Improving Assessment of Drug Safety Through Proteomics: Early Detection and Mechanistic Characterization of the Unforeseen Harmful Effects of Torcetrapib

Circulation. 2018 Mar 6;137(10):999-1010. doi: 10.1161/CIRCULATIONAHA.117.028213. Epub 2017 Oct 3.


Background: Early detection of adverse effects of novel therapies and understanding of their mechanisms could improve the safety and efficiency of drug development. We have retrospectively applied large-scale proteomics to blood samples from ILLUMINATE (Investigation of Lipid Level Management to Understand its Impact in Atherosclerotic Events), a trial of torcetrapib (a cholesterol ester transfer protein inhibitor), that involved 15 067 participants at high cardiovascular risk. ILLUMINATE was terminated at a median of 550 days because of significant absolute increases of 1.2% in cardiovascular events and 0.4% in mortality with torcetrapib. The aims of our analysis were to determine whether a proteomic analysis might reveal biological mechanisms responsible for these harmful effects and whether harmful effects of torcetrapib could have been detected early in the ILLUMINATE trial with proteomics.

Methods: A nested case-control analysis of paired plasma samples at baseline and at 3 months was performed in 249 participants assigned to torcetrapib plus atorvastatin and 223 participants assigned to atorvastatin only. Within each treatment arm, cases with events were matched to controls 1:1. Main outcomes were a survey of 1129 proteins for discovery of biological pathways altered by torcetrapib and a 9-protein risk score validated to predict myocardial infarction, stroke, heart failure, or death.

Results: Plasma concentrations of 200 proteins changed significantly with torcetrapib. Their pathway analysis revealed unexpected and widespread changes in immune and inflammatory functions, as well as changes in endocrine systems, including in aldosterone function and glycemic control. At baseline, 9-protein risk scores were similar in the 2 treatment arms and higher in participants with subsequent events. At 3 months, the absolute 9-protein derived risk increased in the torcetrapib plus atorvastatin arm compared with the atorvastatin-only arm by 1.08% (P=0.0004). Thirty-seven proteins changed in the direction of increased risk of 49 proteins previously associated with cardiovascular and mortality risk.

Conclusions: Heretofore unknown effects of torcetrapib were revealed in immune and inflammatory functions. A protein-based risk score predicted harm from torcetrapib within just 3 months. A protein-based risk assessment embedded within a large proteomic survey may prove to be useful in the evaluation of therapies to prevent harm to patients.

Clinical trial registration: URL: Unique identifier: NCT00134264.

Keywords: aptamers; biomarkers; peptides; precision medicine; prescription drugs; proteins; proteomics.

Publication types

  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aldosterone / metabolism
  • Anticholesteremic Agents / adverse effects*
  • Anticholesteremic Agents / therapeutic use
  • Biomarkers, Pharmacological
  • Case-Control Studies
  • Cholesterol Ester Transfer Proteins / antagonists & inhibitors
  • Drug-Related Side Effects and Adverse Reactions / metabolism*
  • Drug-Related Side Effects and Adverse Reactions / mortality
  • Early Diagnosis
  • Female
  • Heart Failure / etiology
  • Heart Failure / metabolism*
  • Heart Failure / mortality
  • Humans
  • Male
  • Middle Aged
  • Myocardial Infarction / etiology
  • Myocardial Infarction / metabolism*
  • Myocardial Infarction / mortality
  • Prognosis
  • Prospective Studies
  • Proteomics
  • Quinolines / adverse effects*
  • Quinolines / therapeutic use
  • Stroke / etiology
  • Stroke / metabolism*
  • Stroke / mortality
  • Survival Analysis


  • Anticholesteremic Agents
  • Biomarkers, Pharmacological
  • Cholesterol Ester Transfer Proteins
  • Quinolines
  • Aldosterone
  • torcetrapib

Associated data