Clinical practice. Initial management of glycemia in type 2 diabetes mellitus

Smart spectrophotometric methods for the simultaneous determination of newly co-formulated hypoglycemic drugs in binary mixtures

Achieving good glycemic control in patients with type II diabetes mellitus is essential for preventing both microvascular and macrovascular complications. Combination therapy represents the principle strategy for successful long term control of type II diabetes mellitus with minimal complications. Two sensitive, precise and non-destructive spectroscopic methods were developed for the simultaneous estimation of two new co-formulated hypoglycemic drugs; canagliflozin/metformin (CAG/MEF) and empagliflozin/linagliptin (EMG/LIG) in tablets with no need of previous separation. The first method was amplitude modulation (a normalized spectra-based UV spectrophotometric method) for the analysis of (CAG/MEF) binary mixture. The amplitude of the constant at the plateau region at (264-310 nm) on the ratio spectrum was measured and used for the determination of CAG concentration in the mixture. On the other hand, MEF was estimated by subtracting the previously obtained amplitude from the total amplitude of CAG and MEF at the isosbestic point (λ_iso) at 250 nm. The second method was chemometric-assisted FTIR spectrophotometric method for the determination of (EMG/LIG) binary mixture. (EMG/LIG) mixture in chloroform was analyzed using FTIR in the region 4000-400 cm^-1. The spectral region 3900-2900 cm^-1 was selected for (EMG/LIG) determination using principal component regression and partial least squares chemometric methods. The methods were validated according to ICH guidelines. The studied drugs were successfully determined in tablets applying the developed methods. Validation parameters were in agreement with acceptance limits, ensuring methods accuracy and selectivity. Besides, no significant difference was obtained by statistically comparing the obtained results with the reported one.

The effect of diabetes mellitus on the shear bond strength of composite resin to dentin and enamel

Diabetes mellitus might be linked to the deterioration of certain physical properties of dentin and enamel. This study aimed to determine the effect of two types of diabetes on the shear bond strength of enamel and dentin, by using the single bond universal bonding system. Sixty specimens [from 15 teeth; 5 from each group-non-diabetic (ND), Diabetic type I (D1), and Diabetic type II (D2)], were prepared with equal amounts of dentin (n = 5) and enamel (n = 5). Enamel specimens (E20) were etched with 37% phosphoric acid, for 20 s, and dentin specimens (D15) were etched for 15 s. A standard shear bond strength test was performed on all specimens. Their failure modes were also studied under a scanning electron microscope, and the data were analyzed by using ANOVA and Post Hoc Tukey's test (a = 0.050). For the enamel groups, significant differences were only noticed between the ND and D1 (P < 0.050) groups, and between the ND and D2 (P < 0.050) groups. In the dentin groups, there was a significant difference only between the ND and D1 (P < 0.050) groups. The micrographs showed that the ND group had the highest number of specimens with cohesive failure and D1 had the highest number of specimens with adhesive failure. It can be concluded that both types of diabetes reduce the shear bond strength of composite resin on dentin and enamel. However, it seems that the negative effect of diabetes on shear bond strength of dental composite resin is more drastic in individuals with type I diabetes as compared with type II.

LDL-Cholesterol versus Glucose in Microvascular and Macrovascular Disease

BACKGROUND

The causal relationships between increased concentrations of low density lipoprotein (LDL)-cholesterol and glucose and risk of ischemic heart disease are well established. The causal contributions of LDL-cholesterol and glucose to risk of peripheral micro- and macrovascular diseases are less studied, especially in prediabetic stages and in a general population setting.

CONTENT

This review summarizes the current evidence for a causal contribution of LDL-cholesterol and glucose to risk of a spectrum of peripheral micro- and macrovascular diseases and reviews possible underlying disease mechanisms, including differences between vascular compartments, and finally discusses the clinical implications of these findings, including strategies for prevention and treatment.

SUMMARY

Combined lines of evidence suggest that LDL-cholesterol has a causal effect on risk of peripheral arterial disease and chronic kidney disease, both of which represent manifestations of macrovascular disease due to atherosclerosis and accumulation of LDL particles in the arterial wall. In contrast, there is limited evidence for a causal effect on risk of microvascular disease. Glucose has a causal effect on risk of both micro- and macrovascular disease. However, most evidence is derived from studies of individuals with diabetes. Further studies in normoglycemic and prediabetic individuals are warranted. Overall, LDL-cholesterol-lowering reduces risk of macrovascular disease, while evidence for a reduction in risk of microvascular disease is inconsistent. Glucose-lowering has a beneficial effect on risk of microvascular diseases and on risk of chronic kidney disease and estimated glomerular filtration rate (eGFR) in some studies, while results on risk of peripheral arterial disease are conflicting.

Post-Transplant Diabetes Mellitus and Prediabetes in Renal Transplant Recipients: An Update

Post-transplant diabetes mellitus (PTDM) is a frequent and relevant complication after renal transplantation: it affects 20-30% of renal transplant recipients and increases the risk for cardiovascular and infectious events. Thus, understanding pathogenesis of PTDM would help limiting its consequences. In this review, we analyse novel aspects of PTDM, based on studies of the last decade, such as the clinical evolution of PTDM, early and late, the reversibility rate, diagnostic criteria, risk factors, including pre-transplant metabolic syndrome and insulin resistance (IR) and the interaction between these factors and immunosuppressive medications. Also, we discuss novel pathogenic factors, in particular the role of β-cell function in an environment of IR and common pathways between pre-existing cell damage and tacrolimus-induced toxicity. The relevant role of prediabetes in the pathogenesis of PTDM and cardiovascular disease is also addressed. Finally, current evidence on PTDM treatment is discussed.

Establishing a proof of concept for the effects of low-carbohydrate, high-fat diet (LCHFD) and physical activity on body composition in type 2 diabetes

Overweight and obesity are both a risk factor for developing and exacerbating type 2 diabetes (T2D). While the most common diet used to treat overweight and obesity focus on high-carbohydrate, low-fat, energy deficit diets, recently, low-carbohydrate, high-fat diets (LCHFD) have become popular in targeting obesity. This proof-of-concept study attempted to determine if an LCHFD could improve body composition variables, or if a concurrent treatment of LCHFD and physical activity would create an interference effect in individuals with T2D. Overweight and obese with T2D (n = 39) were assigned into either a 16-week combined physical activity and LCHFD group (ConG), LCHFD-only group (DieG) or control group (NonG). No statistically significant (p > 0.01) changes were found in body mass in the ConG (2.0%, F = 0.039, P = 0.846) and DieG (2.5%, F = 0.188, P = 0.669); for body mass index in the ConG (2.2%, F = 0.046, P = 0.832) and DieG (2.3%, F = 0.098, P = 0.758.); and waist-to-hip ratio in the ConG (0%, F = 0.002, P = 0.968) and DieG (0%, F = 0.023, P = 0.882). However, clinically significant changes were observed in HbA1c in the ConG male group (23% decrease); percentage body fat for the ConG (16.7%, F = 1.682, P = 0.208, g = 0.534) and DieG (13.0%, F = 0.638, P = 0435, g = 0.361); for waist circumferences in the ConG (5.4%, F = 0.686, P = 0.416, g = 0.341) and DieG (6.3%, F = 1.327, P = 0.264, g = 0.520); and for hip circumference in the ConG (5.8%, F = 0.993, P = 0.329, g = 0.410) and DieG (7.0%, F = 2.668, P = 0.119, g = 0.737). Results indicate that moderate clinically significant changes in body composition are achievable with LCHFD and/or daily walking in obese adults living with T2D. However, more robust research is required to determine the effects of LCHFD, with or without concurrent physical activity, on obesity and other diabetic complication markers.

Comprehensive structure–activity relationship (SAR) investigation of C-aryl glycoside derivatives for the development of SGLT1/SGLT2 dual inhibitors

Multi-combined computational approaches were used to explore the SAR and design novel potential SGLT1/SGLT2 dual inhibitors.

Untargeted Metabolomic Approach Shows No Differences in Subcutaneous Adipose Tissue of Diabetic and Non-Diabetic Subjects Undergoing Bariatric Surgery: An Exploratory Study

BACKGROUND

Obesity plays a major role in the development of insulin resistance (IR) and diabetes (T2DM). Increased adipose tissue (AT) is particularly of interest because it activates a chronic inflammatory response in adipocytes and other tissues. AT plays key endocrine and metabolic functions, acting in the regulation of insulin sensitivity and energy homeostasis. Additionally, it can be easily collected during bariatric surgery. The purpose of this pilot study was to explore the potential differences in AT metabolism, through comparing the untargeted metabolomic profiles of diabetic and non-diabetic obese patients undergoing bariatric surgery.

METHODS

For this exploratory study, samples were collected from 17 subjects. Subcutaneous AT (SAT) samples from obese-diabetic (n = 8) and Obese-non-Diabetic (n = 9) subjects were obtained from the Human Metabolic Tissue Bank. Untargeted metabolomic profiling was performed by Metabolon® Inc. Statistical analysis was performed using the MetaboAnalyst 4.0 platform.

RESULTS

Among the 421 metabolites identified and analyzed there were no significant differences between the Obese-Diabetics and the Obese-non-Diabetics. Small changes were observed by fold change analysis mainly in lipid (n = 12; e.g. NEFAs) and amino acid (n = 8; e.g. BCAAs) metabolic pathways. Dysregulation of these metabolites has been associated with IR and other T2DM-related pathophysiological processes.

CONCLUSION

Obesity may influence SAT metabolism masking T2DM-dependent dysregulation. Better understanding the metabolic differences within SAT in diabetic populations may help identify potential biomarkers for diagnosis and monitoring of T2DM in patients undergoing bariatric surgery.

An exhaustive perspective on structural insights of SGLT2 inhibitors: A novel class of antidiabetic agent

Diabetes mellitus is the global health issue and become an alarming threat in the modern era where human lifestyle gets compromised with modernization. According to the latest statistical report 2020, USA has 9.47% (31 million among 32.72 cr), China has 8.3% (116.4 million among 139.27 cr) and India has 5.6% (77 million among 135.26 cr) of the diabetic people, indicating that diabetes is more prevailing in developed countries as compared to the developing countries. The number of diabetic patients is rising day by day at a tremendous rate and soon it may affect each and every person in a family. So, there is an urgent need to develop novel entities that can meet the scarcity of present antidiabetic agents. In the last few decades, the sodium-glucose co-transporter 2 (SGLT2) has emerged as a prominent target for the treatment of Type 2 diabetes mellitus due to its novel mechanism of action & no involvement in insulin signaling pathway. Most of the inhibitors that target SGLT2 contain three basic moieties: glucose, two benzene rings (one is connected with glucose and the other with methylene), and the methylene bridge which are similar to dapagliflozin. Several SGLT2 inhibitors and their derivatives such as remogliflozin etabonate (phase-II), sotagliflozin (phase-III) and bexagliflozin (phase-III) are under different phases of clinical trial studies and some have been patented. The present review is focused on SGLT2 inhibitors, structure activity relationships (SARs) of dapagliflozin and its several analogues for their binding affinity with SGLT2. We have also presented and summarized the efforts made by various researchers in terms of the synthesis of various dapagliflozin derivatives till date.

Vortioxetine versus sertraline in metabolic control, distress and depression in Mexican patients with type 2 diabetes

Background

Depression in patients with type 2 diabetes (T2D) is often undiagnosed and remains untreated, leading to poor therapy adherence and ill health-related outcomes. We evaluated the effect of vortioxetine versus sertraline in the treatment of depression, distress and metabolic control in subjects with T2D and depression.

Methods

Participants were selected from the Clinic for Diabetes, diagnosed with depression when the score was ≥14 in the Hamilton Depression Rating Scale, and verified by a psychiatrist in agreement with the DSM-5 instrument (Diagnostic and Statistical Manual of Mental Disorders, fifth edition). The criteria for recruitment also included glycosylated hemoglobin ≥7.5%, 18 to 60 years of age, and written informed consent. Pharmacological treatment for depression was assigned randomly: vortioxetine (10 mg/day) or sertraline (75 mg/day) for 8 weeks. Biochemical parameters, anthropometric measures and depression symptoms were evaluated after antidepressant treatment. This was a randomized singled-blind study.

Results

Subjects that met the inclusion criteria were 50, of which only 21 patients with T2D and depression finished the treatment. Vortioxetine and sertraline showed partial remission of depression. Vortioxetine showed a major effect size in glycosylated hemoglobin and a moderate effect size on weight loss, fasting plasma glucose (FPG), cholesterol and triacylglycerol levels. On the other hand, patients treated with sertraline presented a slight increase in body weight, body mass index (BMI), and in all biochemical markers.

Conclusions

Vortioxetine may ameliorate depressive symptoms and metabolic control in patients with T2D and depression. Trial registration number: NCT03978286.

Development of a Novel Series of Anticancer and Antidiabetic: Spirothiazolidines Analogs

4-(4-Aminophenyl)-1-thia-4-azaspiro[4.5]decan-3-one 1 was prepared and allowed to react with nitrogen nucleophiles to give the corresponding hydrazones 2–4. Further, compound 1 underwent diazotization and afforded the parallel hydrazono derivative 5; moreover, compound 1 refluxed with active methylene derivatives yielded the corresponding aminospirothiazolo pyridine–carbonitrile derivative 6 and spirothiazolopyridinone–carbonitrile derivative 7. Condensation of spirothiazolidine 1 with 4-chlorobenzaldehyde gave the corresponding spiro arylidiene derivative 8, which was utilized as a component of Micheal addition to react with excess of nitrogen nucleophiles to yield novel ring frameworks 4-(3′-(4-chlorophenyl)–spiro [cyclohexane-1,5′-pyrazolo[3,4-d]thiazol]-6′(1′H)-yl)aniline (9) and 4-(3′-(4-chlorophenyl)-6′H- spiro[cyclohexane-1,5′-thiazolo[5,4-d]isoxazol]-6′-yl)aniline (10). Finally, when spirothiazolo pyridinone–carbonitrile derivative 7 sodium salt generated in situ was reacted with different alkyl halides, it produced the corresponding N-derivatives 12–16. Three compounds, 6, 14, and 16, showed high significantly anticancer activities compared with Doxorubicin® (positive control) against human breast carcinoma (MCF-7) and human liver carcinoma (HepG-2) cell lines. On the other hand, compounds 6 and 9 showed higher therapeutic indices for both of alpha-amylase inhibitor and alpha-glucosidase inhibitor than the other tested compounds compared with the antidiabetic Acarbose (positive control).

β-Cell Fate in Human Insulin Resistance and Type 2 Diabetes: A Perspective on Islet Plasticity

Although it is well established that type 2 diabetes (T2D) is generally due to the progressive loss of β-cell insulin secretion against a background of insulin resistance, the actual correlation of reduced β-cell mass to its defective function continues to be debated. There is evidence that a compensatory increase in β-cell mass, and the consequent insulin secretion, can effectively cope with states of insulin resistance, until hyperglycemia supervenes. Recent data strongly indicate that the mechanisms by which islets are able to compensate in response to insulin resistance in peripheral tissues is secondary to hyperplasia, as well as the activation of multiple cellular machineries with diverse functions. Importantly, islet cells exhibit plasticity in altering their endocrine commitment; for example, by switching from secretion of glucagon to secretion of insulin and back (transdifferentiation) or from an active secretory state to a nonsecretory quiescent state (dedifferentiation) and back. Lineage tracing (a method used to track each cell though its differentiation process) has demonstrated these potentials in murine models. A limitation to drawing conclusions from human islet research is that most studies are derived from human autopsy and/or organ donor samples, which lack in vivo functional and metabolic profiling. In this review, we specifically focus on evidence of islet plasticity in humans-from the normal state, progressing to insulin resistance to overt T2D-to explain the seemingly contradictory results from different cross-sectional studies in the literature. We hope the discussion on this intriguing scenario will provide a forum for the scientific community to better understand the disease and in the long term pave the way for personalized therapies.

Impact of Impaired Pancreatic β-Cell Function on Cardiovascular Prognosis in Heart Failure Patients Without Diabetes Mellitus

Background: Insulin resistance as assessed using homeostasis model assessment ratio (HOMA-R) is associated with latent myocardial damage in apparently healthy subjects in health check. Meanwhile, diabetes mellitus (DM) is an unfavorable prognostic risk factor in patients with heart failure (HF). We examined the impact of pancreatic β-cell dysfunction on clinical outcomes in HF patients without DM.

Methods and Results: This study enrolled 312 HF patients without DM. Pancreatic β-cell dysfunction was defined as HOMA-β <30%. A total of 108 patients (35%) had β-cell dysfunction. Plasma brain natriuretic peptide was higher in patients with pancreatic β-cell dysfunction compared with those without (625.2 vs. 399.0 pg/mL, P<0.001). On Kaplan-Meier analysis, a significantly higher cardiovascular events rate was observed in patients with pancreatic β-cell dysfunction (log-rank test, P=0.001), but there was no significant difference between patients with and without insulin resistance. On Cox hazard analysis, pancreatic β-cell dysfunction was independently associated with cardiovascular events after adjustment for confounding factors (HR, 1.58; 95% CI: 1.02–2.45), whereas insulin resistance was not associated with cardiovascular events.

Conclusions: Pancreatic β-cell dysfunction, but not insulin resistance, was associated with unfavorable outcome in HF patients without DM.

The STOP DIABETES study: when prevention works

Although many drugs are now available, a large effort is still needed to prevent diabetes. The STOP DIABETES study evaluated individuals at risk for type 2 diabetes (T2D) by a 2-h 75-g oral glucose tolerance test (OGTT). Based on the three main defective physiological responses, subjects were stratified as at low, intermediate, or high risk, and treated accordingly with lifestyle modifications and drugs. Participants at intermediate and high risk experienced the greatest reduction of T2D conversion. Interestingly, a group of individuals developing T2D presented a normal glucose tolerance at baseline, but a 1-h plasma glucose concentration > 155 mg/dL. These results are critical as prediabetes can increase the incidence of cardiovascular disease. Considering the timeframe between the first defects in glucose metabolism and the manifestation of diabetes complications, the effort to tackle the glycemic impairment as soon as possible represents an outstanding task to reduce the incidence of diabetes. Ideally, the earlier glycemic alterations are recognized, the lesser armamentarium needs to be used, and the lower is the expense in terms of drugs, complications, and related events and costs. Finally, a wealth of studies clearly demonstrated the importance of 1-h plasma glucose concentration, which has been proposed as an adjunctive diagnostic tool to detect prediabetes earlier. In conclusion, by an OGTT, a lot of individuals at risk for T2D may be detected when the central role for the 1-h plasma glucose concentration is also considered. Consequently, these subjects would be treated early and with less drugs and delay T2D complications.

Utilization patterns of insulin for patients with type 2 diabetes from national health insurance claims data in South Korea

Type 2 diabetes mellitus (T2DM) is a chronic disease that requires long-term therapy and regular check-ups to prevent complications. In this study, insurance claim data from the National Health Insurance Service (NHIS) of Korea were used to investigate insulin use in T2DM patients according to the economic status of patients and their access to primary physicians, operationally defined as the frequently used medical care providers at the time of T2DM diagnosis. A total of 91,810 participants were included from the NHIS claims database for the period between 2002 and 2013. The utilization pattern of insulin was set as the dependent variable and classified as one of the following: non-use of antidiabetic drugs, use of oral antidiabetic drugs only, or use of insulin with or without oral antidiabetic drugs. The main independent variables of interest were level of income and access to a frequently-visited physician. Multivariate Cox proportional hazards analysis was performed. Insulin was used by 9,281 patients during the study period, while use was 2.874 times more frequent in the Medical-aid group than in the highest premium group [hazard ratio (HR): 2.874, 95% confidence interval (CI): 2.588–3.192]. Insulin was also used ~50% more often in the patients managed by a frequently-visited physician than in those managed by other healthcare professionals (HR: 1.549, 95% CI: 1.434–1.624). The lag time to starting insulin was shorter when the patients had a low income and no frequently-visited physicians. Patients with a low level of income were more likely to use insulin and to have a shorter lag time from diagnosis to starting insulin. The likelihood of insulin being used was higher when the patients had a frequently-visited physician, particularly if they also had a low level of income. Therefore, the economic statuses of patients should be considered to ensure effective management of T2DM. Utilizing frequently-visited physicians might improve the management of T2DM, particularly for patients with a low income.

Different resolution techniques for management of overlapped spectra: Application for the determination of novel co-formulated hypoglycemic drugs in their combined pharmaceutical dosage form

To maintain intensive glucose control early in the type II diabetes mellitus process, novel combinations of canagliflozin/metformin (CAG/MEF) and empagliflozin/linagliptin (EMG/LIG) offer particular treatment benefits. In this study, sensitive and precise spectrophotometric methods were developed for the determination of such hypoglycemic drug combinations in bulk powder and in pharmaceutical dosage form without prior separation. The first method was ratio difference coupled with modified isosbestic point technique where the amplitude difference between 239 and 291 nm on the ratio spectrum of CAG obtained using 4 μg/ml of MEF as divisor was used for determination of CAG. On the other hand, MEF was estimated using a modified isosbestic spectrophotometric method, where the total concentration of CAG and MEF in mixture could be calculated at 250 nm (isosbestic point) after multiplication by a correction factor. Then concentration of MEF could be calculated by subtraction. The second method was ratio subtraction coupled with extended ratio subtraction, where EMG was determined at 225 nm by subtraction of plateau values from the ratio spectrum followed by multiplication with the spectrum of 6.5 μg/ml of LIG (divisor). Then, an extension of the normal ratio subtraction method was performed in order to determine LIG at 226 nm. Linearity was obtained over 5-30, 2.5-16, 2.5-16 and 1.25-8 μg/ml for CAG, MEF, EMG and LIG, respectively. The developed methods were successfully applied for the determination of studied drugs in tablets. Validation parameters were found to be within acceptance limits, thus confirming methods accuracy and selectivity. The obtained results were statistically compared with the reported one showing no significant difference in terms of accuracy and precision. The methods could be applied for routine analysis of the cited drugs in quality control laboratories.

Short-term feeding of a ketogenic diet induces more severe hepatic insulin resistance than an obesogenic high-fat diet

KEY POINTS

A ketogenic diet is known to lead to weight loss and is considered metabolically healthy; however there are conflicting reports on its effect on hepatic insulin sensitivity. KD fed animals appear metabolically healthy in the fasted state after 3 days of dietary challenge, whereas obesogenic high-fat diet (HFD) fed animals show elevated insulin levels. A glucose challenge reveals that both KD and HFD fed animals are glucose intolerant. Glucose intolerance correlates with increased lipid oxidation and lower respiratory exchange ratio (RER); however, all animals respond to glucose injection with an increase in RER. Hyperinsulinaemic-euglycaemic clamps with double tracer show that the effect of KD is a result of hepatic insulin resistance and increased glucose output but not impaired glucose clearance or tissue glucose uptake in other tissues.

ABSTRACT

Despite being a relevant healthcare issue and heavily investigated, the aetiology of type 2 diabetes (T2D) is still incompletely understood. It is well established that increased endogenous glucose production (EGP) leads to a progressive increase in glucose levels, causing insulin resistance and eventual loss of glucose homeostasis. The consumption of high carbohydrate, high-fat, western style diet (HFD) is linked to the development of T2D and obesity, whereas the consumption of a low carbohydrate, high-fat, ketogenic diet (KD) is considered healthy. However, several days of carbohydrate restriction are known to cause selective hepatic insulin resistance. In the present study, we compare the effects of short-term HFD and KD feeding on glucose homeostasis in mice. We show that, even though KD fed animals appear to be healthy in the fasted state, they exhibit decreased glucose tolerance to a greater extent than HFD fed animals. Furthermore, we show that this effect originates from blunted suppression of hepatic glucose production by insulin, rather than impaired glucose clearance and tissue glucose uptake. These data suggest that the early effects of HFD consumption on EGP may be part of a normal physiological response to increased lipid intake and oxidation, and that systemic insulin resistance results from the addition of dietary glucose to EGP-derived glucose.

Factors associated with physicians' decision to discontinue or down-titrate sulfonylureas for type 2 diabetes patients

BACKGROUND

Sulfonylureas (SUs) can help manage type 2 diabetes mellitus, but often have side effects. The objective of this study was to identify factors impacting physicians' decisions to discontinue (DC) or down-titrate (DT) SU therapy.

METHODS

1,026 physicians from the All Global panel were asked to rate level of concern regarding potential reasons for DC or DT on a 7-point Likert scale (1 = not concerned, 7 = extremely concerned). Physicians also provided information regarding treatment decisions from one DC patient, one DT patient, and two current SU users.

RESULTS

When asked to report what factors might lead them to DC or DT an SU, physicians reported that hypoglycemic events requiring medical assistance (DC = 6.0, DT = 5.9), hypoglycemic events requiring nonmedical assistance (DC = 5.9, DT = 5.9), other hypoglycemic events not requiring assistance (DT = 5.7), and treatment goals not being met (DC = 5.6) were most concerning. DC and DT patients were more likely to have experienced ≥ 1 hypoglycemic events in the previous year vs. current users (DC = 41.0%, DT = 43.1%, current = 8.8%; p < .05).

CONCLUSIONS

Results highlight the strong influence  of hypoglycemia on physicians' decisions to DC or DT SU therapy.

Promotion of Corneal Epithelial Wound Healing in Diabetic Rats by the Fibronectin-Derived Peptide PHSRN

PURPOSE

Topical application of the fibronectin-derived peptide PHSRN facilitates corneal epithelial wound healing in healthy animals and in patients with nonhealing epithelial defects. We have now examined the effect of PHSRN eye drops on the healing of corneal epithelial wounds in diabetic rats.

METHODS

Wistar rats were injected intraperitoneally with streptozotocin to induce diabetes or with a vehicle as a control. Four weeks after confirmation of the corresponding presence or absence of glycosuria, a 3-mm-diameter portion of the corneal epithelium of the right eye was excised and eye drops containing PHSRN (200 μM) or phosphate-buffered saline (PBS) vehicle were administered to the injured eye every 6 hours.

RESULTS

The area of the epithelial defect did not differ significantly among the 4 experimental groups (diabetic or nondiabetic rats treated with PHSRN or vehicle) at 12 hours after wounding. At 18 hours, however, the area of the defect in diabetic rats treated with PHSRN (0.50 ± 0.34 mm) was significantly (P < 0.05) smaller than that in diabetic rats treated with PBS (1.06 ± 0.42 mm) and was similar to that in nondiabetic rats treated with PBS (0.60 ± 0.23 mm). The decrease in the size of the epithelial defect in diabetic rats treated with PHSRN was also found to be dependent on the dose of the peptide.

CONCLUSIONS

Administration of PHSRN significantly facilitated healing of corneal epithelial wounds in diabetic rats, which suggests that PHSRN eye drops warrant further investigation as a treatment option for patients with diabetic keratopathy.

Activated Mast Cells Mediate Low-Grade Inflammation in Type 2 Diabetes: Interleukin-37 Could Be Beneficial

Mast cells (MCs) promote guest immune responses to parasites and play a critical role in allergic and inflammatory reactions. Once they have been activated, MCs release highly inflammatory compounds that can provoke serious pathologic signs that can lead to death. MCs generate a number of preformed, de novo synthesized compounds and inflammatory cytokine/chemokine synthesis in response to the high-affinity (Kd=10^-10 M) immunoglobulin E receptor triggering. Circulating MC progenitors migrate into arterial intima and develop lesions, mediating inflammation. They are involved in several disorders, including metabolic diseases, such as type 2 diabetes mellitus, in which endothelial cells release several inflammatory compounds during acute and chronic vascular damage. Certain inflammatory cytokines, such as interleukin (IL)-1 and IL-33, not only are produced by MCs but also may activate them. These effects mediate systemic inflammatory responses in metabolic disorders. Proinflammatory cytokines, such as tumor necrosis factor, IL-33 and IL-6, secreted by MCs and other immune cells, contribute to insulin resistance by activating kinases. IL-37 (IL-1 family member 7), one of the latest cytokines discovered, binds the IL-18 receptor alpha (IL-18Rα) chain and suppresses innate and acquired immunity, with a therapeutic effect. It also inhibits cytokine levels, including IL-6, IL-18, IL-33, tumor necrosis factor and IL-1, and may improve insulin production and, therefore, the pathogenesis of diabetes, stroke and cardiovascular health. This describes a new concept of inhibition of and cure for inflammatory diseases. However, the safety, dosage and tolerability of this novel therapeutic agent, IL-37, still remains to be determined.

[Why don't doctors use early insulinization therapy in patients with diabetes mellitus type 2?: A qualitative approach in a Mexican city]

Early insulinization therapy is regarded as an efficient aid to improve long term control and quality of life in patients with diabetes mellitus type 2 (DM2). Nevertheless, both patients and medical staff confront barriers in using this therapeutic tool. This study employs a qualitative approach to explore the barriers to early insulinization among medical staff from the public sector in the city of Xalapa, Veracruz, México. Between 2015 and 2016, in-depth interviews were conducted with general and specialist physicians offering primary health care to patients with DM2. The transcribed interviews were analyzed to extract and organize categories and subcategories of barriers among medical staff. These barriers were then grouped into three categories and exemplified with interview excerpts: barriers coming from the medical staff itself, barriers emerging from the doctor-patient interaction, and institutional barriers. Uses for the classification obtained are discussed, as are some of the solutions proposed by study participants.

Quantitative assessment of the bidirectional relationships between diabetes and depression

Diabetes and depression impose an enormous public health burden and the present study aimed to assess quantitatively the bidirectional relationships between the two disorders. We searched databases for eligible articles published until October 2016. A total of 51 studies were finally included in the present bidirectional meta-analysis, among which, 32 studies were about the direction of depression leading to diabetes, and 24 studies about the direction of diabetes leading to depression. Pooled results of the 32 eligible studies covering 1274337 subjects showed that depression patients were at higher risk for diabetes (odds ratio (OR) = 1.34, 95% confidence intervals (CI) = [1.23, 1.46]) than non-depressive subjects. Further gender-subgroup analysis found that the strength of this relationship was stronger in men (OR = 1.63, 95%CI = [1.48, 1.78]) than in women (OR = 1.29, 95%CI = [1.07, 1.51]). For the direction of diabetes leading to depression, pooled data of 24 articles containing 329658 subjects showed that patients with diabetes were at higher risk for diabetes (OR = 1.28, 95%CI = [1.15, 1.42]) than non-diabetic subjects. The available data supports that the relationships between diabetes and depression are bidirectional and the overall strengths are similar in both directions. More mechanistic studies are encouraged to explore the molecular mechanisms underlying the relationships between the two diseases.

What Is the Evidence for Paediatric/Adolescent Bariatric Surgery?

PURPOSE OF REVIEW

In spite of the increasing prevalence of severe and complex obesity in children, surgery as a potential management option is still not widely accepted. The purpose of this review is to examine the evidence for surgical options in the severely obese paediatric population. Increasing evidence supports early rather than later use of bariatric surgery in the treatment of extreme obesity.

RECENT FINDINGS

Prior to 2007, the feasibility and safety of surgery have been reported by predominantly small, sporadic single-centre retrospective case series. Increasing long-term data is now emerging due to the formation of multi-centre prospective national consortiums with two large, prospective long-term outcome studies published within the last year aiding our understanding of the efficacy and safety of bariatric surgery within the adolescent population. It is increasingly clear that adolescent bariatric surgery outcomes are comparable to adults, with similar sustainable weight loss, resolution of co-morbidities and complication rates. However, these studies are solely from dedicated specialist adolescent centres and results may not be reproducible if not performed in regulated environments with specialist multi-disciplinary teams.

Vascular and Endothelial Function in Youth with Type 2 Diabetes Mellitus

PURPOSE OF REVIEW

This review aims to discuss the burden of type 2 diabetes in youth and summarize the studies that have utilized noninvasive techniques to assess early vascular disease in youth with type 2 diabetes.

RECENT FINDINGS

Noninvasive imaging modalities provide researchers with tools to investigate the vasculature in adolescents with type 2 diabetes. The data published to date consistently show adolescents with type 2 diabetes have greater vascular thickness and stiffness and worse endothelial function compared to their obese and lean peers. As the prevalence of type 2 diabetes continues to increase adolescent youth, there is concern adolescents with type 2 diabetes are at risk to develop early onset cardiovascular disease and complications. Future studies need to address treatments that have the potential to improve or reverse vascular dysfunction and decrease the rate of cardiovascular disease and complications.

IDegLira Versus Insulin Glargine U100: A Long-term Cost-effectiveness Analysis in the US Setting

INTRODUCTION

Treatment with IDegLira has the potential to improve glycemic control in patients with type 2 diabetes mellitus (T2DM) without the weight gain and with a lower risk of hypoglycemia than with other therapies. The aim of the present analysis was to evaluate the long-term cost-effectiveness of IDegLira versus insulin glargine U100 with re-education and up-titration of the dose for treatment of patients with T2DM failing to achieve glycemic control on basal insulin in the US setting.

METHODS

Data were obtained from the DUAL V randomized controlled trial in which adults with T2DM failing to achieve glycemic targets with insulin glargine U100 were randomly allocated to receive either IDegLira or insulin glargine U100. Long-term projections of clinical outcomes and direct costs were made using the IMS CORE Diabetes Model. Costs were accounted from a healthcare payer perspective. Future costs and clinical benefits were discounted at 3% annually.

RESULTS

IDegLira was associated with improved discounted life expectancy (13.99 [standard deviation 0.19] versus 13.82 [standard deviation 0.20] years) and quality-adjusted life expectancy (9.14 [standard deviation 0.12] versus 8.87 [standard deviation 0.13] quality-adjusted life years [QALYs]) compared to insulin glargine U100. IDegLira was associated with increased direct costs of $16,970, yielding an incremental cost-effectiveness ratio (ICER) of $63,678 per QALY gained versus insulin glargine U100. Sensitivity analyses identified that the key driver of cost-effectiveness was the greater reduction in glycated hemoglobin with IDegLira compared with insulin glargine U100.

CONCLUSIONS

Based on head-to-head clinical trial data, the present analysis suggests that IDegLira is likely to improve long-term clinical outcomes for patients with T2DM not achieving glycemic control on basal insulin compared to re-education and up-titration of the dose of insulin glargine U100, with these improvements coming at an increased cost from a healthcare payer perspective. An ICER within the range described as high care value was calculated, suggesting IDegLira is a cost-effective treatment option in the US.

FUNDING

Novo Nordisk A/S and Novo Nordisk Inc.

Evaluation of the Short-Term Cost-Effectiveness of IDegLira Versus Continued Up-Titration of Insulin Glargine U100 in Patients with Type 2 Diabetes in the USA

Introduction

Effective glycemic control can reduce the risk of complications and their related costs in type 2 diabetes mellitus (T2DM). However, many patients fail to reach glycemic targets, often because of adverse effects of treatment (including hypoglycemia or weight gain). The present analysis evaluated the short-term cost-effectiveness of IDegLira versus continued up-titration of insulin glargine U100 in patients with T2DM failing to achieve glycemic control on basal insulin in the US setting.

Methods

The cost per patient achieving treatment target (cost of control) was assessed for various single and composite endpoints for the entire trial population and in patients with baseline glycated hemoglobin (HbA1c) >8.0% and HbA1c >9.0%. The proportions of patients achieving treatment targets were analyzed using data obtained in the DUAL V study. Costs were accounted based on published wholesale acquisition costs.

Results

When assessing the full trial population, IDegLira was associated with lower annual cost of control than continued up-titration of insulin glargine U100 for patients achieving HbA1c ≤6.5% without confirmed hypoglycemia (by $10,608), HbA1c ≤6.5% without weight gain (by $29,215), and HbA1c ≤6.5% without confirmed hypoglycemia and weight gain (by $57,351). A similar pattern was observed when multifactorial treatment targets were based on achieving a glycemic target of 7.0%. When only HbA1c was considered, IDegLira was associated with a lower cost per patient achieving HbA1c ≤6.5% (by $3306) but cost of control was equivalent for a target of HbA1c <7.0%. In patients with baseline HbA1c >8.0% and HbA1c >9.0%, IDegLira was associated with a lower cost of control for all treatment targets.

Conclusion

The significantly greater clinical efficacy in terms of bringing patients to treatment targets identified in the DUAL V study results in lower cost of control values for IDegLira versus continued up-titration of insulin glargine U100 in the USA. This suggests IDegLira is a cost-effective treatment option in the USA.

Funding

Novo Nordisk A/S and Novo Nordisk Inc.

A Novel Intervention Including Individualized Nutritional Recommendations Reduces Hemoglobin A1c Level, Medication Use, and Weight in Type 2 Diabetes

Background

Type 2 diabetes (T2D) is typically managed with a reduced fat diet plus glucose-lowering medications, the latter often promoting weight gain.

Objective

We evaluated whether individuals with T2D could be taught by either on-site group or remote means to sustain adequate carbohydrate restriction to achieve nutritional ketosis as part of a comprehensive intervention, thereby improving glycemic control, decreasing medication use, and allowing clinically relevant weight loss.

Methods

This study was a nonrandomized, parallel arm, outpatient intervention. Adults with T2D (N=262; mean age 54, SD 8, years; mean body mass index 41, SD 8, kg·m⁻²; 66.8% (175/262) women) were enrolled in an outpatient protocol providing intensive nutrition and behavioral counseling, digital coaching and education platform, and physician-guided medication management. A total of 238 participants completed the first 10 weeks. Body weight, capillary blood glucose, and beta-hydroxybutyrate (BOHB) levels were recorded daily using a mobile interface. Hemoglobin A_1c (HbA_1c) and related biomarkers of T2D were evaluated at baseline and 10-week follow-up.

Results

Baseline HbA_1c level was 7.6% (SD 1.5%) and only 52/262 (19.8%) participants had an HbA_1c level of <6.5%. After 10 weeks, HbA_1c level was reduced by 1.0% (SD 1.1%; 95% CI 0.9% to 1.1%, P<.001), and the percentage of individuals with an HbA_1c level of <6.5% increased to 56.1% (147/262). The majority of participants (234/262, 89.3%) were taking at least one diabetes medication at baseline. By 10 weeks, 133/234 (56.8%) individuals had one or more diabetes medications reduced or eliminated. At follow-up, 47.7% of participants (125/262) achieved an HbA_1c level of <6.5% while taking metformin only (n=86) or no diabetes medications (n=39). Mean body mass reduction was 7.2% (SD 3.7%; 95% CI 5.8% to 7.7%, P<.001) from baseline (117, SD 26, kg). Mean BOHB over 10 weeks was 0.6 (SD 0.6) mmol·L⁻¹ indicating consistent carbohydrate restriction. Post hoc comparison of the remote versus on-site means of education revealed no effect of delivery method on change in HbA_1c (F_1,260=1.503, P=.22).

Conclusions

These initial results indicate that an individualized program delivered and supported remotely that incorporates nutritional ketosis can be highly effective in improving glycemic control and weight loss in adults with T2D while significantly decreasing medication use.

Correlation of Glypican-4 Level with Basal Active Glucagon-Like Peptide 1 Level in Patients with Type 2 Diabetes Mellitus

BACKGROUND

Previous studies have reported that glypican-4 (GPC4) regulates insulin signaling by interacting with insulin receptor and through adipocyte differentiation. However, GPC4 has not been studied with regard to its effects on clinical factors in patients with type 2 diabetes mellitus (T2DM). We aimed to identify factors associated with GPC4 level in T2DM.

METHODS

Between January 2010 and December 2013, we selected 152 subjects with T2DM and collected serum and plasma into tubes pretreated with aprotinin and dipeptidyl peptidase-4 inhibitor to preserve active gastric inhibitory polypeptide (GIP) and glucagon-like peptide 1 (GLP-1). GPC4, active GLP-1, active GIP, and other factors were measured in these plasma samples. We performed a linear regression analysis to identify factors associated with GPC4 level.

RESULTS

The subjects had a mean age of 58.1 years, were mildly obese (mean body mass index [BMI], 26.1 kg/m²), had T2DM of long-duration (mean, 101.3 months), glycated hemoglobin 7.5%, low insulin secretion, and low insulin resistance (mean homeostatic model assessment of insulin resistance [HOMA-IR], 1.2). Their mean GPC4 was 2.0±0.2 ng/mL. In multivariate analysis, GPC4 was independently associated with age (β=0.224, P=0.009), and levels of active GLP-1 (β=0.171, P=0.049) and aspartate aminotransferase (AST; β=-0.176, P=0.043) after being adjusted for other clinical factors.

CONCLUSION

GPC4 was independently associated with age, active GLP-1, and AST in T2DM patients, but was not associated with HOMA-IR and BMI, which are well known factors related to GPC4. Further study is needed to identify the mechanisms of the association between GPC4 and basal active GLP-1 levels.

Oral Antidiabetic Agents: A Comparative Review

Type 2 diabetes mellitus is a chronic disease characterized by insulin resistance, impaired insulin secretion, and/or increased hepatic glucose production. The mainstays of drug treatment are the oral antidiabetic agents. Insulin is usually reserved for patients who do not achieve fasting plasma glucose or A1C goals with or cannot tolerate the oral antidiabetic agents. There are 5 classes of oral antidiabetic agents available in the United States: sulfonylureas, biguanides, alpha-glucosidase inhibitors, thiazolidinediones, and nonsulfonylurea secretagogues. They have differences and similarities with respect to their pharmacology and role in diabetes. This article reviews the pharmacology, efficacy, safety, and selection of the oral agents used to treat type 2 diabetes mellitus.

Interventions for Human Frailty: Physical Activity as a Model

In the last 100 years, populations in developed countries have experienced an unprecedented addition of 30 years to life expectancy. Developing countries are now experiencing this same phenomenon, but over a shorter time frame. With this success comes the challenge of maximizing health and vitality across these added years. The compression of morbidity to the latest point in the human life span could unleash a sustained third demographic dividend that benefits all of society. To accomplish this, society needs to invest in the prevention and treatment of frailty, as well as in the prevention of chronic diseases at every age and stage of life. A model intervention, physical activity, may offer a road map.

Bariatric Surgery: A Potential Treatment for Type 2 Diabetes in Youth

Type 2 diabetes, once referred to as "adult-onset" diabetes, has now emerged as a formidable threat to the health of obese adolescents. Although there is growing evidence regarding the epidemiology of type 2 diabetes in youth and its multisystem health consequences, treatment options have lagged and progression of disease occurs even with aggressive medical therapy. Increasing interest in the application of bariatric surgery for adolescents with type 2 diabetes has evolved in part because of the evidence demonstrating improvement or remission in many adults with diabetes after surgery. Here, we review the burden of type 2 diabetes in youth including its associated complications, discuss the outcomes and complications of bariatric surgery in adolescents with diabetes, and conclude with recommendations for future research and options for refinement of the use of bariatric surgery in this patient population.

Exercise-like effects by Estrogen-related receptor-gamma in muscle do not prevent insulin resistance in db/db mice

Dissecting exercise-mimicking pathways that can replicate the benefits of exercise in obesity and diabetes may lead to promising treatments for metabolic disorders. Muscle estrogen-related receptor gamma (ERRγ) is induced by exercise, and when over-expressed in the skeletal muscle mimics exercise by stimulating glycolytic-to-oxidative myofiber switch, mitochondrial biogenesis and angiogenesis in lean mice. The objective of this study was to test whether muscle ERRγ in obese mice mitigates weight gain and insulin resistance. To do so, ERRγ was selectively over-expressed in the skeletal muscle of obese and diabetic db/db mice. Muscle ERRγ over-expression successfully triggered glycolytic-to-oxidative myofiber switch, increased functional mitochondrial content and boosted vascular supply in the db/db mice. Despite aerobic remodeling, ERRγ surprisingly failed to improve whole-body energy expenditure, block muscle accumulation of triglycerides, toxic diacylglycerols (DAG) and ceramides or suppress muscle PKCε sarcolemmal translocation in db/db mice. Consequently, muscle ERRγ did not mitigate impaired muscle insulin signaling or insulin resistance in these mice. In conclusion, obesity and diabetes in db/db mice are not amenable to selective ERRγ-directed programming of classic exercise-like effects in the skeletal muscle. Other biochemical pathways or integrated whole-body effects of exercise may be critical for resisting diabetes and obesity.

Study of Insulin Requirement Modeling in Hospitalized Elderly Patients with Type 2 Diabetes at a Late Stage of Stepwise Escalation Therapy

BACKGROUND

This study explored the relationships between exogenous insulin requirements and endogenous variables in elderly patients with type 2 diabetes (T2D).

SUBJECTS AND METHODS

Patients with T2D 65 years of age or older were enrolled for a short hospitalization period in order to start or change their basal-bolus therapy. The following data were collected: age, sex, diabetes duration, body mass index, glycosylated hemoglobin, estimated glomerular filtration rate (eGFR), and triglyceride (TG) levels.

RESULTS

Data from 71 elderly T2D patients (31 men/40 women; 75.7 ± 6 years of age) were analyzed by data mining techniques. The total daily dose of insulin (TDI) ranged from 0.24 U/kg to 2.5 U/kg (ratio >1:10). Three clusters of patients were identified: Cluster 1 (n = 22) consisted of older patients (age, 82.05 ± 3.6 years) (P < 0.0001) with a TDI of 0.59 ± 0.21 U/kg/day and lower TG level (1.1 ± 0.4 mmol/L) (P < 0.0001). Cluster 2 (n = 22) consisted of patients with a TDI of 0.71 ± 0.24 U/kg/day with a higher eGFR (75.3 ± 18.8 mL/min) (P < 0.001) and a shorter duration of diabetes (13.6 ± 6.4 years) (P < 0.001). Cluster 3 (n = 27) consisted of patients with a larger proportion of macroangiopathic complications (P < 0.05), having a TDI of 1.31 ± 0.54 U/kg/day, higher TG level (2.2 ± 0.7 mmol/L) (P < 0.001), and lower eGFR (46.3 ± 16 mL/min). The average basal-bolus ratio was 43%/57% with a maximum bolus requirement due to carbohydrate intake at breakfast.

CONCLUSIONS

Insulin requirements in elderly T2D patients vary widely. Age, TG level, and eGFR appeared to be the most predictive factors of TDI. Because of the small sample size, further studies would be required to extrapolate these results.

Metformin in Amnestic Mild Cognitive Impairment: Results of a Pilot Randomized Placebo Controlled Clinical Trial

Diabetes and hyperinsulinemia may be risk factors for Alzheimer's disease (AD). We conducted a pilot study of metformin, a medication efficacious in treating and preventing diabetes while reducing hyperinsulinemia, among persons with amnestic mild cognitive impairment (aMCI) with the goal of collecting preliminary data on feasibility, safety, and efficacy. Participants were 80 men and women aged 55 to 90 years with aMCI, overweight or obese, without treated diabetes. We randomized participants to metformin 1000 mg twice a day or matching placebo for 12 months. The co-primary clinical outcomes were changes from baseline to 12 months in total recall of the Selective Reminding Test (SRT) and the score of the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog). The secondary outcome was change in relative glucose uptake in the posterior cingulate-precuneus in brain fluorodeoxyglucose positron emission tomography. Change in plasma Aβ42 was an exploratory outcome. The mean age of participants was 65 years. Fifty percent of participants were women. The only baseline variable that was different between the arms was the ADAS-Cog. Metformin could not be tolerated by 7.5% of participants; 15% tolerated 500 mg/day, 35% tolerated 1000 mg/day, 32.5% tolerated 1500 mg/day, and only 10% tolerated the maximum dose. There were no serious adverse events related to metformin. The 7.5% of persons who did not tolerate metformin reported gastrointestinal symptoms. After adjusting for baseline ADAS-cog, changes in total recall of the SRT favored the metformin group (9.7±8.5 versus 5.3±8.5; p = 0.02). Differences for other outcomes were not significant. A larger trial seems warranted to evaluate the efficacy and cognitive safety of metformin in prodromal AD.

Fish oil prevents excessive accumulation of subcutaneous fat caused by an adverse effect of pioglitazone treatment and positively changes adipocytes in KK mice

Pioglitazone, a thiazolidinedione (TZD), is widely used as an insulin sensitizer in the treatment of type 2 diabetes. However, body weight gain is frequently observed in TZD-treated patients. Fish oil improves lipid metabolism dysfunction and obesity. In this study, we demonstrated suppression of body weight gain in response to pioglitazone administration by combination therapy of pioglitazone and fish oil in type 2 diabetic KK mice. Male KK mice were fed experimental diets for 8 weeks. In safflower oil (SO), safflower oil/low-dose pioglitazone (S/PL), and safflower oil/high-dose pioglitazone (S/PH) diets, 20% of calories were provided by safflower oil containing 0%, 0.006%, or 0.012% (wt/wt) pioglitazone, respectively. In fish oil (FO), fish oil/low-dose pioglitazone (F/PL), and fish oil/high-dose pioglitazone (F/PH) diets, 20% of calories were provided by a mixture of fish oil and safflower oil. Increased body weight and subcutaneous fat mass were observed in the S/PL and S/PH groups; however, diets containing fish oil were found to ameliorate these changes. Hepatic mRNA levels of lipogenic enzymes were significantly decreased in fish oil-fed groups. These findings demonstrate that the combination of pioglitazone and fish oil decreases subcutaneous fat accumulation, ameliorating pioglitazone-induced body weight gain, through fish oil-mediated inhibition of hepatic de novo lipogenesis.

Unmasking in an observational vaccine safety study: Using type 2 diabetes mellitus as an example

BACKGROUND

In observational vaccine safety studies, diagnosis codes assigned prior to or on the day of vaccination (Day 0) are often excluded from analysis of safety signals since they usually represent pre-existing conditions. The limitations of this approach have been described for autoimmune conditions but not for other chronic conditions. We draw on our experience in a post-licensure quadrivalent human papillomavirus vaccine (HPV4) safety study to examine the effectiveness of exclusion of pre-existing and Day 0 diagnoses of type 2 diabetes mellitus (T2DM) in excluding prevalent T2DM.

METHODS

Subjects included all 117,402 females ages 9-26 years who received HPV4 August 2006-March 2008 in Kaiser Permanente Southern California. We identified potential incident T2DM cases using ICD9 code 250.xx associated with inpatient and emergency room visits during the 60 days following each HPV4 dose, excluding those with this code prior to their first HPV4 dose. Electronic medical records were reviewed to determine the dates of symptom onset, diagnostic labs, vaccine administration and T2DM diagnosis.

RESULTS

Of 33 potential incident T2DM cases identified using automated data, 4 (12%) were confirmed to have new onset T2DM after medical record review. Nineteen cases were excluded that did not have T2DM or had T2DM diagnosed before Day 0; nine had an abnormal fasting blood sugar (FBS) ordered on Day 0, prompting subsequent evaluation and diagnosis of T2DM; and one had elevated FBS and glucosuria prior to the first dose of HPV4 but T2DM diagnosed at a visit following vaccination.

CONCLUSION

These results suggest that among adolescents and young adults, the workup and subsequent diagnosis of pre-existing conditions may result from a visit at which a vaccination is administered. This "unmasking" phenomenon is not entirely eliminated by exclusion of pre-existing and Day 0 diagnoses. Medical record review should be considered in the evaluation of potential safety signals.

The insulin response integrates increased TGF-β signaling through Akt-induced enhancement of cell surface delivery of TGF-β receptors

Increased activity of transforming growth factor-β (TGF-β), which binds to and stimulates cell surface receptors, contributes to cancer progression and fibrosis by driving epithelial cells toward a migratory mesenchymal phenotype and increasing the abundance of extracellular matrix proteins. The abundance of TGF-β receptors at the cell surface determines cellular responsiveness to TGF-β, which is often produced by the same cells that have the receptors, and thus serves as an autocrine signal. We found that Akt-mediated phosphorylation of AS160, a RabGAP [guanosine triphosphatase (GTPase)-activating protein], promoted the translocation of TGF-β receptors from intracellular stores to the plasma membrane of mouse embryonic fibroblasts and NMuMG epithelial cells. Consequently, insulin, which is commonly used to treat hyperglycemia and activates Akt signaling, increased the amount of TGF-β receptors at the cell surface, thereby enhancing TGF-β responsiveness. This insulin-induced increase in autocrine TGF-β signaling contributed to insulin-induced gene expression responses, attenuated the epithelial phenotype, and promoted the migration of NMuMG cells. Furthermore, the enhanced delivery of TGF-β receptors at the cell surface enabled insulin to increase TGF-β-induced gene responses. The enhancement of TGF-β responsiveness in response to Akt activation may help to explain the biological effects of insulin, the progression of cancers in which Akt is activated, and the increased incidence of fibroses in diabetes.

Peptide modulators of alpha-glucosidase

AIMS/INTRODUCTION

Acute glucose fluctuations during the postprandial period pose great risk for cardiovascular complications and thus represent an important therapeutic approach in type 2 diabetes. In the present study, screening of peptide libraries was used to select peptides with an affinity towards mammalian intestinal alpha-glucosidase as potential leads in antidiabetic agent development.

MATERIALS AND METHODS

Three phage-displayed peptide libraries were used in independent selections with different elution strategies to isolate target-binding peptides. Selected peptides displayed on phage were tested to compete for an enzyme-binding site with known competitive inhibitors, acarbose and voglibose. The four best performing peptides were synthesized. Their binding to the mammalian alpha-glucosidase and their effect on enzyme activity were evaluated.

RESULTS

Two linear and two cyclic heptapeptides with high affinity towards intestinal alpha-glucosidase were selected. Phage-displayed as well as synthetic peptides bind into or to the vicinity of the active site on the enzyme. Both cyclic peptides inhibited enzyme activity, whereas both linear peptides increased enzyme activity.

CONCLUSIONS

Although natural substrates of glycosidase are polysaccharides, in the present study we successfully isolated novel peptide modulators of alpha-glucosidase. Modulatory activity of selected peptides could be further optimized through peptidomimetic design. They represent promising leads for development of efficient alpha-glucosidase inhibitors.

Barriers to initiating insulin in type 2 diabetes patients: development of a new patient education tool to address myths, misconceptions and clinical realities

Purpose

The purpose of this study was to identify patient beliefs as well as clinical realities about insulin that may be barriers to type 2 diabetes patients initiating insulin treatment when recommended by their physician. This information was then used to develop a clinically relevant, cross-culturally valid patient education tool with the goal of providing unbiased, medically informative statements addressing these barriers.

Methods

Thirteen focus groups were conducted in five countries (Germany, Sweden, The Netherlands, UK, and USA) to collect qualitative data on attitudes about insulin therapy from type 2 diabetes patients aged 18 or older whose physician had recommended initiating insulin treatment in the past 6 months (n = 87). Additionally, a panel of four clinical experts was interviewed to ascertain obstacles they experience in initiating insulin with their patients.

Results

On the basis of the interview data, the ten questions that asked about the most important barriers were generated. The clinical expert panel then generated clinically accurate and unbiased responses addressing these concerns, and the educational tool “Questions about Starting Insulin: Information on the Myths, Misconceptions and Clinical Realities about Insulin” was drafted. The draft tool was pilot tested in a group of patients and finalized.

Conclusions

Patient misconceptions, as well as some clinical realities, about insulin treatment and diabetes can influence the decision to initiate insulin treatment and ultimately impact disease management. The educational tool developed through this study was designed to help patients who are deciding whether or not to initiate insulin therapy as recommended by their physician, and facilitate patient–health-care provider interactions.

Delivery aspects of antioxidants in diabetes management

INTRODUCTION

Ample research has been done to study the role of oxidative stress due to the generation of excess reactive species in initiation and progression of diabetic complications. A positive result has been indicated hypothesizing that abating this oxidative stress can prove to be an alternate strategy in therapy apart from oral antidiabetic drugs. But these dietary antioxidants are less efficient because of poor solubility, permeability, instability on storage, gastrointestinal degradation and first-pass metabolism.

AREAS COVERED

This review gives a brief insight into the molecular mechanism of oxidative stress in development of diabetic complications. Major hurdles limiting the translation of antioxidants to clinical area are also discussed. Various delivery approaches including both conventional and novel drug delivery systems explored so far for combating these challenges in antioxidant delivery are also explored. Mitochondrial targeting of such molecules is also briefly discussed.

EXPERT OPINION

A thorough study of clinical efficacy and safety of antioxidants on long-term use judging its clinical applicability is required. The clinical success of antioxidants as a therapeutic strategy involves a combination of effective design of drug delivery carrier that are in turn related to their degradation profile, possibility of cellular uptake at defined site of action and so on and clinical and preclinical trials that will provide a base for the design of dose and administration regimen.

Sulfonylurea in combination with insulin is associated with increased mortality compared with a combination of insulin and metformin in a retrospective Danish nationwide study

AIMS/HYPOTHESIS

Individual sulfonylureas (SUs) and metformin have, in some studies, been associated with unequal hypoglycaemic, cardiovascular and mortality risks when used as monotherapy in type 2 diabetes. We investigated the outcomes in patients treated with different combinations of SUs and insulin vs a combination of metformin and insulin in a retrospective nationwide study.

METHODS

All Danish individuals using dual therapy with SU + insulin or metformin + insulin without prior myocardial infarction (MI) or stroke were followed from 1 January 1997 to 31 December 2009 in nationwide registries. Risks of all-cause mortality, cardiovascular death, hypoglycaemia and a composite endpoint of MI, stroke and cardiovascular death were compared. Rate ratios (RR) [95% CIs] were calculated using time-dependent multivariable Poisson regression analysis.

RESULTS

A total of 11,081 patients used SU + insulin and 16,910 used metformin + insulin. Patients receiving metformin + insulin were younger and had less comorbidity and a longer history of glucose-lowering treatment. SU + insulin was associated with higher mortality rates compared with metformin + insulin (76-126 vs 23 per 1,000 person-years). In adjusted analyses, SU + insulin was associated with increased all-cause mortality (RR 1.81 [1.63, 2.01]), cardiovascular death (RR 1.35 [1.14, 1.60]) and the composite endpoint (RR 1.25 [1.09, 1.42]) compared with metformin + insulin. Hypoglycaemia was more frequent with SU + insulin than with metformin + insulin (17-23 vs six events per 1,000 person-years) and was associated with increased mortality (RR 2.13 [1.97, 2.37]). There were no significant differences in risk between individual SUs in combination with insulin.

CONCLUSIONS/INTERPRETATION

In combination with insulin, the use of SUs was associated with increased mortality compared with metformin. There were no significant risk differences between SUs.

Carotid body, insulin, and metabolic diseases: unraveling the links

The carotid bodies (CB) are peripheral chemoreceptors that sense changes in arterial blood O2, CO2, and pH levels. Hypoxia, hypercapnia, and acidosis activate the CB, which respond by increasing the action potential frequency in their sensory nerve, the carotid sinus nerve (CSN). CSN activity is integrated in the brain stem to induce a panoply of cardiorespiratory reflexes aimed, primarily, to normalize the altered blood gases, via hyperventilation, and to regulate blood pressure and cardiac performance, via sympathetic nervous system (SNS) activation. Besides its role in the cardiorespiratory control the CB has been proposed as a metabolic sensor implicated in the control of energy homeostasis and, more recently, in the regulation of whole body insulin sensitivity. Hypercaloric diets cause CB overactivation in rats, which seems to be at the origin of the development of insulin resistance and hypertension, core features of metabolic syndrome and type 2 diabetes. Consistent with this notion, CB sensory denervation prevents metabolic and hemodynamic alterations in hypercaloric feed animal. Obstructive sleep apnea (OSA) is another chronic disorder characterized by increased CB activity and intimately related with several metabolic and cardiovascular abnormalities. In this manuscript we review in a concise manner the putative pathways linking CB chemoreceptors deregulation with the pathogenesis of insulin resistance and arterial hypertension. Also, the link between chronic intermittent hypoxia (CIH) and insulin resistance is discussed. Then, a final section is devoted to debate strategies to reduce CB activity and its use for prevention and therapeutics of metabolic diseases with an emphasis on new exciting research in the modulation of bioelectronic signals, likely to be central in the future.