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Grunberger G. Will PPAR-γ agonist therapy still have a role in diabetes management in 2013? ACTA ACUST UNITED AC 2013. [DOI: 10.2217/dmt.12.81] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
INTRODUCTION Thiazolidinediones (TZDs) initially showed great promise as unique receptor-mediated oral therapy for type 2 diabetes, but a host of serious side effects, primarily cardiovascular, have limited their utility. It is crucial at this point to perform a risk-benefit analysis to determine what role TZDs should play in our current treatment of type 2 diabetes and where the future of this class of drugs is headed. AREAS COVERED This review provides a comprehensive overview of the literature from 2000 onward reporting the known side effects of rosiglitazone and pioglitazone, with commentary on the quality of the data available, putative mechanism of each side effect and clinical significance. Finally, a perspective on the future of the TZDs as a class is provided. EXPERT OPINION The current TZDs are first-generation, non-specific activators of peroxisome proliferator-activated receptor (PPAR) gamma, resulting in a wide array of deleterious side effects that currently limit their use. However, the development of highly targeted selective PPAR gamma modulators (SPPARγMs) and dual PPAR gamma/alpha agonists is on the horizon.
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Affiliation(s)
- Jacqueline Kung
- Tufts University, Division of Endocrinology, Diabetes and Metabolism, 800 Washington St #268, Boston, MA 02111, USA.
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Bandello F, Cunha-Vaz J, Chong NV, Lang GE, Massin P, Mitchell P, Porta M, Prünte C, Schlingemann R, Schmidt-Erfurth U. New approaches for the treatment of diabetic macular oedema: recommendations by an expert panel. Eye (Lond) 2012; 26:485-93. [PMID: 22241014 PMCID: PMC3325561 DOI: 10.1038/eye.2011.337] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Accepted: 11/10/2011] [Indexed: 02/08/2023] Open
Abstract
The current standard therapy for patients with diabetic macular oedema (DME)--focal/grid laser photocoagulation--usually does not improve impaired vision, and many patients lose vision despite laser therapy. Recent approval of ranibizumab by the European Medicines Agency to treat visual impairment due to DME fulfils the previously unmet medical need for a treatment that can improve visual acuity (VA) in these patients. We reviewed 1- and 2-year clinical trial findings for ranibizumab used as treatment for DME to formulate evidence-based treatment recommendations in the context of this new therapy. DME with or without visual impairment should be considered for treatment when it fulfils the Early Treatment Diabetic Retinopathy Study (ETDRS) criteria for clinically significant oedema. For DME with centre involvement and associated vision loss due to DME, monthly ranibizumab monotherapy with treatment interruption and re-initiation based on VA stability is recommended. Laser therapy based on ETDRS guidelines is recommended for other forms of clinically significant DME without centre involvement or when no vision loss has occurred, despite centre involvement. Because these recommendations are based on randomised controlled trials of 1-2 years duration, guidance may need updating as long-term ranibizumab data become available and as additional therapeutic agents are assessed in clinical trials.
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Affiliation(s)
- F Bandello
- Department of Ophthalmology, University Vita-Salute, Scientific Institute San Raffaele, Milano, Italy
| | - J Cunha-Vaz
- Association for Innovation and Biomedical Research on Light and Image, Coimbra, Portugal
| | - N V Chong
- Oxford Eye Hospital, University of Oxford, Oxford, UK
| | - G E Lang
- Department of Ophthalmology, University Eye Hospital, Ulm, Germany
| | - P Massin
- Assistance Publique des Hôpitaux de Paris, Ophthalmology Department, Hôpital Lariboisière, Paris, France
| | - P Mitchell
- Discipline of Ophthalmology, University of Sydney, Sydney, Australia
| | - M Porta
- Department of Internal Medicine, University of Turin, Turin, Italy
| | - C Prünte
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
- Vista Klinik, Binningen, Switzerland
| | - R Schlingemann
- Medical Retina Unit and Ocular Angiogenesis Group, Department of Ophthalmology, University of Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
- Department of Clinical and Molecular Ophthalmogenetics, The Netherlands Institute for Neuroscience, Royal Netherlands Academy of Arts and Sciences (KNAW), Amsterdam, The Netherlands
| | - U Schmidt-Erfurth
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
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Emerging pharmacotherapies for diabetic macular edema. EXPERIMENTAL DIABETES RESEARCH 2012; 2012:548732. [PMID: 22474425 PMCID: PMC3299388 DOI: 10.1155/2012/548732] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2011] [Revised: 10/27/2011] [Accepted: 10/27/2011] [Indexed: 12/20/2022]
Abstract
Diabetic macular edema (DME) remains an important cause of visual loss in patients with diabetes mellitus. Although photocoagulation and intensive control of systemic metabolic factors have been reported to achieve improved outcomes in large randomized clinical trials (RCTs), some patients with DME continue to lose vision despite treatment. Pharmacotherapies for DME include locally and systemically administered agents. We review several agents that have been studied for the treatment of DME.
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Zhang F, Lavan BE, Gregoire FM. Selective Modulators of PPAR-gamma Activity: Molecular Aspects Related to Obesity and Side-Effects. PPAR Res 2011; 2007:32696. [PMID: 17389769 PMCID: PMC1783742 DOI: 10.1155/2007/32696] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2006] [Revised: 11/21/2006] [Accepted: 11/22/2006] [Indexed: 01/23/2023] Open
Abstract
Peroxisome proliferator-activated receptor gamma (PPAR-gamma) is a key regulator of lipid metabolism and energy balance implicated in the development of insulin resistance and obesity. The identification of putative natural and synthetic ligands and activators of PPAR-gamma has helped to unravel the molecular basis of its function, including molecular details regarding ligand binding, conformational changes of the receptor, and cofactor binding, leading to the emergence of the concept of selective PPAR-gamma modulators (SPPARgammaMs). SPPARgammaMs bind in distinct manners to the ligand-binding pocket of PPAR-gamma, leading to alternative receptor conformations, differential cofactor recruitment/displacement, differential gene expression, and ultimately differential biological responses. Based on this concept, new and improved antidiabetic agents for the treatment of diabetes are in development. This review summarizes the current knowledge on the mechanism of action and biological effects of recently characterized SPPARgammaMs, including metaglidasen/halofenate, PA-082, and the angiotensin receptor antagonists, recently characterized as a new class of SPPARgammaMs.
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Affiliation(s)
- Fang Zhang
- Department of Biology, Metabolex Inc., 3876 Bay Center Place, Hayward, CA 94545, USA
| | - Brian E. Lavan
- Department of Biology, Metabolex Inc., 3876 Bay Center Place, Hayward, CA 94545, USA
| | - Francine M. Gregoire
- Department of Biology, Metabolex Inc., 3876 Bay Center Place, Hayward, CA 94545, USA
- *Francine M. Gregoire:
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PPARgamma Agonists: Potential as Therapeutics for Neovascular Retinopathies. PPAR Res 2011; 2008:164273. [PMID: 18509499 PMCID: PMC2396446 DOI: 10.1155/2008/164273] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2007] [Revised: 03/12/2008] [Accepted: 04/10/2008] [Indexed: 01/16/2023] Open
Abstract
The angiogenic, neovascular proliferative retinopathies, proliferative diabetic retinopathy (PDR), and age-dependent macular degeneration (AMD) complicated by choroidal neovascularization (CNV), also termed exudative or “wet” AMD, are common causes of blindness. The antidiabetic thiazolidinediones (TZDs), rosiglitazone, and troglitazone are PPARγ agonists with demonstrable antiproliferative, and anti-inflammatory effects, in vivo, were shown to ameliorate PDR and CNV in rodent models, implying the potential efficacy of TZDs for treating proliferative retinopathies in humans. Activation of the angiotensin II type 1 receptor (AT1-R) propagates proinflammatory and proliferative pathogenic determinants underlying PDR and CNV. The antihypertensive dual AT1-R blocker (ARB), telmisartan, recently was shown to activate PPARγ and improve glucose and lipid metabolism and to clinically improve PDR and CNV in rodent models. Therefore, the TZDs and telmisartan, clinically approved antidiabetic and antihypertensive drugs, respectively, may be efficacious for treating and attenuating PDR and CNV humans. Clinical trials are needed to test these possibilities.
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Shani M, Feldman L, Kaiserman I, Dresner J, Baevsky T, Vinker S. Is rosiglitazone use associated with an increase in intensive eye treatment in diabetic patients? A community based study. Eur J Gen Pract 2011; 17:205-9. [PMID: 21745121 DOI: 10.3109/13814788.2011.590191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To evaluate the effect of rosiglitazone on diabetic retinopathy in the usual care setting. METHODS Type 2 diabetic patients, aged over 40, who received rosiglitazone therapy for at least one year during the study period, were considered for the study group. All diabetic patients who had never received rosiglitazone or insulin were candidates for the control group. For each subject treated with rosiglitazone, up to five controls were randomly selected and matched on age, gender, and HbA1c%. We retrieved information about ophthalmologist visits, retinal argon laser therapy, vitrectomy and the date of the procedure. Time from the first rosiglitazone prescription to the first intervention was calculated. RESULTS A total of 6689 subjects, 1304 in the rosiglitazone group and 5385 in the control group were followed for a median of 3.6 years. The baseline level of HbA1C% was slightly higher in the rosiglitazone group (9.2 versus 8.8). There were more ophthalmologist visits in the rosiglitazone group compared to the control group. 115/1304 (8.8%) patients in the study group had an event compared to 379/5385 (7.0%) control group (P = 0.027). HR for the study group was 1.3 (95% CI: 1.08-1.64) for any event compared to control group (P = 0.008). CONCLUSION Rosiglitazone was associated with increased laser treatments and vitrectomy. Caution may be needed when treating diabetic patients with rosiglitazone.
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Affiliation(s)
- Michal Shani
- Department of Family Medicine Central District, Clalit Health Service, Israel.
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Tarbett AK, VanRoekel RC, Howard RS, Vigersky RA. The use of optical coherence tomography to determine the effect of thiazolidinediones on retinal thickness in patients with type 2 diabetes. J Diabetes Sci Technol 2011; 5:945-51. [PMID: 21880238 PMCID: PMC3192602 DOI: 10.1177/193229681100500418] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Thiazolidinediones (TZDs) are insulin-sensitizing agents that are associated with peripheral edema and have been reported to be associated with diabetic macular edema (DME). We hypothesized that TZDs produce subclinical increases in retinal thickness that may be detected by optical coherence tomography (OCT) but are not seen on routine dilated funduscopic examination. RESEARCH DESIGN AND METHODS We used OCT to screen for subclinical DME in a cross-sectional study of patients with type 2 diabetes; 29 patients were taking TZDs and 58 were not taking TZDs. We analyzed data using multiple linear regression analysis to investigate associations of retinal thickness with clinical characteristics. RESULTS There was no significant difference between the central subfield retinal thickness in the non-TZD group (206.4 ± 28.0 microns; n = 59) and TZD group (204.1 ± 26.1 microns; n = 29) (p = .72) nor were there significant differences in any other retinal subfield. There was no significant correlation of retinal thickness with laboratory results studies--peripheral edema, gender, age, duration of diabetes, individual, or combinations of medications. Retinal thickness differences between regions displayed normal anatomical variation. However, ethnic differences were found in which African-Americans had thinner retinas in all regions than Caucasians regardless of whether or not they used TZDs. CONCLUSIONS These data suggest that TZDs do not cause subclinical DME in a demographically diverse patient population with diabetes. The established normal ranges for macular thickness may require adjustment based on ethnicity.
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Affiliation(s)
- Aaron K Tarbett
- Optometry Clinic, Walter Reed Army Medical Center, Washington, District of Columbia 20307, USA
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Abstract
There is a rising worldwide prevalence of diabetes, especially type 2 diabetes mellitus (T2DM), which is one of the most challenging health problems in the 21st century. The associated complications of diabetes, such as cardiovascular disease, peripheral vascular disease, stroke, diabetic neuropathy, amputations, renal failure, and blindness result in increasing disability, reduced life expectancy, and enormous health costs. T2DM is a polygenic disease characterized by multiple defects in insulin action in tissues and defects in pancreatic insulin secretion, which eventually leads to loss of pancreatic insulin-secreting cells. The treatment goals for T2DM patients are effective control of blood glucose, blood pressure, and lipids (if elevated) and, ultimately, to avert the serious complications associated with sustained tissue exposure to excessively high glucose concentrations. Prevention and control of diabetes with diet, weight control, and physical activity has been difficult. Treatment of T2DM has centered on increasing insulin levels, either by direct insulin administration or oral agents that promote insulin secretion, improving sensitivity to insulin in tissues, or reducing the rate of carbohydrate absorption from the gastrointestinal tract. This review presents comprehensive and up-to-date information on the mechanism(s) of action, efficacy, pharmacokinetics, pleiotropic effects, drug interactions, and adverse effects of the newer antidiabetic drugs, including (1) peroxisome proliferator-activated-receptor-γ agonists (thiazolidinediones, pioglitazone, and rosiglitazone); (2) the incretin, glucagon-like peptide-) receptor agonists (incretin-mimetics, exenatide. and liraglutide), (3) inhibitors of dipeptidyl-peptidase-4 (incretin enhancers, sitagliptin, and vildagliptin), (4) short-acting, nonsulfonylurea secretagogue, meglitinides (repaglinide and nateglinide), (5) amylin anlog-pramlintide, (6) α-glucosidase inhibitors (miglitol and voglibose), and (7) colesevelam (a bile acid sequestrant). In addition, information is presented on drug candidates in clinical trials, experimental compounds, and some plants used in the traditional treatment of diabetes based on experimental evidence. In the opinion of this reviewer, therapy based on orally active incretins and incretin mimetics with long duration of action that will be efficacious, preserve the β-cell number/function, and block the progression of diabetes will be highly desirable. However, major changes in lifestyle factors such as diet and, especially, exercise will also be needed if the growing burden of diabetes is to be contained.
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Affiliation(s)
- Philip Home
- Newcastle University and Newcastle Diabetes Centre, Institute of Cellular Medicine (Diabetes), The Medical School, Newcastle upon Tyne, UK.
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Nyenwe EA, Jerkins TW, Umpierrez GE, Kitabchi AE. Management of type 2 diabetes: evolving strategies for the treatment of patients with type 2 diabetes. Metabolism 2011; 60:1-23. [PMID: 21134520 PMCID: PMC3746516 DOI: 10.1016/j.metabol.2010.09.010] [Citation(s) in RCA: 208] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Accepted: 09/18/2010] [Indexed: 01/08/2023]
Abstract
The prevalence of type 2 diabetes continues to increase at an alarming rate around the world, with even more people being affected by prediabetes. Although the pathogenesis and long-term complications of type 2 diabetes are fairly well known, its treatment has remained challenging, with only half of the patients achieving the recommended hemoglobin A(1c) target. This narrative review explores the pathogenetic rationale for the treatment of type 2 diabetes, with the view of fostering better understanding of the evolving treatment modalities. The diagnostic criteria including the role of hemoglobin A(1c) in the diagnosis of diabetes are discussed. Due attention is given to the different therapeutic maneuvers and their utility in the management of the diabetic patient. The evidence supporting the role of exercise, medical nutrition therapy, glucose monitoring, and antiobesity measures including pharmacotherapy and bariatric surgery is discussed. The controversial subject of optimum glycemic control in hospitalized and ambulatory patients is discussed in detail. An update of the available pharmacologic options for the management of type 2 diabetes is provided with particular emphasis on newer and emerging modalities. Special attention has been given to the initiation of insulin therapy in patients with type 2 diabetes, with explanation of the pathophysiologic basis for insulin therapy in the ambulatory diabetic patient. A review of the evidence supporting the efficacy of the different preventive measures is also provided.
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Affiliation(s)
- Ebenezer A. Nyenwe
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | | | | | - Abbas E. Kitabchi
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The University of Tennessee Health Science Center, Memphis, TN 38163, USA
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Saha SA, Tuttle KR. Influence of glycemic control on the development of diabetic cardiovascular and kidney disease. Cardiol Clin 2010; 28:497-516. [PMID: 20621253 DOI: 10.1016/j.ccl.2010.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Diabetes mellitus leads to the development of a host of micro- and macrovascular complications, which collectively lead to substantial morbidity and mortality. Among the microvascular complications of diabetes, diabetic kidney disease is the most common. Macrovascular complications from diabetes lead to a 2- to 4-fold increase in the incidence of cardiovascular disease and up to twice the mortality from cardiovascular causes as compared with nondiabetic individuals. This article discusses the various drug classes used to treat diabetes mellitus, and reviews the current clinical evidence linking glycemic control using these drug classes on diabetic kidney and cardiovascular disease.
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Affiliation(s)
- Sandeep A Saha
- Providence Medical Research Center, Spokane, WA 99204, USA.
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Zhang JZ, Ward KW. WY-14 643, a Selective PPARα Agonist, Induces Proinflammatory and Proangiogenic Responses in Human Ocular Cells. Int J Toxicol 2010; 29:496-504. [DOI: 10.1177/1091581810376674] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Peroxisome proliferator-activated receptor α (PPARα) agonism in ocular inflammation has not been thoroughly investigated. The objective of this investigation was to determine the effect of WY-14 643, a selective PPARα agonist, on inflammatory cytokine release in human ocular cells. Stimulation of primary human corneal epithelial cells, keratocytes, and retinal endothelial cells with 1 to 10 ng/mL interleukin 1β (IL-1β) resulted in a significant increase in numerous inflammatory cytokines, including IL-6, IL-8, and tumor necrosis factor α (TNF-α); and dexamethasone was able to significantly inhibit these effects. However, WY-14 643 did not effectively block IL-1β-induced cytokine release in ocular cells; rather, significant increases in IL-1β-induced inflammatory cytokines were observed in these cells but not in aortic smooth muscle cells. WY-14 643 also significantly upregulated vascular endothelial growth factor (VEGF) expression in corneal epithelial cells and keratocytes. These studies demonstrate for the first time that PPARα agonism may be proinflammatory and proangiogenic in a variety of ocular cells and suggest that therapeutic applications of such agents in ophthalmology may be limited.
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Affiliation(s)
| | - Keith W. Ward
- Pharmaceutical R&D, Bausch & Lomb, Inc, Rochester, NY, USA
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Silva PS, Cavallerano JD, Sun JK, Aiello LM, Aiello LP. Effect of systemic medications on onset and progression of diabetic retinopathy. Nat Rev Endocrinol 2010; 6:494-508. [PMID: 20664533 DOI: 10.1038/nrendo.2010.122] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Diabetic retinopathy remains a leading cause of visual loss worldwide. Patients with diabetes mellitus commonly have multiple comorbidities treated with a wide variety of medications. Systemic medications that target glycemic control and coexisting conditions may have beneficial or deleterious effects on the onset or progression of diabetic retinopathy. In addition, data is accumulating to suggest that the use of systemic therapy primarily to address ocular complications of diabetic retinopathy may be a promising therapeutic approach. This article reviews our current understanding of the ocular-specific effects of systemic medications commonly used by patients with diabetes mellitus, including those directed at control of hyperglycemia, dyslipidemia, hypertension, cardiac disease, anemia, inflammation and cancer. Current clinical evidence is strongest for the use of angiotensin-converting enzyme inhibitors and angiotensin-2 receptor blockers in preventing the onset or slowing the progression of early diabetic retinopathy. To a more limited extent, evidence of a benefit of fibrates for diabetic macular edema exists. Numerous other agents hold considerable promise or potential risk. Thus, these compounds must undergo further rigorous study to determine the actual clinical efficacy and adverse effects before definitive therapeutic care recommendations can be offered.
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Affiliation(s)
- Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Department of Ophthalmology, Harvard Medical School, 1 Joslin Place, Boston, MA 02215, USA
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Desouza CV, Shivaswamy V. Pioglitazone in the treatment of type 2 diabetes: safety and efficacy review. CLINICAL MEDICINE INSIGHTS-ENDOCRINOLOGY AND DIABETES 2010; 3:43-51. [PMID: 22879786 PMCID: PMC3411525 DOI: 10.4137/cmed.s5372] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The increase in obesity and the aging of the population has lead to an increase in the incidence of type 2 diabetes. This has led to the development of new drugs such as thiazolidinediones (TZDs) which are Peroxisome Proliferator-Activated Receptor (PPARgamma) agonists, to treat type 2 diabetes. TZDs have recently been at the center of a controversy with regards to their cardiovascular safety. Pioglitazone is a TZD which has been shown to be effective in glycemic control by lowering insulin resistance. Pioglitazone also has beneficial effects on lipid metabolism and cardiovascular risk. The safety and efficacy of pioglitazone including its pleotropic effects are discussed at length in this article.
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Abstract
Diabetic retinopathy is a common and specific microvascular complication of diabetes, and remains the leading cause of preventable blindness in working-aged people. It is identified in a third of people with diabetes and associated with increased risk of life-threatening systemic vascular complications, including stroke, coronary heart disease, and heart failure. Optimum control of blood glucose, blood pressure, and possibly blood lipids remains the foundation for reduction of risk of retinopathy development and progression. Timely laser therapy is effective for preservation of sight in proliferative retinopathy and macular oedema, but its ability to reverse visual loss is poor. Vitrectomy surgery might occasionally be needed for advanced retinopathy. New therapies, such as intraocular injection of steroids and antivascular endothelial growth-factor agents, are less destructive to the retina than are older therapies, and could be useful in patients who respond poorly to conventional therapy. The outlook for future treatment modalities, such as inhibition of other angiogenic factors, regenerative therapy, and topical therapy, is promising.
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Affiliation(s)
- Ning Cheung
- Centre for Eye Research Australia, University of Melbourne, Royal Victorian Eye and Ear Hospital, Melbourne, Australia
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Ambrosius WT, Danis RP, Goff DC, Greven CM, Gerstein HC, Cohen RM, Riddle MC, Miller ME, Buse JB, Bonds DE, Peterson KA, Rosenberg YD, Perdue LH, Esser BA, Seaquist LA, Felicetta JV, Chew EY. Lack of association between thiazolidinediones and macular edema in type 2 diabetes: the ACCORD eye substudy. ACTA ACUST UNITED AC 2010; 128:312-8. [PMID: 20212201 DOI: 10.1001/archophthalmol.2009.310] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To assess the cross-sectional association of thiazolidinediones with diabetic macular edema (DME). METHODS The cross-sectional association of DME and visual acuity with thiazolidinediones was examined by means of baseline fundus photographs and visual acuity measurements from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Visual acuity was assessed in 9690 participants in the ACCORD trial, and 3473 of these participants had fundus photographs that were centrally read in a standardized fashion by masked graders to assess DME and retinopathy from October 23, 2003, to March 10, 2006. RESULTS Among the subsample, 695 (20.0%) people had used thiazolidinediones, whereas 217 (6.2%) people had DME. Thiazolidinedione use was not associated with DME in unadjusted (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.71-1.44; P = .95) and adjusted (OR, 0.97; 95% CI, 0.67-1.40; P = .86) analyses. Significant associations with DME were found for retinopathy severity (P < .001) and age (OR, 0.97; 95% CI, 0.952-0.997; P = .03) but not for hemoglobin A(1c) (P = .06), duration of diabetes (P = .65), sex (P = .72), and ethnicity (P = .20). Thiazolidinedione use was associated with slightly greater visual acuity (0.79 letter; 95% CI, 0.20-1.38; P = .009) of uncertain clinical significance. CONCLUSIONS In a cross-sectional analysis of data from the largest study to date, no association was observed between thiazolidinedione exposure and DME in patients with type 2 diabetes; however, we cannot exclude a modest protective or harmful association. Trial Registration clinicaltrials.gov Identifier: NCT00542178.
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Affiliation(s)
- Walter T Ambrosius
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest University Health Sciences, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
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Kutoh E. Differential effects of pioglitazone on metabolic parameters in newly diagnosed, drug-naïve Japanese patients with type 2 diabetes with or without metabolic syndrome. Endocr Res 2010; 35:118-27. [PMID: 20712426 DOI: 10.3109/07435801003762164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the efficacy of pioglitazone on metabolic parameters in drug-naïve Japanese type 2 diabetic patients with (Diabetes Mellitus Metabolic Syndrome [DMMS] group, n = 36) and without (Diabetes Mellitus non-Metabolic Sundrome [DMNMS] group, n = 36) metabolic syndrome. PATIENTS AND METHODS The patients received monotherapy of 15-30 mg/day pioglitazone for 3 months. The baseline levels of metabolic parameters were compared with the levels after 3 months. RESULTS At baseline, the two groups showed no significant difference in HbA1c (10.05 vs. 9.81%, n.s.) or systolic blood pressure (134.5 vs. 133.0 mmHg, n.s.), but had significant differences in diastolic blood pressure (84.7 vs. 78.9 mmHg, p < 0.05), insulin (14.96 vs. 7.09 microU/mL, p < 0.001), homeostasis model assessment insulin resistance index (HOMA-R) (8.49 vs. 3.96, p < 0.001), triglyceride (TG) (231.4 vs. 131.5 mg/dL, p < 0.0005), high-density lipoprotein (HDL)-C (46.6 vs. 56.1 mg/dL, p < 0.005), body weight (BW) (77.97 vs. 62.52 kg, p < 0.001), and body mass index (BMI) (28.14 vs. 22.86, p < 0.00001). In the DMMS group, significant changes of HbA1c (from 10.05 to 8.01%, p < 0.00001), insulin (-22.7%, p < 0.05), HOMA-R (-48.9%, p < 0.0002), TG (-20.8 %, p < 0.05), HDL-C (+12.0%, p < 0.00001), BW (+1.0 kg/+1.3%, p < 0.05), and BMI (+1.4%, p < 0.02) were observed after 3 months. In the DMNMS group, the reduction of HbA1c (from 9.81 to 8.33%, p < 0.00001) was similar to that in the DMMS group, but the changes of insulin (-4.7%, n.s.), HOMA-R (-15.6%, n.s.), and TG (-12.9%, n.s.) were smaller and not significant. Significant increases of HDL-C (+9.2%, p < 0.02), BW (+0.64 kg/+1.0%, p < 0.05), and BMI (+1.0%, p < 0.02) were observed, but these changes were also smaller than the respective changes in the DMMS group. Based on the change of each parameter relative to its baseline value, significant intergroup differences were found for TG, insulin, or HOMA-R, whereas no such differences were observed for HDL-C, BW, and BMI. No subjects showed any clinically significant adverse events. CONCLUSIONS These results suggest that the glucose-lowering effect of pioglitazone is comparable in patients with type 2 diabetes with or without metabolic syndrome, but that the drug has different effects on nonglycemic parameters including TG, insulin and HOMA-R in the two groups of patients.
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Affiliation(s)
- Eiji Kutoh
- Biomedical Center, Edogawa-ku, Tokyo, Japan.
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71
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Choi HK, Tan GS, Sundar G. Rosiglitazone toxicity: accidental overdose leading to macular edema. Retin Cases Brief Rep 2010; 4:73-77. [PMID: 25390127 DOI: 10.1097/icb.0b013e318196b2db] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND/PURPOSE To highlight the clinical effects of rosiglitazone overdose. METHODS Case report, observational. RESULTS A 60-year-old Chinese man accidentally ingested 20 mg rosiglitazone. His usual dose was 2 mg once in the morning. Complications of drug overdose were monitored. He consequently developed right mild macular edema. This resolved spontaneously without laser treatment. No systemic toxicity, hypoglycemia, or peripheral edema was observed. CONCLUSION Rosiglitazone overdose causes acute macular edema that resolves spontaneously.
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Affiliation(s)
- Harold K Choi
- From the Department of Ophthalmology, National University Hospital, Singapore
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72
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Abstract
BACKGROUND Diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR) continue to cause significant visual loss among patients with diabetes mellitus. In some patients unresponsive to standard laser techniques, as well as improved control of blood pressure and blood sugar, pharmacologic treatment may be beneficial. Although no agent is now approved by the FDA for this purpose, many agents are now being studied in randomized clinical trials (RCTs). OBJECTIVE To review concisely the chief pharmacotherapies for diabetic retinopathy available at present. METHODS Literature review and synopsis. RESULTS Used alone, intravitreal triamcinolone acetonide (IVTA) seems to have some short-term efficacy against DME, but longer-term outcomes (< or = 3 years) using IVTA monotherapy showed a lesser benefit than focal/grid laser treatment in a prospective RCT done by the Diabetic Retinopathy Clinical Research Network. Intravitreal anti-VEGF agents have demonstrated some short-term efficacy against DME, and continuing RCTs will evaluate combination therapies (anti-VEGF and laser) for both DME and PDR. Other agents are being evaluated in pilot studies and Phase II RCTs. CONCLUSION Pharmacotherapies for DME and PDR have potential for vision stabilization or improvement. Continuing RCTs will provide evidence-based data on their role in clinical practice. A potential role for pharmacotherapy in the prevention of DME and PDR is also emerging.
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Affiliation(s)
- Stephen G Schwartz
- University of Miami Miller School of Medicine, Bascom Palmer Eye Institute, 311 9th Street North, #100, Naples, FL 34102, USA.
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73
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Rizos CV, Elisaf MS, Mikhailidis DP, Liberopoulos EN. How safe is the use of thiazolidinediones in clinical practice? Expert Opin Drug Saf 2009; 8:15-32. [PMID: 19236215 DOI: 10.1517/14740330802597821] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Thiazolidinediones (TZDs) are widely used antidiabetic drugs with proven efficacy regarding mainly surrogate markers of diabetes management. However, efficacy on surrogate markers may not always translate into benefits in clinical outcomes. Thiazolidinediones are usually well tolerated; however, their use may be associated with several adverse effects. The first TZD, troglitazone, was withdrawn from the market owing to serious hepatotoxicity. However, this does not seem to be the case with newer TZDs. OBJECTIVE The aim of the present review is to discuss the safety profile of this drug class. METHODS We searched PubMed up to July 2008 using relevant keywords. CONCLUSIONS Common side effects associated with TZDs include edema, weight gain, macular edema and heart failure. Moreover, they may cause hypoglycemia when combined with other antidiabetic drugs as well as decrease hematocrit and hemoglobin levels. Increased bone fracture risk is another TZD-related side effect. Thiazolidinediones tend to increase serum low density lipoprotein cholesterol levels, with rosiglitazone having a more pronounced effect compared with pioglitazone. Moreover, rosiglitazone increases low density lipoprotein particle concentration in contrast to pioglitazone where a decrease is observed. Rosiglitazone has been associated with an increase in myocardial infarction incidence. On the other hand, pioglitazone may reduce cardiovascular events. Overall, TZDs are valuable drugs for diabetes management but physicians should keep in mind that they are associated with several adverse events, the most prominent of which is heart failure.
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Affiliation(s)
- C V Rizos
- Department of Internal Medicine, University of Ioannina, School of Medicine, Ioannina 45110, Greece.
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74
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Barnett AH. Redefining the role of thiazolidinediones in the management of type 2 diabetes. Vasc Health Risk Manag 2009; 5:141-51. [PMID: 19436665 PMCID: PMC2672454 DOI: 10.2147/vhrm.s4664] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
There is a need to evaluate oral glucose-lowering agents not only for their value in achieving glycemic control but also for their impact on cardiac risk factor modification. This article reviews the evidence base for the two thiazolinediones currently available, pioglitazone and rosiglitazone. These drugs exert their effects through actions affecting metabolic control, lipid profiles, and the vascular wall. They have been shown to be as efficacious in establishing glycemic control, in both monotherapy and combination therapy regimens, as more traditional oral agents, and may be able to sustain that control in the long term. Both thiazolidinediones have demonstrated favorable effects on markers of cardiovascular disease. Evidence from the large PROactive outcomes study suggests that pioglitazone may exert protective effects in patients with type 2 diabetes and macrovascular disease. Thiazolidinediones are generally well tolerated but they can cause weight gain, induce fluid retention, and may contribute to bone loss in postmenopausal women. The place of thiazolidinediones in the management of type 2 diabetes is well established. The potential for additional benefits in reducing macrovascular risk encourages further long-term study of these agents.
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Affiliation(s)
- Anthony H Barnett
- University of Birmingham and Heart of England National Health Service Foundation Trust (Teaching), Birmingham, UK.
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75
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Glitazone use associated with diabetic macular edema. Am J Ophthalmol 2009; 147:583-586.e1. [PMID: 19181303 DOI: 10.1016/j.ajo.2008.10.016] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Revised: 10/08/2008] [Accepted: 10/13/2008] [Indexed: 12/14/2022]
Abstract
PURPOSE To determine the ocular safety of glitazones in patients with diabetes, we investigated the association of diabetic macular edema (DME) in a large population of glitazone users. DESIGN Prospective cohort study. METHODS The study was conducted at Kaiser Permanente Southern California. About 170,000 persons with diabetes were identified using the Diabetes Case Identification Database. Glitazone drug use was obtained from the pharmacy database. The main outcome measure was the development of macular edema (ME). The chi2 test was used to compare proportions and t tests were used for means. Logistic regression analysis was used to adjust for potential confounding variables. RESULTS In 2006, there were 996 new cases of ME. Glitazone users were more likely to develop ME in 2006 (odds ratio [OR], 2.6; 95% confidence interval [CI], 2.4 to 3.0). After excluding patients who did not have the drug benefit, did not have an eye exam, and had a HgA1c <7.0, glitazone use was still associated with an increased risk of developing ME (OR, 1.6; 95% CI, 1.4 to 1.8). CONCLUSION The current study appears to show that the glitazone class of drug is associated with DME. After adjusting for confounding factors of age, glycemic control, and insulin use, glitazones are still modestly associated with DME. A more in-depth study will need to be done to evaluate the role of other confounding factors. When treating patients with DME, ophthalmologists should consider the role of the glitazones.
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Oshitari T, Asaumi N, Watanabe M, Kumagai K, Mitamura Y. Severe macular edema induced by pioglitazone in a patient with diabetic retinopathy: a case study. Vasc Health Risk Manag 2009; 4:1137-40. [PMID: 19183764 PMCID: PMC2605323 DOI: 10.2147/vhrm.s3446] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We report a case of severe diabetic macular edema (DME) that developed after pioglitazone was used by a patient with proliferative diabetic retinopathy. A 30-year-old woman with poorly controlled type 2 diabetes mellitus visited our clinic in 2004. She had moderate pre-proliferative diabetic retinopathy OU. Because of the rapid progression of the diabetic retinopathy, she received pan-retinal photocoagulation in both eyes. Two weeks before using pioglitazone, her visual acuity was 0.9 OD and 0.7 OS. On October 2007, pioglitazone was prescribed by her internist because of poorly controlled blood glucose level. Two weeks later, her body weight increased, and her face became edematous. Her visual acuity decreased to 0.5 OU, and ophthlamoscopy showed severe DME in both eyes. Two weeks after stopping pioglitazone, her visual acuity improved to 0.8 OD and 0.5 OS, but the DME was still severe in the optical coherence tomographic images. Then, one half the usual dose (25 mg) of spironolactone, a diuretic, was given and her macular edema was resolved. Her final visual acuity improved to 0.9 OD and 0.7 OS. We recommend that when a patient taking pioglitazone complains of decreased vision, the physician should promptly consult an ophthalmologist.
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Affiliation(s)
- Toshiyuki Oshitari
- Department of Ophthalmology, Kimitsu Central Hospital, Kisarazu City, Chiba, Japan.
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77
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Johnson MW. Etiology and treatment of macular edema. Am J Ophthalmol 2009; 147:11-21.e1. [PMID: 18789796 DOI: 10.1016/j.ajo.2008.07.024] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2007] [Revised: 07/13/2008] [Accepted: 07/15/2008] [Indexed: 12/16/2022]
Abstract
PURPOSE To summarize current concepts and recent literature regarding the pathogenesis, clinical substrates, and treatment of macular edema, in light of evolving pharmacologic and surgical approaches to this prevalent cause of vision loss. DESIGN Interpretive essay. METHODS Review and synthesis of selected recent literature, with interpretation and perspective. RESULTS Macular edema occurs in a wide variety of pathologic conditions and represents the final common phenotype of several basic pathophysiologic processes. A variety of pharmacologic agents targeting inflammatory and vasopermeability molecules have been shown to reduce macular edema and improve visual function over the short-term. Vitreous surgery effectively addresses the tractional components of macular edema, where present. Despite recent advances, laser photocoagulation remains the treatment of choice for macular edema associated with nondiffuse patterns of vascular leakage. CONCLUSIONS Effective management of macular edema is based on recognizing and addressing the pathogenic factors that are operative in a given disease setting. Although treatment options are expanding with the development of new drugs and surgical procedures, the long-term efficacy and safety of most new approaches have yet to be established in controlled clinical trials.
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Affiliation(s)
- Mark W Johnson
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, W. K. Kellogg Eye Center, Ann Arbor, Michigan, USA.
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78
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Diagnostic and therapeutic challenges. Retina 2008; 29:275-9. [PMID: 18827730 DOI: 10.1097/iae.0b013e3181893787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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79
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Singh S, Loke YK. The safety of rosiglitazone in the treatment of Type 2 diabetes. Expert Opin Drug Saf 2008; 7:579-85. [DOI: 10.1517/14740338.7.5.579] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Sonal Singh
- Assistant Professor Wake Forest University School of Medicine, Department of Medicine, Winston-Salem, NC 27103, USA
- Wake Forest University School of Medicine, One Medical Center Boulevard, Section on General Internal Medicine, Winston-Salem, NC 27157, USA ;
| | - Yoon K Loke
- Senior Lecturer in Clinical Pharmacology University of East Anglia, School of Medicine, Norwich, UK
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80
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Liazos E, Broadbent DM, Beare N, Kumar N. Spontaneous resolution of diabetic macular oedema after discontinuation of thiazolidenediones. Diabet Med 2008; 25:860-2. [PMID: 18644073 DOI: 10.1111/j.1464-5491.2008.02491.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To report a case of spontaneous resolution of diabetic maculopathy with cystoid macular oedema in a diabetic patient after discontinuation of rosiglitazone, documented with serial ocular computed tomography (OCT) images. METHODS A 59-year-old male with a 6-year history of well-controlled diabetes mellitus presented with reduced visual acuity (VA) attributed to clinically significant macular oedema (CSMO). The patient had been started on rosiglitazone 8 months previously. Glitazone treatment was stopped and the patient prospectively followed up. RESULTS The patient demonstrated CSMO on OCT at presentation. Three months after cessation of rosiglitazone, CSMO had completely resolved and VA improved. Resolution of CSMO was confirmed on OCT examination. The patient required no interventional treatment, i.e. no laser or intravitreal therapy, for his CSMO. CONCLUSIONS To the best of our knowledge, this is the first case to document spontaneous resolution of CSMO and improvement in VA on discontinuation of a glitazone. Glitazones have a definitive role in the management of diabetic patients and ophthalmologists and physicians should both be aware that there may be an association with weight gain, peripheral oedema and CSMO. We recommend that ophthalmologists consider discontinuing glitazones in consultation with the diabetologist before embarking on interventional management such as laser or intravitreal injections.
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Affiliation(s)
- E Liazos
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK.
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81
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Abstract
Thiazolidinediones (TZDs) are relatively new agents for the treatment of type 2 diabetes. They act as agonists at the PPAR-gamma nuclear receptor and their therapeutic effects include decreased insulin resistance and hyperglycaemia, an improved plasma lipid, inflammation and pro-coagulant profile, and amelioration of hypertension, microalbuminuria and hepatic steatosis. The most common side effects of TZDs include weight gain and oedema, with occasional reports of congestive heart failure (CHF). This review discusses the benefit-risk profile of TZDs in treating patients with type 2 diabetes, with particular reference to the heart. To provide context, we explore briefly the epidemiology and pathophysiology of heart failure in patients with type 2 diabetes, touch on the association of heart disease and cardiovascular mortality with antihyperglycaemic treatment modalities other than TZDs, and then focus on the effects of TZDs on the heart, cardiovascular risk factors and outcomes. We describe the cluster of host factors, which seems to predispose patients with type 2 diabetes to TZD-induced or TZD-exacerbated oedema and CHF and then provide an overview of the putative mechanisms of these TZD-related side effects. We also propose that certain diuretics (amiloride and spironolactone), by targeting the distal nephron that expresses PPARgamma in collecting duct cells, might be of benefit in ameliorating the fluid retention and oedema associated with TZDs.
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Affiliation(s)
- R E Buckingham
- Unit for Metabolic Medicine, Department of Diabetes & Endocrinology, Cardiovascular Division, King's College London School of Medicine, Guy's Hospital, King's College London, London UK.
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82
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Rohatgi A, McGuire DK. Effects of the thiazolidinedione medications on micro- and macrovascular complications in patients with diabetes--update 2008. Cardiovasc Drugs Ther 2008; 22:233-40. [PMID: 18373186 DOI: 10.1007/s10557-008-6093-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Accepted: 01/24/2008] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The thiazolidinedione (TZD) drugs, including pioglitazone (Actos) and rosiglitazone (Avandia), are commonly prescribed in patients with type 2 diabetes mellitus (T2DM), largely due to their favorable effects on hyperglycemia, insulin sensitivity, and cardiometabolic profile. However, the data are sparse assessing the effects of TZDs on micro- and macrovascular disease risk. DISCUSSION Although no studies have been published on microvascular clinical outcomes, both TZDs significantly reduce the urine albumin-to-creatinine ratio. TZDs have consistently been associated with favorable effects on atherosclerosis and cardiovascular disease (CVD) risk. Only one study has been published to date specifically designed to assess the effects of a TZD (pioglitazone) on macrovascular outcomes, the PROactive trial. In this trial, pioglitazone versus placebo was associated with a non-significant 10% reduction in the combined primary endpoint of mortality, coronary and peripheral vascular events, and revascularizations. No individual trial has been published specifically assessing the CVD effects of rosiglitazone, but several meta-analyses and a published interim report from an ongoing trial (RECORD) point to safety concerns regarding rosiglitazone use and the risk of myocardial infarctions (MI), leading to amplified warnings in the product labeling for rosiglitazone to reflect these concerns. CONCLUSION All published trials and meta-analyses of TZDs have consistently shown increased risk of heart failure (HF) with both TZDs, though the actual placebo-subtracted incidence of HF is low (<0.5% per year). The initiation of either TZD is contraindicated in patients with NHYA class III or IV HF, and cautions exist for their use in any patient with heart failure. Much uncertainty remains regarding the aggregate CVD effects of the TZDs, and several trials are presently underway to further address these issues.
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Affiliation(s)
- Anand Rohatgi
- Cardiovascular Division, University of Texas Southwestern Medical Center, Dallas, TX 75235-9047, USA
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84
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Quinn CE, Hamilton PK, Lockhart CJ, McVeigh GE. Thiazolidinediones: effects on insulin resistance and the cardiovascular system. Br J Pharmacol 2007; 153:636-45. [PMID: 17906687 PMCID: PMC2259217 DOI: 10.1038/sj.bjp.0707452] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Thiazolidinediones (TZDs) have been used for the treatment of hyperglycaemia in type 2 diabetes for the past 10 years. They may delay the development of type 2 diabetes in individuals at high risk of developing the condition, and have been shown to have potentially beneficial effects on cardiovascular risk factors. TZDs act as agonists of peroxisome proliferator-activated receptor-gamma (PPAR-gamma) primarily in adipose tissue. PPAR-gamma receptor activation by TZDs improves insulin sensitivity by promoting fatty acid uptake into adipose tissue, increasing production of adiponectin and reducing levels of inflammatory mediators such as tumour necrosis factor-alpha (TNF-alpha), plasminogen activator inhibitor-1(PAI-1) and interleukin-6 (IL-6). Clinically, TZDs have been shown to reduce measures of atherosclerosis such as carotid intima-media thickness (CIMT). However, in spite of beneficial effects on markers of cardiovascular risk, TZDs have not been definitively shown to reduce cardiovascular events in patients, and the safety of rosiglitazone in this respect has recently been called into question. Dual PPAR-alpha/gamma agonists may offer superior treatment of insulin resistance and cardioprotection, but their safety has not yet been assured.
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Affiliation(s)
- C E Quinn
- Department of Therapeutics and Pharmacology, Queen's University Belfast, Belfast, UK.
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85
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Virally M, Blicklé JF, Girard J, Halimi S, Simon D, Guillausseau PJ. Type 2 diabetes mellitus: epidemiology, pathophysiology, unmet needs and therapeutical perspectives. DIABETES & METABOLISM 2007; 33:231-44. [PMID: 17703979 DOI: 10.1016/j.diabet.2007.07.001] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2007] [Accepted: 06/25/2007] [Indexed: 12/25/2022]
Abstract
In France, prevalence of drug-treated diabetes reached 3.60% in 2005, with 92% of type 2 diabetic patients. In 2007, there are probably nearly 3000 000 diagnosed or undiagnosed diabetic patients. Ageing of the population and increase in obesity are the main causes of this "diabetes epidemic". Type 2 diabetes is a multifactorial disease, defined as resulting from defects in insulin secretion (including abnormalities in pulsatility and kinetics, quantitative and qualitative abnormalities of insulin, beta-cell loss progressing with time) associated with insulin resistance (affecting liver, and skeletal muscle) and increased glucagon secretion. The lack of compensation of insulin resistance by augmented insulin secretion results in rise in blood glucose. To achieve satisfactory glycaemic control in order to prevent diabetes related complications, drug therapy is generally required in addition to life style changes. Currently available oral therapies offer a large panel of complementary drugs, but they have several contraindications and side effects. In spite of major advances in the management of type 2 diabetes, and the strictness of new guidelines, some goals remain unachieved and the new family of insulin-secretors (DPP-IV inhibitors, GLP-1 analogues) should enrich therapeutic approaches.
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Affiliation(s)
- M Virally
- Service de médecine B, APHP, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
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Smiley D, Umpierrez G. Metformin/rosiglitazone combination pill (Avandamet) for the treatment of patients with Type 2 diabetes. Expert Opin Pharmacother 2007; 8:1353-64. [PMID: 17563269 DOI: 10.1517/14656566.8.9.1353] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
More than 150 million people worldwide have diabetes, the prevalence of which is increasing so rapidly that the number of adults with diabetes in the world will rise to 300 million by the year 2025. In the US, approximately 21 million people have diabetes and in some areas of the country, the prevalence is as high as 50%. The pathophysiologic hallmarks consist of insulin resistance and progressive pancreatic beta-cell dysfunction. An increased metabolic demand for insulin due to increased insulin resistance usually precedes the development of hyperglycemia. At early stages, pancreatic beta cells compensate for insulin resistance by hypersecretion of insulin. However, the period of beta-cell compensation is followed by beta-cell failure, in which the pancreas fails to secrete sufficient insulin and diabetes ensues. Biguanides and thiazolidinediones (TZDs) are two unique classes of oral antidiabetic agents that are the most commonly used medications to improve insulin sensitivity. They have no direct effect on beta-cell function, although some indirect mechanisms of actions may help to preserve beta-cell function or slow beta-cell apoptosis. Their glucose-lowering effect results from improving insulin sensitivity in a complementary fashion: metformin reduces hepatic glucose production and TZDs increase skeletal muscle glucose use. The combination of metformin and rosiglitazone in a single pill (Avandamet), was approved by the FDA in October 2002 for the treatment of diabetes. As insulin resistance is a pathophysiologic cornerstone of diabetes and cardiovascular disease, the use of Avandamet represents an optimal approach to the treatment of diabetes. This manuscript reviews the pharmacology, safety and benefits of the combination pill Avandamet.
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Affiliation(s)
- Dawn Smiley
- Emory University School of Medicine, Division of Endocrinology, Diabetes and Metabolism, 49 Jesse Hill Jr. Drive, Atlanta, Georgia 30303, USA.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2007. [DOI: 10.1002/pds.1374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Kayýkçýolu O, Ozmen B, Seymenoglu G, Tunali D, Kafesçiler SO, Güclü F, Hekimsoy Z. Macular Edema in Unregulated Type 2 Diabetic Patients Following Glycemic Control. Arch Med Res 2007; 38:398-402. [PMID: 17416286 DOI: 10.1016/j.arcmed.2006.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2006] [Accepted: 12/27/2006] [Indexed: 11/17/2022]
Abstract
BACKGROUND We undertook this study to evaluate the changes in macular edema of uncontrolled type 2 diabetes mellitus patients with the regulation of hyperglycemia. METHODS The study population was comprised of 35 type 2 diabetes mellitus patients who had poorly regulated blood glucose values. Ophthalmic examinations including baseline and 6-month macular edema index values of patients by Heidelberg Retinal Tomography (HRT) macular module were done. RESULTS Twenty four (68.6%) female patients and 11 (31.4%) male patients with a mean age of 50.7 +/- 10.3 (mean +/- SD) years and mean diabetic duration of 9.8 +/- 7.5 years participated in the study. Twenty two (62.9%) did not have diabetic retinopathy (DR), whereas 13 (37.2%) had background DR with macular edema. There was a significant correlation between duration of diabetes and HRT-II macula edema index for the right and left eyes (r = 0.40, p = 0.21 and r = 0.40, p = 0.22, respectively). CONCLUSIONS Macular edema did not change significantly by regulation of glycemic control in the study group.
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Affiliation(s)
- Ozcan Kayýkçýolu
- Ophthalmology Department, Celal Bayar University Medical Faculty, Manisa, Turkey.
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Lee TH, Jin SY, Choi MJ, Kim CG, Kim JW. A Case of Macular Edema after Rosiglitazone Use. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2007. [DOI: 10.3341/jkos.2007.48.10.1425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Taek Hoon Lee
- Department of Ophthalmology, College of Medicine, Konyang University, Daejeon, Korea
| | - Sun Young Jin
- Department of Ophthalmology, College of Medicine, Konyang University, Daejeon, Korea
| | - Moon Jeong Choi
- Myung Gok Eye Research Institute, Kimos Eye Hospital, Konyang University, Seoul, Korea
| | - Chul Gu Kim
- Department of Ophthalmology, College of Medicine, Konyang University, Daejeon, Korea
| | - Jong Woo Kim
- Department of Ophthalmology, College of Medicine, Konyang University, Daejeon, Korea
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Abstract
Thiazolidinediones (TZDs) or glitazones are agents that are widely used for the treatment of type 2 diabetes mellitus. These drugs have a multitude of therapeutic effects including reduction in insulin resistance and hyperglycaemia, anti-inflammatory effects and amelioration of hypertension, microalbuminuria and hepatic steatosis. The TZD molecular target, peroxisome proliferator-activated receptor gamma (PPARgamma), a nuclear transcription factor, is expressed diffusely in humans, including many tissues comprising the cardiovascular and renal systems. This suggests a potential for TZDs to elicit perturbing effects on these systems, which are independent of their effects on glucose and lipid metabolism. One of the most common adverse effects of TZDs is fluid retention, which can result in, or exacerbate, oedema and congestive heart failure (CHF). The frequency of peripheral oedema is approximately 5% when TZDs are used in mono- or combination oral therapy, and about 15% when used with insulin. Patients with type 2 diabetes are at high risk of myriad morbid complications, including CHF. The development of CHF, particularly in the elderly, is a harbinger of premature mortality. TZD-induced oedema is largely peripheral, may have its origins in changes in haemodynamics, with some contribution from molecules, which regulate cell and tissue permeability (e.g. vascular endothelial growth factor and protein kinase Cbeta), and remains the preponderant manifestation of TZD-induced fluid retention even in those with existing heart failure. Preclinical and pilot clinical data attest to the fact that at least part of the fluid retention derives from a direct effect of TZDs on sodium reabsorption via the renal medullary collecting duct, a mechanism that is sensitive to diuretic agents that have this nephron segment as their site of action, in whole or in part (spironolactone, amiloride and hydrochlorothiazide). Our review suggests various potential clinical strategies by which TZD-induced fluid retention might be effectively monitored and addressed.
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Affiliation(s)
- Janaka Karalliedde
- Cardiovascular Division, King's College London School of Medicine, Guy's Hospital, King's College London, London, UK.
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