Diabetes treatment in 2025: can scientific advances keep pace with prevalence?

Plasma N-glycome shows continuous deterioration as the diagnosis of insulin resistance approaches

INTRODUCTION

Prediction of type 2 diabetes mellitus (T2DM) and its preceding factors, such as insulin resistance (IR), is of great importance as it may allow delay or prevention of onset of the disease. Plasma protein N-glycome has emerged as a promising predictive biomarker. In a prospective longitudinal study, we included patients with a first diagnosis of impaired glucose metabolism (IR or T2DM) to investigate the N-glycosylation's predictive value years before diabetes development.

RESEARCH DESIGN AND METHODS

Plasma protein N-glycome was profiled by hydrophilic interaction ultra-performance liquid chromatography in 534 TwinsUK participants free from disease at baseline. This included 89 participants with incident diagnosis of IR or T2DM during the follow-up period (7.14±3.04 years) whose last sample prior to diagnosis was compared using general linear regression with 445 age-matched unrelated controls. Findings were replicated in an independent cohort. Changes in N-glycome have also been presented in connection with time to diagnosis.

RESULTS

Eight groups of plasma N-glycans were different between incident IR or T2DM cases and controls (p<0.05) after adjusting for multiple testing using Benjamini-Hochberg correction. These differences were noticeable up to 10 years prior to diagnosis and are changing continuously as becoming more expressed toward the diagnosis. The prediction model was built using significant glycan traits, displaying a discriminative performance with an area under the receiver operating characteristic curve of 0.77.

CONCLUSIONS

In addition to previous studies, we showed the diagnostic potential of plasma N-glycome in the prediction of both IR and T2DM development years before the clinical manifestation and indicated the continuous deterioration of N-glycome toward the diagnosis.

Pharmacological Management of Diabetes Mellitus: A Century of Expert Opinions in Cecil Textbook of Medicine

BACKGROUND

Drug therapy for diabetes mellitus (DM) has had a significant impact on quality of life and work potential of affected persons and has contributed to a remarkable decrease in the frequency and severity of complications, hospitalizations, and mortality. The current approach is the result of incremental progress in using technological advances to increase the safety and effectiveness of insulin therapy and the introduction of new molecules as oral and injectable antidiabetic drugs.

STUDY QUESTION

What are the milestones of the changes in the expert approach to the pharmacological management of DM in the past century?

STUDY DESIGN

To determine the changes in the experts' approach to the management of DM, as presented in a widely used textbook in the United States.

DATA SOURCES

The chapters on describing the management of DM in the 26 editions of Cecil Textbook of Medicine published from 1927 to 2020.

RESULTS

In 1927, DM was treated with insulin extracted from the pancreas of large animals (cattle, hogs, and sheep) and purified with alcohol to prevent the tissues' proteolytic action on the hormone. The therapeutic milestones in DM marked 2 avenues for innovation. The first created advances in insulin therapy, starting with processes that led to the production of crystalline insulin and protamine zinc insulin (1937), synthetic human insulin (1996), and prandial (2000) and basal (2004) insulin analogues. The second was an effort to develop and introduce in clinical practice in the United States oral antidiabetic drugs, starting with tolbutamide, a sulfonylurea (1955), followed by metformin, a biguanide (1996), thiazolidinediones, alpha-glucosidase inhibitors, and benzoic acid derivatives (2000), dipeptidyl peptidase-4 inhibitors and glucagon-like peptide 1 receptor agonists (2008), and sodium glucose cotransporter 2 inhibitors (2020). A latent period of 40 years between significant advances was likely because of searches for new technologies (eg, recombinant DNA for the production of synthetic insulin and analogues) and, at least in part, to the impact of the controversial University Group Diabetes Project on the development and acceptance of oral antidiabetic drugs.

CONCLUSIONS

The pharmacological management of DM has progressed unevenly, with a long latency period in the second half of the last century followed by highly encouraging advances in the first 2 decades of the 21st century. In chronological order, the major advances were synthetic insulins obtained through DNA recombinant technology, adoption of metformin as first line therapy, and introduction of antidiabetic medication classes that also promote weight reduction and cardiovascular health.

The use of metformin as an add-on therapy to insulin in the treatment of poorly controlled type 1 diabetes mellitus in adolescents

The aim of this integrative literature review was to evaluate the efficacy and safety of Metformin as an add-on therapy to insulin in poorly controlled overweight adolescents with type 1 diabetes mellitus. The research problem centered on providing optimum disease management during the most critical growth period and reducing the potential for cardiovascular-related morbidity and mortality in the future. The findings suggested that Metformin, in conjunction with insulin therapy, helped patients to achieve better metabolic control. The quality of metabolic control varied between studies according to differences in study design, exclusion and inclusion criteria, and methods. Adjunctive Metformin therapy has a positive effect on diabetes management, treatment, and prevention of cardiovascular-related complications with a minimal risk of side effects. Suggestions for further exploration of the research results and clinical implications are included in the review.

Therapeutic potential of mesenchymal stem cells in treating both types of diabetes mellitus and associated diseases

Diabetes mellitus is a common lifestyle disease which can be classified into type 1 diabetes mellitus and type 2 diabetes mellitus. While both result in hyperglycemia due to lack of insulin action and further associated chronic ailments, there is a marked distinction in the cause for each type due to which both require a different prophylaxis. As observed, type 1 diabetes is caused due to the autoimmune action of the body resulting in the destruction of pancreatic islet cells. On the other hand, type 2 diabetes is caused either due to insulin resistance of target cells or lack of insulin production as per physiological requirements. Attempts to cure the disease have been made by bringing drastic changes in the patients' lifestyle; parenteral administration of insulin; prescription of drugs such as biguanides, meglitinides, and amylin; pancreatic transplantation; and immunotherapy. While these attempts cause a certain degree of relief to the patient, none of these can cure diabetes mellitus. However, a new treatment strategy led by the discovery of mesenchymal stem cells and their unique immunomodulatory and multipotent properties has inspired therapies to treat diabetes by essentially reversing the conditions causing the disease. The current review aims to enumerate the role of various mesenchymal stem cells and the different approaches to treat both types of diabetes and its associated diseases as well.

Recent Avenues in Novel Patient-Friendly Techniques for the Treatment of Diabetes

Background:

Diabetes is one of the most common chronic metabolic disorders which affect the quality of human life worldwide. As per the WHO report, between 1980 to 2014, the number of diabetes patients increases from 108 million to 422 million, with a global prevalence rate of 8.5% per year. Diabetes is the prime reason behind various other diseases like kidney failure, stroke, heart disorders, glaucoma, etc. It is recognized as the seventh leading cause of death throughout the world. The available therapies are painful (insulin injections) and inconvenient due to higher dosing frequency. Thus, to find out a promising and convenient treatment, extensive investigations are carried out globally by combining novel carrier system (like microparticle, microneedle, nanocarrier, microbeads etc.) and delivery devices (insulin pump, stimuli-responsive device, inhalation system, bioadhesive patch, insulin pen etc.) for more precise diagnosis and painless or less invasive treatment of disease.

Objective:

The review article is made with an objective to compile information about various upcoming and existing modern technologies developed to provide greater patient compliance and reduce the undesirable side effect of the drug. These devices evade the necessity of daily insulin injection and offer a rapid onset of action, which sustained for a prolonged duration of time to achieve a better therapeutic effect.

Conclusion:

Despite numerous advantages, various commercialized approaches, like Afrezza (inhalation insulin) have been a failure in recent years. Such results call for more potential work to develop a promising system. The novel approaches range from the delivery of non-insulin blood glucose lowering agents to insulin-based therapy with minimal invasion are highly desirable.

Machine learning as new promising technique for selection of significant features in obese women with type 2 diabetes

Background The global trend of obesity and diabetes is considerable. Recently, the early diagnosis and accurate prediction of type 2 diabetes mellitus (T2DM) patients have been planned to be estimated according to precise and reliable methods, artificial networks and machine learning (ML). Materials and methods In this study, an experimental data set of relevant features (adipocytokines and anthropometric levels) obtained from obese women (diabetic and non-diabetic) was analyzed. Machine learning was used to select significant features [by the separability-correlation measure (SCM) algorithm] for classification of women with the best accuracy and the results were evaluated using an artificial neural network (ANN). Results According to the experimental data analysis, a significant difference (p < 0.05) was found between fasting blood sugar (FBS), hemoglobin A1c (HbA1c) and visfatin level in two groups. Moreover, significant correlations were determined between HbA1c and FBS, homeostatic model assessment (HOMA) and insulin, total cholesterol (TC) level and body mass index (BMI) in non-diabetic women and insulin and HOMA, FBS and HbA1c, insulin and HOMA, systolic blood pressure (SBP) and diastolic blood pressure (DBP), BMI and TC and HbA1c and TC in the diabetic group. Furthermore, there were significant positive correlations between adipocytokines except for the resistin and leptin levels for both groups. The excellent (FBS and HbA1c), good (HOMA) and fair (visfatin, adiponectin and insulin) discriminators of diabetic women were determined based on specificities and sensitivities level. The more selected features in the ML method were FBS, apelin, visfatin, TC, HbA1c and adiponectin. Conclusions Thus, the subset of features involving FBS, apelin, visfatin and HbA1c are significant features and make the best discrimination between groups. In this study, based on statistical and ML results, the useful biomarkers for discrimination of diabetic women were FBS, HbA1c, HOMA, insulin, visfatin, adiponectin and apelin. Eventually, we designed useful software for identification of T2DM and the healthy population to be utilized in clinical diagnosis.

Nanoparticulate-based drug delivery systems for small molecule anti-diabetic drugs: An emerging paradigm for effective therapy

Emergence of nanoparticulate drug delivery systems in diabetes has facilitated improved delivery of small molecule drugs which could dramatically improve the quality of life for diabetics. Conventional dosage forms of the anti-diabetic drugs exhibit variable/less bioavailability and short half-life, demanding frequent dosing and causing increased side-effects resulting in ineffectiveness of therapy and non-compliance with the patients. Considering the chronic nature of diabetes, nanotechnology-based approaches are more promising in terms of providing site-specific delivery of drugs with higher bioavailability and reduced dosage regimen. Nanomedicines act at the cellular and molecular levels to enhance the uptake of the drug into the cells or block the efflux mechanisms thus retaining the drug inside the cell for a longer duration of time. Many studies have hinted at the possibility of administering peptide drugs like glucagon like peptides orally by encapsulation into nanoparticles. Nanoparticles also allow further modifications including their encapsulation into microparticles, polyethylene glycol (PEG)-PEGylation- or functionalization with ligands for active targeting. Nevertheless, such remarkable benefits are fraught with their long-term safety concerns, regulatory hurdles, limitations of scale-up and ineffective patent protection which have hindered their commercialization. This review summarizes the latest advances in the area of nanoformulations as applied to the delivery of anti-diabetics. STATEMENT OF SIGNIFICANCE: The present work describes the latest advancements in the area of nanoformulations for anti-diabetic therapy along with highlighting the advantages that these nanoformulations offer at molecular level for diabetes. Although several potent orally active anti-hyperglycemic agents are available, the current challenges in efficient management of diabetes include optimization of the present therapies to ensure an optimum and stable level of glucose, and also to reduce the occurrence of long term complications associated with diabetes. Nanoformulations because of their high surface area to volume ratio provide improved efficacy, targeting their delivery to the desired site of action tends to minimize adverse effects and administration of peptide drugs by oral route is also possible by encapsulating them in nanoparticles. As we reflect on the success and failures of latest research on nanoformulations for the treatment of diabetes, it is important not to dwell on lack of FDA approvals but rather define future directions that guarantee more effective anti-diabetic treatment. In proposed review we have explored the latest advancement in anti-diabetic nanotechnology based formulations.

Effects of Biotin Supplementation During the First Week Postweaning Increases Pancreatic Islet Area, Beta-Cell Proportion, Islets Number, and Beta-Cell Proliferation

During maturation, pancreatic islets achieve their full capacity to secrete insulin in response to glucose, undergo morphological changes in which alpha-cells decrease and beta-cell mass increases, and they acquire the normal alpha- and beta-cell proportion changes that are important for islet functions later in life. In rodents, the first week of postweaning is critical for islet maturation. Multiple studies have documented the detrimental effects of several conditions on pancreatic maturation; however, few studies have addressed the use of pharmacological agents to enhance islet maturation. Biotin might have a potential action on islet maturation. Pharmacological concentrations of biotin have been found to modify islet morphology and function. In a previous study, we found that mice fed a biotin-supplemented diet for 8 weeks after weaning showed an increase in basal and glucose stimulated insulin secretion, enlarged islet size, and modified islet structure. In the present study, we investigated the effect of biotin on maturation features during the first week postweaning. Female BALB/cAnN Hsd mice were fed a control or a biotin-supplemented diet for 1 week after weaning. Compared with the control, biotin-supplemented mice showed an increase in pancreatic islet number and area in addition to an augmented proportion of beta-cells in the islet. These effects were related to an increase in beta-cell proliferation. No differences were found in insulin secretion, blood glucose concentrations, or serum insulin levels. These results indicate that biotin supplementation is capable of affecting beta-cell proliferation and might be a therapeutic agent for establishing strategies for regenerative medicine.

Molecular mechanisms of ROS production and oxidative stress in diabetes

Oxidative stress and chronic inflammation are known to be associated with the development of metabolic diseases, including diabetes. Oxidative stress, an imbalance between oxidative and antioxidative systems of cells and tissues, is a result of over production of oxidative-free radicals and associated reactive oxygen species (ROS). One outcome of excessive levels of ROS is the modification of the structure and function of cellular proteins and lipids, leading to cellular dysfunction including impaired energy metabolism, altered cell signalling and cell cycle control, impaired cell transport mechanisms and overall dysfunctional biological activity, immune activation and inflammation. Nutritional stress, such as that caused by excess high-fat and/or carbohydrate diets, promotes oxidative stress as evident by increased lipid peroxidation products, protein carbonylation and decreased antioxidant status. In obesity, chronic oxidative stress and associated inflammation are the underlying factors that lead to the development of pathologies such as insulin resistance, dysregulated pathways of metabolism, diabetes and cardiovascular disease through impaired signalling and metabolism resulting in dysfunction to insulin secretion, insulin action and immune responses. However, exercise may counter excessive levels of oxidative stress and thus improve metabolic and inflammatory outcomes. In the present article, we review the cellular and molecular origins and significance of ROS production, the molecular targets and responses describing how oxidative stress affects cell function including mechanisms of insulin secretion and action, from the point of view of possible application of novel diabetic therapies based on redox regulation.

Calcium sensing receptor protects high glucose-induced energy metabolism disorder via blocking gp78-ubiquitin proteasome pathway

Diabetic cardiomyopathy (DCM) is a major complication and fatal cause of the patients with diabetes. The calcium sensing receptor (CaSR) is a G protein-coupled receptor, which is involved in maintaining calcium homeostasis, regulating cell proliferation and apoptosis, and so on. In our previous study, we found that CaSR expression, intracellular calcium levels and cardiac function were all significantly decreased in DCM rats; however, the exact mechanism are not clear yet. The present study revealed the protective role of CaSR in myocardial energy metabolism disorder induced by high glucose (HG) as well as the underlying mechanism. Here, we demonstrated that HG decreased the expression of CaSR, mitochondrial fusion proteins (Mfn1, Mfn2), cell gap junction related proteins (Cx43, β-catenin, N-cadherin), and intracellular ATP concentration. In contrast, HG increased extracellular ATP concentration, the expression of gp78, mitochondrial fission proteins (Fis1, Drp1), and the ubiquitination levels of Mfn1, Mfn2 and Cx43. Moreover, CaSR agonist and gp78-siRNA significantly reduced the above changes. Taken together, these results suggest that HG induces myocardial energy metabolism disorder via decrease of CaSR expression, and activation of gp78-ubiquitin proteasome system. In turn, these effects disrupt the structure and function of the mitochondria and the cell gap junction, result in the reduced ATP synthesis and the increased ATP leakage. Stimulation of CaSR significantly attenuates HG-induced abnormal myocardial energy metabolism, suggesting CaSR would be a promising potential therapeutic target for DCM.

Implications of Resveratrol on Glucose Uptake and Metabolism

Resveratrol—a polyphenol of natural origin—has been the object of massive research in the past decade because of its potential use in cancer therapy. However, resveratrol has shown an extensive range of cellular targets and effects, which hinders the use of the molecule for medical applications including cancer and type 2 diabetes. Here, we review the latest advances in understanding how resveratrol modulates glucose uptake, regulates cellular metabolism, and how this may be useful to improve current therapies. We discuss challenges and findings regarding the inhibition of glucose uptake by resveratrol and other polyphenols of similar chemical structure. We review alternatives that can be exploited to improve cancer therapies, including the use of other polyphenols, or the combination of resveratrol with other molecules and their impact on glucose homeostasis in cancer and diabetes.

Development of the endocrine pancreas and novel strategies for β-cell mass restoration and diabetes therapy

Diabetes mellitus represents a serious public health problem owing to its global prevalence in the last decade. The causes of this metabolic disease include dysfunction and/or insufficient number of β cells. Existing diabetes mellitus treatments do not reverse or control the disease. Therefore, β-cell mass restoration might be a promising treatment. Several restoration approaches have been developed: inducing the proliferation of remaining insulin-producing cells, de novo islet formation from pancreatic progenitor cells (neogenesis), and converting non-β cells within the pancreas to β cells (transdifferentiation) are the most direct, simple, and least invasive ways to increase β-cell mass. However, their clinical significance is yet to be determined. Hypothetically, β cells or islet transplantation methods might be curative strategies for diabetes mellitus; however, the scarcity of donors limits the clinical application of these approaches. Thus, alternative cell sources for β-cell replacement could include embryonic stem cells, induced pluripotent stem cells, and mesenchymal stem cells. However, most differentiated cells obtained using these techniques are functionally immature and show poor glucose-stimulated insulin secretion compared with native β cells. Currently, their clinical use is still hampered by ethical issues and the risk of tumor development post transplantation. In this review, we briefly summarize the current knowledge of mouse pancreas organogenesis, morphogenesis, and maturation, including the molecular mechanisms involved. We then discuss two possible approaches of β-cell mass restoration for diabetes mellitus therapy: β-cell regeneration and β-cell replacement. We critically analyze each strategy with respect to the accessibility of the cells, potential risk to patients, and possible clinical outcomes.

The role of air pollutants in initiating liver disease

Recent episodes of severe air pollution in eastern Asia have been reported in the scientific literature and news media. Therefore, there is growing concern about the systemic effects of air pollution on human health. Along with the other well-known harmful effects of air pollution, recently, several animal models have provided strong evidence that air pollutants can induce liver toxicity and act to accelerate liver inflammation and steatosis. This review briefly describes examples where exposure to air pollutants was involved in liver toxicity, focusing on how particulate matter (PM) or carbon black (CB) may be translocated from lung to liver and what liver diseases are closely associated with these air pollutants.

Cortisol: the villain in Metabolic Syndrome?

Objective This article reviews the state of the art regarding the association between glucocorticoid actions and both obesity and insulin resistance, two main features of the metabolic syndrome. Methods A methodological assessment of the literature on PubMed and SciELO databases was conducted by using the following terms: stress, metabolic syndrome, glucocorticoids, obesity, insulin resistance, hypothalamic-pituitary-adrenal-axis and 11β-hydroxysteroid dehydrogenase. Results Chronic stress, mainly through hypothalamic-pituitary-adrenal axis dysregulation, promotes the accumulation of visceral fat. Reciprocally, obesity promotes a systemic low-grade inflammation state, mediated by increased adipokine secretion, which can chronically stimulate and disturb stress system. This vicious cycle, probably initiated by visceral adipose tissue dysfunction, might be the trigger for the development of metabolic syndrome. Conclusion Given the strong evidences linking glucocorticoid release, obesity and type 2 diabetes, better understanding of the mechanisms underlying this connection might be useful for prevention and treatment of the metabolic syndrome.

Exposure to ambient air particulate matter and non-alcoholic fatty liver disease

The present study was designed to alert the public opinion and policy makers on the supposed enhancing effects of exposure to ambient air particulate matter with aerodynamic diameters < 2.5 mm (PM_2.5) on non-alcoholic fatty liver disease (NAFLD), the most common chronic liver disease in Western countries. For far too long literature data have been fixated on pulmonary diseases and/or cardiovascular disease, as consequence of particulate exposure, ignoring the link between the explosion of obesity with related syndromes such as NAFLD and air pollution, the worst characteristics of nowadays civilization. In order to delineate a clear picture of this major health problem, further studies should investigate whether and at what extent cigarette smoking and exposure to ambient air PM_2.5 impact the natural history of patients with obesity-related NAFLD, i.e., development of non alcoholic steatohepatitis, disease characterized by a worse prognosis due its progression towards fibrosis and hepatocarcinoma.