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Ripa RS, Zobel EH, von Scholten BJ, Jensen JK, Binderup T, Diaz LJ, Curovic VR, Hansen TW, Rossing P, Kjaer A. Effect of Liraglutide on Arterial Inflammation Assessed as [ 18F]FDG Uptake in Patients With Type 2 Diabetes: A Randomized, Double-Blind, Placebo-Controlled Trial. Circ Cardiovasc Imaging 2021; 14:e012174. [PMID: 34187185 PMCID: PMC8300846 DOI: 10.1161/circimaging.120.012174] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The mechanism behind the cardiovascular protection observed with human GLP-1 RA (glucagon-like peptide-1 receptor agonists) in type 2 diabetes is unknown. We hypothesized that treatment with the GLP-1 RA liraglutide had a positive effect on vascular inflammation. METHODS LIRAFLAME (Effect of liraglutide on vascular inflammation in type-2 diabetes: A randomized, placebocontrolled, double-blind, parallel clinical PET/CT trial) was a double-blind, randomized controlled trial performed at a single university hospital clinic in Denmark. Patients with type 2 diabetes were via computer-generated randomization list assigned (1:1) liraglutide up to 1.8 mg or placebo once daily for 26 weeks. The primary end point was change in vascular inflammation over 26 weeks assessed by [18F]-fluorodeoxyglucose positron emission tomography/computed tomography. Analyses were based on intention-to-treat. Key secondary outcomes included change in other indices of atherosclerosis. RESULTS Between October 26, 2017, and August 16, 2019, 147 patients were screened and 102 were randomly assigned to liraglutide (n=51) or placebo (n=51) and 99 (97%) completed the trial. Change in the [18F]-fluorodeoxyglucose positron emission tomography measure of vascular inflammation (active-segment target-to-background ratio) did not differ between treatment groups: change from baseline to 26 weeks was -0.04 (95% CI, -0.17 to 0.08) in the liraglutide group compared with -0.09 (-0.19 to 0.01) in the placebo group (mean difference, 0.05 [95% CI, -0.11 to 0.21], P=0.53). Secondary analyses restricted to [18F]-fluorodeoxyglucose positron emission tomography of the carotid arteries as well as other indices of atherosclerosis confirmed the primary result. We performed an explorative analysis of interaction between treatment group and history of cardiovascular disease (P=0.052). CONCLUSIONS In this low to moderate risk population with type 2 diabetes, liraglutide did not change vascular inflammation assessed as [18F]-fluorodeoxyglucose uptake compared with placebo. An explorative analysis indicated a possible effect in persons with history of cardiovascular disease, in line with current guidelines where liraglutide is recommended to patients with history of cardiovascular disease. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03449654.
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Affiliation(s)
- Rasmus S Ripa
- Department of Clinical Physiology, Nuclear Medicine and PET and Cluster for Molecular Imaging, Department of Biomedical Sciences, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark (R.S.R., J.K.J., T.B., A.K.)
| | - Emilie H Zobel
- Steno Diabetes Center Copenhagen, Denmark (E.H.Z., B.J.v.S., L.J.D., V.R.C., T.W.H., P.R.)
| | - Bernt J von Scholten
- Steno Diabetes Center Copenhagen, Denmark (E.H.Z., B.J.v.S., L.J.D., V.R.C., T.W.H., P.R.).,Novo Nordisk A/S, Søborg, Denmark (B.J.v.S.)
| | - Jacob K Jensen
- Department of Clinical Physiology, Nuclear Medicine and PET and Cluster for Molecular Imaging, Department of Biomedical Sciences, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark (R.S.R., J.K.J., T.B., A.K.)
| | - Tina Binderup
- Department of Clinical Physiology, Nuclear Medicine and PET and Cluster for Molecular Imaging, Department of Biomedical Sciences, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark (R.S.R., J.K.J., T.B., A.K.)
| | - Lars J Diaz
- Steno Diabetes Center Copenhagen, Denmark (E.H.Z., B.J.v.S., L.J.D., V.R.C., T.W.H., P.R.)
| | - Viktor R Curovic
- Steno Diabetes Center Copenhagen, Denmark (E.H.Z., B.J.v.S., L.J.D., V.R.C., T.W.H., P.R.)
| | - Tine W Hansen
- Steno Diabetes Center Copenhagen, Denmark (E.H.Z., B.J.v.S., L.J.D., V.R.C., T.W.H., P.R.)
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Denmark (E.H.Z., B.J.v.S., L.J.D., V.R.C., T.W.H., P.R.).,University of Copenhagen, Denmark (P.R.)
| | - Andreas Kjaer
- Department of Clinical Physiology, Nuclear Medicine and PET and Cluster for Molecular Imaging, Department of Biomedical Sciences, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark (R.S.R., J.K.J., T.B., A.K.)
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Hermans MP, Ahn SA, Rousseau MF. Increased CRP: An extended biomarker of microvascular risk in men with type 2 diabetes. J Diabetes Complications 2019; 33:107413. [PMID: 31477553 DOI: 10.1016/j.jdiacomp.2019.107413] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 06/27/2019] [Accepted: 08/02/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND The usefulness of C-reactive protein (CRP) to predict cardiovascular disease (CVD) in type 2 diabetes (T2DM) remains controversial. As many factors linked to obesity can modulate CRP in T2DM, we comprehensively revisited the cardiometabolic phenotype of patients with normal or raised CRP, taking into account the sexual dimorphism of its serum value. METHODS 1005 T2DM patients (651 males, 354 females; macroangiopathy 38%; coronary artery disease 26%; microangiopathy 47%) were divided depending on whether CRP level was ≤ or >3 mg/L. Thirty percent of men (n = 195) and 39% of women (n = 137) had raised CRP. Their cardiometabolic phenotype and presence of micro- and macrovascular complications were compared to those with normal CRP. RESULTS In both gender, patients with elevated CRP had higher body mass index, waist circumference, fat mass, visceral fat, insulinemia, HbA1c, and lower muscle mass and insulin sensitivity. They had more atherogenic dyslipidemia, higher non-HDL-C and apolipoprotein B100, and more lipoprotein(a) (+59% in men and +38% in women). In both sexes, there was no difference between patients with normal or high CRP regarding overall macroangiopathy (42% vs. 45% [men]; 27% vs. 28% [women]), coronary and peripheral artery disease, or stroke. Only in men, microangiopathy was more prevalent when CRP was raised (61% vs 44%; p < 0.0001). CONCLUSIONS This study shows major sex-related differences in microangiopathies in T2DM patients with high CRP levels. The latter are unrelated to prevalent CVD despite an unfavorable metabolic phenotype. By contrast, increased CRP may represent an extended biomarker of microvascular risk in men with T2DM.
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Affiliation(s)
- Michel P Hermans
- Division of Endocrinology & Nutrition, Cliniques universitaires St-Luc and Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain, Brussels, Belgium.
| | - Sylvie A Ahn
- Division of Cardiology, Cliniques universitaires St-Luc and Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain, Brussels, Belgium
| | - Michel F Rousseau
- Division of Cardiology, Cliniques universitaires St-Luc and Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain, Brussels, Belgium
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Kavaric N, Klisic A, Ninic A. Cardiovascular Risk Estimated by UKPDS Risk Engine Algorithm in Diabetes. Open Med (Wars) 2019; 13:610-617. [PMID: 30847393 PMCID: PMC6400147 DOI: 10.1515/med-2018-0086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 10/31/2018] [Indexed: 12/19/2022] Open
Abstract
Since there is a high prevalence of type 2 diabetes mellitus (DM2), as well as CVD in Montenegro, we aimed to estimate CVD risk by United Kingdom Prospective Diabetes Study (UKPDS) risk engine algorithm in individuals with DM2. Furthermore, we aimed to explore whether non-traditional biomarker such as high sensitivity C-reactive protein (hsCRP) is superior for CVD risk prediction over old traditional risk factors. A total of 180 participants with DM2 (of them 50% females) were included in the current cross-sectional study. Biochemical and anthropometric parameters, and blood pressure were obtained. More males than females were classified at high UKPDS risk category (p<0.001). Also, about one third of diabetic patients (29.4%) were classified into the high-risk category. In multivariate regression analysis, triglycerides [Odds ratio (OR) =1.703, p=0.001] and creatinine concentration (OR=1.040, p<0.001) were independent predictors of CVD risk, whereas hsCRP was not correlated with CVD risk. HsCRP is not superior for CVD risk prediction by UKPDS risk engine algorithm over high triglyceride and creatinine levels in diabetic population, which suggests that the old traditional markers must not be underestimated when examining CVD risk in population with diabetes.
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Affiliation(s)
| | - Aleksandra Klisic
- Center for Laboratory Diagnostics, Primary Health Care Center, Trg Nikole Kovacevica 6, 81000 Podgorica, Montenegro
| | - Ana Ninic
- Department for Medical Biochemistry, University of Belgrade - Faculty of Pharmacy, Belgrade, Serbia
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4
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Athyros VG, Imprialos K, Stavropoulos K, Sahinidis A, Doumas M. Understanding the cardiovascular risk with non-insulin antidiabetic drugs. Expert Opin Drug Saf 2019; 18:241-251. [DOI: 10.1080/14740338.2019.1586881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Vasilios G. Athyros
- Second Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
| | - Konstantinos Imprialos
- Second Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
| | | | - Alexandros Sahinidis
- Second Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
| | - Michael Doumas
- Second Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
- Department of Internal Medicine, George Washington University, Washington, DC, USA
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Dhindsa DS, Khambhati J, Sandesara PB, Eapen DJ, Quyyumi AA. Biomarkers to Predict Cardiovascular Death. Card Electrophysiol Clin 2017; 9:651-664. [PMID: 29173408 DOI: 10.1016/j.ccep.2017.07.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This article reviews biomarkers that have been shown to identify subjects at increased risk for cardiovascular death within the general population, in those with established coronary artery disease, and in those with heart failure. Use of biomarkers for risk stratification for sudden cardiac death continues to evolve. It seems that a multimarker strategy for risk stratification using simple measures of circulating proteins and usual clinical risk factors, particularly in patients with known coronary artery disease, can be used to identify patients at near-term risk of death. Whether similar strategies in the general population will prove to be cost-effective needs to be investigated.
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Affiliation(s)
- Devinder S Dhindsa
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1462 Clifton Road Northeast, Suite 507, Atlanta, GA 30322, USA
| | - Jay Khambhati
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1462 Clifton Road Northeast, Suite 507, Atlanta, GA 30322, USA
| | - Pratik B Sandesara
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1462 Clifton Road Northeast, Suite 507, Atlanta, GA 30322, USA
| | - Danny J Eapen
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1462 Clifton Road Northeast, Suite 507, Atlanta, GA 30322, USA
| | - Arshed A Quyyumi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1462 Clifton Road Northeast, Suite 507, Atlanta, GA 30322, USA.
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Ruospo M, Saglimbene VM, Palmer SC, De Cosmo S, Pacilli A, Lamacchia O, Cignarelli M, Fioretto P, Vecchio M, Craig JC, Strippoli GFM. Glucose targets for preventing diabetic kidney disease and its progression. Cochrane Database Syst Rev 2017; 6:CD010137. [PMID: 28594069 PMCID: PMC6481869 DOI: 10.1002/14651858.cd010137.pub2] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Diabetes is the leading cause of end-stage kidney disease (ESKD) around the world. Blood pressure lowering and glucose control are used to reduce diabetes-associated disability including kidney failure. However there is a lack of an overall evidence summary of the optimal target range for blood glucose control to prevent kidney failure. OBJECTIVES To evaluate the benefits and harms of intensive (HbA1c < 7% or fasting glucose levels < 120 mg/dL versus standard glycaemic control (HbA1c ≥ 7% or fasting glucose levels ≥ 120 mg/dL for preventing the onset and progression of kidney disease among adults with diabetes. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register up to 31 March 2017 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings; and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials evaluating glucose-lowering interventions in which people (aged 14 year or older) with type 1 or 2 diabetes with and without kidney disease were randomly allocated to tight glucose control or less stringent blood glucose targets. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for eligibility and risks of bias, extracted data and checked the processes for accuracy. Outcomes were mortality, cardiovascular complications, doubling of serum creatinine (SCr), ESKD and proteinuria. Confidence in the evidence was assessing using GRADE. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. MAIN RESULTS Fourteen studies involving 29,319 people with diabetes were included and 11 studies involving 29,141 people were included in our meta-analyses. Treatment duration was 56.7 months on average (range 6 months to 10 years). Studies included people with a range of kidney function. Incomplete reporting of key methodological details resulted in uncertain risks of bias in many studies. Using GRADE assessment, we had moderate confidence in the effects of glucose lowering strategies on ESKD, all-cause mortality, myocardial infarction, and progressive protein leakage by kidney disease and low or very low confidence in effects of treatment on death related to cardiovascular complications and doubling of serum creatinine (SCr).For the primary outcomes, tight glycaemic control may make little or no difference to doubling of SCr compared with standard control (4 studies, 26,874 participants: RR 0.84, 95% CI 0.64 to 1.11; I2= 73%, low certainty evidence), development of ESKD (4 studies, 23,332 participants: RR 0.62, 95% CI 0.34 to 1.12; I2= 52%; low certainty evidence), all-cause mortality (9 studies, 29,094 participants: RR 0.99, 95% CI 0.86 to 1.13; I2= 50%; moderate certainty evidence), cardiovascular mortality (6 studies, 23,673 participants: RR 1.19, 95% CI 0.73 to 1.92; I2= 85%; low certainty evidence), or sudden death (4 studies, 5913 participants: RR 0.82, 95% CI 0.26 to 2.57; I2= 85%; very low certainty evidence). People who received treatment to achieve tighter glycaemic control probably experienced lower risks of non-fatal myocardial infarction (5 studies, 25,596 participants: RR 0.82, 95% CI 0.67 to 0.99; I2= 46%, moderate certainty evidence), onset of microalbuminuria (4 studies, 19,846 participants: RR 0.82, 95% CI 0.71 to 0.93; I2= 61%, moderate certainty evidence), and progression of microalbuminuria (5 studies, 13,266 participants: RR 0.59, 95% CI 0.38 to 0.93; I2= 75%, moderate certainty evidence). In absolute terms, tight versus standard glucose control treatment in 1,000 adults would lead to between zero and two people avoiding non-fatal myocardial infarction, while seven adults would avoid experiencing new-onset albuminuria and two would avoid worsening albuminuria. AUTHORS' CONCLUSIONS This review suggests that people who receive intensive glycaemic control for treatment of diabetes had comparable risks of kidney failure, death and major cardiovascular events as people who received less stringent blood glucose control, while experiencing small clinical benefits on the onset and progression of microalbuminuria and myocardial infarction. The adverse effects of glycaemic management are uncertain. Based on absolute treatment effects, the clinical impact of targeting an HbA1c < 7% or blood glucose < 6.6 mmol/L is unclear and the potential harms of this treatment approach are largely unmeasured.
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Affiliation(s)
- Marinella Ruospo
- DiaverumMedical Scientific OfficeLundSweden
- Amedeo Avogadro University of Eastern PiedmontDivision of Nephrology and Transplantation, Department of Translational MedicineVia Solaroli 17NovaraItaly28100
| | | | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Salvatore De Cosmo
- Scientific Institute CSSDepartment of MedicineViale CappucciniSan Giovanni RotondoItaly71013
| | - Antonio Pacilli
- Scientific Institute CSSDepartment of MedicineViale CappucciniSan Giovanni RotondoItaly71013
| | - Olga Lamacchia
- University of FoggiaDepartment of EndocrinologyFoggiaItaly
| | | | | | | | - Jonathan C Craig
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Giovanni FM Strippoli
- DiaverumMedical Scientific OfficeLundSweden
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- Diaverum AcademyBariItaly
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Orchard TJ, Cariou B, Connelly MA, Otvos JD, Zhang S, Antalis CJ, Ivanyi T, Hoogwerf BJ. The effects of basal insulin peglispro vs. insulin glargine on lipoprotein particles by NMR and liver fat content by MRI in patients with diabetes. Cardiovasc Diabetol 2017; 16:73. [PMID: 28587667 PMCID: PMC5461740 DOI: 10.1186/s12933-017-0555-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 05/26/2017] [Indexed: 12/23/2022] Open
Abstract
Background In Phase 2/3 studies of basal insulin peglispro (BIL) compared to insulin glargine, patients with type 1 or type 2 diabetes previously treated with insulin and randomized to BIL had an increase in serum triglycerides (TGs). To further understand lipoprotein changes, a lipid substudy which included liver fat content was designed to assess relationships among the measured variables for each diabetes cohort and compare the hepato-preferential insulin BIL to glargine. Methods In three cohorts of patients with diabetes (type 1, type 2 insulin naïve, and type 2 previously on insulin; n = 652), liver fat content (LFC) was determined by magnetic resonance imaging (MRI) and blood lipids were analyzed by nuclear magnetic resonance (NMR) spectroscopy at baseline, 26 and 52 weeks of treatment. Apolipoproteins, adiponectin, and other lipid parameters were also measured. Descriptive statistics were done, as well as correlation analyses to look for relationships among LFC and lipoproteins or other lipid measures. Results In patients with type 1 diabetes treated with BIL, but not glargine, small LDL and medium and large VLDL subclass concentrations increased from baseline. In patients with type 2 diabetes previously on insulin and treated with BIL, large VLDL concentration increased from baseline. In insulin naïve patients with type 2 diabetes treated with BIL, there were very few changes, while in those treated with glargine, small LDL and large VLDL decreased from baseline. Baseline LFC correlated significantly in one or more cohorts with baseline large VLDL, small LDL, VLDL size, and Apo C3. Changes in LFC by treatment showed generally weak correlations with lipoprotein changes, except for positive correlations with large VLDL and VLDL size. Adiponectin was higher in patients with type 1 diabetes compared to patients with type 2 diabetes, but decreased with treatment with both BIL and glargine. Conclusions The lipoprotein changes were in line with the observed changes in serum TGs; i.e., the cohorts experiencing increased TGs and LFC with BIL treatment had decreased LDL size and increased VLDL size. These data and analyses add to the currently available information on the metabolic effects of insulins in a very carefully characterized cohort of patients with diabetes. Clinicaltrials.gov registration numbers and dates NCT01481779 (2011), NCT01435616 (2011), NCT01454284 (2011), NCT01582451 (2012) Electronic supplementary material The online version of this article (doi:10.1186/s12933-017-0555-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Trevor J Orchard
- Department of Epidemiology, GSPH, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bertrand Cariou
- l'Institut du Thorax, CHU Nantes INSERM, CNRS, UNIV Nantes, Nantes, France
| | - Margery A Connelly
- LipoScience, Laboratory Corporation of America Holdings, Morrisville, NC, 27560, USA
| | - James D Otvos
- LipoScience, Laboratory Corporation of America Holdings, Morrisville, NC, 27560, USA
| | - Shuyu Zhang
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA
| | - Caryl J Antalis
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA
| | | | - Byron J Hoogwerf
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA.
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8
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Anyanwagu U, Mamza J, Donnelly R, Idris I. Comparison of cardiovascular and metabolic outcomes in people with type 2 diabetes on insulin versus non-insulin glucose-lowering therapies (GLTs): A systematic review and meta-analysis of clinical trials. Diabetes Res Clin Pract 2016; 121:69-85. [PMID: 27662041 DOI: 10.1016/j.diabres.2016.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 07/28/2016] [Accepted: 09/01/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To compare the cardiovascular and metabolic outcomes of Insulin versus non-insulin glucose lowering therapy (GLT). METHODS We included randomised control trials (RCTs) which randomised patients aged >18years with Type 2 Diabetes (T2D) to insulin vs non-insulin GLT. We used risk ratios (RR), risk difference (RD) and odds ratios (OR) with 95% confidence interval (95%CI) to analyse the treatment effects of dichotomous outcomes and mean differences (with 95% CI) for continuous outcomes. RESULTS We included 18 RCTs with 19,300 participants. There was no significant difference in the risk of all-cause mortality and CV events between the groups (RR=1.01; 95%CI: 0.96-1.06; p=0.69). In 16 trials, insulin showed greater efficacy in glycaemic control (mean diff=-0.20; 95%CI: -0.28 to -0.11) but the proportion achieving HbA1c level of either ⩽7.0% or 7.4% (53 or 57mmol/mol) was similar in both (OR=1.55; 95%CI=0.92-2.62). The non-insulin group had a significant reduction in weight (mean diff=-3.41; 95%CI: -4.50 to -2.32) and an increase in the proportion of adverse events (54.7% vs 45.3%, p=0.044), but the insulin group showed an (RR=1.90; 95%CI: 1.44-2.51) increased risk of hypoglycaemia. CONCLUSION There was no difference in the risk of all-cause mortality and adverse cardiovascular (CV) events between Insulin and non-insulin GLTs. Insulin was associated with superior reduction in HbA1c; least reduction in weight and higher risk of hypoglycaemia. Both showed similar proportion of patients achieving HbA1c target. Non-insulin GLTs were associated with a higher risk in reported adverse drug events.
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Affiliation(s)
- U Anyanwagu
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, United Kingdom
| | - J Mamza
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, United Kingdom
| | - R Donnelly
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, United Kingdom
| | - I Idris
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, United Kingdom.
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Cardoso CRL, Leite NC, Salles GF. Prognostic Importance of C-Reactive Protein in High Cardiovascular Risk Patients With Type 2 Diabetes Mellitus: The Rio de Janeiro Type 2 Diabetes Cohort Study. J Am Heart Assoc 2016; 5:JAHA.116.004554. [PMID: 27912211 PMCID: PMC5210335 DOI: 10.1161/jaha.116.004554] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background The prognostic value of C‐reactive protein (CRP) is controversial in type 2 diabetes mellitus. We aimed to assess it in a cohort of high cardiovascular risk diabetic patients. Methods and Results CRP was measured at baseline and during the second year of follow‐up in 616 patients. The primary end points were a composite of total fatal and nonfatal cardiovascular events (CVEs), major CVEs, and all‐cause and cardiovascular mortalities. Association between baseline and second‐year CRP with end points were evaluated by multivariable Cox survival analyses. Baseline median CRP was 2.8 mg/L (interquartile range: 1.2–6.0 mg/L), and 47.8% of the patients either increased or persisted with high CRP levels during the first 2 years of follow‐up. After a median follow‐up of 8.4 years, 131 total CVEs occurred (89 major CVEs), and 129 patients died (53 of cardiovascular causes). Baseline and second‐year CRP, analyzed as a continuous variable and dichotomized at >3.0 mg/L, were significantly associated with total and major CVEs occurrence (with adjusted hazard ratios between 1.22 and 1.34 for increments of 1‐SD log of continuous CRP, and between 1.47 and 1.89 for dichotomized CRP), but not with mortality. Additionally, increasing CRP levels or persisting with high levels were associated with a 1.84 (95% CI: 1.10–3.06) excess risk of major CVEs, independent of baseline CRP values. Conclusions Baseline and serial changes in CRP levels provide cardiovascular risk prediction independent of standard risk factors and glycemic control, and may be useful to refine cardiovascular risk stratification in high‐risk patients with type 2 diabetes mellitus.
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Affiliation(s)
- Claudia R L Cardoso
- Department of Internal Medicine, University Hospital Clementino Fraga Filho, School of Medicine, Universidade Federal do Rio de Janeiro, Brazil
| | - Nathalie C Leite
- Department of Internal Medicine, University Hospital Clementino Fraga Filho, School of Medicine, Universidade Federal do Rio de Janeiro, Brazil
| | - Gil F Salles
- Department of Internal Medicine, University Hospital Clementino Fraga Filho, School of Medicine, Universidade Federal do Rio de Janeiro, Brazil
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10
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Schnell O, Rydén L, Standl E, Ceriello A. Current perspectives on cardiovascular outcome trials in diabetes. Cardiovasc Diabetol 2016; 15:139. [PMID: 27716274 PMCID: PMC5045635 DOI: 10.1186/s12933-016-0456-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 09/23/2016] [Indexed: 12/23/2022] Open
Abstract
Cardiovascular disease (CVD) is one of the most common diabetes-associated complications, as well as a leading cause for death in type 2 diabetes patients (T2D). Despite the well-known correlation between the two, up until the 2008 FDA industry guidance for licensing of new anti-hyperglycemic drugs, which required an investigation of cardiovascular outcomes (CVO) of glucose-lowering agents, only a few studies had looked into the relationship between glucose lowering drugs and cardiovascular (CV) risk. Thereafter, CVOT design has focused on non-inferiority short-term studies on high-risk patient populations aiming at capturing CV safety issues. Despite the wealth of information and useful data provided by CVOTs, this approach still suffers from certain limitations. The present review will condense the main results of the most recently completed CVOTs, reflect on the lessons learned, discuss on the issues presented by current CVOT design and offer some suggestions for improvement.
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Affiliation(s)
- Oliver Schnell
- Forschergruppe Diabetes e.V., Munich, Ingolstaedter Landstrasse 1, 85764, Neuherberg (Munich), Germany.
| | - Lars Rydén
- Cardiology Unit, Department of Medicine K2, Karolinska Institutet, 171 76, Stockholm, Sweden
| | - Eberhard Standl
- Forschergruppe Diabetes e.V., Munich, Ingolstaedter Landstrasse 1, 85764, Neuherberg (Munich), Germany
| | - Antonio Ceriello
- Institut d'Investigacions Biomèdiques August Pi i Sunyer-IDIBAPS, Mallorca, 183, 08036, Barcelona, Spain.,IRCCS MultiMedica, Via Milanese, 300, 20099, Milan, Italy
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11
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D'Elia JA, Bayliss G, Gleason RE, Weinrauch LA. Cardiovascular-renal complications and the possible role of plasminogen activator inhibitor: a review. Clin Kidney J 2016; 9:705-12. [PMID: 27679717 PMCID: PMC5036907 DOI: 10.1093/ckj/sfw080] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 07/20/2016] [Indexed: 12/14/2022] Open
Abstract
Since angiotensin increases the expression of plasminogen activator inhibitor (PAI), mechanisms associated with an actively functioning renin–angiotensin–aldosterone system can be expected to be associated with increased PAI-1 expression. These mechanisms are present not only in common conditions resulting in glomerulosclerosis associated with aging, diabetes or genetic mutations, but also in autoimmune disease (like scleroderma and lupus), radiation injury, cyclosporine toxicity, allograft nephropathy and ureteral obstruction. While the renin–angiotensin–aldosterone system and growth factors, such as transforming growth factor-beta (TGF-β), are almost always part of the process, there are rare experimental observations of PAI-1 expression without their interaction. Here we review the literature on PAI-1 and its role in vascular, fibrotic and oxidative injury as well as work suggesting potential areas of intervention in the pathogenesis of multiple disorders.
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Affiliation(s)
- John A D'Elia
- Joslin Diabetes Center, Boston, MA, USA; Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - George Bayliss
- Division ofKidney Diseases and Hypertension, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA; The Miriam Hospital, Providence, RI, USA; Alpert Medical School, Brown University, Providence, RI, USA
| | - Ray E Gleason
- Joslin Diabetes Center, Boston, MA, USA; Beth Israel Deaconess Medical Center, Boston, MA, USA; EP Joslin Research Laboratory, Boston, MA, USA; Brigham and Women's Hospital, Boston, MA, USA
| | - Larry A Weinrauch
- Joslin Diabetes Center, Boston, MA, USA; Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; EP Joslin Research Laboratory, Boston, MA, USA; Brigham and Women's Hospital, Boston, MA, USA
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12
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Azad N, Bahn GD, Emanuele NV, Agrawal L, Ge L, Reda D, Klein R, Reaven PD, Hayward R. Association of Blood Glucose Control and Lipids With Diabetic Retinopathy in the Veterans Affairs Diabetes Trial (VADT). Diabetes Care 2016; 39:816-22. [PMID: 27006510 DOI: 10.2337/dc15-1897] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 01/21/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study examined whether lipids modify the relationship between intensive glucose control (INT) and diabetic retinopathy (DR). RESEARCH DESIGN AND METHODS The incidence and progression of DR were assessed in 858 of 1,791 participants with 7-field stereoscopic fundus photographs at baseline and 5 years later. RESULTS Odds of DR progression were lower by ∼40% in those with baseline total cholesterol (TC) ≥200 mg/dL (P = 0.007), LDL-C ≥120 mg/dL (P < 0.02), or HDL-C ≥40 mg/dL (P < 0.007) in the INT arm versus standard glycemic treatment. Odds of DR progression were reduced by ∼40% in those who had TC ≤140 mg/dL (P ≤ 0.024), triglycerides (TG) ≤120 mg/dL (P = 0.004), or HDL-C ≥45 mg/dL (P = 0.01) at the fifth year. Odds of DR progression were lower by ∼40-50% with reductions of TC by ≥40 mg/dL (P < 0.0001), of LDL-C of ≥40 mg/dL (P < 0.004), and of TG by ≥60 mg/dL (P = 0.004) at the fifth year. Odds of DR progression increased by 80% with increases in TC of ≥20 mg/dL (P < 0.0001) and by 180% with increases in LDL-C by ≥60 mg/dL (P < 0.004). After adjusting for covariants, those with higher TC at baseline and lower TC during and at the fifth year and higher HDL-C throughout study had significantly decreased odds of DR progression in INT. CONCLUSIONS INT was associated with decreased odds of progression but not with onset of retinopathy in those with worse lipid levels at baseline and more improved lipid levels during the study. Higher HDL-C was consistently associated with better response to INT throughout the study.
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Affiliation(s)
- Nasrin Azad
- Endocrinology Section, Edward Hines, Jr. VA Hospital, Hines, IL
| | - Gideon D Bahn
- Cooperative Studies Program Coordinating Center, Hines, IL
| | | | - Lily Agrawal
- Endocrinology Section, Edward Hines, Jr. VA Hospital, Hines, IL
| | - Ling Ge
- Cooperative Studies Program Coordinating Center, Hines, IL
| | - Dominic Reda
- Cooperative Studies Program Coordinating Center, Hines, IL
| | - Ronald Klein
- Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, WI
| | - Peter D Reaven
- Endocrinology Section, Carl T. Hayden VA Medical Center, Phoenix, AZ
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13
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Koska J, Yassine H, Trenchevska O, Sinari S, Schwenke DC, Yen FT, Billheimer D, Nelson RW, Nedelkov D, Reaven PD. Disialylated apolipoprotein C-III proteoform is associated with improved lipids in prediabetes and type 2 diabetes. J Lipid Res 2016; 57:894-905. [PMID: 26945091 DOI: 10.1194/jlr.p064816] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Indexed: 11/20/2022] Open
Abstract
The apoC-III proteoform containing two sialic acid residues (apoC-III2) has different in vitro effects on lipid metabolism compared with asialylated (apoC-III0) or the most abundant monosialylated (apoC-III1) proteoforms. Cross-sectional and longitudinal associations between plasma apoC-III proteoforms (by mass spectrometric immunoassay) and plasma lipids were tested in two randomized clinical trials: ACT NOW, a study of pioglitazone in subjects with impaired glucose tolerance (n = 531), and RACED (n = 296), a study of intensive glycemic control and atherosclerosis in type 2 diabetes patients. At baseline, higher relative apoC-III2 and apoC-III2/apoC-III1 ratios were associated with lower triglycerides and total cholesterol in both cohorts, and with lower small dense LDL in the RACED. Longitudinally, changes in apoC-III2/apoC-III1 were inversely associated with changes in triglycerides in both cohorts, and with total and small dense LDL in the RACED. apoC-III2/apoC-III1 was also higher in patients treated with PPAR-γ agonists and was associated with reduced cardiovascular events in the RACED control group. Ex vivo studies of apoC-III complexes with higher apoC-III2/apoC-III1 showed attenuated inhibition of VLDL uptake by HepG2 cells and LPL-mediated lipolysis, providing possible functional explanations for the inverse association between a higher apoC-III2/apoC-III1 and hypertriglyceridemia, proatherogenic plasma lipid profiles, and cardiovascular risk.
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Affiliation(s)
- Juraj Koska
- Phoenix Veterans Affairs Health Care System, Phoenix, AZ
| | | | | | | | | | - Frances T Yen
- Université de Lorraine, URAFPA, INSERM, Vandoeuvre-lès-Nancy, France
| | | | | | | | - Peter D Reaven
- Phoenix Veterans Affairs Health Care System, Phoenix, AZ
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14
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Bardini G, Innocenti M, Rotella CM, Giannini S, Mannucci E. Variability of triglyceride levels and incidence of microalbuminuria in type 2 diabetes. J Clin Lipidol 2015; 10:109-15. [PMID: 26892127 DOI: 10.1016/j.jacl.2015.10.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 07/06/2015] [Accepted: 10/02/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Experimental and clinical studies have shown a strong association between hypertriglyceridemia and diabetic nephropathy. A variability of triglyceride (TG) levels has been reported in diabetes. OBJECTIVES To investigate the relationship of TG variability with the incidence of microalbuminuria (albumin excretion rate > 20 μg/min), in patients with type 2 diabetes. METHODS A longitudinal, retrospective, observational study was performed on a consecutive series of 457 normoalbuminuric outpatients, with measurements of HbA1c, lipids and microalbuminuria thrice per year with 6.8-year follow-up. TG variability, defined as standard deviation of TG (TG-SD) and TG-SD adjusted for the number of visits was calculated. A nested case-control sensitivity analysis was performed to validate the results of the primary cohort study. RESULTS Incident microalbuminuria (N = 124, 27.1%) was associated with higher median TG-SD (33.6 mg/dL vs 29.0 mg/dL, P < .05) and TG-SD adjusted for the number of visits (31.4 mg/dL vs 26.7 mg/dL, P < .05). At multivariate (Cox) analysis, logTG-SD and adj-logTG-SD were significant predictors of incident microalbuminuria (hazard ratio 2.1 [1.1-4.2], P = .028 and 1.5 [1.1-3.3], P = .042, respectively). In the case-control analysis, time spent with TG > 150 mg/dL during the follow-up was significantly higher in cases vs controls (27.2 ± 19 vs 16.7 ± 12.5 months, P < .05) with hazard ratio 2.0 (1.1-5.1), P < .05, for adj-logTG-SD. CONCLUSIONS A higher intraindividual TG variability is a predictor of incident microalbuminuria in type 2 diabetes. In addition, time of exposure to elevated TG levels (>150 mg/dL) predicts incident microalbuminuria.
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Affiliation(s)
- Gianluca Bardini
- Department of Biomedical Clinical and Experimental Sciences, Obesity Agency, University of Florence and Careggi University Hospital, Florence, Italy
| | - Maddalena Innocenti
- Department of Biomedical Clinical and Experimental Sciences, Obesity Agency, University of Florence and Careggi University Hospital, Florence, Italy
| | - Carlo Maria Rotella
- Department of Biomedical Clinical and Experimental Sciences, Obesity Agency, University of Florence and Careggi University Hospital, Florence, Italy
| | - Stefano Giannini
- Section of Endocrinology, Department of Biomedical, Clinical and Experimental Sciences, University of Florence, Florence, Italy.
| | - Edoardo Mannucci
- Department of Geriatric Medicine, Diabetes Agency, Careggi University Hospital, Florence, Italy
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15
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Fox CS, Golden SH, Anderson C, Bray GA, Burke LE, de Boer IH, Deedwania P, Eckel RH, Ershow AG, Fradkin J, Inzucchi SE, Kosiborod M, Nelson RG, Patel MJ, Pignone M, Quinn L, Schauer PR, Selvin E, Vafiadis DK. Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence: A Scientific Statement From the American Heart Association and the American Diabetes Association. Diabetes Care 2015; 38:1777-803. [PMID: 26246459 PMCID: PMC4876675 DOI: 10.2337/dci15-0012] [Citation(s) in RCA: 283] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Cardiovascular disease risk factor control as primary prevention in patients with type 2 diabetes mellitus has changed substantially in the past few years. The purpose of this scientific statement is to review the current literature and key clinical trials pertaining to blood pressure and blood glucose control, cholesterol management, aspirin therapy, and lifestyle modification. We present a synthesis of the recent literature, new guidelines, and clinical targets, including screening for kidney and subclinical cardiovascular disease for the contemporary management of patients with type 2 diabetes mellitus.
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16
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Di Giovine G, Verdoia M, Barbieri L, Schaffer A, Aimaretti G, Bellomo G, Marino P, Suryapranata H, Sinigaglia F, De Luca G. Impact of diabetes on fibrinogen levels and its relationship with platelet reactivity and coronary artery disease: A single-centre study. Diabetes Res Clin Pract 2015; 109:541-50. [PMID: 26163440 DOI: 10.1016/j.diabres.2015.05.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Revised: 02/11/2015] [Accepted: 05/02/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Previous reports have suggested an association between elevated fibrinogen and CAD. Few studies have so far investigated the impact of diabetes on fibrinogen levels and its association with coronary artery disease (CAD) and platelet reactivity in diabetic patients that are therefore the aims of the current study. METHODS We measured fibrinogen in 3280 consecutive patients undergoing coronary angiography. Samples were collected at admission for fibrinogen levels assessment. Coronary disease was defined for at least 1 vessel stenosis >50% as evaluated by QCA. RESULTS Diabetes was observed in 1201 out of 3280 patients. Diabetic patients were older with more hypercholesterolemia, hypertension, higher BMI, more renal failure, previous MI or coronary revascularization (p<0.001, respectively) and smoking (p=0.001). Diabetic patients were more often on ACE-inhibitors, ARBs, b-blockers, calcium-antagonists, diuretics, statins (p<0.001, respectively), and ASA (p=0.004). Diabetic patients displayed higher glycaemia and HbA1c (p<0.001), higher creatinine and triglycerides (p<0.001) but lower total and HDL cholesterol (p<0.001) and haemoglobin (p<0.001). Diabetic patients had higher fibrinogen levels (p=0.003), however neither diabetes nor glucose homeostasis parameters resulted as independent predictors of hyperfibrinogenemia. Furthermore, among diabetic patients, higher fibrinogen levels did not affect platelet reactivity and were not associated with the prevalence of CAD (adjusted OR[95%CI]=0.99 [0.82-1.19], p=0.9). Similar results were found for severe CAD (adjusted OR[95%CI]=0.94 [0.82-1.08], p=0.40). CONCLUSIONS Our study showed that diabetes and glycaemic control are not independent predictors of hyperfibrinogenemia. Among diabetic patients, elevated fibrinogen is not associated with platelet reactivity and the prevalence and extent of CAD.
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Affiliation(s)
| | - Monica Verdoia
- Department of Cardiology, Eastern Piedmont University, Novara, Italy
| | - Lucia Barbieri
- Department of Cardiology, Eastern Piedmont University, Novara, Italy
| | - Alon Schaffer
- Department of Cardiology, Eastern Piedmont University, Novara, Italy
| | - Gianluca Aimaretti
- Department of Translational Medicine, Eastern Piedmont University, Novara, Italy
| | - Giorgio Bellomo
- Department of Translational Medicine, Eastern Piedmont University, Novara, Italy
| | - Paolo Marino
- Department of Cardiology, Eastern Piedmont University, Novara, Italy; Department of Translational Medicine, Eastern Piedmont University, Novara, Italy
| | | | - Fabiola Sinigaglia
- Department of Translational Medicine, Eastern Piedmont University, Novara, Italy
| | - Giuseppe De Luca
- Department of Cardiology, Eastern Piedmont University, Novara, Italy; Department of Translational Medicine, Eastern Piedmont University, Novara, Italy.
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17
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Fox CS, Golden SH, Anderson C, Bray GA, Burke LE, de Boer IH, Deedwania P, Eckel RH, Ershow AG, Fradkin J, Inzucchi SE, Kosiborod M, Nelson RG, Patel MJ, Pignone M, Quinn L, Schauer PR, Selvin E, Vafiadis DK. Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence: A Scientific Statement From the American Heart Association and the American Diabetes Association. Circulation 2015; 132:691-718. [PMID: 26246173 DOI: 10.1161/cir.0000000000000230] [Citation(s) in RCA: 243] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiovascular disease risk factor control as primary prevention in patients with type 2 diabetes mellitus has changed substantially in the past few years. The purpose of this scientific statement is to review the current literature and key clinical trials pertaining to blood pressure and blood glucose control, cholesterol management, aspirin therapy, and lifestyle modification. We present a synthesis of the recent literature, new guidelines, and clinical targets, including screening for kidney and subclinical cardiovascular disease for the contemporary management of patients with type 2 diabetes mellitus.
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18
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Eckel RH. Intestinal Lipoprotein Secretion: Incretin-Based Physiology and Pharmacology Beyond Glucose. Diabetes 2015; 64:2338-40. [PMID: 26106196 DOI: 10.2337/db15-0470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Robert H Eckel
- Division of Endocrinology, Metabolism and Diabetes and Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
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