High-sensitivity C-reactive protein predicts cardiovascular risk in diabetic and nondiabetic patients: effects of insulin-sensitizing treatment with pioglitazone

A Prospective Study of Variability in Glycemic Control during Different Phases of the Menstrual Cycle in Type 2 Diabetic Women Using High Sensitivity C - Reactive Protein

INTRODUCTION

Diabetes mellitus (DM) is one of the metabolic syndromes prevalent worldwide, with more concentration in the Asian region. Many studies have been conducted in order to understand the complex pathogenesis of this disease. Yet, there exists a lacuna in our knowledge about DM. This study aims at establishing the reason for glycemic variation in menstruating Type-2 diabetic women by estimation of C-reactive protein, an inflammatory marker that exhibits significant association with changes in blood glucose levels.

METHODOLOGY

A prospective study was undertaken in Type-2 diabetic women of reproductive age group to assess the variability of glycemic control during different phases of menstrual cycle using high sensitivity C reactive protein (hs-CRP) as the biomarker. Fifty women were enrolled after satisfying a set of inclusion and exclusion criteria. The fasting blood glucose, hs-CRP concentration and endogenous female hormones were assayed in follicular and luteal phases of the cycle. The observed parameters were analyzed statistically for significant correlation. Observation and Result: The result showed that hs-CRP level significantly correlates with increasing levels of fasting blood glucose level in both the phases of menstrual cycle in Type-2 diabetic women. The significance is statistically stronger during luteal phase of the cycle (r = 0.807; p<0.05). The correlation observed between hs-CRP and Estrodiol in follicular phase (r = -0.311; p < 0.05) was not statistically significant. The hs-CRP level increased significantly with progesterone level during luteal phase (r = 0.826; p <0.05).

CONCLUSION

This study concludes that Type-2 diabetic women of reproductive age group encounter a period of poor glycemic control during luteal phase, as shown by statistically high hs-CRP level mediated by endogenous progesterone hormone. Therefore, this study advocates careful monitoring, life style adjustments and drug regime to reduce the fluctuation in glycemic level experienced by Type-2 diabetic premenopausal women in the luteal phase.

Pathophysiology and treatment of type 2 diabetes: perspectives on the past, present, and future

Glucose metabolism is normally regulated by a feedback loop including islet β cells and insulin-sensitive tissues, in which tissue sensitivity to insulin affects magnitude of β-cell response. If insulin resistance is present, β cells maintain normal glucose tolerance by increasing insulin output. Only when β cells cannot release sufficient insulin in the presence of insulin resistance do glucose concentrations rise. Although β-cell dysfunction has a clear genetic component, environmental changes play an essential part. Modern research approaches have helped to establish the important role that hexoses, aminoacids, and fatty acids have in insulin resistance and β-cell dysfunction, and the potential role of changes in the microbiome. Several new approaches for treatment have been developed, but more effective therapies to slow progressive loss of β-cell function are needed. Recent findings from clinical trials provide important information about methods to prevent and treat type 2 diabetes and some of the adverse effects of these interventions. However, additional long-term studies of drugs and bariatric surgery are needed to identify new ways to prevent and treat type 2 diabetes and thereby reduce the harmful effects of this disease.

Is there any association of anxiety-depressive symptoms with vascular endothelial function or systemic inflammation?

BACKGROUND

Studies have shown the association of mood disorders and endothelial dysfunction, and increased risk of cardiovascular disease; however, mediatory mechanisms are not entirely clarified in this regard. We investigated the relationship between depression/anxiety symptoms with systemic inflammation and endothelial function.

MATERIALS AND METHODS

This cross-sectional study was performed in 2011 on employees of an oil company located in the Isfahan city (central Iran). Participants were selected with clustered random sampling. Anxiety and depression were evaluated by Hospital Anxiety Depression Scale (HADS). Systemic inflammatory status was evaluated by measuring sensitive C-reactive protein (high sensitive-CRP). To evaluate the endothelial function flow-mediated dilation (FMD) was measured.

RESULTS

During the study period, 254 participants (mean age = 51.4 ± 6.1 years) were evaluated. No significant relationship was found between high sensitive-CRP or FMD and any of the variables of anxiety or depression. In multivariate analysis, by controlling the possible confounding factors, no association was found between anxiety score, depression, or the overall score of HADS with high sensitive-CRP or FMD. After the separate analysis of patients with and without diabetes, depression score was correlated inversely with FMD among patients with diabetes (r = 0.525, P = 0.021).

CONCLUSION

According to the results, in the studied population, there was no relationship between anxiety/depression with systemic inflammation or endothelial dysfunction, while in individuals with diabetes, depression was associated with endothelial dysfunction. In this regard more cohort studies are recommended.

Effect of folic acid and vitamin B12 on the expression of PPARγ, caspase-3 and caspase-8 mRNA in the abdominal aortas of rats with hyperlipidemia

Hyperlipidemia may lead to endothelial injury, due to its effects on homocysteine and vascular endothelial growth factor in the serum, and the mRNA expression levels of peroxisome proliferator-activated receptor-γ (PPARγ), and caspase-3 and -8 in the vascular wall. In order to prevent and mitigate the high-fat state that results from endothelial injury, this study examined the effect of folic acid (FA) and vitamin B₁₂ (VB12) on the expression of PPARγ and caspase-3 and -8 mRNA in the abdominal aortas of rats with hyperlipidemia. Sixty 4-week-old healthy male Sprague Dawley rats were randomly divided into five groups (each n=12): the normal control (NC), high-fat diet (HL), FA, VB₁₂ and FA+VB12 groups. Following one week of adaptive feeding, the FA, VB12 and FA+VB12 groups were subject to the intraperitoneal injection of FA (0.5 mg/day), VB₁₂ (0.05 mg/day) and FA+VB₁₂ (0.5 mg/day and 0.05 mg/day), respectively, while fed a high-fat diet. The rats in the NC group were injected intraperitoneally with 0.9% NaCl solution (0.5 ml/day) and fed a normal diet, whereas those in the HL group were fed a high-fat diet only. A reverse transcription-polymerase chain reaction (RT-PCR) assay demonstrated that at the end of week 12, the FA treatment had effectively increased the PPARγ mRNA level, while reducing the caspase-3 and -8 mRNA levels, compared with the high-fat diet treatment (P<0.05). The effect of FA on the expression of PPARγ and caspase-3 and -8 was enhanced when used in combination with VB₁₂ (P<0.05). These results revealed that the application of FA, alone or in combination with VB₁₂, improves and mitigates the high-fat state that results from endothelial injury.

Effects of Pioglitazone on Asymmetric Dimethylarginine and Components of the Metabolic Syndrome in Nondiabetic Patients (EPICAMP Study): A Double-Blind, Randomized Clinical Trial

The present trial aimed to investigate the effects of pioglitazone on the serum level of asymmetric dimethylarginine (ADMA), a marker of endothelial function, and some indices of inflammation and glucose and lipid metabolism in nondiabetic metabolic syndrome patients. 104 eligible participants (57% female; age between 20 and 70) were enrolled in a double-blind placebo-controlled trial and were randomized to receive either pioglitazone (uptitrated to 30 mg/day) or matching placebo for 24 weeks. Participants were clinically examined and a blood sample was obtained at baseline and at the end of the trial. Pioglitazone significantly improved C-reactive protein level irrespective of changes in insulin sensitivity. Compared with the placebo group, alanine and aspartate transaminases were decreased and high-density lipoprotein cholesterol was increased after treatment with pioglitazone. A considerably greater weight gain was also recorded in the intervention group. We failed to observe any significant changes in serum ADMA in either group and between groups with and without adjustment for age, sex, and components of the metabolic syndrome. In a nutshell, pioglitazone seems to have positive effects on lipid profile, liver transaminases, and systemic inflammation. However, its previously demonstrated endothelial function-improving properties do not seem to be mediated by ADMA.

Microalbuminuria predicts silent myocardial ischaemia in type 2 diabetes patients

PURPOSE

Myocardial ischaemia is frequently silent in patients with type 2 diabetes. Although it has been proposed as a potential screening tool, the role of myocardial perfusion single photon emission computed tomography (MPS) has recently been questioned, due to the low prevalence of positive scans and the low rate of cardiac events. The aim of this study was to assess if pretest clinical variables can identify a subgroup of asymptomatic patients with type 2 diabetes at risk of silent myocardial ischaemia and a subsequent poor outcome

METHODS

This prospective study included 77 patients (50 men, mean age 63 ± 9 years) with type 2 diabetes and no known coronary artery disease (CAD) or angina pectoris who underwent gated MPS to screen for CAD between March 2006 and October 2008. MPS images were interpreted using a semiquantitative visual 20-segment model to define summed stress, rest and difference scores. Ischaemia was defined as a sum difference score (SDS) ≥2. Patients were followed-up (median 4.1 years, range 0.8 - 6.1 years) and cardiac hard events (cardiac death or nonfatal myocardial infarction) were recorded.

RESULTS

Silent ischaemia was detected in 25 of the 77 patients (32 %). Specifically, 10 patients (13 %) had mild ischaemia (SDS 2 to ≤4) and 15 patients (19 %) had severe ischaemia (SDS >4). In univariate binary logistic analysis, microalbuminuria was the only significant predictor of silent ischaemia on MPS (odds ratio 4.42, 95 % CI 1.27 - 15.40; P = 0.019). The overall accuracy of microalbuminuria for predicting silent ischaemia was 71.4 % and was 89.6 % for predicting severe ischaemia. Kaplan-Meier curves showed no significant group differences in 5-year cardiac event-free survival between patients with and those without microalbuminuria, or between patients with SDS ≥2 and those with SDS <2. In contrast, 5-year event-free survival was significantly lower in patients with SDS >4 than in patients with SDS ≤4: 55.6 % (95 % CI 39.0 - 72.2 %) vs. 94.5 % (95 % CI: 91.4 - 97.6 %), respectively (Breslow test, chi-square 20.9, P < 0.001). Median cardiac event-free survival was not observed in the whole group, while the 25th percentile of cardiac event-free survival was reached only in patients with SDS >4 (2.3 years). In univariate Cox regression analysis, SDS >4 predicted cardiac event-free survival (hazard ratio 12.87, 95 % CI 2.86 - 27.98; P = 0.001), while SDS ≥2 did not (hazard ratio 2.78, 95 % CI 0.62 - 12.46, P = 0.16).

CONCLUSION

In this group of patients with type 2 diabetes, microalbuminuria was the only predictor of silent ischaemia on MPS. Assessment of microalbuminuria should be routinely considered among the first risk stratification steps for CAD in patients with type 2 diabetes, even though severe ischaemia on MPS is a major predictor of cardiac event-free survival.

Macrophage migration inhibitory factor (MIF) enhances palmitic acid- and glucose-induced murine beta cell dysfunction and destruction in vitro

Although several reports suggest a potentially deleterious role of macrophage migration inhibitory factor (MIF) in type 2 diabetes (T2D) pathology, it is still unclear how this pro-inflammatory cytokine acts on pancreatic beta cells. The aim of the present study was to evaluate MIF effects on murine beta cells in the in vitro settings mimicking T2D-associated conditions. Results indicate that recombinant MIF further increased apoptosis of pancreatic islets or MIN6 cells upon exposure to palmitic acid or glucose. This was accompanied by upregulation of several pro-apoptotic molecules. Furthermore, MIF potentiated nutrient-induced islet cell dysfunction, as revealed by lower glucose oxidation rate, ATP content, and depolarized mitochondrial membrane. The final outcome was potentiation of mitochondrial apoptotic pathway. The observed upregulation of nutrient-induced islet cell dysfunction and apoptosis by MIF implicates that silencing MIF may be beneficial for maintaining integrity of endocrine pancreas in obesity-associated T2D.

Inflammatory mediators involved in the progression of the metabolic syndrome

The metabolic syndrome is often associated with type 2 diabetes mellitus, dyslipidemia, atherosclerosis, hypertension, steatosis of the liver and other organs, as well as hypertension, type 2 diabetes mellitus, and atherosclerosis. Recent studies have implicated a number of inflammatory mediators including cytokines, adipokines and eicosanoids in the inflammatory responses that accompany the metabolic syndrome. Measurements of the circulating levels of the inflammatory molecules that accompany this syndrome might provide leads to therapeutic approaches to modulate the inflammatory responses and thereby alter disease progression. In this review, we summarize recent studies on classical and newer inflammatory mediators in the pathogenesis of the metabolic syndrome in humans and experimental models.

Impact of adenotonsillectomy on high-sensitivity C-reactive protein levels in obese children with obstructive sleep apnea

OBJECTIVE

To evaluate the effect of adenotonsillectomy (T&A) in obese children with obstructive sleep apnea (OSA) and to compare changes in high-sensitivity C-reactive protein (hs-CRP) levels before and 6 months after T&A in obese children with OSA.

STUDY DESIGN

Before and after study with planned data collection.

SETTING

Tertiary care, university-based pediatric hospital.

SUBJECTS AND METHODS

Seventy-five obese children with OSA were included. Clinical information such as the apnea-hypopnea index (AHI), nadir oxyhemoglobin saturation (SaO(2)), and body mass index (BMI) were recorded. The hs-CRP level was determined before T&A and at the 6-month follow-up examination.

RESULTS

Reductions in AHI (21.96 ± 9.277 before T&A vs 8.64 ± 5.997 after 6 months of T&A) and higher levels of nadir SaO(2) (74.08 ± 7.860 before T&A vs 86.87 ± 5.586 after 6 months of T&A) were observed. The hs-CRP levels were obviously correlated with BMI (r = 0.7948, P < .001). Other than AHI (r = 0.0579, P = .6217) in obese children, however, hs-CRP levels showed no changes 6 months after T&A therapy.

CONCLUSION

T&A treatment improves clinical signs and symptoms in obese children but does not reduce chronic inflammation as reflected by hs-CRP. To lower the risks of cardiovascular disease and diabetes mellitus morbidity, other treatments should be taken into account.

Double-blind, randomized, multicentre, and active comparator controlled investigation of the effect of pioglitazone, metformin, and the combination of both on cardiovascular risk in patients with type 2 diabetes receiving stable basal insulin therapy: the PIOCOMB study

BACKGROUND

We analyzed specific effects of an add-on therapy with pioglitazone compared to metformin and their combination in patients with basal insulin treatment on biomarkers of CV risk.

METHODS

In this double-blind, randomized, multicentre, active comparator controlled trial, 121 patients with type 2 diabetes were enrolled. Inclusions: treatment with basal insulin, HbA(1C) 6.5%-8.5%, age 30-75 years. After glargine therapy over 2 weeks for titration towards FBG ≤ 7.8 mmol/L, patients received either (A) bid 850 mg metformin (n = 42), (B) bid 15 mg pioglitazone (n = 40), or (C) 30 mg pioglitazone plus 1.7 g metformin (n = 39) over 6 months. Matrix Metal Proteinase 9 (MMP-9) was primary objective, together with biomarkers of CV risk.

RESULTS

Pioglitazone (B) reduced MMP-9 versus baseline by 54.1 ± 187.1 ng/mL, with metformin (A) it was increased by 49.6 ± 336.2 ng/mL (p = 0.0345; B vs. A), and with the combination of both (C) it was decreased by 67.8 ± 231.4 ng/mL (A vs. C: p = 0.0416; B vs. C: p = 0.8695). After logarithmic transformation due to high variances the exploratory results showed significance for A vs. B (p = 0.0043) and for A vs. C (p = 0.0289).Insulin dosage was reduced by 7.3 units in group B (p < 0.0001), by 6.0 units in C (p = 0.0004), but was increased by 2.5 units (p = 0.1539) in A at follow up. Reduction in hs-CRP was significant within treatment groups for B (p = 0.0098) and C (p < 0.0001), and between the groups for A vs. C (p = 0.0124). All three single regimens reduced PAI-1. Adiponectin was significantly elevated in B and C (p < 0.0001) and between-groups. HbA(1C) was only significantly decreased in the combination group. No significant effects were observed for NFkB and PGFα. peripheral edema were seen in 11.9% vs. 40.0% vs. 20.5%, and weight change was -0.7 kg vs. +4.3 kg vs. +2.7 kg (A vs. B vs. C).

CONCLUSIONS

Addition of pioglitazone but not of metformin reduces MMP-9, hs-CRP and increased insulin sensitivity and adiponectin in this study. The combination of both had no additional effect on inflammation. Pioglitazone is suggested to be a rational add-on therapy to basal insulin in patients with high CV risk.

Pioglitazone in the treatment of type 2 diabetes: safety and efficacy review

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.