Thiazolidinediones and vascular damage

Can Pioglitazone Safeguard Patients of Lichen Planus Against Homocysteine Induced Accelerated Cardiovascular Aging and Reduced Myocardial Performance: A Systematic Review

Lichen planus (L.P.) is a long-standing mucocutaneous inflammatory condition. A less familiar but essential illness association is increased arterial stiffness, endothelial dysfunction, and advanced atherosclerosis. Enhanced cardiac reconditioning and reduced performance of the heart have been suggested. Thiazolidinediones were commenced to manage hyperglycemia in diabetes mellitus. Recently, the class attained popularity after its action on vascular physiology was discovered. With this review, we attempted to explore whether an antidiabetic drug, pioglitazone (PIO), a peroxisome proliferator‑activated receptor γ (PPAR gamma) agonist, can defend patients of lichen planus against increased arterial stiffness and cardiac changes. We methodically screened numerous databases using focused words and phrases for relevant articles. After a comprehensive exploration, we applied the inclusion and exclusion criteria and performed a quality appraisal. Items retained were exhaustively studied. High homocysteine (HHcy) levels in lichen planus play a significant role in modifying the arteries and leading to their dysfunction. Not only does homocysteine affect the precursor cells, but it also increases the free radical damage. Arterial damage and upraised resistance encountered by the heart reduce its performance. After an exhaustive analysis, in our opinion, pioglitazone works in various miscellaneous ways to mitigate the homocysteine mediated changes. Early inclusion of the drug in managing patients with lichen planus seems promising in minimizing the harmful effects of high homocysteine. Evaluating the risk-benefit ratio, we believe that a trial of pioglitazone could be given to patients without underlying cardiac conditions.

Thiazolidinediones and cardiovascular risk - a question of balance

BACKGROUND

Several recent meta-analyses of adverse event data from randomized controlled trials with rosiglitazone reveal a possible association between this thiazolidinedione and an increased risk of ischemic myocardial events. This has led to debate on the overall clinical benefit of glitazone therapy for type 2 diabetes. Pioglitazone, on the other hand, has the most extensive cardiovascular outcomes database of all current glucose-lowering therapies, including a large prospective randomized controlled trial designed specifically to assess cardiovascular outcomes (PROactive). The available data suggest that pioglitazone is associated with a reduction in macrovascular risk.

AIMS

In this review, we highlight some of the key factors that need to be considered when assessing the net clinical benefit of thiazolidinediones, focussing on both class effects and those specific to either rosiglitazone or pioglitazone.

RESULTS

For pioglitazone there appears to be no increase in the risk of overall macrovascular events and no adverse clinical consequences of developing signs of heart failure. Furthermore, there is good evidence of significant benefit regarding the composite of death, MI or stroke.

CONCLUSION

The benefits seen with pioglitazone appear to outweigh the risks.

Is vascular stiffness a target for therapy?

BACKGROUND

Early cardiovascular disease starts in the endothelium leading to functional changes in the vasculature. These changes can be depicted by assessment of arterial stiffness or elasticity. There are several techniques to assess arterial stiffness. Increased arterial stiffness or decreased arterial elasticity has been associated with cardiovascular risk factors. There is now evidence that small artery elasticity is a strong predictor for arterial hypertension. Moreover arterial elasticity provides extra prognostic information beyond arterial blood pressure measurement. Arterial stiffness attenuation may reflect the true reduction of arterial wall damage.

RESULTS

ACE-inhibitors, angiotensin II receptor blockers, aldosterone antagonists and calcium antagonists have favorable effects in improving arterial elasticity, while beta-blockers have an inverse effect. Diuretics have not been evaluated. Lipid lowering therapy, some antidiabetic therapy have shown to reduce arterial stiffness. Inflammatory and infectious diseases have been associated with vascular inflammation and consequently increase in arterial stiffness. The effect of anti-inflammatory agents and antiretroviral therapy on arterial stiffness is under investigation.

CONCLUSIONS

Measurement of arterial stiffness will not only be helpful in the detection of early vascular disease but also as a tool in the selection and follow-up monitoring of therapeutic strategies aimed at preventing or delaying progression of vascular disease.