will be collected at the timepoints specified in the Study Flow Chart. Procedures for sample preparation, storage and shipment are in Appendix 6.7. Protocol/Amendment No.: 026-03 Restricted Confidential -Limited Access

Subject Domiciling
During the lipoprotein kinetics assays patients will be required to stay in the CRC for 2 consecutive overnight stays. Patients can be discharged from the CRC following the 24-hour blood draw for lipid turnover. Patients should report to the CRC for the 48 hour blood draw. All other clinic visits will be outpatient visits.

Dispensing of Study Drug
All study drug bottles will be dispensed by the site. Patients will be dispensed study drug at Visit 3 and Visit 6. Extra study drug supplies will be allotted in the bottle, in the event that the subject's next visit is outside of the protocol specified visit window.

Study Visit Scheduling
Every effort should be made to have the subject return to the CRC on the scheduled day of their visit. However, if due to extenuating circumstances the subject cannot keep an appointment, a 7-day window after the scheduled visit will be allowed. In this circumstance, the site will record the actual time and date of the rescheduled visit as it occurs.

Prestudy (Screening) (Visit 1)
Up to approximately 8 weeks (2 months) prior to study start, potential patients will be evaluated to determine whether they fulfill the entry requirements listed in Sections 2.2 and 2.3. The investigator or designate will discuss with the potential subject the nature of the study, its risks, requirements, and its restrictions.
All patients will be given a card, at the time of screening, identifying them as participants in a research study. The card will contain contact information (including direct telephone numbers) to be utilized in the event of an emergency.
Written informed consent will be obtained. After the patients signs the consent form, a unique baseline number should be assigned for identification purposes. Procedures to be conducted at the prestudy visit are given in Table 3 Restricted Confidential -Limited Access

Washout Period (Visit 2)
Patients who are taking statins during the screening visit will undergo a 2-week washout period prior to the randomization. Two days prior to randomization patients will report to the CRC (Visit 2) for a lipid panel to determine if their lipid levels meet the inclusion criteria. If the lipid levels are not within the specified range, patients will be allowed an additional 1 week washout. Statin-naïve patients will not undergo the washout period and can be randomized directly into the study if they otherwise meet all in inclusion criteria specified in Section 2.2.

Period 1: Day 1 Randomization (Visit 3)
Eligible patients will be randomized to blinded treatment and will receive a unique allocation number. Patients will be given the study medication to be taken at home with the dosing instructions. Patients will dose at home with the evening meal. The clinical staff will call the patients once or twice during the dosing interval to review the concomitant therapies/medical history/adverse experience as well as to check dosing compliance and remind patients of dosing instructions.

Period 1: Day 21 (Visit 4)
Visit 4 should occur approximately 1 week prior to the start of the kinetic assay in Period 1.
Patients will report to the CRC having fasted for 12-hours. Laboratory safety tests, including a urine pregnancy test, if applicable, and a lipid panel will be taken during this visit. Patients will be given a 3-day food record to complete prior to reporting to the CRC for Visit 5. Protocol/Amendment No.: 026-03 Restricted Confidential -Limited Access

Period 1: Day 28 through Day 31 (Visit 5 and Visit 6)
After 28 days of dosing (maximum 35 days) patients will undergo a lipoprotein kinetic assay. Patients will fast for 12 hours prior to reporting to the CRC on the morning of Day 28 for fasting blood draws. At the discretion of the investigator the patient can leave the CRC following the morning procedures and return to the CRC in the evening to begin the lipoprotein kinetic assay. Patients will then remain in the CRC until the completion of the 24 hour blood draw for lipoprotein kinetics, and should return to the CRC for the 48 hour blood draw. At the discretion of the investigator patients may be requested to remain in the CRC longer. Procedures to be conducted are outlined in Table 3-2.  Restricted Confidential -Limited Access

Period 2: Day 1 (Visit 6)
There will be no washout between Period 1 and Period 2; therefore Day 1 of Period 2 is the same day as Day 31 of Period 1. While at the CRC for Period 1 Day 31 procedures patients will be given their study medication for Period 2. In Period 2, patients will dose at home with the evening meal. The clinical staff will call the patients once or twice during the dosing interval of each treatment to review the concomitant therapies/medical history/adverse experience as well as to check dosing compliance and remind patients of dosing instructions.

Period 2 Day 28 (Visit 7)
Visit 7 should occur approximately 28 days after the start of dosing in Period 2. Patients will report to the CRC in the morning having fasted for at least 12 hours. Procedures to be conducted during Visit 7 are listed in Table 3-3.

Period 2-Day 29 to 55
The patients will dose at home following the dosing instructions. The patients will be contacted periodically by the clinic staff to monitor concomitant therapies/medical history/adverse experience and drug compliance. The exact time of dosing on Day 55 will be recorded in the CRFs.

Period 2-Day 56 through Day 59 (Visit 8 and Visit 9)
After 56 days of dosing (maximum 63 days), patients will undergo a lipoprotein kinetic assay. Patients will fast for 12 hours prior to reporting to the CRC on the morning of Day 56 for fasting blood draws. At the discretion of the investigator, patients can leave the CRC following the morning procedures and return to the CRC in the evening to begin the lipoprotein kinetic assay. Patients will then remain in the CRC until the completion Protocol/Amendment No.: 026-03 Restricted Confidential -Limited Access of the 24 hour blood draw for lipoprotein kinetics, and should return to the CRC for the 48 hour blood draw. At the discretion of the investigator, patients may be requested to remain in the CRC longer. Visit 8 and Visit 9 procedures are in Table 3-4.

Poststudy
Subjects will be required to return to clinic approximately 14 days after the last dose of study drug for the poststudy visit. If the poststudy visit occurs less than 14 days after the last dose of study drug, a subsequent follow-up phone call should be made to determine if any adverse experiences have occurred since the poststudy clinic visit If a subject discontinues at any time during the course of the study, the subject may be asked to return to the clinic (or be contacted) for a poststudy visit (approximately 14 days after the last dose of study drug) to have the applicable procedures conducted. However, the investigator may decide to perform the poststudy procedures at the time of discontinuation or as soon as possible after discontinuation. If the poststudy visit occurs prior to 14 days after the last dose of study drug, the investigator should perform a follow up phone call to determine if any adverse experiences have occurred since the poststudy clinic visit.
Following this, participation in this study will be complete.
Poststudy evaluations will include those listed in Table 3-5.

Volume of Blood Drawn During the Study
The total blood volume withdrawn from any single subject will not exceed the maximum allowable volume during their participation in the entire study, see Appendix 6.4.

General Informed Consent
The investigator must obtain documented consent from each potential patient in biomedical research or when an investigational drug is administered to the patient in a clinical study, prior to any study related procedures being performed. Protocol/Amendment No.: 026-03 Restricted Confidential -Limited Access Consent must be documented by the patient's dated signature on a Consent Form along with the dated signature of the person conducting the consent discussion. A copy of the signed and dated consent form should be given to the subject before participating in the trial.

Consent and Collection of Specimens for Genetic Analysis
During this study, a separate signed informed consent will be administered for collecting a whole blood specimen for potential future genetic research. Only those patients who have consented to having this genetic sample collected may have this blood sample drawn. The investigator or designate is responsible for explaining and verifying the subject's consent before obtaining such blood samples. At the time of sample collection, the investigator's staff member and a witness from the investigator's staff should verify that the subject has signed consent and the correct subject-specific label is placed on the genetic sample, and then both the investigator's staff member and witness initial and date the left-side of the Genetic Sample Label. It should be explained to the subject that giving the blood sample for genetic information is entirely optional for the subject and participation in the associated clinical study is not dependent giving these samples. The approval of the consent form for analysis and the associated protocol procedures (e.g., collection of a blood sample) may, in some cases, proceed independently through Institutional Review Boards, Ethical Review Boards, Independent Ethical Committees, Privacy Committees, etc. from the associated clinical study. In such cases, the clinical study protocol should proceed ahead independently of the above; donation of the genetic sample, once approved, may then be deferred to subsequent study visits. In cases where the IRB/ERC approval for the donation of a sample for genetic analysis is denied or is not accomplished prior to the completion of the clinical study, samples for genetic analysis will not be collected.

Assignment of Baseline Number/Screening
Each patient screened will be assigned a baseline or screening number. The number is assigned to the subject upon signing the consent form to identify the subject for all procedures that occur prior to randomization. This number is composed of the Merck study number followed by a 4 digit patient number. For example, study site 0001 will assign a baseline number of 00010001 to the first patient screened. Each patient will be assigned only one baseline number and each baseline or screening number will be assigned to only one subject. Patients who are screened multiple times will retain the same baseline number.

Randomization/Allocation
Each subject will be assigned an allocation number at the time of randomization. The allocation number will be used to identify the subject for all procedures occurring after randomization.
A single patient/subject cannot be assigned more than 1 allocation number. In a situation where rerandomization of the subjects/patients is planned (e.g., study extension periods), the rerandomization is done based on a new allocation schedule, however each subject/patient retains his/her original allocation number. Only the treatment regimen associated with the rerandomization period or phase may change.

Blinding/Unblinding
In the event of an emergency, the patient's treatment can be unblinded. Except for an emergency when the information could influence medical care, the investigator should not unblind a subject's treatment without prior approval from Merck. If unblinding of the investigational product(s) should occur (e.g., accidental unblinding, emergency unblinding for a serious adverse experience), the investigator must promptly document the circumstances and immediately notify the Merck Clinical Monitor. If unblinding occurs, only the principal investigator or delegate and the respective patient's code should be unblinded. Site personnel and Merck personnel directly associated with the conduct of the study should not be unblinded. The unblinding should be documented in the unblinding log provided by the Merck.

Discontinuation/Withdrawal from Study
Patients/patients may withdraw at any time or be dropped from the study at the discretion of the investigator should any untoward effects occur. In addition, a subject/patient may be withdrawn by the investigator or the SPONSOR if he/she violates the study plan or for administrative and/or other safety reasons. The investigator or study coordinator must notify the SPONSOR immediately when a subject/patient has been discontinued/ withdrawn due to an adverse experience (telephone or FAX). When a subject/patient discontinues/withdraws prior to study completion, all applicable activities scheduled for the final study visit should be performed at the time of discontinuation. Any adverse experiences which are present at the time of discontinuation/withdrawal should be followed in accordance with the safety requirements outlined in Section 3.4 SAFETY MEASUREMENTS -DETAILS.
Patients/patients who donate a blood sample for future genetic analyses may request that their sample be removed from storage and destroyed in accordance with the terms outlined in the informed consent for genetic analyses. Patients/patients should be informed that withdrawal from the main study does not cause the withdrawal and destruction of the genetic sample. Requests for withdrawal and destruction of the genetic sample should be made in writing to the investigator.
Subjects/patients who discontinue from the study will be replaced as required for the study to meet its objectives. The decision to remove a subject/patient and to replace dropouts will be made jointly by the investigator, SPONSOR Clinical Monitor, and SPONSOR study statistician. The replacement will generally receive the same treatment or treatment sequence (as appropriate) as the allocation number replaced. Both the replacement and originally allocated number will be unique numbers. Biological specimens obtained prior to subject/patient discontinuation can be analyzed unless consent is withdrawn.
Production and fractional clearance rates of apoB100 in LDL, VLDL and IDL, apo A-I and apoA-II in HDL, and apo(a) in Lp(a) will be calculated. Comparisons between groups will be performed for percent conversion of VLDL apoB100 to IDL apoB100, VLDL apoB100 to LDL apoB100, and IDL apoB100 to LDL apoB100. Samples will be archived for potential determination of VLDL TG production, and PCSK9 and CETP kinetics.
Plasma will be analyzed to determine the concentrations of lipoprotein lipase (LPL), hepatic lipase (HL) and apolipoproteins, as well as activities of LPL, HL and lecithincholesterol acyltransferase (LCAT). Additional samples will be archived for possible determination of PCSK9, lathosterol and prebeta HDL concentrations and lipoprotein size by NMR. Samples for determination of CETP activity and mass will also be archived.

Pharmacokinetic Measurements-Archive Plasma for MK-0859
Archive Plasma for MK-0859 The decision as to which plasma and/or urine samples collected will be assayed for evaluation of pharmacokinetics/pharmacodynamics will be collaboratively determined by the Departments of Clinical DM/PK and Clinical Pharmacology (e.g., samples at lower doses may not be assayed if samples at higher doses reveal undetectable drug concentrations). If indicated, these samples may also be assayed and/or pooled for assay in an exploratory manner for metabolites and/or additional pharmacodynamic markers.
At the time points listed in the Study Flow Chart, blood will be collected for the determination of MK-0859 Appendix 6.7 provides instructions for sample collection, storage and shipping procedures.

Blood for Pharmacogenomic Analysis
Laboratory supplies and instructions for the labeling, packaging and overnight shipment of samples for genetic analysis will be provided by the genetic sample bank. Approximately 10 mL of whole venous blood will be collected into EDTA vacuum tubes from each patient consenting to genetic analysis. The blood samples will be shipped the same day, at ambient temperature, to the genetic sample bank, according to the Protocol/Amendment No.: 026-03 Restricted Confidential -Limited Access instructions provided by the genetic sample bank. It is extremely important to remember that the genetic sample tube be labeled only with the barcode label containing the GIC.

Medication Compliance
Adherence to study drug treatment will be assessed by patient report and confirmed by tablet count of each bottle at Visit 5 (Day 28, Period 1), Visit 7 (Day 28, Period 2) and Visit 8 (Day 56, Period 2). At the discretion of the investigator, the site may call patients once or twice on any day to monitor dosing compliance. The site will contact the patient the day prior to Visit 8 (Day 55) to record the exact time of dosing on that day. Every effort should be made to maintain adherence to study drug dosing per protocol.

Clinical and Laboratory Measurements for Safety
Safety will be monitored throughout the study by repeated clinical and laboratory evaluation including vital signs, physical exam, 12-lead ECG, laboratory safety parameters (hematology, chemistry, and urinalysis), plasma lipids (total cholesterol, HDL, LDL and triglycerides) and serum/urine β-hCG at appropriate time points as specified in the Study Flow Chart.

Recording Adverse Experiences
An adverse experience is defined as any unfavorable and unintended change in the structure, function, or chemistry of the body temporally associated with the use of the SPONSOR's product, whether or not considered related to the use of the product. Any worsening (i.e., any clinically significant adverse change in frequency and/or intensity) of a preexisting condition which is temporally associated with the use of the SPONSOR's product, is also an adverse experience.
Changes resulting from normal growth and development which do not vary significantly in frequency or severity from expected levels are not to be considered adverse experiences. Examples of this may include, but are not limited to, teething, typical crying in infants and children, and onset of menses or menopause occurring at a physiologically appropriate time.
Adverse experiences may occur in the course of the use of a Merck product in clinical studies or within the follow-up period specified by the protocol, or prescribed in clinical practice, from overdose (whether accidental or intentional), from abuse, and from withdrawal.
Adverse experiences may also occur in screened patients/patients during any preallocation baseline period as a result of a protocol-specified intervention including washout or discontinuation of usual therapy, diet, placebo treatment, or a procedure.
Such events will be recorded at each examination on the Adverse Experience Case Report Forms/Worksheets.

Definition of an Overdose for This Protocol
The patient has taken, accidentally or intentionally, any drug administered as part of the protocol, and exceeding the dose as prescribed by the protocol. It is up to the investigator or the reporting physician to decide whether a dose is to be considered an overdose, but Merck personnel have the authority to upgrade the determination, if deemed appropriate. Before upgrading a report, it is necessary for Merck personnel to communicate with the investigator and reach a consensus.

Reporting of Overdose to SPONSOR
I e p e (s s ( vaccine, the adverse experience(s) is reported as a serious adverse experience, even if no other criteria for serious are met.
If a dose of test drug or vaccine meeting the protocol definition of overdose is taken without any associated clinical symptoms or abnormal laboratory results, the overdose is reported as a non-serious Event of Clinical Interest (ECI), using the terminology All reports of overdose with and without an adverse experience must be reported within 24 hours to one of the individuals listed on the sponsor contact information page found in the Administrative Binder.

Reporting of Pregnancy to SPONSOR
Although not considered an adverse experience, it is the responsibility of investigators or their designees to report any pregnancy in a subject/patient (spontaneously reported to them) which occurs during the study or within 14 days of completing the study. All subjects/patients who become pregnant must be followed to the completion/termination of the pregnancy. If the pregnancy continues to term, the outcome (health of infant) must also be reported to one of the individuals listed on the SPONSOR Contact Information page found in the Administrative Binder.

Serious Adverse Experiences
Any serious adverse experience, including death due to any cause, which occurs to any subject/patient entered into this study or within 14 days following cessation of treatment or within the established off therapy follow-up period for safety described in the protocol, whether or not related to the investigational product, must be reported within 24 hours to one of the individual(s) listed on the contact information page.
Additionally, any serious adverse experience considered by an investigator who is a qualified physician to be possibly, probably, or definitely related to the investigational product that is brought to the attention of the investigator at any time outside of the time period specified in the previous paragraph also must be reported immediately to one of Protocol/Amendment No.: 026-03 0859_026-03_ProtDet APPROVED 29-Jul-2010 U.S. IND, U.S. Study Restricted Confidential -Limited Access the individuals listed on the sponsor contact information page found in the administrative binder.
All patients/patients with serious adverse experiences must be followed up for outcome.

Evaluating Adverse Experiences
Refer to Table 3 Table 3-6 An investigator who is a qualified physician, will evaluate all adverse experiences as to:

Maximum
Mild awareness of sign or symptom, but easily tolerated (for pediatric studies, awareness of symptom, but easily tolerated) Intensity Moderate discomfort enough to cause interference with usual activity (for pediatric studies, definitely acting like something is wrong) Severe incapacitating with inability to work or do usual activity (for pediatric studies, extremely distressed or unable to do usual activities) Seriousness A serious adverse experience is any adverse experience occurring at any dose that: †Results in death; or †Is life threatening; or places the subject/patient, in the view of the investigator, at immediate risk of death from the experience as it occurred [Note: This does not include an adverse experience that, had it occurred in a more severe form, might have caused death.]; or †Results in a persistent or significant disability/incapacity (substantial disruption of one's ability to conduct normal life functions); or †Results in or prolongs an existing inpatient hospitalization (hospitalization is defined as an inpatient admission, regardless of length of stay, even if the hospitalization is a precautionary measure for continued observation. (Note: Hospitalization [including hospitalization for an elective procedure] for a preexisting condition which has not worsened does not constitute a serious adverse experience.); or †Is a congenital anomaly/birth defect (in offspring of subject/patient taking the product regardless of time to diagnosis); or Is a cancer; or Is an overdose (Whether accidental or intentional.) Any overdose whether or not associated with an adverse experience must be reported within 24 hours to one of the individuals on the Contact Information Page found in the Administrative Binder.
Other important medical events that may not result in death, not be life threatening, or not require hospitalization may be considered a serious adverse experience when, based upon appropriate medical judgment, the event may jeopardize the subject/patient and may require medical or surgical intervention to prevent one of the outcomes listed previously (designated above by a †).

Duration
Record the start and stop dates of the adverse experience. If less than 1 day, indicate the appropriate length of time and units Action taken Did the adverse experience cause the test drug to be discontinued?

Relationship to test drug
Did the test drug cause the adverse experience? The determination of the likelihood that the test drug caused the adverse experience will be provided by an investigator who is a qualified physician. The investigator's signed/dated initials on the source document or worksheet, that supports the causality noted on the AE form, ensures that a medically qualified assessment of causality was done. This initialed document must be retained for the required regulatory time frame. The criteria below are intended as reference guidelines to assist the investigator in assessing the likelihood of a relationship between the test drug and the adverse experience based upon the available information.
The following components are to be used to assess the relationship between the test drug and the AE; the greater the correlation with the components and their respective elements (in number and/or intensity), the more likely the test drug caused the adverse experience (AE):

Exposure
Is there evidence that the subject/patient was actually exposed to the test drug such as: reliable history, acceptable compliance assessment (pill count, diary, etc.), expected pharmacologic effect, or measurement of drug/metabolite in bodily specimen? Is the clinical/pathological presentation of the AE consistent with previous knowledge regarding the test drug or drug class pharmacology or toxicology?
The assessment of relationship will be reported on the case report forms/worksheets by an investigator who is a qualified physician according to his/her best clinical judgment, including consideration of the above elements. Use the following scale of criteria as guidance (not all criteria must be present to be indicative of a drug relationship).

Definitely related
There is evidence of exposure to the test drug. The temporal sequence of the AE onset relative to administration of the test drug is reasonable. The AE is more likely explained by the test drug than by another cause. Dechallenge is positive. Rechallenge (if feasible) is positive. The AE shows a pattern consistent with previous knowledge of the test drug or test drug class.

Probably related
There is evidence of exposure to the test drug. The temporal sequence of the AE onset relative to administration of the test drug is reasonable. The AE is more likely explained by the test drug than by another cause. Dechallenge (if performed) is positive. Possibly related There is evidence of exposure to the test drug. The temporal sequence of the AE onset relative to administration of the test drug is reasonable. The AE could have been due to another equally likely cause. Dechallenge (if performed) is positive.

Probably not related
There is evidence of exposure to the test drug. There is another more likely cause of the AE. Dechallenge (if performed) is negative or ambiguous. Rechallenge (if performed) is negative or ambiguous.

Definitely not related
The subject/patient did not receive the test drug. OR Temporal sequence of the AE onset relative to administration of the test drug is not reasonable. OR There is another obvious cause of the AE. Restricted Confidential -Limited Access

SPONSOR Responsibility for Reporting Adverse Experiences
All adverse experiences will be reported to regulatory agencies, IRB/IECs, and investigators in accordance with all applicable global laws and regulations.

DATA ANALYSIS
The statistical analysis of the data obtained from this study will be conducted by, or under the direct auspices of, the Clinical Pharmacology Statistics Department in collaboration with the Drug Metabolism department, the Clinical Pharmacology Department of the Sponsor, and University of Pennsylvania.
If, after the study has begun, changes are made to the statistical analysis plan stated below, then these deviations to the plan will be listed, along with an explanation as to why they occurred, in the Clinical Study Report.

Variables and Time Points
The primary variables of interest are the production rate (PR) and fractional catabolic rate (FCR) of LDL apoB100. Additional endpoints of interest are as follows: 1) the pool size (PS) of LDL apoB100; 2) the kinetics (PR, FCR and PS) of apoA-I in HDL, apoA-II in HDL, apoB100 in VLDL, apoB100 in IDL and apo(a) in Lp(a); 3) the concentration of proteins involved in the modulation of VLDL, LDL, and HDL lipid composition, including lecithin-cholesterol acyltransferase (LCAT), lipoprotein lipase (LPL) and hepatic lipase (HL); and 4) the concentrations of apoA-I, apoA-II, apoB100, apoC-II, apoC-III, apoE, Lp(a); 5) the activities of lecithin-cholesterol acyltransferase (LCAT), LPL and HL; and 6) the percent conversions of VLDL apoB100 to IDL apoB100, VLDL apoB100 to LDL apoB100, and IDL apoB100 to LDL apoB100 (refer to Appendix 6.9).
Samples for the following variables will be archived: VLDL TG production rate, cholesteryl ester transfer protein (CETP; kinetics, concentration and activity), PCSK9 (kinetics and concentration), lathosterol, prebeta HDL and lipoprotein size by NMR for LDL, HDL and VLDL. These variables may also be included in the statistical analysis if samples are analyzed.
Safety endpoints will include all types of adverse experiences, laboratory tests, ECGs, vital signs and the concentrations of total cholesterol, HDL, LDL and triglycerides.

Approaches to Analyses
The following populations are defined for the analysis and reporting of data. All patients will be reported, and their data analyzed, according to the treatment(s) they actually received.
All Patients as Treated (APT) -All patients who received at least one dose of the investigational drug. This population will be used for assessments of safety and tolerability.
Per-Protocol (PP) -The set of data generated by the subset of patients who comply with the protocol sufficiently to ensure that these data will be likely to exhibit the effects of treatment, according to the underlying scientific model. Compliance covers such considerations as exposure to treatment, availability of measurements and absence of major protocol violations. Major protocol violators will be identified to the extent possible prior to unblinding by individuals responsible for data collection/compliance, and its analysis and interpretation. Any patients or data values excluded from analysis will be identified, along with their reason for exclusion, in the CSR. This population will be used for the PK and PD analyses.

Primary Hypotheses (LDL apoB100 PR & FCR)
The primary hypotheses will be addressed by analyzing both the production rate (PR) and the fractional catabolic rate (FCR) of LDL apoB100 with separate linear mixed effects models containing fixed effects for panel and treatment within panel, and a random effect Restricted Confidential -Limited Access for subject within panel. Covariates for age and gender may also be included in the model. Summary statistics including point estimates, 95% confidence intervals (CIs) and between-treatment p-values (two-tailed) for the true mean differences (MK-0859 w/atorvastatin -atorvastatin) in LDL apoB100 PR and LDL apoB100 FCR will be calculated based on their respective models. The point estimate and CI for LDL apoB100 PR will be compared to the -1.4 mg·kg/d expected mean difference.
The 4A multiple testing procedure of Li and Mehrotra (2008) [1] will be followed in order to account for the disparity in statistical power for the two primary endpoints. If the p-value for the true mean difference (MK-0859 w/atorvastatin versus atorvastatin) in LDL apoB100 PR is statistically significant at the α 1 =0.04 level, the corresponding true mean difference for LDL apoB100 FCR will be tested at the full α 2 =0.05 level. However, if the true mean difference for LDL apoB100 PR is not significant at α 1 =0.04, the true mean difference for LDL apoB100 FCR will be tested at an adjusted α 2 level based on both the observed p-value for PR and the correlation among the two endpoints. The primary hypothesis will be supported if the test for either endpoint is significant at their respective α level. That is, administration of MK-0859 on a background of atorvastatin therapy is associated with a significant change in LDL apoB100 turnover.

Secondary Hypothesis (LDL apoB100 FCR)
The secondary hypothesis and third tertiary hypothesis will be addressed by analyzing the fractional catabolic rate of LDL apoB100 with a linear mixed effects model containing fixed effects for panel and treatment within panel, and a random effect for subject within panel. Covariates for age and gender may also be included in the model. Summary statistics including point estimates, 95% CIs and between-treatment p-values (two-tailed) for the true mean differences (MK-0859 -placebo; atorvastatin -placebo) in LDL apoB100 FCR will be calculated based on this model. The contrast for the cross-panel comparison (i.e., atorvastatin versus placebo) will include the appropriate coefficients for the panel effects. The point estimate and CI for the comparison of MK-0859 versus placebo in LDL apoB100 FCR will be compared to the 0.065 pools/d expected mean difference. Similarly, the point estimate and CI for the comparison of atorvastatin versus placebo in LDL apoB100 FCR will be compared to the 0.20 pools/d expected mean difference.

Tertiary Hypotheses (HDL apoA-I FCR)
The first and second tertiary hypotheses will be addressed by an analyzing the fractional catabolic rate of HDL apoA-I using a similar linear mixed effects model as described above. Summary statistics including point estimates, 95% CIs and between-treatment p-values (two-tailed) for the true mean differences (MK-0859 w/atorvastatinatorvastatin; MK-0859 -placebo) in HDL apoA-I FCR will be calculated based on this model. The point estimates and CIs will then be compared to their respective -0. Restricted Confidential -Limited Access The third tertiary hypothesis for comparison of atorvastatin versus placebo in LDL apoB100 FCR is addressed above.

Exploratory Analyses
Each of the exploratory endpoints listed in Section 3.5.2 will be analyzed with a similar linear mixed effects model as described above. Summary statistics including point estimates, 95% CIs and between-treatment p-values (two-tailed) for the true mean differences in these parameters will be reported. All contrasts for the cross-panel comparisons will include the appropriate coefficients for the panel effects. Descriptive statistics (mean and standard deviation, etc.) by treatment will also be provided.
A correlation analysis including all primary, secondary, tertiary and exploratory endpoints will be conducted to examine the relationships among these parameters. In addition to the Pearson correlation coefficient (ρ), a 95% confidence interval will also be calculated for each pair of endpoints. The upper limit of the 95% CI for ρ of LDL apoB100 PR versus FCR will be used to obtain the α 2 level for the 4A multiple testing method described above if the true mean difference (MK-0859 w/atorvastatinatorvastatin) for LDL apoB100 PR is not significant at α 1 =0.04.

Safety Analyses
Descriptive statistics and plots will be generated by panel for change (or percent change as appropriate) from prestudy of clinically appropriate safety laboratory parameters, vital signs, ECG parameters and the concentrations of total cholesterol, HDL, LDL and triglycerides.

Assumptions
Data will be examined for departures from the assumptions of the statistical model(s) as appropriate; e.g., heteroscedasticity, nonnormality of the error terms. Distribution-free methods may be used if a serious departure from the assumptions of the model(s) is observed, or suitable data transformations may be applied.

Multiplicity
This study has two primary comparisons: change in LDL apoB100 PR and change in LDL apoB100 FCR after administration of MK-0859 on a background of atorvastatin therapy versus atorvastatin alone. Success on either comparison is sufficient to declare a positive trial. Therefore, as outlined above, the method of Li and Mehrotra (2008) [1] will be followed to control the family-wise error rate for the primary hypotheses at α=0.05.
In addition to the primary comparisons, a large number of between-treatment comparisons will be conducted to address the secondary, tertiary and exploratory objectives of the study. In order to facilitate a balanced interpretation of these results, adjusted p-values will be reported in addition to the raw p-values. Using the two-stage method of Mehrotra , the false discovery rate (FDR) [8] will be controlled at 5%. For this purpose, three families of hypotheses are defined: F1) hypothesis tests of the following endpoints: kinetics of apoB100 in LDL, VLDL and IDL, conversions of VLDL apoB100 to IDL apoB100, VLDL apoB100 to LDL apoB100, and IDL apoB100 to LDL apoB100, concentrations and activity of HL and LPL, and concentrations of apoB100, apoC-II, apoC-III and apoE The "Double FDR" method will be implemented separately within each hypothesis family (F) using the three between-treatment differences (Ds) as the procedure subsets. Note that the Ds on some of the endpoints are expected to demonstrate no change (refer to Appendix 6.9). Since a multiplicity adjustment is inappropriate for these comparisons, the relevant endpoint for that D will be excluded from the Double FDR procedure.

Power Calculations
The variability estimates and detectable differences presented in the power calculations below were observed in [2] and from personal communication with

Primary Hypotheses
Assuming a pooled, within-subject standard deviation of

Secondary Hypothesis
Assuming a pooled, within-subject standard deviation of 0.05 pools/d, N=10 subjects in Panel B, and a significance level of 0.05 (two-tailed), there is 95.4% probability to detect a 0.065 pools/d increase in LDL apoB100 FCR for MK-0859 compared to placebo.

Subject and Replacements Information
Clinical supplies will be packaged for 64 subjects to support enrollment and completion of approximately 40 subjects.
MK-0859 active/matching placebo and Atorvastatin (Lipitor active/matching placebo clinical supplies will be packaged according to an allocation schedule generated by the SPONSOR.

Product Descriptions
Investigational materials will be provided by the SPONSOR as summarized in Table 3-7.  Restricted Confidential -Limited Access

Primary Packaging and Labeling Information
The MK-0859 active/matching placebo and Atorvastatin (Lipitor active/matching placebo supplies will be packaged in HDPE bottles with child resistant closures;  Restricted Confidential -Limited Access

Secondary Packaging and Labeling Information (kit)
MK-0859 active/matching placebo and Atorvastatin (Li active/matching placebo supplies will be packaged in kit boxes as outlined in Table 3-9 below. Kit configuration is subject to change as a result of packaging constraints.

Clinical Supplies Disclosure
MK-0859 active/matching placebo and Atorvastatin (Lipitor active/matching placebo supplies will be provided with blinded envelopes containing drug disclosure information. The SPONSOR will provide one sealed envelope to the investigator for each allocation number for each interval ID. Disclosure envelopes must be received by a designated person at the study site and kept in a secured location to which only the investigator and designated assistants have access. The envelope should be opened only in the case of an emergency if the drug identification information is necessary for the welfare of the patient. Every effort should be made not to unblind the patient unless necessary. Prior to unblinding, the investigator Restricted Confidential -Limited Access will attempt to contact the CRA. Any unblinding that occurs at the site must be documented and the unblinded envelope retained at site. At the end of the study, all disclosure envelopes (sealed and unsealed) are to be returned to the SPONSOR.
Envelope information may include the following: Lot Trace ID or Barcode Allocation Number Interval ID Compound ID -Protocol # Drug identity (inside the envelope)

Storage and Handling Requirements
The storage conditions will be indicated on the product label.
The clinical supplies storage area at the site must be monitored by the site staff for temperature consistency with the acceptable storage temperature range specified in this protocol or in the product label attached to the protocol. Documentation of temperature monitoring should be maintained.

Standard Policies / Return of Clinical Supplies
Investigational clinical supplies must be received by a designated person at the study site, handled and stored safely and properly, and kept in a secured location to which only the investigator and designated assistants have access. Clinical supplies are to be dispensed only in accordance with the protocol. The investigator is responsible for keeping accurate records of the clinical supplies received from the SPONSOR, the amount dispensed to and returned by the patients, and the amount remaining at the conclusion of the study. In accordance with Good Pharmacy Practices, gloves should always be worn by study personnel if directly handling tablets or capsules that are returned (i.e., when counting returns). The Clinical Monitor should be contacted with any questions concerning investigational products where special or protective handling is indicated. At the end of the study, all clinical supplies including partial and empty containers must be returned as indicated on the Contact Information page(s).

U.S. sites should follow instructions for the Clinical Supplies Return Form (R464) and
contact your SPONSOR representative for review of shipment and form before shipping.

Comparator Statement
At the close of the study after unblinding, a letter is to be sent by the investigator to those patients who received placebos in the image of the competitor's product to provide the following advice: Restricted Confidential -Limited Access to resemble the drug Li ito 20 mg (atorvastatin) as much as possible. You did not receive the active drug L pi (atorvastatin) as manufactured by Pfizer."

DATA MANAGEMENT
Information regarding Data Management procedures for this protocol will be provided by the SPONSOR.

BIOLOGICAL SPECIMENS
Information regarding biological specimens for this protocol will be provided by the SPONSOR.
It is the responsibility of the primary investigator to ensure that all staff personnel who will be handling, packaging, and/or shipping clinical specimens act in conformance with International Air Transport Association (IATA) regulations to the handling and shipping of hazardous goods.

For All Studies
By signing this protocol, the investigator affirms to the SPONSOR that information furnished to the investigator by the SPONSOR will be maintained in confidence and such information will be divulged to the Institutional Review Board, Ethics Review Committee, or similar or expert committee; affiliated institution; and employees only under an appropriate understanding of confidentiality with such board or committee, affiliated institution and employees. Data generated by this study will be considered confidential by the investigator, except to the extent that it is included in a publication as provided in the Publications section of this protocol.

For All Studies
By signing this protocol, the investigator agrees that the SPONSOR (or SPONSOR representative), Institutional Review Board/Independent Ethics Committee (IRB/IEC), or Regulatory Agency representatives may consult and/or copy study documents in order to verify worksheet/case report form data. By signing the consent form, the subject/patient agrees to this process. If study documents will be photocopied during the process of verifying worksheet/case report form information, the subject/patient will be identified by unique code only; full names/initials will be masked prior to transmission to the SPONSOR.

For Studies Conducted Under the U.S. IND
By signing this protocol, the investigator agrees to treat all patient data used and disclosed in connection with this study in accordance with all applicable privacy laws, rules and regulations, including all applicable provisions of the Health Insurance Portability and Accountability Act and its implementing regulations, as amended from

For All Studies
By signing this protocol, the investigator recognizes that certain personal identifying information with respect to the investigator, and all subinvestigators and study site Consistent with the purposes described above, this information may be transmitted to the SPONSOR, and subsidiaries, affiliates and agents of the SPONSOR, in your country and other countries, including countries that do not have laws protecting such information.
Additionally, the investigator's name and business contact information may be included when reporting certain serious adverse events to regulatory agencies or to other investigators. By signing this protocol, the investigator expressly consents to these uses and disclosures.

For Multicenter Studies
In order to facilitate contact between investigators, the SPONSOR may share an investigator's name and contact information with other participating investigators upon request.

COMPLIANCE WITH LAW, AUDIT, AND DEBARMENT
By signing this protocol, the investigator agrees to conduct the study in an efficient and diligent manner and in conformance with this protocol; generally accepted standards of Good Clinical Practice; and all applicable federal, state, and local laws, rules and regulations relating to the conduct of the clinical study.
The Code of Conduct, a collection of goals and considerations that govern the ethical and scientific conduct of clinical investigations sponsored by Merck & Co., Inc., is attached.
The investigator also agrees to allow monitoring, audits, Institutional Review Board/Independent Ethics Committee review, and regulatory agency inspection of trialrelated documents and procedures and provide for direct access to all study-related source data and documents.
The investigator agrees not to seek reimbursement from subjects/patients, their insurance providers, or from government programs for procedures included as part of the study reimbursed to the investigator by the SPONSOR.
The Investigator shall prepare and maintain complete and accurate study documentation in compliance with Good Clinical Practice standards and applicable federal, state, and local laws, rules and regulations; and, for each subject/patient participating in the study, provide all data, and upon completion or termination of the clinical study submit any Restricted Confidential -Limited Access other reports to the SPONSOR as required by this protocol or as otherwise required pursuant to any agreement with the SPONSOR.
Study documentation will be promptly and fully disclosed to the SPONSOR by the investigator upon request and also shall be made available at the investigator's site upon request for inspection, copying, review, and audit at reasonable times by representatives of the SPONSOR or any regulatory agencies. The investigator agrees to promptly take any reasonable steps that are requested by the SPONSOR as a result of an audit to cure deficiencies in the study documentation and worksheets/case report forms.
International Conference of Harmonization Good Clinical Practice guidelines (Section 4.3.3) recommend that the investigator inform the subject's primary physician about the subject's participation in the trial if the subject has a primary physician and if the subject agrees to the primary physician being informed.
According to European legislation, a SPONSOR must designate a principal or coordinating investigator (CI) to review the report (summarizing the study results) and confirm that to the best of his/her knowledge the report accurately describes conduct and results of the study. The SPONSOR may consider one or more factors in the selection of the individual to serve as the CI (e.g., thorough understanding of clinical trial methods, appropriate enrollment of subject/patient cohort, timely achievement of study milestones, availability of the CI during the anticipated review process).
The investigator will promptly inform the SPONSOR of any regulatory agency inspection conducted for this study.
Persons debarred from conducting or working on clinical studies by any court or regulatory agency will not be allowed to conduct or work on this SPONSOR's studies. The investigator will immediately disclose in writing to the SPONSOR if any person who is involved in conducting the study is debarred, or if any proceeding for debarment is pending or, to the best of the investigator's knowledge, threatened.
In the event the SPONSOR prematurely terminates a particular trial site, the SPONSOR will promptly notify that site's IRB/IEC.

QUALITY CONTROL AND QUALITY ASSURANCE
By signing this protocol, the SPONSOR agrees to be responsible for implementing and maintaining quality control and quality assurance systems with written SOPs to ensure that trials are conducted and data are generated, documented, and reported in compliance with the protocol, accepted standards of Good Clinical Practice, and all applicable federal, state, and local laws, rules and regulations relating to the conduct of the clinical study.

COMPLIANCE WITH INFORMATION PROGRAM ON CLINICAL TRIALS FOR SERIOUS OR LIFE THREATENING CONDITIONS
Under the terms of The Food and Drug Administration Modernization Act (FDAMA), the SPONSOR of the study is solely responsible for determining whether the study is subject to the requirements for submission to the Clinical Trials Data Bank, http://clinicaltrials.gov/. Merck, as SPONSOR of this study, will review this protocol and submit the information necessary to fulfill this requirement. Merck entries are not limited to FDAMA mandated trials. Merck's voluntary listings, beyond those mandated by FDAMA, will be in the same format as for treatments for serious or life-threatening illnesses. Information posted will allow patients to identify potentially appropriate trials for their disease conditions and pursue participation by calling a central contact number for further information on appropriate study locations and site contact information.
By signing this protocol, the investigator acknowledges that the statutory obligation under FDAMA is that of the SPONSOR and agrees not to submit any information about this study to the Clinical Trials Data Bank.

PUBLICATIONS
As this study is part of a multicenter trial, publications derived from this study should include input from the investigator(s) and SPONSOR personnel. Such input should be reflected in publication authorship, and whenever possible, preliminary agreement regarding the strategy for order of authors' names should be established before conducting the study. Subsequent to the multicenter publication, or 24 months after completion of the study, whichever comes first, an investigator and/or his/her colleagues may publish the results for their study site independently. However, the SPONSOR does not recommend separate publication of individual study site results due to scientific concerns.
The SPONSOR must have the opportunity to review all proposed abstracts, manuscripts, or presentations regarding this study 60 days prior to submission for publication/presentation. Any information identified by the SPONSOR as confidential must be deleted prior to submission. SPONSOR review can be expedited to meet publication guidelines. Restricted Confidential -Limited Access 6. APPENDICES

CALCULATING BODY MASS INDEX (BMI)
BMI is calculated by taking the subject's weight, in kg, and dividing by the subject's height, in meters, squared (BMI = (Body weight in kilograms) ÷ (height in meters) 2 .

ALGORITHM FOR ASSESSING OUT-OF RANGE LABORATORY VALUES
For all laboratory values obtained at prestudy (screening) visit evaluation: A. If all protocol-specified laboratory values are normal, the subject may enter the study.
B. If a protocol specified laboratory value is outside of the parameter(s) outlined in the inclusion/exclusion criteria (including a repeat if performed), the subject will be excluded from the study.
C. If ≥ 1 protocol-specified laboratory value not specified in the inclusion/exclusion criteria is outside the normal range, the following choices are available: 1. The subject may be excluded from the study; 2. The subject may be included in the study if the abnormal value(s) is not clinically significant (NCS) (the investigator must annotate the laboratory value on the laboratory safety test source document); 3. The subject be included in the study if the abnormality is consistent with a preexisting medical condition which is not excluded per protocol (e.g., elevated eosinophil count in a subject with asthma or seasonal allergies) (this should be annotated on the laboratory report) or 4. The abnormal test may be repeated (refer items a. and b. below for continuation of algorithm for repeated values).
a. If the repeat test value is within the normal range, the subject may enter the study.
b. If the repeat test value is still abnormal, the study investigator will evaluate the potential subject with a complete history and physical examination, looking especially for diseases that could result in the abnormal laboratory value in question. If such diseases can be ruled out, and if the abnormal laboratory value is not clinically relevant, then the subject may enter the study. Restricted Confidential -Limited Access

ARCHIVE PLASMA FOR PCSK9 LEVELS SAMPLE COLLECTION, HANDLING, LABELING, STORAGE, AND SHIPMENT
A. Plasma for PCSK9 Levels

Collection of Plasma
Samples for plasma PCSK9 levels will be obtained as indicated in the Flow Chart. See Flow Chart (Section 1.7) for blood collection times.

Sample Labeling
Specimens will be labeled with computer-generated labels which have been preprinted and color-coded for convenience. Labels can only be affixed to dry surfaces. They can be used on polyethylene, glass, etc. and will survive freezing and thawing. One label must be affixed directly to the tube containing the blood or plasma sample.

Procedures
a. Collect one 3-mL whole blood in a K2-EDTA (purple-top) tube. Immediately after collection, the blood-containing tubes should be inverted and placed on ice and centrifuged promptly at 3000 rpm (1500 g) at 4˚C for 10 minutes.
c. Immediately after collection, plasma samples should be stored in a freezer at -70˚C until shipment for assay until transfer to Merck on DRY ICE.
d. In the event that the blood samples cannot be immediately processed, samples should be kept on ice. However, no more than 45 minutes should elapse between blood draw and freezing of samples.

B. Shipping of Samples
It is the responsibility of the primary investigator to ensure that all staff personnel who will be handling, packaging, and/or shipping clinical specimens act in conformance with International Air Transport Association (IATA) regulations relating to the handling and shipping of hazardous goods.
1. All shipments will be made in freezer boxes containing at least 20 kg DRY ICE and labeled as HUMAN SAMPLES: NONINFECTIOUS.
2. Please include a sample inventory with each shipment.  Restricted Confidential -Limited Access

ARCHIVE SERUM FOR CETP ACTIVITY SAMPLE COLLECTION, HANDLING, LABELING, STORAGE, AND SHIPMENT
A. Serum for CETP Activity

Collection of Serum
Samples for serum CETP activity will be obtained as indicated in the Flow Chart. See Flow Chart (Section 1.7) for blood collection times.

Sample Labeling
Specimens will be labeled with computer-generated labels which have been preprinted and color-coded) for convenience. Labels can only be affixed to dry surfaces. They can be used on polyethylene, glass, etc. and will survive freezing and thawing. One label must be affixed directly to the tube containing the blood or plasma sample.

Procedures
a. At each collection, 3 mL of whole blood will be drawn into labeled VACUTAINER TM (red-top tube) without neither anticoagulant nor serum separator.
b. The blood-containing tubes should be allowed to clot at room temperature, for at least 10 minutes.
c. Blood samples will be centrifuged within 30 minutes of being drawn at 4˚C for 10 minutes at 3000 rpm and the serum withdrawn.
e. Serum samples should be placed in a freezer and stored at -70˚C until shipment to Merck Clinical Development Laboratory, Rahway, New Jersey for assay.

B. Shipping of Samples
It is the responsibility of the primary investigator to ensure that all staff personnel who will be handling, packaging, and/or shipping clinical specimens act in conformance with International Air Transport Association (IATA) regulations relating to the handling and shipping of hazardous goods.
1. All shipments will be made in freezer boxes containing at least 20 kg DRY ICE and labeled as HUMAN SAMPLES: NONINFECTIOUS.  Restricted Confidential -Limited Access

PROCEDURE TO MEASURE FASTING LDL-C AND HDL-C (If TG are >400 mg/dL)
1. 1.5 mL plasma will be spun in an ultracentrifuge at density 1.006 g/ml which separates the VLDL fraction.
2. The top fraction will then be separated from the 1.006 g/ml bottom fraction, which contains LDL and HDL.
5. HDL-cholesterol will than be measured in the supernatant fraction and corrected for the 10% dilution by the precipitating reagent.
Note: HDL-C may be determined according to site-specific SOPs. Atorvastatin calcium is a white to off-white crystalline powder that is insoluble in aqueous solutions of pH 4 and below. Atorvastatin calcium is very slightly soluble in distilled water, pH 7.4 phosphate buffer, and acetonitrile, slightly soluble in ethanol, and freely soluble in methanol.

Mechanism of Action
Atorvastatin is a selective, competitive inhibitor of HMG-CoA reductase, the ratelimiting enzyme that converts 3-hydroxy-3-methylglutaryl-coenzyme A to mevalonate, a precursor of sterols, including cholesterol. Cholesterol and triglycerides circulate in the bloodstream as part of lipoprotein complexes. With ultracentrifugation, these complexes separate into HDL (high-density lipoprotein), IDL (intermediate-density lipoprotein), LDL (low-density lipoprotein), and VLDL (very-low-density lipoprotein) fractions. Triglycerides (TG) and cholesterol in the liver are incorporated into VLDL and released into the plasma for delivery to peripheral tissues. LDL is formed from VLDL and is catabolized primarily through the high-affinity LDL receptor. Clinical and pathologic studies show that elevated plasma levels of total cholesterol (total-C), LDL-cholesterol (LDL-C), and apolipoprotein B (apo B) promote human atherosclerosis and are risk factors for developing cardiovascular disease, while increased levels of HDL-C are associated with a decreased cardiovascular risk.
In animal models, LIPITOR lowers plasma cholesterol and lipoprotein levels by inhibiting HMG-CoA reductase and cholesterol synthesis in the liver and by increasing the number of hepatic LDL receptors on the cell-surface to enhance uptake and catabolism of LDL; LIPITOR also reduces LDL production and the number of LDL particles. LIPITOR reduces LDL-C in some patients with homozygous familial hypercholesterolemia (FH), a population that rarely responds to other lipid-lowering medication(s).
A variety of clinical studies have demonstrated that elevated levels of total-C, LDL-C, and apo B (a membrane complex for LDL-C) promote human atherosclerosis. Similarly, decreased levels of HDL-C (and its transport complex, apo A) are associated with the development of atherosclerosis. Epidemiologic investigations have established that cardiovascular morbidity and mortality vary directly with the level of total-C and LDL-C, and inversely with the level of HDL-C.
LIPITOR reduces total-C, LDL-C, and apo B in patients with homozygous and heterozygous FH, nonfamilial forms of hypercholesterolemia, and mixed dyslipidemia. LIPITOR also reduces VLDL-C and TG and produces variable increases in HDL-C and apolipoprotein A-1. LIPITOR reduces total-C, LDL-C, VLDL-C, apo B, TG, and non-HDL-C, and increases HDL-C in patients with isolated hypertriglyceridemia. LIPITOR reduces intermediate density lipoprotein cholesterol (IDL-C) in patients with dysbetalipoproteinemia.
Like LDL, cholesterol-enriched triglyceride-rich lipoproteins, including VLDL, intermediate density lipoprotein (IDL), and remnants, can also promote atherosclerosis. Elevated plasma triglycerides are frequently found in a triad with low HDL-C levels and small LDL particles, as well as in association with non-lipid metabolic risk factors for coronary heart disease. As such, total plasma TG has not consistently been shown to be an independent risk factor for CHD. Furthermore, the independent effect of raising HDL or lowering TG on the risk of coronary and cardiovascular morbidity and mortality has not been determined.

Pharmacodynamics
Atorvastatin as well as some of its metabolites are pharmacologically active in humans. The liver is the primary site of action and the principal site of cholesterol synthesis and LDL clearance. Drug dosage rather than systemic drug concentration correlates better with LDL-C reduction. Individualization of drug dosage should be based on therapeutic response (see DOSAGE AND ADMINISTRATION).

Pharmacokinetics and Drug Metabolism
Absorption: Atorvastatin is rapidly absorbed after oral administration; maximum plasma concentrations occur within 1 to 2 hours. Extent of absorption increases in proportion to atorvastatin dose. The absolute bioavailability of atorvastatin (parent drug) is approximately 14% and the systemic availability of HMG-CoA reductase inhibitory activity is approximately 30%. The low systemic availability is attributed to presystemic clearance in gastrointestinal mucosa and/or hepatic first-pass metabolism. Although food decreases the rate and extent of drug absorption by approximately 25% and 9%, respectively, as assessed by Cmax and AUC, LDL-C reduction is similar whether atorvastatin is given with or without food. Plasma atorvastatin concentrations are lower (approximately 30% for Cmax and AUC) following evening drug administration compared with morning. However, LDL-C reduction is the same regardless of the time of day of drug administration (see DOSAGE AND ADMINISTRATION).

Distribution: Mean volume of distribution of atorvastatin is approximately 381 liters.
Atorvastatin is ≥98% bound to plasma proteins. A blood/plasma ratio of approximately 0.25 indicates poor drug penetration into red blood cells. Based on observations in rats, atorvastatin is likely to be secreted in human milk (see CONTRAINDICATIONS, Pregnancy and Lactation, and PRECAUTIONS, Nursing Mothers).

Metabolism:
Atorvastatin is extensively metabolized to ortho-and parahydroxylated derivatives and various beta-oxidation products. In vitro inhibition of HMG-CoA reductase by ortho-and parahydroxylated metabolites is equivalent to that of atorvastatin. Approximately 70% of circulating inhibitory activity for HMG-CoA reductase is attributed to active metabolites. In vitro studies suggest the importance of atorvastatin metabolism by cytochrome P450 3A4, consistent with increased plasma concentrations of atorvastatin in humans following coadministration with erythromycin, a known inhibitor of this isozyme (see PRECAUTIONS, Drug Interactions). In animals, the ortho-hydroxy metabolite undergoes further glucuronidation.
Excretion: Atorvastatin and its metabolites are eliminated primarily in bile following hepatic and/or extra-hepatic metabolism; however, the drug does not appear to undergo enterohepatic recirculation. Mean plasma elimination half-life of atorvastatin in humans is approximately 14 hours, but the half-life of inhibitory activity for HMG-CoA reductase is 20 to 30 hours due to the contribution of active metabolites. Less than 2% of a dose of atorvastatin is recovered in urine following oral administration.

Special Populations
Geriatric: Plasma concentrations of atorvastatin are higher (approximately 40% for Cmax and 30% for AUC) in healthy elderly subjects (age ≥65 years) than in young adults. Clinical data suggest a greater degree of LDL-lowering at any dose of drug in the elderly patient population compared to younger adults (see PRECAUTIONS section; Geriatric Use subsection).
Pediatric: Pharmacokinetic data in the pediatric population are not available.
Gender: Plasma concentrations of atorvastatin in women differ from those in men (approximately 20% higher for Cmax and 10% lower for AUC); however, there is no clinically significant difference in LDL-C reduction with LIPITOR between men and women.
Renal Insufficiency: Renal disease has no influence on the plasma concentrations or LDL-C reduction of atorvastatin; thus, dose adjustment in patients with renal dysfunction is not necessary (see DOSAGE AND ADMINISTRATION).
Hemodialysis: While studies have not been conducted in patients with end-stage renal disease, hemodialysis is not expected to significantly enhance clearance of atorvastatin since the drug is extensively bound to plasma proteins.
Hepatic Insufficiency: In patients with chronic alcoholic liver disease, plasma concentrations of atorvastatin are markedly increased. Cmax and AUC are each 4-fold greater in patients with Childs-Pugh A disease. Cmax and AUC are approximately 16fold and 11-fold increased, respectively, in patients with Childs-Pugh B disease (see CONTRAINDICATIONS).

Prevention of Cardiovascular Disease
In the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT), the effect of LIPITOR (atorvastatin calcium) on fatal and non-fatal coronary heart disease was assessed in 10,305 hypertensive patients 40-80 years of age (mean of 63 years), without a previous myocardial infarction and with TC levels ≤251 mg/dl (6.5 mmol/l). Additionally all patients had at least 3 of the following cardiovascular risk factors: male gender (81.1%), age >55 years (84.5%), smoking (33.2%), diabetes (24.3%), history of CHD in a firstdegree relative (26%), TC:HDL >6 (14.3%), peripheral vascular disease (5.1%), left ventricular hypertrophy (14.4%), prior cerebrovascular event (9.8%), specific ECG abnormality (14.3%), proteinuria/albuminuria (62.4%). In this double-blind, placebocontrolled study patients were treated with anti-hypertensive therapy (Goal BP <140/90 mm Hg for non-diabetic patients, <130/80 mm Hg for diabetic patients) and allocated to either LIPITOR 10 mg daily (n=5168) or placebo (n=5137), using a covariate adaptive method which took into account the distribution of nine baseline characteristics of patients already enrolled and minimized the imbalance of those characteristics across the groups. Patients were followed for a median duration of 3.3 years.
The effect of 10 mg/day of LIPITOR on lipid levels was similar to that seen in previous clinical trials.
LIPITOR significantly reduced the rate of coronary events [either fatal coronary heart disease (46 events in the placebo group vs. 40 events in the LIPITOR group) or nonfatal MI (108 events in the placebo group vs. 60 events in the LIPITOR group)] with a relative risk reduction of 36% [(based on incidences of 1.9% for LIPITOR vs. 3.0% for placebo), p=0.0005 (see Figure 1)]. The risk reduction was consistent regardless of age, smoking status, obesity or presence of renal dysfunction. The effect of LIPITOR was seen regardless of baseline LDL levels. Due to the small number of events, results for women were inconclusive.

Figure 1: Effect of LIPITOR 10 mg/day on Cumulative Incidence of Nonfatal Myocardial Infarction or Coronary Heart Disease Death (in ASCOT-LLA)
LIPITOR also significantly decreased the relative risk for revascularization procedures by 42%. Although the reduction of fatal and non-fatal strokes did not reach a pre-defined significance level (p=0.01), a favorable trend was observed with a 26% relative risk reduction (incidences of 1.7% for LIPITOR and 2.3% for placebo). There was no significant difference between the treatment groups for death due to cardiovascular causes (p=0.51) or noncardiovascular causes (p=0.17).
In the Collaborative Atorvastatin Diabetes Study (CARDS), the effect of LIPITOR (atorvastatin calcium) on cardiovascular disease (CVD) endpoints was assessed in 2838 subjects (94% White, 68% male), ages 40-75 with type 2 diabetes based on WHO criteria, without prior history of cardiovascular disease and with LDL 160 mg/dL and TG 600 mg/dL. In addition to diabetes, subjects had 1 or more of the following risk factors: current smoking (23%), hypertension (80%), retinopathy (30%), or microalbuminuria (9%) or macroalbuminuria (3%). No subjects on hemodialysis were enrolled in the study. In this multicenter, placebo-controlled, double-blind clinical trial, subjects were randomly allocated to either LIPITOR 10 mg daily (1429) or placebo (1411) in a 1:1 ratio and were followed for a median duration of 3.9 years. The primary endpoint was the occurrence of any of the major cardiovascular events: myocardial infarction, acute CHD death, unstable angina, coronary revascularization, or stroke. The primary analysis was the time to first occurrence of the primary endpoint.
The effect of LIPITOR 10 mg/ day on lipid levels was similar to that seen in previous clinical trials.
LIPITOR significantly reduced the rate of major cardiovascular events (primary endpoint events) (83 events in the LIPITOR group vs. 127 events in the placebo group) with a relative risk reduction of 37%, HR 0.63, 95% CI (0.48,0.83) (p=0.001) (see Figure 2). An effect of LIPITOR was seen regardless of age, sex, or baseline lipid levels. Treatment with LIPITOR 80 mg/day significantly reduced the rate of MCVE (434 events in the 80mg/day group vs 548 events in the 10 mg/day group) with a relative risk reduction of 22%, HR 0.78, 95% CI (0.69,0.89), p=0.0002 (see Figure 3 and Table 1). The overall risk reduction was consistent regardless of age (<65, ≥65) or gender.  Of the events that comprised the primary efficacy endpoint, treatment with LIPITOR 80 mg/day significantly reduced the rate of nonfatal, non-procedure related MI and fatal and non-fatal stroke, but not CHD death or resuscitated cardiac arrest (Table 1). Of the predefined secondary endpoints, treatment with LIPITOR 80 mg/day significantly reduced the rate of coronary revascularization, angina and hospitalization for heart failure, but not peripheral vascular disease. The reduction in the rate of CHF with hospitalization was only observed in the 8% of patients with a prior history of CHF.
There was no significant difference between the treatment groups for all-cause mortality ( Table 1). The proportions of subjects who experienced cardiovascular death, including the components of CHD death and fatal stroke were numerically smaller in the LIPITOR 80 mg group than in the LIPITOR 10 mg treatment group. The proportions of subjects who experienced noncardiovascular death were numerically larger in the LIPITOR 80 mg group than in the LIPITOR 10 mg treatment group.
In the Incremental Decrease in Endpoints Through Aggressive Lipid Lowering Study (IDEAL), treatment with LIPITOR 80 mg/day was compared to treatment with simvastatin 20-40 mg/day in 8,888 subjects up to 80 years of age with a history of CHD to assess whether reduction in CV risk could be achieved. Patients were mainly male (81%), white (99%) with an average age of 61.7 years, and an average

Hypercholesterolemia (Heterozygous Familial and Nonfamilial) and Mixed Dyslipidemia (Fredrickson Types IIa and IIb)
LIPITOR reduces total-C, LDL-C, VLDL-C, apo B, and TG, and increases HDL-C in patients with hypercholesterolemia and mixed dyslipidemia. Therapeutic response is seen within 2 weeks, and maximum response is usually achieved within 4 weeks and maintained during chronic therapy.
LIPITOR is effective in a wide variety of patient populations with hypercholesterolemia, with and without hypertriglyceridemia, in men and women, and in the elderly. Experience in pediatric patients has been limited to patients with homozygous FH. In two multicenter, placebo-controlled, dose-response studies in patients with hypercholesterolemia, LIPITOR given as a single dose over 6 weeks significantly reduced total-C, LDL-C, apo B, and TG (Pooled results are provided in Table 2). In patients with Fredrickson Types IIa and IIb hyperlipoproteinemia pooled from 24 controlled trials, the median (25 th and 75 th percentile) percent changes from baseline in HDL-C for atorvastatin 10, 20, 40, and 80 mg were 6.4 (-1.4, 14), 8.7(0, 17), 7.8(0, 16), and 5.1 (-2.7, 15), respectively. Additionally, analysis of the pooled data demonstrated consistent and significant decreases in total-C, LDL-C, TG, total-C/HDL-C, and LDL-C/HDL-C.
In three multicenter, double-blind studies in patients with hypercholesterolemia, LIPITOR was compared to other HMG-CoA reductase inhibitors. After randomization, patients were treated for 16 weeks with either LIPITOR 10 mg per day or a fixed dose of the comparative agent (Table 3). The impact on clinical outcomes of the differences in lipid-altering effects between treatments shown in Table 3 is not known. Table 3 does not contain data comparing the effects of atorvastatin 10 mg and higher doses of lovastatin, pravastatin, and simvastatin. The drugs compared in the studies summarized in the table are not necessarily interchangeable.

Hypertriglyceridemia (Fredrickson Type IV)
The response to LIPITOR in 64 patients with isolated hypertriglyceridemia treated across several clinical trials is shown in the table below. For the atorvastatin-treated patients, median (min, max) baseline TG level was 565 (267-1502).

Homozygous Familial Hypercholesterolemia
In a study without a concurrent control group, 29 patients ages 6 to 37 years with homozygous FH received maximum daily doses of 20 to 80 mg of LIPITOR. The mean LDL-C reduction in this study was 18%. Twenty-five patients with a reduction in LDL-C had a mean response of 20% (range of 7% to 53%, median of 24%); the remaining 4 patients had 7% to 24% increases in LDL-C. Five of the 29 patients had absent LDLreceptor function. Of these, 2 patients also had a portacaval shunt and had no significant reduction in LDL-C. The remaining 3 receptor-negative patients had a mean LDL-C reduction of 22%.

Heterozygous Familial Hypercholesterolemia in Pediatric Patients
In a double-blind, placebo-controlled study followed by an open-label phase, 187 boys and postmenarchal girls 10-17 years of age (mean age 14.1 years) with heterozygous familial hypercholesterolemia (FH) or severe hypercholesterolemia were randomized to LIPITOR (n=140) or placebo (n=47) for 26 weeks and then all received LIPITOR for 26 weeks. Inclusion in the study required 1) a baseline LDL-C level 190 mg/dL or 2) a baseline LDL-C 160 mg/dL and positive family history of FH or documented premature cardiovascular disease in a first-or second-degree relative. The mean baseline LDL-C value was 218.6 mg/dL (range: 138.5-385.0 mg/dL) in the LIPITOR group compared to 230.0 mg/dL (range: 160.0-324.5 mg/dL) in the placebo group. The dosage of LIPITOR (once daily) was 10 mg for the first 4 weeks and up-titrated to 20 mg if the LDL-C level was > 130 mg/dL. The number of LIPITOR-treated patients who required up-titration to 20 mg after Week 4 during the double-blind phase was 80 (57.1%).
LIPITOR significantly decreased plasma levels of total-C, LDL-C, triglycerides, and apolipoprotein B during the 26 week double-blind phase (see Table 6). The safety and efficacy of doses above 20 mg have not been studied in controlled trials in children. The long-term efficacy of LIPITOR therapy in childhood to reduce morbidity and mortality in adulthood has not been established.

INDICATIONS AND USAGE Prevention of Cardiovascular Disease
In adult patients without clinically evident coronary heart disease, but with multiple risk factors for coronary heart disease such as age, smoking, hypertension, low HDL-C, or a family history of early coronary heart disease, LIPITOR is indicated to: Reduce the risk of myocardial infarction Reduce the risk of stroke Reduce the risk for revascularization procedures and angina In patients with type 2 diabetes, and without clinically evident coronary heart disease, but with multiple risk factors for coronary heart disease such as retinopathy, albuminuria, smoking, or hypertension, LIPITOR is indicated to: Reduce the risk of myocardial infarction Reduce the risk of stroke In patients with clinically evident coronary heart disease, LIPITOR is indicated to: Reduce the risk of non-fatal myocardial infarction Reduce the risk of fatal and non-fatal stroke Reduce the risk for revascularization procedures Reduce the risk of hospitalization for CHF Reduce the risk of angina Hypercholesterolemia LIPITOR is indicated: 1. as an adjunct to diet to reduce elevated total-C, LDL-C, apo B, and TG levels and to increase HDL-C in patients with primary hypercholesterolemia (heterozygous familial and nonfamilial) and mixed dyslipidemia (Fredrickson Types IIa and IIb); 2. as an adjunct to diet for the treatment of patients with elevated serum TG levels(Fredrickson Type IV); 3. for the treatment of patients with primary dysbetalipoproteinemia (Fredrickson Type III) who do not respond adequately to diet; 4. to reduce total-C and LDL-C in patients with homozygous familial hypercholesterolemia as an adjunct to other lipid-lowering treatments (eg, LDL apheresis) or if such treatments are unavailable; 5. as an adjunct to diet to reduce total-C, LDL-C, and apo B levels in boys and postmenarchal girls, 10 to 17 years of age, with heterozygous familial hypercholesterolemia if after an adequate trial of diet therapy the following findings are present: a. LDL-C remains 190 mg/dL or b. LDL-C remains 160 mg/dL and: there is a positive family history of premature cardiovascular disease or two or more other CVD risk factors are present in the pediatric patient Therapy with lipid-altering agents should be a component of multiple-risk-factor intervention in individuals at increased risk for atherosclerotic vascular disease due to hypercholesterolemia. Lipid-altering agents should be used in addition to a diet restricted in saturated fat and cholesterol only when the response to diet and other nonpharmacological measures has been inadequate (see National Cholesterol Education Program (NCEP) Guidelines, summarized in Table 7). drug optional) a CHD, coronary heart disease b Some authorities recommend use of LDL-lowering drugs in this category if an LDL-C level of < 100 mg/dL cannot be achieved by therapeutic lifestyle changes. Others prefer use of drugs that primarily modify triglycerides and HDL-C, e.g., nicotinic acid or fibrate. Clinical judgement also may call for deferring drug therapy in this subcategory. c Almost all people with 0-1 risk factor have 10-year risk <10%; thus, 10-year risk assessment in people with 0-1 risk factor is not necessary.
After the LDL-C goal has been achieved, if the TG is still 200 mg/dL, non-HDL-C (total-C minus HDL-C) becomes a secondary target of therapy. Non-HDL-C goals are set 30 mg/dL higher than LDL-C goals for each risk category.
Prior to initiating therapy with LIPITOR, secondary causes for hypercholesterolemia (e.g., poorly controlled diabetes mellitus, hypothyroidism, nephrotic syndrome, dysproteinemias, obstructive liver disease, other drug therapy, and alcoholism) should be excluded, and a lipid profile performed to measure total-C, LDL-C, HDL-C, and TG. For patients with TG <400 mg/dL (<4.5 mmol/L), LDL-C can be estimated using the following equation: LDL-C = total-C -(0.20 x [TG] + HDL-C). For TG levels >400 mg/dL (>4.5 mmol/L), this equation is less accurate and LDL-C concentrations should be determined by ultracentrifugation.
LIPITOR has not been studied in conditions where the major lipoprotein abnormality is elevation of chylomicrons (Fredrickson Types I and V).
The NCEP classification of cholesterol levels in pediatric patients with a familial history of hypercholesterolemia or premature cardiovascular disease is summarized below:

Category
Total-C (mg/dL) LDL-C (mg/dL) Acceptable Borderline High Hypersensitivity to any component of this medication. It is recommended that liver function tests be performed prior to and at 12 weeks following both the initiation of therapy and any elevation of dose, and periodically (e.g., semiannually) thereafter. Liver enzyme changes generally occur in the first 3 months of treatment with atorvastatin. Patients who develop increased transaminase levels should be monitored until the abnormalities resolve. Should an increase in ALT or AST of >3 times ULN persist, reduction of dose or withdrawal of atorvastatin is recommended.

Pregnancy and Lactation
Atorvastatin should be used with caution in patients who consume substantial quantities of alcohol and/or have a history of liver disease. Active liver disease or unexplained persistent transaminase elevations are contraindications to the use of atorvastatin (see CONTRAINDICATIONS).

Rare cases of rhabdomyolysis with acute renal failure secondary to myoglobinuria have been reported with atorvastatin and with other drugs in this class.
Uncomplicated myalgia has been reported in atorvastatin-treated patients (see ADVERSE REACTIONS). Myopathy, defined as muscle aches or muscle weakness in conjunction with increases in creatine phosphokinase (CPK) values >10 times ULN, should be considered in any patient with diffuse myalgias, muscle tenderness or weakness, and/or marked elevation of CPK. Patients should be advised to report promptly unexplained muscle pain, tenderness or weakness, particularly if accompanied by malaise or fever.
Atorvastatin therapy should be discontinued if markedly elevated CPK levels occur or myopathy is diagnosed or suspected.
The risk of myopathy during treatment with drugs in this class is increased with concurrent administration of cyclosporine, fibric acid derivatives, erythromycin, clarithromycin, combination of ritonavir plus saquinavir or lopinavir plus ritonavir, niacin, or azole antifungals. Physicians considering combined therapy with atorvastatin and fibric acid derivatives, erythromycin, clarithromycin, a combination of ritonavir plus saquinavir or lopinavir plus ritonavir, immunosuppressive drugs, azole antifungals, or lipid-modifying doses of niacin should carefully weigh the potential benefits and risks and should carefully monitor patients for any signs or symptoms of muscle pain, tenderness, or weakness, particularly during the initial months of therapy and during any periods of upward dosage titration of either drug. Lower starting and maintenance doses of atorvastatin should be considered when taken concomitantly with the aforementioned drugs (See DRUG INTERACTIONS). Periodic creatine phosphokinase (CPK) determinations may be considered in such situations, but there is no assurance that such monitoring will prevent the occurrence of severe myopathy.
Atorvastatin therapy should be temporarily withheld or discontinued in any patient with an acute, serious condition suggestive of a myopathy or having a risk factor predisposing to the development of renal failure secondary to rhabdomyolysis (e.g., severe acute infection, hypotension, major surgery, trauma, severe metabolic, endocrine and electrolyte disorders, and uncontrolled seizures).

General
Before instituting therapy with atorvastatin, an attempt should be made to control hypercholesterolemia with appropriate diet, exercise, and weight reduction in obese patients, and to treat other underlying medical problems (see INDICATIONS AND USAGE).

Information for Patients
Patients should be advised to report promptly unexplained muscle pain, tenderness, or weakness, particularly if accompanied by malaise or fever. Colestipol: Plasma concentrations of atorvastatin decreased approximately 25% when colestipol and atorvastatin were coadministered. However, LDL-C reduction was greater when atorvastatin and colestipol were coadministered than when either drug was given alone.
Digoxin: When multiple doses of atorvastatin and digoxin were coadministered, steadystate plasma digoxin concentrations increased by approximately 20%. Patients taking digoxin should be monitored appropriately.
Oral Contraceptives: Coadministration of atorvastatin and an oral contraceptive increased AUC values for norethindrone and ethinyl estradiol by approximately 30% and 20%. These increases should be considered when selecting an oral contraceptive for a woman taking atorvastatin.
Warfarin: Atorvastatin had no clinically significant effect on prothrombin time when administered to patients receiving chronic warfarin treatment.
Amlodipine: In a drug-drug interaction study in healthy subjects, co-administration of atorvastatin 80 mg and amlodipine 10 mg resulted in an 18% increase in exposure to atorvastatin which was not clinically meaningful.

CNS Toxicity
Brain hemorrhage was seen in a female dog treated for 3 months at 120 mg/kg/day. Brain hemorrhage and optic nerve vacuolation were seen in another female dog that was sacrificed in moribund condition after 11 weeks of escalating doses up to 280 mg/kg/day. The 120 mg/kg dose resulted in a systemic exposure approximately 16 times the human plasma area-under-the-curve (AUC, 0-24 hours) based on the maximum human dose of 80 mg/day. A single tonic convulsion was seen in each of 2 male dogs (one treated at 10 mg/kg/day and one at 120 mg/kg/day) in a 2-year study. No CNS lesions have been observed in mice after chronic treatment for up to 2 years at doses up to 400 mg/kg/day or in rats at doses up to 100 mg/kg/day. These doses were 6 to 11 times (mouse) and 8 to 16 times (rat) the human AUC (0-24) based on the maximum recommended human dose of 80 mg/day.
CNS vascular lesions, characterized by perivascular hemorrhages, edema, and mononuclear cell infiltration of perivascular spaces, have been observed in dogs treated with other members of this class. A chemically similar drug in this class produced optic nerve degeneration (Wallerian degeneration of retinogeniculate fibers) in clinically normal dogs in a dose-dependent fashion at a dose that produced plasma drug levels about 30 times higher than the mean drug level in humans taking the highest recommended dose.

Carcinogenesis, Mutagenesis, Impairment of Fertility
In a 2-year carcinogenicity study in rats at dose levels of 10, 30, and 100 mg/kg/day, 2 rare tumors were found in muscle in high-dose females: in one, there was a rhabdomyosarcoma and, in another, there was a fibrosarcoma. This dose represents a plasma AUC (0-24) value of approximately 16 times the mean human plasma drug exposure after an 80 mg oral dose.
A 2-year carcinogenicity study in mice given 100, 200, or 400 mg/kg/day resulted in a significant increase in liver adenomas in high-dose males and liver carcinomas in highdose females. These findings occurred at plasma AUC (0-24) values of approximately 6 times the mean human plasma drug exposure after an 80 mg oral dose.
In vitro, atorvastatin was not mutagenic or clastogenic in the following tests with and without metabolic activation: the Ames test with Salmonella typhimurium and Escherichia coli, the HGPRT forward mutation assay in Chinese hamster lung cells, and the chromosomal aberration assay in Chinese hamster lung cells. Atorvastatin was negative in the in vivo mouse micronucleus test.
Studies in rats performed at doses up to 175 mg/kg (15 times the human exposure) produced no changes in fertility. There was aplasia and aspermia in the epididymis of 2 of 10 rats treated with 100 mg/kg/day of atorvastatin for 3 months (16 times the human AUC at the 80 mg dose); testis weights were significantly lower at 30 and 100 mg/kg and epididymal weight was lower at 100 mg/kg. Male rats given 100 mg/kg/day for 11 weeks prior to mating had decreased sperm motility, spermatid head concentration, and increased abnormal sperm. Atorvastatin caused no adverse effects on semen parameters, or reproductive organ histopathology in dogs given doses of 10, 40, or 120 mg/kg for two years.

Pregnancy
Pregnancy Category X

See CONTRAINDICATIONS
Safety in pregnant women has not been established. Atorvastatin crosses the rat placenta and reaches a level in fetal liver equivalent to that of maternal plasma. Atorvastatin was not teratogenic in rats at doses up to 300 mg/kg/day or in rabbits at doses up to 100 mg/kg/day. These doses resulted in multiples of about 30 times (rat) or 20 times (rabbit) the human exposure based on surface area (mg/m 2 ).
In a study in rats given 20, 100, or 225 mg/kg/day, from gestation day 7 through to lactation day 21 (weaning), there was decreased pup survival at birth, neonate, weaning, and maturity in pups of mothers dosed with 225 mg/kg/day. Body weight was decreased on days 4 and 21 in pups of mothers dosed at 100 mg/kg/day; pup body weight was decreased at birth and at days 4, 21, and 91 at 225 mg/kg/day. Pup development was delayed (rotorod performance at 100 mg/kg/day and acoustic startle at 225 mg/kg/day; pinnae detachment and eye opening at 225 mg/kg/day). These doses correspond to 6 times (100 mg/kg) and 22 times (225 mg/kg) the human AUC at 80 mg/day. Rare reports of congenital anomalies have been received following intrauterine exposure to HMG-CoA reductase inhibitors. There has been one report of severe congenital bony deformity, tracheo-esophageal fistula, and anal atresia (VATER association) in a baby born to a woman who took lovastatin with dextroamphetamine sulfate during the first trimester of pregnancy. LIPITOR should be administered to women of child-bearing potential only when such patients are highly unlikely to conceive and have been informed of the potential hazards. If the woman becomes pregnant while taking LIPITOR, it should be discontinued and the patient advised again as to the potential hazards to the fetus.

Nursing Mothers
Nursing rat pups had plasma and liver drug levels of 50% and 40%, respectively, of that in their mother's milk. Because of the potential for adverse reactions in nursing infants, women taking LIPITOR should not breast-feed (see CONTRAINDICATIONS).

Pediatric Use
Safety and effectiveness in patients 10-17 years of age with heterozygous familial hypercholesterolemia have been evaluated in a controlled clinical trial of 6 months duration in adolescent boys and postmenarchal girls. Patients treated with LIPITOR had an adverse experience profile generally similar to that of patients treated with placebo, the most common adverse experiences observed in both groups, regardless of causality assessment, were infections. Doses greater than 20 mg have not been studied in this patient population. In this limited controlled study, there was no detectable effect on growth or sexual maturation in boys or on menstrual cycle length in girls (see CLINICAL PHARMACOLOGY, Clinical Studies section; ADVERSE REACTIONS, Pediatric Patients (ages 10-17 years); and DOSAGE AND ADMINISTRATION, Heterozygous Familial Hypercholesterolemia in Pediatric Patients (10-17 years of age). Adolescent females should be counseled on appropriate contraceptive methods while on LIPITOR therapy (see CONTRAINDICATIONS and PRECAUTIONS, Pregnancy). LIPITOR has not been studied in controlled clinical trials involving pre-pubertal patients or patients younger than 10 years of age.
Clinical efficacy with doses up to 80 mg/day for 1 year have been evaluated in an uncontrolled study of patients with homozygous FH including 8 pediatric patients (see CLINICAL PHARMACOLOGY, Clinical Studies: Homozygous Familial Hypercholesterolemia).

Geriatric Use
The safety and efficacy of atorvastatin (10-80 mg) in the geriatric population (>65 years of age) was evaluated in the ACCESS study. In this 54-week open-label trial 1,958 patients initiated therapy with atorvastatin 10 mg. Of these, 835 were elderly (>65 years) and 1,123 were non-elderly. The mean change in LDL-C from baseline after 6 weeks of treatment with atorvastatin 10 mg was -38.2% in the elderly patients versus -34.6% in the non-elderly group.
The rates of discontinuation due to adverse events were similar between the two age groups. There were no differences in clinically relevant laboratory abnormalities between the age groups.

Use in Patients with Recent Stroke or TIA
In a post-hoc analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) study where LIPITOR 80 mg vs placebo was administered in 4,731 subjects without CHD who had a stroke or TIA within the preceding 6 months, a higher incidence of hemorrhagic stroke was seen in the LIPITOR 80 mg group compared to placebo. Subjects with hemorrhagic stroke on study entry appeared to be at increased risk for hemorrhagic stroke.

ADVERSE REACTIONS
LIPITOR is generally well-tolerated. Adverse reactions have usually been mild and transient. In controlled clinical studies of 2502 patients, <2% of patients were discontinued due to adverse experiences attributable to atorvastatin. The most frequent adverse events thought to be related to atorvastatin were constipation, flatulence, dyspepsia, and abdominal pain.

Clinical Adverse Experiences
Adverse experiences reported in ≥2% of patients in placebo-controlled clinical studies of atorvastatin, regardless of causality assessment, are shown in Table 8.

Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT)
In ASCOT (see CLINICAL PHARMACOLOGY, Clinical Studies) involving 10,305 participants treated with LIPITOR 10 mg daily (n=5,168) or placebo (n=5,137), the safety and tolerability profile of the group treated with LIPITOR was comparable to that of the group treated with placebo during a median of 3.3 years of follow-up.

Collaborative Atorvastatin Diabetes Study (CARDS)
In CARDS (see CLINICAL PHARMACOLOGY, Clinical Studies) involving 2838 subjects with type 2 diabetes treated with LIPITOR 10 mg daily (n=1428) or placebo (n=1410), there was no difference in the overall frequency of adverse events or serious adverse events between the treatment groups during a median follow-up of 3.9 years. No cases of rhabdomyolysis were reported.

Pediatric Patients (ages 10-17 years)
In a 26-week controlled study in boys and postmenarchal girls (n=140), the safety and tolerability profile of LIPITOR 10 to 20 mg daily was generally similar to that of placebo (see CLINICAL PHARMACOLOGY, Clinical Studies section and PRECAUTIONS, Pediatric Use).

OVERDOSAGE
There is no specific treatment for atorvastatin overdosage. In the event of an overdose, the patient should be treated symptomatically, and supportive measures instituted as required. Due to extensive drug binding to plasma proteins, hemodialysis is not expected to significantly enhance atorvastatin clearance.

DOSAGE AND ADMINISTRATION
The patient should be placed on a standard cholesterol-lowering diet before receiving LIPITOR and should continue on this diet during treatment with LIPITOR.

Hypercholesterolemia (Heterozygous Familial and Nonfamilial) and Mixed Dyslipidemia (Fredrickson Types IIa and IIb)
The recommended starting dose of LIPITOR is 10 or 20 mg once daily. Patients who require a large reduction in LDL-C (more than 45%) may be started at 40 mg once daily.
The dosage range of LIPITOR is 10 to 80 mg once daily. LIPITOR can be administered as a single dose at any time of the day, with or without food. The starting dose and maintenance doses of LIPITOR should be individualized according to patient characteristics such as goal of therapy and response (see NCEP Guidelines, summarized in Table 7). After initiation and/or upon titration of LIPITOR, lipid levels should be analyzed within 2 to 4 weeks and dosage adjusted accordingly.
Since the goal of treatment is to lower LDL-C, the NCEP recommends that LDL-C levels be used to initiate and assess treatment response. Only if LDL-C levels are not available, should total-C be used to monitor therapy.

Heterozygous Familial Hypercholesterolemia in Pediatric Patients (10-17 years of age)
The recommended starting dose of LIPITOR is 10 mg/day; the maximum recommended dose is 20 mg/day (doses greater than 20 mg have not been studied in this patient population). Doses should be individualized according to the recommended goal of therapy (see NCEP Pediatric Panel Guidelines 1 , CLINICAL PHARMACOLOGY, and INDICATIONS AND USAGE). Adjustments should be made at intervals of 4 weeks or more.

Homozygous Familial Hypercholesterolemia
The dosage of LIPITOR in patients with homozygous FH is 10 to 80 mg daily. LIPITOR should be used as an adjunct to other lipid-lowering treatments (e.g., LDL apheresis) in these patients or if such treatments are unavailable.

Receipt and Archival of the Pharmacogenomic Specimen
At the Genetic Sample Bank, the 10-mL sample will be routed directly to the appropriate department and accessioned. At the time of receipt, the Genetic Sample Bank will also capture the data fields that travel with the specimen, including collection date and type of specimen. These data are considered to be not personally identifying. The Genetic Sample Bank will also capture as a field in the database the date of specimen receipt and time of receipt. However, investigator information on the airbill will not be recorded in the database, since these may be considered personally identifying. No linkage between the laboratory safety specimens and the pharmacogenomic sample will be maintained by the Genetic Sample Bank. 9.

Post-Receipt Processing of Pharmacogenomic Specimen and Storage
The genomic samples will be processed as specified in the contract after receipt by the Genetic Sample Bank, according to the specific pharmacogenomic analyses being performed. MERCK will continuously monitor the disposition of the samples at the Genetic Sample Bank, for example to meet the agreement specified in the consent with respect to sample storage duration. Sample condition will also be carefully monitored so that each sample may be appropriately used for its intended purpose, also as described in the consent document. The Genetic Sample Bank will track samples using only accession numbers or GICs. Only the above specified fields will be associated with the sample in the Genetic Sample Bank database. No other information about the patient, including study site or geographic location of origination of the sample will be present in the database associated with the sample. Discrepancies/problem vials are to be destroyed and not accessioned, with notation in the database and appropriate notification of MERCK.

Sample Destruction Procedures for Withdrawal of Consent
If a patient withdraws consent for the pharmacogenomic analyses portion of the study, any samples taken specifically for pharmacogenomic analyses will be destroyed according to the standard operating procedures of the Genetic Sample Bank where the samples reside. Additionally, if the medical records for the main study are no longer available, for example if the investigator is no longer required by regulatory agencies to retain the main study records, there will no longer be a link between the patient's personal information and their genetic sample. Therefore, the request for sample destruction can not be processed, Patients that request their samples to be withdrawn are instructed in the consent form to contact the Investigator in writing. The Investigator will contact MERCK using the supplied telephone contact (see Sponsor Contact Information section) and a form will be provided by MERCK to obtain appropriate information to complete sample withdrawal. MERCK will identify samples to be destroyed using an agreed upon form provided by the Genetic Sample Bank. After appropriate sign-off by both parties and affirmation of destruction, samples will be retrieved from -70˚C storage and incinerated or pyrolyzed such that DNA and other biomolecules are completely destroyed, i.e. rendered to a state such that the DNA is not able to be manipulated by standard molecular biological techniques (i.e. PCR). A confirmatory letter will be sent from the Genetic Sample Bank to MERCK and then later from MERCK to the investigator.

Conclusions
Merck recognizes both the tremendous potential, and the inherent responsibility that pharmacogenomic research provides to clinical studies. The procedures outlined in this document are intended to ensure that meaningful investigation of pharmacogenomics influences in disease and/or responses to therapies can be achieved while providing the highest degree of protection for patients in the study. Restricted Confidential -Limited Access 8. SIGNATURES

SPONSOR'S REPRESENTATIVE
TYPED NAME SIGNATURE DATE

INVESTIGATOR
I agree to conduct this clinical study in accordance with the design outlined in this protocol and to abide by all provisions of this protocol (including other manuals and documents referenced from this protocol); deviations from the protocol are acceptable only with a mutually agreed upon protocol amendment. I agree to conduct the study in accordance with generally accepted standards of Good Clinical Practice. I also agree to report all information or data in accordance with the protocol and, in particular, I agree to report any serious adverse experiences as defined in the SAFETY MEASUREMENTS section of this protocol. I also agree to handle all clinical supplies provided by the SPONSOR and collect and handle all clinical specimens in accordance with the protocol. I understand that information that identifies me will be used and disclosed as described in the protocol, and that such information may be transferred to countries that do not have laws protecting such information. Since the information in this protocol and the referenced Investigator's brochure is confidential, I understand that its disclosure to any third parties, other than those involved in approval, supervision, or conduct of the study is prohibited. I will ensure that the necessary precautions are taken to protect such information from loss, inadvertent disclosure, or access by third parties.
TYPED NAME SIGNATURE DATE