Diabetes surgery: a new approach to an old disease

Future treatment of Diabetes - Tyrosine Kinase inhibitors

Background

Diabetes mellitus (DM) is a group of metabolic disorders that have an increased risk of macro and micro-vascular complications due to lipid dysfunction. The present drug treatments for the management of DM either have numerous side effects or do not have long-lasting therapeutic effects. So it is essential to find a newer class of drug for DM treatment.

Method

Broad information has been researched regarding Tyrosine kinase Inhibitors (TKIs) and their mechanism of action. They are proven for the management of various kinds of cancers. TKIs produce anti-hyperglycemic effects by acting on multiple targets such as c-Abl, Platelet-Derived Growth Factor Receptor (PDGFR), Vascular Endothelial Growth Factor Receptor (VEGFR), Epidermal Growth Factor Receptor (EGFR), and c-Kit.

Result

This family of drugs blocks numerous tyrosine kinases by acting as a partial agonist of PPAR-γ receptors and results in an anti-diabetic effect by improving insulin sensitivity and glucose disposal rate.

Conclusion

Therefore, it is said that TKI drugs will be great potential for the treatment of Diabetes. This review summarizes the possible targets of TKIs and TKIs being a potential drug class in the management of Diabetes mellitus.

Relapse of Diabetes After Roux-en-Y Gastric Bypass for Patients With Obesity: 12 Years Follow-up Study

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is a recommended treatment for type 2 diabetes mellitus (T2DM) in patients with obesity, with superiority over medical therapy. While diabetes remission is achieved initially in 60-90% of patients following surgery, many may experience relapse of diabetes on the long-term. Data on long-term follow-up of bariatric surgery is scarce. We report this 12-year follow-up study of glycaemic control following RYGB.

METHODS

Two hundred seventeen patients with obesity (109 diabetic, 108 matched nondiabetic) who underwent RYGB between 2000 and 2008 were identified. Data was recorded prospectively for these patients at baseline and 2 years postoperatively. The long-term data was obtained via direct contact with the patients cross-checked with our hospital/national patients' electronic databases.

RESULTS

The follow-up rate was 88% (initial age 44 ± 9 years, female 79%). The mean (± SD) percentage total weight loss was 28% (± 15%) and 27% (± 17%) at 2 years and 12 years, respectively. Diabetes remission rate was 69% at 2 years, but decreased to 36% at 12 years following surgery. The 12-year incidence of new-onset T2DM in the control group was 4.3%. On univariate analysis, age, preoperative duration of diabetes and use of insulin were associated with less chance of diabetes remission at long-term (p value 0.06, 0.01 and 0.03, respectively). However, on multivariate regression analysis, only the duration of diabetes preoperatively remained significant (p = 0.025).

CONCLUSION

This study shows a high relapse of diabetes 12-year post-RYGB despite the durability of weight loss. This affects preoperative counselling and indicates a need for a longer follow-up to detect relapse.

From diabetes remedy to diabetes remission; could single-anastomosis gastric bypass be a safe bridge to reach target in non-obese patients?

BACKGROUND/AIMS

Type 2 diabetes mellitus (T2DM) is considered a chronic progressive incurable metabolic disease. Single-anastomosis gastric bypass (SAGB) has proved to be effective in obese patients, yet its impact on non-obese diabetics is not extensively studied. The aim is to determine the anthropometric and glycemic outcomes of SAGB as a proposed line of treatment for T2DM patients with body mass index (BMI) 25-30 kg/m².

METHODS

From November 2013 to March 2016, a prospective study has been conducted at Ain-Shams University Hospitals on 17 consecutive patients who have undergone SAGB. The demographic and anthropometric data, as well as the relevant laboratory results, were reported. Complete T2DM remission is considered if glycosylated hemoglobin (HbA1c) <6 % for at least 1 year without medication, whereas partial remission is considered if HbA1c<6.5%.

RESULTS

The mean age was 42.6 ±13.8 years, mean BMI was 26.7 ± 2.3 kg/m² and mean duration of DM was 6.3 ± 2.7 years. The mean baseline values of HbA1c, FPG (fasting plasma glucose), and 2-hours postprandial glucose (2-H PPG) were 9.9%, 176.3 mg/dl, and 310.3 mg/dl respectively. These values significantly dropped at the 18^th month to reach 5.8%, 93.4 mg/dl, and 156.2 mg/dl, with 13/17 patients became off-treatment (complete remission rate 76.4%).

CONCLUSION

T2DM patients with BMI 25-30 kg/m² are considered the most controversial group. SAGB is an efficient metabolic procedure and could be integrated into the treatment algorithm of T2DM. Such line of treatment opens new horizons to change the concept of treatment from diabetes remedy to diabetes remission.

The impact of laparoscopic diverted sleeve gastrectomy with ileal transposition (DSIT) on short term diabetic medication costs

Background

Type 2 diabetes mellitus (T2DM) has gained pandemic proportions becoming a global threat within the last few decades. In parallel to the increasing prevalence, healthcare costs have become a huge economic burden for the hospital and governments. Bariatric surgery has been proven to induce glycemic control in obese type 2 diabetics. However, the cost effectiveness of metabolic surgery in overweight, obese and morbidly obese individuals has not been documented. We aimed to demonstrate the efficacy and reduced diabetic-medication cost after diverted sleeve gastrectomy with ileal interposition (DSIT) in type 2 diabetic individuals followed more than 1 year.

Methods

Records of 116 type 2 diabetic patients operated by DSIT at a dedicated metabolic surgery clinic between October 2011 and April 2013 were retrospectively reviewed. A comparison was made between the annual diabetic medication cost before and after surgery using the paired t test. The alterations in BMI and HbA1c were recorded and analyzed.

Results

Diverted sleeve gastrectomy with ileal interposition led to a marked reduction in BMI and improved glycemic control after 1 year follow-up. Mean HbA1c levels decreased from a mean of 8.9 ± 1.7 to 6.6 ± 1.1 1 year after surgery (p < 0.001). Mean preoperative BMI declined from 32.9 ± 4.3  to 24.7 ± 2.7 kg/m² (p < 0.001). Cost of diabetic medication decreased from a mean 660.08 USD/year to 65.12 USD 1 year after surgery (p < 0.001).

Conclusion

Our results have shown that DSIT operation leads to a significantly better glycemic control and lower diabetic medication costs at 1 year.

Hormonal signaling in the gut

The gut is anatomically positioned to play a critical role in the regulation of metabolic homeostasis, providing negative feedback via nutrient sensing and local hormonal signaling. Gut hormones, such as cholecystokinin (CCK) and glucagon-like peptide-1 (GLP-1), are released following a meal and act on local receptors to regulate glycemia via a neuronal gut-brain axis. Additionally, jejunal nutrient sensing and leptin action are demonstrated to suppress glucose production, and both are required for the rapid antidiabetic effect of duodenal jejunal bypass surgery. Strategies aimed at targeting local gut hormonal signaling pathways may prove to be efficacious therapeutic options to improve glucose control in diabetes.

Glucose-dependent insulinotropic polypeptide regulates dipeptide absorption in mouse jejunum

Glucose-dependent insulinotropic polypeptide (GIP) secreted from jejunal mucosal K cells augments insulin secretion and plays a critical role in the pathogenesis of obesity and Type 2 diabetes mellitus. In recent studies, we have shown GIP directly activates Na-glucose cotransporter-1 (SGLT1) and enhances glucose absorption in mouse jejunum. It is not known whether GIP would also regulate other intestinal nutrient absorptive processes. The present study investigated the effect of GIP on proton-peptide cotransporter-1 (PepT1) that mediates di- and tripeptide absorption as well as peptidomimetic drugs. Immunohistochemistry studies localized both GIP receptor (GIPR) and PepT1 proteins on the basolateral and apical membranes of normal mouse jejunum, respectively. Anti-GIPR antibody detected 50-, 55-, 65-, and 70-kDa proteins, whereas anti-PepT1 detected a 70-kDa proteins in mucosal homogenates of mouse jejunum. RT-PCR analyses established the expression of GIPR- and PepT1-specific mRNA in mucosal cells of mouse jejunum. Absorption of Gly-Sar (a nondigestible dipeptide) measured under voltage-clamp conditions revealed that the imposed mucosal H(+) gradient-enhanced Gly-Sar absorption as an evidence for the presence of PepT1-mediated H(+):Gly-Sar cotransport on the apical membranes of mouse jejunum. H(+):Gly-Sar absorption was completely inhibited by cephalexin (a competitive inhibitor of PepT1) and was activated by GIP. The GIP-activated Gly-Sar absorption was completely inhibited by RP-cAMP (a cAMP antagonist). In contrast to GIP, the ileal L cell secreting glucagon-like peptide-1 (GLP-1) did not affect the H(+):Gly-Sar absorption in mouse jejunum. We conclude from these observations that GIP, but not GLP-1, directly activates PepT1 activity by a cAMP-dependent signaling pathway in jejunum.

Moral challenges with surgical treatment of type 2 diabetes

AIM

To review the most important moral challenges following from the widespread use of bariatric surgery for type 2 diabetes for patients with BMI <35kg/m(2), although high quality evidence for its short and long term effectiveness and safety is limited.

METHODS

Extensive literature search to identify and analyze morally relevant issues. A question based method in ethics was applied to facilitate assessment and decision making.

RESULTS

Several important moral issues were identified: assessing and informing about safety, patient outcomes, and stakeholder interests; acquiring valid informed consent; defining and selecting outcome measures; stigmatization and discrimination of the patient group, as well as providing just distribution of health care. The main sources of these challenges are lack of high quality evidence, disagreement on clinical indications and endpoints, and the disciplining of human behavior by surgical interventions.

CONCLUSION

A lack of high quality evidence on the effect of bariatric surgery for the treatment of T2DM in patients with BMI<35/kg/m(2) poses a wide variety of moral challenges, which are important for decisions on the individual patient level, on the management level, and on the health policy making level. Strong preferences among surgeons and patients may hamper high quality research.

The gut microbiota elicits a profound metabolic reorientation in the mouse jejunal mucosa during conventionalisation

OBJECTIVE

Proper interactions between the intestinal mucosa, gut microbiota and nutrient flow are required to establish homoeostasis of the host. Since the proximal part of the small intestine is the first region where these interactions occur, and since most of the nutrient absorption occurs in the jejunum, it is important to understand the dynamics of metabolic responses of the mucosa in this intestinal region.

DESIGN

Germ-free mice aged 8-10 weeks were conventionalised with faecal microbiota, and responses of the jejunal mucosa to bacterial colonisation were followed over a 30-day time course. Combined transcriptome, histology, (1)H NMR metabonomics and microbiota phylogenetic profiling analyses were used.

RESULTS

The jejunal mucosa showed a two-phase response to the colonising microbiota. The acute-phase response, which had already started 1 day after conventionalisation, involved repression of the cell cycle and parts of the basal metabolism. The secondary-phase response, which was consolidated during conventionalisation (days 4-30), was characterised by a metabolic shift from an oxidative energy supply to anabolic metabolism, as inferred from the tissue transcriptome and metabonome changes. Detailed transcriptome analysis identified tissue transcriptional signatures for the dynamic control of the metabolic reorientation in the jejunum. The molecular components identified in the response signatures have known roles in human metabolic disorders, including insulin sensitivity and type 2 diabetes mellitus.

CONCLUSION

This study elucidates the dynamic jejunal response to the microbiota and supports a prominent role for the jejunum in metabolic control, including glucose and energy homoeostasis. The molecular signatures of this process may help to find risk markers in the declining insulin sensitivity seen in human type 2 diabetes mellitus, for instance.

Effects of LX4211, a dual SGLT1/SGLT2 inhibitor, plus sitagliptin on postprandial active GLP-1 and glycemic control in type 2 diabetes

BACKGROUND

Combination therapy is required to provide adequate glycemic control in many patients with type 2 diabetes mellitus (T2DM). Because sodium-dependent glucose transporter (SGLT)-1 inhibition results in an increased release of glucagon-like peptide (GLP)-1, and because dipeptidyl peptidase (DPP)-4 inhibitors prevent its inactivation, the 2 mechanisms together provide an intriguing potential combination therapy.

OBJECTIVES

This combination was explored in preclinical models and then tested in patients with T2DM to compare the effects of single-dose LX4211 400 mg and sitagliptin 100 mg, administered as monotherapy or in combination, on GLP-1, peptide tyrosine tyrosine (PYY), gastric inhibitory peptide (GIP), glucose, and insulin.

METHODS

Preclinical: Obese male C57BL6J mice were assigned to 1 of 4 treatment groups: LX4211 60 mg/kg, sitagliptin 30 mg/kg, LX4211 + sitagliptin, or inactive vehicle. Clinical: This 3-treatment, 3-crossover, randomized, open-label study was conducted at a single center. Patients on metformin monotherapy were washed out from metformin and were randomly assigned to receive sequences of single-dose LX4211, sitagliptin, or the combination. In both studies, blood was collected for the analysis of pharmacodynamic variables (GLP-1, PYY, GIP, glucose, and insulin). In the clinical study, urine was collected to assess urinary glucose excretion.

RESULTS

Preclinical: 120 mice were treated and assessed (5/time point/treatment group). With repeat daily dosing, the combination was associated with apparently synergistic increases in active GLP-1 relative to monotherapy with either agent; this finding was supported by findings from an additional 14-day repeated-dose experiment. Clinical: 18 patients were enrolled and treated (mean age, 49 years; 56% male; 89% white). The LX4211 + sitagliptin combination was associated with significantly increased active GLP-1, total GLP-1, and total PYY; with a significant reduction in total GIP; and with a significantly improved blood glucose level, with less insulin, compared with sitagliptin monotherapy. LX4211 was associated with a significant increase in total GLP-1 and PYY and a reduced total GIP, likely due to a reduction in SGLT1-mediated intestinal glucose absorption, whereas sitagliptin was associated with suppression of all 3 peptides relative to baseline. All treatments were well tolerated, with no evidence of diarrhea with LX4211 treatment.

CONCLUSIONS

The findings from the preclinical studies suggest that the LX4211 + sitagliptin combination produced synergistic increases in active GLP-1 after a meal challenge containing glucose. These initial clinical results also suggest that a LX4211 + DPP-4 inhibitor combination may provide an option in patients with T2DM. The potential long-term clinical benefits of such combination treatment need to be confirmed in large clinical trials. ClinicalTrials.gov identifier: NCT01441232.

Perioperative Morbidity, Mortality and Early Outcome of the First 360 Gastric Bypass Operations Performed in a District Hospital

Background and Aims:

We report the results for the first consecutive 360 Roux-en-Ygastric bypass (RYGB) operations performed in a district hospital in Finland.

Material and Methods:

Demographic data, perioperative characteristics, and follow-up data were entered prospectively in the hospital's database for bariatric patients.

Results:

We performed 325 primary laparoscopic Roux-en-Ygastric bypass (LRYGB) operations, one open RYGB, and 34 revisions. Mean BMI before the operations was 47.5 ± 7.8 kg/m2 (31.5–91.0 kg/m2). The percentage of patients with type 2 diabetes mellitus (T2DM) was high; 52.3% (170 patients). The mean operative time decreased from 110 minutes during the first 108 operations to 82 minutes for the second 108 operations, and to 74 minutes for the last 109 operations (P < 0.001). Postoperative hospital stay was significantly reduced (P < 0.001) for the last 109 patients compared to the first and second group of patients. Overall morbidity averaged 19.1% (62/325). Severe complications were detected in 15 patients (4.6%). There was a tendency to more serious complications in the first group of patients. There was one death (mortality 0.3%). With a follow-up rate of 97% at 3 months T2DM had resolved in 48.2%, and had resolved or improved in a minimum of 92.9% of the diabetic patients. Weight loss (WL) and excess weight loss (EWL) averaged 20% and 46% respectively.

Conclusions:

Operative time and postoperative hospital stay decrease significantly with increasing experience. The first one hundred patients may be at higher risk for complications. LRYGB operations may have an important impact on the resolution of T2DM in the operated population.

Management of diabetes across the course of disease: minimizing obesity-associated complications

Obesity increases the risk for developing type 2 diabetes mellitus (T2DM) and this in turn correlates with an elevated probability of long-term diabetes complications once diabetes is established. Interventions aimed at lowering weight via changes in diet and lifestyle have repeatedly been shown to improve glycemic control in patients with T2DM and even to reverse early disease. Weight gain, a potential side effect of treatment for patients with T2DM, is also an important concern, and it has been noted that weight increases associated with antidiabetes therapy may blunt cardiovascular risk reductions achieved by decreasing blood glucose. Among older agents, metformin and acarbose have the lowest risk for weight gain, while sulfonylureas, meglitinides, and thiazolidinediones are all associated with weight increases. Clinical trial results have also consistently demonstrated that treatment with glucagon-like peptide-1 receptor agonists and amylin lowers weight, and that dipeptidyl peptidase-4 inhibitors are weight neutral in patients with T2DM. Conventional human insulin formulations are known to increase weight in patients with T2DM. However, some insulin analogs, particularly insulin detemir, have lower liability for this adverse event. The use of both pharmacologic and surgical therapies aimed at treating obesity rather than lowering blood glucose have the potential to improve glycemic control and even resolve T2DM in some patients.

Is sleeve gastrectomy as effective as gastric bypass for remission of type 2 diabetes in morbidly obese patients?

BACKGROUND

The benefits of Roux-en-Y gastric bypass (RYGB) for the control of type 2 diabetes mellitus (T2DM) in morbidly obese patients are well known, although the implicated mechanisms have not yet been elucidated. However, little is known about the remission of T2DM after sleeve gastrectomy (SG). The aim of our study was to compare the outcomes of T2DM after both procedures.

METHODS

We performed a retrospective analysis of diabetic morbidly obese patients who had undergone RYGB or SG. The variables analyzed included weight, fasting glycemia, and glycosylated hemoglobin.

RESULTS

A total of 90 patients were included (60 RYGB and 30 SG). The body mass index was 46.22 kg/m(2) for the RYGB group and 56.80 kg/m(2) for the SG group. The fasting glycemia was 10.63 mmol/L and 8.05 mmol/L and the glycated hemoglobin was 8.1% and 7.3% in the RYGB and SG groups, respectively. No significant differences were seen in the amount of weight loss after 2 years between the 2 techniques. Similarly, no significant differences were found in T2DM control after either 1 year (91.8% versus 82.3%) or 2 years (91.8% versus 88.9%). No significant differences were found in the duration of T2DM in either group nor in the percentage of patients treated with insulin and oral hypoglycemic drugs before and 2 years after surgery.

CONCLUSION

We did not find any significant differences in weight loss or T2DM resolution between the 2 techniques. Our results highlight that 1 of the mechanisms implicated in T2DM remission after bariatric surgery is weight loss. The role of other factors, such as incretins, that we have not studied cannot be ruled out and should be analyzed further.

Preoperative factors predicting remission of type 2 diabetes mellitus after Roux-en-Y gastric bypass surgery for obesity

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is an effective treatment for morbid obesity. This bariatric procedure has also been noted to resolve hyperglycaemia in up to 70% of obese diabetics. We evaluated outcomes in diabetic patients undergoing RYGB in our institution, aiming to identify factors predicting diabetes remission.

METHODS

One hundred ten type 2 diabetic (T2DM) patients undergoing RYGB were studied. Baseline demographics, diabetic status pre- and post-surgery and outcomes were evaluated. Outcomes were compared to a matched non-diabetic cohort.

RESULTS

The mean age of the patients was 45 +/- 11. The majority (70%; n = 77) were female and the mean baseline body mass index was 47 +/- 7. Mean (+/-SD range) excess weight loss at 6, 12 and 24 months was 58.3 +/- 26.4% (30.5-167%), 63.2 +/- 17.2% (0-99.2%) and 84.1 +/- 21.3% (16.5-121%), respectively. Diabetic medication was discontinued in 68.4% patients and reduced in a further 14.3%. Mean preoperative HbA1c was 7.1 +/- 2.0 and mean postoperative HbA1c 5.48 +/- 0.2. Patients with a baseline HbA1c >10 had a 50% rate of remission compared to 77.3% with an HbA1c of 6.5-7.9. The mean duration of T2DM preoperatively was 5.5 +/- 7 years. A preoperative duration of T2DM greater than 10 years was shown to significantly reduce the chances of remission (p = 0.005).

CONCLUSIONS

RYGB for morbid obesity achieves significant weight reduction in diabetic patients with remission of pre-surgical hyperglycaemia in the majority. The study supports findings that a shorter duration and better control of diabetes prior to surgery corresponds to a higher rate of remission. It supports the argument for early surgical intervention in the morbidly obese diabetic patient.