Antihypertensive drugs and incidence of type 2 diabetes: Evidence and implications for clinical practice

Association between testosterone with type 2 diabetes in adult males, a meta-analysis and trial sequential analysis

OBJECTIVE

We performed this meta-analysis to assess serum testosterone changes in adult males with Type 2 diabetes (T2DM).

METHODS

PubMed, Embase, Web of Science, and Cochrane Library were searched to identify qualified studies. Pooled weighted mean differences (WMDs) with 95% confidence intervals (CIs) were utilized to test the changes of total testosterone (TT), free testosterone (FT) and sex hormone-binding globulin (SHBG) in patients with T2DM. Besides, trial sequential analysis was used to verify the pooled results.

RESULTS

A total of 56 studies were enrolled in our meta-analysis. Meta-analyses of the cross-sectional studies showed that patients with T2DM has significant decreases in TT (WMD: -2.98, 95%CI: -3.48 to -2.47), FT (WMD: -32.82, 95%CI: -39.70 to -25.95) and SHBG (WMD: -2.47, 95%CI: -3.93 to -1.02). In terms of the prospective studies, our results showed decreases in TT (WMD: -2.35, 95%CI: -3.24 to -1.46), FT (WMD: -25.96, 95%CI: -83.98 to 32.05), and SHBG (WMD: -10.06, 95%CI: -13.29 to -6.84) in patients with T2DM. By trial sequential analyses, the findings in current meta-analysis were based on reliable evidence.

CONCLUSION

Our results indicate that patients with T2DM have lower serum TT, FT, and SHBG levels.

An update on the assessment and management of metabolic syndrome, a growing medical emergency in paediatric populations

In the last decades the increasing rate of obesity in children and adolescents worldwide has led to the onset in paediatric age of metabolic syndrome, a disease commonly associated to adulthood. Central obesity, dyslipidaemia, hyperglycaemia, and hypertension are typical features of metabolic syndrome that seem to hesitate often in type 2 diabetes, cardiovascular disease, non-alcoholic fatty liver disease, and many other clinical conditions. Thus preventing and curing metabolic syndrome in paediatric patients is becoming an urgent need for public health. While diagnostic criteria and therapy of metabolic syndrome in adults are very well defined, there is no consensus on the definition of metabolic syndrome in children and adolescents as well as on healing approaches. The aim of this review is to describe the recent advances on the pathogenesis and clinical outcomes of paediatric metabolic syndrome. We then detail the therapeutic strategies (i.e. dietary regimens, physical exercise, nutraceuticals, and medications) employed to manage the disease. Finally, we analyse the safety profile of the drugs used in children and adolescents by performing a retrospective review of paediatric adverse reactions reported in the FDA's Adverse Event Reporting System database.

Uso de medicamentos, glicemia capilar e índice de massa corpórea em pacientes com diabetes mellitus

Objetivou-se relacionar o uso de medicamentos com a glicemia capilar e o índice de massa corpórea em pacientes com diabetes mellitus tipo 2. Estudo transversal realizado entre janeiro e julho de 2009, nos domicílios de 437 pacientes de doze centros de saúde de Fortaleza-CE. Utilizou-se um formulário para o registro das variáveis sociodemográficas e clinicas, glicemia capilar, índice de massa corpórea e uso de medicamentos. Dos pacientes com glicemia capilar normal, 93% não utilizavam antidepressivos / ansiolíticos (p = 0,02). Aproximadamente 99% dos que apresentavam a glicemia capilar elevada não utilizavam cálcio diariamente (p = 0,04). Entre aqueles com índice de massa corpórea normal, 45,5% tomavam diariamente anti-hipertensivos da classe inibidor da ECA (p = 0,03). O uso diário de drogas inibidoras da ECA, antidepressivos / ansiolíticos e cálcio apresentou associação com a glicemia capilar e o índice de massa corpórea, respectivamente. É importante que o enfermeiro avalie o peso corporal e a glicemia capilar dos pacientes com diabetes, em particular daqueles que fazem uso contínuo de medicamentos.

Effect of delapril/manidipine vs olmesartan/ hydrochlorothiazide combination on insulin sensitivity and fibrinogen in obese hypertensive patients

OBJECTIVE

To compare the effect of delapril/manidipine vs olmesartan/hydrochlorothiazide (HCTZ) combination on insulin sensitivity and plasma fibrinogen in obese hypertensive patients.

PATIENTS AND METHODS

After a 4-week placebo period, 88 obese, hypertensive (DBP >95 and <110 mmHg) outpatients were randomized to delapril 30 mg/manidipine 10 mg combination or to olmesartan 20 mg/HCTZ 12.5 mg combination for 24 weeks according to a prospective, randomized, open-label, blinded endpoint, parallel group design. At the end of the placebo period and treatment period, clinical BP, fasting plasma glucose (FPG), plasma insulin, insulin sensitivity (by euglycemic hyperinsulinemic clamp) and plasma fibrinogen were evaluated. Insulin sensitivity was expressed as the amount of glucose infused during the last 30 minutes (glucose infusion rate, GIR) in mg/Kg/min. The total glucose requirement (TGR) to maintain a steady-state blood glucose level in response to a defined increase in plasma insulin concentration was also evaluated.

RESULTS

Both combinations significantly reduced SBP/DBP values (-22.3/16.4 mmHg and -22.6/17.2 mmHg, respectively, all p <0.001 vs placebo). GIR was significantly increased only by delapril/manidipine (+3.01 mg/min/Kg, p=0.038 vs placebo), the difference between treatments being significant (p <0.05). TGR was significantly increased by delapril/manidipine (+9.7 g, p=0.034), while it was unaffected by olmesartan/HCTZ. Plasma insulin as well as fibrinogen were significantly reduced by delapril/manidipine (-17.8 pmol/l, p=0.047 and -67.5 mg/dl, p=0.021, respectively), but not by olmesartan/HCTZ, the difference between the two treatments being statistically significant (p <0.05).

CONCLUSION

In obese hypertensive patients the delapril/manidipine combination but not the olmesartan/HCTZ combination significantly decreased insulin resistance and plasma fibrinogen levels, despite the similar BP lowering efficacy.

Antihypertensive medications and risk of diabetes mellitus

PURPOSE OF REVIEW

Over the past decade post-hoc analyses of clinical trials and observational studies have tended to show that participants treated with thiazide diuretics are at greater risk for newly diagnosed diabetes mellitus than those treated with other medication classes. We review the results of several recent studies on the impact of thiazide-related hyperglycemia and diabetes mellitus on cardiovascular disease outcomes. We also examine the impact of the glucose-sparing effects of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on preventing cardiovascular disease.

RECENT FINDINGS

No consistent or conclusive evidence has been found that hyperglycemia or diabetes mellitus in association with thiazide diuretic use is associated with increased cardiovascular disease outcomes. This benign outcome may be a consequence of the fact that only a segment of such diuretic-associated cases is induced by the usual etiologic mechanisms that are associated with classic 'diabetes mellitus'. Likewise, no evidence has been found that the glucose-lowering effect of angiotensin-converting enzyme inhibitors is associated with decreased cardiovascular disease risk.

SUMMARY

We conclude that thiazide diuretics are safe to use, even in hypertensive individuals at risk for incident glucose disorders. The use of angiotensin-converting enzyme inhibitors for protection against glucose disorders and subsequent cardiovascular disease remains to be determined.

Management of Hypertension in Children and Adolescents With the Metabolic Syndrome

Because elevated blood pressure is one of the defining criteria of the metabolic syndrome, treatment of hypertension will be required in many, if not most, children and adolescents diagnosed with the metabolic syndrome. This review highlights several aspects of the approach to treatment of hypertension in young patients with the metabolic syndrome, including the definition of hypertension, use of nonpharmacologic measures, indications for instituting antihypertensive medications, and the potential adjunctive role that insulin-sensitizing agents may play in blood pressure reduction. The choice of antihypertensive agent is also discussed, along with consideration of the diabetogenic effects of various classes of antihypertensive agents. Consideration of all of these issues is important in achieving blood pressure control in children and adolescents with the metabolic syndrome, as appropriate treatment may help to forestall the development not only of type 2 diabetes but also of the cardiovascular disease that is frequently already present at the time of diagnosis of type 2 diabetes in adults.

Telmisartan/hydrochlorothiazide in the treatment of hypertension

Telmisartan blocks the detrimental actions of angiotensin II mediated via the angiotensin type 1 receptor. Unique features of telmisartan are high lipophilicity and a long terminal elimination half-life (~ 24 h). Telmisartan/hydrochlorothiazide is indicated for hypertensive patients unable to achieve target blood pressure with either monotherapy. Fixed-dose combination tablets containing telmisartan 40 or 80 mg and hydrochlorothiazide 12.5 mg are widely available; in addition, telmisartan/hydrochlorothiazide 80/25 mg is available in the USA. Telmisartan/hydrochlorothiazide is superior to losartan/hydrochlorothiazide and valsartan/hydrochlorothiazide in maintaining blood pressure control in the risky early morning hours at the end of the dosing interval. Furthermore, telmisartan/ hydrochlorothiazide provides superior 24-h mean blood pressure reduction and is better tolerated than amlodipine/hydrochlorothiazide in elderly patients with predominantly systolic hypertension. Telmisartan has the potential to confer additional reno- and cardioprotection to that due to blood pressure control. The cardioprotective activity of renin–angiotensin system blockade with telmisartan alone and in combination with ramipril is currently being evaluated in the ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) and the Telmisartan Randomized AssessmeNt Study in aCE iNtolerant subjects with cardiovascular Disease (TRANSCEND). In total, 31,546 patients have been enrolled worldwide and are being followed for up to 5.5 years.