701
|
|
702
|
Abstract
Obesity is a worldwide epidemic that predisposes individuals to cardiometabolic complications, such as type 2 diabetes mellitus (T2DM) and nonalcoholic fatty liver disease (NAFLD), which are all related to inappropriate ectopic lipid deposition. Identification of the pathogenic molecular mechanisms and effective therapeutic approaches are highly needed. The peroxisome proliferator-activated receptors (PPARs) modulate several biological processes that are perturbed in obesity, including inflammation, lipid and glucose metabolism and overall energy homeostasis. Here, we review how PPARs regulate the functions of adipose tissues, such as adipogenesis, lipid storage and adaptive thermogenesis, under healthy and pathological conditions. We also discuss the clinical use and mechanism of PPAR agonists in the treatment of obesity comorbidities such as dyslipidaemia, T2DM and NAFLD. First generation PPAR agonists, primarily those acting on PPARγ, are associated with adverse effects that outweigh their clinical benefits, which led to the discontinuation of their development. An improved understanding of the physiological roles of PPARs might, therefore, enable the development of safe, new PPAR agonists with improved therapeutic potential.
Collapse
Affiliation(s)
- Barbara Gross
- Université de Lille, INSERM, CHU Lille, Institut Pasteur de Lille, U1011-EGID, F-59000 Lille, France
| | - Michal Pawlak
- International Institute of Molecular and Cell Biology, 4 Ks. Trojdena Street, 02-109 Warsaw, Poland
| | - Philippe Lefebvre
- Université de Lille, INSERM, CHU Lille, Institut Pasteur de Lille, U1011-EGID, F-59000 Lille, France
| | - Bart Staels
- Université de Lille, INSERM, CHU Lille, Institut Pasteur de Lille, U1011-EGID, F-59000 Lille, France
| |
Collapse
|
703
|
Jeejeebhoy K, Dhaliwal R, Heyland DK, Leung R, Day AG, Brauer P, Royall D, Tremblay A, Mutch DM, Pliamm L, Rhéaume C, Klein D. Family physician-led, team-based, lifestyle intervention in patients with metabolic syndrome: results of a multicentre feasibility project. CMAJ Open 2017; 5:E229-E236. [PMID: 28401139 PMCID: PMC5378505 DOI: 10.9778/cmajo.20160101] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Metabolic syndrome (MetS) is a medical condition with major complications and health care costs. Previous research has shown that diet and exercise can improve and reverse this condition. The goal of this study was to test the feasibility and effectiveness of implementing the Canadian Health Advanced by Nutrition and Graded Exercise (CHANGE) program into diverse family medicine practices to improve MetS. METHODS In this longitudinal before-after study, 305 adult patients with MetS were recruited from 3 diverse family medicine team-based organizations to the CHANGE personalized diet and exercise program. Participants were followed for 12 months. Primary outcomes included feasibility and reversal of MetS. Secondary outcomes included improvement in MetS components, changes in diet quality, aerobic fitness and cardiovascular risk. RESULTS Participants attended 76% and 90% of the kinesiologist and dietitian visits, respectively. At 12 months, 19% of patients (95% confidence interval [CI] 14%-24%) showed reversal of MetS, VO2max increased by 16% (95% CI 13%-18%), and Healthy Eating Index and Mediterranean Diet Scores improved by 9.6% (95% CI 7.6%-11.6%) and 1.4% (1.1%-1.6%), respectively. In addition, the Prospective Cardiovascular Munster (PROCAM) 10-year risk of acute coronary event decreased by 1.4%, from a baseline of 8.6%. INTERPRETATION A team-based program led by the family physician that educates patients about the risks of MetS, and with a dietitian and kinesiologist, empowers them to undertake an individualized supervised program of diet modification and exercise, is feasible, improves aerobic capacity and diet quality, reverses MetS and improves MetS components at 12 months.
Collapse
Affiliation(s)
- Khursheed Jeejeebhoy
- Metabolic Syndrome Canada is a not-for-profit charitable organization that funded the current study. Daren Heyland received grant funds from Metabolic Syndrome Canada for program development, study coordination and data analyses. Rupinder Dhaliwal, Andrew Day and Roger Leung were paid for their work on the study by Kingston General Hospital and Queen's University from this grant. Rupinder Dhaliwal became an employee of Metabolic Syndrome Canada after the completion of study enrolment. Lew Pliamm, Caroline Rhéuame and Doug Klein received grants as participating sites for patient enrolment and data collection from Metabolic Syndrome Canada. Paula Brauer, Dawna Royall, David Mutch and Angelo Tremblay received grants for program development from Metabolic Syndrome Canada. Khursheed Jeejeebhoy is on the board of directors for Metabolic Syndrome Canada and will be involved in discussions about fundraising for this nonprofit organization
| | - Rupinder Dhaliwal
- Metabolic Syndrome Canada is a not-for-profit charitable organization that funded the current study. Daren Heyland received grant funds from Metabolic Syndrome Canada for program development, study coordination and data analyses. Rupinder Dhaliwal, Andrew Day and Roger Leung were paid for their work on the study by Kingston General Hospital and Queen's University from this grant. Rupinder Dhaliwal became an employee of Metabolic Syndrome Canada after the completion of study enrolment. Lew Pliamm, Caroline Rhéuame and Doug Klein received grants as participating sites for patient enrolment and data collection from Metabolic Syndrome Canada. Paula Brauer, Dawna Royall, David Mutch and Angelo Tremblay received grants for program development from Metabolic Syndrome Canada. Khursheed Jeejeebhoy is on the board of directors for Metabolic Syndrome Canada and will be involved in discussions about fundraising for this nonprofit organization
| | - Daren K Heyland
- Metabolic Syndrome Canada is a not-for-profit charitable organization that funded the current study. Daren Heyland received grant funds from Metabolic Syndrome Canada for program development, study coordination and data analyses. Rupinder Dhaliwal, Andrew Day and Roger Leung were paid for their work on the study by Kingston General Hospital and Queen's University from this grant. Rupinder Dhaliwal became an employee of Metabolic Syndrome Canada after the completion of study enrolment. Lew Pliamm, Caroline Rhéuame and Doug Klein received grants as participating sites for patient enrolment and data collection from Metabolic Syndrome Canada. Paula Brauer, Dawna Royall, David Mutch and Angelo Tremblay received grants for program development from Metabolic Syndrome Canada. Khursheed Jeejeebhoy is on the board of directors for Metabolic Syndrome Canada and will be involved in discussions about fundraising for this nonprofit organization
| | - Roger Leung
- Metabolic Syndrome Canada is a not-for-profit charitable organization that funded the current study. Daren Heyland received grant funds from Metabolic Syndrome Canada for program development, study coordination and data analyses. Rupinder Dhaliwal, Andrew Day and Roger Leung were paid for their work on the study by Kingston General Hospital and Queen's University from this grant. Rupinder Dhaliwal became an employee of Metabolic Syndrome Canada after the completion of study enrolment. Lew Pliamm, Caroline Rhéuame and Doug Klein received grants as participating sites for patient enrolment and data collection from Metabolic Syndrome Canada. Paula Brauer, Dawna Royall, David Mutch and Angelo Tremblay received grants for program development from Metabolic Syndrome Canada. Khursheed Jeejeebhoy is on the board of directors for Metabolic Syndrome Canada and will be involved in discussions about fundraising for this nonprofit organization
| | - Andrew G Day
- Metabolic Syndrome Canada is a not-for-profit charitable organization that funded the current study. Daren Heyland received grant funds from Metabolic Syndrome Canada for program development, study coordination and data analyses. Rupinder Dhaliwal, Andrew Day and Roger Leung were paid for their work on the study by Kingston General Hospital and Queen's University from this grant. Rupinder Dhaliwal became an employee of Metabolic Syndrome Canada after the completion of study enrolment. Lew Pliamm, Caroline Rhéuame and Doug Klein received grants as participating sites for patient enrolment and data collection from Metabolic Syndrome Canada. Paula Brauer, Dawna Royall, David Mutch and Angelo Tremblay received grants for program development from Metabolic Syndrome Canada. Khursheed Jeejeebhoy is on the board of directors for Metabolic Syndrome Canada and will be involved in discussions about fundraising for this nonprofit organization
| | - Paula Brauer
- Metabolic Syndrome Canada is a not-for-profit charitable organization that funded the current study. Daren Heyland received grant funds from Metabolic Syndrome Canada for program development, study coordination and data analyses. Rupinder Dhaliwal, Andrew Day and Roger Leung were paid for their work on the study by Kingston General Hospital and Queen's University from this grant. Rupinder Dhaliwal became an employee of Metabolic Syndrome Canada after the completion of study enrolment. Lew Pliamm, Caroline Rhéuame and Doug Klein received grants as participating sites for patient enrolment and data collection from Metabolic Syndrome Canada. Paula Brauer, Dawna Royall, David Mutch and Angelo Tremblay received grants for program development from Metabolic Syndrome Canada. Khursheed Jeejeebhoy is on the board of directors for Metabolic Syndrome Canada and will be involved in discussions about fundraising for this nonprofit organization
| | - Dawna Royall
- Metabolic Syndrome Canada is a not-for-profit charitable organization that funded the current study. Daren Heyland received grant funds from Metabolic Syndrome Canada for program development, study coordination and data analyses. Rupinder Dhaliwal, Andrew Day and Roger Leung were paid for their work on the study by Kingston General Hospital and Queen's University from this grant. Rupinder Dhaliwal became an employee of Metabolic Syndrome Canada after the completion of study enrolment. Lew Pliamm, Caroline Rhéuame and Doug Klein received grants as participating sites for patient enrolment and data collection from Metabolic Syndrome Canada. Paula Brauer, Dawna Royall, David Mutch and Angelo Tremblay received grants for program development from Metabolic Syndrome Canada. Khursheed Jeejeebhoy is on the board of directors for Metabolic Syndrome Canada and will be involved in discussions about fundraising for this nonprofit organization
| | - Angelo Tremblay
- Metabolic Syndrome Canada is a not-for-profit charitable organization that funded the current study. Daren Heyland received grant funds from Metabolic Syndrome Canada for program development, study coordination and data analyses. Rupinder Dhaliwal, Andrew Day and Roger Leung were paid for their work on the study by Kingston General Hospital and Queen's University from this grant. Rupinder Dhaliwal became an employee of Metabolic Syndrome Canada after the completion of study enrolment. Lew Pliamm, Caroline Rhéuame and Doug Klein received grants as participating sites for patient enrolment and data collection from Metabolic Syndrome Canada. Paula Brauer, Dawna Royall, David Mutch and Angelo Tremblay received grants for program development from Metabolic Syndrome Canada. Khursheed Jeejeebhoy is on the board of directors for Metabolic Syndrome Canada and will be involved in discussions about fundraising for this nonprofit organization
| | - David M Mutch
- Metabolic Syndrome Canada is a not-for-profit charitable organization that funded the current study. Daren Heyland received grant funds from Metabolic Syndrome Canada for program development, study coordination and data analyses. Rupinder Dhaliwal, Andrew Day and Roger Leung were paid for their work on the study by Kingston General Hospital and Queen's University from this grant. Rupinder Dhaliwal became an employee of Metabolic Syndrome Canada after the completion of study enrolment. Lew Pliamm, Caroline Rhéuame and Doug Klein received grants as participating sites for patient enrolment and data collection from Metabolic Syndrome Canada. Paula Brauer, Dawna Royall, David Mutch and Angelo Tremblay received grants for program development from Metabolic Syndrome Canada. Khursheed Jeejeebhoy is on the board of directors for Metabolic Syndrome Canada and will be involved in discussions about fundraising for this nonprofit organization
| | - Lew Pliamm
- Metabolic Syndrome Canada is a not-for-profit charitable organization that funded the current study. Daren Heyland received grant funds from Metabolic Syndrome Canada for program development, study coordination and data analyses. Rupinder Dhaliwal, Andrew Day and Roger Leung were paid for their work on the study by Kingston General Hospital and Queen's University from this grant. Rupinder Dhaliwal became an employee of Metabolic Syndrome Canada after the completion of study enrolment. Lew Pliamm, Caroline Rhéuame and Doug Klein received grants as participating sites for patient enrolment and data collection from Metabolic Syndrome Canada. Paula Brauer, Dawna Royall, David Mutch and Angelo Tremblay received grants for program development from Metabolic Syndrome Canada. Khursheed Jeejeebhoy is on the board of directors for Metabolic Syndrome Canada and will be involved in discussions about fundraising for this nonprofit organization
| | - Caroline Rhéaume
- Metabolic Syndrome Canada is a not-for-profit charitable organization that funded the current study. Daren Heyland received grant funds from Metabolic Syndrome Canada for program development, study coordination and data analyses. Rupinder Dhaliwal, Andrew Day and Roger Leung were paid for their work on the study by Kingston General Hospital and Queen's University from this grant. Rupinder Dhaliwal became an employee of Metabolic Syndrome Canada after the completion of study enrolment. Lew Pliamm, Caroline Rhéuame and Doug Klein received grants as participating sites for patient enrolment and data collection from Metabolic Syndrome Canada. Paula Brauer, Dawna Royall, David Mutch and Angelo Tremblay received grants for program development from Metabolic Syndrome Canada. Khursheed Jeejeebhoy is on the board of directors for Metabolic Syndrome Canada and will be involved in discussions about fundraising for this nonprofit organization
| | - Doug Klein
- Metabolic Syndrome Canada is a not-for-profit charitable organization that funded the current study. Daren Heyland received grant funds from Metabolic Syndrome Canada for program development, study coordination and data analyses. Rupinder Dhaliwal, Andrew Day and Roger Leung were paid for their work on the study by Kingston General Hospital and Queen's University from this grant. Rupinder Dhaliwal became an employee of Metabolic Syndrome Canada after the completion of study enrolment. Lew Pliamm, Caroline Rhéuame and Doug Klein received grants as participating sites for patient enrolment and data collection from Metabolic Syndrome Canada. Paula Brauer, Dawna Royall, David Mutch and Angelo Tremblay received grants for program development from Metabolic Syndrome Canada. Khursheed Jeejeebhoy is on the board of directors for Metabolic Syndrome Canada and will be involved in discussions about fundraising for this nonprofit organization
| |
Collapse
|
704
|
Tanaka A, Node K. Emerging roles of sodium-glucose cotransporter 2 inhibitors in cardiology. J Cardiol 2016; 69:501-507. [PMID: 28043708 DOI: 10.1016/j.jjcc.2016.10.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 10/27/2016] [Indexed: 12/18/2022]
Abstract
The ultimate goal of treatment in people with diabetes mellitus is to prevent development of cardiovascular (CV) disease, resulting in prolongation of healthy life expectancy. Although impaired glycemic metabolism has a central role in its pathology, a number of studies have demonstrated that remedy for its imbalance cannot necessarily be accomplished as a therapeutic goal. A comprehensive medical approach against multi-factorial pathologies in diabetes, such as insulin resistance, obesity, hypertension, and dyslipidemia, in addition to diet and exercise therapy should be rather performed in the routine clinical setting. Along with such conceptual transition, what is required in anti-diabetes agents has also changed, and several anti-diabetes agents have been newly placed on the market in this decade. Such agents are required to undergo global pre- or post-marketing clinical trials assessing CV safety. A growing body of clinical evidence from those trials is now accumulating, and empagliflozin, a sodium-glucose cotransporter 2 (SGLT2) inhibitor, has first demonstrated significant risk reduction, relative to placebo, in CV death, overall mortality, and hospitalization for worsened heart failure in high-risk patients with diabetes mellitus. An SGLT2 inhibitor is a unique glucose-lowering agent and at the same time has multifaceted effects on hemodynamic and metabolic parameters beyond glycemic control. A major mode of action of SGLT2 inhibitors appears to be 'glycosuria' and 'natriuresis,' leading to amelioration of systemic glycemic homeostasis and potential cardio-renal protection. However, the precise mechanisms by which SGLT2 inhibitors affect benefits on the CV systems are yet to be fully elucidated. Thus, although we are now facing several unanswered concerns lurking behind the successful trial, SGLT2 inhibitors surely play several important roles in high-quality management of not only diabetes, but also CV medicine. This review summarizes our current understandings and future perspectives of SGLT2 inhibitors in CV medicine.
Collapse
Affiliation(s)
- Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Saga, Japan.
| |
Collapse
|
705
|
Lee M, Saver JL, Liao HW, Lin CH, Ovbiagele B. Pioglitazone for Secondary Stroke Prevention: A Systematic Review and Meta-Analysis. Stroke 2016; 48:388-393. [PMID: 27999139 DOI: 10.1161/strokeaha.116.013977] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 11/04/2016] [Accepted: 11/14/2016] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND PURPOSE Pioglitazone reduced major vascular events after ischemic stroke in a recent randomized controlled trial. The purpose of this study was to conduct a meta-analysis of randomized controlled trials to evaluate the effect of pioglitazone therapy in reducing the risk of recurrent stroke in stroke patients. METHODS Pubmed, EMBASE, Medline, and Cochrane Central Register of Controlled Trials from 1966 to March 2016 were searched to identify relevant studies. We included randomized controlled trials that included comparison of pioglitazone versus control and trials in which quantitative estimates of the hazard ratio and 95% confidence interval for recurrent stroke associated with pioglitazone therapy among stroke patients were reported. Hazard ratios with 95% confidence intervals were used as a measure of the association between use of pioglitazone and risks of recurrent stroke (ischemic and hemorrhagic) and major vascular events (nonfatal stroke, nonfatal myocardial infarction, and cardiovascular death) after pooling data across trials. Between-study heterogeneity was assessed using the I2 statistic. RESULTS Three randomized controlled trials with 4980 participants were identified. Use of pioglitazone in stroke patients with insulin resistance, prediabetes, and diabetes mellitus was associated with lower risk of recurrent stroke (hazard ratio 0.68; 95% confidence interval, 0.50-0.92; P=0.01) and future major vascular events (hazard ratio 0.75; 95% confidence interval, 0.64-0.87; P=0.0001). There was no heterogeneity across trials. There was no evidence of an effect on all-cause mortality and heart failure. CONCLUSIONS Pioglitazone reduces recurrent stroke and major vascular events in ischemic stroke patients with insulin resistance, prediabetes, and diabetes mellitus.
Collapse
Affiliation(s)
- Meng Lee
- From the Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan (M.L., C.-H.L.); Stroke Center, Geffen School of Medicine, University of California, Los Angeles (J.L.S.); Jia-Yi Clinic, Taoyuan, Taiwan (H.-W.L.); and Department of Neurology, Medical University of South Carolina, Charleston (B.O.)
| | - Jeffrey L Saver
- From the Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan (M.L., C.-H.L.); Stroke Center, Geffen School of Medicine, University of California, Los Angeles (J.L.S.); Jia-Yi Clinic, Taoyuan, Taiwan (H.-W.L.); and Department of Neurology, Medical University of South Carolina, Charleston (B.O.)
| | - Hung-Wei Liao
- From the Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan (M.L., C.-H.L.); Stroke Center, Geffen School of Medicine, University of California, Los Angeles (J.L.S.); Jia-Yi Clinic, Taoyuan, Taiwan (H.-W.L.); and Department of Neurology, Medical University of South Carolina, Charleston (B.O.)
| | - Chun-Hsien Lin
- From the Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan (M.L., C.-H.L.); Stroke Center, Geffen School of Medicine, University of California, Los Angeles (J.L.S.); Jia-Yi Clinic, Taoyuan, Taiwan (H.-W.L.); and Department of Neurology, Medical University of South Carolina, Charleston (B.O.)
| | - Bruce Ovbiagele
- From the Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan (M.L., C.-H.L.); Stroke Center, Geffen School of Medicine, University of California, Los Angeles (J.L.S.); Jia-Yi Clinic, Taoyuan, Taiwan (H.-W.L.); and Department of Neurology, Medical University of South Carolina, Charleston (B.O.).
| |
Collapse
|
706
|
Cusi K. Diabetes medications improve cardiovascular outcomes: the paradigm shifts. Curr Opin Lipidol 2016; 27:633-635. [PMID: 27805974 DOI: 10.1097/mol.0000000000000361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Kenneth Cusi
- Division of Endocrinology, Diabetes and Metabolism, University of Florida, Gainesville, Florida, USA
| |
Collapse
|
707
|
Trujillo JM, Wettergreen SA, Nuffer WA, Ellis SL, McDermott MT. Cardiovascular Outcomes of New Medications for Type 2 Diabetes. Diabetes Technol Ther 2016; 18:749-758. [PMID: 27835045 DOI: 10.1089/dia.2016.0295] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Cardiovascular (CV) disease remains the leading cause of death in people with diabetes, highlighting the importance of using treatment options that do not increase CV risk or possibly decrease CV outcomes. Since 2008, the Food and Drug Administration has required demonstration of CV safety for all new medications developed for the glycemic management of diabetes. Seven trials have been published that have established CV safety for three DPP-4 inhibitors (alogliptin, saxagliptin, and sitagliptin), three GLP-1 receptor agonists (liraglutide, lixisenatide, and semaglutide), and one sodium-glucose cotransporter-2 inhibitor (empagliflozin). Three of those studies also established superiority with liraglutide, empagliflozin, and semaglutide at reducing the composite primary endpoint of major CV events (CV death, nonfatal myocardial infarction, and nonfatal stroke). In addition, one trial found an increase in heart failure hospitalizations with saxagliptin. The findings of these trials must be compared and contrasted cautiously given the differences in patient populations and trial designs, but together they provide important information that can be used to shape our treatment guideline recommendations and patient-specific treatment decisions.
Collapse
Affiliation(s)
- Jennifer M Trujillo
- 1 Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado , Aurora, Colorado
| | | | - Wesley A Nuffer
- 1 Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado , Aurora, Colorado
| | - Samuel L Ellis
- 1 Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado , Aurora, Colorado
| | - Michael T McDermott
- 1 Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado , Aurora, Colorado
- 3 School of Medicine, University of Colorado , Aurora, Colorado
| |
Collapse
|
708
|
Abstract
EMPA-REG OUTCOME was a multicenter, randomized placebo-controlled trial that examined the effect of empagliflozin, a sodium-glucose cotransporter 2 (SGLT2) inhibitor in addition to standard of care in patients with type 2 diabetes and established cardiovascular (CV) disease. The primary goal was to assess CV safety, as mandated by the US Food and Drug Administration since 2008 for all new glucose-lowering agents. Secondary goals were to examine the effects of empagliflozin on microvascular outcomes and, in particular, kidney disease. This landmark study had several important findings, including striking reductions in the incidence of CV death and heart failure hospitalization and in the progression of renal dysfunction. In this review, we describe the trial's main findings, discuss the possible mechanisms that could explain its results, suggest ways in which clinical care may be influenced, and propose directions for future research.
Collapse
Affiliation(s)
- Angeliki M Stamatouli
- Section of Endocrinology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520-8020, USA
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520-8020, USA.
| |
Collapse
|
709
|
Zonszein J, Groop PH. Strategies for Diabetes Management: Using Newer Oral Combination Therapies Early in the Disease. Diabetes Ther 2016; 7:621-639. [PMID: 27796904 PMCID: PMC5118246 DOI: 10.1007/s13300-016-0208-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION The duration of uncontrolled type 2 diabetes mellitus (T2DM) can adversely impact small and large vessels, eventually leading to microvascular and macrovascular complications. Failure of therapeutic lifestyle changes, monotherapy, and clinical inertia contribute to persistent hyperglycemia and disease progression. The aim was to review the complex pathophysiology of type 2 diabetes and how different oral agents can be used effectively as first-line therapy in combination with metformin, as well as in patients not achieving glycemic goals with metformin therapy. METHODS For this review, a non-systematic literature search of PubMed, NCBI, and Google Scholar was conducted. RESULTS New oral agents have made it possible to improve glycemic control to near-normal levels with a low risk of hypoglycemia and without weight gain, and sometimes with weight loss. Early combination therapy is effective and has been shown to have a favorable legacy effect. A number of agents are available in a single-pill combination (SPC) that provides fewer pills and better adherence. Compared with adding a sulfonylurea, still the most common oral combination used, empagliflozin has been shown to decrease cardiovascular (CV) events in a dedicated CV outcome study, and pioglitazone has been effective in reducing the risk of secondary CV endpoints, whereas sulfonylureas have been associated with an increased risk of CV disease. In those failing metformin, triple oral therapy by adding a non-metformin SPC such as empagliflozin/linagliptin or pioglitazone/alogliptin is a good option for reducing glycated hemoglobin (HbA1c) without significant hypoglycemia. CONCLUSION Clinicians have a comprehensive armamentarium of medications to treat patients with T2DM. Clinical evidence has shown that dual or triple oral combination therapy is effective for glycemic control, and early treatment is effective in getting patients to goal more quickly. Use of SPCs is an option for double or triple oral combination therapy and may result in better adherence.
Collapse
Affiliation(s)
- Joel Zonszein
- Montefiore Medical Center, University Hospital for Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Per-Henrik Groop
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Helsinki, Finland
- Baker IDI Heart & Diabetes Institute, Melbourne, Australia
| |
Collapse
|
710
|
Flory JH, Ukena JK, Floyd JS. Novel Anti-glycemic Drugs and Reduction of Cardiovascular Risk in Diabetes: Expectations Realized, Promises Unmet. Curr Atheroscler Rep 2016; 18:79. [PMID: 27817160 PMCID: PMC5509052 DOI: 10.1007/s11883-016-0633-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW The purpose is to review evidence on cardiovascular risks and benefits of new treatments for type 2 diabetes mellitus. RECENT FINDINGS In response to guidance issued by the Food and Drug Administration, thousands of patients have been enrolled in large randomized trials evaluating the cardiovascular effects of the three newest diabetes drug classes: glucagon-like peptide-1 (GLP-1) receptor agonists, sodium glucose cotransporter 2 (SGLT-2) inhibitors, and dipeptidyl peptidase-4 (DPP-4) inhibitors. Two studies of GLP-1 receptor agonists-one of liraglutide and one of semaglutide-have shown cardiovascular benefit relative to placebo, and one study of the SGLT-2 inhibitor empagliflozin has shown benefit. The other published cardiovascular outcome studies of the newest drug classes have generally supported safety, apart from an as-yet unresolved safety concern about increased rates of heart failure with DPP-4 inhibitors. Recent research suggests the thiazolidinedione pioglitazone may have beneficial effects on some cardiovascular outcomes as well, but these are counterbalanced by a known increase of the risk of heart failure with this drug. In general, more prospective randomized trial data is now available regarding the cardiovascular effects of the newer diabetes drugs than on the older drug classes. New evidence suggests that the newest diabetes drugs are safe from a cardiovascular perspective. Evidence on benefit from at least some members of the GLP-1 receptor agonist and SGLT-2 inhibitor classes is encouraging but not yet decisive.
Collapse
Affiliation(s)
- James H Flory
- Weill Cornell Medical College, 425 E 61st Street, Suite 301, New York, NY, 10065, USA.
| | - Jenny K Ukena
- Weill Cornell Medical College, 425 E 61st Street, Suite 301, New York, NY, 10065, USA
| | - James S Floyd
- Cardiovascular Health Research Unit, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
711
|
Lee JE, Shin DW, Yun JM, Kim SH, Nam YS, Cho B, Lim JS, Jeong HY, Kwon HM, Park JH. Insulin Resistance Is a Risk Factor for Silent Lacunar Infarction. Stroke 2016; 47:2938-2944. [DOI: 10.1161/strokeaha.116.014097] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 09/24/2016] [Accepted: 10/05/2016] [Indexed: 12/26/2022]
Abstract
Background and Purpose—
This study aims to investigate the association between insulin resistance (IR) and silent lacunar infarction (SLI) in healthy adults.
Methods—
We recruited 2326 healthy Korean adults who took health checkups, including a brain magnetic resonance imaging. SLI was defined as an infarction measuring 0.3 to 1.5 cm in diameter that was localized in the territory of perforating branches of cerebral arteries, as seen in the brain magnetic resonance imaging. The homeostasis model assessment–estimated insulin resistance index was used for IR estimation, and the cutoff value for its diagnosis for Koreans was 2.56.
Results—
The mean age of the study population was 56.2 years (range, 40–79 years), and 1279 subjects (55.0%) were male. The prevalence of SLI and IR was 8.1% and 18.1%, respectively. In multivariate logistic analysis, after adjusting for traditional SLI-associated risk factors, IR was positively associated with the prevalence of SLI (adjusted odds ratio, 1.69; 95% confidence interval, 1.16–2.46). The proportion of subjects with multiple SLI lesions (≥2) was also higher in the IR (+) group than that in the IR (−) group (4.3% versus 1.7%;
P
<0.001). In ordered logistic regression, IR was positively associated with an increase in SLI severity (adjusted odds ratio, 1.76; 95% confidence interval, 1.21–2.56).
Conclusions—
IR is an independent risk factor of SLI presence and its severity in Koreans. Whether improvement of IR might prevent SLI occurrence needs to be addressed by clinical trials.
Collapse
Affiliation(s)
- Ji Eun Lee
- From the Department of Family Medicine (J.E.L., D.W.S., J.M.Y., S.H.K., Y.-S.N., B.C., J.-H.P.) and Health Promotion Center (J.E.L., D.W.S., J.M.Y., S.H.K., Y.-S.N., B.C., J.-H.P.), Seoul National University Hospital, Republic of Korea; Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (J.-S.L.); Department of Neurology, Aerospace Medical Center, Cheongju, Republic of Korea (H.-Y.J.); and Department of Neurology, Seoul National University-Seoul Municipal
| | - Dong Wook Shin
- From the Department of Family Medicine (J.E.L., D.W.S., J.M.Y., S.H.K., Y.-S.N., B.C., J.-H.P.) and Health Promotion Center (J.E.L., D.W.S., J.M.Y., S.H.K., Y.-S.N., B.C., J.-H.P.), Seoul National University Hospital, Republic of Korea; Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (J.-S.L.); Department of Neurology, Aerospace Medical Center, Cheongju, Republic of Korea (H.-Y.J.); and Department of Neurology, Seoul National University-Seoul Municipal
| | - Jae Moon Yun
- From the Department of Family Medicine (J.E.L., D.W.S., J.M.Y., S.H.K., Y.-S.N., B.C., J.-H.P.) and Health Promotion Center (J.E.L., D.W.S., J.M.Y., S.H.K., Y.-S.N., B.C., J.-H.P.), Seoul National University Hospital, Republic of Korea; Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (J.-S.L.); Department of Neurology, Aerospace Medical Center, Cheongju, Republic of Korea (H.-Y.J.); and Department of Neurology, Seoul National University-Seoul Municipal
| | - Sang Hyuck Kim
- From the Department of Family Medicine (J.E.L., D.W.S., J.M.Y., S.H.K., Y.-S.N., B.C., J.-H.P.) and Health Promotion Center (J.E.L., D.W.S., J.M.Y., S.H.K., Y.-S.N., B.C., J.-H.P.), Seoul National University Hospital, Republic of Korea; Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (J.-S.L.); Department of Neurology, Aerospace Medical Center, Cheongju, Republic of Korea (H.-Y.J.); and Department of Neurology, Seoul National University-Seoul Municipal
| | - You-Seon Nam
- From the Department of Family Medicine (J.E.L., D.W.S., J.M.Y., S.H.K., Y.-S.N., B.C., J.-H.P.) and Health Promotion Center (J.E.L., D.W.S., J.M.Y., S.H.K., Y.-S.N., B.C., J.-H.P.), Seoul National University Hospital, Republic of Korea; Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (J.-S.L.); Department of Neurology, Aerospace Medical Center, Cheongju, Republic of Korea (H.-Y.J.); and Department of Neurology, Seoul National University-Seoul Municipal
| | - BeLong Cho
- From the Department of Family Medicine (J.E.L., D.W.S., J.M.Y., S.H.K., Y.-S.N., B.C., J.-H.P.) and Health Promotion Center (J.E.L., D.W.S., J.M.Y., S.H.K., Y.-S.N., B.C., J.-H.P.), Seoul National University Hospital, Republic of Korea; Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (J.-S.L.); Department of Neurology, Aerospace Medical Center, Cheongju, Republic of Korea (H.-Y.J.); and Department of Neurology, Seoul National University-Seoul Municipal
| | - Jae-Sung Lim
- From the Department of Family Medicine (J.E.L., D.W.S., J.M.Y., S.H.K., Y.-S.N., B.C., J.-H.P.) and Health Promotion Center (J.E.L., D.W.S., J.M.Y., S.H.K., Y.-S.N., B.C., J.-H.P.), Seoul National University Hospital, Republic of Korea; Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (J.-S.L.); Department of Neurology, Aerospace Medical Center, Cheongju, Republic of Korea (H.-Y.J.); and Department of Neurology, Seoul National University-Seoul Municipal
| | - Han-Yeong Jeong
- From the Department of Family Medicine (J.E.L., D.W.S., J.M.Y., S.H.K., Y.-S.N., B.C., J.-H.P.) and Health Promotion Center (J.E.L., D.W.S., J.M.Y., S.H.K., Y.-S.N., B.C., J.-H.P.), Seoul National University Hospital, Republic of Korea; Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (J.-S.L.); Department of Neurology, Aerospace Medical Center, Cheongju, Republic of Korea (H.-Y.J.); and Department of Neurology, Seoul National University-Seoul Municipal
| | - Hyung-Min Kwon
- From the Department of Family Medicine (J.E.L., D.W.S., J.M.Y., S.H.K., Y.-S.N., B.C., J.-H.P.) and Health Promotion Center (J.E.L., D.W.S., J.M.Y., S.H.K., Y.-S.N., B.C., J.-H.P.), Seoul National University Hospital, Republic of Korea; Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (J.-S.L.); Department of Neurology, Aerospace Medical Center, Cheongju, Republic of Korea (H.-Y.J.); and Department of Neurology, Seoul National University-Seoul Municipal
| | - Jin-Ho Park
- From the Department of Family Medicine (J.E.L., D.W.S., J.M.Y., S.H.K., Y.-S.N., B.C., J.-H.P.) and Health Promotion Center (J.E.L., D.W.S., J.M.Y., S.H.K., Y.-S.N., B.C., J.-H.P.), Seoul National University Hospital, Republic of Korea; Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (J.-S.L.); Department of Neurology, Aerospace Medical Center, Cheongju, Republic of Korea (H.-Y.J.); and Department of Neurology, Seoul National University-Seoul Municipal
| |
Collapse
|
712
|
Tomlinson B, Hu M, Zhang Y, Chan P, Liu ZM. Evaluation of the pharmacokinetics, pharmacodynamics and clinical efficacy of empagliflozin for the treatment of type 2 diabetes. Expert Opin Drug Metab Toxicol 2016; 13:211-223. [PMID: 27817207 DOI: 10.1080/17425255.2017.1258401] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Sodium-glucose co-transporter 2 (SGLT2) inhibitors are the latest class of drugs to be introduced for the treatment of type 2 diabetes mellitus. These drugs improve glycemic control by increasing urinary glucose excretion and exert additional benefits of weight loss and blood pressure reductions. Areas covered: This review outlines the background to SGLT2 inhibitors and provides details on the pharmacokinetics, pharmacodynamics and clinical efficacy of empagliflozin and discusses the cardiovascular outcome trial. Expert opinion: Empagliflozin was the first from a new group of antidiabetic drugs to show benefits in a cardiovascular outcome trial. There were significant reductions in cardiovascular and all-cause mortality and empagliflozin treatment reduced hospitalizations for heart failure and reduced the progression of diabetic nephropathy. These benefits, which occurred at a very early stage during the study, may be related to a reduction in circulating volume or changes in metabolic fuel utilization in the heart and kidneys. Whether these effects are shared by other SGLT2 inhibitors is not yet known, but there may be differences between drugs related to selectivity for inhibition of SGLT2 compared to SGLT1 or other pharmacological effects. Currently the outcome evidence is only available to support the use of empagliflozin in this drug class.
Collapse
Affiliation(s)
- Brian Tomlinson
- a Research Center for Translational Medicine , Shanghai East Hospital, Tongji University School of Medicine , Shanghai , China.,b Department of Medicine & Therapeutics , The Chinese University of Hong Kong , Shatin , Hong Kong
| | - Miao Hu
- b Department of Medicine & Therapeutics , The Chinese University of Hong Kong , Shatin , Hong Kong
| | - Yuzhen Zhang
- a Research Center for Translational Medicine , Shanghai East Hospital, Tongji University School of Medicine , Shanghai , China
| | - Paul Chan
- c Division of Cardiology, Department of Internal Medicine, Wan Fang Hospital , Taipei Medical University , Taipei City , Taiwan
| | - Zhong-Min Liu
- d Department of Cardiac Surgery, Shanghai East Hospital , Tongji University , Shanghai , China
| |
Collapse
|
713
|
Lansberg MG, Bhat NS, Yeatts SD, Palesch YY, Broderick JP, Albers GW, Lai TL, Lavori PW. Power of an Adaptive Trial Design for Endovascular Stroke Studies: Simulations Using IMS (Interventional Management of Stroke) III Data. Stroke 2016; 47:2931-2937. [PMID: 27895297 DOI: 10.1161/strokeaha.116.015436] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 09/13/2016] [Accepted: 10/05/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND PURPOSE Adaptive trial designs that allow enrichment of the study population through subgroup selection can increase the chance of a positive trial when there is a differential treatment effect among patient subgroups. The goal of this study is to illustrate the potential benefit of adaptive subgroup selection in endovascular stroke studies. METHODS We simulated the performance of a trial design with adaptive subgroup selection and compared it with that of a traditional design. Outcome data were based on 90-day modified Rankin Scale scores, observed in IMS III (Interventional Management of Stroke III), among patients with a vessel occlusion on baseline computed tomographic angiography (n=382). Patients were categorized based on 2 methods: (1) according to location of the arterial occlusive lesion and onset-to-randomization time and (2) according to onset-to-randomization time alone. The power to demonstrate a treatment benefit was based on 10 000 trial simulations for each design. RESULTS The treatment effect was relatively homogeneous across categories when patients were categorized based on arterial occlusive lesion and time. Consequently, the adaptive design had similar power (47%) compared with the fixed trial design (45%). There was a differential treatment effect when patients were categorized based on time alone, resulting in greater power with the adaptive design (82%) than with the fixed design (57%). CONCLUSIONS These simulations, based on real-world patient data, indicate that adaptive subgroup selection has merit in endovascular stroke trials as it substantially increases power when the treatment effect differs among subgroups in a predicted pattern.
Collapse
Affiliation(s)
- Maarten G Lansberg
- From the Stanford Stroke Center, School of Medicine (M.G.L., N.S.B., G.W.A.), Department of Statistics (T.L.L., P.W.L.), Department of Biomedical Data Science, School of Medicine (T.L.L., P.W.L.), Stanford University, CA; Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); and Department of Neurology, University of Cincinnati Medical Center, OH (J.P.B.).
| | - Ninad S Bhat
- From the Stanford Stroke Center, School of Medicine (M.G.L., N.S.B., G.W.A.), Department of Statistics (T.L.L., P.W.L.), Department of Biomedical Data Science, School of Medicine (T.L.L., P.W.L.), Stanford University, CA; Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); and Department of Neurology, University of Cincinnati Medical Center, OH (J.P.B.)
| | - Sharon D Yeatts
- From the Stanford Stroke Center, School of Medicine (M.G.L., N.S.B., G.W.A.), Department of Statistics (T.L.L., P.W.L.), Department of Biomedical Data Science, School of Medicine (T.L.L., P.W.L.), Stanford University, CA; Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); and Department of Neurology, University of Cincinnati Medical Center, OH (J.P.B.)
| | - Yuko Y Palesch
- From the Stanford Stroke Center, School of Medicine (M.G.L., N.S.B., G.W.A.), Department of Statistics (T.L.L., P.W.L.), Department of Biomedical Data Science, School of Medicine (T.L.L., P.W.L.), Stanford University, CA; Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); and Department of Neurology, University of Cincinnati Medical Center, OH (J.P.B.)
| | - Joseph P Broderick
- From the Stanford Stroke Center, School of Medicine (M.G.L., N.S.B., G.W.A.), Department of Statistics (T.L.L., P.W.L.), Department of Biomedical Data Science, School of Medicine (T.L.L., P.W.L.), Stanford University, CA; Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); and Department of Neurology, University of Cincinnati Medical Center, OH (J.P.B.)
| | - Gregory W Albers
- From the Stanford Stroke Center, School of Medicine (M.G.L., N.S.B., G.W.A.), Department of Statistics (T.L.L., P.W.L.), Department of Biomedical Data Science, School of Medicine (T.L.L., P.W.L.), Stanford University, CA; Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); and Department of Neurology, University of Cincinnati Medical Center, OH (J.P.B.)
| | - Tze L Lai
- From the Stanford Stroke Center, School of Medicine (M.G.L., N.S.B., G.W.A.), Department of Statistics (T.L.L., P.W.L.), Department of Biomedical Data Science, School of Medicine (T.L.L., P.W.L.), Stanford University, CA; Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); and Department of Neurology, University of Cincinnati Medical Center, OH (J.P.B.)
| | - Philip W Lavori
- From the Stanford Stroke Center, School of Medicine (M.G.L., N.S.B., G.W.A.), Department of Statistics (T.L.L., P.W.L.), Department of Biomedical Data Science, School of Medicine (T.L.L., P.W.L.), Stanford University, CA; Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); and Department of Neurology, University of Cincinnati Medical Center, OH (J.P.B.)
| |
Collapse
|
714
|
Abstract
Patients who have had a stroke are at high risk for recurrent stroke, myocardial infarction, and vascular death. Prevention of these events should be initiated promptly after stroke, because many recurrent events occur early, and should be tailored to the precise cause of stroke, which may require specific treatment. Lifestyle advice including abstinence from smoking, regular exercise, Mediterranean-style diet, and reduction of salt intake and alcohol consumption are recommended for all patients with stroke. For most patients with ischemic stroke or TIA, control of risk factors, including lowering blood pressure under 140/90mmHg and LDL cholesterol under 1g/L, together with antiplatelet or oral anticoagulant therapy, depending on the cause of stroke, have been shown to decrease the risk of recurrent stroke and cardiovascular events. Aspirin, clopidogrel, or the combination of aspirin and dipyridamole, are all acceptable options for secondary prevention in patients with ischemic stroke or TIA of arterial origin. Dual therapy with aspirin and clopidogrel might be considered for 3 weeks after a minor ischemic stroke or TIA and for 3 months in patients with stroke due to severe intracranial stenosis. Oral anticoagulants are very effective to prevent cardioembolic stroke. Non-VKA oral anticoagulants have a favorable risk-benefit profile compared with VKAs, with significant reductions in stroke, intracranial hemorrhage, mortality, with similar major bleeding, but increased gastrointestinal bleeding. Carotid endarterectomy reduces the risk of ipsilateral stroke in patients with recent (<6 months) non disabling ischemic stroke or TIA in the territory and severe carotid artery stenosis. Carotid stenting is a potential alternative to surgery in patients younger than ≈70 years or patients with greater risk of surgery due to anatomic or medical conditions or specific circumstances such as radiation-induced stenosis or restenosis after surgery. For patients with hemorrhagic stroke due to hypertension-associated small vessel disease or cerebral amyloid angiopathy, strict control of blood pressure is essential. Restarting oral anticoagulants in patients after intracranial hemorrhage is a difficult decision that should weigh the risks of recurrent ischemic and hemorrhage stroke with and without oral anticoagulants. Several areas of uncertainty persist including the optimal target of blood pressure in patients with cerebrovascular disease, the benefit of PFO closure in patients with PFO-associated stroke, of stenting procedures in patients with atherosclerotic intracranial artery or extracranial vertebral artery stenosis, and of interventional procedures in patients with brain arteriovenous or cavernous malformations.
Collapse
|
715
|
The Association between Impaired Glucose Regulation and Prognosis of Chinese Patients with Intracerebral Hemorrhage. Sci Rep 2016; 6:36220. [PMID: 27796374 PMCID: PMC5086982 DOI: 10.1038/srep36220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 10/12/2016] [Indexed: 12/16/2022] Open
Abstract
This study aimed at observing the influence of impaired glucose regulation (IGR) on 1-year outcomes in patients with intracerebral hemorrhage (ICH). Patients hospitalized for ICH from 2008 to 2009 were recruited consecutively at 35 centres across China. A standard oral glucose tolerance test at day 14 ± 3 after stroke onset or before discharge was performed to identify IGR. The outcomes were death (modified Rankin scale [mRS] score of 6), dependency (mRS score of 2 to 5) and poor outcome (mRS score of 2 to 6) at 1 year. Cox proportion hazard model for death and logistic regression model for dependency and poor outcome were performed to investigate the influence of IGR on 1-year outcomes. A total of 288 non-diabetic ICH patients were included in this analysis, among which 150 (52.1%) were IGR. IGR was associated with 1-year dependency (adjusted odds ratio [OR] 2.18, 95% confidence interval [CI], 1.19–3.99; P = 0.01) and poor outcome (adjusted OR 2.17; 95% CI, 1.24–3.80; P = 0.007) of patients with ICH. However, IGR showed no significant association with 1-year death (adjusted hazard ratio 1.49, 95% CI, 0.60–3.67; P = 0.39). IGR was independently associated with 1-year poor outcome of ICH in Chinese patients, with more important influence on dependency than death.
Collapse
|
716
|
Stuart AC, Sico JJ, Viscoli CM, Tayal AH, Inzucchi SE, Ford GA, Furie KL, Cote R, Spence JD, Tanne D, Kernan WN. Taking care of volunteers in a stroke trial: a new assisted-management strategy. Stroke Vasc Neurol 2016; 1:108-114. [PMID: 28959471 PMCID: PMC5435205 DOI: 10.1136/svn-2016-000029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 08/22/2016] [Accepted: 08/25/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND AND PURPOSE Providing participants with evidence-based care for secondary prevention is an ethical and scientific priority for trials in stroke therapy. The optimal strategy, however, is uncertain. We report the performance of a new approach for delivering preventive care to trial participants. METHODS Participants were enrolled in the Insulin Resistance Intervention after Stroke trial, which examined the insulin sensitiser, pioglitazone versus placebo for prevention of stroke and myocardial infarction after ischaemic stroke or transient ischaemic attack. Preventive care was the responsibility of the participants' personal healthcare providers, but investigators monitored care and provided feedback annually. We studied achievement of 8 prevention goals at baseline and 3 annual visits, with a focus on 3 priority goals: blood pressure <140/90 mm Hg, low-density lipoprotein (LDL) cholesterol <2.59 mmol/L and antithrombotic therapy. RESULTS The proportion of participants achieving the priority goals was highest for antithrombotic use (96-99% in each year) and similar for blood pressure (66-72% in each year) and LDL (68-70% in each year). All 3 priority goals were achieved by 47-52% of participants in any given year. However, only 22% of participants achieved all 3 goals in each year. CONCLUSIONS A strategy of monitoring care and providing feedback was associated with high average yearly achievement of 3 priority secondary prevention goals, but the majority of trial participants did not persist in being at goal over time. TRIAL REGISTRATION NUMBER NCT00091949.
Collapse
Affiliation(s)
- Amber C Stuart
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jason J Sico
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Neurology Service, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Catherine M Viscoli
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ashis H Tayal
- Neuroscience Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.,Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Silvio E Inzucchi
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Gary A Ford
- Division of Medical Sciences, Oxford University, Oxford, UK
| | - Karen L Furie
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Robert Cote
- Department of Neurology, Neurosurgery and Medicine, McGill University, Montreal, Quebec, Canada
| | | | - David Tanne
- Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Walter N Kernan
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
717
|
Sánchez-Iñigo L, Navarro-González D, Fernández-Montero A, Pastrana-Delgado J, Martínez JA. Risk of incident ischemic stroke according to the metabolic health and obesity states in the Vascular-Metabolic CUN cohort. Int J Stroke 2016; 12:187-191. [DOI: 10.1177/1747493016672083] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Whether obesity is a major risk factor for cardiovascular disease in the absence of metabolic comorbidities remains under debate. Indeed, some obese individuals may be at low risk of metabolic-related complications, while normal-weight individuals may not be “healthy.” Aims To assess the incidence of ischemic stroke according to the metabolic health and obesity states of 5171 participants from the Vascular-Metabolic CUN cohort. Methods A Cox proportional-hazard analysis was conducted to estimate the hazard ratio and their 95% confidence interval of stroke according to the metabolic health and obesity states based on TyG index and Adult Treatment Panel-III criteria, during 9.1 years of follow-up. Results After 50,056.2 person-years of follow-up, 162 subjects developed an ischemic stroke (incidence rate 3.23 per 1000 person-years). Metabolically healthy obese subjects did not show greater risk of stroke, while metabolically unhealthy participants, obese and non-obese, had an increased risk of stroke, compared with healthy non-obese. The hazard ratios for the multivariable adjusted model were 1.55 (95% CI: 1.36–1.77) and 1.86 (95% CI: 1.57–2.21), respectively. Conclusions Metabolically unhealthy individuals exhibited a greater risk of ischemic stroke than metabolically healthy obese individuals.
Collapse
Affiliation(s)
- Laura Sánchez-Iñigo
- Hospital Garcia Orcoyen, Navarra, Spain
- Centro de Salud de Burlada, Navarra, Spain
- University of Navarra
| | | | - Alejandro Fernández-Montero
- University of Navarra
- Department of Occupational Medicine, University of Navarra Clinic, Pamplona, Spain
- Department of Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain
| | - Juan Pastrana-Delgado
- University of Navarra
- Department of Internal Medicine, University of Navarra Clinic, Pamplona, Spain
- IdiSNA, Pamplona, Spain
| | - JA Martínez
- University of Navarra
- IdiSNA, Pamplona, Spain
- Centre for Nutrition Research, Food Science and Physiology, University of Navarra, Pamplona, Spain
- Centro de Investigación Biomédica en Red de Fiosiopatología de la Obesidad y Nutrición (CIBERObn), Instituto CarlosIII, Madrid, Spain
| |
Collapse
|
718
|
Di Pino A, Urbano F, Piro S, Purrello F, Rabuazzo AM. Update on pre-diabetes: Focus on diagnostic criteria and cardiovascular risk. World J Diabetes 2016; 7:423-432. [PMID: 27795816 PMCID: PMC5065662 DOI: 10.4239/wjd.v7.i18.423] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 06/24/2016] [Accepted: 08/15/2016] [Indexed: 02/05/2023] Open
Abstract
Pre-diabetes, which is typically defined as blood glucose concentrations higher than normal but lower than the diabetes threshold, is a high-risk state for diabetes and cardiovascular disease development. As such, it represents three groups of individuals: Those with impaired fasting glucose (IFG), those with impaired glucose tolerance (IGT) and those with a glycated haemoglobin (HbA1c) between 39-46 mmol/mol. Several clinical trials have shown the important role of IFG, IGT and HbA1c-pre-diabetes as predictive tools for the risk of developing type 2 diabetes. Moreover, with regard to cardiovascular disease, pre-diabetes is associated with more advanced vascular damage compared with normoglycaemia, independently of confounding factors. In view of these observations, diagnosis of pre-diabetes is mandatory to prevent or delay the development of the disease and its complications; however, a number of previous studies reported that the concordance between pre-diabetes diagnoses made by IFG, IGT or HbA1c is scarce and there are conflicting data as to which of these methods best predicts cardiovascular disease. This review highlights recent studies and current controversies in the field. In consideration of the expected increased use of HbA1c as a screening tool to identify individuals with alteration of glycaemic homeostasis, we focused on the evidence regarding the ability of HbA1c as a diagnostic tool for pre-diabetes and as a useful marker in identifying patients who have an increased risk for cardiovascular disease. Finally, we reviewed the current evidence regarding non-traditional glycaemic biomarkers and their use as alternatives to or additions to traditional ones.
Collapse
|
719
|
Ekström N, Svensson AM, Miftaraj M, Franzén S, Zethelius B, Eliasson B, Gudbjörnsdottir S. Cardiovascular safety of glucose-lowering agents as add-on medication to metformin treatment in type 2 diabetes: report from the Swedish National Diabetes Register. Diabetes Obes Metab 2016; 18:990-8. [PMID: 27282621 DOI: 10.1111/dom.12704] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 05/26/2016] [Accepted: 06/04/2016] [Indexed: 12/20/2022]
Abstract
AIM To investigate the relative safety of various glucose-lowering agents as add-on medication to metformin in type 2 diabetes in an observational study linking five national health registers. RESEARCH DESIGN AND METHODS Patients with type 2 diabetes who had been on metformin monotherapy and started another agent in addition to metformin were eligible for inclusion. The study period was 2005-2012. Adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of mortality, cardiovascular disease (CVD), coronary heart disease (CHD), stroke and congestive heart failure (CHF) were estimated using Cox proportional hazards models, weighted for a propensity score. RESULTS Of the 20 422 patients included in the study, 43% started on second-line treatment with sulphonylurea (SU), 21% basal insulin, 12% thiazolidinedione (TZD), 11% meglitinide, 10% dipeptidyl peptidase-4 (DPP-4) inhibitor, 1% glucagon-like peptide-1 (GLP-1) receptor agonist and 1% acarbose. At the index date, the mean patient age was ~60 years for all groups except the GLP-1 receptor agonist (56.0 years) and SU (62.9 years) groups. Diabetes duration and glycated haemoglobin levels were similar in all groups. When compared with SU, basal insulin was associated with an 18% higher risk and TZD with a 24% lower risk of mortality [HR 1.18 (95% CI 1.03-1.36) and 0.76 (95% CI 0.62-0.94)], respectively. DPP-4 inhibitor treatment was associated with significantly lower risks of CVD, fatal CVD, CHD, fatal CHD and CHF. CONCLUSIONS This nationwide observational study showed that second-line treatment with TZD and DPP-4 inhibitor as add-on medication to metformin were associated with significantly lower risks of mortality and cardiovascular events compared with SU, whereas basal insulin was associated with a higher risk of mortality.
Collapse
Affiliation(s)
- Nils Ekström
- Department of Medicine, University of Gothenburg, Gothenburg, Sweden.
- Department of Medicine Solna, Center for Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden.
| | | | - Mervete Miftaraj
- Center of Registers in Region Västra Götaland, Gothenburg, Sweden
| | - Stefan Franzén
- Center of Registers in Region Västra Götaland, Gothenburg, Sweden
| | - Björn Zethelius
- Department of Public Health and Caring Sciences/Geriatrics, Uppsala University, Uppsala, Sweden
- Medical Products Agency, Uppsala, Sweden
| | - Björn Eliasson
- Department of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Soffia Gudbjörnsdottir
- Department of Medicine, University of Gothenburg, Gothenburg, Sweden
- Center of Registers in Region Västra Götaland, Gothenburg, Sweden
| |
Collapse
|
720
|
Abstract
Depression and fatigue are common after stroke and negatively impact the quality of life of stroke survivors. The biological bases of these symptoms are unknown, but an abundance of data point to a role for inflammation. This review highlights evidence supporting the contribution of inflammation to poststroke depression and poststroke fatigue. Potential treatments for poststroke depression and poststroke fatigue are explored, with a special emphasis on those that modulate the immune response.
Collapse
Affiliation(s)
- Kyra J Becker
- University of Washington School of Medicine, Seattle, WA, USA.
| |
Collapse
|
721
|
Inzucchi SE, Viscoli CM, Young LH, Furie KL, Gorman M, Lovejoy AM, Dagogo-Jack S, Ismail-Beigi F, Korytkowski MT, Pratley RE, Schwartz GG, Kernan WN. Pioglitazone Prevents Diabetes in Patients With Insulin Resistance and Cerebrovascular Disease. Diabetes Care 2016; 39:1684-92. [PMID: 27465265 PMCID: PMC5033078 DOI: 10.2337/dc16-0798] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 07/04/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The Insulin Resistance Intervention after Stroke (IRIS) trial recently found that pioglitazone reduced risk for stroke and myocardial infarction in patients with insulin resistance but without diabetes who had had a recent ischemic stroke or transient ischemic attack (TIA). This report provides detailed results on the metabolic effects of pioglitazone and the trial's prespecified secondary aim of diabetes prevention. RESEARCH DESIGN AND METHODS A total of 3,876 patients with recent ischemic stroke or TIA, no history of diabetes, fasting plasma glucose (FPG) <126 mg/dL, and insulin resistance by homeostasis model assessment of insulin resistance (HOMA-IR) score >3.0 were randomly assigned to pioglitazone or placebo. Surveillance for diabetes onset during the trial was accomplished by periodic interviews and annual FPG testing. RESULTS At baseline, the mean FPG, HbA1c, insulin, and HOMA-IR were 98.2 mg/dL (5.46 mmol/L), 5.8% (40 mmol/mol), 22.4 μIU/mL, and 5.4, respectively. After 1 year, mean HOMA-IR and FPG decreased to 4.1 and 95.1 mg/dL (5.28 mmol/L) in the pioglitazone group and rose to 5.7 and 99.7 mg/dL (5.54 mmol/L), in the placebo group (all P < 0.0001). Over a median follow-up of 4.8 years, diabetes developed in 73 (3.8%) participants assigned to pioglitazone compared with 149 (7.7%) assigned to placebo (hazard ratio [HR] 0.48 [95% CI 0.33-0.69]; P < 0.0001). This effect was predominately driven by those with initial impaired fasting glucose (FPG >100 mg/dL [5.6 mmol/L]; HR 0.41 [95% CI 0.30-0.57]) or elevated HbA1c (>5.7% [39 mmol/mol]; HR 0.46 [0.34-0.62]). CONCLUSIONS Among patients with insulin resistance but without diabetes who had had a recent ischemic stroke or TIA, pioglitazone decreased the risk of diabetes while also reducing the risk of subsequent ischemic events. Pioglitazone is the first medication shown to prevent both progression to diabetes and major cardiovascular events as prespecified outcomes in a single trial.
Collapse
Affiliation(s)
| | | | | | - Karen L Furie
- Alpert Medical School of Brown University, Providence, RI
| | | | | | | | | | | | | | - Gregory G Schwartz
- VA Medical Center and University of Colorado School of Medicine, Denver, CO
| | | | | |
Collapse
|
722
|
|
723
|
Lovre D, Htun W, Carrion C, Fonseca VA. What Are We Learning from the FDA-Mandated Cardiovascular Outcome Studies for New Pharmacological Antidiabetic Agents? Curr Diab Rep 2016; 16:94. [PMID: 27541296 DOI: 10.1007/s11892-016-0788-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cardiovascular disease (CVD) is common in patients with diabetes. For these patients, clinicians should seek diabetes treatment that is beneficial rather than harmful in relation to CVD. Until recently, there have been many treatments for hyperglycemia, whose impact on CVD has been controversial. The aims of this review are to evaluate the effectiveness of antihyperglycemic medications on risk factors for CVD and to examine the impact of these drugs on CVD in cardiovascular (CV) outcome trials. In this article, we summarize current knowledge about the impacts of these drugs on various risk factors as well as CV outcomes. We identify the recent emergence of trials with antihyperglycemic agents showing newly discovered CV benefits as well as past trials with antihyperglycemic agents not showing much benefit on CV events. Rather than focusing on treatment strategies, we review the effects of individual drug classes on CV outcomes. We also briefly review goal-driven glycemia reduction and its impact on CVD. We conclude that antihyperglycemic agents are associated with improvement in CV risk factors in patients with diabetes and insulin resistance; in fact, a few drugs reduced CV events in randomized CV outcome trials. Therefore, the use of these drugs is appropriate for reducing glucose and decreasing CV event risk in a select subpopulation.
Collapse
Affiliation(s)
- Dragana Lovre
- Tulane University Health Sciences Center, 1430 Tulane Ave., SL-53, New Orleans, LA, 70112, USA.
| | - Wynn Htun
- Tulane University Health Sciences Center, 1430 Tulane Ave., SL-53, New Orleans, LA, 70112, USA
| | - Carly Carrion
- Tulane University Health Sciences Center, 1430 Tulane Ave., SL-53, New Orleans, LA, 70112, USA
| | - Vivian A Fonseca
- Tulane University Health Sciences Center, 1430 Tulane Ave., SL-53, New Orleans, LA, 70112, USA
- Southeast Louisiana Veterans Health Care Systems, New Orleans, USA
| |
Collapse
|
724
|
Lee CH, Shih AZL, Woo YC, Fong CHY, Leung OY, Janus E, Cheung BMY, Lam KSL. Optimal Cut-Offs of Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) to Identify Dysglycemia and Type 2 Diabetes Mellitus: A 15-Year Prospective Study in Chinese. PLoS One 2016; 11:e0163424. [PMID: 27658115 PMCID: PMC5033570 DOI: 10.1371/journal.pone.0163424] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 09/08/2016] [Indexed: 01/14/2023] Open
Abstract
Background The optimal reference range of homeostasis model assessment of insulin resistance (HOMA-IR) in normal Chinese population has not been clearly defined. Here we address this issue using the Hong Kong Cardiovascular Risk Factor Prevalence Study (CRISPS), a prospective population-based cohort study with long-term follow-up. Material & Methods In this study, normal glucose tolerance (NGT), impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and type 2 diabetes mellitus (T2DM) were defined according to the 1998 World Health Organization criteria. Dysglycemia referred to IFG, IGT or T2DM. This study comprised two parts. Part one was a cross-sectional study involving 2,649 Hong Kong Chinese subjects, aged 25–74 years, at baseline CRISPS-1 (1995–1996). The optimal HOMA-IR cut-offs for dysglycemia and T2DM were determined by the receiver-operating characteristic (ROC) curve. Part two was a prospective study involving 872 subjects who had persistent NGT at CRISPS-4 (2010–2012) after 15 years of follow-up. Results At baseline, the optimal HOMA-IR cut-offs to identify dysglyceia and T2DM were 1.37 (AUC = 0.735; 95% confidence interval [CI] = 0.713–0.758; Sensitivity [Se] = 65.6%, Specificity [Sp] = 71.3%] and 1.97 (AUC = 0.807; 95% CI = 0.777–0.886; Se = 65.5%, Sp = 82.9%) respectively. These cut-offs, derived from the cross-sectional study at baseline, corresponded closely to the 75th (1.44) and 90th (2.03) percentiles, respectively, of the HOMA-IR reference range derived from the prospective study of subjects with persistent NGT. Conclusions HOMA-IR cut-offs, of 1.4 and 2.0, which discriminated dysglycemia and T2DM respectively from NGT in Southern Chinese, can be usefully employed as references in clinical research involving the assessment of insulin resistance.
Collapse
Affiliation(s)
- C. H. Lee
- Department of Medicine, The University of Hong Kong, Hong Kong S.A.R., China
- Research Center of Heart, Brain, Hormone and Healthy Aging, The University of Hong Kong, Hong Kong S.A.R., China
| | - A. Z. L. Shih
- Department of Medicine, The University of Hong Kong, Hong Kong S.A.R., China
| | - Y. C. Woo
- Department of Medicine, The University of Hong Kong, Hong Kong S.A.R., China
| | - C. H. Y. Fong
- Department of Medicine, The University of Hong Kong, Hong Kong S.A.R., China
| | - O. Y. Leung
- Department of Medicine, The University of Hong Kong, Hong Kong S.A.R., China
| | - E. Janus
- Department of Medicine, University of Melbourne and Western Health, Melbourne, Victoria, Australia
| | - B. M. Y. Cheung
- Department of Medicine, The University of Hong Kong, Hong Kong S.A.R., China
- Research Center of Heart, Brain, Hormone and Healthy Aging, The University of Hong Kong, Hong Kong S.A.R., China
| | - K. S. L. Lam
- Department of Medicine, The University of Hong Kong, Hong Kong S.A.R., China
- Research Center of Heart, Brain, Hormone and Healthy Aging, The University of Hong Kong, Hong Kong S.A.R., China
- State Key Laboratory of Pharmaceutical Biotechnology, The University of Hong Kong, Hong Kong S.A.R., China
- * E-mail:
| |
Collapse
|
725
|
Fitchett DH, Udell JA, Inzucchi SE. Heart failure outcomes in clinical trials of glucose‐lowering agents in patients with diabetes. Eur J Heart Fail 2016; 19:43-53. [DOI: 10.1002/ejhf.633] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 07/08/2016] [Accepted: 07/09/2016] [Indexed: 01/27/2023] Open
Affiliation(s)
| | - Jacob A. Udell
- Toronto General Hospital and Women's College Hospital University of Toronto Canada
| | - Silvio E. Inzucchi
- Section of Endocrinology Yale University School of Medicine New Haven CT USA
| |
Collapse
|
726
|
Tomlinson B, Hu M, Zhang Y, Chan P, Liu ZM. Effects of glucose-lowering drugs on cardiovascular outcomes in patients with type 2 diabetes. Expert Opin Drug Metab Toxicol 2016; 12:1267-1271. [PMID: 27607315 DOI: 10.1080/17425255.2016.1234608] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Brian Tomlinson
- Research Center for Translational Medicine, Shanghai East Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Miao Hu
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Yuzhen Zhang
- Research Center for Translational Medicine, Shanghai East Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Paul Chan
- Division of Cardiology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei City, Taiwan
| | - Zhong-Min Liu
- Department of Cardiac Surgery, Shanghai East Hospital, Tongji University, Shanghai, China
| |
Collapse
|
727
|
Abdul-Ghani M, DeFronzo RA, Jayyousi A. Prediabetes and risk of diabetes and associated complications: impaired fasting glucose versus impaired glucose tolerance: does it matter? Curr Opin Clin Nutr Metab Care 2016; 19:394-399. [PMID: 27389083 DOI: 10.1097/mco.0000000000000307] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the distinct metabolic and pathophysiologic phenotype of impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) and the subsequent clinical implications with regard to future type 2 diabetes mellitus (T2DM) and cardiovascular risk. RECENT FINDINGS Both IFG and IGT manifest the two core defects of T2DM, that is, insulin resistance and β-cell dysfunction. However, the site of insulin resistance and shape of β-cell dysfunction differ. These distinct metabolic and pathophysiologic phenotypes explain the greater cardiovascular disease (CVD) risk associated with an increase in the 2-h plasma glucose concentration, that is, IGT compared with an increase in the fasting plasma glucose (FPG) concentration, that is, IFG. Moreover, the increase in future T2DM risk in IFG study participants is, at least in part, explained by the strong correlation between the increase in FPG and the increase in 2-h plasma glucose concentration. SUMMARY Last, recent studies have reported the presence of diabetic microvascular complications, that is, retinopathy and neuropathy, at the IGT stage.Thus, a glucose load (e.g. oral glucose tolerance test) is required in study participants with elevated FPG concentration to accurately assess their future risk for T2DM, as well as their risk for CVD to identify the subgroup of IFG who are at greater risk and subject them to an intervention program to decrease their future T2DM and CVD risk.
Collapse
Affiliation(s)
- Muhammad Abdul-Ghani
- aDivision of Diabetes, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA bDepartment of Medicine, Diabetes and Obesity Clinical Research Center, Hamad General Hospital, Doha, Qatar
| | | | | |
Collapse
|
728
|
Schwartz SS, Zangeneh F. Evidence-based practice use of quick-release bromocriptine across the natural history of type 2 diabetes mellitus. Postgrad Med 2016; 128:828-838. [PMID: 27458683 DOI: 10.1080/00325481.2016.1214059] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To provide an evidence-based practice overview on the clinical use of bromocriptine-quick release (QR) across the natural history of type 2 diabetes mellitus (T2DM). METHODS Articles for inclusion were selected after a comprehensive literature search of English-language PubMed articles and identification of other relevant references through other sources. Inclusion criteria were animal studies examining the mechanism of action and efficacy of bromocriptine, and clinical studies examining the safety and efficacy of bromocriptine-QR in patients with T2DM, without a time limitation. RESULTS The brain plays a key role in total body metabolism, in particular ensuring that sufficient levels of glucose are available for proper neural functioning. The hypothalamic suprachiasmatic nucleus (SCN), the body's biological clock, plays a key role in the regulation of seasonal and diurnal variations of insulin sensitivity. A daily surge of dopaminergic activity in the SCN upon waking enables insulin sensitivity throughout the day. When this is disrupted (e.g. by a high fat/sugar diet, stress, altered [diminished] exercise, altered sleep/wake cycle, diabetes), insulin resistance persists throughout the day and overnight. Improving the morning surge in dopaminergic activity with the short-acting dopamine D2 receptor agonist bromocriptine-QR can safely and effectively improve glycemic control, while improving cardiovascular disease risk factors and related adverse events, and reducing sympathetic tone, as demonstrated by 5 reports of the Cycloset Safety Trial and 3 additional clinical studies of bromocriptine-QR. CONCLUSIONS In patients with T2DM, the dopamine D2 receptor agonist bromocriptine-QR has been shown to be well tolerated, efficacious, and a logical treatment option.
Collapse
Affiliation(s)
- Stanley S Schwartz
- a Main Line Health System , Wynnewood , PA , USA.,b University of Pennsylvania , Philadelphia , PA , USA
| | - Farhad Zangeneh
- c Endocrine, Diabetes & Osteoporosis Clinic , Sterling , VA , USA
| |
Collapse
|
729
|
|
730
|
Barb D, Portillo-Sanchez P, Cusi K. Pharmacological management of nonalcoholic fatty liver disease. Metabolism 2016; 65:1183-95. [PMID: 27301803 DOI: 10.1016/j.metabol.2016.04.004] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 04/16/2016] [Accepted: 04/18/2016] [Indexed: 12/12/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) affects one-third of the population and two-thirds of patients with obesity or type 2 diabetes (T2DM). Its more aggressive form is known as nonalcoholic steatohepatitis (NASH) and is characterized by hepatocyte necrosis, inflammation and often fibrosis. The presence of fibrosis indicates a more aggressive course and may lead to cirrhosis. Premature mortality in NASH is related to both hepatic (cirrhosis and hepatocellular carcinoma) and extra-hepatic complications, largely cardiovascular disease (CVD). Many therapeutic agents have been tested, but still none approved specifically for NASH. Treatment of NAFLD includes aggressive management of diabetes and cardiovascular risk factors, although the role of controlling hyperglycemia per se in patients with T2DM and NASH remains unknown. Agents tested with some success in non-diabetic patients with NASH include pioglitazone, liraglutide, vitamin E and to a lesser degree, pentoxiphylline. In patients with T2DM and NASH only pioglitazone has shown to significantly improve liver histology, with only a handful of patients with diabetes having been studied with other modalities. This review focuses on available agents for NASH to assist clinicians in the management of these complex patients. Many novel compounds are being studied and will likely make combination therapy for NASH a reality in the future.
Collapse
Affiliation(s)
- Diana Barb
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA; Division of Endocrinology, Diabetes and Metabolism at Malcom Randall Veterans Affairs Medical Center, Gainesville, FL, USA
| | - Paola Portillo-Sanchez
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA; Division of Endocrinology, Diabetes and Metabolism at Malcom Randall Veterans Affairs Medical Center, Gainesville, FL, USA
| | - Kenneth Cusi
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA; Division of Endocrinology, Diabetes and Metabolism at Malcom Randall Veterans Affairs Medical Center, Gainesville, FL, USA.
| |
Collapse
|
731
|
Lai SW, Lin HF, Lin CL, Liao KF. Long-term effects of pioglitazone on first attack of ischemic cerebrovascular disease in older people with type 2 diabetes: A case-control study in Taiwan. Medicine (Baltimore) 2016; 95:e4455. [PMID: 27495077 PMCID: PMC4979831 DOI: 10.1097/md.0000000000004455] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Long-term studies demonstrating the effect of pioglitazone use on primary prevention of ischemic cerebrovascular disease in older people with type 2 diabetes mellitus are lacking. This study investigated the relationship between pioglitazone use and first attack of ischemic cerebrovascular disease in Taiwan.We conducted a case-control study using the database of the Taiwan National Health Insurance Program. There were 2359 type 2 diabetic subjects aged ≥65 years with newly diagnosed ischemic cerebrovascular disease from 2005 to 2011 as the case group and 4592 sex- and age-matched, randomly selected type 2 diabetic subjects aged ≥65 years without ischemic cerebrovascular disease as the control group. The odds ratio (OR) with 95% confidence interval (CI) of ischemic cerebrovascular disease associated with pioglitazone use was measured by the multivariable unconditional logistic regression model.After adjustment for confounding factors, the multivariable logistic regression analysis disclosed that the adjusted ORs of first attack of ischemic cerebrovascular disease associated with cumulative duration of using pioglitazone were 3.34 for <1 year (95% CI 2.59-4.31), 2.53 for 1 to 2 years (95% CI 1.56-4.10), 2.20 for 2 to 3 years (95% CI 1.05-4.64), and 1.09 for ≥3 years (95% CI 0.55-2.15), respectively.Our findings suggest that pioglitazone use does not have a protective effect on primary prevention for ischemic cerebrovascular disease among older people with type 2 diabetes mellitus during the first 3 years of use. Whether using pioglitazone for >3 years would have primary prevention for ischemic cerebrovascular disease needs a long-term research to prove.
Collapse
Affiliation(s)
- Shih-Wei Lai
- College of Medicine, China Medical University, Taichung, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Hsien-Feng Lin
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
- School of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Cheng-Li Lin
- College of Medicine, China Medical University, Taichung, Taiwan
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Kuan-Fu Liao
- College of Medicine, Tzu Chi University, Hualien, Taiwan
- Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
- Department of Internal Medicine, Taichung Tzu Chi General Hospital, Taichung, Taiwan
- Correspondence: Kuan-Fu Liao, Department of Internal Medicine, Taichung Tzu Chi General Hospital, No. 66, Sec. 1, Fongsing Road, Tanzi District, Taichung City 427, Taiwan (e-mail: )
| |
Collapse
|
732
|
Bath PM, Appleton JP, Sprigg N. The Insulin Resistance Intervention after Stroke trial: A perspective on future practice and research. Int J Stroke 2016; 11:741-3. [DOI: 10.1177/1747493016660099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 05/30/2016] [Indexed: 12/18/2022]
Abstract
The prevention of recurrent events after ischaemic stroke and transient ischaemic attack is well established and based on lifestyle changes, antithrombotics, statins, antihypertensives and carotid surgery. The international IRIS trial assessed whether pioglitazone, a glucose-lowering insulin-sensitizing drug, would reduce recurrent vascular events in patients with ischaemic stroke or transient ischaemic attack. After 4.8 years, pioglitazone therapy was associated with reduced vascular events and new diabetes, and an increase in weight, oedema and bone fractures. Pioglitazone may add to the strategies for preventing further events in patients with stroke or transient ischaemic attack.
Collapse
Affiliation(s)
- Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| |
Collapse
|
733
|
Bloomgarden Z. Glycemic control and the heart: it matters how you get there. J Diabetes 2016; 8:453-4. [PMID: 26990043 DOI: 10.1111/1753-0407.12398] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/11/2016] [Indexed: 11/28/2022] Open
|
734
|
Abstract
INTRODUCTION Cardiovascular disease remains the major contributor to morbidity and mortality in diabetes. From the need to reduce cardiovascular risk in diabetes and to ensure that such risk is not exacerbated by drug treatments, governmental regulators and drug manufacturers have focused on clinical trials evaluating cardiovascular outcomes. AREAS COVERED Findings from mechanistic and clinical trials of biguanides, sulfonylureas, thiazolidinediones, dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and sodium-glucose co-transporter 2 (SGLT-2) inhibitors will be reviewed. These drug classes will be compared within the context of available cardiovascular outcomes data. Clinical implications of new study regulations will be examined. EXPERT OPINION Recent cardiovascular studies provide a more comprehensive evaluation of specific anti-diabetes therapy in individuals with high cardiovascular risk. Long-term effects of anti-hyperglycemic agents in patients with lower cardiovascular risk are still speculative. Historical data supports continued use of metformin as a first-line agent. DPP-4 inhibitors and GLP-1 receptor agonists appear to have neutral effects on cardiovascular outcomes. The significantly decreased cardiovascular risk associated with empagliflozin SGLT-2 inhibitor therapy is impressive and may change how practitioners prescribe add-on therapy to metformin.
Collapse
Affiliation(s)
- Lisa M Younk
- a Department of Medicine , University of Maryland School of Medicine , Baltimore , MD , USA
| | - Elizabeth M Lamos
- b Division of Endocrinology, Diabetes and Nutrition , University of Maryland School of Medicine , Baltimore , MD , USA
| | - Stephen N Davis
- a Department of Medicine , University of Maryland School of Medicine , Baltimore , MD , USA
| |
Collapse
|
735
|
Scientific surgery. Br J Surg 2016. [DOI: 10.1002/bjs.10231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
736
|
Low Wang CC, Hess CN, Hiatt WR, Goldfine AB. Clinical Update: Cardiovascular Disease in Diabetes Mellitus: Atherosclerotic Cardiovascular Disease and Heart Failure in Type 2 Diabetes Mellitus - Mechanisms, Management, and Clinical Considerations. Circulation 2016; 133:2459-502. [PMID: 27297342 PMCID: PMC4910510 DOI: 10.1161/circulationaha.116.022194] [Citation(s) in RCA: 675] [Impact Index Per Article: 84.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cardiovascular disease remains the principal cause of death and disability among patients with diabetes mellitus. Diabetes mellitus exacerbates mechanisms underlying atherosclerosis and heart failure. Unfortunately, these mechanisms are not adequately modulated by therapeutic strategies focusing solely on optimal glycemic control with currently available drugs or approaches. In the setting of multifactorial risk reduction with statins and other lipid-lowering agents, antihypertensive therapies, and antihyperglycemic treatment strategies, cardiovascular complication rates are falling, yet remain higher for patients with diabetes mellitus than for those without. This review considers the mechanisms, history, controversies, new pharmacological agents, and recent evidence for current guidelines for cardiovascular management in the patient with diabetes mellitus to support evidence-based care in the patient with diabetes mellitus and heart disease outside of the acute care setting.
Collapse
Affiliation(s)
- Cecilia C Low Wang
- From Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Colorado School of Medicine, Aurora (C.C.L.); CPC Clinical Research, Aurora, CO (C.C.L., C.N.H., W.R.H.); Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora (C.N.H., W.R.H.); Joslin Diabetes Center, and Harvard Medical School, Boston, MA (A.B.G.)
| | - Connie N Hess
- From Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Colorado School of Medicine, Aurora (C.C.L.); CPC Clinical Research, Aurora, CO (C.C.L., C.N.H., W.R.H.); Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora (C.N.H., W.R.H.); Joslin Diabetes Center, and Harvard Medical School, Boston, MA (A.B.G.)
| | - William R Hiatt
- From Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Colorado School of Medicine, Aurora (C.C.L.); CPC Clinical Research, Aurora, CO (C.C.L., C.N.H., W.R.H.); Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora (C.N.H., W.R.H.); Joslin Diabetes Center, and Harvard Medical School, Boston, MA (A.B.G.)
| | - Allison B Goldfine
- From Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Colorado School of Medicine, Aurora (C.C.L.); CPC Clinical Research, Aurora, CO (C.C.L., C.N.H., W.R.H.); Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora (C.N.H., W.R.H.); Joslin Diabetes Center, and Harvard Medical School, Boston, MA (A.B.G.).
| |
Collapse
|
737
|
Bae JC. Diabetes Drugs and Cardiovascular Safety. Endocrinol Metab (Seoul) 2016; 31:239-44. [PMID: 27302713 PMCID: PMC4923407 DOI: 10.3803/enm.2016.31.2.239] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 05/19/2016] [Accepted: 05/24/2016] [Indexed: 02/06/2023] Open
Abstract
Diabetes is a well-known risk factor of cardiovascular morbidity and mortality, and the beneficial effect of improved glycemic control on cardiovascular complications has been well established. However, the rosiglitazone experience aroused awareness of potential cardiovascular risk associated with diabetes drugs and prompted the U.S. Food and Drug Administration to issue new guidelines about cardiovascular risk. Through postmarketing cardiovascular safety trials, some drugs demonstrated cardiovascular benefits, while some antidiabetic drugs raised concern about a possible increased cardiovascular risk associated with drug use. With the development of new classes of drugs, treatment options became wider and the complexity of glycemic management in type 2 diabetes has increased. When choosing the appropriate treatment strategy for patients with type 2 diabetes at high cardiovascular risk, not only the glucose-lowering effects, but also overall benefits and risks for cardiovascular disease should be taken into consideration.
Collapse
Affiliation(s)
- Ji Cheol Bae
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea.
| |
Collapse
|
738
|
Abstract
Epidemiological studies have illustrated convincingly that fat distribution is associated with cardiometabolic risk. Fat deposition preferentially in the lower body, commonly seen in premenopausal women, is associated with lower risk, while central obesity in men and postmenopausal women is associated with higher risk. Studies of the physiology and the tissue and cellular characteristics of different adipose tissue depots, visceral and abdominal, gluteal, and femoral subcutaneous, corroborate this idea. In this report, we chose to focus on interventions-surgical, hormonal, lifestyle, and pharmacological-that directly or indirectly affect fat distribution, seeking further evidence for its pathophysiological significance.
Collapse
Affiliation(s)
- Pornpoj Pramyothin
- Division of Nutrition, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Asadang building, 8th floor, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Kalypso Karastergiou
- Department of Medicine, Evans Biomedical Research Center, Boston University School of Medicine, 650 Albany St, Rm 810, Boston, MA, 02118, USA.
| |
Collapse
|
739
|
Gabbay KH. Insulin sensitivity is a Rubik's Cube. Am J Clin Nutr 2016; 103:1381-2. [PMID: 27194307 DOI: 10.3945/ajcn.116.136127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Kenneth H Gabbay
- Baylor College of Medicine, The Harry B and Aileen Gordon Diabetes Research Center, Houston, TX
| |
Collapse
|
740
|
Heart Failure Considerations of Antihyperglycemic Medications for Type 2 Diabetes. Circ Res 2016; 118:1830-43. [DOI: 10.1161/circresaha.116.306924] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 03/30/2016] [Indexed: 12/21/2022]
Abstract
Prevalent and incident heart failure (HF) is increased in people with type 2 diabetes mellitus, with risk directly associated with the severity of hyperglycemia. Furthermore, in patients with type 2 diabetes mellitus, mortality is increased ≈10-fold in patients with versus without HF. Reducing HF with antihyperglycemic therapies, however, has been unsuccessful until recently. In fact, HF as an important outcome in patients with type 2 diabetes mellitus seems to be heterogeneously modulated by antihyperglycemic medications, as evidenced by results from cardiovascular outcome trials (CVOTs) and large observational cohort studies. Appropriately powered and executed CVOTs are necessary to truly evaluate cardiovascular safety and efficacy of new antihyperglycemic medications, as reflected by the guidance of the US Food and Drug Administration and other regulatory agencies since 2008. In light of the best available evidence at present, metformin and the sodium-glucose-co-transporter 2-inhibitor empagliflozin seem to be especially advantageous with regard to HF effects, with their use associated with reduced HF events and improved mortality. Acarbose, the dipeptidyl-peptidase 4-inhibitor sitagliptin, the glucagon-like peptide 1-receptor agonist lixisenatide based on presently available CVOT results comprise reasonable additional options, as significant harm in terms of HF has been excluded for those drugs. Additions to this list are anticipated pending results of ongoing CVOTs. Although no HF harm was seen in CVOTs for insulin or sulfonylureas, they should be used only with caution in patients with HF, given their established high risk for hypoglycemia and some uncertainties on their safety in patients with HF derived from epidemiological observations. Pioglitazone is contraindicated in patients with HF>New York Heart Association I, despite some benefits suggested by CVOT subanalyses.
Collapse
|
741
|
Ntaios G, Kent TA. Insulin Resistance Intervention After Stroke Trial of Pioglitazone: Is This Perhaps the End of the Beginning? Stroke 2016; 47:1962-4. [PMID: 27222525 DOI: 10.1161/strokeaha.116.013230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 05/04/2016] [Indexed: 11/16/2022]
Affiliation(s)
- George Ntaios
- From the Department of Medicine, University of Thessaly, Larissa, Greece (G.N.); Stroke Outcomes Laboratory, Department of Neurology, Baylor College of Medicine, Houston, TX (T.A.K.); and Center for Translational Research on Inflammatory Diseases, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (T.A.K.).
| | - Thomas A Kent
- From the Department of Medicine, University of Thessaly, Larissa, Greece (G.N.); Stroke Outcomes Laboratory, Department of Neurology, Baylor College of Medicine, Houston, TX (T.A.K.); and Center for Translational Research on Inflammatory Diseases, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (T.A.K.)
| |
Collapse
|
742
|
Schernthaner G, Schernthaner-Reiter MH, Schernthaner GH. EMPA-REG and Other Cardiovascular Outcome Trials of Glucose-lowering Agents: Implications for Future Treatment Strategies in Type 2 Diabetes Mellitus. Clin Ther 2016; 38:1288-1298. [PMID: 27210264 DOI: 10.1016/j.clinthera.2016.04.037] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 04/25/2016] [Accepted: 04/26/2016] [Indexed: 02/07/2023]
Abstract
During the last decade, the armamentarium for glucose-lowering drugs has increased enormously by the development of DPP-4 inhibitors, GLP-1 receptor agonists and SGLT2 inhibitors, allowing individualization of antidiabetic therapy for patients with type 2 diabetes (T2DM). Some combinations can now be used without an increased risk for severe hypoglycemia and weight gain. Following a request of the US Food and Drug Administration, many large cardiovascular (CV) outcome studies have been performed in patients with longstanding disease and established CV disease. In the majority of CV outcome studies, CV risk factors were well controlled and a high number of patients were already treated with ACE inhibitors/angiotensin receptor blockers, statins and antiplatelet drugs. Most studies with insulin glargine and newer glucose-lowering drugs (saxagliptin, alogliptin, sitagliptin, lixisenatide) demonstrated safety of newer glucose-lowering agents but did not show superiority in the CV outcomes compared with placebo. By contrast, in the EMPA-REG OUTCOME (Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients) study, CV death, all-cause mortality, and hospitalization for heart failure were significantly decreased when empagliflozin was added instead of placebo to therapy for patients with high CV risk and T2DM already well treated with statins, glucose-lowering drugs, and blood pressure-lowering drugs as well as antiplatelet agents. In addition, renal endpoints including endstage renal disease were also significantly reduced when empagliflozin was added instead of placebo. Interestingly, the reduction of these clinically relevant end points was observed after a few months, making antiatherogenic effects an unlikely cause. The fact that the incidence of myocardial infarction (MI) and stroke were not reduced is in line with the hypothesis that hemodynamic factors in particular have contributed to the impressive improvement of the prognosis. To reduce the CV burden of patients with T2DM, drugs influencing factors involved in atherogenesis (eg, insulin resistance, chronic inflammation, increase of HDL, prothrombotic state) are more promising. The recent IRIS (Insulin Resistance Intervention after Stroke) study documented a significant reduction in stroke and MI when pioglitazone instead of placebo was given to nondiabetic patients presenting with both stroke/transient ischemic attack and insulin resistance, confirming results from the PROactive (Prospective Pioglitazone Clinical Trial in Macrovascular Events) study in patients with T2DM. Based on these new data, we suggest that the addition of both empagliflozin and pioglitazone to metformin might be the relative best option to reduce the high CV morbidity and mortality of patients with T2DM and already established CV complications. The very recent announcement that the CV outcome study with liraglutide (LEADER) also demonstrated a significant reduction of the composite endpoint (cardiovascular death, non-fatal myocardial infarction or non-fatal stroke) gives new hope for further beneficial treatment options for T2DM patients with established CVD.
Collapse
|
743
|
Rizos CV, Kei A, Elisaf MS. The current role of thiazolidinediones in diabetes management. Arch Toxicol 2016; 90:1861-81. [DOI: 10.1007/s00204-016-1737-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 04/28/2016] [Indexed: 12/17/2022]
|
744
|
DeFronzo RA, Chilton R, Norton L, Clarke G, Ryder REJ, Abdul-Ghani M. Revitalization of pioglitazone: the optimum agent to be combined with a sodium-glucose co-transporter-2 inhibitor. Diabetes Obes Metab 2016; 18:454-62. [PMID: 26919068 DOI: 10.1111/dom.12652] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 02/06/2016] [Accepted: 02/21/2016] [Indexed: 12/15/2022]
Abstract
The recently completed EMPA-REG study showed that empagliflozin significantly decreased the major adverse cardiac events (MACE) endpoint, which comprised cardiovascular death, non-fatal myocardial infarction (MI) and stroke, in patients with high-risk type 2 diabetes (T2DM), primarily through a reduction in cardiovascular death, without a significant decrease in either MI or stroke. In the PROactive study, pioglitazone decreased the MACE endpoint by a similar degree to that observed in the EMPA-REG study, through a marked reduction in both recurrent MI and stroke and a modest reduction in cardiovascular death. These observations suggest that pioglitazone might be an ideal agent to combine with empagliflozin to further reduce cardiovascular events in patients with high-risk diabetes as empagliflozin also promotes salt/water loss and would be expected to offset any fluid retention associated with pioglitazone therapy. In the present paper, we provide an overview of the potential benefits of combined pioglitazone/empagliflozin therapy to prevent cardiovascular events in patients with T2DM.
Collapse
Affiliation(s)
- R A DeFronzo
- Diabetes Division, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, TX, USA
| | - R Chilton
- Cardiology Division, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, TX, USA
| | - L Norton
- Diabetes Division, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, TX, USA
| | - G Clarke
- Diabetes Division and Department of Radiology, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, TX, USA
| | - R E J Ryder
- Diabetes and Endocrine Unit, City Hospital, Birmingham, UK
| | - M Abdul-Ghani
- Diabetes Division, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, TX, USA
| |
Collapse
|
745
|
Abstract
Prevention of cardiovascular morbidity and mortality remains the key factor in the treatment of type 2 diabetes (T2DM). In the early phase of T2DM, multifactorial intervention is mandatory and glucose levels should be near normal, in particular in younger patients presenting with the highest cardiovascular risk. Anti-diabetic drugs without any risk for hypoglycaemia should be preferred in order to reduce clinical inertia and increase the long-term adherence to the treatment. In patients already presenting with cardiovascular disease, the best outcome may be expected with the triple oral therapy of metformin, pioglitazone, and empagliflozin, although a controlled prospective study versus insulin therapy is needed to confirm the expectation.
Collapse
Affiliation(s)
| | - G-H Schernthaner
- Department of Medicine II, Division of Angiology, Medical University Vienna, Wien, Österreich
| |
Collapse
|
746
|
Abdul-Ghani M, Del Prato S, Chilton R, DeFronzo RA. SGLT2 Inhibitors and Cardiovascular Risk: Lessons Learned From the EMPA-REG OUTCOME Study. Diabetes Care 2016; 39:717-25. [PMID: 27208375 PMCID: PMC4839176 DOI: 10.2337/dc16-0041] [Citation(s) in RCA: 216] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 02/24/2016] [Indexed: 02/03/2023]
Abstract
Although cardiovascular (CV) mortality is the principal cause of death in individuals with type 2 diabetes (T2DM), reduction of plasma glucose concentration has little effect on CV disease (CVD) risk. Thus, novel strategies to reduce CVD risk in T2DM patients are needed. The recently published BI 10773 (Empagliflozin) Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients (EMPA-REG OUTCOME) study demonstrated that in T2DM patients with high CVD risk empagliflozin reduced the primary major adverse cardiac event end point (CV death, nonfatal myocardial infarction, nonfatal stroke) by 14%. This beneficial effect was driven by a 38% reduction in CV mortality with no significant decrease in nonfatal myocardial infarction or stroke. Empagliflozin also caused a 35% reduction in hospitalization for heart failure without affecting hospitalization for unstable angina. Although sodium-glucose cotransporter 2 inhibitors exert multiple metabolic benefits (decreases in HbA1c, body weight, and blood pressure and an increase in HDL cholesterol), all of which could reduce CVD risk, it is unlikely that the reduction in CV mortality can be explained by empagliflozin's metabolic effects. More likely, hemodynamic effects, specifically reduced blood pressure and decreased extracellular volume, are responsible for the reduction in CV mortality and heart failure hospitalization. In this Perspective, we will discuss possible mechanisms for these beneficial effects of empagliflozin and their implications for the care of T2DM patients.
Collapse
Affiliation(s)
- Muhammad Abdul-Ghani
- Division of Diabetes, University of Texas Health Science Center at San Antonio, San Antonio, TX Diabetes and Obesity Clinical Research Center, Department of Medicine, Hamad General Hospital, Doha, Qatar
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, University of Pisa School of Medicine, Pisa, Italy
| | - Robert Chilton
- Division of Cardiology, University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System, San Antonio, TX
| | - Ralph A DeFronzo
- Division of Diabetes, University of Texas Health Science Center at San Antonio, San Antonio, TX
| |
Collapse
|
747
|
Xu J, Viscoli CM, Ford GA, Gorman M, Kernan WN. A Diagnostic Score for Insulin Resistance in Nondiabetic Patients with Ischemic Stroke or Transient Ischemic Attack. J Stroke Cerebrovasc Dis 2016; 25:1705-1712. [PMID: 27080156 DOI: 10.1016/j.jstrokecerebrovasdis.2016.03.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 03/19/2016] [Indexed: 01/17/2023] Open
Abstract
GOAL We sought to develop an instrument to screen for insulin resistance in nondiabetic patients with recent ischemic stroke or transient ischemic attack (TIA). MATERIALS AND METHODS Subjects were 7262 nondiabetic patients aged greater than or equal to 40 years with ischemic strokes or TIA within the past 6 months. Features were analyzed in bivariate analysis for association with insulin resistance, measured by the homeostasis model assessment of insulin resistance (HOMA-IR). Features significantly associated with HOMA-IR (P < .05) were entered into multivariable analysis. The magnitudes of regression coefficients from the multivariable model were used to assign point values for 2 diagnostic scoring instruments: a basic instrument that did not incorporate laboratory test values and an enhanced instrument that did. The performance of the instruments was tested using receiver operating characteristic (ROC) analysis. FINDINGS In the basic model, 5 features were retained in the multivariable regression analysis: male gender, abdominal obesity, body mass index (BMI), elevated waist-to-hip ratio, and systolic blood pressure. In the enhanced model, 4 features were retained in the multivariable regression analysis: BMI, abdominal obesity, fasting glucose greater than or equal to 100 mg/dL, and triglyceride/high-density lipoprotein ratio. In the basic model, the area under the ROC curve (aROC) was .73 in the validation cohort. In the enhanced model, the aROC was .78 in the validation cohort. CONCLUSIONS Our 2 scoring systems performed well in identifying stroke patients with insulin resistance, but they are probably not sufficiently accurate for high-stake clinical decisions. We suggest strategies for improving the accuracy of future instruments.
Collapse
Affiliation(s)
- Jin Xu
- Department of Internal Medicine, Yale Health, Yale University, New Haven, Connecticut.
| | - Catherine M Viscoli
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Gary A Ford
- The University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, UK
| | - Mark Gorman
- Department of Neurological Sciences, Vermont College of Medicine, Burlington, Vermont
| | - Walter N Kernan
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | | |
Collapse
|
748
|
Affiliation(s)
- Clay F Semenkovich
- From the Division of Endocrinology, Metabolism and Lipid Research, Washington University, St. Louis
| |
Collapse
|
749
|
Chen R, Ovbiagele B, Feng W. Diabetes and Stroke: Epidemiology, Pathophysiology, Pharmaceuticals and Outcomes. Am J Med Sci 2016; 351:380-6. [PMID: 27079344 PMCID: PMC5298897 DOI: 10.1016/j.amjms.2016.01.011] [Citation(s) in RCA: 328] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 01/25/2016] [Accepted: 01/25/2016] [Indexed: 01/01/2023]
Abstract
There has been a significant increase in obesity rates worldwide with the corresponding surge in diabetes. Diabetes causes various microvascular and macrovascular changes often culminating in major clinical complications, 1 of which, is stroke. Although gains have been made over the last 2 decades in reducing the burden of stroke, the recent rise in rates of diabetes threatens to reverse these advances. Of the several mechanistic stroke subtypes, individuals with diabetes are especially susceptible to the consequences of cerebral small vessel diseases. Hyperglycemia confers greater risk of stroke occurrence. This increased risk is often seen in individuals with diabetes and is associated with poorer clinical outcomes (including higher mortality), especially following ischemic stroke. Improving stroke outcomes in individuals with diabetes requires prompt and persistent implementation of evidence-based medical therapies as well as adoption of beneficial lifestyle practices.
Collapse
Affiliation(s)
- Rong Chen
- Department of Neurology, Affiliated Hospital of Hainan Medical College, Haikou, Hainan, China; Department of Neurology, MUSC Stroke Center, Medical University of South Carolina, Charleston, South Carolina
| | - Bruce Ovbiagele
- Department of Neurology, MUSC Stroke Center, Medical University of South Carolina, Charleston, South Carolina
| | - Wuwei Feng
- Department of Neurology, MUSC Stroke Center, Medical University of South Carolina, Charleston, South Carolina.
| |
Collapse
|
750
|
Huynh K. Pioglitazone reduces risk of stroke or MI. Nat Rev Cardiol 2016. [DOI: 10.1038/nrcardio.2016.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|