Diabetes Treatment, Part 2: Oral Agents for Glycemic Management

Active coating of immediate-release evogliptin tartrate to prepare fixed dose combination tablet with sustained-release metformin HCl

This study was aimed to develop a fixed dose combination (FDC) tablet containing a low dose of evogliptin tartrate (6.87 mg) for immediate release combined with a high dose (1000 mg) of sustained-release (SR) metformin HCl appropriate for once daily dosing the treatment of type 2 diabetes. To prepare the FDC tablets, an active coating was used in this study, whereby evogliptin tartrate film was layered on a matrix core tablet containing metformin HCl. To overcome the problem caused by a low-dose drug in combination with a relatively large matrix tablet containing high-dose drug, it was also aimed to confirm the formulation and coating operation for satisfactory content uniformity, and to describe the chemical stability during storage of the amorphous active coating layer formulation in relation to molecular mobility. Furthermore, the in vitro release and in vivo pharmacokinetic profiles of metformin HCl and evogliptin tartrate in the FDC active coating tablet were compared to those of the commercially marketed reference drugs, Diabex XR® (Daewoong, Seoul, Korea) containing metformin HCl and Suganon® (Donga ST, Seoul, Korea) containing evogliptin tartrate. In conclusion, the newly developed FDC active coating tablet in this study was confirmed to be bioequivalent to the reference marketed products in beagle dogs, with satisfactory content uniformity and stability.

Inhibition Mechanism of Components Isolated from Morus alba Branches on Diabetes and Diabetic Complications via Experimental and Molecular Docking Analyses

Previously, we reported the anti-diabetic effect of Morus alba root bark and the compounds therein. In our continuous study of other parts of this plant, the ability of the branch of Morus alba to inhibit α-glucosidase, protein tyrosine phosphatase 1B (PTP1B), and advanced glycation end products (AGEs) formation was evaluated. Moreover, there are no previous studies that have performed enzyme kinetics and molecular docking analyses, along with assessments of peroxynitrite (ONOO⁻) inhibitory activities. Since the Morus alba branch exhibited favorable inhibitory effects, repeated column chromatography was performed to obtain eight compounds, including four flavonoids (1, 3, 6, 8), one arylbenzofuran (2), one stilbene (5), one Diels–Alder-type adduct (7), and one sterol (4). Among them, compounds 1–3 and 5–7 were mixed-type inhibitors of α-glucosidase, sharing the same catalytic residues with acarbose and the same allosteric sites with (Z)-3-bytylidenephthalide. On the other hand, kuwanon C (1) and oxyresveratrol (5) interacted with residues of the allosteric site (α3 and α6 helices) of PTP1B, indicating their use as non-competitive inhibitors. Interestingly, kuwanon G (7) directly bound the catalytic site, or interrupted the binding between the substrate and the active site, as a mixed-type inhibitor. Moreover, most of the compounds exhibited greater activity against AGE formation and ONOO⁻ than positive controls. The IC₅₀ values required to inhibit ONOO⁻ using compounds 1, 3, 5, 6, and 7 were reported for the first time, and range from 1.08 to 12.92 μM. Based on the structure–activity relationship, the presence of hydroxyl, resorcinol, and prenyl moieties was important in the prevention of diabetes’ pathological mechanisms, and these findings have been further supported by molecular docking analysis. These computational and experimental results will be useful in the development of therapeutic candidates to prevent/treat diabetes and its complications.

Cytotoxicity, Anti-Obesity and Anti-Diabetic Activities of Heteromorpha arborescens (Spreng.) Cham Leaves

This study investigated the cytotoxicity, anti-obesity and anti-diabetic potentials of blanched, aqueous and ethanol extracts of Heteromorpha arborescens (Spreng.) Cham leaves. The results revealed that both ethanol and aqueous extracts exhibited considerable inhibition against α-glucosidase (IC50 of 627.29 ± 4.62 µg/mL and 576.46 ± 3.21 µg/mL respectively), while the blanched extract showed weak α-glucosidase inhibition (IC50; 855.38 ± 4.29 µg/mL) and the aqueous extract showed the best α-amylase inhibition (IC50; 583.74 ± 5.87 µg/mL). However, weak α-amylase inhibition was observed in the ethanol (IC50; 724.60 ± 4.33 µg/mL) and blanched extracts (IC50; 791.63 ± 3.76 µg/mL). The toxicity of the extracts is indicated by LC50 values as 154.75 µg/mL, 125 µg/mL and 90.58 µg/mL for ethanol, aqueous and blanched extracts respectively, indicating the blanched extract to be the most toxic. Moderate glucose utilization in both C3A and L6 cells was also observed for the aqueous and ethanol extracts which may be attributed to the relatively lower toxicity levels present. However, glucose utilization was very weak for the blanched extract, which may be due to higher level of cytotoxicity it possessed. Relatively weaker lipase inhibition was observed for the ethanol (IC50; 699.3 ± 1.33 µg/mL), aqueous (IC50; 811.52 ± 3.52 µg/mL) and blanched extracts (IC50; 1152.7 ± 4.61 µg/mL) compared to orlistat (IC50; 56.88 ± 0.11 µg/mL). However, there was no reasonable reduction in lipid accumulation observed in all the extract treated cells. These observations suggest that ethanol and aqueous extracts of H. arborescens leaf are promising as new agents for the treatment of diabetes and its acclaimed anti-obesity potentials are likely due to its lipase, α-amylase and α-glucosidase inhibition.

Optimization of bilayer tablet manufacturing process for fixed dose combination of sustained release high-dose drug and immediate release low-dose drug based on quality by design (QbD)

A fixed dose combination (FDC) bilayer tablet, consisting of high-dose metformin HCl in a sustained release layer and low-dose evogliptin tartrate in an immediate release layer, was developed based on a quality by design (QbD) approach. To implement QbD approach, the bilayer tableting process parameters judged as high risk through risk analysis were optimized by a central composite face-centered design as a design of experiment (DOE) methodology. Using DOE, the optimized conditions of the tableting process for drug products that satisfy the established quality target product profiles were obtained. The content uniformity of low-dose evogliptin tartrate in the optimized bilayer tablet prepared on a large scale was confirmed by at-line transmittance Raman spectroscopy as a process analytical technology. In addition, the in vitro drug release and in vivo pharmacokinetic studies showed that metformin HCl and evogliptin tartrate in the bilayer tablet is bioequivalent to those of the respective reference drugs. Furthermore, the physicochemical stability of the optimized bilayer tablet during storage under long-term and accelerated conditions was also confirmed. Therefore, it can be concluded that the QbD approach is an effective way to develop a new FDC bilayer tablet that is easy to scale up for successful commercialization.

Evaluation of Acute and Chronic Antidiabetic Activity of Ivy (<i>Hedera helix</i> L.) Aqueous Leaf Extract in Rat Model

BACKGROUND AND OBJECTIVE

Hedera helix L. (Ivy) has been utilized as an alternative medicine for cough however, through extensive literature search; we found no reported activity of ivy on α-glucosidase inhibition, HbA1c levels and its protective effect on vital organs. Therefore, the present study aimed to evaluate the antidiabetic and protective effect of ivy in alloxan induced rat model.

MATERIALS AND METHODS

The hypoglycemic activity of ivy was examined in normoglycemic, glucose overloaded and alloxan-induced rats. The antidiabetic potential was also confirmed by estimation of HbA1c and α-glucosidase inhibitory activity.

RESULTS

Results of acute and chronic study revealed that ivy produced highly significant decline (p<0.01) in fasting and post-prandial blood sugar levels as compared to diabetic control and standard group respectively. Furthermore, highly significant decline (p<0.01) in HbA1c levels were seen after chronic administration of ivy indicating its therapeutic effect in lowering HbA1c levels during long term use. It was found that ivy produced stronger and highly significant (p<0.05) inhibition of α-glucosidase activity than the standard agent acarbose at 500 μg mL-1.

CONCLUSION

The histopathological studies of vital organs revealed protective effect of ivy via maintaining the normal architecture as compared to alloxan model. Hence, our findings support the potential use of ivy for diabetes management.

A Markov decision process for modeling adverse drug reactions in medication treatment of type 2 diabetes

Type 2 diabetes has an increasing prevalence and high cost of treatment. The goal of type 2 diabetes treatment is to control patients' blood glucose level by pharmacological interventions and to prevent adverse disease-related complications. Therefore, it is important to optimize the medication treatment plans for type 2 diabetes patients to enhance the quality of their lives and to decrease the economic burden of this chronic disease. Since the treatment of type 2 diabetes relies on medication, it is vital to consider adverse drug reactions. Adverse drug reaction is undesired harmful reactions that may result from some certain medications. Therefore, a Markov decision process is developed in this article to model the medication treatment of type 2 diabetes, considering the possibility of adverse drug reaction occurring adverse drug reaction. The optimal policy of the proposed Markov decision process model is compared with clinical guidelines and existing models in the literature. Moreover, a sensitivity analysis is conducted to address the manner in which model behavior depends on model parameterization and then therapeutic insights are obtained based on the results. The satisfying results show that the model has the capability to offer an optimal treatment policy with an acceptable expected quality of life by utilizing fewer medications and provide significant implications in endocrinology and metabolism applications.

Antidiabetic, antihyperlipidemic and antioxidant effect of Vincamine, in streptozotocin-induced diabetic rats

Diabetes mellitus is the most common endocrine disorder characterized by hyperglycemia resulting from defects in insulin secretion or insulin action. The present study was designed to investigate the antidiabetic effects of vincamine, one of the monoterpenoid indole alkaloid, in streptozotocin-induced diabetic rat model. Diabetes was induced in rats by an intraperitoneal injection of streptozotocin (40 mg/kg bw). Vincamine 20 and 30 mg/kg.bw were administrated orally as a single dose per day to the diabetic rats for 30 days. The vehicle control group received 0.5% dimethyl sulfoxide for the same duration. After 30 days of treatment, fasting blood glucose, glycosylated haemoglobin, total cholesterol, triglyceride, low-density lipoprotein cholesterol and very low-density lipoprotein cholesterol levels were significantly increased, whereas, body weight, plasma insulin, high-density lipoprotein cholesterol, antioxidant enzymes and reduced glutathione were markedly decreased in diabetic rats. Treatment with vincamine significantly restored these parameters to the normal level. The protective effect of vincamine was compared with glibenclamide, a well-known hypoglycemic drug. Our results clearly suggest that vincamine exhibit hypoglycemic, hypolipidemic and antioxidant activity. The anti-diabetic effect of vincamine was comparable to the protective effect of glibenclamide, suggesting its potential as a natural anti-diabetic compound with therapeutic benefits.

Antidiabetic activity, glucose uptake stimulation and α-glucosidase inhibitory effect of Chrysophyllum cainito L. stem bark extract

Background

Chrysophyllum cainito L., a tropical fruit tree, has been used as an alternative medicine for the treatment of diabetic patients in many countries. However, there is very limited scientific rationale for this medical use. The present study aimed to evaluate the antidiabetic activity of the extract from C. cainito stem bark and the possible mechanisms underlying this activity.

Methods

Phytochemistry and in vitro antioxidant capacity of the extract were studied. Hypoglycemic activity of the extract was examined in normal and alloxan-induced diabetic mice. The effect of C. cainito extract on glucose absorption and glucose uptake were conducted using mouse isolated jejunum and abdominal muscle, respectively. Finally, an in vitro effect of C. cainito extract on α-glucosidase activity was evaluated.

Results

C. cainito extract possessed a strong antioxidant activity comparable to the ascorbic acid and butylated hydroxytoluene. The extract at 500 mg/kg significantly reduced the area under curve of blood glucose level in oral glucose tolerance test in normal mice. In alloxan-induced diabetic model, similar to glibenclamide, a single dose of the extract significantly decreased fasting blood glucose level from 387.17 ± 29.84 mg/dl to 125.67 ± 62.09 mg/dl after 6 h of administration. From the isolated jejunum experiment, the extract at any doses used did not inhibit glucose absorption. However, the extract at 50 μg/ml significantly increased the amount of glucose uptake by abdominal muscles in the presence of insulin (P < 0.05). Lastly, it was found that the extract produced stronger inhibition of α-glucosidase activity (IC₅₀ = 1.20 ± 0.09 μg/ml) than acarbose (IC₅₀ = 198.17 ± 4.74 μg/ml).

Conclusion

Direct evidence of antidiabetic activity of C. cainito stem bark with possible modes of action, glucose uptake stimulation and α-glucosidase inhibitory effect, was reported for the first time herein. These data support the potential use of this plant for the treatment of diabetic patients.

The role of beta cell heterogeneity in islet function and insulin release

It is becoming increasingly apparent that not all insulin-secreting beta cells are equal. Subtle differences exist at the transcriptomic and protein expression levels, with repercussions for beta cell survival/proliferation, calcium signalling and insulin release. Notably, beta cell heterogeneity displays plasticity during development, metabolic stress and type 2 diabetes mellitus (T2DM). Thus, heterogeneity or lack thereof may be an important contributor to beta cell failure during T2DM in both rodents and humans. The present review will discuss the molecular and cellular features of beta cell heterogeneity at both the single-cell and islet level, explore how this influences islet function and insulin release and look into the alterations that may occur during obesity and T2DM.

Pharmacological therapy selection of type 2 diabetes based on the SWARA and modified MULTIMOORA methods under a fuzzy environment

Medication selection for Type 2 Diabetes (T2D) is a challenging medical decision-making problem involving multiple medications that can be prescribed to control the patient's blood glucose. The wide range of hyperglycemia lowering agents with varying effects and various side effects makes the decision quite difficult. This paper presents computer-aided medical decision support using a fuzzy Multi-Criteria Decision-Making (MCDM) model that hybridizes a Step-wise Weight Assessment Ratio Analysis (SWARA) method with a modification of Fuzzy Multi-Objective Optimization on the basis of a Ratio Analysis plus the full multiplicative form (FMULTIMOORA) method for pharmacological therapy selection of T2D. It makes the use of SWARA for obtaining the relative significance of every selected criterion by soliciting experts' opinions and FMULTIMOORA method for evaluation of each alternative according to all criteria based on a published clinical guideline. In this paper, an extended reference point approach is considered in the proposed hybrid MCDM model that resolves the classic reference point limitations and improves the FMULTIMOORA ranking procedure. Computational results indicate that Metformin is confirmed as the first-line medication and Sulfonylurea as the second-line add-on therapy. The Glucagon-like peptide-1 receptor agonist, Dipeptidyl peptidase-4 inhibitor, and Insulin are placed 3rd, 4th, and 5th, respectively. A sensitivity analysis is conducted to validate the model performance by comparing its result with studies in the literature, other fuzzy MCDM techniques and an interval MULTIMOORA method based on an observational dataset. The close correspondence between the final rankings of anti-diabetic agents resulted from the proposed hybrid model and other methodologies provide significant implications for endocrinologists to refer.

YH18421, a novel GPR119 agonist exerts sustained glucose lowering and weight loss in diabetic mouse model

G-protein-coupled receptor 119 (GPR119) represents a promising target for the treatment of type 2 diabetes as it can increase both GLP-1 secretion from intestinal L cells and glucose-stimulated insulin secretion (GSIS) from pancreatic β cells. Due to this dual mechanism of action, the development of small molecule GPR119 agonists has received much interest for the treatment of type 2 diabetes. Here, we identified a novel small-molecule GPR119 agonist, YH18421 and evaluated its therapeutic potential. YH18421 specifically activated human GPR119 with high potency and potentiated GLP-1 secretion and GSIS in vitro cell based systems. In normal mice, single oral administration of YH18421 improved glucose tolerance. Combined treatment of YH18421 and the DPP-4 inhibitor augmented both plasma active GLP-1 levels and glycemic control. In diet induced obese (DIO) mice model, glucose lowering effect of YH18421 was maintained after 4 weeks of repeat dosing and YH18421 acted additively with DPP-IV inhibitor. We also observed that YH18421 inhibited weight gain during 4 weeks of administration in DIO mice. These data demonstrate that YH18421 is capable of delivering sustained glucose control and preventing weight gain and combination with the DPP-IV inhibitor maybe an effective strategy for the treatment of type 2 diabetes.

Effect of solvents extraction on phytochemical components and biological activities of Tunisian date seeds (var. Korkobbi and Arechti)

Background

The interest in natural antioxidants, especially polyphenols, is growing more and more thanks to their positive contribution to human health. Thus, the prevention from the harmful action of oxidative stress which has been involved in many diseases such as cancer, inflammation diabetes, and cardiovascular illness.

Recent research proved the bioactive compounds richness of date seeds which could be a good biological matrix of natural antioxidants. Unfortunately, an important quantity of Tunisian dates seed is discarded yearly.

Methods

In this study, different solvents extraction (water, methanol, absolute acetone and aqueous acetone 80%) were used and the evaluation of its effect on phytochemical level, in vitro antioxidant activities, in vitro hyperglycemia key enzymes inhibition and in vivo anti-inflammatory proprieties were established for Tunisian date seeds.

Results

The result revealed that the polar solvent exhibited the highest amount of bioactive compounds. The correlation between polyphenol compounds and the antioxidant potentiality explains the powerful effect of used polar solvents on inflammation, TBARS and hyperglycemia inhibition. Furthermore, it showed its higher capacity to scavenge radicals.

Conclusions

Therefore, this big waste of Tunisian seeds could be used as cheap source of natural antioxidant compounds which are considered as a health challenge for the poor countries.

Electronic supplementary material

The online version of this article (doi:10.1186/s12906-017-1751-y) contains supplementary material, which is available to authorized users.

Remote control of glucose homeostasis in vivo using photopharmacology

Photopharmacology describes the use of light to precisely deliver drug activity in space and time. Such approaches promise to improve drug specificity by reducing off-target effects. As a proof-of-concept, we have subjected the fourth generation photoswitchable sulfonylurea JB253 to comprehensive toxicology assessment, including mutagenicity and maximum/repeated tolerated dose studies, as well as in vivo testing in rodents. Here, we show that JB253 is well-tolerated with minimal mutagenicity and can be used to optically-control glucose homeostasis in anesthetized mice following delivery of blue light to the pancreas. These studies provide the first demonstration that photopharmacology may one day be applicable to the light-guided treatment of type 2 diabetes and other metabolic disease states in vivo in humans.

Update on Glucose Management Among Noncritically Ill Patients Hospitalized on Medical and Surgical Wards

Hyperglycemia is a common issue affecting inpatient care. Although this is in part because of the higher rate of hospitalization among patients with preexisting diabetes, multiple factors complicate inpatient glucose management, including acute stress from illness or surgery, erratic dietary intake, and contribution of medications. It has been repeatedly demonstrated that poorly controlled blood glucose levels are associated with negative clinical outcomes, such as increased mortality, higher rate of surgical complications, and longer length of hospital stay. Given these concerns, there has been extensive study of the optimal strategy for management of glucose levels, with the bulk of existing literature focusing on insulin therapy in the intensive care unit setting. This review shifts the focus to the general adult medical and surgical wards, using clinical guidelines and sentinel studies to describe the scientific basis behind the current basal-bolus insulin-based approach to blood sugar management among noncritically ill inpatients. Patient-centered clinical trials looking at alternative dosing regimens and insulin analog and noninsulin agents, such as glucagon-like peptide-1 agonist therapies, introduce safe and effective options in the management of inpatient hyperglycemia. Data from these studies reveal that these approaches are of comparable safety and efficacy to the traditional basal-bolus insulin regimen, and may offer additional benefit in terms of less monitoring requirements and lower rates of hypoglycemia. Although existing data are encouraging, outcome studies will be needed to better establish the clinical impact of these more recently proposed approaches in an effort to broaden and improve current clinical practices in inpatient diabetes care.

Evaluation of extraction protocols for anti-diabetic phytochemical substances from medicinal plants

AIM

To examine the efficacy of three extraction techniques: Soxhlet-extraction (SE), cold-maceration (CM) and microwave-assisted-extraction (MAE) using 80% methanol as solvent.

METHODS

The study was performed on each of 50 g of Vernonia amygdalina (VA) and Occimum gratissimum (OG) leaves respectively. The percentage yield, duration of extraction, volume of solvent used, qualitative and quantitative phytoconstituents present was compared. The biological activities (hypoglycemic effect) were investigated using albino wistar rat model of diabetes mellitus (n = 36) with a combined dose (1:1) of the two plants leaf extracts (250 mg/kg b.w.) from the three methods. The extracts were administered orally, once daily for 21 d.

RESULTS

In this report, the percentage VA extract yield from MAE was highest (20.9% ± 1.05%) within 39 min using 250 mL of solvent, when compared to the CM (14.35% ± 0.28%) within 4320 min using 900 mL of solvent and SE (15.75% ± 0.71%) within 265 min using 500 mL of solvent. The percentage differences in OG extract yield between: MAE vs SE was 41.05%; MAE vs CM was 46.81% and SE vs CM was 9.77%. The qualitative chemical analysis of the two plants showed no difference in the various phytoconstituents tested, but differs quantitatively in the amount of the individual phytoconstituents, as MAE had significantly high yield (P > 0.05) on phenolics, saponins and tannins. SE technique gave significantly high yield (P > 0.05) on alkaloid, while CM gave significant high yield on flavonoids. The extracts from CM exhibited a significantly (P > 0.05) better hypoglycemic activity within the first 14-d of treatment (43.3% ± 3.62%) when compared to MAE (36.5% ± 0.08%) and SE methods (33.3% ± 1.60%). However, the percentage hypoglycemic activity, 21 d post-treatment with 250 mg/kg b.w. extract from MAE was 72.6% ± 1.03% and it was more comparable to 10 mg/kg b.w. glibenclamide treated group (75.0% ± 0.73%), unlike the SE (69.5% ± 0.71%) and CM (69.1% ± 1.03%).

CONCLUSION

CM technique produces extract with better hypoglycemic activity, whereas; MAE is a better option for high yield of phytoconstituents using less solvent within a short time.

Comparison of charges and resource use associated with saxagliptin and sitagliptin

OBJECTIVES

Saxagliptin and sitagliptin are two commonly used dipeptidyl peptidase-4 (DPP-4) inhibitors. Little is known about their comparative effectiveness in the real world, particularly their impact on cost and resources use. The objective of this study was to analyze charges and resource use associated with saxagliptin and sitagliptin to understand the impact of these DPP-4 inhibitor treatment options in a real-world setting.

METHODS

This was a retrospective, new-user study approved by the Institutional Review Board at the University of Toledo. Data were collected from a US insurance claims dataset (OptumInsight) for patients newly initiating treatment with saxagliptin or sitagliptin between January 1, 2010 and December 31, 2011. ICD-9 code 250 was used to identify patients with T2D. Overall and diabetes-related medical and pharmacy charges were observed. Inpatient hospitalizations were also compared. Propensity score matching was used to balance the cohorts of patients prescribed saxagliptin and sitagliptin. Appropriate univariate statistical tests were applied to the propensity-matched sample to examine differences in resource utilization outcomes. Statistical significance was evaluated at P < 0.05.

RESULT

After the propensity score matching, each cohort included 7711 patients. Saxagliptin treatment was associated with lower overall charges ($13,292 vs $14,032; P = 0.0023) and overall medical charges ($9,540 vs $10,296; P = 0.0024) during the 6-month follow-up period compared with sitagliptin treatment. No significant differences were observed in the overall pharmacy charges ($3,751 vs $3,753; P = 0.6937) and the diabetes-related charges ($5,141 vs $5,232; P = 0.2957). All-cause and diabetes-related inpatient hospitalization rates were significantly lower with saxagliptin treatment (p = 0.0001 and p = 0.0019, respectively). All-caused inpatient charges were also significantly lower with saxagliptin ($2,917.26 vs $3445.89; P < 0.0001).

CONCLUSION

Compared with patients initiating sitagliptin treatment, patients initiating saxagliptin treatment reported lower overall and medical charges and lower overall and diabetes-related hospitalization rates. These findings may aid payers in managing patients with T2D.

Supplements for Diabetes Mellitus: A Review of the Literature

The primary approach to controlling diabetes involves diet and lifestyle modification combined with pharmacologic interventions. Patients who are interested in exploring dietary supplements in the management of diabetes may have questions about which supplement to choose and whether any issues will arise with their current medication regimen. After reading this review, the pharmacist should be able to identify supplements that may provide benefit to improve diabetes management, understand what potential harm to the patient may occur, and be able to assist the patient in choosing high-quality supplements. This review will focus on the safety and efficacy data surrounding nicotinamide, ginseng, fenugreek, vitamin D, chromium, and cinnamon. These supplements are commonly listed in general circulation periodicals with claims to improve blood sugar management. Efficacy data showed a modest decrease in fasting plasma glucose of -0.96 mmol/dL (-17.29 mg/dL) for fenugreek and -24.59 mg/dL for cinnamon. It remains to be seen whether supplementation with these products can affect outcomes such as morbidity and mortality. Despite many studies being available, the majority lack uniformity across multiple dimensions, including varying participant characteristics, inconsistent formulations of supplement and dose, and differing study durations. This, coupled with variation in quality and purity of commercially available products, prevents universal recommendation for use in diabetes management.

Novel Therapeutics for Diabetes: Uptake, Usage Trends, and Comparative Effectiveness

The number of available therapies for treating type 2 diabetes has grown considerably in recent years. This growth has been fueled by availability of newer medications, whose benefits and risks have not been fully established. In this study, we review and synthesize the existing literature on the uptake, efficacy, safety, and cost-effectiveness of novel antidiabetic agents. Specifically, we focus on three drug classes that were introduced in the market recently: thiazolidinediones (TZDs), dipeptidyl peptidase-4 (DPP-4) inhibitors, and glucagon-like peptide-1 (GLP-1) receptor agonists. Not surprisingly, we find that the usage trends reflect the efficacy and safety profile of these novel drugs. The use of TZDs increased initially but decreased after a black-box warning was issued for rosiglitazone in 2007 that highlighted the cardiovascular risks associated with using the drug. Conversely, DPP-4 inhibitors and GLP-1 receptor agonists gained market shares due to their efficacy in glycemic control as an add-on treatment to metformin. DPP-4 inhibitors were the most commonly prescribed agents among the three novel drug classes, likely because they are relatively less expensive, have better safety profile, are administered orally, and are weight neutral. Sitagliptin was the most preferred DPP-4 inhibitor. The level of evidence on the comparative effectiveness, safety, and cost implications of using novel antidiabetic agents remains low and further studies with long-term follow-ups are needed.

Antidiabetic potentials of ethanolic extract of Aristolochia ringens (Vahl.) roots

ETHNOPHARMACOLOGICAL IMPORTANCE

Oral administration of alcoholic decoctions of Aristolochia ringens is used extensively by Traditional Medicine Practitioners (TMP) of Yoruba heritage in South west, Nigeria for the management of diabetes and its associated complications.

AIM OF THE STUDY

To assess the potentials of root ethanolic extract of Aristolochia ringens V. (REAR) in the management of diabetes using chemical induced experimental animal model.

MATERIALS AND METHODS

Qualitative and quantitative analyses were carried out to elucidate chemical constituents of the REAR extract using phytochemical analyses and gas chromatography-mass spectrometry (GC-MS) technique. Streptozotocin (STZ)-induced diabetic rats were orally administered with 75, 150 and 300mg/kg body weight of the REAR, once a day and the blood glucose (GLU) levels were monitored for 14 days. Mechanisms of GLU lowering effect were investigated by performing oral glucose tolerance test (OGTT) and modulation of diabetes associated biomarkers including hepatic glycogen (GLY), GLU, alpha amylase (αAMY) and glucose-6-phosphate dehydrogenase (GPDH) by the extract.

RESULTS

Extraction from A. ringens roots using ethanol/water (70/30) yielded 10.25% w/w REAR extract. Preliminary phytochemical profiling of REAR extract revealed the presence of flavonoids (23.03%), phenols (19.15%), alkaloids (16.13%), tannins (4.21%), saponins (1.44%) and GC-MS analyses showed that bulk of the extract was constituted by aristolone (92.3%). Oral administration of 300mg/kg b. wt. REAR extract caused significant reduction (>90%) in hyperglycemia to normal GLU level (≤ 120mg/dl) after 11 days of treatment. Lower doses of 75 and 150mg/kg b. wt. caused similar effect after 13 days. The extract also normalized postprandial GLU to baseline level within 90-120min. Also, GLY concentrations and GPDH activity were significantly increased, whereas GLU levels and αAMY activity were reduced in the liver of diabetic rats treated with REAR extract compared to values in non-treated diabetic group.

CONCLUSION

These findings revealed that ethanolic extract from A. ringens root possess antihyperglycemic activity and the data established its usage in folkloric decoctions for management of diabetes.

Review of head-to-head comparisons of glucagon-like peptide-1 receptor agonists

Currently, six glucagon-like peptide-1 receptor agonists (GLP-1RAs) are approved for treating type 2 diabetes. These fall into two classes based on their receptor activation: short-acting exenatide twice daily and lixisenatide once daily; and longer-acting liraglutide once daily, exenatide once weekly, albiglutide once weekly and dulaglutide once weekly. The phase III trial of a seventh GLP-1RA, taspoglutide once weekly, was stopped because of unacceptable adverse events (AEs). Nine phase III head-to-head trials and one large phase II study have compared the efficacy and safety of these seven GLP-1RAs. All trials were associated with notable reductions in glycated haemoglobin (HbA1c) levels, although liraglutide led to greater decreases than exenatide formulations and albiglutide, and HbA1c reductions did not differ between liraglutide and dulaglutide. As the short-acting GLP-1RAs delay gastric emptying, they have greater effects on postprandial glucose levels than the longer-acting agents, whereas the longer-acting compounds reduced plasma glucose throughout the 24-h period studied. Liraglutide was associated with weight reductions similar to those with exenatide twice daily but greater than those with exenatide once weekly, albiglutide and dulaglutide. The most frequently observed AEs with GLP-1RAs were gastrointestinal disorders, particularly nausea, vomiting and diarrhoea. Nauseaoccurred less frequently, however, with exenatide once weekly and albiglutide than exenatide twice daily and liraglutide. Both exenatide formulations and albiglutide may be associated with higher incidences of injection-site reactions than liraglutide and dulaglutide. GLP-1RA use in clinical practice should be customized for individual patients, based on clinical profile and patient preference. Ongoing assessments of novel GLP-1RAs and delivery methods may further expand future treatment options.

Noninsulin Antidiabetic Drugs for Patients with Type 2 Diabetes Mellitus: Are We Respecting Their Contraindications?

AIM

To assess prescribing practices of noninsulin antidiabetic drugs (NIADs) in T2DM with several major contraindications according to prescribing information or clinical guidelines: renal failure, heart failure, liver dysfunction, or history of bladder cancer.

METHODS

Cross-sectional, descriptive, multicenter study. Electronic medical records were retrieved from all T2DM subjects who attended primary care centers pertaining to the Catalan Health Institute in Catalonia in 2013 and were pharmacologically treated with any NIAD alone or in combination.

RESULTS

Records were retrieved from a total of 255,499 pharmacologically treated patients. 78% of patients with some degree of renal impairment (glomerular filtration rate (GFR) < 60 mL/min) were treated with metformin and 31.2% with sulfonylureas. Even in the event of severe renal failure (GFR < 30 mL/min), 35.3% and 22.5% of patients were on metformin or sulfonylureas, respectively. Moreover, metformin was prescribed to more than 60% of patients with moderate or severe heart failure.

CONCLUSION

Some NIADs, and in particular metformin, were frequently used in patients at high risk of complications when they were contraindicated. There is a need to increase awareness of potential inappropriate prescribing and to monitor the quality of prescribing patterns in order to help physicians and policymakers to yield better clinical outcomes in T2DM.

Empagliflozin: a sodium-glucose cotransporter 2 inhibitor for treatment of type 2 diabetes

PURPOSE

The pharmacology, pharmacokinetics, pharmacodynamics, clinical efficacy, adverse effects, dosage and administration, and drug-drug interactions of empagliflozin are reviewed.

SUMMARY

Empagliflozin is a direct inhibitor of sodium-glucose cotransporter 2 (SGLT2), which acts to lower the renal threshold and increase urinary glucose excretion. SGLT2 is found in the proximal tubules of the kidneys and reabsorbs about 90% of the filtered glucose. Because the mechanism of action of empagliflozin is not insulin dependent or insulin sensitive, it may be used in patients at different stages of diabetes with nonfunctional or impaired pancreatic β cells. Furthermore, empagliflozin can be used with other antidiabetic drugs due to its lack of any additive hypoglycemic effects. Long-term efficacy studies revealed significant reductions with empagliflozin in glycosylated hemoglobin (HbA1c) values at week 78 compared with placebo. Secondary endpoints in clinical trials showed improvements in lowering blood pressure and reductions in body weight. The risk:benefit ratio must be assessed for empagliflozin as the safety profile includes an increase in urinary and genital infections.

CONCLUSION

Empagliflozin has shown efficacy in lowering HbA1c and blood glucose levels both as monotherapy and as an add-on to existing therapy. Despite the drug's promising outlook, empagliflozin also leads to common but serious adverse events not seen with other classes of antihyperglycemic agents. Considering the current data on its efficacy and its safety profile, empagliflozin can be used as a second- or third-line agent in treating diabetes.

Genetics and pharmacology of longevity: the road to therapeutics for healthy aging

Aging can be defined as the progressive decline in tissue and organismal function and the ability to respond to stress that occurs in association with homeostatic failure and the accumulation of molecular damage. Aging is the biggest risk factor for human disease and results in a wide range of aging pathologies. Although we do not completely understand the underlying molecular basis that drives the aging process, we have gained exceptional insights into the plasticity of life span and healthspan from the use of model organisms such as the worm Caenorhabditis elegans and the fruit fly Drosophila melanogaster. Single-gene mutations in key cellular pathways that regulate environmental sensing, and the response to stress, have been identified that prolong life span across evolution from yeast to mammals. These genetic manipulations also correlate with a delay in the onset of tissue and organismal dysfunction. While the molecular genetics of aging will remain a prosperous and attractive area of research in biogerontology, we are moving towards an era defined by the search for therapeutic drugs that promote healthy aging. Translational biogerontology will require incorporation of both therapeutic and pharmacological concepts. The use of model organisms will remain central to the quest for drug discovery, but as we uncover molecular processes regulated by repurposed drugs and polypharmacy, studies of pharmacodynamics and pharmacokinetics, drug-drug interactions, drug toxicity, and therapeutic index will slowly become more prevalent in aging research. As we move from genetics to pharmacology and therapeutics, studies will not only require demonstration of life span extension and an underlying molecular mechanism, but also the translational relevance for human health and disease prevention.

[Sulfonylureas in today's blood glucose lowering therapy. New data on advantages and potential barriers of an "old" antidiabetic group]

Sulfonylurea compounds have been basic elements of antidiabetic treatment in type 2 diabetes for a long time. However, with the introduction of incretin type insulin secretagogues it is often arises, whether is still there a place for sulfonylureas in the today's therapy. To answer this question the author overviews general pharmaceutical characteristics of the sulfonylurea compounds as well as individual particularities of the second generation derivatives used at present in Hungary. The author details also the most important differences between incretin type drugs - first of all dipeptidyl peptidase-4 inhibitors - and sulfonylureas. On the basis of available data it can be concluded in accordance with the latest international guidelines, that sulfonylureas have still role in the blood glucose lowering therapy of type 2 diabetes, though they became somewhat pushed back among insulin secretagogue type drugs. If a sulfonylurea compound is the drug of choice, it is important to select the appropriate molecule (in case of normal renal function gliclazide or glimepiride). It is also important to re-educate the patient, as well as to apply the minimal dose providing the desired glycaemic effect.

Shared medical appointments for patients with diabetes mellitus: a systematic review

OBJECTIVES

Shared medical appointments (SMAs) are an increasingly used system-redesign strategy for improving access to and quality of chronic illness care. We conducted a systematic review of the existing literature on SMA interventions for patients with diabetes in order to understand their impact on outcomes.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, PsycINFO, and Web of Science from January 1996 through April 2012. PubMed search updated June 2013.

STUDY SELECTION

English-language peer-reviewed publications of randomized controlled trials (RCTs), nonrandomized cluster controlled trials, controlled before-and-after studies, or interrupted time-series designs conducted among adult patients with diabetes. Two independent reviewers used prespecified criteria to screen titles and abstracts for full text review.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two different reviewers abstracted data and rated study quality and strength of evidence. When possible, we used random-effects models to synthesize the effects quantitatively, reporting by a weighted difference of the means when the same scale was used across studies, and a standardized mean difference when the scales differed. We measured heterogeneity in study effects using Forest Plots, Cochran's Q, and I(2), and explored heterogeneity by using subgroup analyses for categorical variables and meta-regression analyses for continuous or discrete variables. Outcomes not suitable to meta-analysis were summarized qualitatively.

RESULTS

Twenty-five articles representing 17 unique studies compared SMA interventions with usual care. Among patients with diabetes, SMAs improved hemoglobin A1c (∆ = -0.55 percentage points [95 % CI, -0.11 to -0.99]); improved systolic blood pressure (∆ = -5.2 mmHg [95 % CI, -3.0 to -7.4]); and did not improve LDL cholesterol (∆ = -6.6 mg/dl [95 % CI, 2.8 to -16.1]). Nonbiophysical outcomes, including economic outcomes, were reported too infrequently to meta-analyze, or to draw conclusions from. The A1c result had significant heterogeneity among studies, likely secondary to the heterogeneity among included SMA interventions.

LIMITATION

Heterogeneity among the components of diabetes SMAs leads to uncertainty about what makes a particular SMA successful.

CONCLUSION

SMA interventions improve biophysical outcomes among patients with diabetes. There was inadequate literature to determine SMA effects on patient experience, utilization, and costs.

Antidiabetic medications and polypharmacy

Polypharmacy, or the use of multiple medications, is a serious concern for providers who care for older adults, as polypharmacy is associated with medication nonadherence, drug-drug interactions, drug-disease interactions, and adverse drug events. Multiple medications, high chronic disease burden, and age-related physiologic changes make management of older adults with diabetes increasingly difficult. Given high medication burden and potential for increased medication sensitivity in this patient population, it is prudent that providers are aware of potential risks and benefits of antidiabetic medications and implement shared decision-making practices to ensure appropriate care for older adults with diabetes.

Efficacy and safety of canagliflozin in subjects with type 2 diabetes: systematic review and meta-analysis

PURPOSE

To assess the efficacy and safety of the novel sodium glucose co-transporter 2 (SGLT2) inhibitor-canagliflozin for type 2 diabetes (T2DM).

METHODS

A search of Medline (1946-January 2014), Embase (1950-January 2014), and The Cochrane Library for randomized controlled trials of canagliflozin compared to placebo or active comparator in T2DM was performed. Clinical Trials website and unpublished U.S. Food and Drug Administration data were also searched.

RESULTS

Ten trials including 6,701 patients were analyzed. Compared with placebo, canagliflozin produced absolute reductions in glycated hemoglobin A1c levels when used as monotherapy (weighted mean difference (WMD) -1.08%, 95% confidence interval (CI) [-1.25 to -0.90], p < 0.00001) or add-on treatment (WMD -0.73%, 95%CI [-0.84 to -0.61], p < 0.00001). When compared with other active comparators, canagliflozin significantly reduced HbA1c by -0.21% (WMD, 95%CI [-0.33 to -0.08], p = 0.001). Canagliflozin led to greater body weight loss (vs. placebo, WMD -2.81 kg, 95%CI [-3.26 to -2.37]; vs. active comparators, WMD -3.49 kg, 95%CI [-4.86 to -2.12]). Hypoglycemia with canagliflozin was similar to placebo or sitagliptin, and was lower than glimepiride (risk ratio (RR) 0.15, 95%CI [0.10 to 0.22]). Genital tract infections were more common with canagliflozin (vs. placebo, RR 3.76, 95%CI [2.23 to 6.35]; vs. active comparators, RR 4.95, 95%CI [3.25 to 7.52]). Similar incidences of urinary tract infections were noted with canagliflozin compared with control groups.

CONCLUSION

Canagliflozin led to improvements in reducing glycated hemoglobin A1c levels and body weight with low risk of hypoglycemia in patients with T2DM. Common adverse effects including genital tract infections and osmotic diuresis-related AEs were identified and reviewed. Risks of cardiovascular events are even less certain, and more data on long-term effects are needed.

Risk perception and self-management in urban, diverse adults with type 2 diabetes: the improving diabetes outcomes study

PURPOSE AND BACKGROUND

The relationship between risk perceptions and diabetes self-care remains ambiguous. This study aimed to assess baseline, 1-year follow-up, and change score relationships among perceived risk, diabetes self-care, and glycemic control for adult individuals participating in a behavioral intervention that improved glycemic control relative to the active control.

METHOD

One-year randomized trial compared a behavioral telephonic intervention with a print only intervention. Participants (N = 526) are members of a union/employer sponsored health benefit plan, with HbA(1c) ≥ 7.5 %, prescribed at least one oral diabetes medication. Participants rated perceived risk of diabetes and its complications and diabetes self-care at baseline and 1 year. Data were collected in a large urban area in the USA.

RESULTS

There were no relationships between risk perceptions and glycemic control during the study. Baseline perceived risk predicted follow-up self-care. Additionally, participants assigned to the intervention group showed significant changes in dietary and exercise adherence at high levels of risk knowledge and low levels of optimistic bias.

CONCLUSION

Perceived risk relates to dietary, exercise, and medication adherence in diabetes. The perceived risk construct might foster a more coherent conceptualization of the relationship between one's diabetes, possible complications, and diabetes self-care behaviors.

“Diabegon”, a safe and effective polyherbal therapy for type 2 diabetes mellitus

AIM: To investigate the antihyperglycemic, antihyperlipidemic and antioxidant functions of a polyherbal formulation, “Diabegon”, in human subjects with type 2 diabetes mellitus.

METHODS: A total of 33 human subjects with type 2 diabetes mellitus were recruited for the study and all anthropological and biochemical parameters were recorded at the time of registration. The subjects were given hot water extract obtained from 10 gm of “Diabegon” powder, “Diabegon kwath”, on an empty stomach everyday in the morning under personal supervision for 6 mo. The therapeutic functions of the “Diabegon kwath” was assessed by monitoring the blood glucose levels at monthly intervals and glycosylated hemoglobin, lipid profile and biomarkers of oxidative stress, liver and kidney function markers at three monthly intervals in the study subjects.

RESULTS: Daily administration of hot water extract of “Diabegon” regularly for 6 mo resulted in significant reductions of blood glucose and glycosylated hemoglobin levels. There was also a significant increase in high density lipoprotein cholesterol levels with concomitant decreases in total cholesterol, triglycerides, low density lipoprotein cholesterol and very low density lipoprotein. A significant improvement in glycosuria and proteinuria was also observed. Also, the subjects exhibited a significant improvement in enzymatic and nonenzymatic biochemical markers of oxidative stress. The kidney and liver functions remained normal and in fact improved in many subjects.

CONCLUSION: The study which is first of its kind, advocates “Diabegon kwath” as a safe and effective Ayurvedic therapy for the treatment of human type 2 diabetes mellitus and further placebo controlled trial may substantiate the therapeutic efficacy of the formulation.

Glycemic control and the first use of oral antidiabetic agents among patients with type 2 diabetes mellitus

OBJECTIVE

Examine how patients diagnosed with type 2 diabetes mellitus (T2DM) are treated with oral antidiabetic (OAD) agents and the relationship between treatment patterns and glycemic control.

RESEARCH DESIGN AND METHODS

Data were obtained from the i3 Invision Data Mart database (OptumInsight, Eden Prairie, MN, USA). The analyses examined 4627 individuals who received a first prescription for an OAD (with first date identified as index date) and received at least one HbA1c test in both the 1 year prior and 2 years post index date. Patients were categorized based upon their level of glycemic control pre index date and logistic multivariate analyses were used to examine the probability of a patient's first treatment pattern change being a switch, augmentation, or discontinuation compared to continuation on the intent-to-treat (ITT) OAD.

RESULTS

Men tended to have worse glycemic control at OAD initiation. During the post-period, younger patients were more likely to switch, augment or discontinue therapy, while patients initially treated with metformin were more likely to switch or augment therapy. Results indicated that patients with moderate or poor glycemic control, compared to those with good glycemic control, were significantly more likely to switch or augment therapy. Practice patterns revealed minimal use of insulin although, on average, many patients were above target HbA1c levels at initiation. Interpretation of results are limited by the fact that only a small subset of patients had valid HbA1c data and that the analyses was not able to account for other factors, such as race and weight, that may also impact the analyses.

CONCLUSIONS

Patient initial level of glycemic control was associated with changes in treatment patterns in the 2 years post initiation on an OAD, with patients with moderate or poor control more likely to switch or augment their ITT therapy, compared to individuals with good control.

Alpha-amylase inhibitory activity of two Anthocleista species and in vivo rat model anti-diabetic activities of Anthocleista djalonensis extracts and fractions

ETHNOPHARMACOLOGICAL RELEVANCE

Anthocleista djalonensis (A. Chev) and Anthocleista vogelii Planch are plants being used in West Africa traditionally to treat various diseases such as malaria, hernia, hypertension, stomach aches, hemorrhoids, syphilis, and diabetes. Diabetes causes about 5% of all deaths globally each year. Chemotherapeutic agents such as biguanides, sulfonylureas, and thiozolidinediones are available for the treatment of diabetes, however, they have undesirable side effects. The need for newer, more effective and less toxic drugs is imperative and the biodiversity of Nigeria has a high potential for drug discovery based on plants used in the ethnomedicine.

AIM OF THE STUDY

To investigate the leaves, stem bark and roots of these plants for their probable alpha-amylase inhibitory activities and establish their anti-diabetic activities. The overall goal is do bioassay-guided fractionation and isolation of active anti-diabetic compounds.

MATERIALS AND METHODS

Powdered samples (leaves, stem bark and roots) macerated with 80% aqueous methanol were evaluated in vitro using alpha-amylase inhibitory assay while in vivo investigations were carried out on hyperglycemic rats. Diabetes was induced in albino rats by an intraperitoneal injection of alloxan monohydrate (80mg/kg). Plant extracts (1g/kg) were given orally for 7 days, while blood glucose levels were monitored using a one touch glucometer. The crude methanol extracts found to be most active were further partitioned into hexane and ethyl acetate fractions which were also tested in vivo on the diabetic animals.

RESULTS

The leaves and stem bark crude methanol extracts of Anthocleista djalonensis gave comparable α-amylase inhibition of 73.66% and 72.90%, respectively which were quite higher than the 38.93% and 22.90% of the same plant parts given by Anthocleista vogelii. The crude stem bark extract of Anthocleista djalonensis exhibited significant peak blood glucose reduction on day 6 (72.59%, p<0.05) which was higher than the leaves or roots which gave 45.73% and 47.46% (p<0.05), respectively The stem bark ethyl acetate fraction of Anthocleista djalonensis gave reduction in blood glucose level of 60.86% (p<0.05).

CONCLUSION

From our results, the leaves, stem bark and whole root of both plants exhibited α-amylase inhibitory activities with Anthocleista djalonensis also showing good anti-diabetic activities in vivo indicating that they contain active principles for the management of diabetes. There is justification for the use of the plants traditionally to manage diabetes.

Transitioning from inpatient to outpatient therapy in patients with in-hospital hyperglycemia

Transition from inpatient to outpatient care for patients with type 2 diabetes mellitus is an important aspect of patient management for which there is no guidance. Intensive glucose lowering with insulin is generally favored for seriously ill hospitalized patients, but after discharge, patients often resume their prior regimens, which may include an array of oral or injected glucose-lowering agents. Factors that should be considered in this transition include goals of care/life expectancy, glycated hemoglobin at hospital admission, home medications for other illnesses and their potential for interactions with antidiabetes treatment, comorbidities, nutritional status, physical disabilities, ability to carry out self-monitoring of blood glucose, risk for hypoglycemia, contraindications to oral medications, health literacy, and financial and other resources. Traditional oral therapies that may be used after the patient leaves the hospital include sulfonylureas, α-glucosidase inhibitors, thiazolidinediones, and metformin. α-Glucosidase inhibitors are limited by gastrointestinal adverse events, and thiazolidinediones by fluid retention and increased risk for heart failure. Thiazolidinediones also require a long period of administration for onset glucose lowering and are not suitable for transitioning hospitalized patients who have been receiving insulin to outpatient care. Metformin is contraindicated in patients with renal, cardiac, or pulmonary insufficiency. Incretin-based therapies, glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors, have limited use in hospitals, but may be suitable for the transition to outpatient treatment. The most common adverse events with glucagon-like peptide-1 inhibitors involve the gastrointestinal system. More formal studies of treatment regimens for patients with hyperglycemia leaving the hospital are needed to guide care for this group.

Computational assessment of insulin secretion and insulin sensitivity from 2-h oral glucose tolerance tests for clinical use for type 2 diabetes

In type 2 diabetes mellitus, glucose homeostasis is tightly maintained through insulin secretion and insulin sensitivity. Therefore, finding an accurate method to assess insulin secretion and sensitivity using clinically available data would enhance the quality of diabetic medical care. In an effort to find such a method, we developed a computational approach to derive indices of these factors using a 2-h oral glucose tolerance test (OGTT). To evaluate our method, clinical data from subjects who received an OGTT and a glucose clamp test were examined. Our insulin secretion index was significantly correlated with an analogous index obtained from a hyperglycemic clamp test (r = 0.90, n = 46, p < 0.001). Our insulin sensitivity index sensitivity was also significantly correlated with an analogous index obtained from a hyperinsulinemic-euglycemic clamp test (r = 0.56, n = 79, p < 0.001). These results suggest that our method can potentially provide an accurate and convenient tool toward improving the management of diabetes in clinical practice by assessing insulin secretion and insulin sensitivity.

Alogliptin: a review of its use in the management of type 2 diabetes mellitus

Alogliptin (Nesina®) is a dipeptidyl peptidase-4 inhibitor that is approved in Japan for the treatment of adult patients with type 2 diabetes mellitus that is inadequately controlled by diet and exercise alone or by diet plus treatment with an α-glucosidase inhibitor. Alogliptin plus diet and exercise is also approved in Japan for use in combination with a thiazolidinedione in patients with type 2 diabetes. In several large (n >250), double-blind, multinational trials of up to 26 weeks' duration, oral alogliptin as monotherapy or in combination with other oral antihyperglycaemic agents (metformin, glibenclamide or pioglitazone) or insulin therapy improved glycaemic control and was generally well tolerated in adult patients with inadequately controlled type 2 diabetes, including elderly patients. Significant improvements in glycaemic control were evident from as early as 1 week in terms of improvements in mean fasting plasma glucose levels and from 4 weeks onwards for improvements in mean glycosylated haemoglobin levels. In general, the incidence of hypoglycaemia was similar to that seen in placebo groups and alogliptin treatment had neutral effects on bodyweight and lipid parameters. The long-term safety of alogliptin therapy remains to be established in clinical studies and with clinical experience. A planned clinical trial evaluating long-term clinical outcomes in patients with acute coronary syndrome and other planned or ongoing short-term trials will help to more definitively determine the position of alogliptin therapy in relation to other available antihyperglycaemic therapies. In the meantime, alogliptin is a promising new option for the treatment of patients with type 2 diabetes, including elderly patients.