Cardiovascular disease prevention in patients with type 2 diabetes: The role of oral anti-diabetic agents

Contribution of calcium dysregulation to impaired coronary artery contraction in Zucker diabetic fatty rats

Diabetic coronary artery injury is closely associated with Ca²⁺ dysregulation, although the underlying mechanism remains unclear. This study explored the role and mechanism of Ca²⁺ handling in coronary artery dysfunction in type 2 diabetic rats. Zucker diabetic fatty (ZDF) rats were used as the type 2 diabetes mellitus model. The contractility of coronary artery rings induced by KCl, CaCl₂ , 5-HT and U46619 was significantly lower in ZDF rats than in Zucker lean rats. Vasoconstriction induced by 5-HT and U46619 was greatly inhibited by nifedipine. However, in the presence of 1 μM nifedipine or in the Ca²⁺ -free KH solution containing 1 μM nifedipine, there was no difference in the vasoconstriction between Zucker lean and ZDF rats. Store-operated calcium channels (SOCs) were not involved in coronary vasoconstriction. The downregulation of contractile proteins and the upregulation of synthesized proteins were in coronary artery smooth muscle cells (CASMCs) from ZDF rats. Metformin reversed the reduction of vasoconstriction in ZDF rats. Taken together, L-type calcium channel is important for regulating the excitation-contraction coupling of VSMCs in coronary arteries, and dysregulation of this channel contributes to the decreased contractility of coronary arteries in T2DM.

Plasma fibrin clot properties and cardiovascular mortality in patients with type 2 diabetes: a long-term follow-up study

Background

Patients with type 2 diabetes mellitus (T2DM) are at high risk of cardiovascular mortality, but the mechanisms behind this remain unclear. Prothrombotic fibrin clot properties have been shown in T2DM and cardiovascular disease. We hypothesized that formation of denser clots, which are resistant to fibrinolysis, has a negative impact on cardiovascular mortality in T2DM.

Methods

We studied 133 T2DM patients aged 43–83 years. Plasma fibrin clot turbidity, permeation, compaction, and efficiency of clot lysis using 3 assays including the determination of maximum concentration (D-D_max) and rate of increase in D-dimer concentration (D-D_rate) released during tissue plasminogen activator-induced degradation, were evaluated at the time of enrollment, along with thrombin generation and fibrinolytic proteins. During a median follow-up period of 72 months, cardiovascular mortality was recorded.

Results

Cardiovascular deaths (n = 16, 12%) occurred more frequently in patients with increased D-D_max (> 4.26 mg/l, hazard ratio [HR] 5.43, 95% confidence interval [CI] 1.99–14.79), or decreased D-D_rate (< 0.07 mg/l/min, HR 2.97, 95% CI 1.07–8.23), or increased peak thrombin (> 283.5 nM, HR 5.65, 95% CI 2.07–15.51). These predictors had an even more potent impact on cardiovascular mortality in patients with prior cardiovascular disease (64.7%) and with corresponding risks as follows: HR 6.18, 95% CI 2.02–18.96; HR 8.98, 95% CI 2.99–26.96; and HR 5.35, 95% CI 1.62–17.72, respectively. Other investigated fibrin variables and fibrinolytic proteins did not associate with cardiovascular mortality. In multivariable analysis, cardiovascular mortality was predicted by D-D_max > 4.26 mg/l, age > 65 years, prior cardiovascular disease, and C-reactive protein > 3 mg/l.

Conclusions

This study is the first to show that formation of denser fibrin clots resistant to fibrinolysis could be a risk factor for long-term cardiovascular mortality in T2DM.

Intelligent therapeutic decision support for 30 days readmission of diabetic patients with different comorbidities

The significance of medication therapy in managing comorbid diabetes is vital for maintaining the overall wellness of patients and reducing the cost of healthcare. Thus, using appropriate medication or medication combinations will be necessary for improved person-centred care and reduce complications associated with diagnosis and treatment. This study explains an intelligent decision support framework for managing 30 days unplanned readmission (30_URD) of comorbid diabetes using the Random Forest (RF) algorithm and Bayesian Network (BN) model. After the analysis of the medical records of 101,756 de-identified diabetic patients treated with 21 medications for 28 comorbidity combinations, the optimal medications for minimizing the likelihood of early readmissions were determined. This approach can help for identifying and managing most vulnerable patients thereby giving room to enhance post-discharge monitoring through clinical specialist supports to build critical-self management skills that will minimize the cost of diabetes care.

Nepeta angustifolia C. Y. Wu improves renal injury in HFD/STZ-induced diabetic nephropathy and inhibits oxidative stress-induced apoptosis of mesangial cells

ETHNOPHARMACOLOGICAL RELEVANCE

As an important medicinal material constituting a variety of traditional Chinese medicine prescriptions, Nepeta angustifolia C. Y. Wu was used as a folk medicine to treat various vascular-related diseases including apoplexia, and cerebral haemorrhage in Tibet, China. Our previous studies have shown that this plant had a significant protective effect on vascular dysfunction of the intracerebral haemorrhage and diabetic rats. In present study, we aimed to investigate the protective effects and underlying mechanisms of Nepeta angustifolia on diabetic nephropathy (DN), a microvascular complication.

AIM OF THE STUDY

This study is aim to evaluate the protective effect of ethanol extracts of N. angustifolia (NA) on DN, and explore mechanism of action to provide basis for its pharmacological action against DN.

MATERIALS AND METHODS

High-fat diet and low-dose streptozotocin administration (HFD/STZ) induced diabetic rats were randomly divided into 5 groups (n = 8): the diabetic model group, metformin group, and three dose groups of NA (60 mg/kg, 120 mg/kg, 240 mg/kg). After administration of NA for 8 weeks, the blood, urine and renal tissue were collected for subsequent experiments. Biochemical markers (urine protein, Cr, BUN), oxidative stress makers (SOD, GSH-px and MDA) and pro-inflammatory mediators (TNF-α, IL-1β, IL-6 and MCP-1) were evaluated by commercial kit and ELISA, respectively. The effect of NA on DN was further confirmed by evaluation of renal histopathology by using the H&E, PAS and Masson staining. The H₂O₂-induced HBZY-1 cells (rat glomerular mesangial cells) were also been used to evaluate the renal protective effect of NA (50 μg/mL, 100 μg/mL, 200 μg/mL). The oxidative stress makers were detected by commercial kit. The levels of apoptosis and related proteins (caspase 3, 9) were detected by TUNEL assay and western blot analysis, respectively. The depolarization of mitochondrial membrane potential was detected by JC-1 staining assay.

RESULTS

The administration of NA is helpful to maintain near normal body weight, blood glucose, urine volume, urine protein, kidney index and serum levels of Cr and BUN. NA treatment significantly improve renal dysfunction by the down-regulation of renal oxidative stress and pro-inflammatory mediators in HFD/STZ induced diabetic rats. In vitro experiments, NA has a significant cellular protective effect in H₂O₂-induced HBZY-1 cells, as well as the regulation in increases of SOD level and the decreases of ROS and MDA levels. Furthermore, NA treatment can significantly inhibit H₂O₂ induced mesangial cells apoptosis by the increasing mitochondrial potential and suppressing caspases-madiated signaling pathway.

CONCLUSIONS

NA has obvious improvement on renal dysfunction in HFD/STZ induced diabetic rats. NA can protect mesangial cells by inhibiting oxidative stress induced apoptosis, which may be related to its regulation of mitochondrial-caspase apoptosis pathway.

QUANTIFICATION OF MENTAL STRESS USING COMPLEXITY ANALYSIS OF EEG SIGNALS

Detection of mental stress has been receiving great attention from the researchers for many years. Many studies have analyzed electroencephalogram signals in order to estimate mental stress using linear methods. In this paper, a novel nonlinear stress assessment method based on multivariate multiscale entropy has been introduced. Since the multivariate multiscale entropy method characterizes the complexity of nonlinear time series, this research determines the mental stress of human during cognitive workload using complexity of electroencephalogram (EEG) signals. To perform this work, 36 subjects including 9 men and 27 women were participated in the cognitive workload experiment. Multivariate multiscale entropy method has been applied to electroencephalogram data collected from those subjects for estimating mental stress in terms of complexity. The complexity feature of brain electroencephalogram signals collected during resting and cognitive workload has shown statistically significant ([Formula: see text]) differences across brain regions and mental tasks which can be implemented practically for building stress detection system. In addition, the complexity profile of electroencephalogram signals has shown that higher stress is reflected in good counting compared to bad counting. Moreover, the support vector machine (SVM) has shown promising classification between resting and mental counting states by providing 80% sensitivity, 100% specificity and 90% classification accuracy.

Androgen Therapy in Male Patients Suffering from Type 2 Diabetes: A Review of Benefits and Risks

BACKGROUND

The current estimated numbers of patients with Type 2 Diabetes (T2D) is believed to be close to 10% of the whole populations of many geographical regions, causing serious concerns over the resulting elevated morbidity and mortality as well as the impact on health care systems around the world. In addition to negatively affecting the quality of life, diabetes is associated with cardiovascular and cerebrovascular complications, indicating that appropriate drug therapy should not only deal with metabolic dysfunction but also protect the vascular system, kidney function and skeletal muscle mass from the effects of the epigenetic changes induced by hyperglycaemia.

OBJECTIVE

To provide an insight into the management of hypogonadism associated with T2D, this review focuses on clinical observations related to androgen therapy in qualified diabetic patients, and discusses the lines of evidence for its benefits and risks. The potential interactions of testosterone with medicines used by patients with T2D will also be discussed.

CONCLUSION

From recent clinical findings, it became evident that a considerable percentage of patients suffering from T2D manifested low serum testosterone and experienced diminished sexual activity, as well as reduced skeletal muscle mass and lower bone density. Although there are some controversies, Testosterone Replacement Therapy (TRT) for this particular population of patients appears to be beneficial overall only if it is implemented carefully and monitored regularly.

Metformin-induced activation of AMPK inhibits the proliferation and migration of human aortic smooth muscle cells through upregulation of p53 and IFI16

The proliferation and migration of vascular smooth muscle cells are significant in the development and progression of atherosclerosis and plaque rupture. Metformin is a widely used antidiabetic drug, which has been reported to inhibit cell growth and migration. The antiproliferative and antimigratory effects of metformin have been attributed to 5′ adenosine monophosphate-activated protein kinase (AMPK) activation. The purpose of the present study was to investigate the effects of metformin on primary human aortic muscle cells (HASMCs) in vitro and to clarify the underlying mechanism. We investigated the effectiveness of metformin in inhibiting the proliferation and migration of HASMCs in vitro using RNA extraction and reverse transcription-quantitative polymerase chain reaction (RT-qPCR), cell number counting, cell viability assay, cell cycle assay and cell migration assay. Through transfection with small interfering (si)RNA targeting p53 and interferon-inducible protein 16 (IFI16), the roles of p53 and IFI16 in these processes were evaluated. The present study demonstrated that p53, IFI16 and AMPK were upregulated in senescent primary HASMCs, which exhibited a decrease in proliferation and migration. In addition, metformin was able to activate p53, IFI16 and AMPK, in order to inhibit proliferation and migration of HASMCs. Furthermore, siRNA-mediated knockdown of p53 and IFI16 attenuated AMPK activation and reversed the suppressive effects of metformin. Notably, in response to metformin, the activation of AMPK was not observed in p53- and IFI16-silenced HASMCs. These results indicated that metformin-induced activation of AMPK suppresses the proliferation and migration of HASMCs by upregulating p53 and IFI16. These findings suggested that metformin may have potential use in the treatment of atherosclerosis.

Liraglutide and Metformin alone or combined therapy for type 2 diabetes patients complicated with coronary artery disease

BACKGROUND

This study is to compare the effects of Liraglutide and Metformin alone or combined treatment on the cardiac function in T2DM patients complicated with CAD.

METHODS

120 T2DM patients were included at Endocrinology Department of Tianjin First Center Hospital (Tianjin, China) from April 2012 to September 2013. The study contained two sections. Section 1: 30 patients in group 1 was treated with Liraglutide (Novo Nordisk) (1.2 mg/d), and 30 patients in group 2 with Metformin (Shiguibao) (1500 mg/d) for 24 weeks. Section 2: 30 patients in group1 was treated with Liraglutide (1.8 mg/d) and 30 in group 2 with Liraglutide (1.2 mg/d) plus Metformin (1500 mg/d) for 24 weeks. Fasting blood glucose (FBG), postprandial glucose (PPG), glycated hemoglobin (HbA1c), body mass index (BMI), blood pressure (BP), triglyceride (TG), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), C reactive protein (CRP), left ventricular end-diastolic diameter (LVEDD), ejection fraction (EF) and the ratio of early (E) to late (A) ventricular filling velocities (E/A ratio) were measured before and after the 24-week treatment.

RESULTS

After 24-week treatment, when blood glucose level was controlled in 4 groups, Liraglutide alone treatment showed better improvements than on all measuring except TG in Section 1, however, combined treatment of Liraglutide and Metformin showed better improvements on all measuring except BMI, TG and BP in Section 2.

CONCLUSIONS

With similar glycemic control, the Liraglutide (1.2 mg/d) monotherapy showed the better effects than either Metformin alone, or combination of Liraglutide and Metformin on lipid metabolism and cardiovascular function.

TRIAL REGISTRATION

This trial was registered at Chinese Clinical Trial Registry ( chictr.org.cn ) # ChiCTR-IPR-16008578 .

Thiazolidinedione drugs in the treatment of type 2 diabetes mellitus: past, present and future

Thiazolidinedione (TZD) drugs used in the treatment of type 2 diabetes mellitus (T2DM) have proven effective in improving insulin sensitivity, hyperglycemia, and lipid metabolism. Though well tolerated by some patients, their mechanism of action as ligands of peroxisome proliferator-activated receptors (PPARs) results in the activation of several pathways in addition to those responsible for glycemic control and lipid homeostasis. These pathways, which include those related to inflammation, bone formation, and cell proliferation, may lead to adverse health outcomes. As treatment with TZDs has been associated with adverse hepatic, cardiovascular, osteological, and carcinogenic events in some studies, the role of TZDs in the treatment of T2DM continues to be debated. At the same time, new therapeutic roles for TZDs are being investigated, with new forms and isoforms currently in the pre-clinical phase for use in the prevention and treatment of some cancers, inflammatory diseases, and other conditions. The aims of this review are to provide an overview of the mechanism(s) of action of TZDs, a review of their safety for use in the treatment of T2DM, and a perspective on their current and future therapeutic roles.

Psoralea corylifolia L. Seed Extract Attenuates Diabetic Nephropathy by Inhibiting Renal Fibrosis and Apoptosis in Streptozotocin-Induced Diabetic Mice

The Psoralea corylifolia L. seed (PCS) is a widely used herbal medicine, but its possible effect against diabetic nephropathy has not been studied. To investigate the anti-nephropathic effect of PCS extracts, we performed experiments using a diabetic mouse model and high glucose-treated mesangial cells. Streptozotocin (STZ)-induced diabetic mice were orally administered PCS extract for 8 weeks (500 mg/kg/day). Increased creatinine clearance, urine volume, urine microalbumin, and mesangial expansion were observed in STZ-induced diabetic mice; these were significantly reduced by PCS extract administration. PCS extract significantly reduced fibrosis in the kidney tissue of diabetic mice as evidenced by decreased mRNA expression of collagen type IV-α2, fibronectin, PAI-1, and TGF-β1. In addition, cleaved PARP, an apoptotic gene, was upregulated in the diabetic nephropathy mice, and this was ameliorated after PCS extract treatment. Treatment of high glucose-treated MES-13 cells with isopsoralen and psoralen, major components of PCS extract, also decreased the expression of fibrosis and apoptosis marker genes and increased cell viability. PCS extract exerts protective effects against STZ-induced diabetic nephropathy via anti-fibrotic and anti-apoptotic effects. PCS extract might be a potential pharmacological agent to protect against high glucose-induced renal damage under diabetic conditions.

Developing a metformin prescribing tool for use in adults with mental illness to reduce medication-related weight gain and cardiovascular risk

OBJECTIVES

There is considerable evidence that metformin reduces weight gain associated with antipsychotic medication. The aim of this study was to develop an easy-to-use metformin prescribing tool in order to enable clinicians to prescribe metformin safely and confidently.

METHODS

The authors undertook a survey of clinicians and reviewed the published literature and existing guidelines concerning the use of metformin to reduce weight gain in adults with mental illness.

RESULTS

A metformin prescribing tool was devised based on the literature, national cardiovascular and diabetes guidelines and Australian metformin prescribing recommendations. The metformin prescribing tool guides clinicians through the considerations required for appropriate selection of the target patient population and safe prescription of metformin.

CONCLUSIONS

A novel, easy-to-use, one-page reference has been developed for busy clinicians that can be laminated and displayed in consulting rooms and psychiatric inpatient units to address weight gain and obesity associated with antipsychotic medications in people with mental illness.

Effects of metformin on blood and urine pro-inflammatory mediators in patients with type 2 diabetes

Background

Metformin has been used for the treatment of type 2 diabetes by suppressing hepatic gluconeogenesis. It has been shown that the subclinical inflammatory responses play important roles in the pathogenesis of type 2 diabetes. In the present study, we determined the effects of metformin on the levels of pro-inflammatory cytokines (i.e., IL-6, TNF-α, and MCP-1) and anti-inflammatory mediator IL-10 in blood and urine of patients with type 2 diabetes. There were 210 patients with type 2 diabetes, which were randomized into metformin (n = 112) and non-metformin (gliclazide, acarbose, and repaglinide, n = 98) groups. The levels of cytokines were measured by the ELISA.

Results

We found that metformin reduced the levels of IL-6 in blood and MCP-1 in urine, but increased IL-10 levels in blood of patients with type 2 diabetes. There were no significant differences of TNF-α between metformin and non-metformin groups. Furthermore, compared to individual drug treatment, metformin significantly reduced the levels of serum IL-6 and TNF-α, as well as urine MCP-1. When the patients were stratified based on the durations and doses of metformin, we found that there was only change (i.e., increase) in serum IL-10 levels in patients with metformin for more than 1 year compared to treatment for less than 1 year. Metformin (1.5 g) treatment reduced the urinary levels of MCP-1 as compared with dose of 1.0 g in patients with type 2 diabetes.

Conclusion

Metformin reduces inflammatory responses without influence on renal function in type 2 diabetic patients.

Mental stress assessment using simultaneous measurement of EEG and fNIRS

Previous studies reported mental stress as one of the major contributing factors leading to various diseases such as heart attack, depression and stroke. An accurate stress assessment method may thus be of importance to clinical intervention and disease prevention. We propose a joint independent component analysis (jICA) based approach to fuse simultaneous measurement of electroencephalography (EEG) and functional near-infrared spectroscopy (fNIRS) on the prefrontal cortex (PFC) as a means of stress assessment. For the purpose of this study, stress was induced by using an established mental arithmetic task under time pressure with negative feedback. The induction of mental stress was confirmed by salivary alpha amylase test. Experiment results showed that the proposed fusion of EEG and fNIRS measurements improves the classification accuracy of mental stress by +3.4% compared to EEG alone and +11% compared to fNIRS alone. Similar improvements were also observed in sensitivity and specificity of proposed approach over unimodal EEG/fNIRS. Our study suggests that combination of EEG (frontal alpha rhythm) and fNIRS (concentration change of oxygenated hemoglobin) could be a potential means to assess mental stress objectively.

Cardiovascular impact of drugs used in the treatment of diabetes

The International Diabetes Federation predicts that by 2035 10% of the population of the world will have been diagnosed with diabetes, raising serious concerns over the resulting elevated morbidity and mortality as well as the impact on health care budgets. It is also well recognized that cardiovascular disease is the primary cause of the high morbidity and mortality associated with diabetes, raising the concern that appropriate drug therapy should not only correct metabolic dysfunction, but also protect the cardiovascular system from the effects of, in particular, the epigenetic changes that result from hyperglycaemia. A number of new classes of drugs for the treatment of diabetes have been introduced in the past decade, providing the opportunity to optimize treatment; however, comparative information of the cardiovascular benefits, or risks, of the newer drugs versus older therapies such as metformin is variable. This review, in addition to summarizing the cellular basis for the therapeutic action of these drugs, addresses the evidence for their cardiovascular benefits and risks. A particular focus is provided on metformin as it is the first choice drug for most patients with type 2 diabetes.

Statistical methods for active pharmacovigilance, with applications to diabetes drugs

Pharmacovigilance aims to identify adverse drug reactions using postmarket surveillance data under real-world conditions of use. Unlike passive pharmacovigilance, which is based on largely voluntary (and hence incomplete) spontaneous reports of adverse drug reactions with limited information on patient characteristics, active pharmacovigilance is based on electronic health records containing detailed information about patient populations, thereby allowing consideration of modifying factors such as polypharmacy and comorbidity, as well as sociodemographic characteristics. With the present shift toward active pharmacovigilance, statistical methods capable of addressing the complexities of such data are needed. We describe four such methods here, and demonstrate their application in the analysis of a large retrospective cohort of diabetics taking anti-hyperglycemic medications that may increase the risk of adverse cardiovascular events.

Association of hypoglycemic treatment regimens with cardiovascular outcomes in overweight and obese subjects with type 2 diabetes: a substudy of the SCOUT trial

OBJECTIVE

To assess the association of hypoglycemic treatment regimens with cardiovascular adverse events and mortality in a large population of type 2 diabetic patients at increased cardiovascular risk.

RESEARCH DESIGN AND METHODS

This analysis included 8,192 overweight patients with type 2 diabetes from the Sibutramine Cardiovascular Outcomes (SCOUT) trial randomized to lifestyle intervention with or without sibutramine for up to 6 years. Patients were grouped according to hypoglycemic treatment at baseline. The primary end point was the time from randomization to the first occurrence of a primary outcome event (POE), nonfatal myocardial infarction, nonfatal stroke, resuscitation after cardiac arrest, or cardiovascular death. Multivariable Cox proportional hazards regression models were used to assess the impact of antiglycemic treatment on POE and all-cause mortality.

RESULTS

Treatments for type 2 diabetes were as follows: diet alone (n = 1,394 subjects), metformin monotherapy (n = 1,631), insulin monotherapy (n = 1,116), sulfonylurea monotherapy (n = 1,083), metformin plus sulfonylurea (n = 1,565), and metformin plus insulin (n = 1,000); 905 subjects experienced a POE and 708 died. Metformin monotherapy was associated with lower risk of POE than insulin (hazard ratio [HR], 0.74; 95% CI, 0.57-0.95; P = 0.02). Diet alone also was associated with lower risk of POE (HR, 0.65; 95% CI, 0.48-0.87; P = 0.004). Metformin monotherapy also was associated with lower mortality (HR, 0.73; 95% CI, 0.54-0.99; P < 0.05), whereas no other monotherapies or combination therapies were significantly associated with POE or all-cause mortality compared with insulin as monotherapy.

CONCLUSIONS

In obese patients with type 2 diabetes and high risk of cardiovascular disease, monotherapy with metformin or diet-only treatment was associated with lower risk of cardiovascular events than treatment with insulin.

Effects of Syzygium aromaticum-derived oleanolic acid on glucose transport and glycogen synthesis in the rat small intestine

BACKGROUND

In the present study, we investigated the effects of oleanolic acid (OA), which has hypoglycemic properties, on glucose transport and glycogen synthesis in the small intestine, an organ that secretes enzymes involved in carbohydrate metabolism.

METHODS

The OA was isolated from Syzygium aromaticum ethyl acetate-soluble fractions followed by recrystallization with ethanol. It was diluted to required concentrations in freshly prepared dimethyl sulfoxide (2 mL) and normal saline (19 mL) before being administered to rats (p.o.). Glycogen concentrations were determined in isolated small intestines from fasted and non-fasted non-diabetic and streptozotocin-diabetic rats after 18 h treatment with 80 mg/kg, p.o., OA or standard hypoglycemic drugs (i.e. 100 μg/kg, s.c., insulin; 500 mg/kg, p.o., metformin). In a separate series of experiments, the effects of 30-min incubation with graded concentrations of OA (0.82-6.56 mmol/L) on d-glucose were evaluated by monitoring changes in glucose concentrations inside and outside of intestinal sacs isolated from fasted, non-diabetic rats and mounted in an organ bath containing Krebs-Henseleit bicarbonate buffer.

RESULTS

All in vivo treatments increased the glycogen concentration in rat small intestine, although the effects of metformin treatment in non-fasted diabetic rats failed to reach statistical significance. In vitro, both OA (1.64-6.56 mmol/L) and phlorizin (10(-5) -10(-3) mol/L) decreased glucose transport from the mucosa to the serosa.

CONCLUSION

The data suggest that OA may be a potential alternative drug treatment for postprandial hyperglycemia because of its inhibition of glucose uptake across the small intestine and its concomitant conversion of glucose to glycogen in the intestinal wall.

Characteristics of People with Newly Diagnosed Type 2 Diabetes Depending on Age at Onset

Objectives. The aim of this study was to compare the cardio-metabolic profilebetween younger (< 45 years) and older (≥ 45 years) people with newly diagnosedtype 2 diabetes (T2DM). Material and Methods. A cross-sectional study including910 persons with newly diagnosed T2DM and registered at the Clinical Center ofDiabetes Cluj-Napoca was carried out between 2006 - 2008. Results: The mean agewas 40.21±3.60 yrs. in the younger group and 60.08±8.22 yrs. in the older group.Both groups of patients were obese, but the younger-onset group was significantlymore obese as measured by body mass index (BMI), than the older group (BMI 32.45vs. 30.61 kg/m2, p=0.001). The absolute coronary heart disease (CHD) risk level wassignificantly higher in older than younger individuals (p<0.001). Conclusions:Despite being two decades younger, it is remarkable that many young people withnewly diagnosed T2DM have a clustering of cardiovascular risk factors.

Antidiabetic effects of Corni Fructus extract in streptozotocin-induced diabetic rats

PURPOSE

Diabetes is the leading cause of end-stage renal failure. The present study was undertaken to characterize the effects of Corni Fructus on diabetic nephropathy in streptozotocin-induced diabetic rats and their mechanisms.

MATERIALS AND METHODS

Streptozotocin-diabetic rats were orally administrated with Corni Fructus at a dose of 100, 200 or 400 mg/kg body mass for 40 days.

RESULTS

Corni Fructus-treated diabetic rats showed significant decreases of blood glucose, urinary protein levels and water consumption. Corni Fructus also reduced serum total cholesterol, total triglyceride and low-density lipoprotein cholesterol levels, and showed a tendency of enhancing high-density lipoprotein cholesterol level. Levels of serum albumin and creatinine in diabetic rats were also significantly reduced by Corni Fructus administration at a dose of 200 and 400 mg/kg body mass compared with non-treated diabetic rats. Corni Fructus increased catalase (CAT), superoxide dismutase (SOD) and glutathione peroxidose (GSH-px) activities in the kidneys of diabetic rats. Furthermore, Corni Fructus treatment enhanced renal peroxisome proliferator-activated receptor-γ (PPARγ) expression in diabetic rats.

CONCLUSION

These results demonstrated that Corni Fructus may have the potential to protect the animals from diabetic nephropathy by amelioration of oxidative stress and stimulation of PPARγ expression.

Hepatitis C virus induced insulin resistance impairs response to anti viral therapy

Hepatitis C virus (HCV) infection is an important risk factor for insulin resistance (IR). The latter is the pathogenic foundation underlying metabolic syndrome, steatosis and cirrhosis, and possibly hepatocellular carcinoma (HCC). The interplay between genetic and environmental risk factors ultimately leads to the development of IR. Obesity is considered a major risk factor, with dysregulation of levels of secreted adipokines from distended adipose tissue playing a major role in IR. HCV-induced IR may be due to the HCV core protein inducing proteasomal degradation of insulin receptor substrates 1 and 2, blocking intracellular insulin signaling. The latter is mediated by increased levels of both tumour necrosis factor-α (TNF-α) and suppressor of cytokine signaling 3 (SOC-3). IR, through different mechanisms, plays a role in the development of steatosis and its progression to steatohepatitis, cirrhosis and even HCC. In addition, IR has a role in impairing TNF signaling cascade, which in turn blocks STAT-1 translocation and interferon stimulated genes production avoiding the antiviral effect of interferon.

Associations between the use of metformin, sulphonylureas, or diet alone and cardiovascular outcomes in 6005 people with type 2 diabetes in the FIELD study

AIMS

We aimed to determine the associations between metformin or sulphonylurea monotherapy at study entry into the FIELD diabetes trial and (1) metabolic risk factors, (2) risk of a first major cardiovascular (CVD) outcome, and (3) the effect of each therapy on the risk-modifying effect of fenofibrate.

METHODS

Patients receiving metformin or sulphonylureas without insulin therapy were compared for the relative risk of CVD outcomes, adjusted for differences in baseline characteristics likely to affect risk.

RESULTS

Metformin-treated patients were likely to be younger, female, or obese. Metformin was associated with higher levels of lipids (other than LDL-C) and homocysteine (P<0.001). Sulphonylurea-treated patients had a longer history of diabetes and more CVD and microvascular disease. Sulphonylurea treatment was associated with higher plasma creatinine and lower plasma HDL-C (P<0.001). The risks of all CVD outcomes were higher for those on sulphonylureas than diet alone, but were nonsignificant after adjustment for the duration and intensity of diabetes and severity of risk factors. Metformin and sulphonylureas did not significantly influence the benefits of fenofibrate on CVD outcomes.

CONCLUSIONS

Apparent differences in the risk of CVD outcomes associated with oral hypoglycemics therapy were largely abolished by adjustment for diabetes and CVD risk factors.

Inflammation and thrombosis in diabetes

Patients with diabetes mellitus are at increased risk of cardiovascular morbidity and mortality. Atherothrombosis, defined as atherosclerotic lesion disruption with superimposed thrombus formation, is the most common cause of death among these patients. Following plaque rupture, adherence of platelets is followed by local activation of coagulation, the formation of a cross-linked fibrin clot and the development of an occlusive platelet rich fibrin mesh. Patients with diabetes exhibit a thrombotic risk clustering which is composed of hyper-reactive platelets, up regulation of pro-thrombotic markers and suppression of fibrinolysis. These changes are mainly mediated by the presence of insulin resistance and dysglycaemia and an increased inflammatory state which directly affects platelet function, coagulation factors and clot structure. This prothrombotic state is related to increased cardiovascular risk and may account for the reduced response to antithrombotic therapeutic approaches, underpinning the need for adequate antithrombotic therapy in patients with diabetes to reduce their cardiovascular mortality.

Importance of hepatitis C virus-associated insulin resistance: Therapeutic strategies for insulin sensitization

Insulin resistance is one of the pathological features in patients with hepatitis C virus (HCV) infection. Generally, persistence of insulin resistance leads to an increase in the risk of life-threatening complications such as cardiovascular diseases. However, these complications are not major causes of death in patients with HCV-associated insulin resistance. Indeed, insulin resistance plays a crucial role in the development of various complications and events associated with HCV infection. Mounting evidence indicates that HCV-associated insulin resistance may cause (1) hepatic steatosis; (2) resistance to anti-viral treatment; (3) hepatic fibrosis and esophageal varices; (4) hepatocarcinogenesis and proliferation of hepatocellular carcinoma; and (5) extrahepatic manifestations. Thus, HCV-associated insulin resistance is a therapeutic target at any stage of HCV infection. Although the risk of insulin resistance in HCV-infected patients has been documented, therapeutic guidelines for preventing the distinctive complications of HCV-associated insulin resistance have not yet been established. In addition, mechanisms for the development of HCV-associated insulin resistance differ from lifestyle-associated insulin resistance. In order to ameliorate HCV-associated insulin resistance and its complications, the efficacy of the following interventions is discussed: a late evening snack, coffee consumption, dietary iron restriction, phlebotomy, and zinc supplements. Little is known regarding the effect of anti-diabetic agents on HCV infection, however, a possible association between use of exogenous insulin or a sulfonylurea agent and the development of HCC has recently been reported. On the other hand, insulin-sensitizing agents are reported to improve sustained virologic response rates. In this review, we summarize distinctive complications of, and therapeutic strategies for, HCV-associated insulin resistance. Furthermore, we discuss supplementation with branched-chain amino acids as a unique insulin-sensitizing strategy for patients with HCV-associated insulin resistance.

Plasma proteome analysis for anti-obesity and anti-diabetic potentials of chitosan oligosaccharides in ob/ob mice

Altered levels of adipokines, derived as a result of distorted adipocytes, are the major factors responsible for changing biochemical parameters in obesity that leads to the development of metabolic disorders such as insulin resistance and atherosclerosis. In our previous reports, chitosan oligosaccharides (CO) were proved to inhibit the differentiation of 3T3-L1 adipocytes. In the present study, an attempt was made to investigate the anti-obesity and anti-diabetic effect of CO on ob/ob mice, by means of differential proteomic analysis of plasma. This was followed by immunoblotting, and gene expression in adipose tissue to clarify the molecular mechanism. CO treatment showed reduced diet intake (13%), body weight gain (12%), lipid (29%) and glucose levels (35%). 2-DE results showed differential levels of five proteins namely RBP4, apoE, and apoA-IV by >2-fold down-regulation and by >2-fold of apoA-I and glutathione peroxidase (GPx) up-regulation after CO treatment. Immunoblotting studies of adiponectin and resistin showed amelioration in their levels in plasma. Furthermore, the results of gene expressions for adipose tissue specific TNF-alpha, and IL-6 secretary molecules were also down-regulated by CO treatment. Gene expressions of PPAR gamma in adipose tissue were in good agreement with the ameliorated levels of adipokines, thereby improving the pathological state. Taken together, CO might act as a potent down-regulator of obesity-related gene expression in ob/ob mice that may normalize altered plasma proteins to overcome metabolic disorders of obesity.

Integrating glycaemic variability in the glycaemic disorders of type 2 diabetes: a move towards a unified glucose tetrad concept

The high incidence of atherosclerosis and cardiovascular disease (CVD) is the leading cause of morbidity and mortality among patients with diabetes. Evidence is accumulating that postprandial hyperglycaemia is an independent risk factor for diabetes-associated complications and mortality, and that worsening diabetes control is characterized by postprandial glucose (PPG) deterioration preceding an impairment in fasting glucose levels. Postprandial and general glucose fluctuations play a major role in activating oxidative stress, leading to the endothelial dysfunction, one of the mechanisms responsible for vascular complications. Therefore, the management of PPG is key for any strategy used in the monitoring and treatment of diabetes. We recommend that any strategy aimed at controlling the glycaemic disorders associated with type 2 diabetes, and limiting the risk of complications, should target the 'glucose tetrad', which comprises the following components: HbA(1c), fasting and postprandial plasma glucose, and markers of glycaemic variability, such as the mean amplitude of glycaemic excursions (MAGE) index. This brings together, in a simple, unified concept, the conventional markers (HbA(1c) and fasting glucose) and the more recently recognized markers of glycaemic control (PPG excursions and acute glycaemic variability).

Long-term pioglitazone therapy improves arterial stiffness in patients with type 2 diabetes mellitus

Pioglitazone, a peroxisome proliferator-activated receptor gamma agonist, not only improves insulin resistance and glycemic control, but may also have additional beneficial vascular effects in patients with type 2 diabetes mellitus. We investigated whether pioglitazone had an influence on arterial stiffness, which is an independent predictor of cardiovascular events, in 204 patients with type 2 diabetes mellitus. A prospective, nonrandomized, open-label trial was performed that involved 41 patients treated with pioglitazone, 46 patients receiving sulfonylureas, 67 patients on insulin, and 50 patients on diet/exercise only. The follow-up period was 56 +/- 3 months. Arterial stiffness was evaluated by using the arterial stiffness index (ASI), which was based on analysis of the pulse wave amplitude pattern obtained during automated blood pressure measurement in the upper limb. The 4 groups had a similar baseline ASI, which was greater than the reference range in each group. Although antidiabetic therapies improved hemoglobin A(1c) and low-density lipoprotein cholesterol, ASI only decreased significantly in the pioglitazone group. Thus, pioglitazone improved abnormal arterial stiffness in patients with type 2 diabetes mellitus via a mechanism beyond the metabolic improvement. These findings may have important clinical implications in the use of pioglitazone in patients with type 2 diabetes mellitus.

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

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

Confusion over thiazolidinedione-induced heart failure: need for a better definition of heart failure

Evaluation of: Erdmann E, Wilcox RG. Weighing up the cardiovascular benefits of thiazolidinedione therapy: the impact of increased risk of heart failure. Eur. Heart J. 29(1), 12-20 (2008). Thiazolidinediones (TZDs) reduce insulin resistance through the modulation of peroxisome proliferator-activated receptor (PPAR)-gamma activity and are, therefore, used for the treatment of individuals with Type 2 diabetes. TZDs have been blamed for inducing heart failure (HF) and are contraindicated in patients with impaired ventricular function. Whether precipitation of HF by TZDs is overestimated or not remains hotly debated in the scientific community. One message from the TZD-HF debacle is that current definitions of HF lack scientific rigour as they fail to assess cardiac organ function directly using a representative and reliable method. Once cardiologists reappraise and update the current definition of HF, appropriate steps can then be taken to answer the question of whether TZDs really induce true HF.

Intensification of oxidative stress and inflammation in type 2 diabetes despite antihyperglycemic treatment

INTRODUCTION

The metabolic deregulation associated with diabetes mellitus (DM) causes secondary pathophysiologic changes in multiple organ systems. Endothelial injury is induced by oxidative stress (OS) and inflammation. We have previously shown that DM type 2 patients are exposed to increased OS and inflammation contributed in part by primed peripheral polymorphonuclear leukocytes (PMNLs).

AIMS

To characterize the effect of oral medication on PMNL priming, on PMNL-related and on systemic inflammation, in correlation to changed diabetes parameters in patient with newly diagnosed type 2 DM.

METHODS

PMNLs were separated from DM patient's prior and following treatment with either metformin (Glucophage), or Thiazolidinedione (rosiglitazone) and from healthy control subjects (HC). Rate of superoxide release from phorbol ester-stimulated PMNLs and CD11b on PMNLs assessed PMNL priming. White blood cells (WBC) and PMNL counts and apoptosis reflected PMNL-related inflammation. CRP, fibrinogen, transferrin and albumin blood levels reflected systemic inflammation.

RESULTS

Both metformin and rosiglitazone treatments reduced significantly the high levels of glucose and HbA1c, and slightly improved lipid profile during 2 months. PMNL priming parameters, higher compared to HC, increased after 2 months of metformin treatment. Rosiglitazone treatment decreased PMNL priming. ALP, higher in DM, significantly decreased following 2 months of both treatments. Systemic inflammation markers (fibrinogen, CRP), higher in DM, decreased following both treatments. Transferrin and albumin were similar to HC. PMNL-related inflammation markers were higher in DM; however, only PMNL apoptosis decreased after both treatments. Monocyte counts, higher in DM compared to HC, decreased following both treatments. Serum insulin levels, higher in DM compared to HC, decreased following both treatments. PMNL-related priming and inflammation parameters positively correlated with HbA1c.

CONCLUSION

The present research adds new facet in evaluating anti-hyperglycemic treatment in type 2 DM patients. Despite sufficient glycemic control using both treatments, some PMNL-related parameters deteriorated. Thus, anti hyperglycemic treatment should be favored due to its combined anti-PMNL priming and anti-inflammatory effect, in addition to its anti-hyperglycemic characteristics, according to the correlation among these parameters. Such combined treatment may reduce morbidity and mortality common in DM patients.

American ginseng berry juice intake reduces blood glucose and body weight in ob/ob mice

Diabetes is a serious chronic metabolic disease and has a significant impact on patients' lives and the health care system. We previously observed that the organic solvent extract of American ginseng berry possessed significant antidiabetic effects in obese diabetic ob/ob mice after intraperitoneal injection. If American ginseng berry is useful as a dietary supplement, simple preparation and oral intake would be a convenient, safe, and practical means for consumers. In this study, the simply prepared berry juice was first analyzed using high-performance liquid chromatography, and then administered orally in the ob/ob mice. The animals received daily berry juice 0.6 mL/kg or vehicle for 10 consecutive days. The results indicated that oral juice administration significantly lowered fasting blood glucose levels, and this effect continued for at least 10 d after cessation of the treatment. Data from intraperitoneal glucose tolerance test demonstrated that there was a notable improvement in glucose tolerance in the juice treated group. In addition, the berry juice significantly reduced body weight. Our data suggest that ginseng berry juice, as a dietary supplement, may have functional efficacy in consumers with diabetes.

Cardiovascular benefits and safety profile of acarbose therapy in prediabetes and established type 2 diabetes

Dysglycaemic disease is one of the most important health issues facing the world in the 21^st century. Patients with type 2 diabetes and individuals with prediabetes are at risk of developing macrovascular and microvascular complications. Long-term management strategies are therefore required that are effective at controlling dysglycaemia, well tolerated and, ideally, offer additional cardiovascular disease (CVD) risk-reduction benefits. The efficacy, safety and tolerability of the α-glucosidase inhibitor acarbose have been well-established in a wide range of patient populations in both clinical and community trials. In addition, acarbose has been shown to reduce cardiovascular complications in type 2 diabetes and prevent hypertension and CVD in individuals with impaired glucose tolerance (IGT). Acarbose has a very good safety profile and, owing to its straightforward, non-systemic mode of action, avoids most adverse events. The most common side-effects of acarbose are mild-to-moderate gastrointestinal complaints that subside as treatment continues. They can be minimised through the use of an appropriate stepwise dosing regimen and careful choice of diet. Acarbose is therefore a valuable option for the management of type 2 diabetes and, as the only oral antidiabetes agent approved for the treatment of prediabetes, can help to improve clinical management across the dysglycaemic disease continuum.