The sulfonylurea controversy

An abundant, truncated human sulfonylurea receptor 1 splice variant has prodiabetic properties and impairs sulfonylurea action

An alternatively spliced form of human sulfonylurea receptor (SUR) 1 mRNA lacking exon 2 (SUR1Δ2) has been identified. The omission of exon 2 caused a frame shift and an immediate stop codon in exon 3 leading to translation of a 5.6-kDa peptide that comprises the N-terminal extracellular domain and the first transmembrane helix of SUR1. Based on a weak first splice acceptor site in the human SUR1 gene (ABCC8), RT-PCR revealed a concurrent expression of SUR1Δ2 and SUR1. The SUR1Δ2/(SUR1 + SUR1Δ2) mRNA ratio differed between tissues, and was lowest in pancreas (46%), highest in heart (88%) and negatively correlated with alternative splice factor/splicing factor 2 (ASF/SF2) expression. In COS-7 cells triple transfected with SUR1Δ2/SUR1/Kir6.2, the SUR1Δ2 peptide co-immunoprecipitated with Kir6.2, thereby displacing two of four SUR1 subunits on the cell surface. The ATP sensitivity of these hybrid ATP-sensitive potassium channels (K(ATP)) channels was reduced by about sixfold, as shown with single-channel recordings. RINm5f rat insulinoma cells, which genuinely express SUR1 but not SUR1Δ2, exhibited a strongly increased K(ATP) channel current upon transfection with SUR1Δ2. This led to inhibition of glucose-induced depolarization, calcium flux, insulin release and glibenclamide action. A non-mutagenic SNP on nucleotide position 333 (Pro69Pro) added another exonic splicing enhancer sequence detected by ASF/SF2, reduced relative abundance of SUR1Δ2 and slightly protected from non-insulin dependent diabetes in homozygotic individuals. Thus, SUR1Δ2 represents an endogenous K(ATP)-channel modulator with prodiabetic properties in islet cells. Its predominance in heart may explain why high-affinity sulfonylurea receptors are not found in human cardiac tissue.

Protective effect of Lycium barbarum polysaccharide 4 on kidneys in streptozotocin-induced diabetic rats

Lycium barbarum polysaccharide (LBP) has been shown to have hypoglycemic and antioxidative properties, although its mode of action is yet unknown. Because oxidative stress is implicated in the pathogenesis of diabetic nephropathy, we evaluated the protective effect of LBP-4, the major active component of Lycium barbarum, on the defensive antioxidative mechanism in kidneys in a streptozotocin-induced diabetic rat model. Moreover, we investigated the effects of LBP-4 on the activation of extracellular signal-regulated kinases 1 and 2 (ERK1/2) in isolated mesangial cells. The role of protein kinase C (PKC)-dependent and -independent pathways in LBP-4-reduced ERK1/2 was studied by bisindolylmaleimide (BIM) IV, an inhibitor of PKC. Diabetic rats treated with LBP-4 (10 mg/kg) for 8 weeks showed increased activity of antioxidant enzymes and increased scavenging of oxygen radicals, while the activity of PKC in the renal cortex was maintained at a physiological level. The decreased activation of ERK1/2 in mesangial cells, through the involvement of PKC, could explain the protective mechanism in kidneys of diabetic rats treated with LBP-4.

Effect of second-generation sulfonylureas on survival in patients with diabetes mellitus after myocardial infarction

OBJECTIVE

To examine possible adverse effects of sulfonylureas on survival among patients with diabetes mellitus (DM) who experience a myocardial infarction (MI).

PATIENTS AND METHODS

Residents of Olmsted County, Minnesota, with an MI that met standardized criteria from January 1, 1985, through December 31, 2002, were followed up for mortality.

RESULTS

Among 2189 patients with MI (mean+/-SD age, 68+/-14 years; 1237 men [57%]), 409 (19%) had DM. The 23 patients treated with first-generation sulfonylureas, biguanides, or thiazolidinediones were excluded from analyses. Among the remaining 386 patients with DM, 120 (31%) were taking second-generation sulfonylureas, 180 (47%) were taking insulin, and 86 (22%) were receiving nonpharmacological treatment. Patients with DM treated with second-generation sulfonylureas were more likely to be men and have higher creatinine clearance than those treated with insulin. After adjusting for age, sex, Killip class, duration of DM, creatinine clearance, and reperfusion therapy or revascularization, patients treated with second-generation sulfonylureas had a lower risk of death than did diabetic patients receiving insulin (hazard ratio, 0.41; 95% confidence interval, 0.21-0.80; P=.009).

CONCLUSION

These population-based data do not support the concern about an adverse effect of second-generation sulfonylureas on survival after MI and underscore the importance of population-based studies of surveillance of drug safety.

Effect of second-generation sulfonylureas on survival in patients with diabetes mellitus after myocardial infarction

OBJECTIVE

To examine possible adverse effects of sulfonylureas on survival among patients with diabetes mellitus (DM) who experience a myocardial infarction (MI).

PATIENTS AND METHODS

Residents of Olmsted County, Minnesota, with an MI that met standardized criteria from January 1, 1985, through December 31, 2002, were followed up for mortality.

RESULTS

Among 2189 patients with MI (mean+/-SD age, 68+/-14 years; 1237 men [57%]), 409 (19%) had DM. The 23 patients treated with first-generation sulfonylureas, biguanides, or thiazolidinediones were excluded from analyses. Among the remaining 386 patients with DM, 120 (31%) were taking second-generation sulfonylureas, 180 (47%) were taking insulin, and 86 (22%) were receiving nonpharmacological treatment. Patients with DM treated with second-generation sulfonylureas were more likely to be men and have higher creatinine clearance than those treated with insulin. After adjusting for age, sex, Killip class, duration of DM, creatinine clearance, and reperfusion therapy or revascularization, patients treated with second-generation sulfonylureas had a lower risk of death than did diabetic patients receiving insulin (hazard ratio, 0.41; 95% confidence interval, 0.21-0.80; P=.009).

CONCLUSION

These population-based data do not support the concern about an adverse effect of second-generation sulfonylureas on survival after MI and underscore the importance of population-based studies of surveillance of drug safety.

Role of sarcolemmal ATP-sensitive potassium channel in oxidative stress-induced apoptosis: mitochondrial connection

From time of their discovery, sarcolemmal ATP-sensitive K+ (sarcK ATP) channels were thought to have an important protective role in the heart during stress whereby channel opening protects the heart from stress-induced Ca2+ overload and resulting damage. In contrast, some recent studies indicate that sarcK ATP channel closing can lead to cardiac protection. Also, the role of the sarcK ATP channel in apoptotic cell death is unclear. In the present study, the effects of channel inhibition on apoptosis and the specific interaction between the sarcK ATP channel and mitochondria were investigated. Apoptotic cell death of cultured HL-1 and neonatal cardiomyocytes following exposure to oxidative stress was significantly increased in the presence of sarcK ATP channel inhibitor HMR-1098 as evidenced by terminal deoxynucleotidyltransferase-mediated dUTP nick end labeling and caspase-3,7 assays. This was paralleled by an increased release of cytochrome c from mitochondria to cytosol, suggesting activation of the mitochondrial death pathway. sarcK ATP channel inhibition during stress had no effect on Bcl-2, Bad, and phospho-Bad, indicating that the increase in apoptosis cannot be attributed to these modulators of the apoptotic pathway. However, monitoring of mitochondrial Ca2+ with rhod-2 fluorescent indicator revealed that mitochondrial Ca2+ accumulation during stress is potentiated in the presence of HMR-1098. In conclusion, this study provides novel evidence that opening of sarcK ATP channels, through a specific Ca2+-related interaction with mitochondria, plays an important role in preventing cardiomyocyte apoptosis and mitochondrial damage during stress.

Sex-specific and exercise-acquired cardioprotection is abolished by sarcolemmal KATP channel blockade in the rat heart

The present study was conducted to determine whether the infarct sparing effect of short-term exercise is dependent on the operation of the myocardial sarcolemmal ATP-sensitive K+ (KATP) channel. Adult male and female Sprague-Dawley rats were exercised on a motorized treadmill for 5 days. Twenty-four hours following the training or sedentary period, hearts were isolated and exposed to 1 h of regional ischemia followed by 2 h of reperfusion on a modified Langendorf apparatus in the presence or absence of the sarcolemmal KATP channel antagonist HMR-1098 (30 μM). Following the ischemia-reperfusion protocol, infarct size was determined as a percentage of the total ischemic zone at risk (ZAR). Short-term exercise reduced infarct size by 24% in males (32 ± 2% of ZAR; P < 0.01) and by 18% in females (26 ± 2% of ZAR; P < 0.05). Sarcolemmal KATP channel blockade abolished the training-induced cardioprotection in both males and females, increasing infarct size to 43 ± 3% and 52 ± 4% of ZAR, respectively. In the absence of HMR-1098, infarct size was significantly lower in sedentary females than in males (33 ± 4% vs. 42 ± 2% of ZAR, respectively; P < 0.01). However, the presence of HMR-1098 abolished this sex difference, increasing infarct size by 58% in the sedentary females ( P < 0.01) but having no effect on infarct size in sedentary males. This study demonstrates that the sex-specific and exercise-acquired resistance to myocardial ischemia-reperfusion injury is dependent on sarcolemmal KATP activity during ischemia.

Human ether-a-go-go-related (HERG) gene and ATP-sensitive potassium channels as targets for adverse drug effects

Torsades de pointes (TdP) arrhythmia is a potentially fatal form of ventricular arrhythmia that occurs under conditions where cardiac repolarization is delayed (as indicated by prolonged QT intervals from electrocardiographic recordings). A likely mechanism for QT interval prolongation and TdP arrhythmias is blockade of the rapid component of the cardiac delayed rectifier K+ current (IKr), which is encoded by human ether-a-go-go-related gene (HERG). Over 100 non-cardiovascular drugs have the potential to induce QT interval prolongations in the electrocardiogram (ECG) or TdP arrhythmias. The binding site of most HERG channel blockers is located inside the central cavity of the channel. An evaluation of possible effects on HERG channels during the development of novel drugs is recommended by international guidelines. During cardiac ischaemia activation of ATP-sensitive K+ (KATP) channels contributes to action potential (AP) shortening which is either cardiotoxic by inducing re-entrant ventricular arrhythmias or cardioprotective by inducing energy-sparing effects or ischaemic preconditioning (IPC). KATP channels are formed by an inward-rectifier K+ channel (Kir6.0) and a sulfonylurea receptor (SUR) subunit: Kir6.2 and SUR2A in cardiac myocytes, Kir6.2 and SUR1 in pancreatic beta-cells. Sulfonylureas and glinides stimulate insulin secretion via blockade of the pancreatic beta-cell KATP channel. Clinical studies about cardiotoxic effects of sulfonylureas are contradictory. Sulfonylureas and glinides differ in their selectivity for pancreatic over cardiovascular KATP channels, being either selective (tolbutamide, glibenclamide) or non-selective (repaglinide). The possibility exists that non-selective KATP channel inhibitors might have cardiovascular side effects. Blockers of the pore-forming Kir6.2 subunit are insulin secretagogues and might have cardioprotective or cardiotoxic effects during cardiac ischaemia.

Investigation of structure-activity relationships in a series of glibenclamide analogues

In this study, the synthesis of 15 new glibenclamide analogues is described. The conformational trends of these analogues were investigated using Monte Carlo conformational analysis. The conformational analysis results resolved the discrepancy between previous molecular modelling simulations of glibenclamide and allowed rationalizing the effect of aqueous environment on the overall conformation. The 3D-QSAR study was carried out with respect to the compounds' ability to antagonize the [(3)H]-glibenclamide binging in rat cerebral cortex. Superimposition of the antagonists was performed using the conformations derived from atom-by-atom fit to the glibenclamide crystal structure and this alignment was used to develop CoMFA models. CoMFA provided a good predictability: number of PLS components = 2, q(2) = 0.876, R(2) = 0.921, SEE = 0.455 and F = 70. Best CoMFA models showed the steric and lipophilic properties as the major interacting forces whilst the electrostatic property contribution was a minor factor.

The impact of ATP-sensitive K+ channel subtype selectivity of insulin secretagogues for the coronary vasculature and the myocardium

Insulin secretagogues (sulfonylureas and glinides) increase insulin secretion by closing the ATP-sensitive K+ channel (KATP channel) in the pancreatic beta-cell membrane. KATP channels subserve important functions also in the heart. First, KATP channels in coronary myocytes contribute to the control of coronary blood flow at rest and in hypoxia. Second, KATP channels in the sarcolemma of cardiomyocytes (sarcKATP channels) are required for adaptation of the heart to stress. In addition, the opening of sarcKATP channels and of KATP channels in the inner membrane of mitochondria (mitoKATP channels) plays a central role in ischemic preconditioning. Opening of sarcKATP channels also underlies the ST-segment elevation of the electrocardiogram, the primary diagnostic tool for initiation of lysis therapy in acute myocardial infarction. Therefore, inhibition of cardiovascular KATP channels by insulin secretagogues is considered to increase cardiovascular risk. Electrophysiological experiments have shown that the secretagogues differ in their selectivity for the pancreatic over the cardiovascular KATP channels, being either highly selective (approximately 1,000x; short sulfonylureas such as nateglinide and mitiglinide), moderately selective (10-20x; long sulfonylureas such as glibenclamide [glyburide]), or essentially nonselective (<2x; repaglinide). New binding studies presented here give broadly similar results. In clinical studies, these differences are not yet taken into account. The hypothesis that the in vitro selectivity of the insulin secretagogues is of importance for the cardiovascular outcome of diabetic patients with coronary artery disease needs to be tested.