Diabetes Drugs and Cardiovascular Safety

Sodium-glucose cotransporter 2 inhibitors regulate ketone body metabolism via inter-organ crosstalk

AIM

To investigate sodium-glucose cotransporter 2 inhibitor (SGLT2i)-induced changes in ketogenic enzymes and transporters in normal and diabetic mice models.

MATERIALS AND METHODS

Normal mice were randomly assigned to receive either vehicle or SGLT2i (25 mg/kg/d by oral gavage) for 7 days. Diabetic mice were treated with vehicle, insulin (4.5 units/kg/d by subcutaneous injection) or SGLT2i (25 mg/kg/d by intra-peritoneal injection) for 5 weeks. Serum and tissues of ketogenic organs were analysed.

RESULTS

In both normal and diabetic mice, SGLT2i increased beta-hydroxybutyrate (BHB) content in liver, kidney and colon tissue, as well as in serum and urine. In these organs, SGLT2i upregulated mRNA expression of ketogenic enzymes, 3-hydroxy-3-methylglutaryl-coenzyme A synthase 2 and 3-hydroxy-3-methylglutaryl-coenzyme A lyase. Similar patterns were observed in the kidney, ileum and colon for mRNA and protein expression of sodium-dependent monocarboxylate transporters (SMCTs), which mediate the cellular uptake of BHB and butyrate, an important substrate for intestinal ketogenesis. In diabetic mice under euglycaemic conditions, SGLT2i increased major ketogenic enzymes and SMCTs, while insulin suppressed ketogenesis.

CONCLUSIONS

SGLT2i increased systemic and tissue BHB levels by upregulating ketogenic enzymes and transporters in the liver, kidney and intestine, suggesting the integrated physiological consequences for ketone body metabolism of SGLT2i administration.

Dipeptidyl peptidase-4 inhibitor compared with sulfonylurea in combination with metformin: cardiovascular and renal outcomes in a propensity-matched cohort study

Background

To determine the impact of dipeptidyl peptidase-4 inhibitor (DPP4i) on the risk of major cardiocerebrovascular and renal outcomes compared with sulfonylurea (SU) combined with metformin in patients with type 2 diabetes from a population-based cohort.

Methods

From a nationwide cohort in Korea (2008–2013), 23,674 patients with type 2 diabetes treated with DPP4i plus metformin or SU plus metformin were selected and matched by propensity score. Composite cardiocerebrovascular events including incident ischemic heart disease (IHD), ischemic stroke (IS), hospitalization for heart failure (HHF), and cardiocerebrovascular death, as well as renal events including incident end-stage renal disease or initiation of renal-replacement therapy were assessed by Cox proportional-hazards models.

Results

During a median follow-up of 19.6 months (interquartile range 7.2–36.4), 762 composite cardiocerebrovascular events and 17 end-stage renal events occurred. There was no significant difference in the risk of IHD (hazard ratio [HR], 1.00; 95% CI 0.81–1.23), IS (HR, 0.95; 95% CI 0.74–1.23), or cardiocerebrovascular death (HR, 0.74; 95% CI 0.46–1.18) in the DPP4i group compared to that in the SU group. Likewise, DPP4i therapy was not associated with the risk of end-stage renal outcomes (HR, 1.23; 95% CI 0.41–3.62). However, the risk of HHF was significantly higher in the DPP4i group than in the SU group (HR, 1.47; 95% CI 1.07–2.04).

Conclusions

This real-world database analysis showed that DPP4i therapy did not increase the overall risk of major cardiovascular and renal outcomes compared to SU therapy. However, the DPP4i-associated risk of HHF remained significant.

Electronic supplementary material

The online version of this article (10.1186/s12933-019-0835-z) contains supplementary material, which is available to authorized users.

Attenuation of lipid peroxidation and atherogenic factors in diabetic patients treated with gliclazide and metformin

BACKGROUND

Diabetes is associated with oxidative stress and considered as a major risk factor for cardiac disease. We attempted to investigate the role of oral antidiabetic (OAD) agents gliclazide and metformin in lowering the lipid peroxidation and managing the risk for cardiovascular (CV) complications in diabetic patients in comparison with nondiabetic healthy individuals.

MATERIALS AND METHODS

This cross-sectional study was comprised of 150 individuals grouped in three, namely, Group A (n = 60) healthy volunteers, Group B (n = 30) newly diagnosed diabetes, and Group C (n = 60) diabetes treated with OAD. Serum malondialdehyde (MDA), nitric oxide (NO), and Vitamin C were assessed for studying lipid peroxidation status, whereas serum triglyceride (TG) and total cholesterol were monitored as predictors for CV risk.

RESULTS

We found significantly higher concentrations of MDA and NO levels (P < 0.001) in both groups of patients (Group B and C) in comparison to control group (Group A). Regarding antioxidants, significantly lower concentrations of Vitamin C (P = 0.046) were found in Group B and C compared to Group A. Moreover, there was significant difference exhibited in concentration level of MDA (P = 0.001) and NO (P = 0.015) between Group B and C, whereas difference of Vitamin C (P = 0.147) was not statistically significant.

CONCLUSION

Our data confirmed that treatment with gliclazide and metformin significantly reduced the lipid peroxidation accompanied with attenuated levels of serum TGs and cholesterol and suggested that oral hypoglycemic agents have great impact to reduce the oxidative stress and increase the antioxidant status in diabetes.

Dipeptidyl peptidase-4 inhibitor use and risk of diabetic retinopathy: A population-based study

AIMS

This study examined whether dipeptidyl peptidase (DPP)-4 inhibitor use is beneficial or harmful to diabetic retinopathy (DR) compared with other glucose-lowering agents in patients with type 2 diabetes (T2D).

METHODS

From a population-based cohort provided by the National Health Insurance Service in Korea, 67,743 adults with T2D were identified as having been treated with oral glucose-lowering agents between 2008 and 2013. Matching (1:1) was performed for two groups comparing ever-use (cases) and never-use (controls) of DPP-4 inhibitors (n=14,522 in each group). Cox regression analyses were used to assess risk of the following DR events: vitreous haemorrhage; vitrectomy or photocoagulation; intravitreal agent use; and blindness.

RESULTS

During a median follow-up of 28.4 (14.0-45.2) months, there were 305 (in controls) and 342 (in cases) composite DR events. DPP-4 inhibitor ever-use was not associated with overall risk of composite DR events [adjusted hazard ratio (HR): 1.08, 95% CI: 0.93-1.26] compared with never-use, nor was the risk of each DR outcome increased with DPP-4 inhibitor therapy either. However, DPP-4 inhibitor administration for<12 months was associated with a greater risk of composite DR events (adjusted HR: 1.31, 95% CI: 1.09-1.57) compared with other glucose-lowering agents over the same treatment period.

CONCLUSION

In comparison to other oral glucose-lowering agents, DPP-4 inhibitor treatment did not increase overall risk of DR. However, DPP-4 inhibitors may be associated with an increased risk of retinopathy events early in the treatment phase.

Glitazones and alpha-glucosidase inhibitors as the second-line oral anti-diabetic agents added to metformin reduce cardiovascular risk in Type 2 diabetes patients: a nationwide cohort observational study

Objective

Metformin is the standard first-line drug for patients with Type 2 diabetes (T2DM). However, the optimal second-line oral anti-diabetic agent (ADA) remains unclear. We investigated the cardiovascular risk of various ADAs used as add-on medication to metformin in T2DM patients from a nationwide cohort.

Methods

T2DM patients using different add-on oral ADAs after an initial metformin therapy of > 90 days were identified from the Taiwan National Health Insurance Database. Five classes of ADAs, including sulphonylureas (SU), glinides, thiazolidinediones (TZD), alpha-glucosidase inhibitors (AGI), and dipeptidyl peptidase-4 inhibitors (DPP-4I) were selected for analysis. The reference group was the SU added to metformin. Patients were excluded if aged < 20 years, had a history of stroke or acute coronary syndrome (ACS), or were receiving insulin treatment. The primary outcomes included any major adverse cardiovascular event (MACE) including ACS, ischemic/hemorrhagic stroke, and death. A Cox regression model was used to estimate the hazard ratio (HR) for MACE.

Results

A total of 26,742 patients receiving their add-on drug to metformin of either SU (n = 24,277), glinides (n = 962), TZD (n = 581), AGI (n = 808), or DPP-4I (n = 114) were analyzed. After a mean follow-up duration of 6.6 ± 3.4 years, a total of 4775 MACEs occurred. Compared with the SU+metformin group (reference), the TZD+metformin (adjusted HR: 0.66; 95% CI 0.50–0.88, p = 0.004) and AGI+metformin (adjusted HR: 0.74; 95% CI 0.59–0.94, p = 0.01) groups showed a significantly lower risk of MACE.

Conclusion

Both TZD and AGI, when used as an add-on drug to metformin were associated with lower MACE risk when compared with SU added to metformin in this retrospective cohort study.

Trial registration CE13152B-3. Registered 7 Mar, 2013, retrospectively registered

Electronic supplementary material

The online version of this article (10.1186/s12933-018-0663-6) contains supplementary material, which is available to authorized users.

Sex-gender-related therapeutic approaches for cardiovascular complications associated with diabetes

Diabetes is a chronic disease associated with micro- and macrovascular complications and is a well-established risk factor for cardiovascular disease. Cardiovascular complications associated with diabetes are among the most important causes of death in diabetic patients. Interestingly, several sex-gender differences have been reported to significantly impact in the pathophysiology of diabetes. In particular, sex-gender differences have been reported to affect diabetes epidemiology, risk factors, as well as cardiovascular complications associated with diabetes. This suggests that different therapeutic approaches are needed for managing diabetes-associated cardiovascular complications in men and women. In this review, we will discuss about the sex-gender differences that are known to impact on diabetes, mainly focusing on the cardiovascular complications associated with the disease. We will then discuss the therapeutic approaches for managing diabetes-associated cardiovascular complications and how differences in sex-gender can influence the existing therapeutic approaches.

The Landscape of Glucose-Lowering Therapy and Cardiovascular Outcomes: From Barren Land to Metropolis

The choice of glucose-lowering therapy (GLT) has expanded to include 11 different classes in addition to insulin. Since the 2008 Food and Drug Administration guidance for industry and mandate of demonstrating cardiovascular (CV) safety prior to any new drug approval, there were several trials primarily conducted to establish that goal. Some had neutral effects, while there were positively beneficial outcomes with more recent studies. Hospitalization for congestive heart failure has also been a heterogeneous finding among the different classes of GLT, with drug outcomes ranging from risky to beneficial. The current review selectively focuses on the evidence for CV outcomes for each class of GLT and summarizes the existing guidelines with regard to these drugs in heart disease. Moreover, it illustrates the dynamic status in the development of evidence. Finally, the review enables healthcare providers to formulate a plan for hypoglycemic therapy which will optimize CV health, in a patient-centered manner.