The stepwise approach to the management of type 2 diabetes

Exploring the mechanism of active components from ginseng to manage diabetes mellitus based on network pharmacology and molecular docking

A large body of literature has shown that ginseng had a role in diabetes mellitus management. Ginsenosides are the main active components of ginseng. But what ginsenosides can manage in diabetic are not systematic. The targets of these ginsenosides are still incomplete. Our aim was to identify which ginsenosides can manage diabetes mellitus through network pharmacology and molecular docking. To identify the targets of these ginsenosides. In this work, we retrieved and screened ginsenosides and corresponding diabetes mellitus targets across multiple databases. PPI networks of the genes were constructed using STRING, and the core targets were screened out through topological analysis. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes enrichment analyses were performed by using the R language. Finally, molecular docking was performed after bioinformatics analysis for verification. Our research results showed that 28 ginsenosides in ginseng might be against diabetes mellitus by modulating related proteins such as VEGFA, Caspase 3, and TNF-α. Among the 28 ginsenosides, 20(R)-Protopanaxatriol, 20(R)-Protopanaxadiol, and Ginsenoside Rg1 might play a significant role. Kyoto Encyclopedia of Genes and Genomes and Gene Ontology enrichment analysis showed that the management of diabetes mellitus by ginsenosides may be related to the positive regulation of reactive oxygen metabolic processes, associated with the insulin signaling pathway, TNF signaling pathway, and AMPK signaling pathway. Molecular docking results and molecular dynamics simulation showed that most ginsenosides could stably bind to the core target, mainly hydrogen bonding and hydrophobic bond. This study suggests the management of ginseng on diabetes mellitus. We believe that our results can contribute to the systematic study of the mechanism of ginsenosides for the management of diabetes mellitus. At the same time, it can provide a theoretical basis for subsequent studies on the management of ginsenosides in diabetes mellitus.

α-Glucosidase-Mediated Glucometer Readout for Portable Monitoring of Acarbose and Migliol

The α-glucosidase inhibitor is regarded as one of the most important drugs for the treatment of diabetes, which can control postprandial blood glucose levels via prolonging the carbohydrate digestion time and retarding the carbohydrates’ absorption. The present work aims to establish a facile bioanalytical method, based on α-glucosidase catalyzing the hydrolysis of 2-O-alpha-D-Glucopyranosyl-L-ascorbic acid (AA-2G), for the quantification of acarbose and migliol using a personal glucose meter (PGM). The hydrolysis products (ascorbic acid and glucose) can trigger the reduction of K3[Fe(CN)6] to K4[Fe(CN)6] in the glucose test strips, which results in the formation of the electron, which can be measured by PGM. Thus, ascorbic acid and glucose can be simultaneously measured by a simplified and miniaturized PGM method. However, the products produced by the hydrolysis of AA-2G will be decreased after the addition of acarbose or migliol to inhibit the activity of α-glucosidase, thereby resulting in a decreased PGM readout. After being incubated with α-glucosidase for 3.0 min and enzymatic reaction for 5.0 min, the quantitative detection of acarbose and migliol can be achieved within the ranges of 1.0–30.0 μM with the limit of detection of 0.33 μM and 3.0–33.3 μM with the limit of detection of 1.0 μM, respectively. IC50 values for acarbose and migliol are calculated to be 10.0 μM and 16.0 μM, respectively. The recoveries of the acarbose and migliol spiked with three different concentrations (final concentrations of 10.0, 20.0, and 30.0 μM) in human serum sample are in the ranges of 89.6–114.5% and 93.9–106.5%, respectively. These results demonstrate that the developed PGM method may be useful in future studies on therapeutic monitoring of acarbose and migliol.

Conifers Phytochemicals: A Valuable Forest with Therapeutic Potential

Conifers have long been recognized for their therapeutic potential in different disorders. Alkaloids, terpenes and polyphenols are the most abundant naturally occurring phytochemicals in these plants. Here, we provide an overview of the phytochemistry and related commercial products obtained from conifers. The pharmacological actions of different phytochemicals present in conifers against bacterial and fungal infections, cancer, diabetes and cardiovascular diseases are also reviewed. Data obtained from experimental and clinical studies performed to date clearly underline that such compounds exert promising antioxidant effects, being able to inhibit cell damage, cancer growth, inflammation and the onset of neurodegenerative diseases. Therefore, an attempt has been made with the intent to highlight the importance of conifer-derived extracts for pharmacological purposes, with the support of relevant in vitro and in vivo experimental data. In short, this review comprehends the information published to date related to conifers' phytochemicals and illustrates their potential role as drugs.

Cardiovascular Outcomes Comparison of Dipeptidyl Peptidase-4 Inhibitors versus Sulfonylurea as Add-on Therapy for Type 2 Diabetes Mellitus: a Meta-Analysis

Objective

Recent studies have raised concern about the cardiovascular safety of dipeptidyl peptidase-4 (DPP4) inhibitors. We performed a systematic review through meta-analysis to compare cardiovascular outcomes of sulfonylurea (SU) versus DPP4 inhibitors when used in combination with metformin.

Methods

After searching for trials using combination therapy of metformin with DPP4 inhibitor or SU in PubMed, Cochrane Library, and Embase, one prospective observation study and 15 randomized controlled studies were selected.

Results

Regarding the primary analysis endpoint, there were no significant differences in the risk of all-cause mortality between SU and DPP4 inhibitors as an add-on therapy to metformin (random-effect relative risk [RR], 1.14; 95% confidence interval [CI], 0.98–1.33; p=0.811; I²=0%). Cardiovascular death was also similar between the two drug classes in the five studies which reported outcomes (random-effect RR, 1.03; 95% CI, 0.83–1.27; p=0.517; I²=0%). Furthermore, there were no significant differences in major adverse cardiac events (MACE), coronary heart disease, myocardial infarction, ischemic stroke and heart failure. However, there were less hypoglycemic events and weight gain in the DPP4 inhibitor group as compared with the SU group (random-effect RR, 3.79; 95% CI, 1.53–9.39; p<0.001; I²=98.2 and weighted mean difference, 1.68; 95% CI, 1.07–2.29; p<0.001; I²=94.7, respectively).

Conclusion

As add-on therapy to metformin, there were no significant differences in all-cause mortality and cardiovascular mortality between DPP4 inhibitors and SUs.

Efficacy of a Combination of Metformin and Vildagliptin in Comparison to Metformin Alone in Type 2 Diabetes Mellitus: A Multicentre, Retrospective, Real-World Evidence Study

BACKGROUND

Early use of combination therapy in diabetes patients may lead to sustained glycemic control and thereby reduce the progression of diabetic complications. Given the limitation of the traditional stepwise intensification strategy, early combination therapy can be an effective approach. Therefore, this study aims to assess the real-world efficacy of a combination of metformin and vildagliptin in comparison to metformin alone in type 2 diabetes mellitus (T2DM) patients in India.

METHODS

This was an observational, retrospective, non-interventional study based on electronic medical records (EMRs) of 2740 T2DM patients, retrieved from 2010 onwards from 22 diabetes centres across India. Adult drug naïve patients with a 5-year history of T2DM treated with either metformin or a combination of metformin and vildagliptin for at least 3 months were considered for this study. Efficacy assessment was done to evaluate the post-treatment HbA1c levels and patients requiring additional oral antidiabetic drugs (OADs) at the time of follow-up visit. Patients were also analyzed for the occurrence of adverse events.

RESULTS

Out of the total, 2452 patients were in metformin only arm, and 288 patients were in metformin plus vildagliptin treatment arm. A more significant reduction in HbA1c level was observed in metformin plus vildagliptin arm than metformin only arm (median: -0.5% vs 0%, respectively; p<0.001). Patients requiring additional OAD at follow-up were significantly lesser in the metformin plus vildagliptin arm than the metformin only arm (15.6% vs 35.2%, respectively; p<0.001). The adverse events were comparable across the two arms, and commonly reported adverse events were giddiness, fatigue and gastric discomfort.

CONCLUSION

The findings of this EMR-based real-world study emphasizes the need for early initiation of combination therapy (metformin plus vildagliptin) over metformin monotherapy for achieving better glycemic control.

Review of Ginseng Anti-Diabetic Studies

Ginseng is one of the most valuable and commonly used Chinese medicines not only in ancient China but also worldwide. Ginsenosides, also known as saponins or triterpenoids, are thought to be responsible for the beneficial effects of ginseng. In this review, we summarize recent publications on anti-diabetic studies of ginseng extracts and ginsenosides in cells, animals, and humans. It seems that the anti-diabetic effect of ginseng is positive for type 2 diabetic patients but has no significant impact on prediabetes or healthy adults. Regulation of insulin secretion, glucose uptake, anti-oxidative stress, and anti-inflammatory pathways may be the mechanisms involved with ginseng's anti-diabetic effects. Taken together, this summary provides evidence for the anti-diabetes effects of ginseng extracts and ginsenosides as well as the underlying mechanisms of their impact on diabetes.

A facile ultrasonic-aided biosynthesis of ZnO nanoparticles using Vaccinium arctostaphylos L. leaf extract and its antidiabetic, antibacterial, and oxidative activity evaluation

The synthesis of nanoparticles often result in the generation of harmful chemical pollutants. As such, many researchers have focused on developing green processes, which include the biosynthesis. In this research, ZnO nanoparticles were prepared using the leaf extract of whortleberry (Vaccinium arctostaphylos L.) via a simple ultrasonic-assisted method. The morphology, crystal size and structure, surface, thermal, and optical properties of the bio-mediated ZnO sample (ZnO_ext) were analyzed and compared with that produced without incorporating the extract (ZnO_chem). The ZnO samples were evaluated for their antidiabetic, antibacterial, as well as their sono- and photo-catalytic performances. Initially, the samples were intraperitoneal injected to alloxan-diabetic rats to examine their treatment efficiency in terms of effects on fasting blood glucose, insulin, cholesterol, high-density lipoprotein, and total triglyceride levels. The ZnO_ext showed significantly higher efficiency for improving the health status of alloxan-diabetic rats in contrast with other tested treatments, vis. ZnO_chem, insulin, and only leaf extract. In addition, both the ZnO samples were assessed against gram-negative and gram-positive bacteria and through sono- and photo-catalytic processes for removing rhodamine B, respectively. The results of this study indicated that not only the ZnO_ext sample was pollution free, it also exhibited higher potentials for treating diabetic rats, bacterial decontamination, and also oxidative removal of organic compounds under the influences of ultrasound and UV irradiations when compared with ZnO_chem sample.

Metformin causes a futile intestinal-hepatic cycle which increases energy expenditure and slows down development of a type 2 diabetes-like state

OBJECTIVE

Metformin, the first line drug for treatment of type 2 diabetes, suppresses hepatic gluconeogenesis and reduces body weight in patients, the latter by an unknown mechanism.

METHODS

Mice on a high fat diet were continuously fed metformin in a therapeutically relevant dose, mimicking a retarded formulation.

RESULTS

Feeding metformin in pharmacologically relevant doses to mice on a high fat diet normalized HbA1c levels and ameliorated glucose tolerance, as expected, but also considerably slowed down weight gain. This was due to increased energy expenditure, since food intake was unchanged and locomotor activity was even decreased. Metformin caused lactate accumulation in the intestinal wall and in portal venous blood but not in peripheral blood or the liver. Increased conversion of glucose-1-¹³C to glucose-1,6-¹³C under metformin strongly supports a futile cycle of lactic acid production in the intestinal wall, and usage of the produced lactate for gluconeogenesis in liver.

CONCLUSIONS

The reported glucose-lactate-glucose cycle is a highly energy consuming process, explaining the beneficial effects of metformin given continuously on the development of a type 2 diabetic-like state in our mice.

Leonurine, a Potential Agent of Traditional Chinese Medicine: Recent Updates and Future Perspectives

Herba Leonuri, also named Chinese Motherwort, has been extensively investigated as an effective agent on the uterus system. Our group has been studying the natural products of Herba Leonuri for several years, and during this period, many biological activities of the drug were recognized. Leonurine (4-guanidino- N-butyl-syringate) is an alkaloid present in Herba Leonuri. Recently, growing evidence has highlighted the therapeutic potential of leonurine in multiple diseases, especially cardiovascular. In this review, we discuss the biological activities of leonurine, as well as recent advances involving this alkaloid.

Antidiabetic potential of two medicinal plants used in Gabonese folk medicine

BACKGROUND

Diabetes mellitus is a metabolic disorder which is rising globally in rich and developing countries. In the African region this rate is the highest, with 20 million diagnosed diabetics. Despite a noticeable progress in the treatment of diabetes mellitus by synthetic drugs, the search for new natural anti-diabetic agents is going on. Nauclea diderrichii (De Wild.) Merr. (ND) and Sarcocephalus pobeguinii Hua ex Pellegr. (SP) are used as traditional medicines in Gabon for the treatment of different diseases, especially in the case of diabetes. The aim of this study was to evaluate the antidiabetic potential of these two medicinal plants traditionally used in Gabon.

METHODS

Pharmacological (inhibitory action on α and β-glucosidases) and toxicological (effect on human T cell proliferation) studies were conducted on aqueous extracts of ND (leaves and bark) and SP (bark) collected in Gabon. All raw extracts were analyzed by HPTLC and their content in phenolic compounds was determined by using standard method. The most active extracts were submitted to preparative HPLC in order to evidence the most efficient subfractions by biological evaluation.

RESULTS

The results showed that two extracts from ND were potent α-glucosidase inhibitors, the leaf extract being more active that the bark extract: the first one was more than 60 fold more active than Acarbose, which is an oral medication used to treat type 2 diabetes; the extract from SP bark was less efficient. The HPLC subfractions of the extracts of ND leaves and SP bark were tested in the same experimental conditions. In each case, the most active subfractions still show very potent inhibitory effect on α-glucosidase (80-90% inhibition at 0.1 mg/mL). The most efficient extract, from ND leaves, was also characterized by the highest percentage of phenolic compounds, which suggests a relationship between its inhibitory potential on α-glucosidase and its content in phenolic compounds. Conversely, only a moderate inhibitory activity of the three extracts was observed on β-glucosidase.

CONCLUSION

These results clearly indicated that active compounds present in N. diderrichii and S. pobeguinii leaves or/and bark were selective and highly potent inhibitors of α-glucosidase and validate their popular use for the treatment of diabetes.

Acute and subchronic antihyperglycemic activities of Bowdichia virgilioides roots in non-diabetic and diabetic rats

Aim:

The present study was undertaken to evaluate the acute and subchronic antihyperglycemic effects of methanolic extract of Bowdichia virgilioides root bark of B. virgilioides in streptozotocin (STZ)-induced diabetic rats.

Materials and Methods:

The extract (100, 250 or 500 mg/kg) was orally administered to male Wistar diabetic (STZ, 42 mg/kg i.v.) and non-diabetic rats into two main protocols: (i) subchronic experiments, where animals were treated for 21 days with B. virgilioides extract and the following parameters were evaluated: Body weight, fluid and food intake (determined daily), urinary glucose and urea (every 3 days) and glycemia (every 5 days). At the end of the experimental period, skeletal muscles (extensor digitorum longus [EDL] and soleus), retroperitoneal and epididymal white adipose tissues were collected and weighed; liver samples were used for the determination of the lipid and glycogen contents; (ii) acute experiments, which evaluated the alterations on fasting and post-prandial glycemia and on glucose tolerance using the oral glucose tolerance test (OGTT).

Results:

In subchronic experiments, the treatment with B. virgilioides extract did not change any parameter evaluated in diabetic and non-diabetic animals. On fasting and post-prandial glycemia, the extract treatment did not promote changes in the glycemia values in diabetic or non-diabetic animals. In OGTT, the treatment with 500 mg/kg B. virgilioides extract reduced the hyperglycemia peak after a glucose overload, when compared with non-treated diabetic animals, resulting in a lower area under curve.

Conclusion:

The results of our work indicate that B. virgilioides root extract promotes an acute antihyperglycemic effect in STZ-diabetic rats; this effect probably occurs through an inhibition of the intestinal glucose absorption. The continuity of the research is necessary to elucidate these possibilities.

Anti-Diabetic and Hepato-Renal Protective Effects of Ziyuglycoside II Methyl Ester in Type 2 Diabetic Mice

Type 2 diabetes is a metabolic disorder caused by abnormal carbohydrate metabolism, and closely associated with abnormal lipid metabolism and hepato-renal dysfunction. This study investigated the anti-diabetic and hepato-renal protective properties of ziyuglycoside I (ZG01) derivative on type 2 diabetes. ZG01 was isolated from roots of Sanguisorba officinalis and chemically modified by deglycosylation and esterification to obtained ziyuglycoside II methyl ester (ZG02-ME). Here, we showed that ZG02-ME has stronger anti-diabetic activity than the original compound (ZG01) through decreasing blood glucose, glycated hemoglobin (HbA1c), and insulin levels in a mouse model of type 2 diabetes (db/db mice). We further found that ZG02-ME treatment effectively ameliorated serum insulin, leptin and C-peptide levels, which are key metabolic hormones, in db/db mice. In addition, we showed that elevated basal blood lipid levels were decreased by ZG02-ME treatment in db/db mice. Furthermore, treatment of ZG02-ME significantly decreased serum AST, ALT, BUN, creatinine, and liver lipid peroxidation in db/db mice. These results demonstrated that compared to ZG01, chemically modified ZG02-ME possess improved anti-diabetic properties, and has hepato-renal protective activities in type 2 diabetes.

Safety and efficacy of initial combination of linagliptin and metformin in patients with type 2 diabetes: A subgroup analysis of Indian patients from a randomized, double-blind, placebo-controlled study

CONTEXT AND OBJECTIVES

The number of people with diabetes is increasing exponentially in India. Owing to a unique "Asian Indian Phenotype," Indians develop diabetes a decade earlier and have an earlier onset of complications than Western populations. Therefore, it is essential to evaluate more effective treatment strategies at an earlier stage of disease progression, such as initial combination therapy, in Indian patients. In this study, we evaluated the efficacy and safety of initial combination therapy with linagliptin plus metformin in comparison to linagliptin or metformin monotherapy in Indian patients with type 2 diabetes mellitus.

METHODS

This is a subgroup analysis of Indian patients who participated in a Phase III, 24-week, double-blind, placebo-controlled, trial. Overall, 249 Indian patients were randomized to one of six treatment arms (Two free combination therapy arms: Linagliptin 2.5 mg twice daily [bid] + either low [500 mg, n = 36] or high [1000 mg, n = 44] dose metformin bid and four monotherapy arms: Linagliptin 5 mg once daily [qd, n = 40], metformin 500 mg [n = 49] or 1000 mg bid [n = 45], or placebo [n = 23]).

RESULTS

The placebo-corrected mean change in glycated hemoglobin from baseline (8.9%) to week 24 was -1.83% for linagliptin + metformin 1000 mg bid; -1.46% for linagliptin + metformin 500 mg bid; -1.30% for metformin 1000 mg bid; -1.00% for metformin 500 mg bid; and -0.77% for linagliptin 5 mg qd. None of the patients in the combination therapy arms had hypoglycemia, whereas there was one event in the metformin 1000 mg bid arm. Rates of adverse event were similar across various treatments.

CONCLUSIONS

In this subgroup analysis of Indian patients, initial combination therapy with linagliptin + metformin was more efficacious in improving glycemic control than the monotherapy arms, with a comparable tolerability profile. The results were comparable to the overall population.

A review on the medicinal potential of Panax ginseng saponins in diabetes mellitus

This review article summarizes the anti-diabetic effects and mechanisms ofPanax ginsengsaponins and its active specific ginsenosides.

Effects of pectin lyase-modified red ginseng extracts in high-fat diet-fed obese mice

Red ginseng and its extracts have been used as traditional medicines and functional foods in countries worldwide. The aim of this study was to examine the bioavailability of pectin lyase-modified red ginseng extracts (GS-E3D), and the effects of GS-E3D on adipogenesis of 3T3-L1 adipocytes, as well as on metabolic disorders such as hyperglycemia, dyslipidemia, and fatty liver in high-fat diet fed obese C57BL/6 mice. Mice were divided into 5 groups: normal diet group, high fat diet-vehicle group, high fat diet + 0.1 g/kg GS-E3D (0.1-GS-E3D), high fat diet + 0.3 g/kg (0.3-GS-E3D), high fat diet + 1.0 g/kg (1.0-GS-E3D). Treatment of GS-E3D reduced differentiation of 3T3-L1 adipocytes with low cytotoxicity. In the animal model, compared to the high fat diet control, serum glucose, total cholesterol, LDL-cholesterol, HDL-cholesterol, TG, and leptin level were reduced in treatment animals in a dose-dependent manner. In addition, we found that GS-E3D could decrease total hepatic lipid droplets. These results suggest that GS-E3D, as a dietary supplement, has beneficial effects on obesity and may have useful effects in health-care products.

Evaluation of neonatal streptozotocin induced diabetic rat model for the development of cataract

Type 2 diabetes (T2D) generally follows prediabetes (PD) conditions such as impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT). Although studies reported an association of IGT or IFG with cataract, the experimental basis for PD associated cataract is not known. Hence, we evaluated neonatal streptozotocin (nSTZ) induced rat model to study PD associated cataractogenesis by injecting STZ to two-day old rats. While majority (70%) of nSTZ injected pups developed IGT (nSTZ-PD) by two months but not cataract even after seven months, remaining (30%) nSTZ rats developed hyperglycemia (nSTZ-D) by two months and mature cataract by seven months. Lens biochemical analysis indicated increased oxidative stress as indicated by increased SOD activity, lipid peroxidation, and protein carbonyl levels in nSTZ-D cataractous lens. There was also increased polyol pathway as assessed by aldose reductase activity and sorbitol levels. Though nSTZ-PD animals have not shown any signs of lenticular opacity, insolubilization of proteins along with enhanced polyol pathway was observed in the lens. Further there was increased oxidative stress in lens of IGT animals. These results suggest that oxidative stress along with increased polyol pathway might play a role in IGT-associated lens abnormalities. In conclusion, nSTZ-PD rat model could aid to investigate IGT-associated lens abnormalities.

Factors associated with nonadherence to diet and physical activity among Nepalese type 2 diabetes patients; a cross sectional study

Background

Nonadherence to diet and physical activity is a major problem in the management of diabetes mellitus and its complications. This study was undertaken to measure the factors associated with nonadherence to diet and physical activity advice among Nepalese type 2 diabetic patients.

Methods

An analytical cross-sectional study was conducted among type 2 diabetic patients (age, M ± SD, 54.4 ± 11.5 yrs) and interviewed using three days recall method for dietary history and Compendium of Physical Activity for physical activity. Data were analysed by univariate and multivariate statistics.

Results

Out of 385 patients, 87.5% were nonadherent and 12.5% poorly adherent to dietary advice. 42.1% were nonadherent, 36.6% partially adherent while 21.3% good adherent to physical activity. Adherence to dietary advice was higher in males than females (M ± SD, 33 ± 16.7 vs 27 ± 15.5, p = 0.001), those staying nearer to hospital than farther (M ± SD, 32 ± 18.6 vs 28 ± 13.5, p = 0.013), those advice by physician than others (p = 0.001) and from nuclear family than joint and extended (p = 0.001). With increasing age, dietary advice adherence decreased (p = 0.06) and was positively correlated with the knowledge about diabetes mellitus (r = 0.115, p = 0.024). Physical activity adherence was higher in those with positive family history of diabetes than others (M ± SD, 74 ± 24.2 vs 65 ± 23.6, p = 0.001), upper middle socioeconomic class respondents than lower ones (p = 0.047) and from extended family than nuclear or joint ones (p = 0.041). Divorced were more nonadherent to physical activity than married and widowed patients (p = 0.021).

Conclusions

Determinants of nonadherence to dietary advice: Female gender, increasing age, joint or extended family members, farther distance from hospital, poor knowledge about diabetes mellitus and advice by others than physicians. Determinants for nonadherence to physical activity: negative family history of DM, divorced status, lower socioeconomic class.

The effects of chitosan oligosaccharide (GO2KA1) supplementation on glucose control in subjects with prediabetes

We aimed to evaluate the effect of chitosan oligosaccharide (GO2KA1) supplementation on glucose control in subjects with prediabetes. This study was a randomized, double-blind, placebo-controlled clinical trial. Subjects with prediabetes were randomly assigned to the GO2KA1 intervention group or the placebo group for 12 weeks. We assessed the serum levels of glucose, insulin, and C-peptide by a 2 hour value in the 75 g oral glucose tolerance test (OGTT), HbA1c, pro-inflammatory cytokines, and plasma adiponectin at baseline and after the 12 week intervention. The treatment group showed a significant decrease in the serum glucose level at 30 min (p = 0.013) and at 60 min (p = 0.028). The change of the serum glucose level at 60 min was significant in the treatment group compared with the placebo group (p = 0.030). Also, the plasma level of HbA1c (p = 0.023) and the pro-inflammatory cytokines (IL-6 and TNF-α) were reduced and plasma adiponectin was increased in the GO2KA1 intervention group after the 12 week treatment. However, the placebo group did not show any significant changes in these biomarkers. In subjects with prediabetes, 12 week supplement with GO2KA1 may help control postprandial glucose compared with control.

Fermentation with Aquilariae Lignum enhances the anti-diabetic activity of green tea in type II diabetic db/db mouse

The major components of tea may be significantly influenced according to the type of fermentation, and consequently the effects of different teas will differ. We examined whether green tea fermented with Aquilariae Lignum (fGT) shows a stronger anti-diabetic effect than unfermented green tea (GT) on mice with type 2 diabetes. To evaluate the anti-obesity effect of fGT, we assessed body weight, fecal excretion, serum leptin levels, exocrine pancreatic zymogen granule contents, and periovarian fat weight and adiponectin contents. Blood glucose levels, pancreatic weight, and numbers of pancreatic islet insulin- and glucagon-producing cells were determined to evaluate anti-hypoglycemic effects, while total cholesterol, triglyceride, and low- and high-density lipoprotein levels were determined to evaluate anti-hyperlipidemic effects. The antioxidant effect of fGT was detected by measuring malondialdehyde and glutathione contents and the activities of catalase and superoxide dismutase. fGT showed anti-obesity, anti-hypoglycemic, anti-hyperlipidemia, and antioxidant effects. Additionally, fGT exerted stronger anti-diabetic effects compared with GT. Collectively, these results suggested that fGT fermented with the appropriate amounts of Aquilariae Lignum (49:1) has a stronger effect compared with GT. Thus, fGT is a promising and potent new therapeutic agent for type 2 diabetes.

Antidiabetic potential of commonly consumed legumes: a review

Over the last few decades, lifestyle changes have resulted in a drastic increase in the incidence of diabetes all over the world, especially in the developing countries. Oral hypoglycemic agents and insulin form the mainstay in controlling diabetes, but they have prominent side effects and fail to significantly alter the course of diabetic complications. Appropriate diet and exercise programs that form a part of lifestyle modifications have proven to be greatly effective in the management of this disease. Dietary therapy is showing a bright future in the prevention and treatment of diabetes. Legumes, owing to their high nutritive value, are increasingly being used in dietetic formulations in the treatment and prevention of diabetes on account of their antidiabetic potential. Given this background, this paper reviews the glucose- and lipid-lowering action possessed by various commonly consumed legumes through several animal and human studies. It is concluded that the various legumes not only have varying degrees of antidiabetic potential but are also beneficial in decreasing the risk factors for cardiovascular and renal disease.

Pectinase-Processed Ginseng Radix (GINST) Ameliorates Hyperglycemia and Hyperlipidemia in High Fat Diet-Fed ICR Mice

To develop a ginseng product possessing an efficacy for diabetes, ginseng radix ethanol extract was treated with pectinase and obtained the GINST. In the present study, we evaluate the beneficial effect of GINST on high fat diet (HFD)-induced hyper-glycemia and hyperlipidemia and action mechanism(s) in ICR mice. The mice were randomly divided into five groups: regular diet group (RD), high fat diet group (HFD), HFD plus GINST at 75 mg/kg (GINST75), 150 mg/kg (GINST150), and 300 mg/kg (GINST300). Oral glucose tolerance test reveals that GINST improves the glucose tolerance after glucose challenge. Fasting plasma glucose and insulin levels were decreased by 4.3% and 4.2% in GINST75, 10.9% and 20.0% in GINST150, and 19.6% and 20.9% in GINST300 compared to those in HFD control group. Insulin resistance indices were also markedly decreased by 8.2% in GINST75, 28.7% in GINST150, and 36.4% in GINST300, compared to the HFD control group. Plasma triglyceride, total cholesterol and non-esterified fatty acid levels in the GINST300 group were decreased by 13.5%, 22.7% and 24.1%, respectively, compared to those in HFD control group. Enlarged adipocytes of HFD control group were markedly decreased in GINST-treated groups, and shrunken islets of HFD control mice were brought back to near normal shape in GINST300 group. Furthermore, GINST enhanced phosphorylation of AMP-activated protein kinase (AMPK) and glucose transporter 4 (GLUT4). In summary, GINST prevents HFD-induced hyperglycemia and hyperlipidemia through reducing insulin resistance via activating AMPK-GLUT4 pathways, and could be a potential therapeutic agent for type 2 diabetes.

Hypoglycemic action of borapetoside A from the plant Tinospora crispa in mice

AIM

This study explores the hypoglycemic effects of borapetoside A, the most active principle among three major diterpenoids (borapetosides A, B, and C) isolated from ethanol extract of Tinospora crispa vines.

METHODS

We employed mouse mitogenic C2C12 and hepatocellular carcinoma Hep3B cells in this study. Furthermore, the mice were divided into three groups, including streptozotocin-induced type 1 diabetes mellitus, diet-induced type 2 diabetes mellitus, and normal control. The mice in each group were treated with assigned vehicle control, borapetoside A, or other active agents.

RESULTS

Borapetoside A was shown to increase the glycogen content and decrease the plasma glucose concentration in a concentration or dose-dependent manner in vitro and in vivo. The hypoglycemic effects in the normal mice and the mice with type 2 diabetes mellitus were associated with the increases of the plasma insulin levels; whereas, the insulin levels remained unchanged in the mice with type 1 diabetes mellitus. Borapetoside A not only attenuated the elevation of plasma glucose induced by an intraperitoneal glucose tolerance test, but also increased the glycogen synthesis of IL-6 treated C2C12 cells. Moreover, the elevated protein expression levels of phosphoenolpyruvate carboxykinase were reversed after borapetoside A treatment twice a day for 7 days.

CONCLUSIONS

The hypoglycemic effects of borapetoside A were mediated through both the insulin-dependent and the insulin-independent pathways. Furthermore, borapetoside A was shown to increase the glucose utilization in peripheral tissues, to reduce the hepatic gluconeogenesis, and to activate the insulin signaling pathway; they thereby contributed to the lowering of the plasma glucose. Comparison of the structures of three borapetosides suggests clearly that the C-8 stereochemistry plays a key role in hypoglycemic effect since the active borapetoside A and C possess 8R-chirality but the inactive borapetoside B possess 8S-chirality. The location of glycoside at C-3 for borapetoside A but C-6 for borapetoside C and the formation of lactone between C-4 and C-6 for borapetoside A, could account for the different potency in hypoglycemic action for these two compounds.

Ginseng and diabetes: the evidences from in vitro, animal and human studies

Panax ginseng exhibits pleiotropic beneficial effects on cardiovascular system, central nervous system, and immune system. In the last decade, numerous preclinical findings suggest ginseng as a promising therapeutic agent for diabetes prevention and treatment. The mechanism of ginseng and its active components is complex and is demonstrated to either modulate insulin production/secretion, glucose metabolism and uptake, or inflammatory pathway in both insulin-dependent and insulin-independent manners. However, human studies are remained obscure because of contradictory results. While more studies are warranted to further understand these contradictions, ginseng holds promise as a therapeutic agent for diabetes prevention and treatment. This review summarizes the evidences for the therapeutic potential of ginseng and ginsenosides from in vitro studies, animal studies and human clinical trials with a focus on diverse molecular targets including an AMP-activated protein kinase signaling pathway.

Novel anti-diabetic effect of SCM-198 via inhibiting the hepatic NF-κB pathway in db/db mice

There are reports of early evidence that suggest the involvement of chronic low-grade inflammation in the pathogenesis of Type 2 diabetes. Thus, substances that have effects in reducing inflammation could be potential drugs for Type 2 diabetes. Leonurine (4-guanidino-n-butyl syringate; SCM-198) is an alkaloid in HL (Herba leonuri), which was reported to possess anti-inflammatory properties. We hypothesize that SCM-198 may have beneficial effects on Type 2 diabetes. In the present study, we attempted to test this hypothesis by evaluating the anti-diabetic effect of SCM-198 and the possible underlying mechanisms of its effects in db/db mice. SCM-198 (50, 100 and 200 mg/kg of body weight), pioglitazone (50 mg/kg of body weight, as a positive control) or 1% CMC-Na (sodium carboxymethylcellulose) were administered to the db/db or db/m mice once daily for 3 weeks. After 3 weeks, SCM-198 (200 mg/kg of body weight) treatment significantly reduced the fasting blood glucose level and increased the plasma insulin concentration in the db/db mice, meanwhile it significantly lowered the plasma TAG (triacylglycerol) concentration and increased the HDL (high-density lipoprotein)-cholesterol concentration. Moreover, the dysregulated transcription of the hepatic glucose metabolic enzymes, including GK (glucokinase), G6Pase (glucose-6-phosphatase) and PEPCK (phosphoenolpyruvate carboxykinase), was recovered by an Akt-dependent pathway. The pro-inflammatory mediators {such as TNFα (tumour necrosis factor α), IL (interleukin)-6, IL-1β, degradation of IκB [inhibitor of NF-κB (nuclear factor-κB)] α and thereafter activation of NF-κB} were reversed by SCM-198 treatment in the db/db mice. The present study provides first evidence that SCM-198 exhibits anti-inflammatory activity and has an ameliorating effect on diabetic symptoms via inhibiting of NF-κB/IKK (IκB kinase) pathway. Consequently, we suggest that SCM-198 may be a prospective agent for prevention and/or moderation of the progress of Type 2 diabetes.

Synergistic improvement in insulin resistance with a combination of fenofibrate and rosiglitazone in obese type 2 diabetic mice

Peroxisome proliferator-activated receptor (PPAR) α, which is abundant in the liver, increases lipoprotein lipase activity, resulting in a decrease of triglyceride (TG) levels. PPARγ, which is abundant in adipose tissue, stimulates adipocyte differentiation and adipogenesis, and results in an increase in insulin sensitivity. Fenofibrate, a PPARα agonist, is commonly used to treat dyslipidemia, and rosiglitazone, a PPARγ agonist, is effective in improving glycemic control. To examine the synergistic effects of rosiglitazone in combination with fenofibrate, an obese type 2 diabetes mellitus (DM) mouse model was established by the combined administration of streptozotocin and nicotinamide and fed on a high-fat diet (35% of energy as fat) for 3 weeks. The mice had significantly higher plasma glucose concentrations and insulin resistance, as examined by an oral glucose tolerance test and insulin challenge test compared with normal mice. After establishing a dose-response curve for each drug, the drugs were orally administered for 3 weeks either alone or in combination. After individual administration of fenofibrate, HDL cholesterol levels significantly increased, and plasma glucose and TG levels decreased in obese type 2 DM mice. The individual administration of rosiglitazone showed increased insulin resistance (QUICKI). However, HDL cholesterol and TG levels were not significantly changed. In a combination of fenofibrate at 25 mg/kg and rosiglitazone at 1.25 mg/kg there was a decrease in plasma glucose and TG levels, and a combination of fenofibrate at 50 mg/kg and rosiglitazone at 2.5 mg/kg showed an increase in plasma HDL cholesterol levels. Moreover, parameters related to insulin resistance (HOMA-IR) and insulin sensitivity (QUICKI) were improved significantly. Thus, our results show that combination therapy with lower doses of fenofibrate and rosiglitazone ameliorates the type 2 DM condition to a greater extent than high doses of either individual monotherapy.

Antihyperglycemic and antioxidative effects of new herbal formula in streptozotocin-induced diabetic rats

Herbal prescriptions have been recognized as potentially valid by the scientific medical establishment, and their use has been increasing. The present study investigated the antidiabetic effects of a new herbal formula (NHF) consisting of Polygonati Rhizoma, Rehmanniae Radix, Salviae Miltiorrhizae Radix, Puerariae Radix, Schizandrae Fructus, and Glycyrrhizae Radix. Streptozotocin-induced diabetic rats were orally administered NHF (300 mg/kg of body weight/day) for 4 weeks. The diabetic rats exhibited hyperglycemia, increased food and water intake, loss of body weight gain, elevated hepatic thiobarbituric acid-reactive substances (TBARS), and decreased activities of hepatic antioxidant enzymes (such as superoxide dismutase [SOD], catalase [CAT], and glutathione peroxidase [GSH-Px]), level of mRNA of glucose transporter (GLUT) 4 in soleus muscle, and numbers of insulin-positive cells and the size of beta-cells in pancreas. Administration of NHF significantly decreased the blood glucose level and the food and water intake and considerably increased the body weights of diabetic rats. Also, NHF treatment significantly increased plasma insulin levels and the number and size of insulin-immunoreactive cells in the pancreas of diabetic rats. Administration of NHF significantly lowered the levels of TBARS and increased the activities of SOD, CAT, and GSH-Px in the liver of diabetic rats. In addition, treatment with NHF increased the mRNA levels of GLUT4 in soleus muscle. Therefore NHF may be an effective preventive and therapeutic agent for diabetes mellitus.

Association between depression and concurrent Type 2 diabetes outcomes varies by diabetes regimen

AIMS

Although depression has weak associations with several Type 2 diabetes mellitus (DM) outcomes, it is possible that these associations are concentrated within certain patient subgroups that are more vulnerable to their effects. This study tested the hypothesis that depression is related to glycaemic control and diabetes-related quality of life (DQOL) in patients who are prescribed injected insulin, but not those on oral glucose-lowering agents alone.

METHODS

Participants (103 on insulin, 155 on oral glucose-lowering agents alone) with Type 2 DM were recruited from a large US healthcare system and underwent assessment of glycaemic control (glycated haemoglobin; HbA(1c)), medication adherence and diabetes self-care behaviours, DQOL and depression (none, mild, moderate/severe).

RESULTS

There was a significant regimen x depression interaction on HbA(1c) (P = 0.002), such that depression was associated with HbA(1c) in patients using insulin (beta = 0.35, P < 0.001) but not in patients using oral agents alone (beta = -0.08, P = NS). There was a similar interaction when quality of life was analysed as an outcome (P = 0.002). Neither effect was mediated by regimen adherence.

CONCLUSIONS

The generally weak association between depression and glycaemic control is concentrated among patients who are prescribed insulin. Similarly, the association between depression and illness quality of life is strongest in patients prescribed insulin. Because this is not attributable to depression-related adherence problems, psychophysiological mechanisms unique to this group ought to be carefully investigated. Clinicians might be especially vigilant for depression in Type 2 DM patients who use insulin and consider its potential impact upon their illness course.

Type 2 diabetes among women: clinical considerations for pharmacological management to achieve glycemic control and reduce cardiovascular risk

The purpose of this paper is to highlight specific considerations in the medical management of women with type 2 diabetes mellitus (T2DM). T2DM, a significant source of morbidity and mortality, has become an ever growing epidemic within the United States. Although it is well understood that diabetes can significantly increase the risk for microvascular and macrovascular complications, there has been limited research examining the differential impact of these complications on men and women. Women, in particular, are subject to especially high risk for the development of myocardial infarction (MI), claudication, and stroke and are disproportionately afflicted by cardiovascular, cerebrovascular, and peripheral vascular disease. There is new evidence that tight glycemic control and earlier initiation of insulin therapy can improve outcomes and thereby reduce the risk for development of both macrovascular and microvascular complications of the disease. Although there are many commonalities in the treatment of men and women, women with diabetes have several unique issues, including the possible effects of therapy on reproductive health, fetal health, breastfeeding, potential interactions with hormonal contraceptives, and effects on bone health, that should be considered when determining a therapeutic approach. This paper presents evidence-based treatment strategies for reducing the risk of diabetes-associated complications overall and cardiovascular disease in particular through glycemic control. Special attention is paid to the selection of antidiabetic agents that are best suited to the unique needs of women.

20(S)-ginsenoside Rg3 enhances glucose-stimulated insulin secretion and activates AMPK

Although Panax ginseng has been widely used in oriental countries for pharmacological effects such as anti-diabetic, anti-inflammatory, adaptogenic and anti-fatigue activities, the active ingredient is not yet fully identified. In our preliminary studies, protopanaxadiol ginsenosides showed the insulin secretion-stimulating activity. In HIT-T15 cells, Rg3 enhanced the insulin secretion in a concentration dependent manner. This effect, however, was almost completely abolished in the presence of diazoxide (K+ channel opener) or nifedipine (Ca2+ channel blocker). Oral glucose tolerance test (OGTT) was also performed using ICR mice and Rg3 suppressed the blood glucose levels from rising by enhancing an insulin secretion at 30 min after administration. From these studies, we may conclude that Rg3 lowered the plasma glucose level by stimulating an insulin secretion and this action was presumably associated with ATP sensitive K+ channel. Next, to explore the hypothesis that ginsenoside Rg3 epimers may exhibit differential effects, glucose-stimulated insulin secretion activity and phosphorylation of AMP-activated protein kinase (AMPK) were compared between 20(S)- and 20(R)-ginsenoside Rg3. 5 microM of 20(S)-Rg3 enhanced the glucose-stimulated insulin secretion by 58% compared to the control, but 20(R)-Rg3 did not show any effect. In C2C12 myotubes, 20(S)- and 20(R)-Rg3 both markedly phosphorylated AMPK and acetyl-CoA carboxylase (ACC), although 20(R)-Rg3 showed a little less effect. Taken together, our results suggest that ginsenoside Rg3 epimers showed differential activities, and 20(S)-Rg3 epimer exhibited the higher pharmacological effects in insulin secretion and AMPK activation than 20(R)-Rg3. The novel characteristics of 20(S)-Rg3 may be a valuable candidate for anti-diabetic agent.

Treatment of type 2 diabetes with combined therapy: what are the pros and cons?

Type 2 diabetes is a progressive syndrome that evolves toward complete insulin deficiency during the patient's life. A stepwise approach for its treatment should be tailored according to the natural course of the disease, including adding insulin when hypoglycemic oral agent failure occurs. Treatment with insulin alone should eventually be considered in a relevant number of cases. Experience has shown the protective effects of insulin on beta-cell survival and function, resulting in more stable metabolic control. On the contrary, treatment with most insulin secretagogues has been associated with increased beta-cell apoptosis, reduced responsiveness to high glucose, and impairment of myocardial function during ischemic conditions. In addition, macrovascular complications are associated with postprandial hyperglycemia, indicating the need for tight glycemic control. Insulin treatment, especially with rapid-acting analogs, has been demonstrated to successfully control postprandial glucose excursions. Finally, a reason for concern with regard to combined therapy is represented by the evidence that polipharmacy reduces compliance to the treatment regimen. This can be particularly relevant in patients with type 2 diabetes usually taking drugs for complications and for concomitant diseases with consequent deterioration not only of metabolic control but also of other conditions. In conclusion, therapy with insulin alone immediately after hypoglycemic oral agent failure may be a useful and safe therapeutic approach in type 2 diabetes.

Anti-diabetic effects of compound K versus metformin versus compound K-metformin combination therapy in diabetic db/db mice

Compound K (CK) is a major intestinal metabolite of ginsenosides derived from ginseng radix. In our preliminary studies, CK has shown to exhibit anti-hyperglycemic effect through its insulin-secreting action, similar to that of insulin secretagogue sulfonylureas. Metformin, a biguanide, improves insulin resistance by reducing gluconeogenesis and enhancing peripheral glucose uptake, promoting reduction of the plasma glucose level. The aim of this study was to compare the anti-diabetic effects of CK and metformin due to differences in their mechanisms of action and also to investigate whether treatment of CK and metformin in combination show synergistic or additive effects compared to each drug alone. Seven week-old male db/db mice were treated for 8 weeks. CK was given at a dose of 10 mg/kg, metformin at 150 mg/kg and the same dosage of each drug was applied to CK plus metformin combination group. Significant improvements were observed in plasma glucose and insulin levels, homeostasis model assessment-insulin resistance (HOMA-IR) index and in hematoxylin and eosin-stained liver tissues in combination group. Although further studies to elucidate the benefits of co-administration of CK and metformin are needed, our findings may provide basis to the discovery of a new combination therapy on diabetes control in type 2 diabetics.

Compound K enhances insulin secretion with beneficial metabolic effects in db/db mice

Compound K (CK) is a final metabolite of panaxadiol ginsenosides. Although Panax ginseng is known to have antidiabetic activity, the active ingredient is not yet fully identified. In our preliminary studies, panaxadiol ginsenosides showed insulin secretion stimulating activity. Therefore, it would be interesting to know whether and how CK has antidiabetic activity. In in vitro studies using HIT-T15 cells and primary cultured islets, CK enhanced the insulin secretion in a concentration-dependent manner. This effect, however, was completely abolished in the presence of diazoxide (K+ channel opener) or nifedipine (Ca2+ channel blocker). Insulin secretion stimulating activity of a single oral CK administration was also confirmed with an oral glucose tolerance test (OGTT) using ICR mice. From these studies, we may conclude that CK lowered the plasma glucose level by stimulating insulin secretion and this action was presumably associated with an ATP-sensitive K+ channel. In a long-term study using C57BL/KsJ db/ db mice, CK treatment significantly decreased the fasting blood glucose levels in a dose-dependent fashion. OGTT revealed that CK improved glucose tolerance with increased insulin levels 30 min after the glucose challenge. Concurrently, CK treatment prevented the destruction of islets and preserved more insulin. Next, to gain insight into the extra-pancreatic molecular mechanism of CK, we performed a global gene expression profiling study in the liver and adipose tissues. According to DNA microarray analysis, CK shifted glucose metabolism from hepatic glucose production to hepatic glucose utilization in the liver and improved insulin sensitivity through enhancing plasma adiponectin levels, resulting in overexpression of genes for adipogenesis and glucose transporter in the adipose tissue. Taken together, we may suggest that CK could be developed as a therapeutic tool in type 2 diabetic patients with disability of insulin secretion and/or insulin resistance.

Diabetes-associated macrovasculopathy: pathophysiology and pathogenesis

The complications associated with diabetic vasculopathy are commonly grouped into two categories: microvascular and macrovascular complications. In diabetes, macrovascular disease is the commonest cause of mortality and morbidity and is responsible for high incidence of vascular diseases such as stroke, myocardial infarction and peripheral vascular diseases. Macrovascular diseases are traditionally thought of as due to underlying obstructive atherosclerotic diseases affecting major arteries. Pathological changes of major blood vessels leading to functional and structural abnormalities in diabetic vessels include endothelial dysfunction, reduced vascular compliance and atherosclerosis. Besides, advanced glycation end product formation interacts with specific receptors that lead to overexpression of a range of cytokines. Haemodynamic pathways are activated in diabetes and are possibly amplified by concomitant systemic hypertension. Apart from these, hyperglycaemia, non-enzymatic glycosylation, lipid modulation, alteration of vasculature and growth factors activation contribute to development of diabetic vasculopathy. This review focuses on pathophysiology and pathogenesis of diabetes-associated macrovasculopathy.

Self-reported predictors of depressive symptomatology in an elderly population with type 2 diabetes mellitus: a prospective cohort study

Background

The prevalence of depression increases among the elderly with chronic medical conditions like diabetes. Hence, the purpose of this study was to determine predictors of depressive symptomatology in Medicare enrolled elderly population with type 2 diabetes mellitus.

Methods

A prospective cohort study was conducted by administrating health risk assessment questionnaire to elderly (≥65 years) with type 2 diabetes. Responses were linked with administrative claim's data. Data were obtained from elderly with type 2 diabetes who were enrolled in Medicare Health Maintenance Organization (HMO) in southeastern United States. The instrument collected information related to demographics, health status, medication use, and healthcare service utilization prior to enrollment. Responses were combined with the administrative claims data of HMO to obtain information on actual utilization of healthcare resources. The Short Form Center for Epidemiologic Studies Depression scale was used to assess depressive symptoms. Multivariable logistic regression analyses were conducted to determine predictor variables.

Results

Of 792 respondents, about 17% had depressive symptoms. Almost 96% of patients were using 1 or more antidiabetic medications. Overall, increased risk of depression was associated with lower health related quality of life (HRQoL) (OR: 0.97; 95% CI: 0.96–0.98) and higher impairments in instrumental activities of daily living (IADLs) (OR: 1.31; 95% CI: 1.14–0.52) in elderly patients. Poor health related quality of life (OR: 0.97, 95%CI: 0.95–0.99) was associated with higher risk of depression in patients on insulin therapy.

Conclusion

Impairments in daily activities and lower HRQoL were predictors of depressive symptomatology in elderly with diabetes. Determinants of depression varied according to pharmacotherapeutic class of antidiabetic medications.

The when and how of insulin initiation in type 2 diabetes

BACKGROUND

Insulin has traditionally been viewed as a 'last resort' in the treatment of type 2 diabetes. However, accumulating evidence on the benefits of early insulin initiation brings this traditional viewpoint into question. Increasing recognition of the importance of insulin therapy in type 2 diabetes has also raised the issue of how best to initiate insulin in this patient group. Evidence-based guidelines are currently limited and, sometimes, conflicting.

AIMS AND SCOPE

In the absence of clear evidence-based guidelines, this commentary focuses on clinical experience and recent findings, to ascertain the most commonly used and effective insulin initiation regimens for patients with type 2 diabetes. Recent findings were identified via a literature search using PubMed during the last 5 years in addition to key congress abstract searches from the last 2 years.

FINDINGS

Two commonly used regimens that have emerged as effective, safe and easy to implement are bedtime basal and premixed insulin analogues. In addition, the latter treatment option provides greater post-prandial glucose regulation and the prospect of simple intensification, such that patients' ongoing clinical needs can be more easily met, with minimal disruption to their lifestyle.

CONCLUSION

Current data and clinical experience highlight bedtime basal and premixed insulin analogues as favourable options for the initiation of insulin in patients with type 2 diabetes. Further insights on the optimal initiation regimen will be provided by studies such as the ongoing 4T trial, which is comparing the long-term impact of three different approaches to commencing insulin therapy in patients with type 2 diabetes.