Effects of oral hypoglycaemic agents on platelet functions

Exposure to hypoglycemia and risk of stroke

In the treatment of both type 1 and type 2 diabetes mellitus, maintaining a euglycemic state represents one of the key challenges. Improper dosing and administration of glucose-lowering drugs is associated with an increased risk of recurrent hypoglycemia episodes. In addition, the risk of adverse cardiovascular events in diabetic patients, particularly myocardial infarctions and strokes, is well established. Current research indicates a potential link between the baseline risk of cardio/cerebrovascular events in diabetic patients and exposure to hypoglycemia. In this review of the literature, we aim to determine if a relationship exists between recurrent hypoglycemia and adverse neurovascular events.

Effects of oral hypoglycemic agents on platelet function

Platelet dysfunction plays a role in diabetic macrovascular complications. Several studies have assessed the effect of oral hypoglycemic agents (OHAs) on platelet function. Data from both in vivo and in vitro studies show a favorable effect for most of the traditional glucose-lowering therapies, while evidence is limited for the newer ones. Metformin, sulfonylureas, glitazones and acarbose exert a favorable effect on platelet function. Among incretin therapies, only sitagliptin has so far been demonstrated to have a beneficial effect on platelet aggregation. More in vivo and in vitro evidence is required to increase our knowledge on any potential beneficial effects of OHAs on platelet function. Any such effect may have implications for the reduction of cardiovascular risk in type 2 diabetes mellitus.

Anticoagulant effects of an antidiabetic drug on monocytes in vitro

INTRODUCTION

Monocyte- and microparticle (MP)-associated tissue factor (TF) is upregulated in diabetes. Lipopolysaccharide (LPS) induces expression of TF and alternatively spliced TF (asTF) and increases MP release from monocytes. Using LPS-stimulated TF-bearing human monocytes, we examined whether glibenclamide, a sulfonylurea used to treat diabetes type 2, might possess anticoagulant properties.

METHODS

We studied the effects of glibenclamide on cell- and supernatant-associated procoagulant activity (Factor Xa-generating assay and clot formation assay), on expression of TF and asTF (flow cytometry, RT-qPCR, western blot) and on cell viability and MP release (flow cytometry).

RESULTS

Glibenclamide dose-dependently decreased procoagulant activity of cells and supernatants. The reduction in cellular procoagulant activity coincided with reduced expression of TF and asTF in cells, whereas cell viability remained almost unchanged. The glibenclamide-induced reduction in procoagulant activity of supernatants appeared to be associated with a decreased number of released MPs.

CONCLUSIONS

Reduction of monocyte- and supernatant-associated procoagulant activity by glibenclamide is associated with decreased expression of TF and asTF and possibly with a reduced MP number. Our data indicate that glibenclamide reduces the prothrombotic state in LPS-stimulated monocytes in vitro. Glibenclamide might therefore also have an anticoagulant effect in vivo, but this needs to be further evaluated.

Repurposing an old drug for a new use: glybenclamide exerts antiplatelet activity by interacting with the thromboxane A(2) receptor

AIM

To investigate the potential antagonistic activity of the antidiabetic agent glybenclamide for the human platelet thromboxane A(2) receptor (abbreviated as TPR).

METHODS

Platelets were obtained from healthy donors. Aggregation studies were performed in a model 700 aggregometry system. Radioactivity was counted in a Beckman LS 6000 liquid scintillation counter and calcium imaging was performed using an LS50B PerkinElmer Fluorescence Spectrometer.

RESULTS

It was found that glybenclamide: 1) inhibited aggregation induced by the TPR agonist U46619 (IC(50)=2.3+/-0.31 micromol/L) and by the thromboxane A(2) precursor arachidonic acid (IC(50)=2.6+/-0.24 micromol/L); 2) displaced SQ29,548 from its binding sites on platelets; 3) lacked any detectable effects on aggregation stimulated by ADP, or the thrombin receptor activating-peptide 4; 4) blocked calcium mobilization induced by U46619, but not by ADP; and 5) failed to raise cAMP levels.

CONCLUSION

The findings indicate that glybenclamide exerts inhibitory effects on platelets by interacting with TPR. Thus, glybenclamide or a rationally designed derivative has the potential to serve as an antithrombotic agent.

Meal-induced platelet activation in Type 2 diabetes mellitus: effects of treatment with repaglinide and glibenclamide

AIMS

To compare the effects of treatment with repaglinide and glibenclamide on platelet function and endothelial markers in patients with Type 2 diabetes mellitus, before and after a standardized meal.

METHODS

Fifteen patients with Type 2 diabetes were investigated on three occasions: at baseline without oral hypoglycaemic drug treatment, and after 6 weeks' treatment with repaglinide or glibenclamide, respectively, in an open randomized cross-over study. Agonist-induced platelet P-selectin expression and platelet aggregation, urinary thromboxane, soluble P-selectin, von Willebrand factor (VWF), soluble E-selectin, intercellular adhesion molecule (ICAM-1) and C-reactive protein (CRP) were measured. In addition, pre-meal data were compared with non-diabetic control subjects (n = 15), matched for sex, age and BMI.

RESULTS

Adenosine diphosphate (ADP)-induced platelet P-selectin expression increased post-meal in Type 2 diabetic patients both at baseline and after treatment with repaglinide and glibenclamide (P < 0.01 for all; repeated measures anova). Repaglinide treatment reduced fasting ADP-induced P-selectin expression compared with baseline (P = 0.01), but did not influence meal-induced platelet hyper-reactivity (P = 0.32). No significant anti-platelet effects of glibenclamide treatment were found. Plasma concentrations of VWF and ICAM-1 were elevated in patients with Type 2 diabetes compared with control subjects (P < 0.05 for both) and were reduced during treatment with repaglinide (P < 0.01 for both) but did not change during glibenclamide treatment.

CONCLUSIONS

The post-meal state is associated with enhanced platelet reactivity in patients with Type 2 diabetes mellitus. Pre-meal treatment with repaglinide or glibenclamide does not inhibit postprandial platelet activation, but repaglinide treatment is associated with attenuated platelet and endothelial activity in the fasting state.

Hypertensive patients with carotid artery plaque exhibit increased platelet aggregability

BACKGROUND

Platelets play an important role in myocardial infarction and ischemic stroke events, but whether platelet aggregability is related to early stage arteriosclerosis remains unclear.

METHODS

We used a novel platelet counting system which makes it possible to detect spontaneous platelet aggregation, to evaluate the relationship between platelet aggregability and carotid artery arteriosclerosis in 125 outpatients with primary hypertension (46-73 years old: 65 men, 60 women). All subjects underwent carotid artery ultrasonography to determine whether plaque was present and to estimate intima-media thickness.

RESULTS

Patients with carotid artery plaques (Plaque(+), n=63) were older and had higher systolic blood pressures than patients without plaques (Plaque(-), n=62), but no significant differences in sex, body mass index, diastolic blood pressure, plasma concentrations of glucose, total cholesterol, triglyceride, lipoprotein cholesterol, fibrinogen or the platelet count in whole blood were observed between Plaque(+) and Plaque(-) groups. Plaque(+) subjects showed greater spontaneous platelet aggregability and platelet aggregation induced by 2 microM or 0.5 microM of ADP or 0.3 microM of epinephrine than the Plaque(-) group. When age and systolic blood pressure were matched (n=52 in both groups), the Plaque(+) subjects exhibited greater platelet aggregability than the Plaque(-) subjects. Platelet aggregation induced by 2 microM of ADP showed statistical significant positive correlation coefficients with age, HbA1c and diastolic blood pressure.

CONCLUSION

Our results indicate that hypertensive patients with carotid artery plaque have increased platelet aggregability. A prospective study is recommended to clarify whether this increase in platelet aggregability promotes the progression of arteriosclerosis.

Glibenclamide inhibits thromboxane-mediated vasoconstriction by thromboxane receptor blockade

Because sulfonylureas, such as glibenclamide, are used to treat Type 2 diabetes and because this disease is associated with various cardiovascular complications that may be mediated by thromboxane (TX), this study was designed to characterize the role of glibenclamide on TX-mediated contractions in isolated ring segments of bovine coronary arteries and rabbit aortas. A series of TXA(2) analogs [9,11 Dideoxy-9alpha, 11alpha-methanoepoxy prostaglandin F(2alpha) (U46619), [1S-(1alpha, 2beta(5Z),3alpha(1E, 3R*),4alpha)]-7-[3-(3-hydroxy-4-(4'-iodophenoxy)-1-butenyl)-7-oxabicyclo [2.2.1]heptan-2-yl]-5-heptenoic acid (I-BOP), carbocyclic TXA(2) (CTA(2)) and 9,11-dideoxy-9alpha,11alpha-epoxymethano prostaglandin F(2alpha) (U44069)], endothelin and phenylephrine contracted both types of blood vessels. Glibenclamide (10 microM) inhibited the contraction to each of the TX agonists but had no effect on endothelin- or phenylephrine-induced contractions. We hypothesized that this effect was due to a direct effect to block the vascular smooth muscle cell TX receptor. Receptor binding studies were performed in rabbit vascular smooth muscle cells and indicated that glibenclamide (10 microM) inhibited (125)I-BOP binding by more than 80%. The inhibition constants or K(i) for glibenclamide was 0.53 microM. These studies provide the first evidence that the ability of glibenclamide to inhibit TX-mediated contractions occurs independent of the vascular K(ATP) channel and is, instead, mediated by the blockade of the vascular TX receptor.

Are hypoglycaemia and other adverse effects similar among sulphonylureas?

This review provides an updated overview of the adverse effects of sulphonylureas and identifies factors associated with variation in adverse effect rates among sulphonylureas published by different studies. A search of Medline, Embase, Current Contents and Cochrane Library was conducted to identify all papers related to sulphonylureas and adverse effects published from 1950-2001. The reference lists of all relevant papers were also searched for additional articles. The frequency of sulphonylurea-induced hypoglycaemia varied from 1.8-59%. Severe hypoglycaemia due to sulphonylurea use has been reported from 1.9-3.5%. Variation in hypoglycaemia rates may be due to differences in definitions, methods to detect and to collect information, patient characteristics, patient knowledge of the condition, threshold for symptoms, and activity level during hypoglycaemia. Other adverse effects associated with sulphonylurea use include bodyweight gain, gastrointestinal distress, disulphiram-like syndrome, dermatological reactions, haematological changes, ocular problems, and the syndrome of inappropriate secretion of antidiuretic hormone. Bodyweight gain has been reported to vary from 1.7-4.8 kg, according to the United Kingdom Prospective Diabetes Study (UKPDS-33). Controversy exists regarding cardiovascular adverse effects, but the consensus is to exercise caution in the use of these drugs as first-line therapy for patients with diabetes mellitus and coronary artery disease. The benefits of sulphonylurea treatment should be weighed against the risks associated with them. More work in this area is needed to homogenise the definition of hypoglycaemia, to get consensus on the methods for detection and data collection, as well as to further patient and physician education.

Comparison of the efficacy of glibenclamide and glimepiride in reperfusion-induced arrhythmias in rats

The effect of glibenclamide and glimepiride, two orally active antidiabetic sulphonylurea derivatives, was investigated on the development of reperfusion-induced arrhythmias and it was compared to their blood glucose lowering action. Arrhythmias were produced by reperfusion following 6 min coronary artery ligation in anaesthetised rats. Glimepiride pretreatment (0.001-0.01-0.1-5.0 mg/kg i.p., 30 min before coronary occlusion) significantly decreased the incidence of irreversible ventricular fibrillation and increased the survival rate during reperfusion (64%, 61%, 60%, and 67% vs. 27% in controls). Glibenclamide produced similar effect (81% survival) only in a dose of 5 mg/kg, while smaller doses were ineffective. The minimal hypoglycaemic dose and the dose required to inhibit significantly the oral glucose loading-induced hyperglycaemia were similar (1 and 0.1 mg/kg, respectively) after glibenclamide and glimepiride. It is concluded that although the blood glucose lowering potency of glibenclamide and glimepiride is rather similar, glimepiride appears to be more potent than glibenclamide in preventing reperfusion-induced cardiac arrhythmias.

Cardiovascular effects of oral hypoglycaemic drugs

1. There is increasing evidence that sulfonylurea and biguanide oral hypoglycaemic drugs have cardiovascular effects and influence risk factors for cardiovascular disease in patients with non-insulin-dependent diabetes because of actions that are unrelated to alterations in glycaemic control. 2. While sulfonylureas may have anti-arrhythmic effects following myocardial ischaemia, there is concern that their action on vascular ATP-sensitive potassium channels may contribute to elevated blood pressure and enhanced vascular responsiveness. 3. In contrast to sulfonylureas, metformin (a biguanide) appears to reduce blood pressure and have beneficial effects on plasma lipoproteins by reducing low-density lipoprotein cholesterol and possibly increasing high-density lipoprotein cholesterol levels. 4. The pharmacological basis and clinical significance of these effects of sulfonylureas and biguanides require further investigation.

Sulphonylurea agents inhibit platelet aggregation and [Ca2+]i elevation induced by arachidonic acid

The effects of three hypoglycaemic agents--glimepiride, glibenclamide and gliclazide--were evaluated on platelet aggregation and intracellular Ca2+ elevation induced by arachidonic acid. Platelet aggregation was assessed both by the conventional method using changes in light transmission and by a newly-developed procedure using light scattering which allows the detection of small as well as large aggregates. Glimepiride and glibenclamide inhibited the formation of small and large aggregates induced by optimal concentrations of arachidonic acid in a dose-dependent manner. The ID50 values for the inhibition of platelet aggregation were approximately one third of those for arachidonic acid metabolism, suggesting that both agents have certain direct inhibitory effects on platelet aggregation unrelated to arachidonic acid metabolism. Gliclazide inhibited the formation of small aggregates induced by low concentrations of arachidonic acid to a limited extent. However, it inhibited the formation of large aggregates but not small aggregates when higher concentrations of arachidonic acid were used. Glimepiride and glibenclamide inhibited [Ca2+]i elevation induced by arachidonic acid in a dose-dependent manner, whereas gliclazide had no inhibitory effect. Taken together, these suggest that gliclazide does not inhibit arachidonic acid metabolism but does have certain direct inhibitory effects on platelet aggregation.

Effects of sulfonylurea agents on platelet arachidonic acid metabolism; study on platelet homogenates

Effects of three sulfonylurea agents on arachidonic acid metabolism of platelet homogenates were evaluated using HPLC. Gliclazide had no significant inhibitory effects on arachidonic acid metabolism. Glibenclamide and glimepiride both inhibited the production of cyclooxygenase-related metabolites, thromboxane B2 (TXB2) and 12-hydroxy 5,8,10-heptadecatrienoic acid (HHT), whereas 12-hydroxy 5,8,10,14-eicosatetraenoic acid (12-HETE), a 12-lipoxygenase-related product, was unaffected. These findings confirmed part of our previous report using intact platelets, except that we found in the present study that glibenclamide had no inhibitory effect on 12-lipoxygenase.