1
|
Lee YS, Park JW, Joo M, Moon S, Kim K, Kim MG. Effects of Omega-3 Fatty Acids on Flow-mediated Dilatation and Carotid Intima Media Thickness: A Meta-analysis. Curr Atheroscler Rep 2023; 25:629-641. [PMID: 37552456 DOI: 10.1007/s11883-023-01137-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2023] [Indexed: 08/09/2023]
Abstract
PURPOSE OF REVIEW To investigate the effects of omega-3 fatty acids on flow-mediated dilatation (FMD) and carotid intima-media thickness (CIMT) and explore the factors influencing these effects. RECENT FINDINGS FMD was significantly higher in the omega-3 fatty acid group compared to the control group (mean difference = 0.90%; p = 0.0003). In particular, the subgroup with CHD (both EPA + DHA < 1 g/day and ≥ 1 g/day) and the subgroup without CHD but with CHD risk factors (only EPA + DHA ≥ 1 g/day) showed significantly increased FMD after supplementation of omega-3 fatty acids. CIMT was not significantly different between the omega-3 fatty acid and control groups (standardized mean difference = -0.08; p = 0.26). Subgroup analysis of CHD patients was not conducted because of the limited number of studies. Intake of omega-3 fatty acids improved FMD in patients with CHD and patients with risk factors for CHD. Further research is needed on the effects of omega-3 fatty acids on CIMT.
Collapse
Affiliation(s)
- Young Seo Lee
- College of Pharmacy, Ewha Womans University, Seoul, 03760, Republic of Korea
| | - Ji Won Park
- College of Pharmacy, Korea University, Sejong, 30019, Republic of Korea
| | - Minjin Joo
- College of Pharmacy, Ewha Womans University, Seoul, 03760, Republic of Korea
| | - Sumin Moon
- College of Pharmacy, Ewha Womans University, Seoul, 03760, Republic of Korea
| | - Kyungim Kim
- College of Pharmacy, Korea University, Sejong, 30019, Republic of Korea.
- Institute of Pharmaceutical Science, Korea University, Sejong, 30019, Republic of Korea.
| | - Myeong Gyu Kim
- College of Pharmacy, Ewha Womans University, Seoul, 03760, Republic of Korea.
- Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, 03760, Republic of Korea.
| |
Collapse
|
2
|
Manubolu VS, Budoff MJ, Lakshmanan S. Multimodality Imaging Trials Evaluating the Impact of Omega-3 Fatty Acids on Coronary Artery Plaque Characteristics and Burden. Heart Int 2022; 16:2-11. [PMID: 36275355 PMCID: PMC9524586 DOI: 10.17925/hi.2022.16.1.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/06/2022] [Indexed: 06/16/2023] Open
Abstract
Treatment of established risk factors, especially low-density lipoprotein (LDL) cholesterol, is the cornerstone of preventing atherosclerotic coronary artery disease. Despite reducing LDL cholesterol, there remains a significant risk of cardiovascular disease. Inflammatory and metabolic pathways contribute to recurrence of cardiovascular events, and are often missed in clinical practice. Eicosapentaenoic acid (EPA) may play a crucial role in reducing residual risk of cardiovascular disease. In this review we discuss the clinical applications of omega-3 fatty acids (OM3FAs), their mechanism of action, the difference between pure EPA and docosahexaenoic acid components, and the latest cardiovascular outcome trials and imaging trials evaluating coronary plaque. PubMed and EMBASE were searched to include all the remarkable clinical trials investigating OM3FAs and cardiovascular disease. Beyond statins, additional medications are required to reduce the risk of cardiovascular disease. EPA has shown cardiovascular benefit in addition to statins in large outcome trials. Additionally, multiple serial-imaging studies have demonstrated benefits on plaque progression and stabilization. Due to its pleotropic properties, icosapent ethyl outperforms other OM3FAs in decreasing cardiovascular disease risk in both patients with and without high triglycerides, and is currently recommended as an adjunct to statins. To further strengthen the current evidence, additional research is required to elucidate the inconsistencies between the effects of pure EPA and EPA plus docosahexaenoic acid.
Collapse
Affiliation(s)
| | | | - Suvasini Lakshmanan
- Division of Cardiology, The University of Iowa Carver College of Medicine, Iowa City, IA, USA
| |
Collapse
|
3
|
Alvarez Campano CG, Macleod MJ, Aucott L, Thies F. Marine-derived n-3 fatty acids therapy for stroke. Cochrane Database Syst Rev 2022; 6:CD012815. [PMID: 35766825 PMCID: PMC9241930 DOI: 10.1002/14651858.cd012815.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Currently, with stroke burden increasing, there is a need to explore therapeutic options that ameliorate the acute insult. There is substantial evidence of a neuroprotective effect of marine-derived n-3 polyunsaturated fatty acids (PUFAs) in animal models of stroke, leading to a better functional outcome. OBJECTIVES To assess the effects of administration of marine-derived n-3 PUFAs on functional outcomes and dependence in people with stroke. SEARCH METHODS We searched the Cochrane Stroke Trials Register (last searched 31 May 2021), the Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 5), MEDLINE Ovid (from 1948 to 31 May 2021), Embase Ovid (from 1980 to 31 May 2021), CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; from 1982 to 31 May 2021), Science Citation Index Expanded ‒ Web of Science (SCI-EXPANDED), Conference Proceedings Citation Index-Science - Web of Science (CPCI-S), and BIOSIS Citation Index. We also searched ongoing trial registers, reference lists, relevant systematic reviews, and used the Science Citation Index Reference Search. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing marine-derived n-3 PUFAs to placebo or open control (no placebo) in people with a history of stroke or transient ischaemic attack (TIA), or both. DATA COLLECTION AND ANALYSIS At least two review authors independently selected trials for inclusion, extracted data, assessed risk of bias, and used the GRADE approach to assess the certainty of the body of evidence. We contacted study authors for clarification and additional information on stroke/TIA participants. We conducted random-effects meta-analysis or narrative synthesis, as appropriate. The primary outcome was efficacy (functional outcome) assessed using a validated scale, for example, the Glasgow Outcome Scale Extended (GOSE) dichotomised into poor or good clinical outcome, the Barthel Index (higher score is better; scale from 0 to 100), or the Rivermead Mobility Index (higher score is better; scale from 0 to 15). Our secondary outcomes were vascular-related death, recurrent events, incidence of other type of stroke, adverse events, quality of life, and mood. MAIN RESULTS We included 30 RCTs; nine of them provided outcome data (3339 participants). Only one study included participants in the acute phase of stroke (haemorrhagic). Doses of marine-derived n-3 PUFAs ranged from 400 mg/day to 3300 mg/day. Risk of bias was generally low or unclear in most trials, with a higher risk of bias in smaller studies. We assessed results separately for short (up to three months) and longer (more than three months) follow-up studies. Short follow-up (up to three months) Functional outcome was reported in only one pilot study as poor clinical outcome assessed with the GOSE (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.36 to 1.68, P = 0.52; 40 participants; very low-certainty evidence). Mood (assessed with the GHQ-30, lower score better) was reported by only one study and favoured control (mean difference (MD) 1.41, 95% CI 0.07 to 2.75, P = 0.04; 102 participants; low-certainty evidence). We found no evidence of an effect of the intervention for the remainder of the secondary outcomes: vascular-related death (two studies, not pooled due to differences in population, RR 0.33, 95% CI 0.01 to 8.00, P = 0.50, and RR 0.33, 95% CI 0.01 to 7.72, P = 0.49; 142 participants; low-certainty evidence); recurrent events (RR 0.41, 95% CI 0.02 to 8.84, P = 0.57; 18 participants; very low-certainty evidence); incidence of other type of stroke (two studies, not pooled due to different type of index stroke, RR 6.11, 95% CI 0.33 to 111.71, P = 0.22, and RR 0.63, 95% CI 0.25 to 1.58, P = 0.32; 58 participants; very low-certainty evidence); and quality of life (physical component, MD -2.31, 95% CI -4.81 to 0.19, P = 0.07, and mental component, MD -2.16, 95% CI -5.91 to 1.59, P = 0.26; 1 study; 102 participants; low-certainty evidence). Adverse events were reported by two studies (57 participants; very low-certainty evidence), one trial reporting extracranial haemorrhage (RR 0.25, 95% CI 0.04 to 1.73, P = 0.16) and the other one reporting bleeding complications (RR 0.32, 95% CI 0.01 to 7.35, P = 0.47). Longer follow-up (more than three months) One small trial assessed functional outcome with both the Barthel Index for activities of daily living (MD 7.09, 95% CI -5.16 to 19.34, P = 0.26), and the Rivermead Mobility Index for mobility (MD 1.30, 95% CI -1.31 to 3.91, P = 0.33) (52 participants; very low-certainty evidence). We carried out meta-analysis for vascular-related death (RR 1.02, 95% CI 0.78 to 1.35, P = 0.86; 5 studies; 2237 participants; low-certainty evidence) and fatal recurrent events (RR 0.69, 95% CI 0.31 to 1.55, P = 0.37; 3 studies; 1819 participants; low-certainty evidence). We found no evidence of an effect of the intervention for mood (MD 1.00, 95% CI -2.07 to 4.07, P = 0.61; 1 study; 14 participants; low-certainty evidence). Incidence of other type of stroke and quality of life were not reported. Adverse events (all combined) were reported by only one study (RR 0.94, 95% CI 0.56 to 1.58, P = 0.82; 1455 participants; low-certainty evidence). AUTHORS' CONCLUSIONS We are very uncertain of the effect of marine-derived n-3 PUFAs therapy on functional outcomes and dependence after stroke as there is insufficient high-certainty evidence. More well-designed RCTs are needed, specifically in acute stroke, to determine the efficacy and safety of the intervention. Studies assessing functional outcome might consider starting the intervention as early as possible after the event, as well as using standardised, clinically relevant measures for functional outcomes, such as the modified Rankin Scale. Optimal doses remain to be determined; delivery forms (type of lipid carriers) and mode of administration (ingestion or injection) also need further consideration.
Collapse
Affiliation(s)
| | | | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Frank Thies
- The Rowett Institute, University of Aberdeen, Aberdeen, UK
| |
Collapse
|
4
|
Manubolu VS, Budoff MJ, Lakshmanan S. Multimodality Imaging Trials Evaluating the Impact of Omega-3 Fatty Acids on Coronary Artery Plaque Characteristics and Burden. Heart Int 2022. [DOI: 10.17925/hi.2022.16.1.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Treatment of established risk factors, especially low-density lipoprotein (LDL) cholesterol, is the cornerstone of preventing atherosclerotic coronary artery disease. Despite reducing LDL cholesterol, there remains a significant risk of cardiovascular disease. Inflammatory and metabolic pathways contribute to recurrence of cardiovascular events, and are often missed in clinical practice. Eicosapentaenoic acid (EPA) may play a crucial role in reducing residual risk of cardiovascular disease. In this review we discuss the clinical applications of omega-3 fatty acids (OM3FAs), their mechanism of action, the difference between pure EPA and docosahexaenoic acid components, and the latest cardiovascular outcome trials and imaging trials evaluating coronary plaque. PubMed and EMBASE were searched to include all the remarkable clinical trials investigating OM3FAs and cardiovascular disease. Beyond statins, additional medications are required to reduce the risk of cardiovascular disease. EPA has shown cardiovascular benefit in addition to statins in large outcome trials. Additionally, multiple serial-imaging studies have demonstrated benefits on plaque progression and stabilization. Due to its pleotropic properties, icosapent ethyl outperforms other OM3FAs in decreasing cardiovascular disease risk in both patients with and without high triglycerides, and is currently recommended as an adjunct to statins. To further strengthen the current evidence, additional research is required to elucidate the inconsistencies between the effects of pure EPA and EPA plus docosahexaenoic acid.
Collapse
|
5
|
Frigerio B, Werba JP, Amato M, Ravani A, Sansaro D, Coggi D, Vigo L, Tremoli E, Baldassarre D. Traditional Risk Factors are Causally Related to Carotid Intima-Media Thickness Progression: Inferences from Observational Cohort Studies and Interventional Trials. Curr Pharm Des 2020; 26:11-24. [PMID: 31838990 DOI: 10.2174/1381612825666191213120339] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 12/02/2019] [Indexed: 12/24/2022]
Abstract
In the present review, associations between traditional vascular risk factors (VRFs) and carotid intimamedial thickness progression (C-IMTp) as well as the effects of therapies for VRFs control on C-IMTp were appraised to infer causality between each VRF and C-IMTp. Cohort studies indicate that smoking, binge drinking, fatness, diabetes, hypertension and hypercholesterolemia are associated with accelerated C-IMTp. An exception is physical activity, with mixed data. Interventions for the control of obesity, diabetes, hypertension and hypercholesterolemia decelerate C-IMTp. Conversely, scarce information is available regarding the effect of smoking cessation, stop of excessive alcohol intake and management of the metabolic syndrome. Altogether, these data support a causative role of several traditional VRFs on C-IMTp. Shortcomings in study design and/or ultrasonographic protocols may account for most negative studies, which underlines the importance of careful consideration of methodological aspects in investigations using C-IMTp as the outcome.
Collapse
Affiliation(s)
| | - José P Werba
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Mauro Amato
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | | | | | - Daniela Coggi
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Universita di Milano, Milan, Italy
| | - Lorenzo Vigo
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Elena Tremoli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Dipartimento di Scienze Farmacologiche e Biomolecolari, Universita di Milano, Milan, Italy
| | - Damiano Baldassarre
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Department of Medical Biotechnology and Translational Medicine, Università di Milano, Milan, Italy
| |
Collapse
|
6
|
Willeit P, Tschiderer L, Allara E, Reuber K, Seekircher L, Gao L, Liao X, Lonn E, Gerstein HC, Yusuf S, Brouwers FP, Asselbergs FW, van Gilst W, Anderssen SA, Grobbee DE, Kastelein JJP, Visseren FLJ, Ntaios G, Hatzitolios AI, Savopoulos C, Nieuwkerk PT, Stroes E, Walters M, Higgins P, Dawson J, Gresele P, Guglielmini G, Migliacci R, Ezhov M, Safarova M, Balakhonova T, Sato E, Amaha M, Nakamura T, Kapellas K, Jamieson LM, Skilton M, Blumenthal JA, Hinderliter A, Sherwood A, Smith PJ, van Agtmael MA, Reiss P, van Vonderen MGA, Kiechl S, Klingenschmid G, Sitzer M, Stehouwer CDA, Uthoff H, Zou ZY, Cunha AR, Neves MF, Witham MD, Park HW, Lee MS, Bae JH, Bernal E, Wachtell K, Kjeldsen SE, Olsen MH, Preiss D, Sattar N, Beishuizen E, Huisman MV, Espeland MA, Schmidt C, Agewall S, Ok E, Aşçi G, de Groot E, Grooteman MPC, Blankestijn PJ, Bots ML, Sweeting MJ, Thompson SG, Lorenz MW. Carotid Intima-Media Thickness Progression as Surrogate Marker for Cardiovascular Risk: Meta-Analysis of 119 Clinical Trials Involving 100 667 Patients. Circulation 2020; 142:621-642. [PMID: 32546049 PMCID: PMC7115957 DOI: 10.1161/circulationaha.120.046361] [Citation(s) in RCA: 253] [Impact Index Per Article: 63.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 07/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND To quantify the association between effects of interventions on carotid intima-media thickness (cIMT) progression and their effects on cardiovascular disease (CVD) risk. METHODS We systematically collated data from randomized, controlled trials. cIMT was assessed as the mean value at the common-carotid-artery; if unavailable, the maximum value at the common-carotid-artery or other cIMT measures were used. The primary outcome was a combined CVD end point defined as myocardial infarction, stroke, revascularization procedures, or fatal CVD. We estimated intervention effects on cIMT progression and incident CVD for each trial, before relating the 2 using a Bayesian meta-regression approach. RESULTS We analyzed data of 119 randomized, controlled trials involving 100 667 patients (mean age 62 years, 42% female). Over an average follow-up of 3.7 years, 12 038 patients developed the combined CVD end point. Across all interventions, each 10 μm/y reduction of cIMT progression resulted in a relative risk for CVD of 0.91 (95% Credible Interval, 0.87-0.94), with an additional relative risk for CVD of 0.92 (0.87-0.97) being achieved independent of cIMT progression. Taken together, we estimated that interventions reducing cIMT progression by 10, 20, 30, or 40 μm/y would yield relative risks of 0.84 (0.75-0.93), 0.76 (0.67-0.85), 0.69 (0.59-0.79), or 0.63 (0.52-0.74), respectively. Results were similar when grouping trials by type of intervention, time of conduct, time to ultrasound follow-up, availability of individual-participant data, primary versus secondary prevention trials, type of cIMT measurement, and proportion of female patients. CONCLUSIONS The extent of intervention effects on cIMT progression predicted the degree of CVD risk reduction. This provides a missing link supporting the usefulness of cIMT progression as a surrogate marker for CVD risk in clinical trials.
Collapse
Affiliation(s)
- Peter Willeit
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Lena Tschiderer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Elias Allara
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- National Institute for Health Research Blood and Transplant Research Unit in Donor Health and Genomics, University of Cambridge, Cambridge, UK
| | - Kathrin Reuber
- Department of Neurology, Goethe University, Frankfurt am Main, Germany
| | - Lisa Seekircher
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lu Gao
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Ximing Liao
- Department of Neurology, Goethe University, Frankfurt am Main, Germany
| | - Eva Lonn
- Department of Medicine and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Hertzel C. Gerstein
- Department of Medicine and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Department of Medicine and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Frank P. Brouwers
- Department of Cardiology, Haga Teaching Hospital, the Hague, the Netherlands
| | - Folkert W. Asselbergs
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Wiek van Gilst
- Department of Experimental Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Sigmund A. Anderssen
- Department of Sports Medicine, Norwegian School of Sports Sciences, Oslo, Norway
| | - Diederick E. Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - John J. P. Kastelein
- Department of Vascular Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Frank L. J. Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - George Ntaios
- Department of Medicine, University of Thessaly, Larissa, Greece
| | - Apostolos I. Hatzitolios
- 1st Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christos Savopoulos
- 1st Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Pythia T. Nieuwkerk
- Department of Medical Psychology, Amsterdam UMC- Location AMC, Amsterdam, the Netherlands
| | - Erik Stroes
- Department of Vascular Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Matthew Walters
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Peter Higgins
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Paolo Gresele
- Division of Internal and Cardiovascular Medicine, Department of Medicine, University of Perugia, Perugia, Italy
| | - Giuseppe Guglielmini
- Division of Internal and Cardiovascular Medicine, Department of Medicine, University of Perugia, Perugia, Italy
| | - Rino Migliacci
- Division of Internal Medicine, Cortona Hospital, Cortona, Italy
| | - Marat Ezhov
- Laboratory of Lipid Disorders, National Medical Research Center of Cardiology, Moscow, Russia
| | - Maya Safarova
- Atherosclerosis Department, National Medical Research Center of Cardiology, Moscow, Russia
| | - Tatyana Balakhonova
- Ultrasound Vascular Laboratory, National Medical Research Center of Cardiology, Moscow, Russia
| | - Eiichi Sato
- Division of Nephrology, Shinmatsudo Central General Hospital, Chiba, Japan
| | - Mayuko Amaha
- Division of Nephrology, Shinmatsudo Central General Hospital, Chiba, Japan
| | - Tsukasa Nakamura
- Division of Nephrology, Shinmatsudo Central General Hospital, Chiba, Japan
| | - Kostas Kapellas
- Australian Research Centre for Population Oral Health, University of Adelaide, Adelaide, SA, Australia
| | - Lisa M. Jamieson
- Australian Research Centre for Population Oral Health, University of Adelaide, Adelaide, SA, Australia
| | - Michael Skilton
- Boden Institute of Obesity, Nutrition, Exercise and Eating Disorders, University of Sydney, Sydney, NSW, Australia
| | - James A. Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Alan Hinderliter
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Andrew Sherwood
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Patrick J. Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Michiel A. van Agtmael
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Peter Reiss
- Department of Global Health, Amsterdam UMC- Location AMC, Amsterdam, the Netherlands
- Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Stefan Kiechl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- VASCage GmbH, Research Centre on Vascular Ageing and Stroke, Innsbruck, Austria
| | | | - Matthias Sitzer
- Department of Neurology, Goethe University, Frankfurt am Main, Germany
- Department of Neurology, Klinikum Herford, Herford, Germany
| | - Coen D. A. Stehouwer
- Department of Internal Medicine and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Heiko Uthoff
- Department of Angiology, University Hospital Basel, Basel, Switzerland
| | - Zhi-Yong Zou
- Institute of Child and Adolescent Health, School of Public Health, Peking University, Beijing, China
| | - Ana R. Cunha
- Department of Clinical Medicine, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mario F. Neves
- Department of Clinical Medicine, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Miles D. Witham
- AGE Research Group, NIHR Newcastle Biomedical Research Centre, Newcastle University and Newcastle-upon-Tyne Hospitals Trust, Newcastle, UK
| | - Hyun-Woong Park
- Department of Internal Medicine, Gyeongsang National University Hospital, Daejeon, South Korea
| | - Moo-Sik Lee
- Department of Internal Medicine, Gyeongsang National University Hospital, Daejeon, South Korea
- Department of Preventive Medicine, Konyang University, Jinju, South Korea
| | - Jang-Ho Bae
- Heart Center, Konyang University Hospital, Daejeon, South Korea
- Department of Cardiology, Konyang University College of Medicine, Daejeon, South Korea
| | - Enrique Bernal
- Infectious Diseases Unit, Reina Sofia Hospital, Murcia, Spain
| | | | | | - Michael H. Olsen
- Department of Internal Medicine, Holbaek Hospital, University of Southern Denmark, Odense, Denmark
| | - David Preiss
- MRC Population Health Research Unit, Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Naveed Sattar
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Edith Beishuizen
- Department of Internal Medicine, HMC+ (Bronovo), the Hague, the Netherlands
| | - Menno V. Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Mark A. Espeland
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Caroline Schmidt
- Wallenberg Laboratory for Cardiovascular Research, University of Gothenburg, Gothenburg, Sweden
| | - Stefan Agewall
- Oslo University Hospital Ullevål and Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Ercan Ok
- Nephrology Department, Ege University School of Medicine, Bornova-Izmir, Turkey
| | - Gülay Aşçi
- Nephrology Department, Ege University School of Medicine, Bornova-Izmir, Turkey
| | - Eric de Groot
- Imagelabonline & Cardiovascular, Eindhoven and Lunteren, the Netherlands
| | | | - Peter J. Blankestijn
- Department of Nephrology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Michiel L. Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Michael J. Sweeting
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Simon G. Thompson
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | |
Collapse
|
7
|
O'Mahoney LL, Dunseath G, Churm R, Holmes M, Boesch C, Stavropoulos-Kalinoglou A, Ajjan RA, Birch KM, Orsi NM, Mappa G, Price OJ, Campbell MD. Omega-3 polyunsaturated fatty acid supplementation versus placebo on vascular health, glycaemic control, and metabolic parameters in people with type 1 diabetes: a randomised controlled preliminary trial. Cardiovasc Diabetol 2020; 19:127. [PMID: 32787879 PMCID: PMC7425064 DOI: 10.1186/s12933-020-01094-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/25/2020] [Indexed: 12/11/2022] Open
Abstract
Background The role of omega-3 polyunsaturated fatty acids (n-3PUFA), and the potential impact of n-3PUFA supplementation, in the treatment and management of type 1 diabetes (T1D) remains unclear and controversial. Therefore, this study aimed to examine the efficacy of daily high-dose-bolus n-3PUFA supplementation on vascular health, glycaemic control, and metabolic parameters in subjects with T1D. Methods Twenty-seven adults with T1D were recruited to a 6-month randomised, double-blind, placebo-controlled trial. Subjects received either 3.3 g/day of encapsulated n-3PUFA or encapsulated 3.0 g/day corn oil placebo (PLA) for 6-months, with follow-up at 9-months after 3-month washout. Erythrocyte fatty acid composition was determined via gas chromatography. Endpoints included inflammation-associated endothelial biomarkers (vascular cell adhesion molecule-1 [VCAM-1], intercellular adhesion molecule-1 [ICAM-1], E-selectin, P-selectin, pentraxin-3, vascular endothelial growth factor [VEGF]), and their mediator tumor necrosis factor alpha [TNFα] analysed via immunoassay, vascular structure (carotid intima-media thickness [CIMT]) and function (brachial artery flow mediated dilation [FMD]) determined via ultrasound technique, blood pressure, glycosylated haemoglobin (HbA1c), fasting plasma glucose (FPG), and postprandial metabolism. Results Twenty subjects completed the trial in full. In the n-3PUFA group, the mean ± SD baseline n-3PUFA index of 4.93 ± 0.94% increased to 7.67 ± 1.86% (P < 0.001) after 3-months, and 8.29 ± 1.45% (P < 0.001) after 6-months. Total exposure to n-3PUFA over the 6-months (area under the curve) was 14.27 ± 3.05% per month under n-3PUFA, and 9.11 ± 2.74% per month under PLA (P < 0.001). VCAM-1, ICAM-1, E-selectin, P-selectin, pentraxin-3, VEGF, TNFα, CIMT, FMD, blood pressure, HbA1c, FPG, and postprandial metabolism did not differ between or within groups after treatment (P > 0.05). Conclusions This study indicates that daily high-dose-bolus of n-3PUFA supplementation for 6-months does not improve vascular health, glucose homeostasis, or metabolic parameters in subjects with T1D. The findings from this preliminary RCT do not support the use of therapeutic n-3PUFA supplementation in the treatment and management of T1D and its associated complications. Trial Registration ISRCTN, ISRCTN40811115. Registered 27 June 2017, http://www.isrctn.com/ISRCTN40811115.
Collapse
Affiliation(s)
| | - Gareth Dunseath
- Diabetes Research Group, Swansea University Medical School, Swansea University, Swansea, UK
| | - Rachel Churm
- Applied Sports, Technology, Exercise and Medicine (A-STEM) Research Centre, Swansea University, Swansea, UK
| | - Mel Holmes
- School of Food Science and Nutrition, Faculty of Environment, University of Leeds, Leeds, LS2 9JT, UK
| | - Christine Boesch
- School of Food Science and Nutrition, Faculty of Environment, University of Leeds, Leeds, LS2 9JT, UK
| | | | - Ramzi A Ajjan
- Leeds Institute of Cardiovascular and Metabolic Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Karen M Birch
- School of Biomedical Sciences, University of Leeds, Leeds, UK
| | - Nicolas M Orsi
- Leeds Institute of Medical Research at St James's, St James's University Hospital, Leeds, UK
| | - Georgia Mappa
- Leeds Institute of Medical Research at St James's, St James's University Hospital, Leeds, UK
| | - Oliver J Price
- Carnegie School of Sport, Leeds Beckett University, Leeds, UK
| | - Matthew D Campbell
- School of Food Science and Nutrition, Faculty of Environment, University of Leeds, Leeds, LS2 9JT, UK.
| |
Collapse
|
8
|
Abdelhamid AS, Brown TJ, Brainard JS, Biswas P, Thorpe GC, Moore HJ, Deane KHO, Summerbell CD, Worthington HV, Song F, Hooper L. Omega-3 fatty acids for the primary and secondary prevention of cardiovascular disease. Cochrane Database Syst Rev 2020; 3:CD003177. [PMID: 32114706 PMCID: PMC7049091 DOI: 10.1002/14651858.cd003177.pub5] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Omega-3 polyunsaturated fatty acids from oily fish (long-chain omega-3 (LCn3)), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)), as well as from plants (alpha-linolenic acid (ALA)) may benefit cardiovascular health. Guidelines recommend increasing omega-3-rich foods, and sometimes supplementation, but recent trials have not confirmed this. OBJECTIVES To assess the effects of increased intake of fish- and plant-based omega-3 fats for all-cause mortality, cardiovascular events, adiposity and lipids. SEARCH METHODS We searched CENTRAL, MEDLINE and Embase to February 2019, plus ClinicalTrials.gov and World Health Organization International Clinical Trials Registry to August 2019, with no language restrictions. We handsearched systematic review references and bibliographies and contacted trial authors. SELECTION CRITERIA We included randomised controlled trials (RCTs) that lasted at least 12 months and compared supplementation or advice to increase LCn3 or ALA intake, or both, versus usual or lower intake. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, extracted data and assessed validity. We performed separate random-effects meta-analysis for ALA and LCn3 interventions, and assessed dose-response relationships through meta-regression. MAIN RESULTS We included 86 RCTs (162,796 participants) in this review update and found that 28 were at low summary risk of bias. Trials were of 12 to 88 months' duration and included adults at varying cardiovascular risk, mainly in high-income countries. Most trials assessed LCn3 supplementation with capsules, but some used LCn3- or ALA-rich or enriched foods or dietary advice compared to placebo or usual diet. LCn3 doses ranged from 0.5 g a day to more than 5 g a day (19 RCTs gave at least 3 g LCn3 daily). Meta-analysis and sensitivity analyses suggested little or no effect of increasing LCn3 on all-cause mortality (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.93 to 1.01; 143,693 participants; 11,297 deaths in 45 RCTs; high-certainty evidence), cardiovascular mortality (RR 0.92, 95% CI 0.86 to 0.99; 117,837 participants; 5658 deaths in 29 RCTs; moderate-certainty evidence), cardiovascular events (RR 0.96, 95% CI 0.92 to 1.01; 140,482 participants; 17,619 people experienced events in 43 RCTs; high-certainty evidence), stroke (RR 1.02, 95% CI 0.94 to 1.12; 138,888 participants; 2850 strokes in 31 RCTs; moderate-certainty evidence) or arrhythmia (RR 0.99, 95% CI 0.92 to 1.06; 77,990 participants; 4586 people experienced arrhythmia in 30 RCTs; low-certainty evidence). Increasing LCn3 may slightly reduce coronary heart disease mortality (number needed to treat for an additional beneficial outcome (NNTB) 334, RR 0.90, 95% CI 0.81 to 1.00; 127,378 participants; 3598 coronary heart disease deaths in 24 RCTs, low-certainty evidence) and coronary heart disease events (NNTB 167, RR 0.91, 95% CI 0.85 to 0.97; 134,116 participants; 8791 people experienced coronary heart disease events in 32 RCTs, low-certainty evidence). Overall, effects did not differ by trial duration or LCn3 dose in pre-planned subgrouping or meta-regression. There is little evidence of effects of eating fish. Increasing ALA intake probably makes little or no difference to all-cause mortality (RR 1.01, 95% CI 0.84 to 1.20; 19,327 participants; 459 deaths in 5 RCTs, moderate-certainty evidence),cardiovascular mortality (RR 0.96, 95% CI 0.74 to 1.25; 18,619 participants; 219 cardiovascular deaths in 4 RCTs; moderate-certainty evidence), coronary heart disease mortality (RR 0.95, 95% CI 0.72 to 1.26; 18,353 participants; 193 coronary heart disease deaths in 3 RCTs; moderate-certainty evidence) and coronary heart disease events (RR 1.00, 95% CI 0.82 to 1.22; 19,061 participants; 397 coronary heart disease events in 4 RCTs; low-certainty evidence). However, increased ALA may slightly reduce risk of cardiovascular disease events (NNTB 500, RR 0.95, 95% CI 0.83 to 1.07; but RR 0.91, 95% CI 0.79 to 1.04 in RCTs at low summary risk of bias; 19,327 participants; 884 cardiovascular disease events in 5 RCTs; low-certainty evidence), and probably slightly reduces risk of arrhythmia (NNTB 91, RR 0.73, 95% CI 0.55 to 0.97; 4912 participants; 173 events in 2 RCTs; moderate-certainty evidence). Effects on stroke are unclear. Increasing LCn3 and ALA had little or no effect on serious adverse events, adiposity, lipids and blood pressure, except increasing LCn3 reduced triglycerides by ˜15% in a dose-dependent way (high-certainty evidence). AUTHORS' CONCLUSIONS This is the most extensive systematic assessment of effects of omega-3 fats on cardiovascular health to date. Moderate- and low-certainty evidence suggests that increasing LCn3 slightly reduces risk of coronary heart disease mortality and events, and reduces serum triglycerides (evidence mainly from supplement trials). Increasing ALA slightly reduces risk of cardiovascular events and arrhythmia.
Collapse
Affiliation(s)
- Asmaa S Abdelhamid
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Tracey J Brown
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Julii S Brainard
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Priti Biswas
- University of East AngliaMED/HSCNorwich Research ParkNorwichUKNR4 7TJ
| | - Gabrielle C Thorpe
- University of East AngliaSchool of Health SciencesEarlham RoadNorwichUKNR4 7TJ
| | - Helen J Moore
- Teesside UniversitySchool of Social Sciences, Humanities and LawMiddlesboroughUKTS1 3BA
| | - Katherine HO Deane
- University of East AngliaSchool of Health SciencesEarlham RoadNorwichUKNR4 7TJ
| | - Carolyn D Summerbell
- Durham UniversityDepartment of Sport and Exercise Sciences42 Old ElvetDurhamUKDH13HN
| | - Helen V Worthington
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthCoupland Building 3Oxford RoadManchesterUKM13 9PL
| | - Fujian Song
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Lee Hooper
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | | |
Collapse
|
9
|
Sekikawa A, Cui C, Sugiyama D, Fabio A, Harris WS, Zhang X. Effect of High-Dose Marine Omega-3 Fatty Acids on Atherosclerosis: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Nutrients 2019; 11:nu11112599. [PMID: 31671524 PMCID: PMC6893789 DOI: 10.3390/nu11112599] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/23/2019] [Accepted: 10/25/2019] [Indexed: 12/13/2022] Open
Abstract
A recent randomized controlled trial (RCT), the Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial (REDUCE-IT), reported that high-dose marine omega-3 fatty acids (OM3) significantly reduce cardiovascular disease (CVD) outcomes, yet the mechanisms responsible for this benefit remain unknown. To test the hypothesis that high-dose OM3 is anti-atherosclerotic, we performed a systematic review and meta-analysis of RCT of high-dose OM3 on atherosclerosis. The protocol of this systematic review was registered with PROSPERO (CRD42019125566). PubMed, Embase, Cochran Central Register for Controlled Trials, and Clinicaltrials.gov databases were searched using the following criteria: adult participants, high-dose OM3 (defined as ≥3.0 g/day, or in Japan 1.8 g/day and purity ≥90%) as the intervention, changes in atherosclerosis as the outcome, and RCTs with an intervention duration of ≥6 months. A random-effects meta-analysis was used to pool estimates across studies. Among the 598 articles retrieved, six articles met our criteria. Four RCTs evaluated atherosclerosis in the coronary and two in the carotid arteries. High-dose OM3 significantly slowed the progression of atherosclerosis (standardized mean difference −1.97, 95% confidence interval −3.01, −0.94, p < 0.001). The results indicate that anti-atherosclerotic effect of high-dose OM3 is one potential mechanism in reducing CVD outcomes demonstrated in the REDUCE-IT trial.
Collapse
Affiliation(s)
- Akira Sekikawa
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15213, USA.
| | - Chendi Cui
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15213, USA.
| | - Daisuke Sugiyama
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15213, USA.
- Faculty of Nursing and Medical Care, Keio University, 4411 Endo, Fujisawa, 252-0883 Kanagawa, Japan.
| | - Anthony Fabio
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15213, USA.
| | - William S Harris
- OmegaQuant Analytics, LLC and Sanford School of Medicine, University of South Dakota, Sioux Falls, SD 57106, USA.
| | - Xiao Zhang
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15213, USA.
| |
Collapse
|
10
|
Chatterjee S, Khunti K, Davies MJ. Achieving Glycaemic Control with Concentrated Insulin in Patients with Type 2 Diabetes. Drugs 2019; 79:173-186. [PMID: 30623349 DOI: 10.1007/s40265-018-1048-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The recent introduction of the second-generation long-acting analogue insulins degludec and insulin glargine U300 have increased the choice of basal insulin therapy for patients with type 2 diabetes. The pharmacokinetic and pharmacodynamic properties of these insulins result in a flatter profile that lasts over 24 h and provides an increased window of administration of 6 h once daily. Large-scale multicentre randomised clinical trial programmes (BEGIN for degludec U100 and U200 and EDITION for glargine U300) evaluating these insulin therapies against glargine U100 have demonstrated that they are either non-inferior or superior for glycaemic efficacy and safety, but less likely to result in severe or nocturnal hypoglycaemia than glargine U100. The disposable pen devices for these insulins have been designed with patient satisfaction and convenience in mind. No concerns have arisen with adverse events with insulin analogues or cardiovascular safety from the ORIGIN and DEVOTE trials. As they demonstrate equivalent glycaemic efficacy to other basal insulins, they should be considered more in selected patient groups including those with recurrent or increased risk of hypoglycaemia, especially severe or nocturnal episodes, in the elderly or those living alone, and in patients with multiple co-morbidities such as cardiovascular or renal disease.
Collapse
Affiliation(s)
- Sudesna Chatterjee
- University Hospitals of Leicester NHS Trust, Senior Clinical Researcher, University of Leicester, Leicester, UK.
- Abbott Diabetes Care, Abbott Laboratories, Maidenhead, UK.
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK
| |
Collapse
|
11
|
Abstract
BACKGROUND Currently, with stroke burden increasing, there is a need to explore therapeutic options that ameliorate the acute insult. There is substantial evidence of a neuroprotective effect of marine-derived n-3 polyunsaturated fatty acids (PUFAs) in experimental stroke, leading to a better functional outcome. OBJECTIVES To assess the effects of administration of marine-derived n-3 PUFAs on functional outcomes and dependence in people with stroke.Our secondary outcomes were vascular-related death, recurrent events, incidence of other type of stroke, adverse events, quality of life, and mood. SEARCH METHODS We searched the Cochrane Stroke Group trials register (6 August 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 1, January 2019), MEDLINE Ovid (from 1948 to 6 August 2018), Embase Ovid (from 1980 to 6 August 2018), CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; from 1982 to 6 August 2018), Science Citation Index Expanded ‒ Web of Science (SCI-EXPANDED), Conference Proceedings Citation Index-Science - Web of Science (CPCI-S), and BIOSIS Citation Index. We also searched ongoing trial registers, reference lists, relevant systematic reviews, and used the Science Citation Index Reference Search. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing marine-derived n-3 PUFAs to placebo or open control (no placebo) in people with a history of stroke or transient ischaemic attack (TIA), or both. DATA COLLECTION AND ANALYSIS At least two review authors independently selected trials for inclusion, extracted data, assessed risk of bias, and used the GRADE approach to assess the quality of the body of evidence. We contacted study authors for clarification and additional information on stroke/TIA participants. We conducted random-effects meta-analysis or narrative synthesis, as appropriate. The primary outcome was efficacy (functional outcome) assessed using a validated scale e.g. Glasgow Outcome Scale Extended (GOSE) dichotomised into poor or good clinical outcome, Barthel Index (higher score is better; scale from 0 to 100) or Rivermead Mobility Index (higher score is better; scale from 0 to 15). MAIN RESULTS We included 29 RCTs; nine of them provided outcome data (3339 participants). Only one study included participants in the acute phase of stroke (haemorrhagic). Doses of marine-derived n-3 PUFAs ranged from 400 mg/day to 3300 mg/day. Risk of bias was generally low or unclear in most trials, with a higher risk of bias in smaller studies. We assessed results separately for short (up to three months) and longer (more than three months) follow-up studies.Short follow-up (up to three months)Functional outcome was reported in only one pilot study as poor clinical outcome assessed with GOSE (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.36 to 1.68; 40 participants; very low quality evidence). Mood (assessed with GHQ-30, lower score better), was reported by only one study and favoured control (mean difference (MD) 1.41, 95% CI 0.07 to 2.75; 102 participants; low-quality evidence).We found no evidence of an effect of the intervention for the remainder of the secondary outcomes: vascular-related death (two studies, not pooled due to differences in population, RR 0.33, 95% CI 0.01 to 8.00, and RR 0.33, 95% CI 0.01 to 7.72; 142 participants; low-quality evidence); recurrent events (RR 0.41, 95% CI 0.02 to 8.84; 18 participants; very low quality evidence); incidence of other type of stroke (two studies, not pooled due to different type of index stroke, RR 6.11, 95% CI 0.33 to 111.71, and RR 0.63, 95% CI 0.25 to 1.58; 58 participants; very low quality evidence); and quality of life (physical component mean difference (MD) -2.31, 95% CI -4.81 to 0.19, and mental component MD -2.16, 95% CI -5.91 to 1.59; one study; 102 participants; low-quality evidence).Adverse events were reported by two studies (57 participants; very low quality evidence), one trial reporting extracranial haemorrhage (RR 0.25, 95% CI 0.04 to 1.73) and the other one reporting bleeding complications (RR 0.32, 95% CI 0.01 to 7.35).Longer follow-up (more than three months)One small trial assessed functional outcome with both Barthel Index (MD 7.09, 95% CI -5.16 to 19.34) for activities of daily living, and Rivermead Mobility Index (MD 1.30, 95% CI -1.31 to 3.91) for mobility (52 participants; very low quality evidence). We carried out meta-analysis for vascular-related death (RR 1.02, 95% CI 0.78 to 1.35; five studies; 2237 participants; low-quality evidence) and fatal recurrent events (RR 0.69, 95% CI 0.31 to 1.55; three studies; 1819 participants; low-quality evidence).We found no evidence of an effect of the intervention for mood (MD 1.00, 95% CI -2.07 to 4.07; one study; 14 participants; low-quality evidence). Incidence of other type of stroke and quality of life were not reported.Adverse events (all combined) were reported by only one study (RR 0.94, 95% CI 0.56 to 1.58; 1455 participants; low-quality evidence). AUTHORS' CONCLUSIONS We are very uncertain of the effect of marine-derived n-3 PUFAs therapy on functional outcomes and dependence after stroke as there is insufficient high-quality evidence. More well-designed RCTs are needed, specifically in acute stroke, to determine the efficacy and safety of the intervention.Studies assessing functionality might consider starting the intervention as early as possible after the event, as well as using standardised clinically-relevant measures for functional outcomes, such as the modified Rankin Scale. Optimal doses remain to be determined; delivery forms (type of lipid carriers) and mode of administration (ingestion or injection) also need further consideration.
Collapse
|
12
|
Dagenais GR, Jung H, Bogaty P, Bosch J, Yusuf S, Gerstein HC. Effects of basal insulin glargine and omega-3 on lower limb arterial disease outcome in patients with dysglycaemia: An analysis of the Outcome Reduction with an Initial Glargine INtervention (ORIGIN) trial. Diabetes Obes Metab 2019; 21:1502-1505. [PMID: 30785660 DOI: 10.1111/dom.13674] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 02/11/2019] [Accepted: 02/15/2019] [Indexed: 11/30/2022]
Abstract
The impact of insulin or omega-3 supplements on the incidence and progression of peripheral artery disease (PAD) in patients with dysglycaemia has not been well studied. The Outcome Reduction with an Initial Glargine INtervention (ORIGIN) trial randomized participants with dysglycaemia and cardiovascular risk factors to titrated insulin glargine vs standard care, and to either 1 g of omega-3 per day or placebo. We assessed incident PAD, defined as the composite of either asymptomatic or symptomatic PAD according to the randomized interventions in the 11 119 ORIGIN participants whose baseline ankle-brachial index (ABI) was >0.9 (no PAD), and PAD progression in the 971 ORIGIN participants whose baseline ABI was ≤0.9. Hazard ratios (HR) were adjusted for confounders. During a 6.2-year follow-up period, allocation to insulin glargine vs standard care had a neutral effect on the composite of PAD incidence (HR, 0.99; 95% CI, 0.86-1.15) and progression (HR, 0.88; 95% CI, 0.63-1.22). Similar findings were noted for allocation to omega-3 vs placebo for PAD incidence (HR, 1.02; 95% CI, 0.89-1.18) and progression (HR, 0.93; 95% CI, 0.67-1.28). In this large study, neither insulin glargine nor omega-3 affected the incidence or progression of PAD.
Collapse
Affiliation(s)
- Gilles R Dagenais
- Department of Cardiology, Institut Universitaire de Cardiologie et Pneumologie de Québec-Université Laval, Québec City, Canada
| | - Hyejung Jung
- Population Health Research Institute, Hamilton General Hospital, McMaster University, Hamilton, Canada
| | - Peter Bogaty
- Department of Cardiology, Institut Universitaire de Cardiologie et Pneumologie de Québec-Université Laval, Québec City, Canada
| | - Jackie Bosch
- Population Health Research Institute, Hamilton General Hospital, McMaster University, Hamilton, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton General Hospital, McMaster University, Hamilton, Canada
| | - Hertzel C Gerstein
- Population Health Research Institute, Hamilton General Hospital, McMaster University, Hamilton, Canada
| |
Collapse
|
13
|
Abdelhamid AS, Brown TJ, Brainard JS, Biswas P, Thorpe GC, Moore HJ, Deane KHO, AlAbdulghafoor FK, Summerbell CD, Worthington HV, Song F, Hooper L. Omega-3 fatty acids for the primary and secondary prevention of cardiovascular disease. Cochrane Database Syst Rev 2018; 11:CD003177. [PMID: 30521670 PMCID: PMC6517311 DOI: 10.1002/14651858.cd003177.pub4] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Researchers have suggested that omega-3 polyunsaturated fatty acids from oily fish (long-chain omega-3 (LCn3), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)), as well as from plants (alpha-linolenic acid (ALA)) benefit cardiovascular health. Guidelines recommend increasing omega-3-rich foods, and sometimes supplementation, but recent trials have not confirmed this. OBJECTIVES To assess effects of increased intake of fish- and plant-based omega-3 for all-cause mortality, cardiovascular (CVD) events, adiposity and lipids. SEARCH METHODS We searched CENTRAL, MEDLINE and Embase to April 2017, plus ClinicalTrials.gov and World Health Organization International Clinical Trials Registry to September 2016, with no language restrictions. We handsearched systematic review references and bibliographies and contacted authors. SELECTION CRITERIA We included randomised controlled trials (RCTs) that lasted at least 12 months and compared supplementation and/or advice to increase LCn3 or ALA intake versus usual or lower intake. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data and assessed validity. We performed separate random-effects meta-analysis for ALA and LCn3 interventions, and assessed dose-response relationships through meta-regression. MAIN RESULTS We included 79 RCTs (112,059 participants) in this review update and found that 25 were at low summary risk of bias. Trials were of 12 to 72 months' duration and included adults at varying cardiovascular risk, mainly in high-income countries. Most studies assessed LCn3 supplementation with capsules, but some used LCn3- or ALA-rich or enriched foods or dietary advice compared to placebo or usual diet. LCn3 doses ranged from 0.5g/d LCn3 to > 5 g/d (16 RCTs gave at least 3g/d LCn3).Meta-analysis and sensitivity analyses suggested little or no effect of increasing LCn3 on all-cause mortality (RR 0.98, 95% CI 0.90 to 1.03, 92,653 participants; 8189 deaths in 39 trials, high-quality evidence), cardiovascular mortality (RR 0.95, 95% CI 0.87 to 1.03, 67,772 participants; 4544 CVD deaths in 25 RCTs), cardiovascular events (RR 0.99, 95% CI 0.94 to 1.04, 90,378 participants; 14,737 people experienced events in 38 trials, high-quality evidence), coronary heart disease (CHD) mortality (RR 0.93, 95% CI 0.79 to 1.09, 73,491 participants; 1596 CHD deaths in 21 RCTs), stroke (RR 1.06, 95% CI 0.96 to 1.16, 89,358 participants; 1822 strokes in 28 trials) or arrhythmia (RR 0.97, 95% CI 0.90 to 1.05, 53,796 participants; 3788 people experienced arrhythmia in 28 RCTs). There was a suggestion that LCn3 reduced CHD events (RR 0.93, 95% CI 0.88 to 0.97, 84,301 participants; 5469 people experienced CHD events in 28 RCTs); however, this was not maintained in sensitivity analyses - LCn3 probably makes little or no difference to CHD event risk. All evidence was of moderate GRADE quality, except as noted.Increasing ALA intake probably makes little or no difference to all-cause mortality (RR 1.01, 95% CI 0.84 to 1.20, 19,327 participants; 459 deaths, 5 RCTs),cardiovascular mortality (RR 0.96, 95% CI 0.74 to 1.25, 18,619 participants; 219 cardiovascular deaths, 4 RCTs), and CHD mortality (1.1% to 1.0%, RR 0.95, 95% CI 0.72 to 1.26, 18,353 participants; 193 CHD deaths, 3 RCTs) and ALA may make little or no difference to CHD events (RR 1.00, 95% CI 0.80 to 1.22, 19,061 participants, 397 CHD events, 4 RCTs, low-quality evidence). However, increased ALA may slightly reduce risk of cardiovascular events (from 4.8% to 4.7%, RR 0.95, 95% CI 0.83 to 1.07, 19,327 participants; 884 CVD events, 5 RCTs, low-quality evidence with greater effects in trials at low summary risk of bias), and probably reduces risk of arrhythmia (3.3% to 2.6%, RR 0.79, 95% CI 0.57 to 1.10, 4,837 participants; 141 events, 1 RCT). Effects on stroke are unclear.Sensitivity analysis retaining only trials at low summary risk of bias moved effect sizes towards the null (RR 1.0) for all LCn3 primary outcomes except arrhythmias, but for most ALA outcomes, effect sizes moved to suggest protection. LCn3 funnel plots suggested that adding in missing studies/results would move effect sizes towards null for most primary outcomes. There were no dose or duration effects in subgrouping or meta-regression.There was no evidence that increasing LCn3 or ALA altered serious adverse events, adiposity or lipids, except LCn3 reduced triglycerides by ˜15% in a dose-dependant way (high-quality evidence). AUTHORS' CONCLUSIONS This is the most extensive systematic assessment of effects of omega-3 fats on cardiovascular health to date. Moderate- and high-quality evidence suggests that increasing EPA and DHA has little or no effect on mortality or cardiovascular health (evidence mainly from supplement trials). Previous suggestions of benefits from EPA and DHA supplements appear to spring from trials with higher risk of bias. Low-quality evidence suggests ALA may slightly reduce CVD event and arrhythmia risk.
Collapse
Affiliation(s)
- Asmaa S Abdelhamid
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Tracey J Brown
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Julii S Brainard
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Priti Biswas
- University of East AngliaMED/HSCNorwich Research ParkNorwichUKNR4 7TJ
| | - Gabrielle C Thorpe
- University of East AngliaSchool of Health SciencesEarlham RoadNorwichUKNR4 7TJ
| | - Helen J Moore
- Durham UniversityWolfson Research InstituteDurhamUKDH1 3LE
| | - Katherine HO Deane
- University of East AngliaSchool of Health SciencesEarlham RoadNorwichUKNR4 7TJ
| | - Fai K AlAbdulghafoor
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Carolyn D Summerbell
- Durham UniversityDepartment of Sport and Exercise Science42 Old ElvetDurhamUKDH13HN
| | - Helen V Worthington
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthJR Moore BuildingOxford RoadManchesterUKM13 9PL
| | - Fujian Song
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Lee Hooper
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | | |
Collapse
|
14
|
Abdelhamid AS, Martin N, Bridges C, Brainard JS, Wang X, Brown TJ, Hanson S, Jimoh OF, Ajabnoor SM, Deane KHO, Song F, Hooper L. Polyunsaturated fatty acids for the primary and secondary prevention of cardiovascular disease. Cochrane Database Syst Rev 2018; 11:CD012345. [PMID: 30484282 PMCID: PMC6517012 DOI: 10.1002/14651858.cd012345.pub3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Evidence on the health effects of total polyunsaturated fatty acids (PUFA) is equivocal. Fish oils are rich in omega-3 PUFA and plant oils in omega-6 PUFA. Evidence suggests that increasing PUFA-rich foods, supplements or supplemented foods can reduce serum cholesterol, but may increase body weight, so overall cardiovascular effects are unclear. OBJECTIVES To assess effects of increasing total PUFA intake on cardiovascular disease and all-cause mortality, lipids and adiposity in adults. SEARCH METHODS We searched CENTRAL, MEDLINE and Embase to April 2017 and clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform to September 2016, without language restrictions. We checked trials included in relevant systematic reviews. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing higher with lower PUFA intakes in adults with or without cardiovascular disease that assessed effects over 12 months or longer. We included full texts, abstracts, trials registry entries and unpublished data. Outcomes were all-cause mortality, cardiovascular disease mortality and events, risk factors (blood lipids, adiposity, blood pressure), and adverse events. We excluded trials where we could not separate effects of PUFA intake from other dietary, lifestyle or medication interventions. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts, assessed trials for inclusion, extracted data, and assessed risk of bias. We wrote to authors of included trials for further data. Meta-analyses used random-effects analysis, sensitivity analyses included fixed-effects and limiting to low summary risk of bias. We assessed GRADE quality of evidence. MAIN RESULTS We included 49 RCTs randomising 24,272 participants, with duration of one to eight years. Eleven included trials were at low summary risk of bias, 33 recruited participants without cardiovascular disease. Baseline PUFA intake was unclear in most trials, but 3.9% to 8% of total energy intake where reported. Most trials gave supplemental capsules, but eight gave dietary advice, eight gave supplemental foods such as nuts or margarine, and three used a combination of methods to increase PUFA.Increasing PUFA intake probably has little or no effect on all-cause mortality (risk 7.8% vs 7.6%, risk ratio (RR) 0.98, 95% confidence interval (CI) 0.89 to 1.07, 19,290 participants in 24 trials), but probably slightly reduces risk of coronary heart disease events from 14.2% to 12.3% (RR 0.87, 95% CI 0.72 to 1.06, 15 trials, 10,076 participants) and cardiovascular disease events from 14.6% to 13.0% (RR 0.89, 95% CI 0.79 to 1.01, 17,799 participants in 21 trials), all moderate-quality evidence. Increasing PUFA may slightly reduce risk of coronary heart disease death (6.6% to 6.1%, RR 0.91, 95% CI 0.78 to 1.06, 9 trials, 8810 participants) andstroke (1.2% to 1.1%, RR 0.91, 95% CI 0.58 to 1.44, 11 trials, 14,742 participants, though confidence intervals include important harms), but has little or no effect on cardiovascular mortality (RR 1.02, 95% CI 0.82 to 1.26, 16 trials, 15,107 participants) all low-quality evidence. Effects of increasing PUFA on major adverse cardiac and cerebrovascular events and atrial fibrillation are unclear as evidence is of very low quality.Increasing PUFA intake probably slightly decreases triglycerides (by 15%, MD -0.12 mmol/L, 95% CI -0.20 to -0.04, 20 trials, 3905 participants), but has little or no effect on total cholesterol (mean difference (MD) -0.12 mmol/L, 95% CI -0.23 to -0.02, 26 trials, 8072 participants), high-density lipoprotein (HDL) (MD -0.01 mmol/L, 95% CI -0.02 to 0.01, 18 trials, 4674 participants) or low-density lipoprotein (LDL) (MD -0.01 mmol/L, 95% CI -0.09 to 0.06, 15 trials, 3362 participants). Increasing PUFA probably has little or no effect on adiposity (body weight MD 0.76 kg, 95% CI 0.34 to 1.19, 12 trials, 7100 participants).Effects of increasing PUFA on serious adverse events such as pulmonary embolism and bleeding are unclear as the evidence is of very low quality. AUTHORS' CONCLUSIONS This is the most extensive systematic review of RCTs conducted to date to assess effects of increasing PUFA on cardiovascular disease, mortality, lipids or adiposity. Increasing PUFA intake probably slightly reduces risk of coronary heart disease and cardiovascular disease events, may slightly reduce risk of coronary heart disease mortality and stroke (though not ruling out harms), but has little or no effect on all-cause or cardiovascular disease mortality. The mechanism may be via TG reduction.
Collapse
Affiliation(s)
- Asmaa S Abdelhamid
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Nicole Martin
- University College LondonInstitute of Health Informatics Research222 Euston RoadLondonUKNW1 2DA
| | - Charlene Bridges
- University College LondonInstitute of Health Informatics Research222 Euston RoadLondonUKNW1 2DA
| | - Julii S Brainard
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Xia Wang
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Tracey J Brown
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Sarah Hanson
- University of East AngliaSchool of Health SciencesEdith Cavell BuildingNorwichUKNR4 7TJ
| | - Oluseyi F Jimoh
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Sarah M Ajabnoor
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Katherine HO Deane
- University of East AngliaSchool of Health SciencesEdith Cavell BuildingNorwichUKNR4 7TJ
| | - Fujian Song
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Lee Hooper
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | | |
Collapse
|
15
|
Talari HR, Poladchang S, Hamidian Y, Samimi M, Gilasi HR, Ebrahimi FA, Asemi Z. The Effects of Omega-3 and Vitamin E Co-supplementation on Carotid Intima-media Thickness and Inflammatory Factors in Patients with Polycystic Ovary Syndrome. Oman Med J 2018; 33:473-479. [PMID: 30410689 DOI: 10.5001/omj.2018.88] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objectives We sought to evaluate the effects of omega-3 and vitamin E co-supplementation on carotid intima-media thickness (CIMT) and inflammatory factors in patients with polycystic ovary syndrome (PCOS). Methods This randomized, double-blind, placebo-controlled trial was done among 60 women with PCOS. Participants were randomly assigned into two groups (n = 30 each group) and assigned to take either 1000 mg omega-3 plus 400 IU vitamin E supplements or a placebo for 12 weeks. Results Compared with placebo, omega-3 and vitamin E co-supplementation led to significant decreases in maximum levels of left CIMT (-0.006±0.006 vs. +0.002±0.007 mm, p < 0.001), mean levels of left CIMT (-0.005±0.006 vs. +0.002±0.010 mm, p = 0.010), maximum levels of right CIMT (-0.006±0.010 vs. +0.006±0.010 mm, p = 0.010), and mean levels of right CIMT (-0.005±0.005 vs. +0.001±0.010 mm, p = 0.020). Change in high-sensitivity C-reactive protein (hs-CRP) (-390.6±942.9 vs. +237.0±754.3 ng/mL, p = 0.006) was significantly different between the supplemented patients and placebo group. We did not observe any significant effect in plasma nitric oxide (NO) values following supplementation with omega-3 plus vitamin E compared with the placebo. Conclusions Co-supplementation with omega-3 and vitamin E for 12 weeks among patients with PCOS had beneficial effects on CIMT and serum hs-CRP values, but unchanged NO values.
Collapse
Affiliation(s)
- Hamid Reza Talari
- Department of Radiology, Kashan University of Medical Sciences, Kashan, Iran
| | - Somayyeh Poladchang
- Department of Radiology, Kashan University of Medical Sciences, Kashan, Iran
| | - Yaser Hamidian
- Department of Radiology, Kashan University of Medical Sciences, Kashan, Iran
| | - Mansooreh Samimi
- Department of Gynecology and Obstetrics, Kashan University of Medical Sciences, Kashan, Iran
| | - Hamid Reza Gilasi
- Department of Epidemiology and Biostatistics, Kashan University of Medical Sciences, Kashan, Iran
| | - Faraneh Afshar Ebrahimi
- Department of Gynecology and Obstetrics, Kashan University of Medical Sciences, Kashan, Iran
| | - Zatollah Asemi
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran
| |
Collapse
|
16
|
Abdelhamid AS, Martin N, Bridges C, Brainard JS, Wang X, Brown TJ, Hanson S, Jimoh OF, Ajabnoor SM, Deane KHO, Song F, Hooper L. Polyunsaturated fatty acids for the primary and secondary prevention of cardiovascular disease. Cochrane Database Syst Rev 2018; 7:CD012345. [PMID: 30019767 PMCID: PMC6513571 DOI: 10.1002/14651858.cd012345.pub2] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Evidence on the health effects of total polyunsaturated fatty acids (PUFA) is equivocal. Fish oils are rich in omega-3 PUFA and plant oils in omega-6 PUFA. Evidence suggests that increasing PUFA-rich foods, supplements or supplemented foods can reduce serum cholesterol, but may increase body weight, so overall cardiovascular effects are unclear. OBJECTIVES To assess effects of increasing total PUFA intake on cardiovascular disease and all-cause mortality, lipids and adiposity in adults. SEARCH METHODS We searched CENTRAL, MEDLINE and Embase to April 2017 and clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform to September 2016, without language restrictions. We checked trials included in relevant systematic reviews. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing higher with lower PUFA intakes in adults with or without cardiovascular disease that assessed effects over 12 months or longer. We included full texts, abstracts, trials registry entries and unpublished data. Outcomes were all-cause mortality, cardiovascular disease mortality and events, risk factors (blood lipids, adiposity, blood pressure), and adverse events. We excluded trials where we could not separate effects of PUFA intake from other dietary, lifestyle or medication interventions. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts, assessed trials for inclusion, extracted data, and assessed risk of bias. We wrote to authors of included trials for further data. Meta-analyses used random-effects analysis, sensitivity analyses included fixed-effects and limiting to low summary risk of bias. We assessed GRADE quality of evidence. MAIN RESULTS We included 49 RCTs randomising 24,272 participants, with duration of one to eight years. Eleven included trials were at low summary risk of bias, 33 recruited participants without cardiovascular disease. Baseline PUFA intake was unclear in most trials, but 3.9% to 8% of total energy intake where reported. Most trials gave supplemental capsules, but eight gave dietary advice, eight gave supplemental foods such as nuts or margarine, and three used a combination of methods to increase PUFA.Increasing PUFA intake probably has little or no effect on all-cause mortality (risk 7.8% vs 7.6%, risk ratio (RR) 0.98, 95% confidence interval (CI) 0.89 to 1.07, 19,290 participants in 24 trials), but probably slightly reduces risk of coronary heart disease events from 14.2% to 12.3% (RR 0.87, 95% CI 0.72 to 1.06, 15 trials, 10,076 participants) and cardiovascular disease events from 14.6% to 13.0% (RR 0.89, 95% CI 0.79 to 1.01, 17,799 participants in 21 trials), all moderate-quality evidence. Increasing PUFA may slightly reduce risk of coronary heart disease death (6.6% to 6.1%, RR 0.91, 95% CI 0.78 to 1.06, 9 trials, 8810 participants) andstroke (1.2% to 1.1%, RR 0.91, 95% CI 0.58 to 1.44, 11 trials, 14,742 participants, though confidence intervals include important harms), but has little or no effect on cardiovascular mortality (RR 1.02, 95% CI 0.82 to 1.26, 16 trials, 15,107 participants) all low-quality evidence. Effects of increasing PUFA on major adverse cardiac and cerebrovascular events and atrial fibrillation are unclear as evidence is of very low quality.Increasing PUFA intake slightly reduces total cholesterol (mean difference (MD) -0.12 mmol/L, 95% CI -0.23 to -0.02, 26 trials, 8072 participants) and probably slightly decreases triglycerides (MD -0.12 mmol/L, 95% CI -0.20 to -0.04, 20 trials, 3905 participants), but has little or no effect on high-density lipoprotein (HDL) (MD -0.01 mmol/L, 95% CI -0.02 to 0.01, 18 trials, 4674 participants) or low-density lipoprotein (LDL) (MD -0.01 mmol/L, 95% CI -0.09 to 0.06, 15 trials, 3362 participants). Increasing PUFA probably causes slight weight gain (MD 0.76 kg, 95% CI 0.34 to 1.19, 12 trials, 7100 participants).Effects of increasing PUFA on serious adverse events such as pulmonary embolism and bleeding are unclear as the evidence is of very low quality. AUTHORS' CONCLUSIONS This is the most extensive systematic review of RCTs conducted to date to assess effects of increasing PUFA on cardiovascular disease, mortality, lipids or adiposity. Increasing PUFA intake probably slightly reduces risk of coronary heart disease and cardiovascular disease events, may slightly reduce risk of coronary heart disease mortality and stroke (though not ruling out harms), but has little or no effect on all-cause or cardiovascular disease mortality. The mechanism may be via lipid reduction, but increasing PUFA probably slightly increases weight.
Collapse
Affiliation(s)
- Asmaa S Abdelhamid
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Nicole Martin
- University College LondonFarr Institute of Health Informatics Research222 Euston RoadLondonUKNW1 2DA
| | - Charlene Bridges
- University College LondonFarr Institute of Health Informatics Research222 Euston RoadLondonUKNW1 2DA
| | - Julii S Brainard
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Xia Wang
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Tracey J Brown
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Sarah Hanson
- University of East AngliaSchool of Health SciencesEdith Cavell BuildingNorwichUKNR4 7TJ
| | - Oluseyi F Jimoh
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Sarah M Ajabnoor
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Katherine HO Deane
- University of East AngliaSchool of Health SciencesEdith Cavell BuildingNorwichUKNR4 7TJ
| | - Fujian Song
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Lee Hooper
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| |
Collapse
|
17
|
Abdelhamid AS, Brown TJ, Brainard JS, Biswas P, Thorpe GC, Moore HJ, Deane KHO, AlAbdulghafoor FK, Summerbell CD, Worthington HV, Song F, Hooper L. Omega-3 fatty acids for the primary and secondary prevention of cardiovascular disease. Cochrane Database Syst Rev 2018; 7:CD003177. [PMID: 30019766 PMCID: PMC6513557 DOI: 10.1002/14651858.cd003177.pub3] [Citation(s) in RCA: 114] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Researchers have suggested that omega-3 polyunsaturated fatty acids from oily fish (long-chain omega-3 (LCn3), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)), as well as from plants (alpha-linolenic acid (ALA)) benefit cardiovascular health. Guidelines recommend increasing omega-3-rich foods, and sometimes supplementation, but recent trials have not confirmed this. OBJECTIVES To assess effects of increased intake of fish- and plant-based omega-3 for all-cause mortality, cardiovascular (CVD) events, adiposity and lipids. SEARCH METHODS We searched CENTRAL, MEDLINE and Embase to April 2017, plus ClinicalTrials.gov and World Health Organization International Clinical Trials Registry to September 2016, with no language restrictions. We handsearched systematic review references and bibliographies and contacted authors. SELECTION CRITERIA We included randomised controlled trials (RCTs) that lasted at least 12 months and compared supplementation and/or advice to increase LCn3 or ALA intake versus usual or lower intake. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data and assessed validity. We performed separate random-effects meta-analysis for ALA and LCn3 interventions, and assessed dose-response relationships through meta-regression. MAIN RESULTS We included 79 RCTs (112,059 participants) in this review update and found that 25 were at low summary risk of bias. Trials were of 12 to 72 months' duration and included adults at varying cardiovascular risk, mainly in high-income countries. Most studies assessed LCn3 supplementation with capsules, but some used LCn3- or ALA-rich or enriched foods or dietary advice compared to placebo or usual diet.Meta-analysis and sensitivity analyses suggested little or no effect of increasing LCn3 on all-cause mortality (RR 0.98, 95% CI 0.90 to 1.03, 92,653 participants; 8189 deaths in 39 trials, high-quality evidence), cardiovascular mortality (RR 0.95, 95% CI 0.87 to 1.03, 67,772 participants; 4544 CVD deaths in 25 RCTs), cardiovascular events (RR 0.99, 95% CI 0.94 to 1.04, 90,378 participants; 14,737 people experienced events in 38 trials, high-quality evidence), coronary heart disease (CHD) mortality (RR 0.93, 95% CI 0.79 to 1.09, 73,491 participants; 1596 CHD deaths in 21 RCTs), stroke (RR 1.06, 95% CI 0.96 to 1.16, 89,358 participants; 1822 strokes in 28 trials) or arrhythmia (RR 0.97, 95% CI 0.90 to 1.05, 53,796 participants; 3788 people experienced arrhythmia in 28 RCTs). There was a suggestion that LCn3 reduced CHD events (RR 0.93, 95% CI 0.88 to 0.97, 84,301 participants; 5469 people experienced CHD events in 28 RCTs); however, this was not maintained in sensitivity analyses - LCn3 probably makes little or no difference to CHD event risk. All evidence was of moderate GRADE quality, except as noted.Increasing ALA intake probably makes little or no difference to all-cause mortality (RR 1.01, 95% CI 0.84 to 1.20, 19,327 participants; 459 deaths, 5 RCTs),cardiovascular mortality (RR 0.96, 95% CI 0.74 to 1.25, 18,619 participants; 219 cardiovascular deaths, 4 RCTs), and it may make little or no difference to CHD events (RR 1.00, 95% CI 0.80 to 1.22, 19,061 participants, 397 CHD events, 4 RCTs, low-quality evidence). However, increased ALA may slightly reduce risk of cardiovascular events (from 4.8% to 4.7%, RR 0.95, 95% CI 0.83 to 1.07, 19,327 participants; 884 CVD events, 5 RCTs, low-quality evidence), and probably reduces risk of CHD mortality (1.1% to 1.0%, RR 0.95, 95% CI 0.72 to 1.26, 18,353 participants; 193 CHD deaths, 3 RCTs), and arrhythmia (3.3% to 2.6%, RR 0.79, 95% CI 0.57 to 1.10, 4,837 participants; 141 events, 1 RCT). Effects on stroke are unclear.Sensitivity analysis retaining only trials at low summary risk of bias moved effect sizes towards the null (RR 1.0) for all LCn3 primary outcomes except arrhythmias, but for most ALA outcomes, effect sizes moved to suggest protection. LCn3 funnel plots suggested that adding in missing studies/results would move effect sizes towards null for most primary outcomes. There were no dose or duration effects in subgrouping or meta-regression.There was no evidence that increasing LCn3 or ALA altered serious adverse events, adiposity or lipids, although LCn3 slightly reduced triglycerides and increased HDL. ALA probably reduces HDL (high- or moderate-quality evidence). AUTHORS' CONCLUSIONS This is the most extensive systematic assessment of effects of omega-3 fats on cardiovascular health to date. Moderate- and high-quality evidence suggests that increasing EPA and DHA has little or no effect on mortality or cardiovascular health (evidence mainly from supplement trials). Previous suggestions of benefits from EPA and DHA supplements appear to spring from trials with higher risk of bias. Low-quality evidence suggests ALA may slightly reduce CVD event risk, CHD mortality and arrhythmia.
Collapse
Affiliation(s)
- Asmaa S Abdelhamid
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Tracey J Brown
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Julii S Brainard
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Priti Biswas
- University of East AngliaMED/HSCNorwich Research ParkNorwichUKNR4 7TJ
| | - Gabrielle C Thorpe
- University of East AngliaSchool of Health SciencesEarlham RoadNorwichUKNR4 7TJ
| | - Helen J Moore
- Durham UniversityWolfson Research InstituteDurhamUKDH1 3LE
| | - Katherine HO Deane
- University of East AngliaSchool of Health SciencesEarlham RoadNorwichUKNR4 7TJ
| | - Fai K AlAbdulghafoor
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Carolyn D Summerbell
- Durham UniversityDepartment of Sport and Exercise Science42 Old ElvetDurhamUKDH13HN
| | - Helen V Worthington
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthJR Moore BuildingOxford RoadManchesterUKM13 9PL
| | - Fujian Song
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Lee Hooper
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| |
Collapse
|
18
|
Candido R, Wyne K, Romoli E. A Review of Basal-Bolus Therapy Using Insulin Glargine and Insulin Lispro in the Management of Diabetes Mellitus. Diabetes Ther 2018; 9:927-949. [PMID: 29654514 PMCID: PMC5984925 DOI: 10.1007/s13300-018-0422-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Indexed: 12/29/2022] Open
Abstract
UNLABELLED Basal-bolus therapy (BBT) refers to the combination of a long-acting basal insulin with a rapid-acting insulin at mealtimes. Basal insulin glargine 100 U/mL and prandial insulin lispro have been available for many years and there is a substantial evidence base to support the efficacy and safety of these agents when they are used in BBT or basal-plus therapy for patients with type 1 or type 2 diabetes mellitus (T1DM, T2DM). With the growing availability of alternative insulins for use in such regimens, it seems timely to review the data regarding BBT with insulin glargine 100 U/mL and insulin lispro. In patients with T1DM, BBT with insulin glargine plus insulin lispro provides similar or better glycemic control and leads to less nocturnal hypoglycemia compared to BBT using human insulin as the basal and/or prandial component, and generally provides similar glycemic control and rates of severe hypoglycemia to those achieved with insulin lispro administered by continuous subcutaneous insulin infusion (CSII). Studies evaluating BBT with insulin glargine plus insulin lispro in patients with T2DM also demonstrate the efficacy and safety of these insulins. Available data suggest that BBT with insulin glargine and insulin lispro provides similar levels of efficacy and safety in pediatric and adult populations with T1DM and in adult patients and those aged more than 65 years with T2DM. These insulin preparations also appear to be safe and effective for controlling T2DM in people of different ethnicities and in patients with T1DM or T2DM and comorbidities. FUNDING Eli Lilly and Company.
Collapse
Affiliation(s)
- Riccardo Candido
- Diabetes Centre District 3, Azienda Sanitaria Universitaria Integrata di Trieste, Via Puccini 48/50, 34100, Trieste, Italy.
| | - Kathleen Wyne
- The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
| | - Ester Romoli
- Eli Lilly Italia SPA, via A. Gramsci 731/733, 50019, Sesto Fiorentino, Italy
| |
Collapse
|
19
|
Makino H, Tanaka A, Hosoda H, Koezuka R, Tochiya M, Ohata Y, Tamanaha T, Miyamoto Y, Kangawa K, Kishimoto I. Effect of basal insulin therapy on vascular endothelial function and adipokine profiles in people with Type 2 diabetes. Diabet Med 2016; 33:1737-1743. [PMID: 27150701 DOI: 10.1111/dme.13151] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2016] [Indexed: 12/21/2022]
Abstract
AIM To compare the effects of the basal insulin analogues glargine and detemir on endothelial function and adipocytokine levels in people with Type 2 diabetes. METHODS We studied 32 people with Type 2 diabetes whose blood glucose control was unsatisfactory while receiving only oral hypoglycaemic drugs. Participants were randomized to either insulin glargine or detemir for 24 weeks and then crossed over to the other treatment without a washout period. Flow-mediated vasodilatation, adipocytokine levels (plasminogen activator inhibitor-1 and leptin/adiponectin ratio), and fasting ghrelin levels were monitored. RESULTS HbA1c levels were significantly decreased by both basal insulin therapies. Body weight was significantly increased by glargine but not by detemir. The proportion of flow-mediated vasodilatation was significantly increased by detemir but not glargine (glargine: from 5.17 ± 0.69 to 5.94 ± 0.83%; detemir: from 4.89 ± 0.78 to 7.92 ± 0.69%). Plasminogen activator inhibitor-1 level was significantly decreased by only detemir (glargine: from 16.4 ± 1.8 to 17.3 ± 2.1; detemir: from 19.2 ± 2.8 to 16.0 ± 1.6 ng/ml). The leptin/adiponectin ratio was significantly increased only by glargine. Acyl ghrelin level was significantly decreased by glargine but not detemir. CONCLUSIONS These results suggest that the effect on endothelial function and adipocytokine profiles may differ between glargine and detemir in people with diabetes (Trial registration ID: UMIN000004973).
Collapse
Affiliation(s)
- H Makino
- Division of Atherosclerosis and Diabetes, National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| | - A Tanaka
- Division of Atherosclerosis and Diabetes, National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| | - H Hosoda
- National Cerebral and Cardiovascular Centre Research Institute, Suita, Osaka, Japan
| | - R Koezuka
- Division of Atherosclerosis and Diabetes, National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| | - M Tochiya
- Division of Atherosclerosis and Diabetes, National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| | - Y Ohata
- Division of Atherosclerosis and Diabetes, National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| | - T Tamanaha
- Division of Atherosclerosis and Diabetes, National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| | - Y Miyamoto
- Division of Preventive Cardiology, National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| | | | - I Kishimoto
- Division of Atherosclerosis and Diabetes, National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| |
Collapse
|
20
|
Stefan N, Fritsche A, Schick F, Häring HU. Phenotypes of prediabetes and stratification of cardiometabolic risk. Lancet Diabetes Endocrinol 2016; 4:789-798. [PMID: 27185609 DOI: 10.1016/s2213-8587(16)00082-6] [Citation(s) in RCA: 143] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 02/17/2016] [Accepted: 02/26/2016] [Indexed: 02/07/2023]
Abstract
Prediabetes is associated with increased risks of type 2 diabetes, cardiovascular disease, dementia, and cancer, and its prevalence is increasing worldwide. Lifestyle and pharmacological interventions in people with prediabetes can prevent the development of diabetes and possibly cardiovascular disease. However, prediabetes is a highly heterogeneous metabolic state, both with respect to its pathogenesis and prediction of disease. Improved understanding of these features and precise phenotyping of prediabetes could help to improve stratification of disease risk. In this Personal View, we focus on the extreme metabolic phenotypes of metabolically healthy obesity and metabolically unhealthy normal weight, insulin secretion failure, insulin resistance, visceral obesity, and non-alcoholic fatty liver disease. We present new analyses aimed at improving characterisation of phenotypes in lean, overweight, and obese people with prediabetes. We discuss evidence from lifestyle intervention studies to explore whether these phenotypes can also be used for individualised prediction and prevention of cardiometabolic diseases.
Collapse
Affiliation(s)
- Norbert Stefan
- Department of Internal Medicine IV, University Hospital Tübingen, Tübingen, Germany; Institute of Diabetes Research and Metabolic Diseases (IDM) of the Helmholtz Centre Munich at the University of Tübingen, Tübingen, Germany; German Centre for Diabetes Research (DZD), Tübingen, Germany.
| | - Andreas Fritsche
- Department of Internal Medicine IV, University Hospital Tübingen, Tübingen, Germany; Institute of Diabetes Research and Metabolic Diseases (IDM) of the Helmholtz Centre Munich at the University of Tübingen, Tübingen, Germany; German Centre for Diabetes Research (DZD), Tübingen, Germany
| | - Fritz Schick
- Section of Experimental Radiology, University Hospital Tübingen, Tübingen, Germany; Institute of Diabetes Research and Metabolic Diseases (IDM) of the Helmholtz Centre Munich at the University of Tübingen, Tübingen, Germany; German Centre for Diabetes Research (DZD), Tübingen, Germany
| | - Hans-Ulrich Häring
- Department of Internal Medicine IV, University Hospital Tübingen, Tübingen, Germany; Institute of Diabetes Research and Metabolic Diseases (IDM) of the Helmholtz Centre Munich at the University of Tübingen, Tübingen, Germany; German Centre for Diabetes Research (DZD), Tübingen, Germany
| |
Collapse
|
21
|
Affiliation(s)
- Eberhard Standl
- Munich Diabetes Research Group e.V. at the Munich Helmholtz Centre, Munich-Neuherberg, Germany
| | - David R Owen
- Diabetes Research Group, Institute of Life Sciences, College of Medicine, Swansea University, Swansea, Wales, U.K
| |
Collapse
|
22
|
Hanefeld M, Monnier L, Schnell O, Owens D. Early Treatment with Basal Insulin Glargine in People with Type 2 Diabetes: Lessons from ORIGIN and Other Cardiovascular Trials. Diabetes Ther 2016; 7:187-201. [PMID: 26861811 PMCID: PMC4900970 DOI: 10.1007/s13300-016-0153-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Indexed: 01/09/2023] Open
Abstract
UNLABELLED Dysglycemia results from a deficit in first-phase insulin secretion compounded by increased insulin insensitivity, exposing β cells to chronic hyperglycemia and excessive glycemic variability. Initiation of intensive insulin therapy at diagnosis of type 2 diabetes mellitus (T2DM) to achieve normoglycemia has been shown to reverse glucotoxicity, resulting in recovery of residual β-cell function. The United Kingdom Prospective Diabetes Study (UKPDS) 10-year post-trial follow-up reported reductions in cardiovascular outcomes and all-cause mortality in persons with T2DM who initially received intensive glucose control compared with standard therapy. In the cardiovascular outcome trial, outcome reduction with an initial glargine intervention (ORIGIN), a neutral effect on cardiovascular disease was observed in the population comprising prediabetes and T2DM. Worsening of glycemic control was prevented over the 6.7 year treatment period, with few serious hypoglycemic episodes and only moderate weight gain, with a lesser need for dual or triple oral treatment versus standard care. Several other studies have also highlighted the benefits of early insulin initiation as first-line or add-on therapy to metformin. The decision to introduce basal insulin to metformin must, however be individualized based on a risk-benefit analysis. The landmark ORIGIN trial provides many lessons relating to the concept and application of early insulin therapy for the prevention and safe and effective induction and maintenance of glycemic control in type 2 diabetes. FUNDING Sanofi.
Collapse
Affiliation(s)
| | - Louis Monnier
- Institute of Clinical Research, University Montpellier 1, Montpellier, France
| | | | - David Owens
- Institute of Life Sciences, Swansea University, Swansea, UK.
| |
Collapse
|
23
|
Beta-cell function is associated with carotid intima-media thickness independently of insulin resistance in healthy individuals. J Hypertens 2016; 34:685-91. [DOI: 10.1097/hjh.0000000000000842] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
24
|
Hussain MA, Bin-Ayeed SA, Saeed OQ, Verma S, Al-Omran M. Impact of diabetes on carotid artery revascularization. J Vasc Surg 2016; 63:1099-107.e4. [DOI: 10.1016/j.jvs.2015.12.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 12/19/2015] [Indexed: 11/15/2022]
|
25
|
Lundby-Christensen L, Vaag A, Tarnow L, Almdal TP, Lund SS, Wetterslev J, Gluud C, Boesgaard TW, Wiinberg N, Perrild H, Krarup T, Snorgaard O, Gade-Rasmussen B, Thorsteinsson B, Røder M, Mathiesen ER, Jensen T, Vestergaard H, Hedetoft C, Breum L, Duun E, Sneppen SB, Pedersen O, Hemmingsen B, Carstensen B, Madsbad S. Effects of biphasic, basal-bolus or basal insulin analogue treatments on carotid intima-media thickness in patients with type 2 diabetes mellitus: the randomised Copenhagen Insulin and Metformin Therapy (CIMT) trial. BMJ Open 2016; 6:e008377. [PMID: 26916685 PMCID: PMC4771974 DOI: 10.1136/bmjopen-2015-008377] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To assess the effect of 3 insulin analogue regimens on change in carotid intima-media thickness (IMT) in patients with type 2 diabetes. DESIGN AND SETTING Investigator-initiated, randomised, placebo-controlled trial with a 2 × 3 factorial design, conducted at 8 hospitals in Denmark. PARTICIPANTS AND INTERVENTIONS Participants with type 2 diabetes (glycated haemoglobin (HbA1c) ≥ 7.5% (≥ 58 mmol/mol), body mass index >25 kg/m(2)) were, in addition to metformin versus placebo, randomised to 18 months open-label biphasic insulin aspart 1-3 times daily (n=137) versus insulin aspart 3 times daily in combination with insulin detemir once daily (n=138) versus insulin detemir alone once daily (n=137), aiming at HbA1c ≤ 7.0% (≤ 53 mmol/mol). OUTCOMES Primary outcome was change in mean carotid IMT (a marker of subclinical cardiovascular disease). HbA1c, insulin dose, weight, and hypoglycaemic and serious adverse events were other prespecified outcomes. RESULTS Carotid IMT change did not differ between groups (biphasic -0.009 mm (95% CI -0.022 to 0.004), aspart+detemir 0.000 mm (95% CI -0.013 to 0.013), detemir -0.012 mm (95% CI -0.025 to 0.000)). HbA1c was more reduced with biphasic (-1.0% (95% CI -1.2 to -0.8)) compared with the aspart+detemir (-0.4% (95% CI -0.6 to -0.3)) and detemir (-0.3% (95% CI -0.4 to -0.1)) groups (p<0.001). Weight gain was higher in the biphasic (3.3 kg (95% CI 2.7 to 4.0) and aspart+detemir (3.2 kg (95% CI 2.6 to 3.9)) compared with the detemir group (1.9 kg (95% CI 1.3 to 2.6)). Insulin dose was higher with detemir (1.6 IU/kg/day (95% CI 1.4 to 1.8)) compared with biphasic (1.0 IU/kg/day (95% CI 0.9 to 1.1)) and aspart+detemir (1.1 IU/kg/day (95% CI 1.0 to 1.3)) (p<0.001). Number of participants with severe hypoglycaemia and serious adverse events did not differ. CONCLUSIONS Carotid IMT change did not differ between 3 insulin regimens despite differences in HbA1c, weight gain and insulin doses. The trial only reached 46% of planned sample size and lack of power may therefore have affected our results. TRIAL REGISTRATION NUMBER NCT00657943.
Collapse
Affiliation(s)
- Louise Lundby-Christensen
- Steno Diabetes Center, Gentofte, Denmark
- Department of Endocrinology, Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Paediatrics, Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark
| | - Allan Vaag
- Steno Diabetes Center, Gentofte, Denmark
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- University of Copenhagen, Copenhagen, Denmark
| | - Lise Tarnow
- Steno Diabetes Center, Gentofte, Denmark
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands University Hospital—Hillerød, Hillerød, Denmark
- Department of Health, University of Aarhus, Aarhus, Denmark
| | - Thomas P Almdal
- Department of Endocrinology, Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Søren S Lund
- Steno Diabetes Center, Gentofte, Denmark
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Niels Wiinberg
- Department of Physiology and Nuclear Medicine, Frederiksberg, Copenhagen University Hospital, Frederiksberg, Denmark
| | - Hans Perrild
- Department of Endocrinology, Bispebjerg, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thure Krarup
- Department of Endocrinology, Bispebjerg, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole Snorgaard
- Department of Endocrinology, Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark
| | - Birthe Gade-Rasmussen
- Department of Endocrinology, Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark
| | - Birger Thorsteinsson
- University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands University Hospital—Hillerød, Hillerød, Denmark
| | - Michael Røder
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands University Hospital—Hillerød, Hillerød, Denmark
- Department of Medicine, Gentofte, Copenhagen University Hospital, Gentofte, Denmark
| | - Elisabeth R Mathiesen
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- University of Copenhagen, Copenhagen, Denmark
| | - Tonny Jensen
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Vestergaard
- University of Copenhagen, Copenhagen, Denmark
- Department of Endocrinology, Herlev, Copenhagen University Hospital, Herlev, Denmark
- Section of Metabolic Genetics, The Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen,Copenhagen, Denmark
| | | | - Leif Breum
- Department of Medicine, University Hospital Køge, Køge, Denmark
| | - Elsebeth Duun
- Department of Medicine, Gentofte, Copenhagen University Hospital, Gentofte, Denmark
| | - Simone B Sneppen
- Department of Medicine, Gentofte, Copenhagen University Hospital, Gentofte, Denmark
| | - Oluf Pedersen
- Steno Diabetes Center, Gentofte, Denmark
- University of Copenhagen, Copenhagen, Denmark
- Section of Metabolic Genetics, The Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen,Copenhagen, Denmark
| | - Bianca Hemmingsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands University Hospital—Hillerød, Hillerød, Denmark
| | | | - Sten Madsbad
- Department of Endocrinology, Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark
- University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
26
|
Bhatia L, Scorletti E, Curzen N, Clough GF, Calder PC, Byrne CD. Improvement in non-alcoholic fatty liver disease severity is associated with a reduction in carotid intima-media thickness progression. Atherosclerosis 2015; 246:13-20. [PMID: 26748347 DOI: 10.1016/j.atherosclerosis.2015.12.028] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 12/09/2015] [Accepted: 12/21/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS n-3 polyunsaturated fatty acid (PUFA) treatment may decrease liver fat in non-alcoholic fatty liver disease (NAFLD), but uncertainty exists whether this treatment also decreases cardiovascular disease (CVD) risk in NAFLD. We tested whether 15-18 months n-3 PUFA [docosahexaenoic acid (DHA) and eicosapentaenoic acid] (Omacor/Lovaza, 4 g/day) vs placebo decreased carotid intima-media thickness (CIMT) progression, a surrogate marker of CVD risk. We also evaluated if improvement in markers of NAFLD severity was associated with decreased CIMT progression over time. METHODS In a pre-specified sub-study of the WELCOME (Wessex Evaluation of fatty Liver and Cardiovascular markers in NAFLD with OMacor thErapy) trial (NCT00760513), CIMT was measured using B-mode ultrasound while NAFLD severity was assessed by measuring liver fat percentage (magnetic resonance spectroscopy) and hepatic necro-inflammation (serum cytokeratin-18 (CK-18) concentration), at baseline and end of study. RESULTS 92 patients (age 51.5 ± 10.7 years, 57.6% men) completed the study. In the treatment group (n = 45), CIMT progressed by 0.012 mm (IQR 0.005-0.020 mm) compared to 0.015 mm (IQR 0.007-0.025 mm) in the placebo group (n = 47) (p = 0.17). Reduced CIMT progression in the entire cohort was independently associated with decreased liver fat (standardized β-coefficient 0.32, p = 0.005), reduced CK-18 levels (standardized β-coefficient 0.22, p = 0.04) and antihypertensive usage (standardized β-coefficient -0.31, p = 0.009) in multivariable regression analysis after adjusting for all potential confounders. Decreased weight (standardized β-coefficient 0.30, p < 0.001) and increased DHA tissue enrichment during the 18-month study (standardized β-coefficient -0.19, p = 0.027) were both independently associated with decreased liver fat, but not with CK-18. CONCLUSION Improvement in two markers of NAFLD severity is independently associated with reduced CIMT progression.
Collapse
Affiliation(s)
- Lokpal Bhatia
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK; National Institute for Health Research Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK; Wessex Cardiac Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
| | - Eleonora Scorletti
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK; National Institute for Health Research Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nicholas Curzen
- National Institute for Health Research Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK; Wessex Cardiac Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Geraldine F Clough
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK; National Institute for Health Research Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Philip C Calder
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK; National Institute for Health Research Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Christopher D Byrne
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK; National Institute for Health Research Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| |
Collapse
|
27
|
Hanefeld M. Use of insulin in type 2 diabetes: what we learned from recent clinical trials on the benefits of early insulin initiation. DIABETES & METABOLISM 2015; 40:391-9. [PMID: 25451189 DOI: 10.1016/j.diabet.2014.08.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 08/08/2014] [Accepted: 08/22/2014] [Indexed: 01/09/2023]
Abstract
The majority of people with type 2 diabetes mellitus (T2DM) require insulin therapy to maintain HbA(1c) levels < 7% during the first decade of diagnosis. Large prospective trials investigating the cardiovascular (CV) benefits of intensive glycaemic control have produced inconsistent results; however, meta-analyses have suggested that intensive glycaemic control provides both micro- and macrovascular benefits. The ORIGIN study investigated the impact of basal insulin glargine therapy targeting ≤ 5.3 mmol/L for fasting plasma glucose compared with standard care on CV outcomes in people with pre- or early diabetes, and demonstrated a neutral effect on CV outcomes with long-term use of insulin glargine early in the course of diabetes, with a low rate of severe hypoglycaemia and modest weight gain. The EARLY, GLORY and EASIE studies also demonstrated that insulin use earlier in the treatment pathway led to improved glycaemic control, reduced weight gain and fewer hypoglycaemic episodes than when insulin was added later in the course of disease. The beneficial effect of early transient intensive insulin therapy (TIIT) at diagnosis has been demonstrated in a number of trials; it rapidly limits the damage caused by gluco- and lipotoxicity, improving residual β-cell function and potentially slowing disease progression. The evidence suggests that people newly diagnosed with T2DM and HbA(1c) > 9% should be given early TIIT to achieve normoglycaemia within weeks, after which standard care should then be adopted. Insulin use earlier in the treatment pathway should be considered, as it reduces the risk of hypoglycaemia as well as allows β-cell rest, which can help preserve β-cell function.
Collapse
|
28
|
Ferrannini E, DeFronzo RA. Impact of glucose-lowering drugs on cardiovascular disease in type 2 diabetes. Eur Heart J 2015; 36:2288-96. [PMID: 26063450 DOI: 10.1093/eurheartj/ehv239] [Citation(s) in RCA: 182] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 05/16/2015] [Indexed: 12/11/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is characterized by multiple pathophysiologic abnormalities. With time, multiple glucose-lowering medications are commonly required to reduce and maintain plasma glucose concentrations within the normal range. Type 2 diabetes mellitus individuals also are at a very high risk for microvascular complications and the incidence of heart attack and stroke is increased two- to three-fold compared with non-diabetic individuals. Therefore, when selecting medications to normalize glucose levels in T2DM patients, it is important that the agent not aggravate, and ideally even improve, cardiovascular risk factors (CVRFs) and reduce cardiovascular morbidity and mortality. In this review, we examine the effect of oral (metformin, sulfonylureas, meglitinides, thiazolidinediones, DPP4 inhibitors, SGLT2 inhibitors, and α-glucosidase inhibitors) and injectable (glucagon-like peptide-1 receptor agonists and insulin) glucose-lowering drugs on established CVRFs and long-term studies of cardiovascular outcomes. Firm evidence that in T2DM cardiovascular disease can be reversed or prevented by improving glycaemic control is still incomplete and must await large, long-term clinical trials in patients at low risk using modern treatment strategies, i.e., drug combinations designed to maximize HbA1c reduction while minimizing hypoglycaemia and excessive weight gain.
Collapse
Affiliation(s)
- Ele Ferrannini
- Institute of Clinical Physiology, National Research Council (CNR), Pisa, Italy
| | - Ralph A DeFronzo
- Diabetes Division, University of Texas Health Science Center, San Antonio, TX, USA
| |
Collapse
|
29
|
Buysschaert M, Medina JL, Bergman M, Shah A, Lonier J. Prediabetes and associated disorders. Endocrine 2015; 48:371-93. [PMID: 25294012 DOI: 10.1007/s12020-014-0436-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 09/20/2014] [Indexed: 12/14/2022]
Abstract
Prediabetes represents an elevation of plasma glucose above the normal range but below that of clinical diabetes. Prediabetes includes individuals with IFG, IGT, IFG with IGT and elevated HbA1c levels. Insulin resistance and β-cell dysfunction are characteristic of this disorder. The diagnosis of prediabetesis is vital as both IFG and IGT are indeed well-known risk factors for type 2 diabetes with a greater risk in the presence of combined IFG and IGT. Furthermore, as will be illustrated in this review, prediabetes is associated with associated disorders typically only considered in with established diabetes. These include cardiovascular disease, periodontal disease, cognitive dysfunction, microvascular disease, blood pressure abnormalities, obstructive sleep apnea, low testosterone, metabolic syndrome, various biomarkers, fatty liver disease, and cancer. As the vast majority of individuals with prediabetes are unaware of their diagnosis, it is therefore vital that the associated conditions are identified, particularly in the presence of mild hyperglycemia, so they may benefit from early intervention.
Collapse
Affiliation(s)
- Martin Buysschaert
- Department of Endocrinology and Diabetology, University Clinic Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | | | | | | | | |
Collapse
|
30
|
Joseph JJ, Donner TW. Long-term insulin glargine therapy in type 2 diabetes mellitus: a focus on cardiovascular outcomes. Vasc Health Risk Manag 2015; 11:107-16. [PMID: 25657589 PMCID: PMC4315664 DOI: 10.2147/vhrm.s50286] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Cardiovascular disease is the leading cause of mortality in type 2 diabetes mellitus. Hyperinsulinemia is associated with increased cardiovascular risk, but the effects of exogenous insulin on cardiovascular disease progression have been less well studied. Insulin has been shown to have both cardioprotective and atherosclerosis-promoting effects in laboratory animal studies. Long-term clinical trials using insulin to attain improved diabetes control in younger type 1 and type 2 diabetes patients have shown improved cardiovascular outcomes. Shorter trials of intensive diabetes control with high insulin use in higher risk patients with type 2 diabetes have shown either no cardiovascular benefit or increased all cause and cardiovascular mortality. Glargine insulin is a basal insulin analog widely used to treat patients with type 1 and type 2 diabetes. This review focuses on the effects of glargine on cardiovascular outcomes. Glargine lowers triglycerides, leads to a modest weight gain, causes less hypoglycemia when compared with intermediate-acting insulin, and has a neutral effect on blood pressure. The Outcome Reduction With Initial Glargine Intervention (ORIGIN trial), a 6.2 year dedicated cardiovascular outcomes trial of glargine demonstrated no increased cardiovascular risk.
Collapse
Affiliation(s)
- Joshua J Joseph
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thomas W Donner
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
31
|
Oikonomou D, Kopf S, von Bauer R, Djuric Z, Cebola R, Sander A, Englert S, Vittas S, Hidmark A, Morcos M, Korosoglou G, Nawroth PP, Humpert PM. Influence of insulin and glargine on outgrowth and number of circulating endothelial progenitor cells in type 2 diabetes patients: a partially double-blind, randomized, three-arm unicenter study. Cardiovasc Diabetol 2014; 13:137. [PMID: 25300286 PMCID: PMC4195950 DOI: 10.1186/s12933-014-0137-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 09/30/2014] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Endothelial progenitor cells (EPC) are bone marrow-derived cells which can undergo differentiation into endothelial cells and participate in endothelial repair and angiogenesis. Insulin facilitates this in vitro mediated by the IGF-1 receptor. Clinical trials showed that the number of circulating EPCs is influenced by glucose control and EPC are a predictor of cardiovascular death. To study direct effects of insulin treatment on EPCs in type 2 diabetes patients, add-on basal insulin treatment was compared to an escalation of oral medication aiming at similar glucose control between the groups. METHODS 55 patients with type 2 diabetes (61.6±5.9 years) on oral diabetes medication were randomized in a 2:2:1 ratio in 3 groups. Patients were treated additionally with insulin glargine (n=20), NPH insulin (n=22) or escalated with oral medication (n=13). Number of circulating EPC, EPC-outgrowth, intima media thickness, skin microvascular function and HbA1c were documented at baseline and/or after 4 weeks and 4 months. RESULTS HbA1c at baseline was, 7.3+/-0.7% in the oral group, 7.3+/-0.9% and 7.5+/-0.7% in the glargine and NPH insulin respectively (p=0.713). HbA1c after 4 months decreased to 6.8+/-0.8%, 6.6+/-0.7% and 6.7+/-0.6%, in the oral, glargine and NPH insulin group respectively (p=0.61). FACS analysis showed no difference in number of circulating EPC between the groups after 4 weeks and 4 months. However, the outgrowth of EPCs as detected by colony forming assay was increased in the NPH insulin and glargine groups (29.2+/-6.4 and 29.4+/- 6.7 units respectively) compared to the group on oral medication (23.2+/-6.3, p=0.013) after 4 months of treatment. A significant decrease of IMT from 0.80mm (+/-0.14) at baseline to 0.76mm (+/-0.12) after 4 months could be observed in all patients only (p=0.03) with a trend towards a reduction of IMT after 4 months when all patients on insulin treatment were compared to the oral treatment group (p=0.06). Skin microvascular function revealed no differences between the groups (p=0.74). CONCLUSION The study shows that a 4-month treatment with add-on insulin significantly increases the outgrowth of EPC in patients with type 2 diabetes mellitus. TRIAL REGISTRATION (Clinical Trials Identifier: NCT00523393).
Collapse
Affiliation(s)
- Dimitrios Oikonomou
- Department of Medicine I and Clinical Chemistry, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Abstract
With respect to clinical phenotype and pathophysiology, prediabetes is akin to diabetes. Prediabetes is prevalent in the global population, and those affected are at high risk of progression to overt diabetes, and also at risk of cardiovascular disease (CVD). Progression to diabetes can occur because of worsening insulin resistance, β-cell dysfunction, or both, but the timecourse can be non-linear and, therefore, unpredictable. Intervention-by lifestyle modification, glucose-lowering drugs, or a combination-can postpone deterioration of glucose control, but effects of intervention are variable and can be transient. Furthermore, to what extent interventions can reduce cardiovascular risk is uncertain. Lifestyle intervention mainly hinges on weight loss; as such, risk of failure in the long-term is high, and implementation at the community level is difficult. The ideal candidate for intervention is an individual with prediabetes-identified by targeted screening-with many well documented cardiovascular risk factors, and who is highly motivated to initiate and maintain multifactorial risk-control using a personalised mix of lifestyle-adaptation and pharmacological treatment.
Collapse
Affiliation(s)
- Ele Ferrannini
- Department of Clinical and Experimental Medicine, University of Pisa School of Medicine, Pisa, Italy.
| |
Collapse
|
33
|
Tripolt NJ, Narath SH, Eder M, Pieber TR, Wascher TC, Sourij H. Multiple risk factor intervention reduces carotid atherosclerosis in patients with type 2 diabetes. Cardiovasc Diabetol 2014; 13:95. [PMID: 24884694 PMCID: PMC4041351 DOI: 10.1186/1475-2840-13-95] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 05/18/2014] [Indexed: 11/25/2022] Open
Abstract
Background Patients with rapid progression of carotid intima media thickness (CIMT) were shown to have a higher future risk for cardiovascular events. The aim of this study was to investigate the impact of multiple risk factor intervention on CIMT progression and to establish whether new cardiovascular surrogate measurements would allow prediction of CIMT changes. Materials and methods In this prospective, open, 2-years study, we included 97 patients with type 2 diabetes and at least two insufficiently treated cardiovascular risk factors, i.e. HbA1c > 7.5% (58 mmol/mol); LDL-cholesterol >3.1 mmol/l or blood pressure >140/90 mmHg. Treatment was intensified according to current guidelines over 3 months with the aim to maintain intensification over 2 years. The primary outcome was the change in CIMT after 2 years. We also assessed markers of mechanical and biochemical endothelial function and endothelial progenitor cells before and after 3 months of treatment intensification. For testing differences between before and after multifactorial treatment measurements we used either the paired student’s t-test or the Wilcoxon signed-rank test, depending on the distribution of the data. Additional, explorative statistical data analysis was done on CIMT progression building a linear multivariate regression model. Results Blood glucose, lipids and blood pressure significantly improved during the first 3 months of intensified treatment, which was sustained over the 2-year study duration. Mean CIMT significantly decreased from baseline to 2 year (0.883 ± 0.120 mm vs. 0.860 ± 0.130 mm; p = 0.021). None of the investigated surrogate measures, however, was able to predict changes in IMT early after treatment intensification. Conclusions Intensification of risk factor intervention in type 2 diabetes results in CIMT regression over a period of 2 years. None of the biomarkers used including endothelial function parameters or endothelial progenitor cells turned out to be useful to predict CIMT changes. Trial registration Clinical Trial Registration – Unique identifier:
NCT00660790
Collapse
Affiliation(s)
| | | | | | | | | | - Harald Sourij
- Department for Internal Medicine, Division of Endocrinology and Metabolism, Medical University of Graz, Graz, Austria.
| |
Collapse
|
34
|
Preiss D, Lloyd SM, Ford I, McMurray JJ, Holman RR, Welsh P, Fisher M, Packard CJ, Sattar N. Metformin for non-diabetic patients with coronary heart disease (the CAMERA study): a randomised controlled trial. Lancet Diabetes Endocrinol 2014; 2:116-24. [PMID: 24622715 DOI: 10.1016/s2213-8587(13)70152-9] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Metformin reduces cardiovascular risk in patients with type 2 diabetes seemingly independent of lowering blood glucose concentration. We assessed the cardiovascular effects of metformin in individuals without type 2 diabetes. METHODS We did a single-centre, double-blind, placebo-controlled trial at the Glasgow Clinical Research Facility (Glasgow, UK). We enrolled patients taking statins who did not have type 2 diabetes but who did have coronary heart disease and large waist circumferences. Participants were randomly assigned (1:1) by computer to either metformin (850 mg twice daily) or matching placebo in block sizes of four. Patients, investigators, trial staff, and statisticians were masked to treatment allocation. The primary endpoint was progression of mean distal carotid intima-media thickness (cIMT) over 18 months in the modified intention-to-treat population. Secondary endpoints were changes in carotid plaque score (in six regions), measures of glycaemia (HbA1c, fasting glucose, and insulin concentrations, and Homeostasis Model Assessment of Insulin Resistance [HOMA-IR]), and concentrations of lipids, high sensitivity C-reactive protein, and tissue plasminogen activator. The trial was registered at ClinicalTrials.gov, number NCT00723307. FINDINGS We screened 356 patients, of whom we enrolled 173 (86 in the metformin group, 87 in the placebo group). Average age was 63 years. At baseline, mean cIMT was 0·717 mm (SD 0·129) and mean carotid plaque score was 2·43 (SD 1·55). cIMT progression did not differ significantly between groups (slope difference 0·007 mm per year, 95% CI -0·006 to 0·020; p=0·29). Change of carotid plaque score did not differ significantly between groups (0·01 per year, 95% CI -0·23 to 0·26; p=0·92). Patients taking metformin had lower HbA1c, insulin, HOMA-IR, and tissue plasminogen activator compared with those taking placebo, but there were no significant differences for total cholesterol, HDL-cholesterol, non-HDL-cholesterol, triglycerides, high sensitivity C-reactive protein, or fasting glucose. 138 adverse events occurred in 64 patients in the metformin group versus 120 in 60 patients in the placebo group. Diarrhoea and nausea or vomiting were more common in the metformin group than in the placebo group (28 vs 5). INTERPRETATION Metformin had no effect on cIMT and little or no effect on several surrogate markers of cardiovascular disease in non-diabetic patients with high cardiovascular risk, taking statins. Further evidence is needed before metformin can be recommended for cardiovascular benefit in this population. FUNDING Chief Scientist Office (Scotland).
Collapse
Affiliation(s)
- David Preiss
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
| | - Suzanne M Lloyd
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - John J McMurray
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Rury R Holman
- Diabetes Trials Unit, University of Oxford, Oxford, UK
| | - Paul Welsh
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Miles Fisher
- Department of Diabetes, Glasgow Royal Infirmary, Glasgow, UK
| | - Chris J Packard
- Glasgow Clinical Research Facility, Tennent Building, Western Infirmary, Glasgow, UK
| | - Naveed Sattar
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| |
Collapse
|
35
|
Kawamori R, Node K, Hanafusa T, Atsumi Y, Naito Y, Oka Y. Baseline and 1-year interim follow-up assessment of Japanese patients initiating insulin therapy who were enrolled in the cardiovascular risk evaluation in people with type 2 diabetes on insulin therapy study: an international, multicenter, observational study. Cardiovasc Diabetol 2013; 12:131. [PMID: 24011395 PMCID: PMC3846906 DOI: 10.1186/1475-2840-12-131] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 08/21/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Cardiovascular Risk Evaluation in people with type 2 Diabetes on Insulin Therapy (CREDIT) study is an international, multicenter, observational study designed to assess metabolic parameters and cardiovascular risk of patients with type 2 diabetes mellitus (T2DM) on insulin therapy. The present report summarizes results at baseline and 1-year follow-up for the cohort of Japanese patients. METHODS Male and female patients (n = 511), aged >40 years, with T2DM for >1 year, treated with insulin therapy for ≥1 month and <6 months were eligible for participation in the study. Glycemic and lipid parameters, duration of diabetes, diabetic complications, oral antidiabetic medications, and all hypoglycemic episodes were recorded. Effectiveness was assessed based on changes in clinical parameters and attainment of target HbA1c levels. Safety was evaluated based on episodes of hypoglycemia and weight gain. RESULTS At baseline, the mean ± SD duration of diabetes was 11.8 ± 8.8 years. Microvascular and macrovascular diabetic complications were present in 83.4% and 25.1% of patients, respectively. At the 1-year follow-up, significant improvements were observed in mean HbA1c (10.3 ± 2.0% vs. 7.5 ± 1.3%, P < .001), fasting plasma glucose (217.3 ± 80.8 mg/dL vs. 139.0 ± 48.7 mg/dL, P < .001), and postprandial plasma glucose levels (296.1 ± 96.0 mg/dL vs. 178.2 ± 68.6 mg/dL, P < .001) compared with baseline. Mean total cholesterol (P < .001), low-density lipoprotein cholesterol (P < .001), triglycerides (P < .01), and diastolic blood pressure (P < .01) also significantly decreased. Good glycemic control (HbA1c < 7.0%) was achieved in 40% of patients at the 1-year follow-up. Glycemic control tended to be better in patients with lower baseline HbA1c levels (P < .01). Patients with a shorter duration of diabetes were more likely to achieve glycemic control and discontinue insulin for diabetes control at the 1-year follow-up (P < .05 for trend). Symptomatic hypoglycemic episodes occurred in 21.8% of patients over 6 to 12 months. CONCLUSIONS Our results suggest that insulin treatment is an effective and safe therapeutic option in Japanese patients with T2DM, and earlier insulin initiation might be associated with better glycemic control.
Collapse
Affiliation(s)
- Ryuzo Kawamori
- Department of Medicine, Metabolism and Endocrinology, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan.
| | | | | | | | | | | |
Collapse
|
36
|
Abstract
The natural history of type 2 diabetes mellitus (T2DM) is a relentless progression of β-cell failure and dysregulation of β-cell function with increasing metabolic derangement. Insulin remains the only glucose-lowering therapy that is efficacious throughout this continuum. However, the timing of introduction and the choice of insulin therapy remain contentious because of the heterogeneity of T2DM and the well-recognized behavioral and therapeutic challenges associated with this mode of therapy. Nevertheless, the early initiation of basal insulin has been shown to improve glycemic control and affect long-term outcomes in people with T2DM and is a treatment strategy supported by international guidelines as part of an individualized approach to chronic disease management. The rationale for early initiation of insulin is based on evidence demonstrating multifaceted benefits, including overcoming the glucotoxic effects of hyperglycemia, thereby facilitating "β-cell rest," and preserving β-cell mass and function, while also improving insulin sensitivity. Independent of its effects on glycemic control, insulin possesses anti-inflammatory and antioxidant properties that may help protect against endothelial dysfunction and damage resulting in vascular disease. Insulin therapy and the achievement of good glycemic control earlier in T2DM provide long-term protection to end organs via "metabolic memory" regardless of subsequent treatments and degree of glycemic control. This is evidenced from long-term observations continuing from trials such as the United Kingdom Prospective Diabetes Study. As such, early initiation of insulin therapy may not only help to avoid the effects of prolonged glycemic burden, but may also positively alter the course of disease progression.
Collapse
Affiliation(s)
- David R Owens
- Diabetes Research Group, Institute of Life Sciences College of Medicine, Swansea University, Swansea SA2 8PP, United Kingdom.
| |
Collapse
|