Vascular reactivity and thiazolidinediones

A Real-World Study of Long-Term Safety and Efficacy of Lobeglitazone in Korean Patients with Type 2 Diabetes Mellitus

BACKGROUND

Thiazolidinediones (TZDs) have been associated with various safety concerns including weight gain, bladder cancer, and congestive heart failure (CHF). This study evaluated the efficacy and safety of lobeglitazone, a novel TZD in patients with type 2 diabetes mellitus (T2DM) in real practice.

METHODS

In this non-interventional, multi-center, retrospective, and observational study conducted at 15 tertiary or secondary referral hospitals in Korea, a total of 2,228 patients with T2DM who received lobeglitazone 0.5 mg for more than 1 year were enrolled.

RESULTS

Overall adverse events (AEs) occurred in 381 patients (17.10%) including edema in 1.97% (n=44). Cerebrovascular and cardiovascular diseases were identified in 0.81% (n=18) and 0.81% (n=18), respectively. One case of CHF was reported as an AE. Edema occurred in 1.97% (n=44) of patients. Hypoglycemia occurred in 2.47% (n=55) of patients. Fracture occurred in 1.17% (n=26) of all patients. Lobeglitazone significantly decreased HbA1c level, resulting in a mean treatment difference of -1.05%± 1.35% (P<0.001), and decreased total cholesterol, triglyceride, and low-density lipoprotein cholesterol. However, it increased high-density lipoprotein cholesterol, regardless of statin administration. The patients who received lobeglitazone 0.5 mg showed an apparent reduction in glycosylated hemoglobin (HbA1c) from baseline during the first 6 months of treatment. The HbA1c levels remained stable between months 6 and 42.

CONCLUSION

Lobeglitazone has long-term safety profile, good glycemic-lowering effect and long-term durability of glycemic control in real-world clinical settings.

Effects of contrast baths on skin blood flow on the dorsal and plantar foot in people with type 2 diabetes and age-matched controls

Contrast baths have been used for therapy for over 2,000 years. The basic concept is to alternate warm and cool water baths during a treatment session. It is believed that this will increase circulation better than just placing the limb in a warm water bath. However, there is little supportive evidence for this assertion. Further, for subjects with diabetes, with underlying impairments in their circulation, this may not work at all. Fourteen people with type 2 diabetes were compared to 14 age-matched controls. Skin blood flow of the foot (BF) was measured during 16 minutes of contrast baths at two different intervals: 3 minutes warm and 1 minute cold and 6 minutes warm and 2 minutes cold. In control subjects, warm and cold contrast baths with the ratio 3 minutes warm to 1 minute cold elicited significantly (p < 0.01) greater BF than placing the limb continuously in warm water or using a 6:2 ratio of warm to cold bath time. In control subjects, there was also a greater plantar than dorsal BF. For subjects with diabetes, there was no statistical difference between BF with contrast baths versus warm whirlpool; but in both cases BF was significantly less than that seen in control subjects under similar circumstances. There was also very little difference between BF on the plantar and dorsal aspects of the foot in the subjects with diabetes. Patients with diabetes do not show a vascular response to contrast bath therapy. The BF response to contrast temperatures may be a good diagnostic test for diabetic vascular impairment.

Interleukin-6 and Oxidative Stress in Plasma of Alloxan-Induced Diabetic Rabbits after Pioglitazone Treatment

There is evidence that oxidative stress might be implicated in promoting a state of systemic inflammation in diabetic patients. Understanding the role of reactive oxygen species in the inflammatory response in diabetes becomes essential in finding preventive treatments. Pioglitazone is a new oral antidiabetic agent with potent antioxidant and anti-inflammatory properties. The drug is a high affinity ligand of peroxisome proliferator-activated receptor gamma. This receptor seems to be involved in the control of inflammation by modulating the production of inflammatory mediators. In the present study, the changes in some markers of enhanced oxidative stress and in the level of pro-inflammatory interleukin-6 (IL-6) were examined in plasma of diabetic rabbits after 4 and 8 weeks of pioglitazone treatment. Ascorbic acid (AA) concentration and total antioxidant status (TAS) in plasma of diabetic animals were diminished and significantly elevated after pioglitazone treatment (p < 0.05). Protein carbonyl groups (PCG) content and IL-6 concentration were elevated in plasma of diabetic animals and significantly diminished after pioglitazone treatment. The results obtained in the present study confirm the relations of cytokine systems with oxidative stress in plasma of diabetic subjects. They also suggest the antioxidative and antinflammatory properties of pioglitazone.

The peroxisome proliferator-activated receptor-gamma agonist pioglitazone represses inflammation in a peroxisome proliferator-activated receptor-alpha-dependent manner in vitro and in vivo in mice

OBJECTIVES

Our aim was to investigate if the peroxisome proliferator-activated receptor (PPAR)-gamma agonist pioglitazone modulates inflammation through PPARalpha mechanisms.

BACKGROUND

The thiazolidinediones (TZDs) pioglitazone and rosiglitazone are insulin-sensitizing PPARgamma agonists used to treat type 2 diabetes (T2DM). Despite evidence for TZDs limiting inflammation and atherosclerosis, questions exist regarding differential responses to TZDs. In a double-blinded, placebo-controlled 16-week trial among recently diagnosed T2DM subjects (n = 34), pioglitazone-treated subjects manifested lower triglycerides and lacked the increase in soluble vascular cell adhesion molecules (sVCAM)-1 evident in the placebo group. Previously we reported PPARalpha but not PPARgamma agonists could repress VCAM-1 expression. Since both triglyceride-lowering and VCAM-1 repression characterize PPARalpha activation, we studied pioglitazone's effects via PPARalpha.

METHODS

Pioglitazone effects on known PPARalpha responses--ligand binding domain activation and PPARalpha target gene expression--were tested in vitro and in vivo, including in wild-type and PPARalpha-deficient cells and mice, and compared with the effects of other PPARgamma (rosiglitazone) and PPARalpha (WY14643) agonists.

RESULTS

Pioglitazone repressed endothelial TNFalpha-induced VCAM-1 messenger ribonucleic acid expression and promoter activity, and induced hepatic IkappaBalpha in a manner dependent on both pioglitazone exposure and PPARalpha expression. Pioglitazone also activated the PPARalpha ligand binding domain and induced PPARalpha target gene expression, with in vitro effects that were most pronounced in endothelial cells. In vivo, pioglitazone administration modulated sVCAM-1 levels and IkappaBalpha expression in wild-type but not PPARalpha-deficient mice.

CONCLUSIONS

Pioglitazone regulates inflammatory target genes in hepatic (IkappaBalpha) and endothelial (VCAM-1) settings in a PPARalpha-dependent manner. These data offer novel mechanisms that may underlie distinct TZD responses.

Obesity and vascular dysfunction

One of the most profound challenges facing public health and public health policy in Western society is the increased incidence and prevalence of both overweight and obesity. While this condition can have significant consequences for patient mortality and quality of life, it can be further exacerbated as overweight/obesity can be a powerful stimulus for the development of additional risk factors for a negative cardiovascular outcome, including increased insulin resistance, dyslipidemia and hypertension. This manuscript will present the effects of systemic obesity on broad issues of vascular function in both afflicted human populations and in the most relevant animal models. Among the topics that will be covered are alterations to vascular reactivity (both dilator and constrictor responses), adaptations in microvascular network and vessel wall structure, and alterations to the patterns of tissue/organ perfusion as a result of the progression of the obese condition. Additionally, special attention will be paid to the contribution of chronic inflammation as a contributor to alterations in vascular function, as well as the role of perivascular adipose tissue in terms of impacting vessel behavior. When taken together, it is clearly apparent that the development of the obese condition can have profound, and frequently difficult to predict, impacts on integrated vascular function. Much of this complexity appears to have its basis in the extent to which other co-morbidities associated with obesity (e.g., insulin resistance) are present and exert contributing effects.

Thiazolidinediones-improving endothelial function and potential long-term benefits on cardiovascular disease in subjects with type 2 diabetes

Endothelial dysfunction, which leads to impaired vasodilation, is an early event in the development of atherosclerosis. A number of mechanisms involving, for example, cell adhesion molecules, chemokines, and cytokines, contribute to this inflammatory disease, and insulin resistance plays a cardinal role in accelerating these processes. Hyperglycemia and other metabolic abnormalities that are commonly associated with insulin resistance also contribute to impaired endothelial function. In addition, the important role of the endothelium in damage repair following a cardiovascular event is emerging. The combination of proatherogenic factors in patients with type 2 diabetes results in blunted endothelial function and an increased risk of cardiovascular disease. Insulin-sensitizing agents such as thiazolidinediones have demonstrated a number of clinical benefits, including anti-inflammatory and antithrombotic properties, which may impact on the course of atherosclerosis. Recent studies have demonstrated that thiazolidinediones improve endothelial function in subjects with and without type 2 diabetes.

The risk of coronary heart disease in type 2 diabetic patients exposed to thiazolidinediones compared to metformin and sulfonylurea therapy

PURPOSE

To evaluate whether the risk of coronary heart disease (CHD) differs among adult diabetic patients treated with thiazolidinediones (TZDs) and similar patients treated with combined oral metformin and sulfonylurea (M + S) therapy.

METHODS

We conducted a retrospective cohort study involving 25 140 diabetic patients aged 18 and older who had at least one pharmacy claim for a TZD or combined M + S therapy between 1 January 1999 and 30 June 2002. We used propensity score matching to adjust for observable differences between initiators of combined M + S therapy and TZD initiators. The data were analyzed in two ways: first based on the original matched groups, 'as balanced', without accounting for switching to another medication during follow-up, and second based on actual antidiabetic drug use during follow-up, 'as treated'. Cox proportional hazards regression and multivariable Poisson regression were performed to compare the risk of CHD events.

RESULTS

In the 'as balanced' analysis, the risk for CHD among TZD users relative to combination drug users was close to the null value (adjusted hazard ratio: 1.02, 95% confidence intervals (CI): 0.87-1.20). In the 'as treated' analysis, the risk of CHD was similar for periods of current use of TZDs compared to periods of non-use (incidence rate ratio: 1.10, 95%CI: 0.96-1.25).

CONCLUSIONS

These results do not suggest a cardioprotective or deleterious effects of TZDs compared with combined M + S oral therapy on the short-term CHD event risk in persons with type 2 diabetes after accounting for the greater baseline CHD risk in TZD initiators.

Rationale, design, and methods for glycemic control in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) Trial

A major therapeutic question in considering accelerated atherogenesis in patients with type 2 diabetes mellitus is whether reducing insulin resistance, as a proximal defect of a host of proatherogenic abnormalities including hyperglycemia, will be superior for decreasing mortality and coronary artery disease (CAD) risk compared with treating hyperglycemia to overcome insulin resistance with insulin-providing agents. This question is highly relevant, since earlier targeted glycemic control trials utilizing conventional glucose-lowering strategies that increase insulin levels have generally failed to reduce CAD risk despite markedly reducing microvascular risk. The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial seeks to determine whether primarily using an insulin-sensitizing strategy for treatment of type 2 diabetes is superior when compared with primarily using an insulin-providing strategy with regard to cardiovascular outcomes. This article presents the rationale, design, and methods being used to test the glycemic control hypothesis in BARI 2D.

Insulin resistance does not impair contractile responses of cerebral arteries

Insulin resistance (IR) impairs endothelium-mediated vasodilation in cerebral arteries as well as K+ channel function in vascular smooth muscle. Peripheral arteries also show an impaired endothelium-dependent vasodilation in IR and concomitantly show an enhanced contractile response to endothelin-1 (ET-1). However, the contractile responses of the cerebral arteries in IR have not been examined systematically. This study examined the contractile responses of pressurized isolated middle cerebral arteries (MCAs) in fructose-fed IR and control rats. IR MCAs showed no difference in pressure-mediated (80 mmHg) vasoconstriction compared to controls, either in time to develop spontaneous tone (control: 61+/-3 min, n=30; IR: 63+/-2 min, n=26) or in the degree of that tone (control: 60 min: 33+/-2%, n=22 vs. IR 60 min: 34+/-3%, n=17). MCAs treated with ET-1 (10(-8.5) M) constrict similarly in control (53+/-3%, n=14) and IR (53+/-3%, n=14) arteries. Constrictor responses to U46619 (10(-6) M) are also similar in control (48+/-9%, n=8) and IR (42+/-5%, n=6) MCAs as are responses to extraluminal uridine 5'-triphosphate (UTP; 10(-4.5) M) (control: 35+/-7%, n=11 vs. IR: 38+/-3%, n=10). These findings demonstrate that constrictor responses remain intact in IR despite a selective impairment of dilator responses and endothelial and vascular smooth muscle K+ channel function in cerebral arteries. Thus, it appears that the increased susceptibility to cerebrovascular abnormalities associated with IR and diabetes (including cerebral ischemia, stroke, vertebrobasilar transient ischemic attacks) is not due to an enhanced vasoreactivity to constrictor agents.

Modification of oxidative stress by pioglitazone in the heart of alloxan-induced diabetic rabbits

The study was undertaken to analyze the effect of pioglitazone on superoxide dismutase (Cu, Zn-SOD), catalase (CAT), glutathione peroxidase (GSH-Px), glutathione reductase (GSSG-R), glutathione (GSH), ascorbic acid (AA), lipid peroxidation products (LPO) and protein carbonyl groups (PCG) in the heart of alloxan-induced diabetic rabbits after 4 and 8 weeks of pioglitazone treatment. In diabetic animals, Cu, Zn-SOD and CAT were elevated by 60 and 55%, and 90 and 77% as compared to controls at 4 and 8 weeks, respectively. GSH-Px, GSSG-R and GSH were diminished by 11, 14 and 33% as compared to controls at 4 or 8 weeks. AA was diminished by 52 and 41%. At P <0.05, pioglitazone normalized the activities of Cu, Zn-SOD, GSH-Px and GSSG-R. The activity of CAT was modified as compared to diabetic non-treated rabbits. After pioglitazone treatment, GSH and AA were increased as compared to diabetic non-treated animals. In diabetic rabbits, LPO was elevated by 52 and 111% and normalized by pioglitazone treatment. PCG was elevated by 72 and 133% and diminished as compared to diabetic non-treated animals at 8 weeks. The study shows that pioglitazone reduces oxidative stress in the heart of diabetic rabbits. In therapy, similar action can improve the cardiovascular system of diabetic patients.

Mechanisms of endothelial dysfunction in obesity

Obesity is a chronic disease, whose incidence is alarmingly growing, affecting not only adults but also children and adolescents. It is associated with severe metabolic abnormalities and increased cardiovascular morbidity and mortality. Adipose tissue secretes a great number of hormones and cytokines that not only regulate substrate metabolism but may deeply and negatively influence endothelial physiology, a condition which may lead to the formation of the atherosclerotic plaque. In this review, the physiology of the endothelium is summarised and the mechanisms by which obesity, through the secretory products of adipose tissue, influences endothelial function are explained. A short description of methodological approaches to diagnose endothelial dysfunction is presented. The possible pathogenetic links between obesity and cardiovascular disease, mediated by oxidative stress, inflammation and endothelial dysfunction are described as well.

Safety and tolerability of pioglitazone, metformin, and gliclazide in the treatment of type 2 diabetes

This analysis compares the safety and tolerability of pioglitazone (a thiazolidinedione), metformin (a biguanide), and gliclazide (a sulfonylurea). Data collected from four 1-year, double-blind studies comparing treatment of over 3700 patients with type 2 diabetes with pioglitazone, metformin, or gliclazide have been combined to provide comparative tolerability and safety profiles. All treatments were well tolerated with approximately 6% of patients withdrawing from treatment because of side-effects. The side-effects profile varied between treatments, with pioglitazone being associated with edema, metformin with gastrointestinal side-effects, and gliclazide with hypoglycemia. Cardiovascular outcome was similar with all treatments, with no excess reports of cardiac failure with pioglitazone treatment. Both pioglitazone and gliclazide resulted in mean weight gain, whilst with metformin there was mean weight loss. Mean liver enzyme values decreased with pioglitazone and to a lesser extent with metformin. With gliclazide, mean liver enzyme values increased. The expected small decreases in mean hemoglobin and hematocrit seen with pioglitazone also occurred with metformin and to a lesser degree with gliclazide. The results show that all three drugs are safe, but that tolerability profiles vary. Each treatment provides an alternative therapy for type 2 diabetes, dependent on the particular needs of individual patients.

Metabolic and vascular abnormalities in subjects at risk for type 2 diabetes: the early start of a dangerous situation

Various groups at risk for type 2 diabetes have been identified, including individuals with family history of type 2 diabetes, obesity, prior gestational diabetes, polycystic ovary syndrome, metabolic syndrome, hypertension, dyslipidemia and particularly those with pre-diabetes (impaired glucose tolerance and/or impaired fasting glucose). To various degrees, all these groups have also been identified with significant vascular abnormalities that range from endothelial dysfunction and low-grade or sub-clinical inflammation to evident atherosclerosis. The mechanisms involved in establishing a link between the risk of type 2 diabetes and vascular dysfunction are multiple and complex. The presence in the circulation of various cytokines, hormones and substrates associated with increased visceral fat and insulin resistance, the frequent appearance of associated cardiovascular risk factors and/or the possibility of some genetically determined intrinsic vascular abnormalities are all explanatory mechanisms that are being evaluated in clinical research. Whereas the possibility of appreciating a significant reduction in cardiovascular outcomes in long-term prospective clinical trials in all these groups at risk for type 2 diabetes is still lacking, understanding these mechanisms and recognizing how various interventions may improve vascular health is a worthwhile area of research that may translate into important clinical strategies to reduce the burden of type 2 diabetes and cardiovascular disease.

A role for sphingolipids in producing the common features of type 2 diabetes, metabolic syndrome X, and Cushing's syndrome

Metabolic syndrome X and type 2 diabetes share many metabolic and morphological similarities with Cushing's syndrome, a rare disorder caused by systemic glucocorticoid excess. Pathologies frequently associated with these diseases include insulin resistance, atherosclerosis, susceptibility to infection, poor wound healing, and hypertension. The similarity of the clinical profiles associated with these disorders suggests the influence of a common molecular mechanism for disease onset. Interestingly, numerous studies identify ceramides and other sphingolipids as potential contributors to these sequelae. Herein we review studies demonstrating that aberrant ceramide accumulation contributes to the development of the deleterious clinical manifestations associated with these diseases.

Type 2 Diabetes and Chronic Systolic Heart Failure

Diabetes is a chronic progressive endocrinopathy associated with significant macrovascular and microvascular complications as well as cardiomyopathy and heart failure (HF). Diabetes and chronic systolic HF result in similar activation of pathologic neurohormonal pathways. When diabetes and HF coexist, morbidity and mortality significantly increase. This article reviews important clinical issues in the care of patients with diabetes and HF. A review of pertinent pathophysiologic principles is provided, followed by a discussion of the treatment issues related to this population. Treatment issues include vascular disease risk factor modification, HF pharmacotherapy, glycemic management, and control of other common comorbid conditions.

Endothelial dysfunction, inflammation, and insulin resistance: a focus on subjects at risk for type 2 diabetes

Subjects with obesity, family history of type 2 diabetes, polycystic ovary syndrome, previous gestational diabetes, dyslipidemia, hypertension, impaired glucose tolerance or impaired fasting glucose, and those with metabolic syndrome are at risk for the development of type 2 diabetes. Some of them are also at risk for cardiovascular disease. Some underlying abnormalities such as insulin resistance, endothelial dysfunction, and low-grade chronic inflammation are frequently present and closely associated in all these groups. The flow of substrates, hormones, and cytokines from visceral fat to skeletal muscle and to the endothelial cells, along with some genetic abnormalities that lead to impaired insulin action in the peripheral tissues and to impaired insulin-stimulated nitric oxide production in endothelial cells, may play a role in establishing these shared metabolic and vascular derangements. Weight loss, thiazolidinediones, and metformin improve vascular function in subjects at risk for type 2 diabetes and may prove to reduce cardiovascular events in these individuals.

Clinical use of thiazolidinediones: recommendations

Type 2 diabetes mellitus is characterized by progressive beta-cell secretory dysfunction against a background of insulin resistance, which is present many years before the onset of hyperglycemia in most patients. Intensive treatment of diabetes reduces the risk of the onset and progression of microvascular complications and may impact the risk of development of macrovascular complications, notably coronary artery disease. Therefore, aggressive treatment with the goal of achieving serum glucose concentrations as close to normal as possible is warranted. Although medical nutritional therapy and exercise remain the cornerstones of therapy for type 2 diabetes, >90% of patients ultimately require pharmacologic therapy, and most need >1 agent to achieve therapeutic objectives. When considering which agent or agents to use to treat type 2 diabetes, one must consider the mechanism of action of the drug, its ability to lower serum glucose concentrations, the durability of effect, and potential adverse effects. In addition, some medications have potential benefits that extend beyond glucose lowering. These include beneficial effects on the adverse metabolic consequences of insulin resistance and possibly beta-cell preservation. Thiazolidinediones should be considered as early as possible in the natural history of type 2 diabetes because of their persistent glucose-lowering effect and their ability to reduce insulin resistance as well as because these agents may preserve beta-cell function and reverse some of the adverse metabolic consequences of insulin resistance.