Long-term safety of linagliptin monotherapy in Japanese patients with type 2 diabetes

AIMS

In a phase III study conducted among Japanese patients with type 2 diabetes mellitus (T2DM), linagliptin 5 and 10 mg showed clinically meaningful improvements in glycaemic parameters after 12 and 26 weeks compared with placebo and voglibose, respectively. This extension study assessed long-term tolerability of linagliptin over 52 weeks.

METHODS

Japanese patients with T2DM who completed either phase of a 12-week/26-week study comparing linagliptin monotherapy with placebo or voglibose were eligible to enrol. In the extension study, the comparator groups switched to linagliptin 5 or 10 mg, while the linagliptin groups maintained dosage.

RESULTS

In all, 540 patients received at least one dose of linagliptin 5 or 10 mg and 494 completed the extension. Long-term treatment with linagliptin was well tolerated; adverse events (AEs) of special interest and serious AEs occurred in small percentages of patients. Drug-related AEs occurred in 10.2 and 10.6% of patients in the linagliptin 5- and 10-mg groups, respectively, and discontinuations due to drug-related AEs occurred in 1.1 and 0.7%, respectively. Only one (0.4%) patient in each dose group experienced investigator-defined hypoglycaemia during the treatment period (both events were non-severe). Body weight was not clinically altered in either group. The glycated haemoglobin A1c profiles over time were similar with linagliptin 5 and 10 mg.

CONCLUSIONS

These findings provide evidence for the safety and tolerability of oral linagliptin at either 5 or 10 mg for up to 52 weeks for the treatment of Japanese patients with T2DM, without clinically relevant increase in the risk of hypoglycaemia or weight gain.

Renoprotective effects of telmisartan on renal injury in obese Zucker rats

The purpose of the present study was to investigate the renoprotective effect of telmisartan, an angiotensin II receptor antagonist, on the early stages of diabetic nephropathy in obese Zucker rats, which is a type 2-related diabetes mellitus model. Telmisartan 1, 3 or 10 mg/kg/day was orally administered to 7-week-old rats that demonstrated glucose tolerance without albuminuria or proteinuria, for 24 consecutive weeks (Experiment A). In another experiment (Experiment B), oral administration of telmisartan 10 mg/kg/day was initiated at the age of 16 weeks after the rats demonstrated marked proteinuria, and continued for 24 weeks. Telmisartan inhibited the increase in proteinuria and albuminuria in a dose-dependent manner, and the inhibition for all telmisartan groups was statistically significant by the completion of administration (Experiment A). Telmisartan also displayed similar inhibitory effects on proteinuria and albuminuria in Experiment B. Histologically, telmisartan [3 and 10 mg/kg/day] was associated with a significant decrease in the progression of glomerulosclerosis, and significantly improved interstitial cell infiltration, interstitial fibrosis and dilation and atrophy of renal tubules. Furthermore, telmisartan treatment was associated with a tendency towards normalized plasma lipids (total cholesterol and triglyceride). Our results suggest that telmisartan has a definite renoprotective effect against renal injury in type II diabetic nephropathy.

Microstructural level response of HMX–Estane polymer-bonded explosive under effects of transient stress waves

The effect of transient stress waves on the microstructure of HMX–Estane, a polymer-bonded explosive (PBX), is studied. Calculations carried out concern microstructures with HMX grain sizes on the order of 200 μm and grain volume fractions in the range of 0.50–0.82. The microstructural samples analysed have an aspect ratio of 5:1 (15×3 mm), allowing the transient wave propagation process resulting from normal impact to be resolved. Boundary loading is effected by the imposition of impact face velocities of 50–200 m s −1 . Different levels of grain–binder interface strength are considered. The analysis uses a recently developed cohesive finite element framework that accounts for coupled thermal–mechanical processes involving deformation, heat generation and conduction, failure in the forms of microcracks in both bulk constituents and along grain/matrix interfaces, and frictional heating along crack faces. Results show that the overall wave speed through the microstructures depends on both the grain volume fraction and interface bonding strength between the constituents and that the distance traversed by the stress wave before the initiation of frictional dissipation is independent of the grain volume fraction but increases with impact velocity. Energy dissipated per unit volume owing to fracture is highest near the impact surface and deceases to zero at the stress wavefront. On the other hand, the peak temperature rises are noted to occur approximately 2–3 mm from the impact surface. Scaling laws are developed for the maximum dissipation rate and the highest temperature rise as functions of impact velocity, grain volume fraction and grain–binder interfacial bonding strength.

Linagliptin monotherapy provides superior glycaemic control versus placebo or voglibose with comparable safety in Japanese patients with type 2 diabetes: a randomized, placebo and active comparator-controlled, double-blind study

AIMS

To evaluate the efficacy and safety of linagliptin 5 and 10 mg vs. placebo and voglibose in Japanese patients with type 2 diabetes mellitus (T2DM).

METHODS

This study enrolled patients with inadequately controlled T2DM who were previously treated with one or two oral antidiabetics or were drug naÏve. After a 2 to 4-week washout and placebo run-in, 561 patients were randomized (2 : 2 : 2 : 1) to double-blind treatment with linagliptin 5 or 10 mg qd, voglibose 0.2 mg tid or placebo. The primary endpoint was the change from baseline in haemoglobin A1c (HbA1c) with linagliptin vs. placebo after 12 weeks and vs. voglibose after 26 weeks.

RESULTS

Baseline characteristics were well balanced across treatment groups (overall mean HbA1c was 8.01%). The adjusted mean (95% confidence interval) treatment differences at week 12 were -0.87% (-1.04, -0.70; p < 0.0001) and -0.88% (-1.05, -0.71; p < 0.0001) for linagliptin 5 and 10 mg vs. placebo and at week 26 were -0.32% (-0.49, -0.15; p = 0.0003) and -0.39% (-0.56, -0.21; p < 0.0001) for linagliptin 5 and 10 mg vs. voglibose. At week 12, mean HbA1c was 7.58, 7.48 and 8.34% in patients receiving linagliptin 5 mg, linagliptin 10 mg and placebo, respectively. At week 26, mean HbA1c was 7.63% with linagliptin 5 mg, 7.50% with linagliptin 10 mg and 7.91% with voglibose. Drug-related adverse event rates were comparable across treatment groups over 12 weeks (9.4% linagliptin 5 mg, 8.8% linagliptin 10 mg and 10.0% placebo) and 26 weeks (11.3% linagliptin 5 mg, 10.6% linagliptin 10 mg and 18.5% voglibose). There were no documented cases of hypoglycaemia.

CONCLUSIONS

Linagliptin showed superior glucose-lowering efficacy and comparable safety and tolerability to both placebo and voglibose in Japanese patients with T2DM.

Birt-Hogg-Dubé syndrome and familial adenomatous polyposis: an association or a coincidence?

An association between Birt-Hogg-Dubé syndrome (BHDS) and colon cancer remains conjectural, but herein we describe a case who may illustrate a significant link between them. The 60-year-old woman was diagnosed at 28 years of age with colon carcinoma and familial adenomatous polyposis (FAP). She also had repeated pneumothoraces, and was diagnosed with BHDS following the finding of pneumothorax in her son. We confirmed the presence of germline mutations in both her folliculin (FLCN) and adenomatous polyposis coli (APC) genes. The family pedigree suggested that a de novo FLCN mutation might have contributed to the development of colon carcinoma at a younger age than her family members.

[A case of clopidogrel-induced eosinophilic pneumonia]

An 83-year-old man had been prescribed clopidogrel for pontine infarction since 8 months previously, and had had a cough for the last 2 weeks of this period. Laboratory examinations on admission showed a marked increase in eosinophils and elevated serum immunoglobulin E levels. Chest radiography showed bilateral ground-glass opacities, mild reticulation, and interlobar pleural effusion in the minor fissure. After clopidogrel was discontinued his symptoms resolved, and his laboratory tests showed normal results. Bronchoalveolar lavage also showed an increase in eosinophils, and transbronchial biopsy revealed infiltration of eosinophils in the subepithelium of the bronchial mucosa. On the basis of these findings, we diagnosed eosinophilic pneumonia induced by clopidogrel. Reports on cases of lung diseases caused by anti-platelet drugs are rare. To the best of our knowledge, this case is the first report on clopidogrel-induced eosinophilic pneumonia.

[A case of negative pressure pulmonary hemorrhage associated with upper-airway obstruction due to a giant vocal cord nodule]

A 68-year-old woman was brought by ambulance because of sudden choking sensation and dyspnea after coughing. A physical examination showed hoarseness and blood-stained sputum. A chest computed tomography (CT) showed bilateral diffusely-distributed ground-glass opacity. A bronchoscopy examination revealed a large nodule on the left larynx and bloody bronchoalveolar lavage fluid. We diagnosed negative pressure pulmonary hemorrhage (NPPH) based on suspected upper-airway obstruction, but it resolved without further treatment. We found no other causes. We report a rare case of NPPH due to a giant vocal cord nodule.

Adhesion Evaluation of TiN and (Ti, Al)N Coatings on Titanium 6Al-4V

To assess the adhesion of nitride coatings on metals, titanium 6% aluminum 4% vanadium substrates were coated with titanium nitride (TiN) using both cathodic arc and electron beam evaporation. Titanium aluminum nitride ((Ti, Al)N) was also deposited using cathodic arc evaporation. The interfaces of the coated samples were loaded in tension using a high speed shock wave which caused spallation either at the interface, in the coating or in the metal. Scanning acoustic microscopy analysis of the spalled samples detected delaminations at the interface in the samples deposited by cathodic arc evaporation. DYNA2D modeling of plate impact spallation experiments revealed the tensile adhesion strength for TiN deposited by both techniques was ≈ 2.0 GPa. The tensile adhesion strength for (Ti, Al)N was less than 1.5 GPa.

[A case of anaphylactic reaction after pleurodesis with OK-432]

A 60-year-old woman had received adjuvant chemotherapy after abdominal hysterectomy for clear cell carcinoma of the endometrium. She had no history of allergy. She was admitted to our hospital because of massive pleural effusion. She underwent drainage of left-side malignant pleural effusion followed by chemical pleurodesis with OK-432 via a chest tube. Ten minutes after administration of OK-432 to the thoracic cavity, she complained of dyspnea and showed general flushing. Since the clinical course suggested drug-induced anaphylactic reaction, she was immediately treated with an adrenaline subcutaneous injection and methylprednisolone sodium succinate intravenous injection. However, the respiratory insufficiency progressively deteriorated and mechanical ventilation was needed for the next 3 days. This is the first published case of anaphylactic reaction to OK-432 pleurodesis. In Japan, OK-432 is a key drug used for pleurodesis and we should consider possible serious adverse reactions include anaphylactic reaction.

Predicting steady-state HbA1c responses to sitagliptin in patients with type 2 diabetes mellitus

AIMS

To develop predictive formulas using short-term changes in glycaemic parameters [haemoglobin A1c (HbA1c) and fasting plasma glucose (FPG)] with sitagliptin, a highly selective dipeptidyl peptidase-4 inhibitor, to assess longer term steady-state changes in HbA1c.

METHODS

Results from two, 12-week, double-blind studies of sitagliptin in Japanese patients with type 2 diabetes mellitus receiving once-daily sitagliptin 100 mg were used to construct linear models to develop predictive formulas based on study 1 (S1) and to validate them using study 2 (S2). HbA1c and FPG were the primary and the key secondary end-point for both studies and were both used to develop predictive formulas.

RESULTS

The predictive formulas using HbA1c+/-FPG results (slope of change) from week 0 to week 4 in S1 showed high correlations between fitted and observed week 12 HbA1c: for HbA1c alone R2=0.76, for HbA1c+FPG R2=0.89. When using the sitagliptin 100 mg group of S2 data set to assess the validity of the predictive formulas, high correlations for HbA1c alone (R2=0.76) and for HbA1c+FPG (R2=0.77) were also observed. Data using a lower dose (25 mg once daily) of sitagliptin also demonstrated similar results.

CONCLUSIONS

The early responses (over 4 weeks) in HbA1c and FPG with sitagliptin can be used to accurately predict later responses (at week 12) in HbA1c in Japanese patients with type 2 diabetes mellitus. Additional studies applying this approach to other agents with diverse mechanisms are important.

[Case of rapidly progressed pulmonary metastases of superficial bladder cancer]

The patient was a 95-year-old-man admitted to the urological section of our hospital because of hematuria. Transurethral resection of the bladder tumor (TUR-Bt) was performed. This tumor was diagnosed pathologically as bladder cancer (transitional cell carcinoma Grade 3 pT1). After 8 months, local reccurence was seen and TUR-Bt was performed. (pTa). After 1 month, his chest radiograph and computed tomogram showed a mass shadow in the left upper lung field. Cystoscopy did not reveal a local reccurence. The patient's condition worsened, and he died of respiratory failure after about 1 month. At autopsy, pathologic studies of the lung tumor revealed transitional cell carcinoma, and local recurrence was not seen. We report a rare case of pulmonary metastases from superficial bladder cancer without local reccurence.

Tumour necrosis factor alpha signalling through activation of Kupffer cells plays an essential role in liver fibrosis of non-alcoholic steatohepatitis in mice

BACKGROUND

While tumour necrosis factor alpha (TNF-alpha) appears to be associated with the development of non-alcoholic steatohepatitis (NASH), its precise role in the pathogenesis of NASH is not well understood.

METHODS

Male mice deficient in both TNF receptors 1 (TNFR1) and 2 (TNFR2) (TNFRDKO mice) and wild-type mice were fed a methionine and choline deficient (MCD) diet or a control diet for eight weeks, maintaining isoenergetic intake.

RESULTS

MCD dietary feeding of TNFRDKO mice for eight weeks resulted in attenuated liver steatosis and fibrosis compared with control wild-type mice. In the liver, the number of activated hepatic Kupffer cells recruited was significantly decreased in TNFRDKO mice after MCD dietary feeding. In addition, hepatic induction of TNF-alpha, vascular cell adhesion molecule 1, and intracellular adhesion molecule 1 was significantly suppressed in TNFRDKO mice. While in control animals MCD dietary feeding dramatically increased mRNA expression of tissue inhibitor of metalloproteinase 1 (TIMP-1) in both whole liver and hepatic stellate cells, concomitant with enhanced activation of hepatic stellate cells, both factors were significantly lower in TNFRDKO mice. In primary cultures, TNF-alpha administration enhanced TIMP-1 mRNA expression in activated hepatic stellate cells and suppressed apoptotic induction in activated hepatic stellate cells. Inhibition of TNF induced TIMP-1 upregulation by TIMP-1 specific siRNA reversed the apoptotic suppression seen in hepatic stellate cells.

CONCLUSIONS

Enhancement of the TNF-alpha/TNFR mediated signalling pathway via activation of Kupffer cells in an autocrine or paracrine manner may be critically involved in the pathogenesis of liver fibrosis in this NASH animal model.

Metabolic activity in skeletal muscles of patients with non-hypoxaemic chronic obstructive pulmonary disease studied by 31P-magnetic resonance spectroscopy

OBJECTIVE

An alteration of high energy phosphate metabolism in muscles may contribute to exercise intolerance. The objective of this study was to clarify the changes in high energy phosphate metabolites in muscles during exercise in patients with non-hypoxaemic chronic obstructive pulmonary disease (COPD), which influences the impairment of muscle metabolism.

METHODOLOGY

Calf muscle energy metabolism was studied in eight stable non-hypoxaemic COPD patients and eight control subjects, using 31P-magnetic resonance spectroscopy (MRS). MRS spectra were acquired at rest, during exercise at two levels of intensity, and during recovery. The control subjects exercised under both normoxic and hypoxic conditions. The intensity of exercise was standardized by the maximal isometric voluntary contraction (MVC) of the calf muscle and the cross-sectional area (CSA) of calf muscle.

RESULTS

MVC and CSA were lower in COPD patients. No significant differences in intracellular pH, inorganic phosphate/phosphocreatine ratio or percentage recovery in inorganic phosphate/phosphocreatine ratio were observed between the two groups in muscles at rest, during exercise or during recovery.

CONCLUSIONS

Muscle metabolites, during exercise standardized by muscle CSA and MVC, did not differ between non-hypoxaemic COPD patients and control subjects. MVC, CSA or both, are assumed to be closely related to muscle metabolism, as no difference in high energy phosphate metabolites was observed for COPD patients compared to control subjects when the load was standardized for MVC and CSA. This suggests that high energy metabolites are consumed to a similar extent in the same muscle volume in non-hypoxaemic COPD patients and control subjects.

Phylogenetic analysis of newly described Neosartorya species

Isolates representing newly described Neosartorya species, and isolates with abnormal morphologies from Aspergillus section Fumigati were examined by phylogenetic analysis of sequences of part of their beta-tubulin gene. Phylogenetic analyses supported the earlier suggestions that heterothallism is a derived character, and that sexuality was lost several times during the evolution of Aspergillus section Fumigati. The heterothallic N. fennelliae and N. udagawae strains were found to be closely related to the homothallic Neosartorya sp. NRRL 4179 and N. aureola, respectively. Aspergillus sp. FRR 1266, which was earlier described as a variant of A. fumigatus, was found to be closely related to A. viridinutans. Another abnormal asexual isolate was found to be closely related to A. fumigatus and N. fischeri. Phylogenetic relationships among newly described Neosartorya species and other taxa were successfully established based on phylogenetic analysis of beta-tubulin sequences.

Elemental diet modulates the growth of Clostridium difficile in the gut flora

BACKGROUND AND AIMS

Tube feeding is regarded as a risk factor for Clostridium difficile-associated diarrhoea. Recently, we reported that C. difficile toxin was frequently found in patients receiving an elemental diet. The present study was conducted to clarify whether elemental diets are associated with the growth of C. difficile in the gut flora.

METHODS

C. difficile was cultured for 72 h in various concentrations of elemental diet containing 3% thioglycollate, and the growth rate or activity of C. difficile was evaluated by Gram stain or by measuring optical density at 560 nm. Faecal samples from 10 healthy adults were cultured in elemental diet + 3% thioglycollate. RNA was extracted from faeces with glass powder, which can eliminate PCR inhibitors, and mRNA of C. difficile toxin B was measured by reverse transcription PCR.

RESULTS

Maximum OD560 value during culture in thioglycollate-containing elemental diet was 2.4 times higher than that in thioglycollate alone (P = 0.0163). Viability of C. difficile was decreased in thioglycollate but not in thioglycollate-containing elemental diet. Toxin B mRNA was detected in five faecal samples (50%) before culture and in all samples after culture.

CONCLUSIONS

Our results suggest that an elemental diet can modulate the growth of C. difficile in the gut flora.

[A case of multiple myeloma presenting as giant chest wall tumors with calcification]

A 60-year-old man was admitted for investigation of an abnormality detected in chest radiography: a giant tumor with calcification in the right middle lung field. A computed tomography (CT) scan revealed multiple tumors with calcification on the posterior chest wall. Histological analysis of the tumor specimen obtained by surgical biopsy demonstrated an increasing number of plasma cells accompanied with the deposition of amyloid. A bone marrow biopsy contained over 50% of plasma cells. We therefore diagnosed these tumors as multiple myeloma. It has been reported that multiple myeloma is usually characterized by osteolytic lesions; osteosclerotic changes are rare. Multiple myeloma should be taken into account as one of the causes of a chest wall tumor even if it is diffusely calcified.

[Eosinophilic pleural effusion by dirofilariasis]

A 44-year-old man visited our hospital because of right chest pain. Pleural effusion in the right lung was detected on a chest radiograph. A chest CT scan demonstrated no abnormal lesions in either lung field, but passive atelectasis due to the pleural effusion was present. Since many eosinophils were found in the exudative pleural effusion, a parasitic infection was suspected. An enzyme-linked immunosorbent assay test led to a diagnosis of eosinophilic pleural effusion by dirofilariasis. Pleural effusion disappeared spontaneously and the level of anti-Dirofilaria immitis antibody decreased. Continued careful observation is necessary in such cases.

Production of colony-stimulating factor in human dental pulp fibroblasts

Class II major histocompatilibity complex (MHC)-expressing cells are usually distributed in dental pulp, and it was postulated that the colony-stimulating factor (CSF) derived from dental pulp fibroblasts contributes to the migration of class II MHC-expressing cells into pulp tissue. This study aimed to investigate the CSF production of human dental pulp fibroblasts. In pulp tissue sections, granulocyte (G)-CSF was detected from normal teeth, while G-CSF, macrophage (M)-CSF, and granulocyte-macrophage (GM)-CSF were detected from teeth with dentinal caries. In cultured dental pulp fibroblasts, G-CSF was detected by immunostaining, immunoprecipitation, and ELISA, and mRNAs of G-CSF, M-CSF, and GM-CSF were detected by RT-PCR. The dental pulp fibroblasts cultured with TNF-alpha were found to increase the G-CSF expression and to produce M-CSF and GM-CSF. These findings suggest that dental pulp fibroblasts usually produce G-CSF. In the presence of TNF-alpha, dental pulp fibroblast express M-CSF and GM-CSF.