Intensive Glycemic Control and Cardiovascular Disease: Are There Patients Who May Benefit?

Folic acid effect on homocysteine, sortilin levels and glycemic control in type 2 diabetes mellitus patients

Aim

The present study aimed to determine the folic acid supplement (FAS) effects on serum homocysteine and sortilin levels, glycemic indices, and lipid profile in type II diabetic patients.

Method

A double-blind randomized controlled clinical trial have been performed on 100 patients with T2DM randomly divided into two groups that received either placebo or folic acid 5 mg/d for 12 weeks.

Results

FAS caused a significant decrease in homocysteine and sortilin serum levels (28.2% and 33.7%, P < 0.0001, respectively). After 3 months of intervention, 8.7% decrease in fasting blood glucose (P = 0.0005), 8.2% in HbA1c (P = 0.0002), 13.7% in serum insulin (P < 0.0001) and 21.7% in insulin resistance (P < 0.0001) were found in the folic acid group, however no significant difference was observed in the placebo group. Serum hs-CRP level showed significant positive associations with sortilin (r = 0.237, P = 0.018), homocysteine (r = 0.308, P = 0.002) and fasting blood glucose (r = 0.342, P = 0.000). There were no significant changes in lipid profile in both groups after 12 weeks.

Conclusion

FAS might be beneficial for reducing homocysteine and sortilin levels, enhancing glycemic control, and improved insulin resistance in patients with T2DM.

Progression of Albuminuria Among Patients with Type 1 Diabetes Mellitus: A Long Term Observational Follow-up Study

BACKGROUND

The purpose of the present study was to determine whether patients with DM1 have shown improvement, stabilization or deterioration of their urine albumin excretion levels during a close follow-up.

PATIENTS AND METHODS

A cohort of 84 patients, 18-76 years of age, a median duration of diabetes of 24 years (1-50 years) and a median follow-up duration of 12 years (1-37 years) were included in the study.

RESULTS

Among the 84 patients for whom we had UAE levels at the beginning and by the end of the study, mean glycosylated hemoglobin was statistically significantly decreased during the follow-up period, from 8.02±2.04-7.06±1.05% (p=0.036). Normoalbuminuria was present in 66 patients and remained so in 56 patients while 9 patients progressed to microalbuminuria and one patient to macroalbuminuria by the end of the study. Microalbuminuria was present in 15 patients: regression was observed in 8 patients, and progression in one patient. Regression of macroalbuminuria to microalbuminuria was noted in one patient and to normoalbuminuria was noted in one participant, too.

CONCLUSIONS

Improvement of glycemic control with close monitoring of DM1 patients together with the appropriate use ACE or AT2 inhibitors and statins, seems to exert nephron-protective potential and to delay or even reverse the presence of micro/macroalbuminuria. This long term follow-up study has demonstrated a statistically significant increase in serum HDLcholesterol levels. The study also revealed that intensively treated diabetes patients may show reductions in serum ALP levels. Whether this finding is related to diabetic nephropathy, NAFLD, or diabetic hepatosclerosis remains to be assessed in future trials.

Selenium Supplementation Affects Insulin Resistance and Serum hs-CRP in Patients with Type 2 Diabetes and Coronary Heart Disease

To our knowledge, this study is the first indicating the effects of selenium supplementation on metabolic status of patients with type 2 diabetes mellitus (T2DM) and coronary heart disease (CHD). This study was conducted to evaluate the effects of selenium supplementation on metabolic profiles, biomarkers of inflammation, and oxidative stress of patients with T2DM and CHD. This randomized, double-blind, placebo-controlled trial was performed among 60 patients with T2DM and CHD aged 40-85 years. Participants were randomly divided into 2 groups. Group A received 200 μg selenium supplements (n=30) and group B received placebo per day (n=30) for 8 weeks. Fasting blood samples were taken at the beginning of the study and after 8-week intervention to quantify metabolic profiles. After 8 weeks, compared with the placebo, selenium supplementation resulted in a significant decrease in serum insulin levels (- 2.2±4.6 vs. + 3.6±8.4 μIU/ml, p=0.001), homeostasis model of assessment-insulin resistance (HOMA-IR) (- 0.7±1.3 vs. + 0.9±2.4, p=0.004), homeostatic model assessment-beta cell function (HOMA-B) (- 7.5±17.2 vs. + 15.1±34.5, p=0.002) and a significant increase in quantitative insulin sensitivity check index (QUICKI) (+0.01±0.03 vs. - 0.01±0.03, p=0.02). In addition, patients who received selenium supplements had a significant reduction in serum high-sensitivity C-reactive protein (hs-CRP) (- 1 372.3±2 318.8 vs. - 99.8±1 453.6 ng/ml, p=0.01) and a significant rise in plasma total antioxidant capacity (TAC) concentrations (+ 301.3±400.6 vs. - 127.2±428.0 mmol/l, p<0.001) compared with the placebo. A 200 μg/day selenium supplementation among patients with T2DM and CHD resulted in a significant decrease in insulin, HOMA-IR, HOMA-B, serum hs-CRP, and a significant increase in QUICKI score and TAC concentrations.

The effects of coenzyme Q10 administration on glucose homeostasis parameters, lipid profiles, biomarkers of inflammation and oxidative stress in patients with metabolic syndrome

BACKGROUND

Limited data are available indicating the effects of coenzyme Q10 (CoQ10) supplementation on metabolic status of patients with metabolic syndrome (MetS).

PURPOSE

The present study was conducted to determine the effects of CoQ10 administration on glucose homeostasis parameters, lipid profiles, biomarkers of inflammation and oxidative stress among patients with MetS.

METHODS

This randomized, double-blind, placebo-controlled trial was performed among 60 overweight or obese and type 2 diabetes mellitus patients with coronary heart disease aged 40-85 years old. Participants were randomly allocated into two groups. Group A (n = 30) received 100 mg CoQ10 supplements and group B (n = 30) received placebo for 8 weeks. Fasting blood samples were taken at the beginning of the study and after 8-week intervention to quantify glucose homeostasis parameters, lipid profiles and biomarkers of inflammation and oxidative stress.

RESULTS

Compared with the placebo, CoQ10 supplementation resulted in a significant reduction in serum insulin levels (-2.1 ± 7.1 vs. +4.1 ± 7.8 µIU/mL, P = 0.002) and homeostasis model of assessment-insulin resistance (-0.7 ± 2.1 vs. +1.0 ± 2.0, P = 0.002) and homeostatic model assessment-beta cell function (-5.9 ± 22.2 vs. +15.9 ± 34.0, P = 0.005). In addition, patients who received CoQ10 supplements had a significant increase in plasma total antioxidant capacity (TAC) concentrations (+26.0 ± 105.0 vs. -162.2 ± 361.8 mmol/L, P = 0.008) compared with the placebo group. However, after adjustment for the baseline levels, age and baseline BMI, the effect on TAC levels (P = 0.08) disappeared. Additionally, compared with the placebo group, a significant positive trends in plasma glutathione (P = 0.06) and a significant reduction in malondialdehyde (P = 0.08) were seen among patients who received CoQ10 supplement. We did not observe any significant changes in fasting plasma glucose, lipid concentrations and inflammatory markers.

CONCLUSIONS

Overall, daily intake of 100 mg CoQ10 supplements among patients with MetS for 8 weeks had beneficial effects on serum insulin levels, HOMA-IR, HOMA-B and plasma TAC concentrations.

CLINICAL TRIAL REGISTRATION NUMBER

www.irct.ir : IRCT201502245623N35.

The effect of intensive glucose lowering therapy among major racial/ethnic groups in the Veterans Affairs Diabetes Trial

OBJECTIVE

To examine the effect of intensive glycemic control on cardiovascular disease events (CVD) among the major race/ethnic groups in a post-hoc analysis of the VADT.

MATERIALS AND METHODS

Participants included 1111 non-Hispanic Whites, 307 Hispanics and 306 non-Hispanic Blacks randomized to intensive or standard glucose treatment in VADT. Multivariable Cox proportional hazards models were constructed to assess the effect of intensive glucose treatment on CVD events among race/ethnic groups.

RESULTS

Mean age was 60.4 years and median follow-up was 5.6 years. By design, modifiable risk factors were managed equally well in both treatment arms and only differed modestly between race/ethnic groups. HbA(1c) decreased significantly from baseline with intensive glucose treatment in each race/ethnic group, with a trend for a greater response in Hispanics (P=0.02 for overall comparison between groups). Intensive glucose treatment was associated with reduced risk of CVD events for Hispanics but not for others (hazard ratios ranged from 0.54 to 0.75 for Hispanics whereas they were consistently close to 1 for others). Sensitivity analyses with different definitions of race/ethnicity or limited to individuals free of previous known CVD yielded similar results.

CONCLUSIONS

The results of these analyses support the hypothesis that race/ethnicity is worthy of consideration when tailoring intensive treatment for individuals with long-standing type 2 diabetes. However, additional studies are needed to confirm the findings of this post-hoc analysis.

Progressive renal decline as the major feature of diabetic nephropathy in type 1 diabetes

Despite almost universal implementation of renoprotective therapies over the past 25 years, the risk of end-stage renal disease (ESRD) in type 1 diabetes (T1D) is not decreasing, and ESRD remains the major cause of excess morbidity and premature mortality [1]. Such a state of affairs prompts a call to action. In this review we re-evaluated the proteinuria-centric model of diabetic nephropathy and showed its deficiencies. On the basis of extensive studies that we have been conducting on the patients attending the Joslin Clinic, we propose that progressive renal decline, not abnormalities in urinary albumin excretion, should be considered as the major feature of disease processes leading to ESRD in T1D. The etiology of diabetic nephropathy should be reconsidered in light of our new findings so our perspective can be broadened regarding new therapeutic targets available for interrupting the progressive renal decline in T1D. Reduction in the loss of glomerular filtration rate, not reduction of albumin excretion rate, should become the measure for evaluating the effectiveness of new therapeutic interventions. We need new accurate methods for early diagnosis of patients at risk of progressive renal decline or, better still, for detecting in advance which patients will have rapid, moderate or minimal rate of progression to ESRD.

Recent trends in the characteristics of patients prescribed sitagliptin and other oral antihyperglycaemic agents in a large U.S. claims database

AIM

This study was designed to determine if differences in baseline characteristics of patients with type 2 diabetes mellitus (T2DM) being treated with sitagliptin vs. other oral antihyperglycaemic agents (OAHA) during the initial 2 years following sitagliptin's introduction in the U.S. continued during the second 2 years of sitagliptin availability.

METHODS

Patients with T2DM and at least one new prescription for sitagliptin or another OAHA from Oct 2006 to April 2010 were identified in an insurance claims database. Multivariate logistic regression adjusting for age, gender, treatment type (monotherapy, dual or triple therapy), new or existing T2DM diagnosis, and comorbidities and diabetes complications in the prior 12 months was used to estimate odds ratios for sitagliptin vs. other OAHAs.

RESULTS

During 2006-2007 or 2008-2010, new sitagliptin users were older and more likely to be male, have prior diagnosis of T2DM, or initiating combination therapy compared with new users of other OAHAs. Prevalence of comorbidities and complications was consistently higher for new sitagliptin users across most of the conditions assessed during both time periods.

CONCLUSIONS

New sitagliptin users consistently tended to be older and have greater comorbidity/complication burden compared with new users of other OAHAs. These differences in baseline characteristics persisted up to 4 years postapproval. This observation has significant implications for observational studies using electronic medical record or insurance claims databases. Appropriate adjustment is needed to try to control for potential confounding and channelling bias resulting from this non-random prescribing pattern, and the limitations of such analyses acknowledged.

High risk of ESRD in type 1 diabetes: new strategies are needed to retard progressive renal function decline

Care of patients with type 1 diabetes (T1D) has changed during the past 30 years. Tools to control hyperglycemia have improved and it was shown that improvement in glycemic control diminished the risk of late diabetic complications, including nephropathy. Moreover, in patients with impaired renal function, aggressive treatment of hypertension and renoprotective blockade of the renin-angiotensin system were shown to postpone end-stage renal disease (ESRD), albeit for a short while. Despite these achievements, the incidence of ESRD caused by T1D in the US population has not decreased but rather has increased over the past 20 years, although it now occurs at slightly older ages. This state of affairs is a call to action. This should begin with adopting a new model of diabetic nephropathy in human beings. In that model, instead of microalbuminuria or proteinuria, the focus should be on diagnosis and treatment of progressive renal function decline that leads to ESRD. Such a model has received significant support in clinical and epidemiologic studies. Investigation of mechanisms of such progressive renal function decline should help in the identification of new therapeutic targets and the development of new interventions. To evaluate these interventions, accurate diagnostic algorithms are needed so T1D patients will be stratified according to time to onset to ESRD. Consistent with concepts of personalized medicine, the new interventions should be tailored to and evaluated in patients predicted to have rapid, moderate, or even slow progression to ESRD.

Effect of folic acid supplementation on plasma total homocysteine levels and glycemic control in patients with type 2 diabetes: a systematic review and meta-analysis

AIM

The evidences illustrating the effects of folic acid supplementation (FAS) in individuals with type 2 diabetes on plasma total homocysteine (tHcy) levels and glycemic control have been contradictory. The aim of the study was to systematically search and quantitatively analyze the effect of FAS on tHcy levels and HbA1c compared with placebo.

METHODS

We searched PubMed, Scopus, and Embase up to March 2012 without language restriction. Key words "folic acid" and "diabetes mellitus" with slight modifications based on the sources for search strategy were used. References of initially identified articles were examined to identify any other relevant studies. A random-effects model was used for estimation the pooled effect estimates (weighted mean different, WMD).

RESULTS

Of 6185 studies identified, 4 studies with 183 patients were included. FAS had statistically significant effect on tHcy levels [WMD, -3.52; 95% confidence interval (CI), -4.44 to -2.60]. However, the effect on HbA1c levels [WMD, -0.37; 95% CI, -1.10 to 0.35] was not significant.

CONCLUSIONS

Folic acid supplementation in patient with type 2 diabetes mellitus may reduce tHcy levels and have a trend to associate with better glycemic control compared with placebo. Further longitudinal studies on these intervention and outcomes are warranted.