Comparative safety of newer oral antidiabetic drugs

Quercetin, a Plant Flavonol Attenuates Diabetic Complications, Renal Tissue Damage, Renal Oxidative Stress and Inflammation in Streptozotocin-Induced Diabetic Rats

Diabetes mellitus is a metabolic syndrome characterized by increased glucose levels, oxidative stress, hyperlipidemia, and frequently decreased insulin levels. The current research was carried out for eight consecutive weeks to evaluate the possible reno-protective effects of quercetin (50 mg/kg b.w.) on streptozotocin (STZ) (55 mg/kg b.w.) induced diabetes rat models. Various physiological, biochemical, and histopathological parameters were determined in control, diabetic control, and quercetin-treated diabetic rats. The current findings demonstrated that diabetes control rats showed significantly decreased body weights (198 ± 10 vs. 214 ± 13 g) and insulin levels (0.28 ± 0.04 vs. 1.15 ± 0.05 ng/mL) in comparison to normal control. Besides this, the other parameters showed increased values, such as fasting blood glucose, triglyceride (TG), and total cholesterol levels (99 ± 5 vs. 230 ± 7 mg/dL, 122.9 ± 8.7 vs. 230.7 ± 7.2 mg/dL, 97.34 ± 5.7 vs. 146.3 ± 8 mg/dL) (p < 0.05). In addition, the urea and creatinine levels (39.9 ± 1.8 mg/dL and 102.7 ± 7.8 μmol/L) were also high in diabetes control rats. After 8 weeks of quercetin treatment in STZ-treated animals, body weight, insulin, and fasting blood sugar levels were significantly restored (p < 0.05). The inflammatory markers (TNF-α, IL-6, and IL-1β) were significantly increased (52.64 ± 2, 95.64 ± 3, 23.3 ± 1.2 pg/mL) and antioxidant enzymes levels (SOD, GST, CAT, and GSH) were significantly decreased (40.3 ± 3 U/mg, 81.9 ± 10 mU/mg, 14.2 ± 2 U/mg, 19.9 ± 2 μmol/g) in diabetic rats. All the parameters in diabetic animals treated with quercetin were restored towards their normal values. Histopathological findings revealed that the quercetin-treated group showed kidney architecture maintenance, reduction of fibrosis, and decreased expression of COX-2 protein. These results determined that quercetin has reno-protective effects, and conclude that quercetin possesses a strong antidiabetic potential and might act as a therapeutic agent in the prevention or delay of diabetes-associated kidney dysfunction.

Thiazolidinediones versus metformin on improving abnormal liver enzymes in patients with type 2 diabetes mellitus: a meta-analysis

Background

Liver enzyme abnormalities are common in patients with type 2 diabetes. Currently, the inverse relationship between elevated liver enzymes and antidiabetics intake may be explained by rigorous treatment and good control. However, few studies have directly explored the influence of antidiabetics on abnormal liver function, especially the comparison between two insulin sensitizers—thiazolidinediones and metformin.

Materials And Methods

Databases, including PubMed, Cochrane, CNKI, Wanfang and VIP were searched. Two reviewers performed independently. Meta-analysis was used when studies were homogeneous enough.

Results

Six studies, including 4726 patients with type 2 diabetes, were involved in this systematic review. Compared with metformin, thiazolidinediones significantly reduced the alanine transaminase, aspartate aminotransferase and gamma-glutamyl transpeptidase. Further subgroup analysis suggested that pioglitazone-treated participants showed vast improvement in decreasing alanine transaminase (MD = -13.70; 95% CI = -16.91 to -10.52; P < 0.00001; I² = 1%), aspartate aminotransferase (MD = -3.51; 95% CI = -5.74 to –1.28; P = 0.002; I² = 0%) and gamma-glutamyl transpeptidase (MD = -5.41; 95% CI = -9.40 to -1.42; P = 0.008; I² = 0%), while rosiglitazone exhibited no difference in lowering corresponding liver enzyme levels. Besides, thiazolidinediones similarly decreased fasting plasma glucose. However, thiazolidinediones were inferior to metformin in lowering HbA1C and alkaline phosphatase. Additionally, no significant publication bias was seen.

Conclusions

Thiazolidinediones may confer modest biological improvement of liver function in people with type 2 diabetes than metformin. But owing to the limited methodological quality, more clinical researches are warranted in the future.

1-Deoxynojirimycin: Occurrence, Extraction, Chemistry, Oral Pharmacokinetics, Biological Activities and In Silico Target Fishing

1-Deoxynojirimycin (DNJ, C₆H13NO₄, 163.17 g/mol), an alkaloid azasugar or iminosugar, is a biologically active natural compound that exists in mulberry leaves and Commelina communis (dayflower) as well as from several bacterial strains such as Bacillus and Streptomyces species. Deoxynojirimycin possesses antihyperglycemic, anti-obesity, and antiviral features. Therefore, the aim of this detailed review article is to summarize the existing knowledge on occurrence, extraction, purification, determination, chemistry, and bioactivities of DNJ, so that researchers may use it to explore future perspectives of research on DNJ. Moreover, possible molecular targets of DNJ will also be investigated using suitable in silico approach.

Identification of possible adverse drug reactions in clinical notes: The case of glucose-lowering medicines

Objective:

Through manual review of clinical notes for patients with type 2 diabetes mellitus attending a Danish diabetes center, the aim of the study was to identify adverse drug reactions (ADRs) associated with three classes of glucose-lowering medicines: “Combinations of oral blood-glucose lowering medicines” (A10BD), “dipeptidyl peptidase-4 (DDP-4) inhibitors” (A10BH), and “other blood glucose lowering medicines” (A10BX). Specifically, we aimed to describe the potential of clinical notes to identify new ADRs and to evaluate if sufficient information can be obtained for causality assessment.

Methods:

For observed adverse events (AEs) we extracted time to onset, outcome, and suspected medicine(s). AEs were assessed according to World Health Organization-Uppsala Monitoring Centre causality criteria and analyzed with respect to suspected medicines, type of ADR (system organ class), seriousness and labeling status.

Findings:

A total of 207 patients were included in the study leading to the identification of 163 AEs. 14% were categorized as certain, 60% as probable/likely, and 26% as possible. 15 (9%) ADRs were unlabeled of which two were serious: peripheral edema associated with sitagliptin and stomach ulcer associated with liraglutide. Of the unlabeled ADRs, 13 (87%) were associated with “other blood glucose lowering medications,” the remaining 2 (13%) with “DDP-4 inhibitors.”

Conclusion:

Clinical notes could potentially reveal unlabeled ADRs associated with prescribed medicines and sufficient information is generally available for causality assessment. However, manual review of clinical notes is too time-consuming for routine use and hence there is a need for developing information technology (IT) tools for automatic screening of patient records with the purpose to detect information about potentially serious and unlabeled ADRs.

Scorpion in Combination with Gypsum: Novel Antidiabetic Activities in Streptozotocin-Induced Diabetic Mice by Up-Regulating Pancreatic PPARγ and PDX-1 Expressions

The management of diabetes without any side effects remains a challenge in medicine. In this study, antidiabetic activity and the mechanism of action of scorpion combined with gypsum (SG) were investigated. Streptozotocin-induced diabetic mice were orally administrated with scorpion (200 mg kg(-1) per day) in combination with gypsum (200 mg kg(-1) per day) for 5 weeks. SG treatment resulted in decreased body weight, blood glucose and lipid levels, and increased serum and pancreatic insulin levels in diabetic mice. Furthermore, SG significantly increased the number and volume of beta cells in the Islets of Langerhans and promoted peroxisome proliferator-activated receptor gamma and pancreatic duodenal homeobox 1 expressions in pancreatic tissues. However, scorpion or gypsum alone had no significant effect in this animal model. Metformin showed a slight or moderate effect in this diabetic model, but this effect was weak compared with that of SG. Taken together, SG showed a new antidiabetic effect in streptozotocin-induced diabetic mice. This effect may possibly be involved in enhancing beta-cell regeneration and promoting insulin secretion by targeting PPARγ and PDX-1. Moreover, this new effect of SG offers a promising step toward the treatment of diabetic patients with beta-cell failure as a complementary and alternative medicine.

Drug-induced hypoglycaemia: an update

Drugs are the most frequent cause of hypoglycaemia in adults. Although hypoglycaemia is a well known adverse effect of antidiabetic agents, it may occasionally develop in the course of treatment with drugs used in everyday clinical practice, including NSAIDs, analgesics, antibacterials, antimalarials, antiarrhythmics, antidepressants and other miscellaneous agents. They induce hypoglycaemia by stimulating insulin release, reducing insulin clearance or interfering with glucose metabolism. Several drugs may also potentiate the hypoglycaemic effect of antidiabetic agents. Administration of these agents to individuals with diabetes mellitus is of most concern. Many of these drugs, and depending on clinical setting, may also induce hyperglycaemia. Drug-induced hepatotoxicity and nephrotoxicity may lead in certain circumstances to hypoglycaemia. Some drugs may also induce hypoglycaemia by causing pancreatitis. Drug-induced hypoglycaemia is usually mild but may be severe. Effective clinical management can be handled through awareness of this drug-induced adverse effect on blood glucose levels. Herein, we review pertinent clinical information on the incidence of drug-induced hypoglycaemia and discuss the underlying pathophysiological mechanisms, and prevention and management.

Type 2 diabetes: an expanded view of pathophysiology and therapy

Type 2 diabetes mellitus is a complicated metabolic disease affecting millions of individuals worldwide. The medications used to manage the disease are based on different pharmacologic approaches, including decreasing hepatic gluconeogenesis, stimulating pancreatic insulin production, slowing polysaccharide digestion, and increasing insulin sensitivity in muscle, liver, and fat to lower blood glucose. Incretin-based therapies, including glucagon-like peptide-1 (GLP-1) receptor agonists, mimic the effects of native GLP-1, while dipeptidyl peptidase-4 inhibitors increase circulating concentrations of endogenous GLP-1. This review focuses on means by which primary care physicians might evaluate the utility of pharmacologic agents based on their relation to the pathogenesis of type 2 diabetes. In general, patients with type 2 diabetes should be treated to their lowest targeted glycemic goals as soon as they are diagnosed, for as long as possible, as safely as possible, and as rationally as possible.

Future perspectives for insulinotropic agents in the treatment of type 2 diabetes-DPP-4 inhibitors and sulphonylureas

The introduction of dipeptidyl-peptidase IV inhibitors (DPP-4 inhibitors) brought a novel class of insulinotropic agents into the treatment options for type 2 diabetes. This paper compares the actions, clinical efficacy and safety of sulphonylureas with those of the DPP-4 inhibitors. First, the mode of action of both classes of antidiabetic agents is described. Then clinical studies for both substances in monotherapy and combination therapies are compared concerning their effects on glycaemic parameters and long-term duration of action. Hypoglycaemia incidence and other adverse effects are compared and data on cardiovascular parameters and endpoints are summarized. The effects of sulphonylureas and DPP-4 inhibitors on beta-cell function and beta-cell mass are highlighted. The present and future indications for both sulphonylureas and DPP-4 inhibitors are discussed.

Cardiovascular disease and intensive glucose control in type 2 diabetes mellitus: moving practice toward evidence-based strategies

Type 2 diabetes mellitus (T2DM) is associated with a high risk of complications, essentially macrovascular events. Surprisingly, the effect of improved glucose control on coronary and cerebrovascular complications and the target level of glycated hemoglobin (HbA(1c)) in this population remains questionable. We here report the results of 4 recently published randomized controlled trials (ACCORD, ADVANCE, VADT, UKPDS post-trial), which did not demonstrate a significant reduction of cardiovascular events in the intensive group compared to the standard group. On the contrary, in ACCORD, the study with the most ambitious goal (HbA(1c) < 6%), the overall and cardiovascular mortality was greater in the intensive group, although the risk of microangiopathic complications, especially nephropathy, was significantly decreased. VADT suggests that one possibility for the lack of observed effect of intensive therapy could be that the cardiovascular benefit is delayed. This contrasts strongly with the long-term postintervention outcomes of UKPDS, which show a persistent benefit of glycemic control during 10 years of post-trial follow-up ('legacy effect'). Therefore, the best way to protect patients with T2DM against coronary and cerebrovascular disease is to target all cardiovascular risk factors as early as possible by an individualized approach.

Cardiovascular disease and intensive glucose control in type 2 diabetes mellitus: moving practice toward evidence-based strategies

Type 2 diabetes mellitus (T2DM) is associated with a high risk of complications, essentially macrovascular events. Surprisingly, the effect of improved glucose control on coronary and cerebrovascular complications and the target level of glycated hemoglobin (HbA_1c) in this population remains questionable. We here report the results of 4 recently published randomized controlled trials (ACCORD, ADVANCE, VADT, UKPDS post-trial), which did not demonstrate a significant reduction of cardiovascular events in the intensive group compared to the standard group. On the contrary, in ACCORD, the study with the most ambitious goal (HbA_1c < 6%), the overall and cardiovascular mortality was greater in the intensive group, although the risk of microangiopathic complications, especially nephropathy, was significantly decreased. VADT suggests that one possibility for the lack of observed effect of intensive therapy could be that the cardiovascular benefit is delayed. This contrasts strongly with the long-term postintervention outcomes of UKPDS, which show a persistent benefit of glycemic control during 10 years of post-trial follow-up (‘legacy effect’). Therefore, the best way to protect patients with T2DM against coronary and cerebrovascular disease is to target all cardiovascular risk factors as early as possible by an individualized approach.

Treating type 2 diabetes: how safe are current therapeutic agents?

Sulphonylureas (SUs) and biguanides (metformin) are the current mainstays in the treatment of type 2 diabetes (T2DM) and represent the most commonly used oral hypoglycaemic agents (OHAs). In recent years, a variety of new OHAs have become available, including thiazolidinediones, glinides, alpha-glucosidase inhibitors, glucagon-like peptide-1 agonists, amylin analogues and dipeptidyl peptidase-IV inhibitors, providing physicians with a larger therapeutic catalogue than ever before. The traditional drugs metformin and SUs have an established safety profile through long-term use. However, long-term clinical trials and routine use are lacking for many of the new agents, and some potentially serious side effects have been reported with several of these compounds. Until adequate data is obtained, it is difficult to assess the risk-benefit ratio of these agents in relation to the traditional drugs. Until that becomes fully documented, it may be wise to start pharmacologic treatment of patients on an individual basis, weighing the benefits and costs of each medication. Thus, there remains a place for well-established drugs that have a proven safety record and are supported by years of clinical use for the treatment of T2DM.

Thiazolidinediones: effects on the development and progression of type 2 diabetes and associated vascular complications

In addition to reducing hyperglycaemia, the metabolic actions of TZDs (pioglitazone and rosiglitazone) in theory might improve the prognosis of patients with type 2 diabetes. However, it appears from recent data that pioglitazone and rosiglitazone have different cardiovascular risk profiles. The scope of this paper is to examine the benefits and risks of pioglitazone and rosiglitazone. Three large clinical studies (DREAM, and ADOPT with rosiglitazone; PROactive with pioglitazone) have recently been reported. A lower annual rate of decline of ss-cell function observed with rosiglitazone in the ADOPT study, compared with metformin and glyburide (glibenclamide), along with a reduced progression to insulin use seen with pioglitazone in the PROactive study, provides evidence that TZDs are effective in treating progressive hyperglycaemia. In PROactive, although the primary endpoint was not met, pioglitazone was associated with a reduction in a secondary composite endpoint of clinical cardiovascular events in high-risk patients with existing macrovascular disease who were already receiving other glycaemic and cardiovascular medications. Further evidence supporting an anti-atherogenic effect of pioglitazone was gained from the PERISCOPE study of carotid intima-media thickness. Recent controversy concerning a possible increased risk of myocardial infarction associated with rosiglitazone has fuelled uncertainty about the risk-benefit profile of this agent. In 2008, an update of an American Diabetes Association-European Association for the Study of Diabetes consensus statement on initiation and adjustment of therapy in patients with type 2 diabetes advised clinicians against using rosiglitazone. Skeletal fractures have recently emerged as a side effect of both TZDs. Available data suggest that cardiovascular benefits observed with pioglitazone might not be a class effect of TZDs.