Stabilization of postprandial blood glucose fluctuations by addition of glucagon like polypeptide-analog administration to intensive insulin therapy

Identification of Cyclic Sulfonamides with an N-Arylacetamide Group as α-Glucosidase and α-Amylase Inhibitors: Biological Evaluation and Molecular Modeling

Diabetes mellitus (DM), a complicated metabolic disorder, is due to insensitivity to insulin function or reduction in insulin secretion, which results in postprandial hyperglycemia. α-Glucosidase inhibitors (AGIs) and α-amylase inhibitors (AAIs) block the function of digestive enzymes, which delays the carbohydrate hydrolysis process and ultimately helps to control the postprandial hyperglycemia. Diversified 2-(3-(3-methoxybenzoyl)-4-hydroxy-1,1-dioxido-2H-benzo[e][1,2]thiazin-2-yl)-N-arylacetamides were synthesized and evaluated for their in vitro inhibitory potential against α-glucosidase and α-amylase enzymes. The compounds with chloro, bromo and methyl substituents demonstrated good inhibition of α-glucosidase enzymes having IC₅₀ values in the range of 25.88–46.25 μM, which are less than the standard drug, acarbose (IC₅₀ = 58.8 μM). Similarly, some derivatives having chloro, bromo and nitro substituents were observed potent inhibitors of α-amylase enzyme, with IC₅₀ values of 7.52 to 15.06 μM, lower than acarbose (IC₅₀ = 17.0 μM). In addition, the most potent compound, N-(4-bromophenyl)-2-(4-hydroxy-3-(3-methoxybenzoyl)-1,1-dioxido-2H-benzo[e][1,2]thiazin-2-yl)acetamide (12i), was found to be a non-competitive and competitive inhibitor of α-glucosidase and α-amylase enzymes, respectively, during kinetic studies. The molecular docking studies provided the binding modes of active compounds and the molecular dynamics simulation studies of compound 12i in complex with α-amylase also showed that the compound is binding in a fashion similar to that predicted by molecular docking studies.

Design and synthesis of phenoxymethybenzoimidazole incorporating different aryl thiazole-triazole acetamide derivatives as α-glycosidase inhibitors

A novel series of phenoxymethybenzoimidazole derivatives (9a-n) were rationally designed, synthesized, and evaluated for their α-glycosidase inhibitory activity. All tested compounds displayed promising α-glycosidase inhibitory potential with IC₅₀ values in the range of 6.31 to 49.89 μM compared to standard drug acarbose (IC₅₀ = 750.0 ± 10.0 μM). Enzyme kinetic studies on 9c, 9g, and 9m as the most potent compounds revealed that these compounds were uncompetitive inhibitors into α-glycosidase. Docking studies confirmed the important role of benzoimidazole and triazole rings of the synthesized compounds to fit properly into the α-glycosidase active site. This study showed that this scaffold can be considered as a highly potent α-glycosidase inhibitor.

Efficacy and safety of exenatide as add-on therapy for patients with type 2 diabetes with an intensive insulin regimen: A randomized double-blind trial

AIM

To assess the safety and efficacy of the short-acting glucagon-like peptide-1 receptor agonist exenatide on a population of patients with type 2 diabetes (T2D) mostly treated with continuous subcutaneous insulin injection (CSII).

MATERIALS AND METHODS

A phase 2/3, multicentre, randomized, parallel-group, double-blind, placebo-controlled, 6-month trial was conducted. Patients were randomized to receive subcutaneous (SC) injections of exenatide (10 μg BID) or matched placebo.

RESULTS

A total of 46 patients with T2D and elevated HbA1c were randomized (42% of the planned sample size): exenatide (n = 28) and placebo (n = 18). CSII treatment was used by 75% and 89% of patients of the exenatide and placebo groups, respectively. At 6 months, the change in HbA1c was -0.62% ± 0.94% and 0.08% ± 0.81% in the exenatide and placebo groups, respectively (difference, -0.70%; 95% CI [-1.24%; -0.15%], P = .014); body weight and body mass index decreased in the exenatide group (-2.55 ± 3.25 kg and -1.00 ± 1.31 kg/m² ) and increased in the placebo group (1.29 ± 2.82 kg and 0.46 ± 1.16 kg/m² ) (observed difference, -3.85 and -1.45, respectively, both P < .001); the postdinner capillary blood glucose value was lower in the exenatide group compared with the placebo group (162.4 ± 80.5 vs. 259.1 ± 94.4 mg/dL, respectively; observed difference, -96.7, P < .01). Hypoglycaemic risk, quality of life and overall safety were not different between the groups, apart from the expected occurrence of digestive effects in the exenatide group.

CONCLUSIONS

Although we failed to reach our planned sample size, the addition of exenatide treatment 10 μg BID SC in T2D patients with uncontrolled HbA1c despite an intensified insulin regimen, resulted in a significant reduction of HbA1c and body weight with a good overall safety profile and acceptance.

Addition of low-dose liraglutide to insulin therapy is useful for glycaemic control during the peri-operative period: effect of glucagon-like peptide-1 receptor agonist therapy on glycaemic control in patients undergoing cardiac surgery (GLOLIA study)

AIM

To test the hypothesis that the addition of a glucagon-like peptide-1 receptor agonist that can decrease glucose levels without increasing the hypoglycaemia risk will achieve appropriate glycaemic control during the peri-operative period.

METHODS

We studied 70 people with Type 2 diabetes who underwent elective cardiac surgery. Participants were randomized to either an insulin-alone or an insulin plus liraglutide 0.6 mg/day group. We evaluated average M values, which indicated the proximity index of the target glucose level from day 1 to day 10.

RESULTS

The average M value in the liraglutide plus insulin group was significantly lower than that in the insulin-alone group (liraglutide plus insulin 5.8 vs insulin-alone 12.3; P < 0.001). The frequency of insulin dose modification in the liraglutide plus insulin group was significantly lower than that in the insulin-alone group (odds ratio 0.19, 95% CI 0.08-0.49; P < 0.001). The frequency of hypoglycaemia in the liraglutide plus insulin group tended to be lower than that in the insulin-alone group (odds ratio 0.57, 95% CI 0.15-2.23; P = 0.21).

CONCLUSIONS

The results of this study showed that the addition of low-dose liraglutide to insulin achieved lower M values than insulin alone, suggesting that the addition of low-dose liraglutide may achieve better glycaemic control during the peri-operative period. (Clinical trials registry no.: UMIN 000008003).

Effects of sodium-glucose cotransporter 2 inhibitors on hypoglycaemia in brittle diabetic patients with decreased endogenous insulin secretion

AIMS

The effects of sodium-glucose cotransporter 2 inhibitors (SGLT2Is) on fasting blood glucose concentration (FBG) in patients with unstable FBG despite undergoing intensive insulin therapy (IIT) remain unclear. This study aimed to identify the effects of SGLT2Is on unstable FBGs.

MATERIALS AND METHODS

Thirty brittle diabetic patients with unstable FBGs despite undergoing IIT were included in the study. SGLT2Is were added and used in combination. We evaluated the data of the subjects in Evaluation 1 (immediately before using SGLT2Is) and evaluations 2, 3 and 4 (4, 24 and 48 weeks after starting concomitant therapy, respectively). FBGs were measured every day for a period of 28 days immediately before conducting Evaluations 1, 2, 3 and 4. The mean value of the 28 sets of FBG data (FBG mean) and their standard deviation (SD) values were established as each evaluation's FBGs. The changes in the mean values of the 30 subjects as well as their SD before and after concomitant therapy were evaluated.

RESULTS

The concomitant use of SGLT2Is helped reduce not only FBG mean but also SD. FBG max dropped, and the frequency of occurrence of hyperglycaemic FBG (>11.1 mmol/L) decreased. However, FBG min did not drop, and the frequency of occurrence of hypoglycaemic FBG (<3.9 mmol/L) increased. The frequency of occurrence of subjective hypoglycaemia decreased. The decrease in the SD of FBG was related to the decrease in subjective hypoglycaemia.

CONCLUSION

Concomitant use of SGLT2Is in patients with brittle diabetes appears to be useful in terms of improvement of FBG and fewer occurrences of hypoglycaemic events.

Efficacy and safety of adding liraglutide to existing insulin regimens in Japanese patients with type 2 diabetes mellitus: A post-hoc analysis of a phase 3 randomized clinical trial

AIMS/INTRODUCTION

To determine the efficacy and safety of adding liraglutide to three different insulin regimens in Japanese patients with type 2 diabetes mellitus.

MATERIALS AND METHODS

In this post-hoc analysis, results from a 36-week, randomized, double-blind, placebo-controlled, parallel-group trial are reported. Individuals with type 2 diabetes mellitus were stratified according to their pre-trial insulin regimen (basal, basal-bolus and premix). The primary objective was to determine whether adding liraglutide (0.9 mg/day) to fixed-dose insulin therapy was superior vs fixed-dose insulin monotherapy, assessed by the effect on glycemic control after 16 weeks of treatment.

RESULTS

The treatment effect on glycated hemoglobin reduction was independent of the pre-trial insulin regimen. Comparing liraglutide with a placebo, liraglutide was associated with glycated hemoglobin reduction in all insulin regimens, with placebo-corrected reductions at 16 weeks ranging from -1.45 to -1.17%, and maintained at 36 weeks. Liraglutide resulted in a greater reduction in mean plasma glucose obtained from seven-point self-monitoring, and greater proportions of patients achieved target glycated hemoglobin. With liraglutide, slightly higher proportions of patients receiving basal and basal-bolus insulin reported confirmed hypoglycemia from 0 to 16 weeks.

CONCLUSIONS

The efficacy and safety of adding liraglutide to insulin therapy was confirmed, regardless of pre-trial insulin regimen.

The impact of extended release exenatide as adjuvant therapy on hemoglobin A1C, weight, and total daily dose of insulin in patients with type 2 diabetes mellitus using U-500 insulin

AIMS

To evaluate the efficacy and safety of adjuvant exenatide extended release (ER) therapy in patients treated with regular U-500 insulin.

METHODS

In this retrospective chart review at an ambulatory care center in the Midwest, 18 patients with type 2 diabetes being treated with regular U-500 insulin and adjuvant exenatide ER were identified. These patients were evaluated for outcomes following the addition of exenatide ER. The primary outcome was change in HbA_1C from baseline to 3, 6, and 12months. Secondary outcomes included change in weight, total daily dose (TDD) of insulin, and hypoglycemia. Repeated measures ANOVA was performed to assess the differences in mean scores over four time periods.

RESULTS

A total of 18 of 50 patients met inclusion criteria with sufficient data to be included in analysis. HbA_1C showed non-significant findings from baseline to 12months (8.08% vs. 8.23%; p=0.75). A non-significant, modest weight loss occurred (146.4kgvs. 144.2kg; -2.2kg; p=0.31). A significant decrease in TDD of insulin was observed (378 units vs. 326 units; p<0.001). There was a trend towards hypoglycemia from baseline to month 3 post addition of exenatide ER (0.33 events vs. 1.33 events; p=0.055).

CONCLUSIONS

In patients treated with regular U-500 insulin, adjuvant exenatide ER therapy showed no significant improvement in HbA_1C, but did show modest weight loss as well as decreased insulin requirements to achieve a HbA_1C that was comparable to baseline.

Impact of postprandial glucose control on diabetes-related complications: How is the evidence evolving?

Conflicting findings in the literature and lack of long-term definitive outcome studies have led to difficulty in drawing conclusions about the role of postprandial hyperglycemia in diabetes and its complications. Recent scientific publications support the role of postprandial glucose (PPG) as a key contributor to overall glucose control and a predictor of microvascular and macrovascular events. However, the need remains for definitive evidence to support the precise relationship between PPG excursions and the development and progression of cardiovascular complications of diabetes. Drawing firm conclusions on the relationship between PPG and microvascular and macrovascular complications is challenged by the absence of antidiabetic agents that can specifically exert their action on PPG alone, without a basal glucose-lowering effect. Areas under investigation include interventions that more closely approximate 'normal' physiological postprandial responses, as well as technologies that advance the mode of insulin delivery or optimize methods to sense glycemic levels and variation. In conclusion, the precise role of postprandial hyperglycemia in relation to development of diabetic complications is unclarified and is one of the remaining unanswered questions in diabetes. Nevertheless, current evidence supports PPG control as an important strategy to consider in the comprehensive management plan of individuals with diabetes.