Pleiotropic effects of hypoglycemic agents: implications in asthma and COPD

PPARG stimulation restored lung mRNA expression of core clock, inflammation- and metabolism-related genes disrupted by reversed feeding in male mice

The circadian rhythm system regulates lung function as well as local and systemic inflammations. The alteration of this rhythm might be induced by a change in the eating rhythm. Peroxisome proliferator-activated receptor gamma (PPARG) is a key molecule involved in circadian rhythm regulation, lung functions, and metabolic processes. We described the effect of the PPARG agonist pioglitazone (PZ) on the diurnal mRNA expression profile of core circadian clock genes (Arntl, Clock, Nr1d1, Cry1, Cry2, Per1, and Per2) and metabolism- and inflammation-related genes (Nfe2l2, Pparg, Rela, and Cxcl5) in the male murine lung disrupted by reversed feeding (RF). In mice, RF disrupted the diurnal expression pattern of core clock genes. It decreased Nfe2l2 and Pparg and increased Rela and Cxcl5 expression in lung tissue. There were elevated levels of IL-6, TNF-alpha, total cells, macrophages, and lymphocyte counts in bronchoalveolar lavage (BAL) with a significant increase in vascular congestion and cellular infiltrates in male mouse lung tissue. Administration of PZ regained the diurnal clock gene expression, increased Nfe2l2 and Pparg expression, and reduced Rela, Cxcl5 expression and IL-6, TNF-alpha, and cellularity in BAL. PZ administration at 7 p.m. was more efficient than at 7 a.m.

Folate derivatives, 5-methyltetrahydrofolate and 10-formyltetrahydrofolate, protect BEAS-2B cells from high glucose-induced oxidative stress and inflammation

Folate (vitamin B₉) and its biologically active derivatives are well-known antioxidant molecules protecting cells from oxidative degradation. The presence of high glucose, often found in diabetic patients, causes oxidative stress resulting in cellular stress and inflammatory injury. Cells in organs such as the lung are highly prone to inflammation, and various protective mechanisms exist to prevent the progressive disorders arising from inflammation. In the present study, the synthetic form of folate, i.e. folic acid, and active forms of folate, i.e. 5-methyltetrahydrofolate and 10-formyltetrahydrofolate, were evaluated for their antioxidant and antiinflammatory potential against high glucose (50 mM)–mediated oxidative stress and inflammation in BEAS-2B cells, an immortalised bronchial epithelial cell line. High glucose treatment showed a 67% reduction in the viability of BEAS-2B cells, which was restored to the viability levels seen in control cultures by the addition of active folate derivatives to the culture media. The DCFH-DA fluorometric assay was performed for oxidative stress detection. The high glucose–treated cells showed a significantly higher fluorescence intensity (1.81- and 3.8-fold for microplate assay and microscopic observation, respectively), which was normalised to control levels on supplementation with active folate derivatives. The proinflammatory NF-κB p50 protein expression in the active folate derivative–supplemented high glucose–treated cells was significantly lower compared to the folic acid treatment. In support of these findings, in silico microarray GENVESTIGATOR database analysis showed that in bronchiolar small airway epithelial cells exposed to inflammatory condition, folate utilization pathway genes are largely downregulated. However, the folate-binding protein gene, which encodes to the folate receptor 1 (FOLR1), is significantly upregulated, suggesting a high demand for folate by these cells  in inflammatory situations. Supplementation of the active folate derivatives 5-methyltetrahydrofolate and 10-formyltetrahydrofolate resulted in significantly higher protection over the folic acid from high glucose–induced oxidative stress and inflammation. Therefore, the biologically active folate derivatives could be a suitable alternative over the folic acid for alleviating inflammatory injury-causing oxidative stress.

Combination therapies with thiazolidinediones are associated with a lower risk of acute exacerbations in new-onset COPD patients with advanced diabetic mellitus: a cohort-based case-control study

BACKGROUND

The effects of oral antihyperglycaemic drugs (OADs) for type 2 diabetes mellitus (T2DM) on the outcomes of co-existing chronic obstructive pulmonary disease (COPD) patients are not well studied. We examined the association of combinational OADs and the risk of acute exacerbations of COPD (AECOPD) in T2DM patients with co-existing COPD.

METHODS

A cohort-based case-control study was conducted using data from the National Health Insurance Research Database of Taiwan. Among new-onset COPD-T2DM patients, 65,370 were prescribed metformin and 2nd-line OADs before the date of COPD onset. Each AECOPD case was matched to 4 randomly selected controls according to the propensity score estimated by the patient's baseline characteristics. Conditional logistic regression analysis was performed to estimate the association between AECOPD risk and OAD use.

RESULTS

Among COPD-T2DM patients, 3355 AECOPD cases and 13,420 matched controls were selected. Of the patients treated with a double combination of oral OADs (n = 12,916), those treated with sulfonylurea (SU) and thiazolidinediones (TZD) had a lower AECOPD risk than the patients who received metformin (MET) and SU, with an adjusted odds ratio (OR) of 0.69 (95% confidence interval [CI] 0.51-0.94, P = 0.02). Of the patients with a triple combination of oral OADs (n = 3859), we found that those treated with MET, SU and TZD had a lower risk of AECOPD (adjusted OR 0.81 (0.68-0.96, P = 0.01) than a combination of MET, SU and α-glucosidase inhibitors (AGIs) regardless of the level of COPD complexity.

CONCLUSION

Combination therapies with TZD were associated with a reduced risk of AECOPD in advanced T2DM patients with co-existing COPD.

The Effects of Asthma on the Association Between Pulmonary Function and Obesity: A 16-Year Longitudinal Study

Background

Asthma and obesity are important public health issues around the world. Obesity is considered a risk factor associated with the severity and incidence of asthma. We investigated the relationships between poor pulmonary function (defined by forced vital capacity (FVC) and percentage of predicted FVC (FVC%)) and obesity.

Methods

This is a retrospective longitudinal study using the MJ health examination database in Taiwan from 2000 to 2015. There were 160,609 participants aged ≥20 years with complete obesity indicators and lung function data, and having at least two visits. A generalized estimation equation (GEE) model was applied to estimate the association between lung function and obesity.

Results

BMI was the best indicator to predict poor pulmonary function for our participants. Results of BMI are presented as an example: Obesity (body mass index (BMI) ≥27.0 kg/m²) is significantly associated with lower FVC [adjusted coefficients (β) for asthmatics: -0.11 L (95% CI: -0.14, -0.08); adjusted β for non-asthmatics: -0.08 L (-0.09, -0.08)] and FVC% [adjusted β for asthmatics: -1.91% (95% CI: -2.64, -1.19); adjusted β for non-asthmatics: 1.48% (-1.63, -1.33)]. Annual change of BMI (ΔBMI/year) is an independent risk factor for decreased FVC [adjusted β for asthmatics: -0.030 L (-0.048, -0.013); adjusted β for non-asthmatics: -0.019 L (-0.022, -0.016)] and FVC% [adjusted β for non-asthmatics: -0.603% (-1.063, -0.142); adjusted β for non-asthmatics: -0.304% (-0.393, -0.214)], and is significantly associated with accelerated FVC decline [adjusted β of ΔFVC/year and ΔFVC %/year for asthmatics: -0.038 L (-0.054, -0.022) and -0.873% (-1.312, -0.435); adjusted β of ΔFVC/year and ΔFVC %/year for non-asthmatics: -0.033 L (-0.042, -0.024) and -0.889% (-1.326, -0.452)].

Conclusion

Obesity is significantly associated with decreased lung function, and asthmatics had a higher risk than non-asthmatics.

Vitamin C deficiency and risk of metabolic complications among adults with chronic respiratory diseases: A case-control study

BACKGROUND

Chronic respiratory disease (CRD) is an airflow limitation that represents a wide array of serious diseases. The aim of this study is to examine the influence of vitamin C deficiency on metabolic health-related quality in individuals with and without chronic respiratory disease in the Gaza Strip.

METHODS

A matched case-control study including 52 cases of CRD and 52 controls of healthy participants were matched by age, sex, body mass index (BMI) and waist circumferences (WC). The study was conducted at the Ministry of Health secondary health-care centers in Gaza strip, Palestine. The biochemical data included Protein Carbonyl (PC), high sensitivity C reactive protein (CRP), vitamin C, fasting blood glucose (FBG) and markers of the lipid profile.

RESULTS

By the qualitative estimation of vitamin C consumption, there was a significantly lower consumption of foods that are rich in vitamin C by CRD patients than the matched controls. By comparing the results between both groups, CRD patients had significantly lower plasma concentrations of vitamins C than the control group (18.43 ± 11.93 μgm/ml vs. 24.06 ± 11.19 μgm/ml, P = 0.025), but significantly higher in PC (3.86 ± 4.21 μgm/ml vs. 2.11 ± 0.97 μgm/ml, P = 0.005), CRP (5.98 ± 8.84 mg/l vs. 1.87 ± 1.96 mg/l, P = 0.001), and FBG (102.46 ± 15.09 mg/dl vs. 95.92 ± 10.88 mg/dl, P = 0.017). The results revealed that CRD patients had significantly lower blood oxygen saturation than the control group (96.36 ± 3.81 vs. 98.51 ± 0.75, P < 0.001), whereas no significant differences were observed regarding the lipid profiles markers.

CONCLUSION

CRD patients have lower levels of vitamin C in their plasma and their diet than do healthy matched people; they also have higher oxidative stress and inflammatory markers than healthy people, which are risk factors for predicting metabolic complications.

Use of antidiabetic medications and risk of chronic obstructive pulmonary disease exacerbation requiring hospitalization: a disease risk score-matched nested case-control study

BACKGROUND

Exacerbation of chronic obstructive pulmonary disease (COPD) severely impacts the quality of life and causes high mortality and morbidity. COPD is involved with systemic and pulmonary inflammation, which may be attenuated with antidiabetic agents exerting anti-inflammatory effects. Real-world evidence is scant regarding the effects of antidiabetic agents on COPD exacerbation. Accordingly, we conducted a disease risk score (DRS)-matched nested case-control study to systemically assess the association between each class of oral hypoglycemic agents (OHAs) and risk of severe COPD exacerbation in a nationwide COPD population co-diagnosed with diabetes mellitus (DM).

METHODS

We enrolled 23,875 COPD patients receiving at least one OHA for management of DM by analyzing the Taiwan National Health Insurance claims database between January 1, 2000, and December 31, 2015. Cases of severe exacerbation were defined as those who had the first hospital admission for COPD. Each case was individually matched with four randomly-selected controls by cohort entry date, DRS (the estimated probability of encountering a severe COPD exacerbation), and COPD medication regimens using the incidence density sampling approach. Conditional logistic regressions were performed to estimate odds ratios (OR) of severe COPD exacerbation for each type of OHAs.

RESULTS

We analyzed 2700 cases of severe COPD exacerbation and 9272 corresponding controls after DRS matching. Current use of metformin versus other OHAs was associated with a 15% (adjusted OR [aOR], 0.85; 95% confidence interval [CI] 0.75-0.95) reduced risk of severe COPD exacerbation, whereas the reduced risk was not observed with other types of antidiabetic agents. When considering the duration of antidiabetic medication therapy, current use of metformin for 91-180 and 181-365 days was associated with a 28% (aOR, 0.72; 95% CI 0.58-0.89) and 37% (aOR, 0.63; 95% CI 0.51-0.77) reduced risk of severe COPD exacerbation, respectively. Similarly, 91-180 days of sulfonylureas therapy led to a 28% (aOR, 0.72; 95% CI 0.58-0.90) lower risk, and longer treatments consistently yielded 24-30% lower risks. Current use of thiazolidinediones for more than 181 days yielded an approximately 40% decreased risk.

CONCLUSIONS

Duration-dependent beneficial effects of current metformin, sulfonylurea, and thiazolidinedione use on severe COPD exacerbation were observed in patients with COPD and DM.

A Molecular Perspective on the Potential Benefits of Metformin for the Treatment of Inflammatory Skin Disorders

Due to its anti-hyperglycemic effect, metformin is the first-line medication for the treatment of type 2 diabetes, particularly in people who are obese. However, metformin is a drug with a very wide range of pharmacological properties and reports of its therapeutic effect on diseases including inflammation and cancer are increasing. Numerous research groups have reported that metformin has beneficial effects on a variety of inflammatory skin disorders including psoriasis, acanthosis nigricans, acne, hidradenitis suppurativa, and allergic contact dermatitis. According to these reports, in addition to the well-known action of metformin, that is, its anti-hyperglycemic effect, NF-kB inhibition and the resulting alteration to the cytokine network may be the potential targets of metformin. Its anti-hyperandrogenism effect has also been confirmed as the major action of metformin in some inflammatory skin diseases. Moreover, novel regulatory mechanisms, including autophagy and antioxidant processes, have been suggested as promising mechanisms of action for metformin in inflammatory skin disorders.

Clinical Effectiveness of a Combination of Black Elder Berries, Violet Herb, and Calendula Flowers in Chronic Obstructive Pulmonary Disease: The Results of a Double-Blinded Placebo-Controlled Study

Chronic obstructive pulmonary disease (COPD) is a multifactorial disease, in which systemic inflammation plays a key role. This 6-month randomized double-blinded placebo-controlled study evaluates the possible effect of natural preparation Inflaminat on clinical symptoms of COPD, indicators of respiratory function, and exacerbation frequency in 60 patients with moderate severity of COPD. Inflaminat is a combination of natural ingredients black elder (Sambucus nigra L.) berries, violet (Viola tricolor L.) herb, and calendula (Calendula officinalis L.) flowers. The preparation has been previously demonstrated to possess anticytokine and anti-inflammatory effects in experimental studies. In present study, COPD dynamics were evaluated by means of BCSS (Breathlessness, Cough, and Sputum Scale) and spirometry tests. It was shown that 6-months Inflaminat administration led to significant decrease of BCSS points from 3.0 ± 0.6 to 1.9 ± 0.7, (p = 0.002) as well as significant increase of FEV1 from 66 ± 18% to 73 ± 17%, (p = 0.042); there were no beneficial dynamics in placebo group. Side effects associated with preparation administration were not identified. The results of the study suggest that Inflaminat may be employed in treatment of patients with moderate severity of COPD, since it has a positive effect on COPD symptoms according BCSS and indicators of respiratory function FEV1.

Metformin to reduce metabolic complications and inflammation in patients on systemic glucocorticoid therapy: a randomised, double-blind, placebo-controlled, proof-of-concept, phase 2 trial

BACKGROUND

An urgent need to reduce the metabolic side-effects of glucocorticoid overexposure has been recognised, as glucocorticoid excess can lead to Cushing's syndrome, which is associated with high morbidity. We aimed to evaluate the potential of metformin to reverse such effects while sparing the anti-inflammatory benefits of glucocorticoids.

METHODS

We did a randomised, double-blind, placebo-controlled, proof-of-concept, phase 2 trial involving four hospitals in the UK. Patients without diabetes were eligible if they were between the ages of 18 and 75 years with an inflammatory disease treated with continuous prednisolone (≥20 mg/day for ≥4 weeks and remaining on ≥10 mg/day for the subsequent 12 weeks, or its cumulative dose-equivalent). Eligible patients were randomly allocated (1:1) to either the metformin or placebo groups, using a computer-generated randomisation table stratified according to age and BMI. Metformin and placebo were administered orally for 12 weeks in escalating doses: 850 mg/day for the first 5 days, 850 mg twice a day for the next 5 days, and 850 mg three times a day subsequently. The primary outcome was the between-group difference in visceral-to-subcutaneous fat area ratio over 12 weeks, assessed by CT. Secondary outcomes included changes in metabolic, bone, cardiovascular, and inflammatory parameters over 12 weeks. Our analysis followed a modified intention-to-treat principle for the primary outcome. This study is registered with ClinicalTrials.gov, NCT01319994.

FINDINGS

Between July 17, 2012, and Jan 14, 2014, 849 patients were assessed for study eligibility, of which 53 were randomly assigned to receive either metformin (n=26) or placebo (n=27) for 12 weeks. 19 patients in the metformin group and 21 in the placebo group were eligible for the primary outcome analysis. Both groups received an equivalent cumulative dose of glucocorticoids (1860 mg prednisolone-equivalent [IQR 1060-2810] in the metformin group vs 1770 mg [1020-2356] in the placebo group); p=0·76). No change in the visceral-to-subcutaneous fat area ratio between the treatment groups was observed (0·11, 95% CI -0·02 to 0·24; p=0·09), but patients in the metformin group lost truncal subcutaneous fat compared with the placebo group (-3835 mm², 95% CI -6781 to -888; p=0·01). Improvements in markers of carbohydrate, lipid, liver, and bone metabolism were observed in the metformin group compared with the placebo group. Additionally, those in the metformin group had improved fibrinolysis, carotid intima-media thickness, inflammatory parameters, and clinical markers of disease activity. The frequency of pneumonia (one event in the metformin group vs seven in the placebo group; p=0·01), overall rate of moderate-to-severe infections (two vs 11; p=0·001), and all-cause hospital admissions due to adverse events (one vs nine; p=0·001) were lower in the metformin group than in the placebo group. Patients in the metformin group had more events of diarrhoea than the placebo group (18 events vs eight; p=0·01).

INTERPRETATION

No significant changes in the visceral-to-subcutaneous fat area ratio between the treatment groups were observed; however, metformin administration did improve some of the metabolic profile and clinical outcomes for glucocorticoid-treated patients with inflammatory disease, which warrants further investigation.

FUNDING

Barts Charity and Merck Serono.

Kinase and GPCR polypharmacological approach for the identification of efficient anticancer medicines

Discovery of an anticancer medicine using a single target protein has often been unsuccessful due to the complexity of pathogenic mechanisms as well as the presence of redundant signaling pathways. In this work, we attempted to find promising anticancer drug candidates by simultaneously targeting casein kinase 1 delta (CK1δ) and muscarinic acetylcholine receptor M3 (M3R). Through the structure-based virtual screening and de novo design with the modified potential function for protein-ligand binding, a series of benzo[4,5]imidazo[1,2-a][1,3,5]triazine-2-amine (BITA) derivatives were identified as CK1δ inhibitors and also as M3R antagonists. The biochemical potencies of these bifunctional molecules reached the nanomolar and low-micromolar levels with respect to CK1δ and M3R, respectively. A common interaction feature in the calculated CK1δ-inhibitor and M3R-antagonist complexes is that the BITA moiety is well-stabilized in the orthosteric site of M3R and the hinge region of CK1δ through the establishment of the three hydrogen bonds and the hydrophobic contacts in the vicinity. The computational and experimental results found in this work exemplify the efficiency of kinase and GPCR polypharmacology in developing anticancer medicines.

Reduced mortality from lower respiratory tract disease in adult diabetic patients treated with metformin

BACKGROUND AND OBJECTIVE

Chronic lower respiratory diseases (CLRD) increase the risk of type 2 diabetes, which in turn may worsen lung function. Metformin, a common antidiabetic with anti-inflammatory and antioxidant properties, may improve respiratory outcomes. Therefore, we examined the association of metformin use with the risk of mortality from CLRD.

METHODS

We analysed data from the National Health and Nutrition Examination Survey during 1988-1994 and 1999-2010 for participants aged 40 years or older who had diabetes and were followed up for mortality through 2011. Information on prescription medicine was collected at baseline and CLRD-related mortality during follow-up was defined using the 10th Revision of the International Classification of Diseases (ICD-10). Cox proportional hazards modelling was used to determine the mortality hazard ratio (HR) associated with metformin use, adjusting for relevant covariates.

RESULTS

A total of 5266 participants with a median follow-up of 6.1 years were included. The prevalence of metformin use was 31.9% and 1869 participants died during follow-up, including 72 of CLRD. In the adjusted Cox proportional regression analysis, metformin was associated with a decreased risk of CLRD mortality in the overall population (HR: 0.39, 95% CI: 0.15-0.99) and among participants with baseline CLRD (HR: 0.30, 95% CI: 0.10-0.93), after adjusting for age, gender, race/ethnicity, cigarette smoking, body mass index, current asthma and chronic obstructive pulmonary disease (COPD), insulin and other diabetic medications, and glycohaemoglobin level. We found no association between other antidiabetic medications and CLRD mortality.

CONCLUSION

In this sample representative of the U.S. population, metformin was associated with lower CLRD mortality in adults with diabetes.

Relationship between diabetes and respiratory diseases-Clinical and therapeutic aspects

Diabetes is a common metabolic disorder affecting the entire body with high morbidity and mortality worldwide. The major complications related to diabetes are mostly due to the macrovascular and microvascular bed impairment due to metabolic, hemodynamic and inflammatory factors. However, studies over the past decades have added also the lung as a target organ in both type 1 and type 2 diabetes. Diabetes has always been addressed as a major comorbidity conditioning the disease behaviour and the natural history of several respiratory diseases. Increased interest has recently focused on the pathophysiology of the metabolic glycaemic disorder and the respiratory diseases suggesting a similar background shared by the two conditions. The true relationship between pulmonary diseases and diabetes mellitus has not been clarified, this review aims to summarize the link between diabetes and coexisting respiratory diseases such as asthma, chronic obstructive pulmonary disease, respiratory infections, cystic fibrosis, lung cancer and obstructive sleep apnea from a pathogenetic and therapeutic point of view.

Polypharmacology by Design: A Medicinal Chemist's Perspective on Multitargeting Compounds

Multitargeting compounds comprising activity on more than a single biological target have gained remarkable relevance in drug discovery owing to the complexity of multifactorial diseases such as cancer, inflammation, or the metabolic syndrome. Polypharmacological drug profiles can produce additive or synergistic effects while reducing side effects and significantly contribute to the high therapeutic success of indispensable drugs such as aspirin. While their identification has long been the result of serendipity, medicinal chemistry now tends to design polypharmacology. Modern in vitro pharmacological methods and chemical probes allow a systematic search for rational target combinations and recent innovations in computational technologies, crystallography, or fragment-based design equip multitarget compound development with valuable tools. In this Perspective, we analyze the relevance of multiple ligands in drug discovery and the versatile toolbox to design polypharmacology. We conclude that despite some characteristic challenges remaining unresolved, designed polypharmacology holds enormous potential to secure future therapeutic innovation.

The pharmacological treatment of chronic comorbidities in COPD: mind the gap!

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is commonly associated with other chronic diseases, which poses several diagnostic and therapeutic problems. Indeed, important comorbidities frequently remain unrecognized and, then, untreated, whereas respiratory drugs may have non respiratory side effects, and selected non respiratory drugs may variably affect the respiratory function.

OBJECTIVE

to describe: how COPD affects the presentation and contributes to the diagnostic challenges of its most common comorbidities; how coexisting COPD impacts the therapeutic approach to selected comorbidities and viceversa.

METHODS

we distinguish comorbidities of COPD depending upon whether they are complications of COPD or share risk factors, mainly smoke, with it or, finally, aggravate COPD. We describe atypical presentations of and diagnostic clues to comorbidities and suggest screening procedures. Finally, the main therapeutic problems, as resulting from the risk of untoward effects of therapies of COPD and its comorbidity, with special attention to drug-drug interactions and possible overdosages, are described.

RESULTS

selected complications of COPD, such as osteoporosis, sarcopenia and dysphagia, are rarely recognized and treated, likely due to the poor awareness of them. Important comorbidities, such as coronary artery disease, chronic heart failure, obstructive sleep apnoea syndrome and chronic renal failure, also should be systematically searched for because of their commonly variant presentation. Disease-related symptoms should be distinguished from drug effects or drug-drug interaction effects.

CONCLUSIONS

a truly comprehensive view of the complex COPD patient, hopefully capitalizing on multidimensional geriatric assessment, is needed to dissect the many components of health status impairment and to provide the optimal care. Selected screening procedures are highly desirable to identify frequently missed comorbidities. Pharmacosurveillance is an essential part of the approach to COPD and its comorbidities.