Cardiovascular benefits and safety of non-insulin medications used in the treatment of type 2 diabetes mellitus

Cardiovascular and kidney outcomes of combination therapy with sodium-glucose cotransporter-2 inhibitors and mineralocorticoid receptor antagonists in patients with type 2 diabetes and chronic kidney disease: A systematic review and network meta-analysis

AIMS

Both sodium-glucose cotransporter-2 (SGLT-2) inhibitors and mineralocorticoid receptor antagonists (MRAs) have been shown to reduce cardiovascular (CV) event in patients with type 2 diabetes (T2D) and chronic kidney disease (CKD). However, little evidence pertains to the benefits of their combined use.

METHODS

We systematically searched the PubMed, MEDLINE, EMBASE, and Cochrane Library databases through July 2022. We selected randomized controlled trials comparing SGLT-2 inhibitors, MRAs, or SGLT-2 inhibitor + MRA combination therapy, with placebo in patients with T2D and CKD. We performed a network meta-analysis to indirectly compare the treatments. The primary outcome was a composite of CV events.

RESULTS

Eight studies were selected with 36,186 patients. The primary outcome was significantly improved in the combination therapy group compared with the other groups (RR [95% CI]; vs SGLT-2 inhibitors, 0.76 [0.60; 0.96]; vs MRAs, 0.66 [0.53; 0.82]; vs placebo, 0.58 [0.47; 0.73]). Additionally, the combination therapy was associated with a considerable reduction in the risk of hyperkalemia (RR vs MRA, 0.43 [0.23; 0.79]).

CONCLUSION

Combination of SGLT-2 inhibitors and MRAs potentially reduced CV events compared with SGLT-2 inhibitors or MRAs alone. This combination may be a candidate treatment strategy for patients with T2D and CKD.

Network meta-analysis on the effects of finerenone versus SGLT2 inhibitors and GLP-1 receptor agonists on cardiovascular and renal outcomes in patients with type 2 diabetes mellitus and chronic kidney disease

OBJECTIVE

To evaluate the cardiovascular and renal benefits of finerenone, sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagonlike peptide-1 receptor agonists (GLP-1 RA) in patients with Type 2 Diabetes Mellitus (T2DM) and chronic kidney disease (CKD) with network meta-analysis.

METHODS

Systematic literature searches were conducted of PubMed, Cochrane Library, Web of Science, Medline and Embase covering January 1, 2000 to December 30, 2021. Randomized control trials (RCTs) comparing finerenone, SGLT-2i and GLP-1 RA in diabetics with CKD were selected. We performed a network meta-analysis to compare the two drugs and finerenone indirectly. Results were reported as risk ratio (RR) with corresponding 95% confidence interval (CI).

RESULTS

18 RCTs involving 51,496 patients were included. Finerenone reduced the risk of major adverse cardiovascular events (MACE), renal outcome and hospitalization for heart failure (HHF) (RR [95% CI]; 0.88 [0.80-0.97], 0.86 [0.79-0.93], 0.79 [0.67,0.92], respectively). SGLT-2i were associated with reduced risks of MACE (RR [95% CI]; 0.84 [0.78-0.90]), renal outcome (RR [95% CI]; 0.67 [0.60-0.74], HHF (RR [95% CI]; 0.60 [0.53-0.68]), all-cause death (ACD) (RR [95% CI]; 0.89 [0.81-0.91]) and cardiovascular death (CVD) (RR [95% CI]; 0.86 [0.77-0.96]) compared to placebo. GLP-1 RA were associated with a lower risk of MACE (RR [95% CI]; 0.86 [0.78-0.94]). SGLT2i had significant effect in comparison to finerenone (finerenone vs SGLT2i: RR [95% CI]; 1.29 [1.13-1.47], 1.31 [1.07-1.61], respectively) and GLP-1 RA (GLP-1 RA vs SGLT2i: RR [95% CI]; 1.36 [1.16-1.59], 1.49 [1.18-1.89], respectively) in renal outcome and HHF.

CONCLUSIONS

In patients with T2DM and CKD, SGLT2i, GLP-1 RA and finerenone were comparable in MACE, ACD and CVD. SGLT2i significantly decreased the risk of renal events and HHF compared with finerenone and GLP-1 RA. Among GLP-1 RA, GLP-1 analogues showed significant effect in reducing cardiovascular events compared with exendin-4 analogues.

Obesity as a modifier of the cardiovascular effectiveness of sodium-glucose cotransporter-2 inhibitors in type 2 diabetes

AIMS

To assess the association between the use of sodium-glucose cotransporter-2 (SGLT2i) and cardiovascular outcomes and death as a function of obesity among patients with type 2 diabetes.

METHODS

This new-user, active-comparator cohort study used U.K.'s Clinical Practice Research Datalink linked to Hospital Episodes Statistics repository and Office for National Statistics. The cohort included 34,128 new-users of SGLT2i matched 1:1 to 34,128 new-users of dipeptidyl peptidase-4 inhibitors (DPP-4i) on body mass index and propensity score. Cox proportional hazards models were used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) of major adverse cardiovascular events (MACE), overall and in body mass index (BMI) categories (≤24.9 kg/m², 25.0-29.9 kg/m², 30.0-39.9 kg/m², ≥40 kg/m²). Secondary outcomes included all-cause mortality and hospitalization for heart failure.

RESULTS

SGLT2i were associated with a decreased risk of MACE (HR: 0.78, 95 %CI: 0.69-0.88) compared to DPP-4i. This decreased risk was most pronounced among obese and severely obese patients (HR: 0.77, 95 %CI: 0.66-0.91; HR: 0.67, 95% CI: 0.49-0.91, respectively) but not among overweight patients (HR: 0.94, 95 %CI: 0.73-1.22). Similar patterns were observed for cardiovascular mortality, all-cause mortality, and heart failure.

CONCLUSION

Compared with DPP-4i, the cardioprotective effect associated with SGLT2i is stronger among patients with higher BMI.

Part Six: Antidiabetic Medication Benefits Beyond Glucose Lowering in Older People

Older people with type 2 diabetes are at an increased risk for macrovascular (damage to arteries that can lead to myocardial infarction or stroke) and microvascular (damage to small blood vessels including retinopathy and nephropathy) disease. Since 2008, newly approved antidiabetic medications have been required to show cardiovascular safety as part of the US Food and Drug Administration approval process. Since this time, new data have emerged regarding the differences between agents in terms of reducing diabetes-related complications. Older people often are at risk for or currently have one or more diabetes-related complication. When managing antidiabetic medication in older people, it is imperative to consider the risk versus benefit of each medication and to use agents that have proven benefits.

Non-cardiovascular medication and readmission for heart failure: an observational cohort study

Background Among heart failure (HF) patients, hospital readmissions are a major concern. The medication taken by a patient may provide information on comorbidities and conditions and may be used as an indicator to identify populations at an increased risk of HF readmission. Aim This study explored the use of non-cardiovascular medication at hospital discharge from the first HF admission in search of indicators of high risk of readmission for HF. Method The study included 22,476 HF patients from the Dutch PHARMO Database Network at their first HF hospitalization. The data was divided into training and validation sets. A Cox regression model with demographics, date of first HF hospital admission and non-cardiovascular medication present at discharge, adjusted for cardiovascular medication, was developed in the training set and subsequently implemented in the validation set. Results The study included 22,476 patients, mean age 76.7 years (range 18-104) and median follow-up time 2.5 years (range 0-15.7 years). During the study period 6,725 (29.9%) patients were readmitted for HF, with a median time-to-readmission of 7 months (range 0-14.3 years). Non-cardiovascular medication associated with a high risk of readmission for HF were identified as indicators of high risk, with no implied causal relationship. Patients prescribed antigout medications presented a 25% increased risk of readmission (HR 1.25, 95%CI 1.09-1.45, P = 0.002). Patients using insulin had an 18% higher risk of readmission versus patients not using insulin (HR 1.18, 95%CI 1.06-1.32, P = 0.002), but not versus patients treated with other blood-glucose-lowering drugs. No association between the risk of readmission and NSAIDs use was observed. Conclusion The results suggest that diabetes is responsible for the higher HF-readmission risk observed in patients prescribed insulin. The observed risk in users of antigout medication should be further investigated. The absence of an association with the use of NSAIDs should be interpreted with caution.

Predictors of in-hospital mortality in diabetic patients with non-ST-elevation myocardial infarction

Background

There have been little data about the additive effects of coronary risk factors on mortality in diabetic patients presenting with non-ST-segment elevation myocardial infarction (NSTEMI). This study aimed to evaluate the predictors of mortality in diabetic patients presenting with NSTEMI. All patients admitted to Tehran Heart Center (THC) with a confirmed diagnosis of NSTEMI and a history of diabetes mellitus (DM) type 2 between September 2003 and April 2017 were included. Clinical characteristics and paraclinical data such as lipid profiles, creatinine, hemoglobin, and hemoglobin A1C (HbA1C) were evaluated in these patients to predict in-hospital mortality. The approach for model calibration was a logistic regression with the backward elimination method.

Results

Of a total of 9158 patients with non-ST-segment elevation myocardial infarction, 3133 had diabetes mellitus type 2 and met our criteria to enter the final analysis. In the multivariable analysis, age, chronic obstructive pulmonary disease, and a severely reduced left ventricular ejection fraction (LVEF) significantly increased the rate of in-hospital mortality, whereas mildly and moderately reduced left ventricular ejection fraction did not increase the rate of mortality.

Conclusions

Age, chronic obstructive pulmonary disease (COPD), and severely reduced LVEF (< 30%) independently increased in-hospital mortality in our diabetic patients with a confirmed diagnosis of NSTEMI. Severely reduced LVEF had the strongest relationship with in-hospital mortality, whereas the mean HbA1C level and the type of DM management exerted no significant effect on in-hospital mortality.

Synthesis and biological evaluation of 1,6-bis-triazole-2,3,4-tri-O-benzyl-α-d-glucopyranosides as a novel α-glucosidase inhibitor in the treatment of Type 2 diabetes

A novel series of 1,6-bis-triazole-benzyl-α-glucoside derivatives (7a-7ee) were designed, synthesized and evaluated for inhibitory activity against α-glucosidase. Most of the synthesized compounds exhibited good activity with IC₅₀ ranging from 3.73 µM to 53.34 µM and are more potent than the standard drug acarbose (IC₅₀ = 146.25 ± 0.40 µM). SARs study showed the ester and menthol moiety play an important role in the inhibitory activity. The molecular docking model of the potent compounds 7f, 7z, 7cc and 7dd showed good binding energy and interacts well with amino acid residues around the active site of the enzyme, which confirmed the in vitro activity results.

Wearable Glucose Monitoring and Implantable Drug Delivery Systems for Diabetes Management

The global cost of diabetes care exceeds $1 trillion each year with more than $327 billion being spent in the United States alone. Despite some of the advances in diabetes care including continuous glucose monitoring systems and insulin pumps, the technology associated with managing diabetes has largely remained unchanged over the past several decades. With the rise of wearable electronics and novel functional materials, the field is well-poised for the next generation of closed-loop diabetes care. Wearable glucose sensors implanted within diverse platforms including skin or on-tooth tattoos, skin-mounted patches, eyeglasses, contact lenses, fabrics, mouthguards, and pacifiers have enabled noninvasive, unobtrusive, and real-time analysis of glucose excursions in ambulatory care settings. These wearable glucose sensors can be integrated with implantable drug delivery systems, including an insulin pump, glucose responsive insulin release implant, and islets transplantation, to form self-regulating closed-loop systems. This review article encompasses the emerging trends and latest innovations of wearable glucose monitoring and implantable insulin delivery technologies for diabetes management with a focus on their advanced materials and construction. Perspectives on the current unmet challenges of these strategies are also discussed to motivate future technological development toward improved patient care in diabetes management.

Trends in First-Line Glucose-Lowering Drug Use in Adults With Type 2 Diabetes in Light of Emerging Evidence for SGLT-2i and GLP-1RA

OBJECTIVE

We evaluated recent use trends and predictors of first-line antidiabetes treatment in patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Using two large U.S. health insurance databases (Clinformatics and Medicare), we identified adult patients with type 2 diabetes who initiated antidiabetes treatment from 2013 through 2019. Quarterly trends in use of first-line antidiabetes treatment were plotted overall and stratified by cardiovascular disease (CVD). Multinomial logistic regressions were fit to estimate predictors of first-line antidiabetes treatment, using metformin, the recommended first-line treatment for type 2 diabetes, as the common referent.

RESULTS

Metformin was the most frequently initiated medication, used by 80.6% of Medicare beneficiaries and 83.1% of commercially insured patients. Sulfonylureas were used by 8.7% (Medicare) and 4.7% (commercial). Both populations had low use of sodium-glucose cotransporter 2 inhibitors (SGLT-2i, 0.8% [Medicare] and 1.7% [commercial]) and glucagon-like peptide 1 receptor agonists (GLP-1Ra; 1.0% [Medicare] and 3.5% [commercial]), with increasing trends over time (P < 0.01). Initiators of antidiabetes drugs with established cardiovascular benefits (SGLT-2i and GLP-1RA) were more likely to be younger and had prevalent CVD or higher socioeconomic status compared with initiators of metformin.

CONCLUSIONS

Among adult patients with type 2 diabetes, metformin was by far the most frequent first-line treatment. While the use of SGLT-2i and GLP-1RA was low from 2013 through 2019, it increased among patients with CVD.

Cardiovascular Safety and Benefits of Noninsulin Antihyperglycemic Drugs for the Treatment of Type 2 Diabetes Mellitus: Part 2

Ideal drugs to improve outcomes in type 2 diabetes mellitus (T2DM) are those with antiglycemic efficacy, as well as cardiovascular safety that has to be determined in appropriately designed cardiovascular outcome trials as mandated by regulatory agencies. The more recent antihyperglycemic medications have shown promise with regards to cardiovascular disease (CVD) risk reduction in T2DM patients at a high cardiovascular risk. Sodium glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists are associated with better cardiovascular outcomes and mortality in T2DM patients than are dipeptidylpeptidase-4 inhibitors, leading to the Food and Drug Administration's approval of empagliflozin to reduce mortality, and of liraglutide to reduce CVD risk in high-risk T2DM patients. For heart failure outcomes, sodium glucose cotransporter-2 inhibitors are beneficial, while glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors are neutral. Ongoing and planned randomized controlled trials of these newer drugs should clarify the possibility of class effects and of CVD risk reduction benefits in low-moderate cardiovascular risk patients. While we eagerly await the results on ongoing studies, these medications should be appropriately prescribed in T2DM patients with baseline CVD or those at a high CVD risk after carefully evaluating the elevated risk for adverse events like gastrointestinal disturbances, bladder cancer, genital infections, and amputations. Studies to understand the pleotropic and novel pathophysiological mechanisms demonstrated by the sodium glucose cotransporter-2 inhibitors will shed light on the effects of the modulation of microvascular, inflammatory, and thrombotic milieu for improving the CVD risk in T2DM patients. This is part 2 of the series on noninsulin antihyperglycemic drugs for the treatment of T2DM.

Significant effects of Ganoderma lucidum polysaccharide on lipid metabolism in diabetes may be associated with the activation of the FAM3C-HSF1-CAM signaling pathway

Diabetes is a threat to patient health worldwide. Type 2 diabetes (T2DM), one of the two main types of diabetes, is a long-term metabolic disease caused by heredity and environmental factors. It has been reported that Ganoderma lucidum polysaccharide (GLP) significantly decreased the concentration of blood glucose, promoted insulin secretion, improved glucose tolerance and regulated the concentration of blood lipids. In the present study, a T2DM model was established in db/db mice, following which T2DM mice were treated with GLP (100 and 400 mg/kg) for 8 weeks, with MET used as the positive control. The glycosylated hemoglobin (HbAlc) and fasting blood glucose (FBG) levels, and diabetes-associated clinical chemistry indexes were detected in the blood and serum of each mouse. Hematoxylin and eosin, and oil red O staining were performed on the livers of each mouse to evaluate the level of liver fat. The expression levels of family with sequence similarity 3 (FAM3C), heat shock factor 1 (HSF1), calmodulin (CaM), AKT and phosphorylated (p)-AKT were detected in the hepatocytes of T2DM mice using reverse transcription-quantitative PCR and western blotting. The results demonstrated that the unbalanced levels of HbAlc, FBG and diabetes-related index in T2DM mice were significantly improved by treatment with GLP. Lipid droplets in the hepatocytes of mice shrank in the GLP groups compared with the model control group. The expression levels of FAM3C, HSF1, CaM and p-AKT/AKT in the hepatocytes of T2DM mice were significantly increased following treatment with GLP. In conclusion, GLP exerted significant effects on lipid metabolism in diabetes, which may be associated with the activation of the FAM3C-HSF1-CaM signaling pathway.

Sirt1 and Sirt3 Activation Improved Cardiac Function of Diabetic Rats via Modulation of Mitochondrial Function

In the present study, we aimed to evaluate the effect of Sirt1, Sirt3 and combined activation in high fructose diet-induced insulin resistance rat heart and assessed the cardiac function focusing on mitochondrial health and function. We administered the Sirt1 activator; SRT1720 (5 mg/kg, i.p.), Sirt3 activator; Oroxylin-A (10 mg/kg i.p.) and the combination; SRT1720 + Oroxylin-A (5 mg/kg and 10 mg/kg i.p.) daily from 12th week to 20th weeks of study. We observed significant perturbations of most of the cardiac structural and functional parameters in high fructose diet-fed animals. Administration of SRT1720 and Oroxylin-A improved perturbed cardiac structural and functional parameters by decreasing insulin resistance, oxidative stress, and improving mitochondrial function by enhancing mitochondrial biogenesis, OXPHOS expression and activity in high fructose diet-induced insulin-resistant rats. However, we could not observe the synergistic effect of SRT1720 and Oroxylin-A combination. Similar to in-vivo study, perturbed mitochondrial function and oxidative stress observed in insulin-resistant H9c2 cells were improved after activation of Sirt1 and Sirt3. We observed that Sirt1 activation enhances Sirt3 expression and mitochondrial biogenesis, and the opposite effects were observed after Sirt1 inhibition in cardiomyoblast cells. Taken together our results conclude that activation of Sirt1 alone could be a potential therapeutic target for diabetes-associated cardiovascular complications.

Cardiovascular and renal outcomes with SGLT-2 inhibitors versus GLP-1 receptor agonists in patients with type 2 diabetes mellitus and chronic kidney disease: a systematic review and network meta-analysis

BACKGROUND

Emerging evidence suggests that sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are associated with decreased risk of cardiovascular and renal events in type 2 diabetes mellitus (DM) patients. However, no study to date has compared the effect of SGLT-2 inhibitors with that of GLP-1 RAs in type 2 DM patients with chronic kidney disease (CKD). We herein investigated the benefits of SGLT-2 inhibitors and GLP-1 RAs in CKD patients.

METHODS

We performed a systematic literature search through November 2020. We selected randomized control trials that compared the risk of major adverse cardiovascular events (MACE) and a composite of renal outcomes. We performed a network meta-analysis to compare SGLT-2 inhibitors with GLP-1 RAs indirectly. Risk ratios (RRs) with corresponding 95% confidence intervals (CI) were synthesized.

RESULTS

Thirteen studies were selected with a total of 32,949 patients. SGLT-2 inhibitors led to a risk reduction in MACE and renal events (RR [95% CI]; 0.85 [0.75-0.96] and 0.68 [0.59-0.78], respectively). However, GLP-1 RAs did not reduce the risk of cardiovascular or renal adverse events (RR 0.91 [0.80-1.04] and 0.86 [0.72-1.03], respectively). Compared to GLP-1 RAs, SGLT-2 inhibitors did not demonstrate a significant difference in MACE (RR 0.94 [0.78-1.12]), while SGLT-2 inhibitors were associated with a lower risk of renal events compared to GLP-1 RAs (RR 0.79 [0.63-0.99]). A sensitivity analysis revealed that GLP-1 analogues significantly decreased MACE when compared to placebo treatment (RR 0.81 [0.69-0.95]), while exendin-4 analogues did not (RR 1.03 [0.88-1.20]).

CONCLUSIONS

In patients with type 2 DM and CKD, SGLT-2 inhibitors were associated with a decreased risk of cardiovascular and renal events, but GLP-1 RAs were not. SGLT-2 inhibitors significantly decreased the risk of renal events compared to GLP-1 RAs. Among GLP-1 RAs, GLP-1 analogues showed a positive impact on cardiovascular and renal outcomes, while exendin-4 analogues did not.

Can Metformin Exert as an Active Drug on Endothelial Dysfunction in Diabetic Subjects?

Cardiovascular mortality is a major cause of death among in type 2 diabetes (T2DM). Endothelial dysfunction (ED) is a well-known important risk factor for the development of diabetes cardiovascular complications. Therefore, the prevention of diabetic macroangiopathies by preserving endothelial function represents a major therapeutic concern for all National Health Systems. Several complex mechanisms support ED in diabetic patients, frequently cross-talking each other: uncoupling of eNOS with impaired endothelium-dependent vascular response, increased ROS production, mitochondrial dysfunction, activation of polyol pathway, generation of advanced glycation end-products (AGEs), activation of protein kinase C (PKC), endothelial inflammation, endothelial apoptosis and senescence, and dysregulation of microRNAs (miRNAs). Metformin is a milestone in T2DM treatment. To date, according to most recent EASD/ADA guidelines, it still represents the first-choice drug in these patients. Intriguingly, several extraglycemic effects of metformin have been recently observed, among which large preclinical and clinical evidence support metformin’s efficacy against ED in T2DM. Metformin seems effective thanks to its favorable action on all the aforementioned pathophysiological ED mechanisms. AMPK pharmacological activation plays a key role, with metformin inhibiting inflammation and improving ED. Therefore, aim of this review is to assess metformin’s beneficial effects on endothelial dysfunction in T2DM, which could preempt development of atherosclerosis.

Statins and Higher Diabetes Mellitus Risk: Incidence, Proposed Mechanisms, and Clinical Implications

3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors are ubiquitously prescribed for cardiovascular disease (CVD) prevention and treatment. However, the use of statins has been linked to the development of new-onset diabetes mellitus (NODM), which could possibly increase future CVD risk. This phenomenon necessitates a clear discussion of the possible etiologies of this relationship and its broader clinical consequences. We discuss the reported incidence of NODM in statin users through a rigorous review of data from metaanalyses of randomized control trials examining this association. We also highlight the various possible mechanisms responsible for the development of statin-induced diabetes mellitus. Finally, we examine the clinical implications of this effect on future CVD risk and identify specific patient factors that can be used for risk-stratification strategies. Data from 14 randomized control trials metaanalyses suggest a 9-33% higher risk of NODM with statin use. Several cellular, molecular, and genetic mechanisms, as well as lifestyle habits, have been identified as potential underlying factors responsible for this elevated risk. The principle mode of the diabetogenic action of statins is still unclear, though it is likely the result of a complex interplay of pancreatic and extrapancreatic effects. It is understood that patient populations with a greater predisposition to diabetes mellitus, and those with thicker epicardial adiposity are more at risk for the development of statin-induced NODM. Despite these observations, robust data from a variety of investigations suggest that the CVD preventative benefits of statin treatment significantly outweigh the risks associated with the development of NODM. Nevertheless, further study must better identify the causative mechanisms involved in this process, its natural history, and the unique factors that will help clinicians risk stratify and appropriately monitor patients on statin therapy.

Diabetes, and its treatment, as an effector of autonomic nervous system circuits and its functions

Diabetes increases the risk of cardiovascular complications, including heart failure, hypertension, and stroke. There is a strong involvement of autonomic dysfunction in individuals with diabetes that exhibit clinical manifestations of cardiovascular diseases (CVD). Still, the mechanisms by which diabetes and its treatments alter autonomic function and subsequently affect cardiovascular complications remain elusive. For this reason, understanding the brainstem circuits involved in sensing metabolic state(s) and enacting autonomic control of the cardiovascular system are important to develop more comprehensive therapies for individuals with diabetes at increased risk for CVD. We review how autonomic nervous system circuits change during these disease states and discuss their potential role in current pharmacotherapies that target diabetic states. Overall, this review proposes that the brainstem circuits provide an integrative sensorimotor network capable of responding to metabolic cues to regulate cardiovascular function and this network is modified by, and in turn affects, diabetes-induced CVD and its treatment.

Underutilization of insulin and better metabolic control. A NOVA clinic experience

OBJECTIVE

To present the results of metabolic control in patients with type 2 Diabetes Mellitus from a private clinic in Northern Mexico.

METHODS

This cross-sectional study used retrospective data obtained from electronic records from a private outpatient clinic at the end of 2018. Inclusion criteria were a diagnosis of T2DM and age ≥ 18 years. Baseline characteristics (age, gender, drug use) were reported. The achievement of glycated hemoglobin goals was established as <7%.

RESULTS

A total of 3820 patients were evaluated. Their mean age was 59.86 years (+/-15.01). Of the population, 46.72% were men, and 53.28% were women. Glycated hemoglobin goals were adequate in 1872 (54%) patients. There were 3247 patients (85%) treated with oral medications, of which 1948 (60%) reported glycated hemoglobin less than 7%. Insulin use was reported in 573 (15%) patients, with 115 (20%) reporting glycated hemoglobin less than 7%. The most frequently used basal insulin was glargine in 401 (70%) patients.

CONCLUSIONS

Our findings are clearly higher than the control rate reported by our national health surveys of 25% with glycated hemoglobin < 7%, but similar to that reported in other countries. The most commonly used therapeutic scheme was the combination of oral hypoglycemic agents. The percentage of cases that include insulin in their treatment was lower. Clinical inertia to insulin initiation and intensification has been defined as an important cause of this problem.

Why the endothelium? The endothelium as a target to reduce diabetes-associated vascular disease

Over the past 66 years, our knowledge of the role of the endothelium in the regulation of cardiovascular function and dysfunction has advanced from the assumption that it is a single layer of cells that serves as a barrier between the blood stream and vascular smooth muscle to an understanding of its role as an essential endocrine-like organ. In terms of historical contributions, we pay particular credit to (1) the Canadian scientist Dr. Rudolf Altschul who, based on pathological changes in the appearance of the endothelium, advanced the argument in 1954 that "one is only as old as one's endothelium" and (2) the American scientist Dr. Robert Furchgott, a 1998 Nobel Prize winner in Physiology or Medicine, who identified the importance of the endothelium in the regulation of blood flow. This review provides a brief history of how our knowledge of endothelial function has advanced and now recognize that the endothelium produces a plethora of signaling molecules possessing paracrine, autocrine, and, arguably, systemic hormone functions. In addition, the endothelium is a therapeutic target for the anti-diabetic drugs metformin, glucagon-like peptide I (GLP-1) receptor agonists, and inhibitors of the sodium-glucose cotransporter 2 (SGLT2) that offset the vascular disease associated with diabetes.

Adjuvant Therapy With Mushroom Polysaccharides for Diabetic Complications

Background

Diabetic complications seriously endanger the health of most diabetic patients around the world. Most chemical hypoglycemic agents have adverse effects and are unable to improve the progression of diabetic complications. In recent years, a number of medicinal herbs have become increasingly popular for the treatment of diabetic complications due to their relative safety. Polysaccharides extracted from medicinal herbs with multiple pharmacological activities and low toxicity have been reported to be useful in the treatment of diabetic complications.

Methods

Primary studies with keywords including polysaccharide and diabetic complications were retrieved from the Web of Science and NCBI databases and were read and analyzed.

Results

Mushroom polysaccharides were proven to have positive effects on diabetic complications.

Conclusions

We studied the effects of mushroom polysaccharides on hyperglycemia and as adjuvant therapies for diabetic complications and summarized the applications and limitations of mushroom polysaccharides to better understand their application for the treatment of diabetic complications.

Rosiglitazone alleviates myocardial apoptosis in rats with acute myocardial infarction via inhibiting TLR4/NF-κB signaling pathway

Influence of rosiglitazone on the myocardial apoptosis in rats with acute myocardial infarction (AMI) via the Toll-like receptor 4 (TLR4)/nuclear factor-κB (NF-κB) signaling pathway was explored. A total of 30 healthy male Sprague-Dawley (SD) rats were randomly divided into group A (Sham group, n=10), group B (AMI model group, n=10) and group C (AMI model + rosiglitazone group, n=10) using a random number table. It was observed through H&E staining that group A had myocardial cells with normal morphology and infiltration of few inflammatory factors, while group B had swollen myocardial cells with disorderly and irregular morphology, large and dark-colored nuclei, infiltration of massive inflammatory factors, large amounts of fibrous tissue hyperplasia in the intercellular space, disorderly arranged, thickened and lengthened myocardial fibers with widened gaps. Moreover, group C exhibited infiltration of fewer inflammatory factors and more normal myocardial tissue structure compared with group B. According to the sirius-red staining results, group A had normally arranged myocardial cells with a small amount of collagen hyperplasia, while group B had collagen interstitial hyperplasia and higher content of myocardial collagen than group A. Compared with that in group B, the myocardial collagen deposit was substantially reduced in group C. TUNEL staining results showed that the apoptosis rate of rat myocardial cells in group B was obviously higher than that in group A (40.37 vs. 5.23%), and it was notably lower in group C than that in group B (24.82 vs. 40.37%). According to the western blot results, the protein expression levels of the inflammatory factors TLR-4 and NF-κB in rat myocardial tissues were notably raised in group B compared with those in group A, and they were evidently lower in group C than those in group B. Rosiglitazone inhibits the TLR4/NF-κB signaling pathway to produce a myocardioprotective effect.

The effects of rosiglitazone on the neonatal rat cardiomyocyte transcriptome: a temporal analysis

Aim: The objective was to determine via high-throughput RNA sequencing the temporal effects of rosiglitazone (Avandia®) on the neonatal rat ventricular myocyte transcriptome. Materials & methods: Neonatal rat ventricular myocytes (NRVMs) were exposed to rosiglitazone in vitro. Meta analyses utilized temporal comparisons of 0.5 h control versus 0.5 h treatment, 0.5 h treatment versus 24 h treatment and 24 h treatment versus 48 h treatment. Results: Time dependent responses were observed. At 0.5 h, the PI3K-AKT signaling pathway was impacted. At 24 h endoplasmic reticulum activity and protein degradation were altered. At 48 h, oxytocin signaling was perturbed. Conclusion: The effects of rosiglitazone occured early and increased in magnitude over time. A protective molecular response was triggered at 24 h and maintained until 48 h. In parallel, a response that can cause cardiac damage was activated. Our findings suggest that rosiglitazone has deleterious effects.

Statins and the potential for higher diabetes mellitus risk

Introduction: 3-Hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins) are widely used for cardiovascular disease (CVD) prevention. Long-term use of statins has been linked to the development of diabetes mellitus (DM) which increases CVD risk. Areas covered: We discussed the reported incidence of DM in statin users, various possible mechanisms responsible for the development of DM and the clinical implications of this association on CVD risk. Relevant supporting literature was identified using MEDLINE/EMBASE search. Expert opinion: Data from available RCTs and observational studies suggest a 10-45% higher risk of new-onset DM with statin use compared to nonusers. Several cellular, molecular, and genetic mechanisms, and lifestyle changes have been studied and discussed as potential underlying mechanisms responsible for this elevated DM risk with statin therapy. The mode of the diabetogenic action of statins is still unclear and an interplay of pancreatic and peripheral effects in the pathogenesis of DM is a possibility. Despite these observations, the CVD preventative benefit of statin treatment outweighs the CVD risk associated with of development of new DM. There is a need for further research to identify the exact mechanisms involved so as to specifically target causative factors and individualize treatment.

Association between normal triglyceride and insulin resistance in US adults without other risk factors: a cross-sectional study from the US National Health and Nutrition Examination Survey, 2007-2014

OBJECTIVE

Traditionally, the absence of insulin resistance risk factors (IRRFs) was considered a low risk for insulin resistance (IR). However, IR also existed in certain individuals without IRRFs; thus this study aims to explore predictors of IR targeted at the population without IRRFs.

DESIGN

Cross-sectional survey.

SETTING

National Health and Nutrition Examination Survey.

PARTICIPANTS

Participants without regular IRRFs (IRRF-Free, n=2478) and a subgroup without optimal IRRFs (IRRF-Optimal, n=1414) were involved in this study.

PRIMARY AND SECONDARY OUTCOME MEASURE

IRRFs and the optimal cut-off value of triglyceride (TG) to predict IR.

RESULTS

Overall, the prevalence of IR was 6.9% and 5.7% in the IRRF-Free group and the IRRF-Optimal group, respectively. TG and waist circumference were independently associated with the prevalence of IR in both the groups (OR=1.010 to 10.20; p<0.05 for all), where TG was positively associated with IR. The area under the receiver operating characteristic curve of TG was 0.7016 (95% CI: 0.7013 to 0.7018) and 0.7219 (95% CI: 0.7215 to 0.7222), and the optimal cut-off value of TG to predict IR was 79.5 mg/dL and 81.5 mg/dL in the IRRF-Free group and the IRRF-Optimal group, respectively.

CONCLUSION

There is an association between TG and IR even in the normal range of TG concentration. Therefore, normal TG could be used as an important indicator to predict the prevalence of IR in the absence of IRRFs.

Comparative study to evaluate the effect of l-carnitine plus glimepiride versus glimepiride alone on insulin resistance in type 2 diabetic patients

AIM

Insulin resistance (IR) is predominant in type 2 diabetic patients. This study aimed to investigate benefits from adding l-carnitine to ongoing glimepiride compared to glimepiride monotherapy on IR in diabetic patients who failed to achieve their glycemic goals on glimepiride monotherapy.

METHODS

58 patients were recruited from Internal Medicine Department, Tanta University Hospital, Egypt then prospectively randomized to receive their glimepiride dose 2 mg twice daily (group 1) or glimepiride 2 mg twice daily + l-carnitine 1 g m twice daily (group 2) for 6 months. Fasting blood samples were collected at baseline, 3 and 6 months after treatment for analysis of fasting and postprandial blood glucose [FBG &PPBG], glycated hemoglobin [HbA1c %], fasting insulin, extracellular part of insulin regulated aminopeptidase [IRAPe] as a novel marker, tumor necrosis factor-alpha [TNF-α], visfatin and lipid panel. Body mass index [BMI] and homeostasis model assessment of insulin resistance [HOMA-IR] were calculated. Data were statistically analyzed by SPSS using unpaired Student's t-test and one way analysis of variance; p ≤ 0.05 was considered statistically significant.

RESULTS

The obtained data suggested that adding l-carnitine to glimepiride has a significantly beneficial effect on FBG, PPBG, HbA1c, fasting insulin, HOMA-IR index, IRAPe, TNF-α, visfatin and lipid panel parameters but doesn't have effect on BMI and blood pressure.

CONCLUSION

The co-administration of l-carnitine with glimepiride represents a new therapeutic strategy for better controlling diabetic patients as it resulted in more beneficial effects on direct and indirect biomarkers of insulin resistance than glimepiride alone.

Impact of currently used anti-diabetic drugs on myoendothelial communication

Diabetes is associated with a high risk of cardiovascular complications and ideally anti-diabetic drugs should not only reduce metabolic abnormalities but also reduce the negative impact of diabetes on vascular function; however, lowering blood glucose levels does not necessarily reduce cardiovascular events. Endothelial dysfunction, defined as a reduction in endothelium-dependent vasodilation, is the earliest indicator of vascular disease and this raises the question: Do the currently used anti-diabetic drugs protect endothelial function? Metformin, in use for 60 years, is the first choice drug for type 2 diabetes and based on pre-clinical and clinical data metformin has proven cardiovascular protective actions; in contrast SGLT2 inhibitors were only introduced in 2013 but show great promise. This review compares metformin with SGLT2 inhibitors and the data supporting their protective effects on the endothelium.

Cardiovascular safety of DPP-4 inhibitors compared with sulphonylureas: Results of randomized controlled trials and observational studies

After failure of metformin monotherapy, another glucose-lowering agent should be added to improve glucose control. The clinician has several pharmacological choices, including the addition of a sulphonylurea (SU) or a dipeptidyl peptidase-4 inhibitor (DPP-4i). While the cardiovascular safety of SUs remains a matter of controversy, DPP-4is have proven their non-inferiority vs placebo in recent cardiovascular (CV) outcome trials. In the absence of a head-to-head CV outcome trial-the CAROLINA, comparing linagliptin with glimepiride, is still ongoing-only indirect information can be found in the literature to compare CV outcomes (major CV events, myocardial infarction, ischaemic stroke, CV death and all-cause mortality) in patients with type 2 diabetes mellitus (T2DM) treated with SUs or DPP-4is. Thus, this comprehensive review summarizes the CV outcomes (excluding heart failure) reported in meta-analyses of randomized controlled trials (RCTs) of SUs vs placebo or other glucose-lowering agents, DPP-4is vs placebo or other glucose-lowering agents and SUs vs DPP-4is in phase-II/III studies. Also, the results of observational studies reporting CV events in patients treated with either SUs or DPP-4is have been carefully examined. Overall, the CV safety of SUs appears to be poorer than that of DPP-4is in both RCTs and cohort studies. However, the results are somewhat disparate, and such heterogeneity may be explained by different patient characteristics across studies, but also perhaps by differences between various molecules in each pharmacological class. In particular, some doubt about a class effect affecting SU CV safety has been raised. The results of CAROLINA are expected to shed more light on SU CV concerns, especially compared with DPP-4is.

Neutrophils Release Metalloproteinases during Adhesion in the Presence of Insulin, but Cathepsin G in the Presence of Glucagon

In patients with reperfusion after ischemia and early development of diabetes, neutrophils can attach to blood vessel walls and release their aggressive bactericide agents, which damage the vascular walls. Insulin and 17β-estradiol (E2) relieve the vascular complications observed in metabolic disorders. In contrast, glucagon plays an essential role in the pathophysiology of diabetes. We studied the effect of hormones on neutrophil secretion during adhesion to fibronectin. Amino acid analysis revealed that proteins secreted by neutrophils are characterized by a stable amino acid profile enriched with glutamate, leucine, lysine, and arginine. The total amount of secreted proteins defined as the sum of detected amino acids was increased in the presence of insulin and reduced in the presence of glucagon. E2 did not affect the amount of protein secretion. Proteome analysis showed that in the presence of insulin and E2, neutrophils secreted metalloproteinases MMP-9 and MMP-8 playing a key role in modulation of the extracellular matrix. In contrast, glucagon induced the secretion of cathepsin G, a key bactericide protease of neutrophils. Cathepsin G can promote the development of vascular complications because of its proinflammatory activity and ability to stimulate neutrophil adhesion via the proteolysis of surface receptors.

A comparative safety review between GLP-1 receptor agonists and SGLT2 inhibitors for diabetes treatment

INTRODUCTION

Glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium glucose cotransporter 2 inhibitors (SGLT2i) are of particular interest in type 2 diabetes treatment strategies, due to their efficacy in reducing HbA1c with a low risk of hypoglycaemia, to their positive effects on body weight and blood pressure and in light of their effects on cardiovascular risk and on nephroprotection emerged from the most recent cardiovascular outcome trials. Since it is therefore very likely that GLP-1RA and SGLT2i use will become more and more common, it is more and more important to gather and discuss information about their safety profile.

AREAS COVERED

Adverse events and the safety concerns most often emerged in trials with GLP-1RA namely, exenatide long acting release (LAR), dulaglutide, liraglutide, semaglutide, lixisenatide or SGLT2i, namely empagliflozin, dapagliflozin, canagliflozin and SGLT2i with an attempt at comparing the safety profiles of molecules of these two classes.

EXPERT OPINION

GLP-1RA and SGLT2i, although each associated with different specific side effects, share a 'similar' safety profile and are both drugs relatively easy to handle. The potentially complementary mechanisms of action, the cardio and nephroprotective effects demonstrated by molecules of both classes, make these drugs potentially useful even in add on to each other.