Effect of dapagliflozin in patients with type 2 diabetes who have inadequate glycaemic control with glimepiride: a randomized, 24-week, double-blind, placebo-controlled trial

AIMS

Progressive deterioration of glycaemic control in type 2 diabetes mellitus (T2DM) often requires treatment intensification. Dapagliflozin increases urinary glucose excretion by selective inhibition of renal sodium-glucose cotransporter 2 (SGLT2). We assessed the efficacy, safety and tolerability of dapagliflozin added to glimepiride in patients with uncontrolled T2DM.

METHODS

This 24-week, randomized, double-blind, placebo-controlled, parallel-group, international, multicentre trial (ClinicalTrials.gov NCT00680745) enrolled patients with uncontrolled T2DM [haemoglobin A1c (HbA1c) 7-10%] receiving sulphonylurea monotherapy. Adult patients (n = 597) were randomly assigned to placebo or dapagliflozin (2.5, 5 or 10 mg/day) added to open-label glimepiride 4 mg/day for 24 weeks. Primary endpoint was HbA1c mean change from baseline at 24 weeks. Secondary endpoints included change in body weight and other glycaemic parameters.

RESULTS

At 24 weeks, HbA1c adjusted mean changes from baseline for placebo versus dapagliflozin 2.5/5/10 mg groups were -0.13 versus -0.58, -0.63, -0.82%, respectively (all p < 0.0001 vs. placebo by Dunnett's procedure). Corresponding body weight and fasting plasma glucose values were -0.72, -1.18, -1.56, -2.26 kg and -0.11, -0.93, -1.18, -1.58 mmol/l, respectively. In placebo versus dapagliflozin groups, serious adverse events were 4.8 versus 6.0-7.1%; hypoglycaemic events 4.8 versus 7.1-7.9%; events suggestive of genital infection 0.7 versus 3.9-6.6%; and events suggestive of urinary tract infection 6.2 versus 3.9-6.9%. No kidney infections were reported.

CONCLUSIONS

Dapagliflozin added to glimepiride in patients with T2DM uncontrolled on sulphonylurea monotherapy significantly improved HbA1c, reduced weight and was generally well tolerated, although events suggestive of genital infections were reported more often in patients receiving dapagliflozin.

Addition of insulin lispro protamine suspension or insulin glargine to oral type 2 diabetes regimens: a randomized trial

AIMS

The addition of basal insulin to existing oral therapy can help patients with type 2 diabetes (T2D) achieve glycaemic targets. This study compares the efficacy and safety of insulin lispro protamine suspension (ILPS) and insulin glargine in insulin-naive patients with T2D and inadequate control on oral antihyperglycaemic medication (OAM).

MATERIALS AND METHODS

An open-label, randomized, multicentre, multinational 24-week study of 471 patients receiving ≥2 OAMs for ≥3 months with a body mass index between 25 and 45 kg/m(2) and HbA1c 7.5-10.0% was conducted. ILPS was injected once or twice daily vs. glargine injected once daily plus prestudy OAMs. Primary objective compared the HbA1c change from baseline.

RESULTS

HbA1c change from baseline to endpoint was similar in both groups [-1.46% (ILPS) and -1.41% (glargine)]. Least-squares mean difference (95% CI) for HbA1c (-0.05 [-0.21, 0.11]%), glycaemic variability (0.06 [-0.06, 0.19] mmol/l) and weight change (-0.01 [-0.61, 0.59] kg) showed non-inferiority (margins of 0.4%, 0.8 mmol/l and 1.5 kg, respectively). Percentages of patients achieving HbA1c <7.0% were 43.8% ILPS and 41.2% glargine. Mean daily insulin dose was 0.39 vs. 0.35 U/kg (p = 0.02) and weight gain was 1.04 vs. 1.07 kg for ILPS vs. glargine (p = 0.98). Overall hypoglycaemia (episodes/patient/year) was similar for ILPS and glargine (24.2 ± 28.8 vs. 23.0 ± 30.9); nocturnal (6.1 ± 10.6 vs. 4.1 ± 9.4, p < 0.001) rates were higher for ILPS. Severe hypoglycaemia was higher for ILPS vs. glargine (n = 9 vs. n = 2; p = 0.04).

CONCLUSIONS

At endpoint, ILPS was non-inferior to glargine in HbA1c change from baseline, but associated with increased risk of hypoglycaemia.

Blood glucose level on admission determines in-hospital and long-term mortality in patients with ST-segment elevation myocardial infarction complicated by cardiogenic shock treated with percutaneous coronary intervention

BACKGROUND

It has been shown that hyperglycaemia is associated with increased in-hospital and long-term mortality in patients with myocardial infarction (MI). There are only a few reports on the relationship between glycaemia in the acute phase of MI complicated by cardiogenic shock (CS) and prognosis.

AIM

To assess the relationship between blood glucose level on admission and in-hospital as well as long-term mortality in patients with acute ST-segment elevation MI (STEMI) complicated by CS treated with percutaneous coronary intervention (PCI).

METHODS

Consecutive patients with STEMI complicated by CS treated with PCI were included. For the purpose of this analysis, the patients were divided into two groups: the first group included patients with glycaemia on admission < 7.8 mmol/L, and the other group patients with glycaemia > or = 7.8 mmol/L (hyperglycaemia group). Selected parameters from the in-hospital and long-term follow-up were compared between the two groups. Due to a possible linear relationship between blood glucose and mortality in multivariate analysis, glucose level on admission was treated as a continuous variable. The primary outcomes included in-hospital, 1-year and 5-year mortality.

RESULTS

Out of 3166 consecutive patients with STEMI, 258 had CS and available data on glycaemia. In patients with hyperglycaemia on admission, we observed higher in-hospital (41.5% vs 28%, p = 0.041), 1-year (51.4% vs 34.7%, p = 0.015) and 5-year (65.8% vs 43.3%, p = 0.034) mortality in comparison to the patients with blood glucose < 7.8 mmol/L. The multivariate analysis revealed that blood glucose level on admission (per each glycaemia increment by 1 mmol/L) was an independent prognostic factor of in-hospital (OR 1.08, 95% CI 1.02-1.14, p = 0.0044), 1-year (HR 1.04, 95% CI 1.01-1.06, p = 0.005) and 5-year mortality (HR 1.03, 95% CI 1.01-1.05, p = 0.045). Of note, the diagnosis of diabetes mellitus had no influence on in-hospital and long-term mortality.

CONCLUSIONS

Elevated blood glucose level on admission, regardless of the diagnosis of diabetes mellitus, results in increased in-hospital and long-term mortality in patients with STEMI complicated by CS and treated with PCI.

Impact of low-frequency pulsed magnetic fields on defensin and CRP concentrations in patients with painful diabetic polyneuropathy and in healthy subjects

AIM

The aim was to assess whether magnetic field influences defensin and CRP concentrations in patients with diabetic polyneuropathy and in healthy subjects.

METHODS

61 diabetic patients were randomly divided into 2 groups: study group-32 patients exposed to low-frequency magnetic field; and control group-29 patients with sham exposure. Additionally, 20 healthy subjects exposed to low-frequency magnetic field. Exposures were performed during 3 weeks, 5 days in a week. Defensin and CRP concentrations were measured at baseline, after 3 weeks and at the end of the study.

RESULTS

There were no significant changes in defensin concentration in patients with diabetes in both the real and sham exposure group. We observed increased concentration of defensin in healthy subjects in week 5 vs. baseline value (P<0.02).

CONCLUSIONS

Magnetic field has no impact on defensin concentration in diabetic patients but has positive influence on this parameter in healthy subjects.

Prognosis in diabetic patients with acute myocardial infarction treated invasively is related to renal function

BACKGROUND

The prevalence of diabetes mellitus (DM) and chronic kidney disease (CKD) is rapidly increasing. Both comorbidities are considered significant risk factors for cardiovascular complications. The aim of the study was to evaluate the impact of DM with and without CKD on prognosis in patients with acute myocardial infarction (AMI) treated invasively.

MATERIAL/METHODS

This single-center prospective study encompassed 3334 AMI-patients without cardiogenic shock, who were divided into 2 major groups: 999 patients with type 2 DM diagnosed prior to or during index hospitalization, and 2335 non-diabetics. All diabetic patients were divided with respect to their renal status into: diabetics with CKD (DM-CKD; n=264) and without (DM-nCKD; n=735). Short- and long-term outcomes were compared between study groups. Independent predictors of death and composite end-point were selected with multivariate Cox-regression model.

RESULTS

Mortality rates were significantly higher in DM group compared to nDM in all observation periods. DM-CKD was associated with excessive total mortality (35.6%) when compared to DM-nCKD (11.6%, P<0.001) and to nDM (9.8%, P<0.001). Mortality and major adverse cardiovascular event rates did not differ significantly between DM-nCKD and nDM groups. Diabetes coexisting with CKD was one of the strongest independent risk factors for death (hazard ratio 1.93; confidence interval 1.79-2.07; P<0.001).

CONCLUSIONS

The prognosis in diabetics with AMI is significantly related to renal function. Diabetics without CKD had similar prognosis to non-diabetics. Multivariate analyses showed that unlike diabetes without renal dysfunction, DM-CKD was an independent risk factor for cardiovascular complications and total mortality.

Once-daily initiation with biphasic insulin aspart 30 versus insulin glargine in patients with type 2 diabetes inadequately controlled with oral drugs: an open-label, multinational RCT

OBJECTIVES

To assess the efficacy and safety of biphasic insulin aspart 70/30 (BIAsp 30) and insulin glargine, administered once daily in subjects with type 2 diabetes inadequately controlled with oral anti-diabetic drugs.

RESEARCH DESIGN AND METHODS

In this 26-week, open-labeled, randomized, parallel-group, multinational, treat-to-target trial, 480 insulin-naïve subjects were randomized to receive either BIAsp 30 before dinner or insulin glargine at bedtime, both in combination with metformin and glimepiride.

TRIAL REGISTRATION

NCT00469092, ClinicalTrials.gov.

RESULTS

A total of 433 subjects completed the trial. Estimated mean reduction in HbA(1c) from baseline to end of treatment was -1.41% with BIAsp 30 and -1.25% with insulin glargine (BIAsp 30 - insulin glargine = -0.16%, 95% CI [-0.30; -0.02], p = 0.029). At the end of treatment, mean HbA(1c) was 7.1% and 7.3% for BIAsp 30 and insulin glargine, respectively. Significantly lower plasma glucose levels were observed with BIAsp 30 post-dinner (BIAsp 30 - insulin glargine = -0.52 mmol/L, 95% CI [-1.02; -0.03], p = 0.04) and at bedtime (BIAsp 30 - insulin glargine = -0.78 mmol/L, 95% CI [-1.25; -0.31], p < 0.01). The relative risk (RR) of experiencing a nocturnal hypoglycemic episode (00:00-06.00 a.m.) was significantly higher with BIAsp 30 than with insulin glargine (1.1 versus 0.5 episodes/year, RR = 2.41, 95% CI [1.34; 4.34], p = 0.003), but overall hypoglycemia rates were low. There were three major hypoglycemic episodes in each group.

CONCLUSIONS

With respect to HbA(1c), BIAsp 30 fulfilled the statistical criteria for non-inferiority and superiority to insulin glargine and, according to pre-defined criteria, the improvements in HbA(1c) are considered clinically equivalent. Subjects had an increased risk of minor nocturnal hypoglycemia with BIAsp 30. There were no differences in treatment satisfaction between the two groups.

Self-monitoring of blood glucose in treatment of type 2 diabetes

Blood glucose measurements are important components of a effective diabetes management. Self-monitoring of blood glucose (SMBG) provides the possibility for collecting information on glucose levels at different timepoints and facilitates patient empowerment. However, the efficacy of SMBG in particular groups of patients is controversial. Self-monitoring is postulated to have a beneficial effect on metabolic control in type 1 diabetes as it is essential to adjust insulin doses. In type 2 diabetes the efficacy of frequent glucose measurements remains uncertain. The purpose of this paper is to overview recent data in the field of self-control to evaluate the influence of SMBG on glycaemic control in type 2 diabetes. The results of studies suggest that SMBG can have an important role in improving metabolic control if it is an integral part of a wider educational strategy. SMBG can be especially recommended for type 2 diabetic patients with suboptimal metabolic control in order to promote dietary and lifestyle changes as well as treatment correction as a response to feedback provided by blood glucose results.

Prevalence of diabetes and cardiovascular risk factors of industrial area in southern Poland

BACKGROUND

Diabetes mellitus (DM) is a serious health and social problem. We assessed the prevalence of DM and metabolic syndrome in an urban population in southern Poland.

METHODS

Sample of 782 subjects randomly selected from adult inhabitants of industrial district (23 442 voters registered) was invited. The response rate was 56% (including 85% of those aged over 50 years) mean age 53+/-15 years. 75 g OGTT and serum concentration of triglycerides, total cholesterol and HDL/LDL fractions were measured. The percentage+/-assessment error for the disorders were calculated assuming not-responders represented normal glucose tolerance.

RESULTS

Prevalence of DM was 8.06+/-0.9% (7.15+/-1.25 M and 8.94+/-1.3 F) including 5.56+/-0.77% (5.56+/-1.13 M and 5.56+/-1.06 F) with known and 2.52+/-0.55 (1.59+/-0.64 M and 3.37+/-0.89 F) newly diagnosed. Impaired glucose tolerance (IGT and/or IFG) was found in additional 8.44+/-0.93% (6.09+/-1.17 M and 10.7+/-1.41 F). Extrapolated to the general population shown the prevalence 6.54+/-0.73% (5.8+/-1.02 M and 7.25+/-1.05 F). Features of the metabolic syndrome (IDF criteria) were found in 34% of the participants - 75% of patients with DM, 63% with glucose intolerance (IGT and/or IFG) and 19% of individuals with NGT (p<0.001 as compared to other groups). CONCLUSIONS The study confirmed high prevalence of diabetes mellitus with lower percentage of undiagnosed disease. Presence of impaired glucose tolerance allows to identify the high risk of metabolic syndrome and in consequence high risk of cardiovascular disease.

Effects of prandial versus fasting glycemia on cardiovascular outcomes in type 2 diabetes: the HEART2D trial

OBJECTIVE

Hyperglycemia and Its Effect After Acute Myocardial Infarction on Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus (HEART2D) is a multinational, randomized, controlled trial designed to compare the effects of prandial versus fasting glycemic control on risk for cardiovascular outcomes in patients with type 2 diabetes after acute myocardial infarction (AMI).

RESEARCH DESIGN AND METHODS

Patients (type 2 diabetes, aged 30-75 years) were randomly assigned within 21 days after AMI to the 1) prandial strategy (PRANDIAL) (three premeal doses of insulin lispro targeting 2-h postprandial blood glucose <7.5 mmol/l) or the 2) basal strategy (BASAL) (NPH twice daily or insulin glargine once daily targeting fasting/premeal blood glucose <6.7 mmol/l).

RESULTS

A total of 1,115 patients were randomly assigned (PRANDIAL n = 557; BASAL n = 558), and the mean patient participation after randomization was 963 days (range 1-1,687 days). The trial was stopped for lack of efficacy. Risks of first combined adjudicated primary cardiovascular events in the PRANDIAL (n = 174, 31.2%) and BASAL (n = 181, 32.4%) groups were similar (hazard ratio 0.98 [95% CI 0.8-1.21]). Mean A1C did not differ between the PRANDIAL and BASAL groups (7.7 +/- 0.1 vs. 7.8 +/- 0.1%; P = 0.4) during the study. The PRANDIAL group showed a lower daily mean postprandial blood glucose (7.8 vs. 8.6 mmol/l; P < 0.01) and 2-h postprandial blood glucose excursion (0.1 vs. 1.3 mmol/l; P < 0.001) versus the BASAL group. The BASAL group showed lower mean fasting blood glucose (7.0 vs. 8.1 mmol/l; P < 0.001) and similar daily fasting/premeal blood glucose (7.7 vs. 7.3 mmol/l; P = 0.233) versus the PRANDIAL group.

CONCLUSIONS

Treating diabetic survivors of AMI with prandial versus basal strategies achieved differences in fasting blood glucose, less-than-expected differences in postprandial blood glucose, similar levels of A1C, and no difference in risk for future cardiovascular event rates.

The efficacy of self-monitoring of blood glucose in the management of patients with type 2 diabetes treated with a gliclazide modified release-based regimen. A multicentre, randomized, parallel-group, 6-month evaluation (DINAMIC 1 study)

AIM

To determine if therapeutic management programmes for type 2 diabetes that include self-monitoring of blood glucose (SMBG) result in greater reductions in glycated haemoglobin (HbA1c) compared with programmes without SMBG in non-insulin requiring patients.

METHODS

Multicentre, randomized, parallel-group trial. A total of 610 patients were randomized to SMBG or non-SMBG groups. Patients in both groups received the same oral antidiabetic therapy using a gliclazide modified release (MR)-based regimen for 27 weeks. The primary efficacy end-point was the difference between groups in HbA1c at the end of observation.

RESULTS

A total of 610 patients were randomized: 311 to the SMBG group and 299 to the non-SMBG group. HbA1c decreased from 8.12 to 6.95% in the SMBG group and from 8.12 to 7.20% in the non-SMBG group; between-group difference was 0.25% (95% CI: 0.06, 1.03; p = 0.0097). Symptoms suggestive of mild to moderate hypoglycaemia was the most commonly reported adverse event, reported by 27 (8.7%) and 21 (7.0%) patients in the SMBG and non-SMBG groups, respectively; the incidence of symptomatic hypoglycaemia was lower in the SMBG group.

CONCLUSION

In patients with type 2 diabetes, the application of SMBG as an adjunct to oral antidiabetic agent therapy results in further reductions in HbA1c.

Glucose intolerance, insulin resistance and metabolic syndrome in patients with stable angina pectoris. Obesity predicts coronary atherosclerosis and dysglycemia

INTRODUCTION

Disturbances of glucose regulation and other metabolic disorders, as part of metabolic syndrome, are important risk factors for atherosclerosis. Abnormal glucose metabolism is commonly observed in patients with acute coronary syndrome. However, there is no consistent evidence for subjects with stable angina.

OBJECTIVES

To investigate the prevalence of glucose metabolism in patients with stable coronary artery disease (CAD) documented angiographically and to assess correlations of metabolic profile and extent of atherosclerotic lesions.

PATIENTS AND METHODS

100 consecutive non-diabetic patients with stable CAD referred to coronary angiography were studied. Total cholesterol and its fractions, triglycerides, uric acid and fasting insulin levels were determined. Oral glucose tolerance test (OGTT) and then coronary angiography were performed. All patients were divided into groups according to glucometabolic and coronary status and insulin resistance. The sum of all lesions in coronary vessels was calculated for each patient (CAD score).

RESULTS

After OGTT, 44% of patients presented disturbed glucose metabolism: 9% of patients had newly diagnosed diabetes and 35% patients were in the prediabetic state. There was no correlation between glycemic status and insulin resistance, and severity of coronary heart disease. Obesity, reflected by body mass index, waist circumference and waist-to-hip ratio, was a major metabolic disorder and independent predictor of the extent of coronary atherosclerosis and glucose intolerance.

CONCLUSIONS

Abnormal glucose regulation is very common in patients with stable CAD. Only obesity was the independent predictor of coronary atherosclerosis and dysglycemia. Other metabolic risk factors are target for prevention and treatment.

Effect of blood glucose levels on prognosis in acute myocardial infarction in patients with and without diabetes, undergoing percutaneous coronary intervention

BACKGROUND

Diabetes mellitus (DM) is a significant factor regarding poor outcome in patients with myocardial infarction. Recently a new prognostic factor is under consideration - a baseline glucose level on admission. We sought to assess the influence of blood glucose levels on admission on prognosis of patients with acute ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI).

METHODS AND RESULTS

Consecutive patients treated with PCI for STEMI were analyzed. Presence or absence of DM was the first grouping criterion. The secondary criterion was the blood glucose level on admission [threshold >or= 7.8 mmol/L (140 mg/dL)]. Hyperglycemic and non-hyperglycemic subgroups were selected within both DM and non-DM groups according to the threshold. One-year mortality of diabetics was 16.0%. There was no significant difference in 1-year mortality between hyperglycemic and non-hyperglycemic patients with DM. One-year mortality in the non-DM group was 5.6%. Patients without DM but with hyperglycemia showed a higher 1-year mortality rate than non-hyperglycemic patients (8.51% vs. 3.68%, p = 0.001). Multivariate analysis revealed that in the non-DM group blood glucose level (per 1 mmol/L) on admission was a factor affecting 1-year mortality [HR = 1.09 (1.01-1.17)].

CONCLUSIONS

Elevated blood glucose levels in STEMI affect the prognosis of patients without DM; however, it is not an independent death risk factor of patients with DM treated with PCI.

[Inhaled insulin--the breakthrough in the treatment of diabetes?]

Diabetes as a global epidemic is the fourth cause of death in the world currently. Ninety percent of all cases of diabetes represent patients with type 2 diabetes, in whom worsening of glycaemic control is observed with progression of the disease. A number of trials which have been conducted so far showed that lack of sufficient glycaemic control in both type 1 and type 2 diabetic patients accelerates progression of late complications of the disease. Although targets how to treat diabetes have been clearly defined few patients achieve them and maintain optimal metabolic control. Administration of insulin in type 1 diabetes is crucial for survival of the patients. Because of progressive course of the disease insulin is not rarely the only tool to achieve full normalization of glycaemia in type 2 diabetic patients. Chronic hyperglycemia in type 2 diabetic patients is the main reason to start insulin therapy. Decision about insulin administration is usually associated with patient's confusion and fear, mainly because of multiple subcutanoeus injections and risk of hypoglycaemia or secondary weight gain. Studies on inhaled insulin have been successfully completed recently. In the spring of 2005 Exubera, the first insulin inhaler, has been registered. The aim of this overview is to present the current clinical data on Exubera in treatment of patients with type 1 and 2 diabetes.

[Postprandial glycemia--review of current pathophysiological, epidemiological and clinical aspects]

One of the most difficult current medical problems is the growing epidemics of diabetes mellitus. The contemporary treatment aims not only to secure the patients survival and to protect from the acute symptoms but also to avoid the occurrence of the chronic complications of the disease. This paper contains a review of the role that postprandial hyperglycemia plays in the treatment of diabetes mellitus especially type 2. Authors summarize findings of pathophysiological and epidemiological macroangiopathy studies that indicate the use of prandial glucose regulation in clinical practice. This review contains discussion of postulated mechanism in which short-lasting increases in plasma glucose concentration can damage vessel wall lead to atherosclerosis. Epidemiological studies showing the strong correlation between postprandial (and post-challenge) plasma glucose levels with cardiovascular endpoints are also discussed. Moreover, in this paper the reader may find a discussion on practical aspects of postprandial hyperglycemia monitoring in the treatment of diabetic patient, focusing at the relationship between prandial glycaemia and long term glycaemia control expressed by HbA(1c) measurements. The guidelines for monitoring postprandial glycaemia are also included. The modern therapeutic possibilities aiming post-prandial hyperglycaemia are also showed.

Expression pattern of genes in peripheral blood mononuclear cells in diabetic nephropathy

AIMS

Only one-third of Type 1 diabetes patients develop diabetic nephropathy, and a genetic predisposition is postulated. To obtain more insight into processes that lead to diabetic nephropathy, messenger RNA expression profiles of peripheral blood mononuclear cells from patients with and without diabetic nephropathy were compared.

METHODS

We studied seven male patients with Type 1 diabetes and proteinuria and 12 male patients with Type 1 diabetes and normoalbuminuria after at least 20 years of diabetes duration. The expression of genes was examined using the microarray method with Human Genome U133A Arrays (Affymetrix, Santa Clara, CA, USA). We analysed the expression of all candidate genes suggested to be involved in the pathogenesis of diabetic nephropathy in previously published articles. Altogether, expression of 198 genes was analysed.

RESULTS

We found that thrombospondin 1 (THBS1) and cyclooxygenase 1(COX1) genes were over-expressed in patients with diabetic nephropathy, and matrix metalloproteinase 9 (MMP9) and cyclooxygenase 2 (COX2) genes had lower expression in diabetic nephropathy. For other genes, we did not observe different expression between patients with and without diabetic nephropathy,or the expression was too low for analysis.

CONCLUSIONS

The different gene expression pattern in peripheral blood mononuclear cells in patients with diabetic nephropathy might indicate an important pathway in the pathogenesis of this complication.

Charcot's Joint of the Wrist in Type 2 Diabetes Mellitus

In patients with diabetes mellitus, Charcot's neuroarthropathy mainly affects major weight-bearing joints, especially the foot and ankle. Remarkably, we report a case of Charcot's joint of the wrist - an unusually rare localization in type 2 diabetic patient. A review of medical literature identified only three such cases so far.

Salt-sensitive blood pressure—an intermediate phenotype predisposing to diabetic nephropathy?

BACKGROUND

Family studies point to important genetic determinants of diabetic nephropathy (DN). Blood pressure (BP) is higher in offspring of patients with type 2 diabetes and DN, but the pathomechanisms involved have not been elucidated.

METHODS

We examined the salt sensitivity of BP after 5 days equilibration on a low (20 mmol/day) vs high salt diet (220 mmol/day) in three matched groups of 15 subjects each: (i) control individuals; (ii) offspring of type 2 diabetic parents without DN (DN-); and (iii) offspring of type 2 diabetic parents with DN (DN+). Ambulatory BP and hormones involved in sodium homeostasis [plasma renin activity (PRA), aldosterone and atrial natriuretic peptide (ANP)] as well as the tetrahydrocortisol + 5-allotetrahydrocortisol/tetrahydrocortisone (THF + 5alphaTHF)/THE) ratio in the urine as an index of 11beta-hydroxysteroid dehydrogenase type 2 (11betaHSD2) activity were analysed.

RESULTS

In offspring of DN+ patients on a high salt diet, systolic and diastolic BP was 137/82+/-10/8 mmHg vs 125/77+/-12/8 mmHg in offspring of DN- patients (P<0.01 for systolic BP). The salt-induced difference in mean BP between high and low salt diet was 5.2+/-3.3 mmHg in offspring of DN+ patients vs 0.7+/-4.7 mmHg in offspring of DN- patients (P<0.002). The proportion of 'salt-sensitive' individuals was 67% in offspring of DN+ patients vs 20% in offspring of DN- patients (P<0.05). In all groups, a high salt diet caused a comparable decrease of PRA and p-aldosterone accompanied by an increase in ANP. The urinary (THF + 5alphaTHF)/THE ratio was 1.23+/-0.36 in salt-sensitive individuals and 0.99+/-0.33 (P<0.03) in salt-resistant subjects, consistent with increased activity of 11betaHSD2.

CONCLUSIONS

BP is more salt sensitive in offspring of type 2 diabetic patients with diabetic nephropathy. The salt sensitivity of BP may be an intermediate phenotype in individuals with a high risk of future diabetic nephropathy.

Efficacy of pregabalin in neuropathic pain evaluated in a 12-week, randomised, double-blind, multicentre, placebo-controlled trial of flexible- and fixed-dose regimens

Pregabalin binds with high affinity to the alpha2-delta subunit protein of voltage-gated calcium channels and, thereby, reduces release of excitatory neurotransmitters. This 12-week randomised, double-blind, multicentre, placebo-controlled, parallel-group study evaluated the efficacy and safety of pregabalin in patients with chronic postherpetic neuralgia (PHN) or painful diabetic peripheral neuropathy (DPN). Patients were randomised to placebo (n=65) or to one of two pregabalin regimens: a flexible schedule of 150, 300, 450, and 600 mg/day with weekly dose escalation based on patients' individual responses and tolerability (n=141) or a fixed schedule of 300 mg/day for 1 week followed by 600 mg/day for 11 weeks (n=132). Both flexible- and fixed-dose pregabalin significantly reduced endpoint mean pain score (primary outcome) versus placebo (P=0.002, P<0.001) and were significantly superior to placebo in improving pain-related sleep interference (P<0.001). The most common adverse events (AEs) for pregabalin-treated patients were dizziness, peripheral oedema, weight gain (not affecting diabetes control), and somnolence. These results are consistent with previous studies' demonstrating pregabalin's efficacy, tolerability, and safety for treatment of chronic neuropathic pain associated with DPN or PHN. Pregabalin dosing aimed at optimal balance of efficacy and tolerability provides significant pain relief and may reduce risks for AEs and therapy discontinuation.

Hyperglycemia and its effect after acute myocardial infarction on cardiovascular outcomes in patients with Type 2 diabetes mellitus (HEART2D) Study design

OBJECTIVE

Cardiovascular (CV) disease is the major cause of death in patients with diabetes. Up to 40% of patients with Type 2 diabetes mellitus (T2DM) who survive an initial myocardial infarction (MI) suffer a recurrent event within 2 years, the majority of which are fatal. One independent risk factor for cardiovascular disease (CVD) may be postprandial blood glucose (PPBG) excursions. The HEART2D study seeks to determine the effect that PPBG control has on cardiovascular outcomes in patients who suffered an MI within the 21 days before study enrollment.

RESEARCH DESIGN AND METHODS

Approximately 1355 patients with T2DM with recent MI will be entered in this multicenter study of about 3.0-year duration. Using infarct severity and peri-infarct treatment as randomization factors, patients will be assigned to one of two insulin treatment strategies: (1) postprandial strategy: premeal insulin lispro with basal insulin at bedtime if needed (NPH insulin), targeting 2-h PPBG < or = 7.5 mmol/l or (2) basal strategy: insulin (NPH insulin twice daily or insulin glargine once daily; or premixed human insulin (70% NPH/30% regular; 30/70) twice daily), targeting fasting and premeal blood glucose (BG; < or = 6.7 mmol/l). Both groups will aim for a target hemoglobin AlC (AlC) of < 7%.

ANTICIPATED RESULTS

The anticipated difference in PPBG (approximately 2.0 to 2.5 mM) between strategies is expected to demonstrate a 15% to 18.5% relative risk reduction in CV events for the postprandial strategy.

CONCLUSION

This study may provide practical insights into the clinical management of patients with diabetes who have an increased risk of recurrent CV events and death.

Initiating oral glucose-lowering therapy with metformin in tyape 2 diabetic patients: an evidence-based strategy to reduce the burden of late-developing diabetes complications

A major aim of glucose-lowering therapy in people with diabetes is to delay or prevent the late-developing complications of diabetes that threaten the quality and duration of life. While intensive interventions to control hyperglycaemia may impair well-being to some extent, the balance of quality of life is usually highly positive. Diet and exercise therapy remains the cornerstone of management, and should usually be given a trial alone first. However, the magnitude and duration of benefit from this intervention is insufficient for most people. More frequent, early, use of metformin is an evidence-based strategy for reducing the risk of adverse outcomes of diabetes in people with type 2 diabetes with sub-optimal glucose control on lifestyle measures alone. This has been recognised in recent evidenced-based guidelines from the UK National Institute for Clinical Excellence and from Diabetes UK, which now support the use of metformin as initial pharmacological therapy for all people without contraindications to the drug. Other national and local guideline committees should consider updating their recommendations on diabetes management in line with these findings.