Controlling diabetes: the need for intensive therapy and barriers in clinical management

Computational, chemical profiling and biochemical evaluation of antidiabetic potential of Parkia biglobosa stem bark extract in type 2 model of rats

The present study investigated the antidiabetic and antioxidant capacity of hydromethanol extract from Parkia biglobosa stem bark (PBSBHM) in fructose-streptozotocin induced type 2 diabetic rats after 28 days of oral administration. Simultaneously, evaluated the phenolic profiles and mineral compositions of crude extract. Molecular docking analysis of protocatechuic acid, the most abundant phenolic acid with potential downstream partners protein kinase A (PKA), protein kinase C (PKC), and Ca²⁺/calmodulin-dependent protein kinase II (CaMK II), was investigated. The preliminary results showed that PBSBHM crude extract contained 225.2 ± 18.25 mg GAE/g of total phenolic and 99.28 ± 12.3 mg QE/g of total flavonoid. Both protocatechuic and gallic acids were identified as a prominent phenolic compound through HPLC analysis, while vanillic acid was not detected. High mineral composition of K, Mg, P, Ca while Mn and Cr as trace elements were found in PBSBHM by plasma optical emission spectroscopy. PBSBHM extracts showed a significant radical scavenging activity from a therapeutic point of view, a moderate antioxidant potential and improved glucose tolerance after 30 min of glucose loading. PBSBHM extracts significantly attenuated serum glucose level and glycosylated haemoglobin at the tested dosage. However, it elevated the hepatic hexokinase activity and glycogen level compared with the diabetic untreated rats. PBSBHM ameliorates the decreased activity of pancreatic superoxide dismutase, catalase and reduced glutathione but decreased the MDA level. Docking analysis of protocatechuic acid showed a moderate affinity for the target enzymes compared to the standard drugs. Our data showed that the stem bark extract of this botanical has antidiabetic potential and at least in part substantiates its traditional use in the management of diabetes, possibly due to the synergistic interactions of protocatechuic acid with other biologically active components.

Effect of Xylocarpus granatum Bark Extract on Amelioration of Hyperglycaemia and Oxidative Stress Associated Complications in STZ-Induced Diabetic Mice

Xylocarpus granatum is a medicinal mangrove plant, traditionally used for the treatment of diarrhoea, cholera, fever, dyslipidaemia, inflammation, etc. The present study was aimed to evaluate the in vitro antidiabetic (α-glucosidase inhibition assay) and antioxidant (ABTS scavenging and metal chelating assay) activities of ethanol, methanol, and aqueous extracts of leaves and barks of X. granatum followed by in vivo antidiabetic and antioxidant evaluation of ethanol bark extracts in streptozotocin- (STZ-) induced diabetic mice. The in vitro evaluation revealed higher α-amylase inhibition and ABTS scavenging activities in ethanol bark extracts of X. granatum (XGEB). Administration of XGEB at 100 and 200 mg/kg BW doses to STZ-induced diabetic mice resulted in significant decrease (P < 0.05) in blood glucose, triglyceride (TG), total cholesterol (TC), serum glutamate oxaloacetate transaminase (SGOT), serum glutamate pyruvate transminase (SGPT), and urea levels in the serum of the extract administered groups as compared to diabetic control group. The levels of SOD, CAT, GPx, GR, and GST in liver along with LPx, SOD, GST, and GR activities in brain tissues were found to be ameliorated in XGEB treated diabetic mice. Histopathological alternations of liver tissues were also found to be restored in XGEB treated diabetic groups. The HPLC fingerprint analysis of XGEB revealed the presence of simple polyphenols, isoflavone, and flavonol-like compounds. The DSC and UV-VIS analysis also confirmed the presence of phenolic compounds in XGEB. The GC-MS analysis of XGEB showed the presence of a number of bioactive compounds. These results demonstrated the beneficial effect of XGEB in controlling hyperglycaemia and ameliorating oxidative stress associated complications associated with diabetes.

Neu-P11, a novel MT1/MT2 agonist, reverses diabetes by suppressing the hypothalamic-pituitary-adrenal axis in rats

Excessive glucocorticoid (GC) in type 2 diabetes mellitus (T2DM) reduces insulin sensitivity, impairs β-cell function, increases gluconeogenesis and glycogenolysis, impairs glucose uptake and metabolism, and reduces the insulinotropic effects of glucagon-like peptide 1. Melatonin, which serves as a physiological regulator of the hypothalamic-pituitary-adrenal (HPA) axis, has been suggested to have anti-diabetic effects. The objective of the present study was to investigate the effect of the MT1/MT2 melatonin agonist Neu-P11 on glucose and lipid metabolism in T2DM rats induced by a high fat diet combined with low doses of streptozotocin. T2DM rats were intragastrically administered melatonin (20mg/kg), Neu-P11 (20, 10, 5mg/kg), or a vehicle for 4 weeks. The results showed that the increased food intake, water consumption, hyperglycemia, glucose intolerance, and insulin resistance in T2DM rats were all improved by Neu-P11 treatment. Neu-P11 increased GC receptor expression and suppressed 11β-hydroxysteroid dehydrogenase 1 activity in the hippocampus by enhancing GC sensitivity and HPA feedback, thus decreasing the high GC levels. Transcript levels of the glucose metabolism-related genes peroxisome proliferator-activated receptor-γ, glucose transporter type-4, and adiponectin in adipose tissue were significantly increased after Neu-P11 treatment, while leptin mRNA was significantly decreased. Furthermore, MT1 and MT2 protein levels were enhanced by Neu-P11. These data suggest that normalization of the hyperactivated HPA axis by melatonin and Neu-P11 in T2DM regulates metabolic profiles and insulin sensitivity, which may attenuate insulin resistance and glucose homeostasis. Because Neu-P11 has superior pharmacokinetics and a longer half-life than melatonin, it might be beneficial in treating obesity and T2DM.

Butanol fraction of Parkia biglobosa (Jacq.) G. Don leaves enhance pancreatic β-cell functions, stimulates insulin secretion and ameliorates other type 2 diabetes-associated complications in rats

ETHNOPHARMACOLOGICAL RELEVANCE

Ethnopharmacological surveys have reported that Parkia biglobosa (Jacq.) G. Don (Leguminosae) is among the plants commonly used in the traditional management of diabetes mellitus in Nigeria and Togo.

AIM OF THE STUDY

This study investigated the anti-diabetic activity of the butanol fraction of P. biglobosa leaves (PBBF) in a type 2 diabetes (T2D) model of rats and a possible bioactive compound in the fraction.

MATERIALS AND METHODS

T2D was induced by feeding rats with a 10% fructose solution ad libitum for two weeks followed by an intraperitoneal injection of 40mg/kg body weight streptozotocin and the animals were orally treated with 150 and 300mg/kg BW of the PBBF for five days in a week. Another group of rats was non-diabetic but similarly administered with 300mg/kg BW of the PBBF. Food and fluid intakes, body weight changes and blood glucose levels were monitored during the experiment while other relevant diabetes-associated parameters were measured at the end of the experiment.

RESULTS

The PBBF treatments significantly (P<0.05) decreased the blood glucose levels and improved the glucose tolerance ability compared to untreated diabetic rats. Furthermore, the treatments were found to improve pancreatic β cell function (HOMA-β), stimulate insulin secretions, decrease insulin resistance (HOMA-IR), restore liver glycogen, ameliorate serum dyslipidaemia and prevent hepatic and renal damages compared to untreated diabetic rats. Phytochemical analysis of the fraction led to the isolation of lupeol which inhibited α-glucosidase and α-amylase in non-competitive and uncompetitive inhibition patterns respectively.

CONCLUSION

It was concluded that PBBF possessed remarkable anti-T2D activity which is mediated through modulation of β-cell function and stimulation of insulin secretion and the lower dose (150mg/kg BW) was found optimum for anti-T2D activity compared to the high dose (300mg/kg BW) in this study.

Anti-diabetic effects of the acetone fraction of Senna singueana stem bark in a type 2 diabetes rat model

ETHNOPHARMACOLOGICAL RELEVANCE

Senna singueana is currently used in the traditional treatment of diabetes mellitus in Nigeria. The present study examined the anti-diabetic activity of the Senna singueana acetone fraction (SSAF) of stem bark in a type 2 diabetes (T2D) rat model.

MATERIALS AND METHODS

Crude ethyl acetate extract of the Senna singueana stem bark was fractionated with various solvents and the acetone fraction was selected for in vivo studies based on the high α-glucosidase and α-amylase inhibitory activities. In the in vivo study, male Sprague-Dawley rats were induced with T2D and treated with the SSAF at 150 and 300 mg/kg body weight. Several T2D-related parameters were measured in the study.

RESULTS

After 4 weeks of intervention, non-fasting blood glucose concentrations were significantly decreased and the glucose tolerance ability was significantly improved in the SSAF treated groups compared to the diabetic control group. Serum insulin concentrations, pancreatic β-cell function (HOMA-β) and liver glycogen were significantly (P<0.05) increased while serum alanine transaminase, alkaline phosphatase and urea were significantly decreased in the SSAF treated diabetic rats compared to the diabetic control group. Though insignificantly (P>0.05), other T2D-induced abnormalities such as food and fluid intake, body weight, serum lipids, serum fructosamine level and peripheral insulin resistance (HOMA-IR) were also partially ameliorated by the SSAF treatment.

CONCLUSION

Data of this study suggest that orally administered SSAF could ameliorate most of the T2D-induced abnormalities in a T2D model of rats.

Primary care and health outcomes among older patients with diabetes

OBJECTIVE

The aim of this study was to measure the relationship between days spent waiting for primary care and health outcomes among patients diagnosed with diabetes, especially among the elderly population.

DATA SOURCE

Secondary data from VA administrative databases and Medicare claims.

STUDY DESIGN

This is a retrospective observational study. Outcome variables include primary care utilization, mortality, heart attack, stroke, and ambulatory-care sensitive condition (ACSC) hospitalization. The main explanatory variable of interest is VA primary care wait time. Negative binomial models predict utilization and stacked logistic regression models predict the probability of experiencing each health outcome. Models are stratified by the presence of a selected health condition and age.

PRINCIPAL FINDINGS

Longer wait times were predicted to decrease utilization between 2 and 4 percent. There was no significant relationship between wait times and health outcomes for the overall sample. In stratified analyses, longer waits were associated with undesirable outcomes for those over age 70 with one of the selected health conditions or in certain narrower 5-year age groups, but the overall pattern of results does not indicate a systematic and significant effect.

CONCLUSIONS

There was a modest effect of long wait times on primary care utilization but no robust effect of longer wait times on health outcomes. Waiting for care did not significantly compromise long-term health outcomes for veterans with diabetes.

What are the consequences of waiting for health care in the veteran population?

National health reform is expected to increase how long individuals have to wait between requests for appointments and when their appointment is scheduled. The increase in demand for care due to more widespread insurance will result in longer waits if there is not also a concomitant increase in supply of healthcare services. Long waits for healthcare are hypothesized to compromise health because less frequent outpatient visits result in delays in diagnosis and treatment. Research testing this hypothesis is scarce due to a paucity of data on how long individuals wait for healthcare in the United States. The main exception is the Veterans Health Administration (VA) that has been routinely collecting data on how long veterans wait for outpatient care for over a decade. This narrative review summarizes the results of studies using VA wait time data to answer two main questions: 1) How much do longer wait times decrease healthcare utilization and 2) Do longer wait times cause poorer health outcomes? Longer VA wait times lead to small, yet statistically significant decreases in utilization and are related to poorer health in elderly and vulnerable veteran populations. Both long-term outcomes (e.g. mortality, preventable hospitalizations) and intermediate outcomes such as hemoglobin A1C levels are worse for veterans who seek care at facilities with longer waits compared to veterans who visit facilities with shorter waits. Further research is needed on the mechanisms connecting longer wait times and poorer outcomes including identifying patient sub-populations whose risks are most sensitive to delayed access to care. If wait times increase for the general patient population with the implementation of national reform as expected, U.S. healthcare policymakers and clinicians will need to consider policies and interventions that minimize potential harms for all patients.

Patient-reported outcomes in a survey of patients treated with oral antihyperglycaemic medications: associations with hypoglycaemia and weight gain

AIM

To examine the association between medication side-effects (SEs) and patient-reported outcomes (PROs) among patients with type 2 diabetes treated with oral antihyperglycaemic agents (OAHAs).

METHODS

A total of 1984 participants responded to an internet-based survey in the United States. Data were collected on hypoglycaemia 6 months and weight gain 12 months prior to the survey. Health-related quality of life (HRQoL) was measured using the EuroQol-5D (EQ-5D). Also administered were the Treatment Satisfaction Questionnaire for Medication v.1.4 (TSQM) and the Hypoglycaemia Fear Survey II (HFS).

RESULTS

Symptoms of hypoglycaemia were reported by 62.9% of participants, and 36.9% reported weight gain. For those reporting hypoglycaemia, mean scores were lower for TSQM and EQ-5D and higher for HFS when compared with those with no symptoms (TSQM: 69.7 vs. 75.1; EQ-5D: 0.78 vs. 0.86; HFS: 17.5 vs. 6.2; all p < 0.0001). The same remained true when accounting for symptom severity, where severity was monotonically related with PRO scores (all p < 0.0001). Similarly, reported weight gain was associated with lower treatment satisfaction (69.0 vs. 73.3) and HRQoL (0.77 vs. 0.83), and increased fear of hypoglycaemia (15.7 vs. 11.8) (all p < 0.0001). In mixed linear regression analysis, the associations between medication SEs and PROs remained significant after adjusting for patient and disease characteristics.

CONCLUSIONS

Among patients with type 2 diabetes treated with OAHAs, self-reported hypoglycaemia and weight gain were associated with decreased treatment satisfaction and HRQoL. In addition, the presence of these SEs was associated with increased fear of hypoglycaemia.

Subcutaneous insulin: pharmacokinetic variability and glycemic variability

The therapeutic goal in insulin-treated diabetic patients is to maintain on the long-term a tight glucose control (HbA1, < 6.5-7% or less) through an insulin regimen which "mimic" the physiological insulin profile: a basal insulin secretion to maintain glucose homeostasis and an acute post-prandial secretion in response to meal intake. Such goal represents a challenge for the clinician as conventional human insulins have major drawbacks: slow absorption and too late peak with regular insulins, delayed peak and often occuring at an unwanted time with intermediate and long-acting insulins. Furthermore, these insulins are characterised by a large within- and between-subjects variability, which complicate patients' task to self-adapt their daily doses, even for those well educated and compliants. These limitations and unpredictable variations in insulin action are responsible for an increased risk of hypoglycemic events, between meals as well as during the night period. As a consequence, glucose control is frequently insufficient in type 1 diabetic patients, and these limitations may contribute also to the delayed initiation of insulin therapy in type 2 diabetics when oral antidiabetic agents fail. This variability and the non-reproducibility of the conventional insulin pharmacodynamics are explained by several exogenous and endogenous factors describe in this review. Availability of new short-acting (lispro, aspart and glulisine) and long-acting analogs (glargine, detemir) of human insulin, with improved pharmacokinetic characteristics, and a lesser variability and better reproducibility, should facilitate a tight glucose control in insulin-treated patients. The main pharmacokinetic and pharmacodynamic characteristics of these new insulin analogs are presented and discussed in the light of there intra- and inter-individual variability. Their reduced variability should permit to reinforce near "physiological" insulin regimen such as "basal-bolus" technique and to consider new approaches and therapeutic strategies in type 1 and type 2 diabetic patients.

Efficacy of intensive multitherapy for patients with type 2 diabetes mellitus: a randomized controlled trial

BACKGROUND

National guidelines for managing diabetes set standards for care. We sought to determine whether a 1-year intensive multitherapy program resulted in greater goal attainment than usual care among patients with poorly controlled type 2 diabetes mellitus.

METHODS

We identified patients with poorly controlled type 2 diabetes receiving outpatient care in the community or at our hospital. Patients 30-70 years of age with a hemoglobin A1c concentration of 8% or greater were randomly assigned to receive intensive multitherapy (n = 36) or usual care (n = 36).

RESULTS

The average hemoglobin A1c concentration at entry was 9.1% (standard deviation [SD] 1%) in the intensive therapy group and 9.3% (SD 1%) in the usual therapy group. By 12 months, a higher proportion of patients in the intensive therapy group than in the control group had achieved Canadian Diabetes Association (CDA) goals for hemoglobin A(1c) concentrations (goal < or = 7.0%: 35% v. 8%), diastolic blood pressure (goal < 80 mm Hg: 64% v. 37%), low-density lipoprotein cholesterol (LDL-C) levels (goal < 2.5 mmol/L: 53% v. 20%) and triglyceride levels (goal < 1.5 mmol/L: 44% v. 14%). There were no significant differences between the 2 groups in attaining the targets for fasting plasma glucose levels, systolic blood pressure or total cholesterol:high-density lipoprotein cholesterol ratio. None of the patients reached all CDA treatment goals. By 18 months, differences in goal attainment were no longer evident between the 2 groups, except for LDL-C levels. Quality of life, as measured by a specific questionnaire, increased in both groups, with a greater increase in the intensive therapy group (13% [SD 10%] v. 6% [SD 13%], p < 0.003).

INTERPRETATION

Intensive multitherapy for patients with poorly controlled type 2 diabetes is successful in helping patients meet most of the goals set by a national diabetes association. However, 6 months after intensive therapy stopped and patients returned to usual care, the benefits had vanished.

A graphical user interface for diabetes management that integrates glucose prediction and decision support

BACKGROUND

The promise of the Diabetes Control and Complications Trial (DCCT) has yet to be realized in clinical practice. Notwithstanding intensive education and intensified therapy, there is a distinct lack of a suitable alternative to the intensive decision support that was also provided in the DCCT. Recently, a novel glucose predicting engine has been developed and validated. Use of its predictions in decision support in respect to medication dosing, diet, exercise, and stress promises to empower patients to achieve better diabetes control while reducing hypoglycemia and preventing body weight gain. A graphical user interface (GUI) suitable for these purposes is here described.

METHODS

The kernel of the GUI is a registry database located on a server accessible to both patients and their providers. The patient-GUI includes the resources of the glucose predicting engine and user-friendly, intuitive means to enter body weight and all home-monitored blood glucose levels. In response, means to modify medication dosages (dosing decision support) and modify planned diet and physical activity (lifestyle decision support) are afforded the user. Each action is animated so that the patient can visually see the impact of his or her changes on predicted glucose outcomes and the pending risks of hypoglycemia.

RESULTS

A staged sequence of screens supports the self-management tasks, including selection of the current meal period, the entry of data, and documentation. The GUI returns current medications and presents up-down buttons for adjusting dosages, for changing carbohydrates, for changing exercise, and for predicting the effects of stress. For each adjustment, the impact on medications or predicted glycemia outcomes is animated.

CONCLUSIONS

A new GUI that incorporates a novel glucose predicting engine is intended for all insulin-treated patients with diabetes. It may help patients and their providers to realize better glycemic control and thereby achieve the promise of the DCCT.