Randomized, Placebo-Controlled Trial to Evaluate Effects of Eplerenone on Metabolic and Inflammatory Indices in HIV

Randomized, Placebo-Controlled Trial to Evaluate Effects of Eplerenone on Metabolic and... Abstract Context HIV-infected individuals demonstrate increased renin-angiotensin-aldosterone system activation in association with visceral adiposity, insulin resistance, and inflammation. A physiologically based treatment approach targeting mineralocorticoid receptor (MR) blockade may improve metabolic and inflammatory indices in HIV. Objective To investigate effects of eplerenone on insulin sensitivity, inflammatory indices, and other metabolic parameters in HIV. Design Six-month, double-blind, randomized, placebo-controlled trial. Setting Academic clinical research center. Participants HIV-infected individuals with increased waist circumference and abnormal glucose homeostasis. Intervention Eplerenone 50 mg or placebo daily. Outcome The primary end point was change in insulin sensitivity measured by the euglycemic-hyperinsulinemic clamp technique. Secondary end points included change in body composition and inflammatory markers. Results Forty-six individuals were randomized to eplerenone (n = 25) vs placebo (n = 21). Eplerenone did not improve insulin sensitivity [0.48 (−1.28 to 1.48) vs 0.43 (−1.95 to 2.55) mg/min/μIU/mL insulin; P = 0.71, eplerenone vs placebo] when measured by the gold standard euglycemic-hyperinsulinemic clamp technique. Intramyocellular lipids (P = 0.04), monocyte chemoattractant protein-1 (P = 0.04), and high-density lipoprotein (P = 0.04) improved among those randomized to eplerenone vs placebo. Trends toward decreases in interleukin-6 (P = 0.10) and high-sensitivity C-reactive protein (P = 0.10) were also seen with eplerenone vs placebo. Plasma renin activity and aldosterone levels increased in the eplerenone vs placebo-treated group, demonstrating expected physiology. MR antagonism with eplerenone was well tolerated among the HIV population, with no considerable changes in blood pressure or potassium. Conclusion MR blockade may improve selected metabolic and inflammatory indices in HIV-infected individuals. Further studies are necessary to understand the clinical potential of MR antagonism in HIV. Metabolic dysfunction is prevalent among the HIV-infected population. Contemporary antiretroviral therapy (ART) regimens have demonstrated enhanced safety profiles and reduced metabolic consequences. Nonetheless, insulin resistance, body composition changes with ectopic fat accumulation, and chronic inflammation remain leading contributors to cardiovascular morbidity and mortality, even among well-treated HIV-infected individuals with good virologic control (1). Moreover, ectopic fat (2) and chronic inflammation (3, 4) may contribute to the pathogenesis of insulin resistance and more long-term sequelae, such as coronary artery disease (5), in the population with HIV. These abnormalities may be particularly prevalent among HIV-infected individuals with increased abdominal fat accumulation. Conventional therapies for insulin resistance have shown variable efficacy in the HIV population and were not developed to be HIV specific. Moreover, such strategies often do not simultaneously affect inflammatory and immune indices. Therefore, novel treatment approaches leveraging strategies that mechanistically target key mediators of insulin resistance, unique to HIV, with potential broader effects on inflammatory indices, are needed. We previously demonstrated unique renin-angiotensin-aldosterone system (RAAS) physiology among HIV-infected individuals, characterized by increased RAAS activation in association with visceral adiposity, insulin resistance, and inflammation (6, 7). Based on this evidence, we hypothesized that a physiologically based treatment approach targeting mineralocorticoid receptor (MR) blockade may have beneficial effects on improving insulin sensitivity and inflammatory markers in HIV. To test this hypothesis, we conducted a 6-month double-blinded, randomized, placebo-controlled trial using eplerenone among HIV-infected individuals. The trial was designed to assess the effects of eplerenone in HIV on insulin sensitivity using the gold standard euglycemic-hyperinsulinemic clamp technique. These data may have considerable implications that extend to other populations susceptible to metabolic dysfunction and inflammation. Methods Participants The study was conducted between January 2012 and May 2017 at Massachusetts General Hospital (MGH). Individuals between the ages of 30 and 65 years with known history of HIV ≥5 years were recruited from the greater Boston area. Individuals were required to receive continuous ART for >12 months prior to enrollment. Those enrolled were individuals with increased abdominal girth based on National Cholesterol Education Program guidelines for waist circumference (>102 cm in males and >88 cm in females). A standard 75-g oral glucose tolerance test was performed to select for evidence of abnormal glucose homeostasis (impaired fasting glucose >100 and <126 mg/dL; impaired glucose tolerance, 2-hour glucose >140 and <200 mg/dL; or fasting insulin >12 μIU/mL). Elevated systolic blood pressure (BP) or diastolic BP (DBP; systolic BP ≥160 or DBP ≥100 mm Hg), diabetes, cardiovascular disease, and active pregnancy were exclusionary. Individuals receiving strong CYP3A4 inhibitors, the CYP3A4 inducer St. John’s wort, and medications known to affect the RAAS system were excluded (Supplemental Table 1). Individuals with serum potassium >5.5 mEq/L, alanine aminotransferase >2.5 times the upper limit of normal, hemoglobin <11 g/dL, creatinine >1.5 mg/dL, or estimated glomerular filtration rate <60 mL/min/1.73 m2 were also excluded. All participants provided informed consent to participate. This study was approved by the Partners Human Research Committee. Randomization and blinding The randomization was stratified by sex, age (<45 or ≥45 years), and BP (<140/90 or ≥140/90 mm Hg). A permuted block algorithm with a random block size of either two or four was used, and individuals were allocated 1:1 to eplerenone or matching placebo. The randomization key was generated by a biostatistician and only made available to the MGH Clinical Trials Pharmacy. Identical blinded capsules were created and matching dose escalations were employed for both the active study drug and placebo. Following baseline study procedures, doses were started at 25 mg daily for 1 week and then escalated to 50 mg daily for the remaining 6-month study duration if tolerated by BP and potassium levels. Adherence to study medication was assessed by manual pill count of the returned supply. Study participants and investigators were blinded to the randomization. Lifestyle counseling All individuals participated in a standardized lifestyle modification program over 6 months. Goals were derived from the American Association of Clinical Endocrinologists and National Cholesterol Education Program Adult Treatment Panel III guidelines and the Diabetes Prevention Program and are further detailed in the Supplemental Methods. Study outcomes The primary end point was prespecified as insulin-stimulated glucose uptake measured by the euglycemic-hyperinsulinemic clamp technique. Additional end points included measures of body composition and metabolic and inflammatory indices. End points for the primary analyses were assessed at baseline and 6 months postbaseline. Safety monitoring Safety visits were conducted at 1 week, 2 weeks, 4 weeks, 2 months, and 3 months following randomization. Interval medical history and BP were obtained. Laboratory assessment included serum creatinine, potassium, alanine aminotransferase, and urine pregnancy test. A Data and Safety Monitoring Board convened every 3 months for safety monitoring. Standardized sodium diets to characterize the RAAS at baseline and 6 months A 4-day food record was collected from individuals to assess their routine dietary sodium intake. Individuals were instructed by the dietician to supplement their usual diet with the appropriate number of broth packets (47.8 mEq Na+/packet) for 6 days to a goal dietary sodium intake of 200 mEq. On day 6, individuals started a 24-hour urine collection to confirm appropriate sodium balance. Euglycemic-hyperinsulinemic clamp at baseline and 6 months After a 12-hour overnight fast, individuals received a primed infusion of regular insulin mixed with albumin, 80 mU/m2/min, for 120 minutes. A variable infusion rate of dextrose 20% was administered to maintain blood glucose at 90 mg/dL. Blood samples for glucose at time 0 and every 5 minutes thereafter were measured using a B-Glucose analyzer (HemoCue, Lake Forest, CA). Blood samples for insulin were collected at 20-minute intervals from 0 to 120 minutes. Insulin-stimulated glucose uptake (M) was calculated using the DeFronzo technique (8) for the steady-state interval between 100 and 120 minutes. M was corrected for insulin (I) and indexed to fat-free (lean body) mass (LBM) [M/I/LBM in milligrams per minute per microunits per milliliter insulin]. Laboratory assessment at baseline and 6 months On the evening of day 6 of the sodium diet, individuals fasted for 12 hours and were asked to lie supine overnight to assess the RAAS and other metabolic and inflammatory parameters on the following morning. Serum and urine aldosterone were measured by solid-phase radioimmunoassay by the Coat-A-Count method (sensitivity 2.5 ng/dL; Diagnostic Products, Los Angeles, CA). Plasma renin activity (PRA) was assessed using the GammaCoat [125I] RIA kit (sensitivity 0.01 ng/mL/h; DiaSorin, Saluggia, Italy). Serum insulin was measured using the Access immunoassay system (Beckman Coulter, Brea, CA). Plasma high-sensitivity C-reactive protein (hsCRP), plasminogen activator inhibitor-1, monocyte chemoattractant protein-1 (MCP-1), adiponectin (all from R&D Systems, Minneapolis, MN), and interleukin-6 (IL-6; Invitrogen, Carlsbad, CA) were measured via enzyme-linked immunosorbent assay. Body composition assessment at baseline and 6 months Individuals underwent magnetic resonance imaging to measure visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT). In addition, 1H-magnetic resonance spectroscopy of the liver to assess intrahepatic lipids (IHLs) and the tibialis anterior muscle to assess intramyocellular lipids (IMCLs) was performed. Studies were obtained after an 8-hour overnight fast using a 3.0T magnetic resonance imaging system (Siemens Trio; Siemens Medical, Erlangen, Germany) as detailed in the Supplemental Methods. Flow-mediated vasodilation at baseline and 6 months After a 12-hour overnight fast, a BP cuff was placed over the brachial artery. The brachial artery was scanned using ultrasound in the sagittal axis to acquire a cineloop pre- and postdilation (see Supplemental Methods). Statistical analysis The Shapiro-Wilk test was performed to determine normality of variables. Normally distributed variables are reported as mean ± standard error of the mean, nonnormally distributed variables are shown as median (interquartile range), and categorical variables are presented by proportions. Treatment effect was determined by comparing the absolute changes in variables from baseline to 6 months between eplerenone and placebo groups using the Student t test and Wilcoxon rank-sum test for normally and nonnormally distributed data, respectively. The study was powered at 80% to detect a between-group difference of 0.8 standard deviation in the percentage change over 6 months. Based on data from our group, mean ± standard deviation of insulin-stimulated glucose uptake in this population using our clamp protocol is 7.4 ± 1.7 mg/kg/min. The current study was powered to detect a change in glucose uptake of 1.4 mg/kg/min, or ∼20% change, which would be physiologically relevant. All available data were included in an intention-to-treat analysis. Difference in potassium was derived using the composite mean value of all safety visits, as there was no evidence of trends over time. A formal outlier test by the Tukey method was performed for variables identified to be potential outliers upon visual inspection of the data, and a level determined to be >1.5 or <1.5 times the interquartile range was considered an outlier. A sensitivity analysis was performed removing outliers using the appropriate statistical test. We adjusted for current statin use when assessing changes in the lipid profile. Univariate relationships were assessed by Kendall τ test. Statistical significance was determined to a two-sided P value <0.05. Analyses were performed using SAS JMP (version 12; SAS Institute, Cary, NC). Results Participant flow A total of 104 HIV-infected individuals were screened. Forty-six individuals were randomized to receive either eplerenone (n = 25) or placebo (n = 21). Four individuals did not complete the study [P = 0.37 for comparison of dropouts in eplerenone (n = 3) vs placebo (n = 1)] (Fig. 1). Figure 1. View largeDownload slide Participant flow of HIV-infected individuals through the study. ACEi, angiotensin-converting enzyme inhibitor; CVA, cerebrovascular accident; DM, diabetes mellitus; WC, waist circumference. Figure 1. View largeDownload slide Participant flow of HIV-infected individuals through the study. ACEi, angiotensin-converting enzyme inhibitor; CVA, cerebrovascular accident; DM, diabetes mellitus; WC, waist circumference. Baseline demographics and clinical characteristics Both treatment groups (eplerenone vs placebo) were of similar age, race, and sex (all P > 0.05; Table 1). The prevalence of hypertension did not differ (24 vs 33%; P = 0.48) among those randomized to eplerenone vs placebo. DBP was greater in the placebo vs eplerenone group (86 ± 2 vs 80 ± 1 mm Hg; P = 0.03). Both groups were well matched on body composition parameters, including body mass index, VAT, SAT, IHLs, and IMCLs (all P > 0.05). Baseline insulin-stimulated glucose uptake normalized to insulin and LBM [M/I/LBM; 7.26 (5.74 to 9.55) vs 7.52 (5.12 to 10.43) mg/min/μIU/mL; P = 0.86] and hemoglobin A1c [5.7 (5.5 to 6.0) vs 5.8 (5.3 to 6.1)%; P = 0.82] were similar between the eplerenone and placebo arms and consistent with moderate insulin resistance and prediabetes, respectively. Lipid and inflammatory markers, in addition to flow-mediated vasodilation (FMD), were not significantly different between groups at baseline (all P > 0.05). The durations of HIV infection (16 ± 1 vs 18 ± 1 years; P = 0.31) and treatment with ART (10 ± 2 vs 11 ± 2 years; P = 0.74) were comparable among individuals randomized to eplerenone vs placebo. Other HIV-specific characteristics such as CD4+ T-cell count and viral load demonstrated similar, good, immunological control in both groups. Use of protease inhibitors, nucleoside/nucleotide reverse transcription inhibitors, and nonnucleoside reverse transcription inhibitors was similar between groups (all P > 0.05) (Table 1). Table 1. Baseline and Absolute Between-Group Change of HIV, Metabolic, and Inflammation Parameters After 6 Months Treatment Baseline 6 Months Eplerenone (n = 25) Placebo (n = 21) P Value Eplerenone (n = 22) Placebo (n = 20) P Value a Demographics  Age, y 49 ± 1 52 ± 1 0.15 — — —  Race, %   White 60 43 0.25 — — —   African American 36 52 — — — —  Other 4 5 – — — —   Male sex, % 60 71 0.42 — — —   Current hypertension, % 24 33 0.48 — — —   Current statin use, % 16 24 0.51 — — — HIV parameters  CD4+ T-cell count, cells/μL 634 ± 54 608 ± 50 0.73 48 ± 29 3 ± 32 0.30  CD8+ T-cell count, cells/μL 803 ± 51 901 ± 78 0.30 226 ± 80 305 ± 133 0.62  Log HIV viral load, copies/mL 1.45 ± 0.05 1.55 ± 0.13 0.48 −0.04 ± 0.09 −0.09 ± 0.13 0.73  Undetectable viral load, % 84 67 0.17 — — —  Duration HIV, y 16 ± 1 18 ± 1 0.31 — — —  Duration ART use, y 10 ± 2 11 ± 2 0.74 — — —  Current PI use, % 44 43 0.94 — — —  Duration PI use, y 5 ± 1 4 ± 1 0.57 — — —  Current NRTI use, % 96 95 0.90 — — —  Duration NRTI use, y 9 ± 2 10 ± 2 0.51 — — —  Current NNRTI use, % 40 62 0.14 — — —  Duration NNRTI use, y 3 ± 1 4 ± 1 0.63 — — — Body composition and ectopic fat  Waist circumference, cm 112.6 ± 2.4 114.1 ± 2.5 0.68 −0.6 ± 1.0 −0.5 ± 1.0 0.41  BMI, kg/m2 32.8 ± 1.3 32.7 ± 1.4 0.99 −0.1 ± 0.2 −0.1 ± 0.3 0.95  VAT area, cm2 215 (154–324) 241 (147–295) 0.85 −11 (−27 to 10) −2 (−20 to 36) 0.42  SAT area, cm2 350 (271–486) 372 (281–486) 0.56 1 (−14 to 16) −8 (−26 to 32) 0.46  IHL, % 5 (3–12) 5 (2–12) 0.50 −1 (−3 to 2) 0 (−4 to 0) 0.51  IMCL, %b 0.5 (0.2–0.6) 0.3 (0.2–0.5) 0.29 −0.1 (−0.3 to 0.1) 0.0 (−0.1 to 0.2) 0.04 Metabolic parameters  SBP, mm Hg 130 ± 3 132 ± 3 0.77 −5 ± 4 −5 ± 2 0.94  DBP, mm Hg 80 ± 1 86 ± 2 0.03 −1 ± 2 −5 ± 3 0.27  Total cholesterol, mg/dL 174 ± 6 174 ± 7 0.95 6 ± 4 −3 ± 5 0.14  Triglycerides, mg/dL 167 ± 16 158 ± 14 0.67 −1 ± 5 −2 ± 16 0.98  HDL cholesterol, mg/dL 43 ± 3 46 ± 4 0.55 2 ± 2 −2 ± 1 0.04  LDL cholesterol, mg/dL 98 ± 5 96 ± 6 0.83 4 ± 4 −1 ± 4 0.33  HbA1c, % 5.7 (5.5–6.0) 5.8 (5.3–6.1) 0.82 0.1 (−0.2 to 0.2) 0 (−0.2 to 0.2) 0.70  Fasting glucose, mg/dL 95 (87–101) 102 (87–108) 0.33 5 (0–9) 3 (−9 to 9) 0.52  HOMA-IR 1.99 (1.45–3.27) 1.64 (0.93–2.52) 0.16 0.10 (−1.11 to 0.65) 0.41 (−0.49 to 1.61) 0.20  M/I/LBM, mg/min/μIU/mL 7.26 (5.74–9.55) 7.52 (5.12–10.43) 0.86 0.48 (−1.28 to 1.48) 0.43 (−1.95 to 2.55) 0.71  FMD maximum percentage change 13.0 (9.7–19.3) 13.4 (10.8–17.6) 0.97 1.62 (−8.60 to 4.51) −4.80 (−14.17 to 5.94) 0.44 Markers of inflammation and immune activation  IL-6, pg/mL 10.2 (5.2–19.8) 7.9 (6.1–18.3) 0.76 −1.2 (−7.6 to 1.4) 3.1 (−2.5 to 4.8) 0.10  Adiponectin, pg/mL 4016 (3439–5360) 4673 (3302–6042) 0.50 −485 (−962 to 113) −361 (−1109 to 169) 0.78  PAI-1, ng/mL 36.7 ± 3.7 37.0 ± 4.1 0.95 −3 ± 4 1 ± 3 0.37  hsCRP, mg/Lc 3.3 (1.2–9.4) 3.7 (1.6 to 9.8) 0.67 −0.3 (−2.0 to 0.9) 0.9 (−0.1 to 1.9) 0.10  MCP-1, pg/mL 205 ± 16 191 ± 11 0.47 −9 ± 10 26 ± 13 0.04 Baseline 6 Months Eplerenone (n = 25) Placebo (n = 21) P Value Eplerenone (n = 22) Placebo (n = 20) P Value a Demographics  Age, y 49 ± 1 52 ± 1 0.15 — — —  Race, %   White 60 43 0.25 — — —   African American 36 52 — — — —  Other 4 5 – — — —   Male sex, % 60 71 0.42 — — —   Current hypertension, % 24 33 0.48 — — —   Current statin use, % 16 24 0.51 — — — HIV parameters  CD4+ T-cell count, cells/μL 634 ± 54 608 ± 50 0.73 48 ± 29 3 ± 32 0.30  CD8+ T-cell count, cells/μL 803 ± 51 901 ± 78 0.30 226 ± 80 305 ± 133 0.62  Log HIV viral load, copies/mL 1.45 ± 0.05 1.55 ± 0.13 0.48 −0.04 ± 0.09 −0.09 ± 0.13 0.73  Undetectable viral load, % 84 67 0.17 — — —  Duration HIV, y 16 ± 1 18 ± 1 0.31 — — —  Duration ART use, y 10 ± 2 11 ± 2 0.74 — — —  Current PI use, % 44 43 0.94 — — —  Duration PI use, y 5 ± 1 4 ± 1 0.57 — — —  Current NRTI use, % 96 95 0.90 — — —  Duration NRTI use, y 9 ± 2 10 ± 2 0.51 — — —  Current NNRTI use, % 40 62 0.14 — — —  Duration NNRTI use, y 3 ± 1 4 ± 1 0.63 — — — Body composition and ectopic fat  Waist circumference, cm 112.6 ± 2.4 114.1 ± 2.5 0.68 −0.6 ± 1.0 −0.5 ± 1.0 0.41  BMI, kg/m2 32.8 ± 1.3 32.7 ± 1.4 0.99 −0.1 ± 0.2 −0.1 ± 0.3 0.95  VAT area, cm2 215 (154–324) 241 (147–295) 0.85 −11 (−27 to 10) −2 (−20 to 36) 0.42  SAT area, cm2 350 (271–486) 372 (281–486) 0.56 1 (−14 to 16) −8 (−26 to 32) 0.46  IHL, % 5 (3–12) 5 (2–12) 0.50 −1 (−3 to 2) 0 (−4 to 0) 0.51  IMCL, %b 0.5 (0.2–0.6) 0.3 (0.2–0.5) 0.29 −0.1 (−0.3 to 0.1) 0.0 (−0.1 to 0.2) 0.04 Metabolic parameters  SBP, mm Hg 130 ± 3 132 ± 3 0.77 −5 ± 4 −5 ± 2 0.94  DBP, mm Hg 80 ± 1 86 ± 2 0.03 −1 ± 2 −5 ± 3 0.27  Total cholesterol, mg/dL 174 ± 6 174 ± 7 0.95 6 ± 4 −3 ± 5 0.14  Triglycerides, mg/dL 167 ± 16 158 ± 14 0.67 −1 ± 5 −2 ± 16 0.98  HDL cholesterol, mg/dL 43 ± 3 46 ± 4 0.55 2 ± 2 −2 ± 1 0.04  LDL cholesterol, mg/dL 98 ± 5 96 ± 6 0.83 4 ± 4 −1 ± 4 0.33  HbA1c, % 5.7 (5.5–6.0) 5.8 (5.3–6.1) 0.82 0.1 (−0.2 to 0.2) 0 (−0.2 to 0.2) 0.70  Fasting glucose, mg/dL 95 (87–101) 102 (87–108) 0.33 5 (0–9) 3 (−9 to 9) 0.52  HOMA-IR 1.99 (1.45–3.27) 1.64 (0.93–2.52) 0.16 0.10 (−1.11 to 0.65) 0.41 (−0.49 to 1.61) 0.20  M/I/LBM, mg/min/μIU/mL 7.26 (5.74–9.55) 7.52 (5.12–10.43) 0.86 0.48 (−1.28 to 1.48) 0.43 (−1.95 to 2.55) 0.71  FMD maximum percentage change 13.0 (9.7–19.3) 13.4 (10.8–17.6) 0.97 1.62 (−8.60 to 4.51) −4.80 (−14.17 to 5.94) 0.44 Markers of inflammation and immune activation  IL-6, pg/mL 10.2 (5.2–19.8) 7.9 (6.1–18.3) 0.76 −1.2 (−7.6 to 1.4) 3.1 (−2.5 to 4.8) 0.10  Adiponectin, pg/mL 4016 (3439–5360) 4673 (3302–6042) 0.50 −485 (−962 to 113) −361 (−1109 to 169) 0.78  PAI-1, ng/mL 36.7 ± 3.7 37.0 ± 4.1 0.95 −3 ± 4 1 ± 3 0.37  hsCRP, mg/Lc 3.3 (1.2–9.4) 3.7 (1.6 to 9.8) 0.67 −0.3 (−2.0 to 0.9) 0.9 (−0.1 to 1.9) 0.10  MCP-1, pg/mL 205 ± 16 191 ± 11 0.47 −9 ± 10 26 ± 13 0.04 Data reported as mean ± standard error of the mean, percentage, or median (interquartile range). Abbreviations: BMI, body mass index; HbA1c, hemoglobin A1c; LDL, low-density lipoprotein; NNRTI, nonnucleoside reverse transcription inhibitors; NRTI, nucleoside/nucleotide reverse transcription inhibitors; PAI-1, plasminogen activator inhibitor-1; PI, protease inhibitor; SBP, systolic blood pressure. a Adjusted for statin use for lipid panel. b Two outliers excluded for change as per Tukey method. P value obtained based on appropriate statistical test. c One outlier excluded for change as per Tukey method. P value obtained based on appropriate statistical test. View Large Table 1. Baseline and Absolute Between-Group Change of HIV, Metabolic, and Inflammation Parameters After 6 Months Treatment Baseline 6 Months Eplerenone (n = 25) Placebo (n = 21) P Value Eplerenone (n = 22) Placebo (n = 20) P Value a Demographics  Age, y 49 ± 1 52 ± 1 0.15 — — —  Race, %   White 60 43 0.25 — — —   African American 36 52 — — — —  Other 4 5 – — — —   Male sex, % 60 71 0.42 — — —   Current hypertension, % 24 33 0.48 — — —   Current statin use, % 16 24 0.51 — — — HIV parameters  CD4+ T-cell count, cells/μL 634 ± 54 608 ± 50 0.73 48 ± 29 3 ± 32 0.30  CD8+ T-cell count, cells/μL 803 ± 51 901 ± 78 0.30 226 ± 80 305 ± 133 0.62  Log HIV viral load, copies/mL 1.45 ± 0.05 1.55 ± 0.13 0.48 −0.04 ± 0.09 −0.09 ± 0.13 0.73  Undetectable viral load, % 84 67 0.17 — — —  Duration HIV, y 16 ± 1 18 ± 1 0.31 — — —  Duration ART use, y 10 ± 2 11 ± 2 0.74 — — —  Current PI use, % 44 43 0.94 — — —  Duration PI use, y 5 ± 1 4 ± 1 0.57 — — —  Current NRTI use, % 96 95 0.90 — — —  Duration NRTI use, y 9 ± 2 10 ± 2 0.51 — — —  Current NNRTI use, % 40 62 0.14 — — —  Duration NNRTI use, y 3 ± 1 4 ± 1 0.63 — — — Body composition and ectopic fat  Waist circumference, cm 112.6 ± 2.4 114.1 ± 2.5 0.68 −0.6 ± 1.0 −0.5 ± 1.0 0.41  BMI, kg/m2 32.8 ± 1.3 32.7 ± 1.4 0.99 −0.1 ± 0.2 −0.1 ± 0.3 0.95  VAT area, cm2 215 (154–324) 241 (147–295) 0.85 −11 (−27 to 10) −2 (−20 to 36) 0.42  SAT area, cm2 350 (271–486) 372 (281–486) 0.56 1 (−14 to 16) −8 (−26 to 32) 0.46  IHL, % 5 (3–12) 5 (2–12) 0.50 −1 (−3 to 2) 0 (−4 to 0) 0.51  IMCL, %b 0.5 (0.2–0.6) 0.3 (0.2–0.5) 0.29 −0.1 (−0.3 to 0.1) 0.0 (−0.1 to 0.2) 0.04 Metabolic parameters  SBP, mm Hg 130 ± 3 132 ± 3 0.77 −5 ± 4 −5 ± 2 0.94  DBP, mm Hg 80 ± 1 86 ± 2 0.03 −1 ± 2 −5 ± 3 0.27  Total cholesterol, mg/dL 174 ± 6 174 ± 7 0.95 6 ± 4 −3 ± 5 0.14  Triglycerides, mg/dL 167 ± 16 158 ± 14 0.67 −1 ± 5 −2 ± 16 0.98  HDL cholesterol, mg/dL 43 ± 3 46 ± 4 0.55 2 ± 2 −2 ± 1 0.04  LDL cholesterol, mg/dL 98 ± 5 96 ± 6 0.83 4 ± 4 −1 ± 4 0.33  HbA1c, % 5.7 (5.5–6.0) 5.8 (5.3–6.1) 0.82 0.1 (−0.2 to 0.2) 0 (−0.2 to 0.2) 0.70  Fasting glucose, mg/dL 95 (87–101) 102 (87–108) 0.33 5 (0–9) 3 (−9 to 9) 0.52  HOMA-IR 1.99 (1.45–3.27) 1.64 (0.93–2.52) 0.16 0.10 (−1.11 to 0.65) 0.41 (−0.49 to 1.61) 0.20  M/I/LBM, mg/min/μIU/mL 7.26 (5.74–9.55) 7.52 (5.12–10.43) 0.86 0.48 (−1.28 to 1.48) 0.43 (−1.95 to 2.55) 0.71  FMD maximum percentage change 13.0 (9.7–19.3) 13.4 (10.8–17.6) 0.97 1.62 (−8.60 to 4.51) −4.80 (−14.17 to 5.94) 0.44 Markers of inflammation and immune activation  IL-6, pg/mL 10.2 (5.2–19.8) 7.9 (6.1–18.3) 0.76 −1.2 (−7.6 to 1.4) 3.1 (−2.5 to 4.8) 0.10  Adiponectin, pg/mL 4016 (3439–5360) 4673 (3302–6042) 0.50 −485 (−962 to 113) −361 (−1109 to 169) 0.78  PAI-1, ng/mL 36.7 ± 3.7 37.0 ± 4.1 0.95 −3 ± 4 1 ± 3 0.37  hsCRP, mg/Lc 3.3 (1.2–9.4) 3.7 (1.6 to 9.8) 0.67 −0.3 (−2.0 to 0.9) 0.9 (−0.1 to 1.9) 0.10  MCP-1, pg/mL 205 ± 16 191 ± 11 0.47 −9 ± 10 26 ± 13 0.04 Baseline 6 Months Eplerenone (n = 25) Placebo (n = 21) P Value Eplerenone (n = 22) Placebo (n = 20) P Value a Demographics  Age, y 49 ± 1 52 ± 1 0.15 — — —  Race, %   White 60 43 0.25 — — —   African American 36 52 — — — —  Other 4 5 – — — —   Male sex, % 60 71 0.42 — — —   Current hypertension, % 24 33 0.48 — — —   Current statin use, % 16 24 0.51 — — — HIV parameters  CD4+ T-cell count, cells/μL 634 ± 54 608 ± 50 0.73 48 ± 29 3 ± 32 0.30  CD8+ T-cell count, cells/μL 803 ± 51 901 ± 78 0.30 226 ± 80 305 ± 133 0.62  Log HIV viral load, copies/mL 1.45 ± 0.05 1.55 ± 0.13 0.48 −0.04 ± 0.09 −0.09 ± 0.13 0.73  Undetectable viral load, % 84 67 0.17 — — —  Duration HIV, y 16 ± 1 18 ± 1 0.31 — — —  Duration ART use, y 10 ± 2 11 ± 2 0.74 — — —  Current PI use, % 44 43 0.94 — — —  Duration PI use, y 5 ± 1 4 ± 1 0.57 — — —  Current NRTI use, % 96 95 0.90 — — —  Duration NRTI use, y 9 ± 2 10 ± 2 0.51 — — —  Current NNRTI use, % 40 62 0.14 — — —  Duration NNRTI use, y 3 ± 1 4 ± 1 0.63 — — — Body composition and ectopic fat  Waist circumference, cm 112.6 ± 2.4 114.1 ± 2.5 0.68 −0.6 ± 1.0 −0.5 ± 1.0 0.41  BMI, kg/m2 32.8 ± 1.3 32.7 ± 1.4 0.99 −0.1 ± 0.2 −0.1 ± 0.3 0.95  VAT area, cm2 215 (154–324) 241 (147–295) 0.85 −11 (−27 to 10) −2 (−20 to 36) 0.42  SAT area, cm2 350 (271–486) 372 (281–486) 0.56 1 (−14 to 16) −8 (−26 to 32) 0.46  IHL, % 5 (3–12) 5 (2–12) 0.50 −1 (−3 to 2) 0 (−4 to 0) 0.51  IMCL, %b 0.5 (0.2–0.6) 0.3 (0.2–0.5) 0.29 −0.1 (−0.3 to 0.1) 0.0 (−0.1 to 0.2) 0.04 Metabolic parameters  SBP, mm Hg 130 ± 3 132 ± 3 0.77 −5 ± 4 −5 ± 2 0.94  DBP, mm Hg 80 ± 1 86 ± 2 0.03 −1 ± 2 −5 ± 3 0.27  Total cholesterol, mg/dL 174 ± 6 174 ± 7 0.95 6 ± 4 −3 ± 5 0.14  Triglycerides, mg/dL 167 ± 16 158 ± 14 0.67 −1 ± 5 −2 ± 16 0.98  HDL cholesterol, mg/dL 43 ± 3 46 ± 4 0.55 2 ± 2 −2 ± 1 0.04  LDL cholesterol, mg/dL 98 ± 5 96 ± 6 0.83 4 ± 4 −1 ± 4 0.33  HbA1c, % 5.7 (5.5–6.0) 5.8 (5.3–6.1) 0.82 0.1 (−0.2 to 0.2) 0 (−0.2 to 0.2) 0.70  Fasting glucose, mg/dL 95 (87–101) 102 (87–108) 0.33 5 (0–9) 3 (−9 to 9) 0.52  HOMA-IR 1.99 (1.45–3.27) 1.64 (0.93–2.52) 0.16 0.10 (−1.11 to 0.65) 0.41 (−0.49 to 1.61) 0.20  M/I/LBM, mg/min/μIU/mL 7.26 (5.74–9.55) 7.52 (5.12–10.43) 0.86 0.48 (−1.28 to 1.48) 0.43 (−1.95 to 2.55) 0.71  FMD maximum percentage change 13.0 (9.7–19.3) 13.4 (10.8–17.6) 0.97 1.62 (−8.60 to 4.51) −4.80 (−14.17 to 5.94) 0.44 Markers of inflammation and immune activation  IL-6, pg/mL 10.2 (5.2–19.8) 7.9 (6.1–18.3) 0.76 −1.2 (−7.6 to 1.4) 3.1 (−2.5 to 4.8) 0.10  Adiponectin, pg/mL 4016 (3439–5360) 4673 (3302–6042) 0.50 −485 (−962 to 113) −361 (−1109 to 169) 0.78  PAI-1, ng/mL 36.7 ± 3.7 37.0 ± 4.1 0.95 −3 ± 4 1 ± 3 0.37  hsCRP, mg/Lc 3.3 (1.2–9.4) 3.7 (1.6 to 9.8) 0.67 −0.3 (−2.0 to 0.9) 0.9 (−0.1 to 1.9) 0.10  MCP-1, pg/mL 205 ± 16 191 ± 11 0.47 −9 ± 10 26 ± 13 0.04 Data reported as mean ± standard error of the mean, percentage, or median (interquartile range). Abbreviations: BMI, body mass index; HbA1c, hemoglobin A1c; LDL, low-density lipoprotein; NNRTI, nonnucleoside reverse transcription inhibitors; NRTI, nucleoside/nucleotide reverse transcription inhibitors; PAI-1, plasminogen activator inhibitor-1; PI, protease inhibitor; SBP, systolic blood pressure. a Adjusted for statin use for lipid panel. b Two outliers excluded for change as per Tukey method. P value obtained based on appropriate statistical test. c One outlier excluded for change as per Tukey method. P value obtained based on appropriate statistical test. View Large Assessment of the RAAS at baseline Both groups (eplerenone vs placebo) demonstrated similar PRA [0.20 (0.09 to 0.40) vs 0.20 (0.09 to 0.35) ng/mL/h; P = 0.75], serum aldosterone [3.59 (2.49 to 8.77) vs 4.99 (2.49 to 7.47) ng/dL; P = 0.76], and urine aldosterone [3.84 (2.20 to 8.47) vs 5.81 (2.71 to 8.02) ng/24 h; P = 0.83] at baseline under standardized sodium conditions (Table 2). Table 2. Baseline and Absolute Between-Group Change of RAAS Parameters After 6 Months of Treatment Baseline 6 Months Eplerenone (n = 25) Placebo (n = 21) P Value Eplerenone (n = 22) Placebo (n = 20) P Value Urine studies  Urine sodium, mmol/24 h 293 ± 22 310 ± 27 0.63 1 ± 18 −50 ± 33 0.19  Urine potassium, mmol/24 h 62 ± 6 75 ± 7 0.17 6 ± 6 −11 ± 7 0.06  Urine creatinine, mg/24 h 1538 ± 103 1589 ± 150 0.78 5 ± 73 −105 ± 123 0.45  Urine cortisol, μg/24 h 24 (11–38) 27 (17 to 42) 0.49 −3 (−15 to 8) −3 (−13 to 12) 0.64 RAAS parameters  PRA, ng/mL/h 0.20 (0.09–0.40) 0.20 (0.09–0.35) 0.75 0.20 (0.00–1.55) 0.00 (−0.08 to 0.01) 0.002  Serum aldosterone, ng/dL 3.59 (2.49–8.77) 4.99 (2.49–7.47) 0.76 2.50 (−0.32 to 12.81) 0.29 (−0.94 to 1.98) 0.07  Urinary aldosterone excretion, ng/24 h 3.84 (2.20–8.47) 5.81 (2.71–8.02) 0.83 2.59 (0.38–15.43) 0.53 (−1.90 to 1.87) 0.03 Baseline 6 Months Eplerenone (n = 25) Placebo (n = 21) P Value Eplerenone (n = 22) Placebo (n = 20) P Value Urine studies  Urine sodium, mmol/24 h 293 ± 22 310 ± 27 0.63 1 ± 18 −50 ± 33 0.19  Urine potassium, mmol/24 h 62 ± 6 75 ± 7 0.17 6 ± 6 −11 ± 7 0.06  Urine creatinine, mg/24 h 1538 ± 103 1589 ± 150 0.78 5 ± 73 −105 ± 123 0.45  Urine cortisol, μg/24 h 24 (11–38) 27 (17 to 42) 0.49 −3 (−15 to 8) −3 (−13 to 12) 0.64 RAAS parameters  PRA, ng/mL/h 0.20 (0.09–0.40) 0.20 (0.09–0.35) 0.75 0.20 (0.00–1.55) 0.00 (−0.08 to 0.01) 0.002  Serum aldosterone, ng/dL 3.59 (2.49–8.77) 4.99 (2.49–7.47) 0.76 2.50 (−0.32 to 12.81) 0.29 (−0.94 to 1.98) 0.07  Urinary aldosterone excretion, ng/24 h 3.84 (2.20–8.47) 5.81 (2.71–8.02) 0.83 2.59 (0.38–15.43) 0.53 (−1.90 to 1.87) 0.03 Data reported as mean ± standard error of the mean or median (interquartile range). Performed under conditions of equivalent high sodium intake for both groups as described in the text. View Large Table 2. Baseline and Absolute Between-Group Change of RAAS Parameters After 6 Months of Treatment Baseline 6 Months Eplerenone (n = 25) Placebo (n = 21) P Value Eplerenone (n = 22) Placebo (n = 20) P Value Urine studies  Urine sodium, mmol/24 h 293 ± 22 310 ± 27 0.63 1 ± 18 −50 ± 33 0.19  Urine potassium, mmol/24 h 62 ± 6 75 ± 7 0.17 6 ± 6 −11 ± 7 0.06  Urine creatinine, mg/24 h 1538 ± 103 1589 ± 150 0.78 5 ± 73 −105 ± 123 0.45  Urine cortisol, μg/24 h 24 (11–38) 27 (17 to 42) 0.49 −3 (−15 to 8) −3 (−13 to 12) 0.64 RAAS parameters  PRA, ng/mL/h 0.20 (0.09–0.40) 0.20 (0.09–0.35) 0.75 0.20 (0.00–1.55) 0.00 (−0.08 to 0.01) 0.002  Serum aldosterone, ng/dL 3.59 (2.49–8.77) 4.99 (2.49–7.47) 0.76 2.50 (−0.32 to 12.81) 0.29 (−0.94 to 1.98) 0.07  Urinary aldosterone excretion, ng/24 h 3.84 (2.20–8.47) 5.81 (2.71–8.02) 0.83 2.59 (0.38–15.43) 0.53 (−1.90 to 1.87) 0.03 Baseline 6 Months Eplerenone (n = 25) Placebo (n = 21) P Value Eplerenone (n = 22) Placebo (n = 20) P Value Urine studies  Urine sodium, mmol/24 h 293 ± 22 310 ± 27 0.63 1 ± 18 −50 ± 33 0.19  Urine potassium, mmol/24 h 62 ± 6 75 ± 7 0.17 6 ± 6 −11 ± 7 0.06  Urine creatinine, mg/24 h 1538 ± 103 1589 ± 150 0.78 5 ± 73 −105 ± 123 0.45  Urine cortisol, μg/24 h 24 (11–38) 27 (17 to 42) 0.49 −3 (−15 to 8) −3 (−13 to 12) 0.64 RAAS parameters  PRA, ng/mL/h 0.20 (0.09–0.40) 0.20 (0.09–0.35) 0.75 0.20 (0.00–1.55) 0.00 (−0.08 to 0.01) 0.002  Serum aldosterone, ng/dL 3.59 (2.49–8.77) 4.99 (2.49–7.47) 0.76 2.50 (−0.32 to 12.81) 0.29 (−0.94 to 1.98) 0.07  Urinary aldosterone excretion, ng/24 h 3.84 (2.20–8.47) 5.81 (2.71–8.02) 0.83 2.59 (0.38–15.43) 0.53 (−1.90 to 1.87) 0.03 Data reported as mean ± standard error of the mean or median (interquartile range). Performed under conditions of equivalent high sodium intake for both groups as described in the text. View Large Treatment effects on insulin-stimulated glucose uptake Eplerenone did not significantly change insulin sensitivity M/I/LBM [0.48 (−1.28 to 1.48) vs 0.43 (−1.95 to 2.55) mg/min/μIU/mL; P = 0.71, eplerenone vs placebo). There was also no difference in the change in hemoglobin A1c or homeostatic model assessment of insulin resistance (HOMA-IR; Table 1). There was no significant treatment effect of the type of ART use on M/I/LBM, evaluated separately by duration of protease inhibitor (β estimate −0.0850; P = 0.47), nucleoside/nucleotide reverse transcription inhibitors (β estimate −0.0710; P = 0.43), and nonnucleoside reverse transcription inhibitors (β estimate 0.2296; P = 0.14) in modeling assessing the effects of eplerenone vs placebo. Similar results were seen in a sensitivity analysis assessing 3-month change in M/I/LBM between groups (P = 0.69). Treatment effects on body composition No significant effects were seen with respect to VAT [−11 (−27 to 10) vs −2 (−20 to 36) cm2; P = 0.42] or IHLs [−1 (−3 to 2) vs 0 (−4 to 0) %; P = 0.51] in the eplerenone vs placebo-treated groups. Eplerenone significantly reduced IMCLs [−0.1 (−0.3 to 0.1) vs 0.0 (−0.1 to 0.2)%; P = 0.04, eplerenone vs placebo] (Table 1). Treatment effects on metabolic indices and inflammatory markers BP decreased in both groups similarly, without a significant difference between treatment arms (P > 0.05). Within the lipid panel, high-density lipoprotein (HDL; 2 ± 2 vs −2 ± 1 mg/dL; P = 0.04) increased significantly on eplerenone vs placebo study medication. There was a significant treatment effect of eplerenone to lower MCP-1 compared with placebo (−9 ± 10 vs 26 ± 13 pg/mL; P = 0.04) and a trend toward a beneficial treatment effect of eplerenone vs placebo on inflammatory markers IL-6 [−1.2 (−7.6 to 1.4) vs 3.1 (−2.5 to 4.9) pg/mL; P = 0.10] and hsCRP [−0.3 (−2.0 to 0.9) vs 0.9 (−0.1 to 1.9) mg/L; P = 0.10] (Table 1). Treatment effects on FMD The maximal percent change in FMD [1.62 (−8.60 to 4.51) vs −4.80 (−14.17 to 5.94)%; P = 0.44, eplerenone vs placebo] did not reach statistical significance between groups, but was relatively greater in the eplerenone group (Table 1). Treatment effects on the RAAS Consistent with eplerenone’s known mechanism of action as an MR antagonist, individuals randomized to eplerenone had a significant rise in PRA [0.20 (0.00 to 1.55) vs 0.00 (−0.08 to 0.01) ng/mL/h; P = 0.002] and urine aldosterone [2.59 (0.38 to 15.43) vs 0.53 (−1.90 to 1.87) ng/24 h; P = 0.03] and a trend toward an increase in serum aldosterone [2.50 (−0.32 to 12.81) vs 0.29 (−0.94 to 1.98) ng/dL; P = 0.07] compared with those randomized to placebo (Table 2). Relationship of change in PRA with insulin sensitivity In exploratory analyses among the entire group, increases in PRA were inversely related to improvements in M (τ = −0.23; P = 0.04). When the entire group was stratified by median change in PRA, individuals with a below the median change in PRA demonstrated significant improvement in change in M/I/LBM compared with those with an above the median change in PRA [1.56 (−1.61 to 3.19) vs −0.83 (−1.77 to 0.96) mg/min/μIU/mL; P = 0.04]. Adherence of study medication Adherence based on pill counts between both treatment groups was high and similar for all time points for the duration of the 6-month study (Supplemental Table 2). Safety data and adverse side effects There were no serious adverse events reported in either treatment arm. No medication-related hyperkalemia or hypotension were reported in either group. There was a trend toward increased potassium in the eplerenone vs placebo group (4.25 ± 0.04 vs 4.15 ± 0.04 mEq/L; P = 0.07), but the difference (0.1 mEq/L) was not clinically significant. Overall, nonserious adverse events were relatively similar, though there appeared to be more gastrointestinal side effects in the eplerenone arm, none of which led to discontinuation of study medication or participation (Table 3). Table 3. Type and Number of Adverse Events Eplerenone (n = 25) Placebo (n = 21) Serious adverse events 0 0 Nonserious adverse events 20 14  Hyperkalemia 0 0  Elevated creatinine 1 1  Hypotension 0 0  Dizziness 1 1  Hypertension 0 2  Headache 0 1  Abdominal pain 1 0  Nausea 1 0  Diarrhea 2 0  Anorexia 1 0  Rectal bleed 2 0  Rash 1 0  Fatigue 1 0  Upper respiratory infection 4 6  Other infection 1 0  Urinary symptoms 1 0  Musculoskeletal pain 1 2  Mood symptoms 1 1  Insomnia 1 0 Eplerenone (n = 25) Placebo (n = 21) Serious adverse events 0 0 Nonserious adverse events 20 14  Hyperkalemia 0 0  Elevated creatinine 1 1  Hypotension 0 0  Dizziness 1 1  Hypertension 0 2  Headache 0 1  Abdominal pain 1 0  Nausea 1 0  Diarrhea 2 0  Anorexia 1 0  Rectal bleed 2 0  Rash 1 0  Fatigue 1 0  Upper respiratory infection 4 6  Other infection 1 0  Urinary symptoms 1 0  Musculoskeletal pain 1 2  Mood symptoms 1 1  Insomnia 1 0 View Large Table 3. Type and Number of Adverse Events Eplerenone (n = 25) Placebo (n = 21) Serious adverse events 0 0 Nonserious adverse events 20 14  Hyperkalemia 0 0  Elevated creatinine 1 1  Hypotension 0 0  Dizziness 1 1  Hypertension 0 2  Headache 0 1  Abdominal pain 1 0  Nausea 1 0  Diarrhea 2 0  Anorexia 1 0  Rectal bleed 2 0  Rash 1 0  Fatigue 1 0  Upper respiratory infection 4 6  Other infection 1 0  Urinary symptoms 1 0  Musculoskeletal pain 1 2  Mood symptoms 1 1  Insomnia 1 0 Eplerenone (n = 25) Placebo (n = 21) Serious adverse events 0 0 Nonserious adverse events 20 14  Hyperkalemia 0 0  Elevated creatinine 1 1  Hypotension 0 0  Dizziness 1 1  Hypertension 0 2  Headache 0 1  Abdominal pain 1 0  Nausea 1 0  Diarrhea 2 0  Anorexia 1 0  Rectal bleed 2 0  Rash 1 0  Fatigue 1 0  Upper respiratory infection 4 6  Other infection 1 0  Urinary symptoms 1 0  Musculoskeletal pain 1 2  Mood symptoms 1 1  Insomnia 1 0 View Large Discussion These data from a randomized, placebo-controlled trial evaluate MR antagonism as a metabolic therapy in HIV. The current study assessing RAAS blockade was performed to complement our prior studies investigating RAAS activation in HIV (6, 7). Contrary to our hypothesis, eplerenone had no marked treatment effect over placebo on insulin sensitivity, as measured by the gold standard euglycemic-hyperinsulinemic clamp technique, in this population. However, these findings demonstrate effects of the MR blockade to improve select parameters related to inflammation, lipids, and ectopic fat among the population with HIV. We expected to see an improvement in insulin sensitivity based on compelling data linking mineralocorticoid excess with insulin resistance (9) and mineralocorticoid blockade with improved insulin sensitivity (10), particularly because of unique RAAS physiology in HIV. Our prior data assessing RAAS physiology in HIV performed under strict diet and posture techniques showed that PRA and aldosterone were highly correlated with HOMA-IR during RAAS activation compared with the non-HIV group (6). Moreover, in our studies of obese db/db mice, eplerenone significantly improved HOMA-IR (10). Mechanistically, aldosterone has been proposed to inhibit insulin signaling by stimulating the release of inflammatory cytokines and reactive oxygen species (11, 12), further leading to decreased translocation of GLUT4 to the plasma membrane (13), and β-cell and endothelial dysfunction (14, 15). Taken together, these data provided strong rationale to perform the current investigation. To understand why our results differed from the anticipated results, we performed an exploratory analysis correlating longitudinal changes in the RAAS in response to eplerenone, with changes in insulin sensitivity. These data show that increases in PRA, occurring in the context of MR blockade, were associated with decreases in insulin sensitivity. Our interventional physiology studies in HIV corroborate that increased PRA, as simulated in an RAAS-activated state, is indeed linked to insulin resistance (6). This physiologic relationship may provide some insight if the positive benefits of MR blockade were in part negated by the consequent feedback of RAAS activation associated with this therapy. In this scenario, increased activation of the PRA–angiotensin II axis may be acting independent of the MR to impair insulin sensitivity, highlighting that combination therapy of eplerenone with a renin inhibitor or an adrenergic antagonist, such as a β-blocker, to reduce renin could merit future investigations to reduce metabolic disease in HIV. In addition, combining an MR antagonist with an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker would decrease angiotensin II levels, reducing any effects of angiotensin II on insulin resistance. Our results are consistent with a prior study showing that MR antagonism with spironolactone (50 mg daily) does not improve insulin sensitivity assessed by oral glucose tolerance test in obese insulin-resistant individuals (16). MR activation has been linked to inflammation, and we have previously shown increases in inflammatory and immune markers hsCRP, IL-6, and MCP-1 during RAAS-activated conditions using a low-sodium diet relative to an ad libitum sodium diet (6, 7). There was general dampening of all inflammatory markers in the eplerenone arm among the HIV population selected for increased VAT and abnormal glucose homeostasis and most significantly in MCP-1. The reduction in MCP-1 is an important observation for the HIV population in alignment with prior animal data from our group. In these preclinical studies from Guo et al. (10), MCP-1 messenger RNA expression was increased ∼10-fold in VAT from obese db/db mice compared with lean mice db/+. After the obese mice were treated with eplerenone, both plasma levels of MCP-1 and messenger RNA expression in the adipose depot were significantly reduced (10). Wada et al. (17) also reported in a murine model of obesity that eplerenone suppresses inflammation in the adipose depot. The current study may not have been adequately powered to detect a significant effect of eplerenone on inflammation across different indices, and larger studies evaluating inflammatory end points will be critical to perform given these findings. Nonetheless, the absolute changes in favor of eplerenone in MCP-1, IL-6, and hsCRP were relatively large in comparison with baseline, suggesting a potentially relevant biological signal. Other relevant findings include a decrease in IMCLs among those treated with eplerenone vs placebo. Although this finding is statistically significant, the clinical significance of this degree of change and mechanism of this effect is not well defined. There is evidence to suggest that a local RAAS system is present in the adipose depot (18–21), and we have demonstrated that RAAS activation is associated with VAT (6). Lipid deposition in the muscle may develop secondary to VAT accumulation based on the lipid overflow-ectopic fat model, and the changes in IMCLs via eplerenone may be consequent of VAT reduction. In this study, we did not see a statistically significant effect on VAT, but the decrease was relatively larger in the eplerenone group. Further studies to assess the mechanism of eplerenone effects on IMCLs are needed. With respect to lipids, we also saw an increase in HDL cholesterol in the eplerenone-treated group relative to placebo. Cav1 gene polymorphisms, which may modulate MR signaling, are similarly reported to be associated with low HDL and increased aldosterone (22), supporting this finding. As such, this study suggests that among HIV-infected individuals, MR blockade may have greater utility on specific inflammatory and lipid pathways than insulin resistance per se. To that end, eplerenone reduced both MCP-1 and atherosclerotic disease in an animal model (23–25). These key hypotheses relevant to HIV will be addressed in a newly initiated randomized controlled trial known as the MIRACLE HIV study (NCT02740179). Pilot studies have evaluated another RAAS-related medication, telmisartan, an angiotensin receptor blocker and PPAR- γ agonist, for its potential on metabolic disease in HIV. These preliminary studies did not show any definitive benefit on VAT-related metabolic abnormalities (26) or cardiovascular risk (27), but were not placebo-controlled. In contrast to these studies, we conducted a placebo-controlled trial and chose to investigate MR antagonism to minimize the aldosterone escape that is commonly associated with upstream targets along the RAAS pathway. Despite this, we saw a relationship between increased renin and worsened insulin sensitivity, suggesting that there may be independent effects of RAAS components through other pathways. For this study, we chose to investigate the utility of eplerenone, a second-generation MR antagonist, rather than spironolactone, a first-generation antagonist, on our end points. Eplerenone has greater selectivity for the MR (28) and therefore provides an advantage over spironolactone in contributing less to progestogenic and antiandrogenic side effects, such as loss of libido, gynecomastia, and menstrual irregularities. Eplerenone was well tolerated in our group, and no side effects led to discontinuation of study medication or participation. This study adds safety data to the field, demonstrating that this class of medication, at the dose used, is reasonably safe to use in the HIV population, the majority of whom are on multiple classes of ART. As an initial study of eplerenone in HIV, we used a relatively low dose of 50 mg daily to assess the safety profile. Eplerenone was safely administered without evidence of clinically noteworthy hypotension, or hyperkalemia. Given these initial data, administering a higher dose may be considered in future studies to amplify the anti-inflammatory and metabolic enhancing signals seen in the current study. There are limitations to the current study. It is relatively small, but our dropout rate of 9% was lower than expected and not different between treatment groups in this randomized trial. The lower than anticipated dropout helped to ensure a reasonable number of evaluable patients. Moreover, we used state-of-the-art, comprehensive phenotyping to further increase the sensitivity of the study to detect metabolic changes. The study duration was 6 months and thus reasonably long, but further longer-term effects could not be determined. Although individuals were chosen based on impaired fasting glucose, impaired glucose tolerance, or fasting hyperinsulinemia, individuals with diabetes were excluded, and glucose abnormalities were not severe, showing relatively preserved insulin sensitivity by clamp at baseline. This design was chosen to avoid confounding effects of diabetes on the results, but it is possible that larger effects would have been seen in individuals with more impaired glycemia at baseline. In the current study, we used a standardized diet to ensure similar sodium intake across groups at assessment time points in contrast to the low-sodium conditions of RAAS activation in our prior studies. This choice was made to ensure uniformity of the results and avoid potential confounding of dietary activation of the RAAS. In contrast, anti-inflammatory effects of RAAS blockade may be muted in the context of more liberalized sodium intake based on our prior data related to RAAS activation. We did see that the group randomized to eplerenone had significantly greater increases in PRA and aldosterone levels. Based on expected RAAS physiology and MR feedback, these levels may serve as reliable surrogates and suggest good study drug adherence, which was additionally reinforced by the pill count. In conclusion, this study demonstrates that although eplerenone does not have adverse or beneficial effects on insulin sensitivity in HIV-infected individuals with mild abnormalities in glucose homeostasis, it may nonetheless be useful to improve cardiovascular disease risk based on inflammatory, ectopic fat, and lipid levels, as demonstrated in this initial study of this population in whom RAAS activation has been shown. The clinical significance of the magnitude of improvements in inflammatory, ectopic fat, and lipid parameters is unclear, and further studies of eplerenone are merited to determine the full scope of its effects in HIV. Abbreviations: Abbreviations: ART antiretroviral therapy BP blood pressure DBP diastolic blood pressure FMD flow-mediated vasodilation HDL high-density lipoprotein HOMA-IR homeostatic model assessment of insulin resistance hsCRP high-sensitivity C-reactive protein IHL intrahepatic lipid IL-6 interleukin-6 IMCL intramyocellular lipid LBM lean body mass MCP-1 monocyte chemoattractant protein-1 MGH Massachusetts General Hospital MR mineralocorticoid receptor PRA plasma renin activity RAAS renin-angiotensin-aldosterone system VAT visceral adipose tissue Acknowledgments The authors thank the nursing staff of the MGH Translational and Clinical Research Center for dedicated patient care, as well as the volunteers who participated in this study. Financial Support: Funding was provided by National Institutes of Health Grant R01-DK49302 (to S.K.G.); a Harvard Catalyst Medical Research Investigator Training award and National Institutes of Health Grant K23-HL136262 (to S.S.); National Institutes of Health Grant K24-HL103845 (to G.K.A.); the Claflin Distinguished Scholar Award (MGH Executive Committee on Research) (to S.E.L.); National Institutes of Health Grants UL1-TR000170, UL1-RR025758, and UL1-TR001102 to the Harvard Catalyst/Harvard Clinical and Translational Science Center from the National Center for Research Resources and National Center for Advancing Translational Sciences; and National Institutes of Health Grant P30-DK040561 to the Nutrition and Obesity Research Center at Harvard University. Funding sources had no role in the design of the study, data analysis, or writing of the manuscript. Clinical Trial Information: ClinicalTrials.gov no. NCT01405456 (registered 29 July 2011). Disclosure Summary: T.L.S. has received research funding from Kowa Pharmaceuticals and Novo Nordisk and served as a consultant for Theratechnologies. G.K.A. has been a consultant for Pfizer. S.K.G. has received research funding from Gilead Sciences, Kowa Pharmaceuticals, and Theratechnologies and served as a consultant for Navidea Biopharmaceuticals and Theratechnologies. The remaining authors have nothing to disclose. References 1. Brown TT , Cole SR , Li X , Kingsley LA , Palella FJ , Riddler SA , Visscher BR , Margolick JB , Dobs AS . Antiretroviral therapy and the prevalence and incidence of diabetes mellitus in the multicenter AIDS cohort study . Arch Intern Med . 2005 ; 165 ( 10 ): 1179 – 1184 . Google Scholar CrossRef Search ADS PubMed 2. Grunfeld C , Rimland D , Gibert CL , Powderly WG , Sidney S , Shlipak MG , Bacchetti P , Scherzer R , Haffner S , Heymsfield SB . 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PLoS One . 2013 ; 8 ( 3 ): e58135 . Google Scholar CrossRef Search ADS PubMed 27. Lake JE , Seang S , Kelesidis T , Liao DH , Hodis HN , Stein JH , Currier JS . Telmisartan to reduce cardiovascular risk in older HIV-infected adults: a pilot study . HIV Clin Trials . 2015 ; 16 ( 5 ): 197 – 206 . Google Scholar CrossRef Search ADS PubMed 28. Bauersachs J . The ARTS of third-generation mineralocorticoid receptor antagonists: achieving cardiovascular benefit with minimized renal side effects ? Eur Heart J . 2013 ; 34 ( 31 ): 2426 – 2428 . Google Scholar CrossRef Search ADS PubMed Copyright © 2018 Endocrine Society http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Clinical Endocrinology and Metabolism Oxford University Press

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Publisher
Endocrine Society
Copyright
Copyright © 2018 Endocrine Society
ISSN
0021-972X
eISSN
1945-7197
D.O.I.
10.1210/jc.2018-00330
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Abstract

Abstract Context HIV-infected individuals demonstrate increased renin-angiotensin-aldosterone system activation in association with visceral adiposity, insulin resistance, and inflammation. A physiologically based treatment approach targeting mineralocorticoid receptor (MR) blockade may improve metabolic and inflammatory indices in HIV. Objective To investigate effects of eplerenone on insulin sensitivity, inflammatory indices, and other metabolic parameters in HIV. Design Six-month, double-blind, randomized, placebo-controlled trial. Setting Academic clinical research center. Participants HIV-infected individuals with increased waist circumference and abnormal glucose homeostasis. Intervention Eplerenone 50 mg or placebo daily. Outcome The primary end point was change in insulin sensitivity measured by the euglycemic-hyperinsulinemic clamp technique. Secondary end points included change in body composition and inflammatory markers. Results Forty-six individuals were randomized to eplerenone (n = 25) vs placebo (n = 21). Eplerenone did not improve insulin sensitivity [0.48 (−1.28 to 1.48) vs 0.43 (−1.95 to 2.55) mg/min/μIU/mL insulin; P = 0.71, eplerenone vs placebo] when measured by the gold standard euglycemic-hyperinsulinemic clamp technique. Intramyocellular lipids (P = 0.04), monocyte chemoattractant protein-1 (P = 0.04), and high-density lipoprotein (P = 0.04) improved among those randomized to eplerenone vs placebo. Trends toward decreases in interleukin-6 (P = 0.10) and high-sensitivity C-reactive protein (P = 0.10) were also seen with eplerenone vs placebo. Plasma renin activity and aldosterone levels increased in the eplerenone vs placebo-treated group, demonstrating expected physiology. MR antagonism with eplerenone was well tolerated among the HIV population, with no considerable changes in blood pressure or potassium. Conclusion MR blockade may improve selected metabolic and inflammatory indices in HIV-infected individuals. Further studies are necessary to understand the clinical potential of MR antagonism in HIV. Metabolic dysfunction is prevalent among the HIV-infected population. Contemporary antiretroviral therapy (ART) regimens have demonstrated enhanced safety profiles and reduced metabolic consequences. Nonetheless, insulin resistance, body composition changes with ectopic fat accumulation, and chronic inflammation remain leading contributors to cardiovascular morbidity and mortality, even among well-treated HIV-infected individuals with good virologic control (1). Moreover, ectopic fat (2) and chronic inflammation (3, 4) may contribute to the pathogenesis of insulin resistance and more long-term sequelae, such as coronary artery disease (5), in the population with HIV. These abnormalities may be particularly prevalent among HIV-infected individuals with increased abdominal fat accumulation. Conventional therapies for insulin resistance have shown variable efficacy in the HIV population and were not developed to be HIV specific. Moreover, such strategies often do not simultaneously affect inflammatory and immune indices. Therefore, novel treatment approaches leveraging strategies that mechanistically target key mediators of insulin resistance, unique to HIV, with potential broader effects on inflammatory indices, are needed. We previously demonstrated unique renin-angiotensin-aldosterone system (RAAS) physiology among HIV-infected individuals, characterized by increased RAAS activation in association with visceral adiposity, insulin resistance, and inflammation (6, 7). Based on this evidence, we hypothesized that a physiologically based treatment approach targeting mineralocorticoid receptor (MR) blockade may have beneficial effects on improving insulin sensitivity and inflammatory markers in HIV. To test this hypothesis, we conducted a 6-month double-blinded, randomized, placebo-controlled trial using eplerenone among HIV-infected individuals. The trial was designed to assess the effects of eplerenone in HIV on insulin sensitivity using the gold standard euglycemic-hyperinsulinemic clamp technique. These data may have considerable implications that extend to other populations susceptible to metabolic dysfunction and inflammation. Methods Participants The study was conducted between January 2012 and May 2017 at Massachusetts General Hospital (MGH). Individuals between the ages of 30 and 65 years with known history of HIV ≥5 years were recruited from the greater Boston area. Individuals were required to receive continuous ART for >12 months prior to enrollment. Those enrolled were individuals with increased abdominal girth based on National Cholesterol Education Program guidelines for waist circumference (>102 cm in males and >88 cm in females). A standard 75-g oral glucose tolerance test was performed to select for evidence of abnormal glucose homeostasis (impaired fasting glucose >100 and <126 mg/dL; impaired glucose tolerance, 2-hour glucose >140 and <200 mg/dL; or fasting insulin >12 μIU/mL). Elevated systolic blood pressure (BP) or diastolic BP (DBP; systolic BP ≥160 or DBP ≥100 mm Hg), diabetes, cardiovascular disease, and active pregnancy were exclusionary. Individuals receiving strong CYP3A4 inhibitors, the CYP3A4 inducer St. John’s wort, and medications known to affect the RAAS system were excluded (Supplemental Table 1). Individuals with serum potassium >5.5 mEq/L, alanine aminotransferase >2.5 times the upper limit of normal, hemoglobin <11 g/dL, creatinine >1.5 mg/dL, or estimated glomerular filtration rate <60 mL/min/1.73 m2 were also excluded. All participants provided informed consent to participate. This study was approved by the Partners Human Research Committee. Randomization and blinding The randomization was stratified by sex, age (<45 or ≥45 years), and BP (<140/90 or ≥140/90 mm Hg). A permuted block algorithm with a random block size of either two or four was used, and individuals were allocated 1:1 to eplerenone or matching placebo. The randomization key was generated by a biostatistician and only made available to the MGH Clinical Trials Pharmacy. Identical blinded capsules were created and matching dose escalations were employed for both the active study drug and placebo. Following baseline study procedures, doses were started at 25 mg daily for 1 week and then escalated to 50 mg daily for the remaining 6-month study duration if tolerated by BP and potassium levels. Adherence to study medication was assessed by manual pill count of the returned supply. Study participants and investigators were blinded to the randomization. Lifestyle counseling All individuals participated in a standardized lifestyle modification program over 6 months. Goals were derived from the American Association of Clinical Endocrinologists and National Cholesterol Education Program Adult Treatment Panel III guidelines and the Diabetes Prevention Program and are further detailed in the Supplemental Methods. Study outcomes The primary end point was prespecified as insulin-stimulated glucose uptake measured by the euglycemic-hyperinsulinemic clamp technique. Additional end points included measures of body composition and metabolic and inflammatory indices. End points for the primary analyses were assessed at baseline and 6 months postbaseline. Safety monitoring Safety visits were conducted at 1 week, 2 weeks, 4 weeks, 2 months, and 3 months following randomization. Interval medical history and BP were obtained. Laboratory assessment included serum creatinine, potassium, alanine aminotransferase, and urine pregnancy test. A Data and Safety Monitoring Board convened every 3 months for safety monitoring. Standardized sodium diets to characterize the RAAS at baseline and 6 months A 4-day food record was collected from individuals to assess their routine dietary sodium intake. Individuals were instructed by the dietician to supplement their usual diet with the appropriate number of broth packets (47.8 mEq Na+/packet) for 6 days to a goal dietary sodium intake of 200 mEq. On day 6, individuals started a 24-hour urine collection to confirm appropriate sodium balance. Euglycemic-hyperinsulinemic clamp at baseline and 6 months After a 12-hour overnight fast, individuals received a primed infusion of regular insulin mixed with albumin, 80 mU/m2/min, for 120 minutes. A variable infusion rate of dextrose 20% was administered to maintain blood glucose at 90 mg/dL. Blood samples for glucose at time 0 and every 5 minutes thereafter were measured using a B-Glucose analyzer (HemoCue, Lake Forest, CA). Blood samples for insulin were collected at 20-minute intervals from 0 to 120 minutes. Insulin-stimulated glucose uptake (M) was calculated using the DeFronzo technique (8) for the steady-state interval between 100 and 120 minutes. M was corrected for insulin (I) and indexed to fat-free (lean body) mass (LBM) [M/I/LBM in milligrams per minute per microunits per milliliter insulin]. Laboratory assessment at baseline and 6 months On the evening of day 6 of the sodium diet, individuals fasted for 12 hours and were asked to lie supine overnight to assess the RAAS and other metabolic and inflammatory parameters on the following morning. Serum and urine aldosterone were measured by solid-phase radioimmunoassay by the Coat-A-Count method (sensitivity 2.5 ng/dL; Diagnostic Products, Los Angeles, CA). Plasma renin activity (PRA) was assessed using the GammaCoat [125I] RIA kit (sensitivity 0.01 ng/mL/h; DiaSorin, Saluggia, Italy). Serum insulin was measured using the Access immunoassay system (Beckman Coulter, Brea, CA). Plasma high-sensitivity C-reactive protein (hsCRP), plasminogen activator inhibitor-1, monocyte chemoattractant protein-1 (MCP-1), adiponectin (all from R&D Systems, Minneapolis, MN), and interleukin-6 (IL-6; Invitrogen, Carlsbad, CA) were measured via enzyme-linked immunosorbent assay. Body composition assessment at baseline and 6 months Individuals underwent magnetic resonance imaging to measure visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT). In addition, 1H-magnetic resonance spectroscopy of the liver to assess intrahepatic lipids (IHLs) and the tibialis anterior muscle to assess intramyocellular lipids (IMCLs) was performed. Studies were obtained after an 8-hour overnight fast using a 3.0T magnetic resonance imaging system (Siemens Trio; Siemens Medical, Erlangen, Germany) as detailed in the Supplemental Methods. Flow-mediated vasodilation at baseline and 6 months After a 12-hour overnight fast, a BP cuff was placed over the brachial artery. The brachial artery was scanned using ultrasound in the sagittal axis to acquire a cineloop pre- and postdilation (see Supplemental Methods). Statistical analysis The Shapiro-Wilk test was performed to determine normality of variables. Normally distributed variables are reported as mean ± standard error of the mean, nonnormally distributed variables are shown as median (interquartile range), and categorical variables are presented by proportions. Treatment effect was determined by comparing the absolute changes in variables from baseline to 6 months between eplerenone and placebo groups using the Student t test and Wilcoxon rank-sum test for normally and nonnormally distributed data, respectively. The study was powered at 80% to detect a between-group difference of 0.8 standard deviation in the percentage change over 6 months. Based on data from our group, mean ± standard deviation of insulin-stimulated glucose uptake in this population using our clamp protocol is 7.4 ± 1.7 mg/kg/min. The current study was powered to detect a change in glucose uptake of 1.4 mg/kg/min, or ∼20% change, which would be physiologically relevant. All available data were included in an intention-to-treat analysis. Difference in potassium was derived using the composite mean value of all safety visits, as there was no evidence of trends over time. A formal outlier test by the Tukey method was performed for variables identified to be potential outliers upon visual inspection of the data, and a level determined to be >1.5 or <1.5 times the interquartile range was considered an outlier. A sensitivity analysis was performed removing outliers using the appropriate statistical test. We adjusted for current statin use when assessing changes in the lipid profile. Univariate relationships were assessed by Kendall τ test. Statistical significance was determined to a two-sided P value <0.05. Analyses were performed using SAS JMP (version 12; SAS Institute, Cary, NC). Results Participant flow A total of 104 HIV-infected individuals were screened. Forty-six individuals were randomized to receive either eplerenone (n = 25) or placebo (n = 21). Four individuals did not complete the study [P = 0.37 for comparison of dropouts in eplerenone (n = 3) vs placebo (n = 1)] (Fig. 1). Figure 1. View largeDownload slide Participant flow of HIV-infected individuals through the study. ACEi, angiotensin-converting enzyme inhibitor; CVA, cerebrovascular accident; DM, diabetes mellitus; WC, waist circumference. Figure 1. View largeDownload slide Participant flow of HIV-infected individuals through the study. ACEi, angiotensin-converting enzyme inhibitor; CVA, cerebrovascular accident; DM, diabetes mellitus; WC, waist circumference. Baseline demographics and clinical characteristics Both treatment groups (eplerenone vs placebo) were of similar age, race, and sex (all P > 0.05; Table 1). The prevalence of hypertension did not differ (24 vs 33%; P = 0.48) among those randomized to eplerenone vs placebo. DBP was greater in the placebo vs eplerenone group (86 ± 2 vs 80 ± 1 mm Hg; P = 0.03). Both groups were well matched on body composition parameters, including body mass index, VAT, SAT, IHLs, and IMCLs (all P > 0.05). Baseline insulin-stimulated glucose uptake normalized to insulin and LBM [M/I/LBM; 7.26 (5.74 to 9.55) vs 7.52 (5.12 to 10.43) mg/min/μIU/mL; P = 0.86] and hemoglobin A1c [5.7 (5.5 to 6.0) vs 5.8 (5.3 to 6.1)%; P = 0.82] were similar between the eplerenone and placebo arms and consistent with moderate insulin resistance and prediabetes, respectively. Lipid and inflammatory markers, in addition to flow-mediated vasodilation (FMD), were not significantly different between groups at baseline (all P > 0.05). The durations of HIV infection (16 ± 1 vs 18 ± 1 years; P = 0.31) and treatment with ART (10 ± 2 vs 11 ± 2 years; P = 0.74) were comparable among individuals randomized to eplerenone vs placebo. Other HIV-specific characteristics such as CD4+ T-cell count and viral load demonstrated similar, good, immunological control in both groups. Use of protease inhibitors, nucleoside/nucleotide reverse transcription inhibitors, and nonnucleoside reverse transcription inhibitors was similar between groups (all P > 0.05) (Table 1). Table 1. Baseline and Absolute Between-Group Change of HIV, Metabolic, and Inflammation Parameters After 6 Months Treatment Baseline 6 Months Eplerenone (n = 25) Placebo (n = 21) P Value Eplerenone (n = 22) Placebo (n = 20) P Value a Demographics  Age, y 49 ± 1 52 ± 1 0.15 — — —  Race, %   White 60 43 0.25 — — —   African American 36 52 — — — —  Other 4 5 – — — —   Male sex, % 60 71 0.42 — — —   Current hypertension, % 24 33 0.48 — — —   Current statin use, % 16 24 0.51 — — — HIV parameters  CD4+ T-cell count, cells/μL 634 ± 54 608 ± 50 0.73 48 ± 29 3 ± 32 0.30  CD8+ T-cell count, cells/μL 803 ± 51 901 ± 78 0.30 226 ± 80 305 ± 133 0.62  Log HIV viral load, copies/mL 1.45 ± 0.05 1.55 ± 0.13 0.48 −0.04 ± 0.09 −0.09 ± 0.13 0.73  Undetectable viral load, % 84 67 0.17 — — —  Duration HIV, y 16 ± 1 18 ± 1 0.31 — — —  Duration ART use, y 10 ± 2 11 ± 2 0.74 — — —  Current PI use, % 44 43 0.94 — — —  Duration PI use, y 5 ± 1 4 ± 1 0.57 — — —  Current NRTI use, % 96 95 0.90 — — —  Duration NRTI use, y 9 ± 2 10 ± 2 0.51 — — —  Current NNRTI use, % 40 62 0.14 — — —  Duration NNRTI use, y 3 ± 1 4 ± 1 0.63 — — — Body composition and ectopic fat  Waist circumference, cm 112.6 ± 2.4 114.1 ± 2.5 0.68 −0.6 ± 1.0 −0.5 ± 1.0 0.41  BMI, kg/m2 32.8 ± 1.3 32.7 ± 1.4 0.99 −0.1 ± 0.2 −0.1 ± 0.3 0.95  VAT area, cm2 215 (154–324) 241 (147–295) 0.85 −11 (−27 to 10) −2 (−20 to 36) 0.42  SAT area, cm2 350 (271–486) 372 (281–486) 0.56 1 (−14 to 16) −8 (−26 to 32) 0.46  IHL, % 5 (3–12) 5 (2–12) 0.50 −1 (−3 to 2) 0 (−4 to 0) 0.51  IMCL, %b 0.5 (0.2–0.6) 0.3 (0.2–0.5) 0.29 −0.1 (−0.3 to 0.1) 0.0 (−0.1 to 0.2) 0.04 Metabolic parameters  SBP, mm Hg 130 ± 3 132 ± 3 0.77 −5 ± 4 −5 ± 2 0.94  DBP, mm Hg 80 ± 1 86 ± 2 0.03 −1 ± 2 −5 ± 3 0.27  Total cholesterol, mg/dL 174 ± 6 174 ± 7 0.95 6 ± 4 −3 ± 5 0.14  Triglycerides, mg/dL 167 ± 16 158 ± 14 0.67 −1 ± 5 −2 ± 16 0.98  HDL cholesterol, mg/dL 43 ± 3 46 ± 4 0.55 2 ± 2 −2 ± 1 0.04  LDL cholesterol, mg/dL 98 ± 5 96 ± 6 0.83 4 ± 4 −1 ± 4 0.33  HbA1c, % 5.7 (5.5–6.0) 5.8 (5.3–6.1) 0.82 0.1 (−0.2 to 0.2) 0 (−0.2 to 0.2) 0.70  Fasting glucose, mg/dL 95 (87–101) 102 (87–108) 0.33 5 (0–9) 3 (−9 to 9) 0.52  HOMA-IR 1.99 (1.45–3.27) 1.64 (0.93–2.52) 0.16 0.10 (−1.11 to 0.65) 0.41 (−0.49 to 1.61) 0.20  M/I/LBM, mg/min/μIU/mL 7.26 (5.74–9.55) 7.52 (5.12–10.43) 0.86 0.48 (−1.28 to 1.48) 0.43 (−1.95 to 2.55) 0.71  FMD maximum percentage change 13.0 (9.7–19.3) 13.4 (10.8–17.6) 0.97 1.62 (−8.60 to 4.51) −4.80 (−14.17 to 5.94) 0.44 Markers of inflammation and immune activation  IL-6, pg/mL 10.2 (5.2–19.8) 7.9 (6.1–18.3) 0.76 −1.2 (−7.6 to 1.4) 3.1 (−2.5 to 4.8) 0.10  Adiponectin, pg/mL 4016 (3439–5360) 4673 (3302–6042) 0.50 −485 (−962 to 113) −361 (−1109 to 169) 0.78  PAI-1, ng/mL 36.7 ± 3.7 37.0 ± 4.1 0.95 −3 ± 4 1 ± 3 0.37  hsCRP, mg/Lc 3.3 (1.2–9.4) 3.7 (1.6 to 9.8) 0.67 −0.3 (−2.0 to 0.9) 0.9 (−0.1 to 1.9) 0.10  MCP-1, pg/mL 205 ± 16 191 ± 11 0.47 −9 ± 10 26 ± 13 0.04 Baseline 6 Months Eplerenone (n = 25) Placebo (n = 21) P Value Eplerenone (n = 22) Placebo (n = 20) P Value a Demographics  Age, y 49 ± 1 52 ± 1 0.15 — — —  Race, %   White 60 43 0.25 — — —   African American 36 52 — — — —  Other 4 5 – — — —   Male sex, % 60 71 0.42 — — —   Current hypertension, % 24 33 0.48 — — —   Current statin use, % 16 24 0.51 — — — HIV parameters  CD4+ T-cell count, cells/μL 634 ± 54 608 ± 50 0.73 48 ± 29 3 ± 32 0.30  CD8+ T-cell count, cells/μL 803 ± 51 901 ± 78 0.30 226 ± 80 305 ± 133 0.62  Log HIV viral load, copies/mL 1.45 ± 0.05 1.55 ± 0.13 0.48 −0.04 ± 0.09 −0.09 ± 0.13 0.73  Undetectable viral load, % 84 67 0.17 — — —  Duration HIV, y 16 ± 1 18 ± 1 0.31 — — —  Duration ART use, y 10 ± 2 11 ± 2 0.74 — — —  Current PI use, % 44 43 0.94 — — —  Duration PI use, y 5 ± 1 4 ± 1 0.57 — — —  Current NRTI use, % 96 95 0.90 — — —  Duration NRTI use, y 9 ± 2 10 ± 2 0.51 — — —  Current NNRTI use, % 40 62 0.14 — — —  Duration NNRTI use, y 3 ± 1 4 ± 1 0.63 — — — Body composition and ectopic fat  Waist circumference, cm 112.6 ± 2.4 114.1 ± 2.5 0.68 −0.6 ± 1.0 −0.5 ± 1.0 0.41  BMI, kg/m2 32.8 ± 1.3 32.7 ± 1.4 0.99 −0.1 ± 0.2 −0.1 ± 0.3 0.95  VAT area, cm2 215 (154–324) 241 (147–295) 0.85 −11 (−27 to 10) −2 (−20 to 36) 0.42  SAT area, cm2 350 (271–486) 372 (281–486) 0.56 1 (−14 to 16) −8 (−26 to 32) 0.46  IHL, % 5 (3–12) 5 (2–12) 0.50 −1 (−3 to 2) 0 (−4 to 0) 0.51  IMCL, %b 0.5 (0.2–0.6) 0.3 (0.2–0.5) 0.29 −0.1 (−0.3 to 0.1) 0.0 (−0.1 to 0.2) 0.04 Metabolic parameters  SBP, mm Hg 130 ± 3 132 ± 3 0.77 −5 ± 4 −5 ± 2 0.94  DBP, mm Hg 80 ± 1 86 ± 2 0.03 −1 ± 2 −5 ± 3 0.27  Total cholesterol, mg/dL 174 ± 6 174 ± 7 0.95 6 ± 4 −3 ± 5 0.14  Triglycerides, mg/dL 167 ± 16 158 ± 14 0.67 −1 ± 5 −2 ± 16 0.98  HDL cholesterol, mg/dL 43 ± 3 46 ± 4 0.55 2 ± 2 −2 ± 1 0.04  LDL cholesterol, mg/dL 98 ± 5 96 ± 6 0.83 4 ± 4 −1 ± 4 0.33  HbA1c, % 5.7 (5.5–6.0) 5.8 (5.3–6.1) 0.82 0.1 (−0.2 to 0.2) 0 (−0.2 to 0.2) 0.70  Fasting glucose, mg/dL 95 (87–101) 102 (87–108) 0.33 5 (0–9) 3 (−9 to 9) 0.52  HOMA-IR 1.99 (1.45–3.27) 1.64 (0.93–2.52) 0.16 0.10 (−1.11 to 0.65) 0.41 (−0.49 to 1.61) 0.20  M/I/LBM, mg/min/μIU/mL 7.26 (5.74–9.55) 7.52 (5.12–10.43) 0.86 0.48 (−1.28 to 1.48) 0.43 (−1.95 to 2.55) 0.71  FMD maximum percentage change 13.0 (9.7–19.3) 13.4 (10.8–17.6) 0.97 1.62 (−8.60 to 4.51) −4.80 (−14.17 to 5.94) 0.44 Markers of inflammation and immune activation  IL-6, pg/mL 10.2 (5.2–19.8) 7.9 (6.1–18.3) 0.76 −1.2 (−7.6 to 1.4) 3.1 (−2.5 to 4.8) 0.10  Adiponectin, pg/mL 4016 (3439–5360) 4673 (3302–6042) 0.50 −485 (−962 to 113) −361 (−1109 to 169) 0.78  PAI-1, ng/mL 36.7 ± 3.7 37.0 ± 4.1 0.95 −3 ± 4 1 ± 3 0.37  hsCRP, mg/Lc 3.3 (1.2–9.4) 3.7 (1.6 to 9.8) 0.67 −0.3 (−2.0 to 0.9) 0.9 (−0.1 to 1.9) 0.10  MCP-1, pg/mL 205 ± 16 191 ± 11 0.47 −9 ± 10 26 ± 13 0.04 Data reported as mean ± standard error of the mean, percentage, or median (interquartile range). Abbreviations: BMI, body mass index; HbA1c, hemoglobin A1c; LDL, low-density lipoprotein; NNRTI, nonnucleoside reverse transcription inhibitors; NRTI, nucleoside/nucleotide reverse transcription inhibitors; PAI-1, plasminogen activator inhibitor-1; PI, protease inhibitor; SBP, systolic blood pressure. a Adjusted for statin use for lipid panel. b Two outliers excluded for change as per Tukey method. P value obtained based on appropriate statistical test. c One outlier excluded for change as per Tukey method. P value obtained based on appropriate statistical test. View Large Table 1. Baseline and Absolute Between-Group Change of HIV, Metabolic, and Inflammation Parameters After 6 Months Treatment Baseline 6 Months Eplerenone (n = 25) Placebo (n = 21) P Value Eplerenone (n = 22) Placebo (n = 20) P Value a Demographics  Age, y 49 ± 1 52 ± 1 0.15 — — —  Race, %   White 60 43 0.25 — — —   African American 36 52 — — — —  Other 4 5 – — — —   Male sex, % 60 71 0.42 — — —   Current hypertension, % 24 33 0.48 — — —   Current statin use, % 16 24 0.51 — — — HIV parameters  CD4+ T-cell count, cells/μL 634 ± 54 608 ± 50 0.73 48 ± 29 3 ± 32 0.30  CD8+ T-cell count, cells/μL 803 ± 51 901 ± 78 0.30 226 ± 80 305 ± 133 0.62  Log HIV viral load, copies/mL 1.45 ± 0.05 1.55 ± 0.13 0.48 −0.04 ± 0.09 −0.09 ± 0.13 0.73  Undetectable viral load, % 84 67 0.17 — — —  Duration HIV, y 16 ± 1 18 ± 1 0.31 — — —  Duration ART use, y 10 ± 2 11 ± 2 0.74 — — —  Current PI use, % 44 43 0.94 — — —  Duration PI use, y 5 ± 1 4 ± 1 0.57 — — —  Current NRTI use, % 96 95 0.90 — — —  Duration NRTI use, y 9 ± 2 10 ± 2 0.51 — — —  Current NNRTI use, % 40 62 0.14 — — —  Duration NNRTI use, y 3 ± 1 4 ± 1 0.63 — — — Body composition and ectopic fat  Waist circumference, cm 112.6 ± 2.4 114.1 ± 2.5 0.68 −0.6 ± 1.0 −0.5 ± 1.0 0.41  BMI, kg/m2 32.8 ± 1.3 32.7 ± 1.4 0.99 −0.1 ± 0.2 −0.1 ± 0.3 0.95  VAT area, cm2 215 (154–324) 241 (147–295) 0.85 −11 (−27 to 10) −2 (−20 to 36) 0.42  SAT area, cm2 350 (271–486) 372 (281–486) 0.56 1 (−14 to 16) −8 (−26 to 32) 0.46  IHL, % 5 (3–12) 5 (2–12) 0.50 −1 (−3 to 2) 0 (−4 to 0) 0.51  IMCL, %b 0.5 (0.2–0.6) 0.3 (0.2–0.5) 0.29 −0.1 (−0.3 to 0.1) 0.0 (−0.1 to 0.2) 0.04 Metabolic parameters  SBP, mm Hg 130 ± 3 132 ± 3 0.77 −5 ± 4 −5 ± 2 0.94  DBP, mm Hg 80 ± 1 86 ± 2 0.03 −1 ± 2 −5 ± 3 0.27  Total cholesterol, mg/dL 174 ± 6 174 ± 7 0.95 6 ± 4 −3 ± 5 0.14  Triglycerides, mg/dL 167 ± 16 158 ± 14 0.67 −1 ± 5 −2 ± 16 0.98  HDL cholesterol, mg/dL 43 ± 3 46 ± 4 0.55 2 ± 2 −2 ± 1 0.04  LDL cholesterol, mg/dL 98 ± 5 96 ± 6 0.83 4 ± 4 −1 ± 4 0.33  HbA1c, % 5.7 (5.5–6.0) 5.8 (5.3–6.1) 0.82 0.1 (−0.2 to 0.2) 0 (−0.2 to 0.2) 0.70  Fasting glucose, mg/dL 95 (87–101) 102 (87–108) 0.33 5 (0–9) 3 (−9 to 9) 0.52  HOMA-IR 1.99 (1.45–3.27) 1.64 (0.93–2.52) 0.16 0.10 (−1.11 to 0.65) 0.41 (−0.49 to 1.61) 0.20  M/I/LBM, mg/min/μIU/mL 7.26 (5.74–9.55) 7.52 (5.12–10.43) 0.86 0.48 (−1.28 to 1.48) 0.43 (−1.95 to 2.55) 0.71  FMD maximum percentage change 13.0 (9.7–19.3) 13.4 (10.8–17.6) 0.97 1.62 (−8.60 to 4.51) −4.80 (−14.17 to 5.94) 0.44 Markers of inflammation and immune activation  IL-6, pg/mL 10.2 (5.2–19.8) 7.9 (6.1–18.3) 0.76 −1.2 (−7.6 to 1.4) 3.1 (−2.5 to 4.8) 0.10  Adiponectin, pg/mL 4016 (3439–5360) 4673 (3302–6042) 0.50 −485 (−962 to 113) −361 (−1109 to 169) 0.78  PAI-1, ng/mL 36.7 ± 3.7 37.0 ± 4.1 0.95 −3 ± 4 1 ± 3 0.37  hsCRP, mg/Lc 3.3 (1.2–9.4) 3.7 (1.6 to 9.8) 0.67 −0.3 (−2.0 to 0.9) 0.9 (−0.1 to 1.9) 0.10  MCP-1, pg/mL 205 ± 16 191 ± 11 0.47 −9 ± 10 26 ± 13 0.04 Baseline 6 Months Eplerenone (n = 25) Placebo (n = 21) P Value Eplerenone (n = 22) Placebo (n = 20) P Value a Demographics  Age, y 49 ± 1 52 ± 1 0.15 — — —  Race, %   White 60 43 0.25 — — —   African American 36 52 — — — —  Other 4 5 – — — —   Male sex, % 60 71 0.42 — — —   Current hypertension, % 24 33 0.48 — — —   Current statin use, % 16 24 0.51 — — — HIV parameters  CD4+ T-cell count, cells/μL 634 ± 54 608 ± 50 0.73 48 ± 29 3 ± 32 0.30  CD8+ T-cell count, cells/μL 803 ± 51 901 ± 78 0.30 226 ± 80 305 ± 133 0.62  Log HIV viral load, copies/mL 1.45 ± 0.05 1.55 ± 0.13 0.48 −0.04 ± 0.09 −0.09 ± 0.13 0.73  Undetectable viral load, % 84 67 0.17 — — —  Duration HIV, y 16 ± 1 18 ± 1 0.31 — — —  Duration ART use, y 10 ± 2 11 ± 2 0.74 — — —  Current PI use, % 44 43 0.94 — — —  Duration PI use, y 5 ± 1 4 ± 1 0.57 — — —  Current NRTI use, % 96 95 0.90 — — —  Duration NRTI use, y 9 ± 2 10 ± 2 0.51 — — —  Current NNRTI use, % 40 62 0.14 — — —  Duration NNRTI use, y 3 ± 1 4 ± 1 0.63 — — — Body composition and ectopic fat  Waist circumference, cm 112.6 ± 2.4 114.1 ± 2.5 0.68 −0.6 ± 1.0 −0.5 ± 1.0 0.41  BMI, kg/m2 32.8 ± 1.3 32.7 ± 1.4 0.99 −0.1 ± 0.2 −0.1 ± 0.3 0.95  VAT area, cm2 215 (154–324) 241 (147–295) 0.85 −11 (−27 to 10) −2 (−20 to 36) 0.42  SAT area, cm2 350 (271–486) 372 (281–486) 0.56 1 (−14 to 16) −8 (−26 to 32) 0.46  IHL, % 5 (3–12) 5 (2–12) 0.50 −1 (−3 to 2) 0 (−4 to 0) 0.51  IMCL, %b 0.5 (0.2–0.6) 0.3 (0.2–0.5) 0.29 −0.1 (−0.3 to 0.1) 0.0 (−0.1 to 0.2) 0.04 Metabolic parameters  SBP, mm Hg 130 ± 3 132 ± 3 0.77 −5 ± 4 −5 ± 2 0.94  DBP, mm Hg 80 ± 1 86 ± 2 0.03 −1 ± 2 −5 ± 3 0.27  Total cholesterol, mg/dL 174 ± 6 174 ± 7 0.95 6 ± 4 −3 ± 5 0.14  Triglycerides, mg/dL 167 ± 16 158 ± 14 0.67 −1 ± 5 −2 ± 16 0.98  HDL cholesterol, mg/dL 43 ± 3 46 ± 4 0.55 2 ± 2 −2 ± 1 0.04  LDL cholesterol, mg/dL 98 ± 5 96 ± 6 0.83 4 ± 4 −1 ± 4 0.33  HbA1c, % 5.7 (5.5–6.0) 5.8 (5.3–6.1) 0.82 0.1 (−0.2 to 0.2) 0 (−0.2 to 0.2) 0.70  Fasting glucose, mg/dL 95 (87–101) 102 (87–108) 0.33 5 (0–9) 3 (−9 to 9) 0.52  HOMA-IR 1.99 (1.45–3.27) 1.64 (0.93–2.52) 0.16 0.10 (−1.11 to 0.65) 0.41 (−0.49 to 1.61) 0.20  M/I/LBM, mg/min/μIU/mL 7.26 (5.74–9.55) 7.52 (5.12–10.43) 0.86 0.48 (−1.28 to 1.48) 0.43 (−1.95 to 2.55) 0.71  FMD maximum percentage change 13.0 (9.7–19.3) 13.4 (10.8–17.6) 0.97 1.62 (−8.60 to 4.51) −4.80 (−14.17 to 5.94) 0.44 Markers of inflammation and immune activation  IL-6, pg/mL 10.2 (5.2–19.8) 7.9 (6.1–18.3) 0.76 −1.2 (−7.6 to 1.4) 3.1 (−2.5 to 4.8) 0.10  Adiponectin, pg/mL 4016 (3439–5360) 4673 (3302–6042) 0.50 −485 (−962 to 113) −361 (−1109 to 169) 0.78  PAI-1, ng/mL 36.7 ± 3.7 37.0 ± 4.1 0.95 −3 ± 4 1 ± 3 0.37  hsCRP, mg/Lc 3.3 (1.2–9.4) 3.7 (1.6 to 9.8) 0.67 −0.3 (−2.0 to 0.9) 0.9 (−0.1 to 1.9) 0.10  MCP-1, pg/mL 205 ± 16 191 ± 11 0.47 −9 ± 10 26 ± 13 0.04 Data reported as mean ± standard error of the mean, percentage, or median (interquartile range). Abbreviations: BMI, body mass index; HbA1c, hemoglobin A1c; LDL, low-density lipoprotein; NNRTI, nonnucleoside reverse transcription inhibitors; NRTI, nucleoside/nucleotide reverse transcription inhibitors; PAI-1, plasminogen activator inhibitor-1; PI, protease inhibitor; SBP, systolic blood pressure. a Adjusted for statin use for lipid panel. b Two outliers excluded for change as per Tukey method. P value obtained based on appropriate statistical test. c One outlier excluded for change as per Tukey method. P value obtained based on appropriate statistical test. View Large Assessment of the RAAS at baseline Both groups (eplerenone vs placebo) demonstrated similar PRA [0.20 (0.09 to 0.40) vs 0.20 (0.09 to 0.35) ng/mL/h; P = 0.75], serum aldosterone [3.59 (2.49 to 8.77) vs 4.99 (2.49 to 7.47) ng/dL; P = 0.76], and urine aldosterone [3.84 (2.20 to 8.47) vs 5.81 (2.71 to 8.02) ng/24 h; P = 0.83] at baseline under standardized sodium conditions (Table 2). Table 2. Baseline and Absolute Between-Group Change of RAAS Parameters After 6 Months of Treatment Baseline 6 Months Eplerenone (n = 25) Placebo (n = 21) P Value Eplerenone (n = 22) Placebo (n = 20) P Value Urine studies  Urine sodium, mmol/24 h 293 ± 22 310 ± 27 0.63 1 ± 18 −50 ± 33 0.19  Urine potassium, mmol/24 h 62 ± 6 75 ± 7 0.17 6 ± 6 −11 ± 7 0.06  Urine creatinine, mg/24 h 1538 ± 103 1589 ± 150 0.78 5 ± 73 −105 ± 123 0.45  Urine cortisol, μg/24 h 24 (11–38) 27 (17 to 42) 0.49 −3 (−15 to 8) −3 (−13 to 12) 0.64 RAAS parameters  PRA, ng/mL/h 0.20 (0.09–0.40) 0.20 (0.09–0.35) 0.75 0.20 (0.00–1.55) 0.00 (−0.08 to 0.01) 0.002  Serum aldosterone, ng/dL 3.59 (2.49–8.77) 4.99 (2.49–7.47) 0.76 2.50 (−0.32 to 12.81) 0.29 (−0.94 to 1.98) 0.07  Urinary aldosterone excretion, ng/24 h 3.84 (2.20–8.47) 5.81 (2.71–8.02) 0.83 2.59 (0.38–15.43) 0.53 (−1.90 to 1.87) 0.03 Baseline 6 Months Eplerenone (n = 25) Placebo (n = 21) P Value Eplerenone (n = 22) Placebo (n = 20) P Value Urine studies  Urine sodium, mmol/24 h 293 ± 22 310 ± 27 0.63 1 ± 18 −50 ± 33 0.19  Urine potassium, mmol/24 h 62 ± 6 75 ± 7 0.17 6 ± 6 −11 ± 7 0.06  Urine creatinine, mg/24 h 1538 ± 103 1589 ± 150 0.78 5 ± 73 −105 ± 123 0.45  Urine cortisol, μg/24 h 24 (11–38) 27 (17 to 42) 0.49 −3 (−15 to 8) −3 (−13 to 12) 0.64 RAAS parameters  PRA, ng/mL/h 0.20 (0.09–0.40) 0.20 (0.09–0.35) 0.75 0.20 (0.00–1.55) 0.00 (−0.08 to 0.01) 0.002  Serum aldosterone, ng/dL 3.59 (2.49–8.77) 4.99 (2.49–7.47) 0.76 2.50 (−0.32 to 12.81) 0.29 (−0.94 to 1.98) 0.07  Urinary aldosterone excretion, ng/24 h 3.84 (2.20–8.47) 5.81 (2.71–8.02) 0.83 2.59 (0.38–15.43) 0.53 (−1.90 to 1.87) 0.03 Data reported as mean ± standard error of the mean or median (interquartile range). Performed under conditions of equivalent high sodium intake for both groups as described in the text. View Large Table 2. Baseline and Absolute Between-Group Change of RAAS Parameters After 6 Months of Treatment Baseline 6 Months Eplerenone (n = 25) Placebo (n = 21) P Value Eplerenone (n = 22) Placebo (n = 20) P Value Urine studies  Urine sodium, mmol/24 h 293 ± 22 310 ± 27 0.63 1 ± 18 −50 ± 33 0.19  Urine potassium, mmol/24 h 62 ± 6 75 ± 7 0.17 6 ± 6 −11 ± 7 0.06  Urine creatinine, mg/24 h 1538 ± 103 1589 ± 150 0.78 5 ± 73 −105 ± 123 0.45  Urine cortisol, μg/24 h 24 (11–38) 27 (17 to 42) 0.49 −3 (−15 to 8) −3 (−13 to 12) 0.64 RAAS parameters  PRA, ng/mL/h 0.20 (0.09–0.40) 0.20 (0.09–0.35) 0.75 0.20 (0.00–1.55) 0.00 (−0.08 to 0.01) 0.002  Serum aldosterone, ng/dL 3.59 (2.49–8.77) 4.99 (2.49–7.47) 0.76 2.50 (−0.32 to 12.81) 0.29 (−0.94 to 1.98) 0.07  Urinary aldosterone excretion, ng/24 h 3.84 (2.20–8.47) 5.81 (2.71–8.02) 0.83 2.59 (0.38–15.43) 0.53 (−1.90 to 1.87) 0.03 Baseline 6 Months Eplerenone (n = 25) Placebo (n = 21) P Value Eplerenone (n = 22) Placebo (n = 20) P Value Urine studies  Urine sodium, mmol/24 h 293 ± 22 310 ± 27 0.63 1 ± 18 −50 ± 33 0.19  Urine potassium, mmol/24 h 62 ± 6 75 ± 7 0.17 6 ± 6 −11 ± 7 0.06  Urine creatinine, mg/24 h 1538 ± 103 1589 ± 150 0.78 5 ± 73 −105 ± 123 0.45  Urine cortisol, μg/24 h 24 (11–38) 27 (17 to 42) 0.49 −3 (−15 to 8) −3 (−13 to 12) 0.64 RAAS parameters  PRA, ng/mL/h 0.20 (0.09–0.40) 0.20 (0.09–0.35) 0.75 0.20 (0.00–1.55) 0.00 (−0.08 to 0.01) 0.002  Serum aldosterone, ng/dL 3.59 (2.49–8.77) 4.99 (2.49–7.47) 0.76 2.50 (−0.32 to 12.81) 0.29 (−0.94 to 1.98) 0.07  Urinary aldosterone excretion, ng/24 h 3.84 (2.20–8.47) 5.81 (2.71–8.02) 0.83 2.59 (0.38–15.43) 0.53 (−1.90 to 1.87) 0.03 Data reported as mean ± standard error of the mean or median (interquartile range). Performed under conditions of equivalent high sodium intake for both groups as described in the text. View Large Treatment effects on insulin-stimulated glucose uptake Eplerenone did not significantly change insulin sensitivity M/I/LBM [0.48 (−1.28 to 1.48) vs 0.43 (−1.95 to 2.55) mg/min/μIU/mL; P = 0.71, eplerenone vs placebo). There was also no difference in the change in hemoglobin A1c or homeostatic model assessment of insulin resistance (HOMA-IR; Table 1). There was no significant treatment effect of the type of ART use on M/I/LBM, evaluated separately by duration of protease inhibitor (β estimate −0.0850; P = 0.47), nucleoside/nucleotide reverse transcription inhibitors (β estimate −0.0710; P = 0.43), and nonnucleoside reverse transcription inhibitors (β estimate 0.2296; P = 0.14) in modeling assessing the effects of eplerenone vs placebo. Similar results were seen in a sensitivity analysis assessing 3-month change in M/I/LBM between groups (P = 0.69). Treatment effects on body composition No significant effects were seen with respect to VAT [−11 (−27 to 10) vs −2 (−20 to 36) cm2; P = 0.42] or IHLs [−1 (−3 to 2) vs 0 (−4 to 0) %; P = 0.51] in the eplerenone vs placebo-treated groups. Eplerenone significantly reduced IMCLs [−0.1 (−0.3 to 0.1) vs 0.0 (−0.1 to 0.2)%; P = 0.04, eplerenone vs placebo] (Table 1). Treatment effects on metabolic indices and inflammatory markers BP decreased in both groups similarly, without a significant difference between treatment arms (P > 0.05). Within the lipid panel, high-density lipoprotein (HDL; 2 ± 2 vs −2 ± 1 mg/dL; P = 0.04) increased significantly on eplerenone vs placebo study medication. There was a significant treatment effect of eplerenone to lower MCP-1 compared with placebo (−9 ± 10 vs 26 ± 13 pg/mL; P = 0.04) and a trend toward a beneficial treatment effect of eplerenone vs placebo on inflammatory markers IL-6 [−1.2 (−7.6 to 1.4) vs 3.1 (−2.5 to 4.9) pg/mL; P = 0.10] and hsCRP [−0.3 (−2.0 to 0.9) vs 0.9 (−0.1 to 1.9) mg/L; P = 0.10] (Table 1). Treatment effects on FMD The maximal percent change in FMD [1.62 (−8.60 to 4.51) vs −4.80 (−14.17 to 5.94)%; P = 0.44, eplerenone vs placebo] did not reach statistical significance between groups, but was relatively greater in the eplerenone group (Table 1). Treatment effects on the RAAS Consistent with eplerenone’s known mechanism of action as an MR antagonist, individuals randomized to eplerenone had a significant rise in PRA [0.20 (0.00 to 1.55) vs 0.00 (−0.08 to 0.01) ng/mL/h; P = 0.002] and urine aldosterone [2.59 (0.38 to 15.43) vs 0.53 (−1.90 to 1.87) ng/24 h; P = 0.03] and a trend toward an increase in serum aldosterone [2.50 (−0.32 to 12.81) vs 0.29 (−0.94 to 1.98) ng/dL; P = 0.07] compared with those randomized to placebo (Table 2). Relationship of change in PRA with insulin sensitivity In exploratory analyses among the entire group, increases in PRA were inversely related to improvements in M (τ = −0.23; P = 0.04). When the entire group was stratified by median change in PRA, individuals with a below the median change in PRA demonstrated significant improvement in change in M/I/LBM compared with those with an above the median change in PRA [1.56 (−1.61 to 3.19) vs −0.83 (−1.77 to 0.96) mg/min/μIU/mL; P = 0.04]. Adherence of study medication Adherence based on pill counts between both treatment groups was high and similar for all time points for the duration of the 6-month study (Supplemental Table 2). Safety data and adverse side effects There were no serious adverse events reported in either treatment arm. No medication-related hyperkalemia or hypotension were reported in either group. There was a trend toward increased potassium in the eplerenone vs placebo group (4.25 ± 0.04 vs 4.15 ± 0.04 mEq/L; P = 0.07), but the difference (0.1 mEq/L) was not clinically significant. Overall, nonserious adverse events were relatively similar, though there appeared to be more gastrointestinal side effects in the eplerenone arm, none of which led to discontinuation of study medication or participation (Table 3). Table 3. Type and Number of Adverse Events Eplerenone (n = 25) Placebo (n = 21) Serious adverse events 0 0 Nonserious adverse events 20 14  Hyperkalemia 0 0  Elevated creatinine 1 1  Hypotension 0 0  Dizziness 1 1  Hypertension 0 2  Headache 0 1  Abdominal pain 1 0  Nausea 1 0  Diarrhea 2 0  Anorexia 1 0  Rectal bleed 2 0  Rash 1 0  Fatigue 1 0  Upper respiratory infection 4 6  Other infection 1 0  Urinary symptoms 1 0  Musculoskeletal pain 1 2  Mood symptoms 1 1  Insomnia 1 0 Eplerenone (n = 25) Placebo (n = 21) Serious adverse events 0 0 Nonserious adverse events 20 14  Hyperkalemia 0 0  Elevated creatinine 1 1  Hypotension 0 0  Dizziness 1 1  Hypertension 0 2  Headache 0 1  Abdominal pain 1 0  Nausea 1 0  Diarrhea 2 0  Anorexia 1 0  Rectal bleed 2 0  Rash 1 0  Fatigue 1 0  Upper respiratory infection 4 6  Other infection 1 0  Urinary symptoms 1 0  Musculoskeletal pain 1 2  Mood symptoms 1 1  Insomnia 1 0 View Large Table 3. Type and Number of Adverse Events Eplerenone (n = 25) Placebo (n = 21) Serious adverse events 0 0 Nonserious adverse events 20 14  Hyperkalemia 0 0  Elevated creatinine 1 1  Hypotension 0 0  Dizziness 1 1  Hypertension 0 2  Headache 0 1  Abdominal pain 1 0  Nausea 1 0  Diarrhea 2 0  Anorexia 1 0  Rectal bleed 2 0  Rash 1 0  Fatigue 1 0  Upper respiratory infection 4 6  Other infection 1 0  Urinary symptoms 1 0  Musculoskeletal pain 1 2  Mood symptoms 1 1  Insomnia 1 0 Eplerenone (n = 25) Placebo (n = 21) Serious adverse events 0 0 Nonserious adverse events 20 14  Hyperkalemia 0 0  Elevated creatinine 1 1  Hypotension 0 0  Dizziness 1 1  Hypertension 0 2  Headache 0 1  Abdominal pain 1 0  Nausea 1 0  Diarrhea 2 0  Anorexia 1 0  Rectal bleed 2 0  Rash 1 0  Fatigue 1 0  Upper respiratory infection 4 6  Other infection 1 0  Urinary symptoms 1 0  Musculoskeletal pain 1 2  Mood symptoms 1 1  Insomnia 1 0 View Large Discussion These data from a randomized, placebo-controlled trial evaluate MR antagonism as a metabolic therapy in HIV. The current study assessing RAAS blockade was performed to complement our prior studies investigating RAAS activation in HIV (6, 7). Contrary to our hypothesis, eplerenone had no marked treatment effect over placebo on insulin sensitivity, as measured by the gold standard euglycemic-hyperinsulinemic clamp technique, in this population. However, these findings demonstrate effects of the MR blockade to improve select parameters related to inflammation, lipids, and ectopic fat among the population with HIV. We expected to see an improvement in insulin sensitivity based on compelling data linking mineralocorticoid excess with insulin resistance (9) and mineralocorticoid blockade with improved insulin sensitivity (10), particularly because of unique RAAS physiology in HIV. Our prior data assessing RAAS physiology in HIV performed under strict diet and posture techniques showed that PRA and aldosterone were highly correlated with HOMA-IR during RAAS activation compared with the non-HIV group (6). Moreover, in our studies of obese db/db mice, eplerenone significantly improved HOMA-IR (10). Mechanistically, aldosterone has been proposed to inhibit insulin signaling by stimulating the release of inflammatory cytokines and reactive oxygen species (11, 12), further leading to decreased translocation of GLUT4 to the plasma membrane (13), and β-cell and endothelial dysfunction (14, 15). Taken together, these data provided strong rationale to perform the current investigation. To understand why our results differed from the anticipated results, we performed an exploratory analysis correlating longitudinal changes in the RAAS in response to eplerenone, with changes in insulin sensitivity. These data show that increases in PRA, occurring in the context of MR blockade, were associated with decreases in insulin sensitivity. Our interventional physiology studies in HIV corroborate that increased PRA, as simulated in an RAAS-activated state, is indeed linked to insulin resistance (6). This physiologic relationship may provide some insight if the positive benefits of MR blockade were in part negated by the consequent feedback of RAAS activation associated with this therapy. In this scenario, increased activation of the PRA–angiotensin II axis may be acting independent of the MR to impair insulin sensitivity, highlighting that combination therapy of eplerenone with a renin inhibitor or an adrenergic antagonist, such as a β-blocker, to reduce renin could merit future investigations to reduce metabolic disease in HIV. In addition, combining an MR antagonist with an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker would decrease angiotensin II levels, reducing any effects of angiotensin II on insulin resistance. Our results are consistent with a prior study showing that MR antagonism with spironolactone (50 mg daily) does not improve insulin sensitivity assessed by oral glucose tolerance test in obese insulin-resistant individuals (16). MR activation has been linked to inflammation, and we have previously shown increases in inflammatory and immune markers hsCRP, IL-6, and MCP-1 during RAAS-activated conditions using a low-sodium diet relative to an ad libitum sodium diet (6, 7). There was general dampening of all inflammatory markers in the eplerenone arm among the HIV population selected for increased VAT and abnormal glucose homeostasis and most significantly in MCP-1. The reduction in MCP-1 is an important observation for the HIV population in alignment with prior animal data from our group. In these preclinical studies from Guo et al. (10), MCP-1 messenger RNA expression was increased ∼10-fold in VAT from obese db/db mice compared with lean mice db/+. After the obese mice were treated with eplerenone, both plasma levels of MCP-1 and messenger RNA expression in the adipose depot were significantly reduced (10). Wada et al. (17) also reported in a murine model of obesity that eplerenone suppresses inflammation in the adipose depot. The current study may not have been adequately powered to detect a significant effect of eplerenone on inflammation across different indices, and larger studies evaluating inflammatory end points will be critical to perform given these findings. Nonetheless, the absolute changes in favor of eplerenone in MCP-1, IL-6, and hsCRP were relatively large in comparison with baseline, suggesting a potentially relevant biological signal. Other relevant findings include a decrease in IMCLs among those treated with eplerenone vs placebo. Although this finding is statistically significant, the clinical significance of this degree of change and mechanism of this effect is not well defined. There is evidence to suggest that a local RAAS system is present in the adipose depot (18–21), and we have demonstrated that RAAS activation is associated with VAT (6). Lipid deposition in the muscle may develop secondary to VAT accumulation based on the lipid overflow-ectopic fat model, and the changes in IMCLs via eplerenone may be consequent of VAT reduction. In this study, we did not see a statistically significant effect on VAT, but the decrease was relatively larger in the eplerenone group. Further studies to assess the mechanism of eplerenone effects on IMCLs are needed. With respect to lipids, we also saw an increase in HDL cholesterol in the eplerenone-treated group relative to placebo. Cav1 gene polymorphisms, which may modulate MR signaling, are similarly reported to be associated with low HDL and increased aldosterone (22), supporting this finding. As such, this study suggests that among HIV-infected individuals, MR blockade may have greater utility on specific inflammatory and lipid pathways than insulin resistance per se. To that end, eplerenone reduced both MCP-1 and atherosclerotic disease in an animal model (23–25). These key hypotheses relevant to HIV will be addressed in a newly initiated randomized controlled trial known as the MIRACLE HIV study (NCT02740179). Pilot studies have evaluated another RAAS-related medication, telmisartan, an angiotensin receptor blocker and PPAR- γ agonist, for its potential on metabolic disease in HIV. These preliminary studies did not show any definitive benefit on VAT-related metabolic abnormalities (26) or cardiovascular risk (27), but were not placebo-controlled. In contrast to these studies, we conducted a placebo-controlled trial and chose to investigate MR antagonism to minimize the aldosterone escape that is commonly associated with upstream targets along the RAAS pathway. Despite this, we saw a relationship between increased renin and worsened insulin sensitivity, suggesting that there may be independent effects of RAAS components through other pathways. For this study, we chose to investigate the utility of eplerenone, a second-generation MR antagonist, rather than spironolactone, a first-generation antagonist, on our end points. Eplerenone has greater selectivity for the MR (28) and therefore provides an advantage over spironolactone in contributing less to progestogenic and antiandrogenic side effects, such as loss of libido, gynecomastia, and menstrual irregularities. Eplerenone was well tolerated in our group, and no side effects led to discontinuation of study medication or participation. This study adds safety data to the field, demonstrating that this class of medication, at the dose used, is reasonably safe to use in the HIV population, the majority of whom are on multiple classes of ART. As an initial study of eplerenone in HIV, we used a relatively low dose of 50 mg daily to assess the safety profile. Eplerenone was safely administered without evidence of clinically noteworthy hypotension, or hyperkalemia. Given these initial data, administering a higher dose may be considered in future studies to amplify the anti-inflammatory and metabolic enhancing signals seen in the current study. There are limitations to the current study. It is relatively small, but our dropout rate of 9% was lower than expected and not different between treatment groups in this randomized trial. The lower than anticipated dropout helped to ensure a reasonable number of evaluable patients. Moreover, we used state-of-the-art, comprehensive phenotyping to further increase the sensitivity of the study to detect metabolic changes. The study duration was 6 months and thus reasonably long, but further longer-term effects could not be determined. Although individuals were chosen based on impaired fasting glucose, impaired glucose tolerance, or fasting hyperinsulinemia, individuals with diabetes were excluded, and glucose abnormalities were not severe, showing relatively preserved insulin sensitivity by clamp at baseline. This design was chosen to avoid confounding effects of diabetes on the results, but it is possible that larger effects would have been seen in individuals with more impaired glycemia at baseline. In the current study, we used a standardized diet to ensure similar sodium intake across groups at assessment time points in contrast to the low-sodium conditions of RAAS activation in our prior studies. This choice was made to ensure uniformity of the results and avoid potential confounding of dietary activation of the RAAS. In contrast, anti-inflammatory effects of RAAS blockade may be muted in the context of more liberalized sodium intake based on our prior data related to RAAS activation. We did see that the group randomized to eplerenone had significantly greater increases in PRA and aldosterone levels. Based on expected RAAS physiology and MR feedback, these levels may serve as reliable surrogates and suggest good study drug adherence, which was additionally reinforced by the pill count. In conclusion, this study demonstrates that although eplerenone does not have adverse or beneficial effects on insulin sensitivity in HIV-infected individuals with mild abnormalities in glucose homeostasis, it may nonetheless be useful to improve cardiovascular disease risk based on inflammatory, ectopic fat, and lipid levels, as demonstrated in this initial study of this population in whom RAAS activation has been shown. The clinical significance of the magnitude of improvements in inflammatory, ectopic fat, and lipid parameters is unclear, and further studies of eplerenone are merited to determine the full scope of its effects in HIV. Abbreviations: Abbreviations: ART antiretroviral therapy BP blood pressure DBP diastolic blood pressure FMD flow-mediated vasodilation HDL high-density lipoprotein HOMA-IR homeostatic model assessment of insulin resistance hsCRP high-sensitivity C-reactive protein IHL intrahepatic lipid IL-6 interleukin-6 IMCL intramyocellular lipid LBM lean body mass MCP-1 monocyte chemoattractant protein-1 MGH Massachusetts General Hospital MR mineralocorticoid receptor PRA plasma renin activity RAAS renin-angiotensin-aldosterone system VAT visceral adipose tissue Acknowledgments The authors thank the nursing staff of the MGH Translational and Clinical Research Center for dedicated patient care, as well as the volunteers who participated in this study. Financial Support: Funding was provided by National Institutes of Health Grant R01-DK49302 (to S.K.G.); a Harvard Catalyst Medical Research Investigator Training award and National Institutes of Health Grant K23-HL136262 (to S.S.); National Institutes of Health Grant K24-HL103845 (to G.K.A.); the Claflin Distinguished Scholar Award (MGH Executive Committee on Research) (to S.E.L.); National Institutes of Health Grants UL1-TR000170, UL1-RR025758, and UL1-TR001102 to the Harvard Catalyst/Harvard Clinical and Translational Science Center from the National Center for Research Resources and National Center for Advancing Translational Sciences; and National Institutes of Health Grant P30-DK040561 to the Nutrition and Obesity Research Center at Harvard University. Funding sources had no role in the design of the study, data analysis, or writing of the manuscript. Clinical Trial Information: ClinicalTrials.gov no. NCT01405456 (registered 29 July 2011). 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Journal of Clinical Endocrinology and MetabolismOxford University Press

Published: Apr 5, 2018

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