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Eleftheriadou A, Spallone V, Tahrani AA, Alam U. Cardiovascular autonomic neuropathy in diabetes: an update with a focus on management. Diabetologia 2024:10.1007/s00125-024-06242-0. [PMID: 39120767 DOI: 10.1007/s00125-024-06242-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 06/10/2024] [Indexed: 08/10/2024]
Abstract
Cardiovascular autonomic neuropathy (CAN) is an under-recognised yet highly prevalent microvascular complication of diabetes. CAN affects approximately 20% of people with diabetes, with recent studies highlighting the presence of CAN in prediabetes (impaired glucose tolerance and/or impaired fasting glucose), indicating early involvement of the autonomic nervous system. Understanding of the pathophysiology of CAN continues to evolve, with emerging evidence supporting a potential link between lipid metabolites, mitochondrial dysfunction and genetics. Recent advancements, such as streamlining CAN detection through wearable devices and monitoring of heart rate variability, present simplified and cost-effective approaches for early CAN detection. Further research on the optimal use of the extensive data provided by such devices is required. Despite the lack of specific pharmacological interventions targeting the underlying pathophysiology of autonomic neuropathy, several studies have suggested a favourable impact of newer glucose-lowering agents, such as sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists, where there is a wealth of clinical trial data on the prevention of cardiovascular events. This review delves into recent developments in the area of CAN, with emphasis on practical guidance to recognise and manage this underdiagnosed condition, which significantly increases the risk of cardiovascular events and mortality in diabetes.
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Affiliation(s)
- Aikaterini Eleftheriadou
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Vincenza Spallone
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Abd A Tahrani
- Institute of Metabolism and Systems, School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
- Department of Diabetes and Endocrinology, Birmingham Heartlands Hospital, Birmingham, UK
| | - Uazman Alam
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
- Department of Medicine, University Hospital Aintree, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
- Centre for Biomechanics and Rehabilitation Technologies, Staffordshire University, Stoke-on-Trent, UK.
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Morioka T, Takeuchi M, Ozeki A, Emoto M. A randomized, double-blind trial assessing the efficacy and safety of two doses of dulaglutide in Japanese participants with type 2 diabetes (AWARD-JPN). Diabetes Obes Metab 2024; 26:3167-3175. [PMID: 38715179 DOI: 10.1111/dom.15644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/19/2024] [Accepted: 04/19/2024] [Indexed: 07/10/2024]
Abstract
AIM To assess the efficacy and safety of dulaglutide 1.5 mg versus dulaglutide 0.75 mg in Japanese participants with type 2 diabetes (T2D). MATERIALS AND METHODS A Phase 3, multicentre, randomized, double-blind, parallel-group study was conducted in Japanese participants aged ≥20 years, with T2D for ≥6 months and inadequate glycaemic control, while on a single oral antihyperglycaemic medication (NCT04809220). The primary objective was to evaluate superiority of dulaglutide 1.5 mg versus dulaglutide 0.75 mg measured by mean change in glycated haemoglobin (HbA1c) from baseline to 26 weeks. Other efficacy and safety endpoints were evaluated at 26 and 52 weeks. All statistical analyses were conducted using the intention-to-treat population. RESULTS Overall, 591 participants were randomized to once-weekly dulaglutide 1.5 mg or 0.75 mg. At Week 26, dulaglutide 1.5 mg was superior to dulaglutide 0.75 mg in HbA1c reduction from baseline (least squares mean [LSM] difference -0.29% [95% confidence interval {CI} -0.43, -0.14]). At Week 52, the dulaglutide 1.5-mg arm had a significantly greater proportion of participants who achieved HbA1c <7.0% (46.3% vs. 38.5%; p = 0.03) and showed significantly greater reduction in fasting serum glucose (LSM difference -9.4 mg/dL [95% CI -14.4, -4.3]; p < 0.001) versus the dulaglutide 0.75-mg arm. No statistically significant change in body weight was observed in either treatment arm. Overall, 442 participants (75.4%) experienced treatment emergent adverse events (TEAEs). Constipation (11.3%), diarrhoea (9.6%) and pyrexia (9.0%) were the most commonly reported TEAEs. CONCLUSIONS Dulaglutide 1.5 mg once weekly demonstrated superior glycaemic control versus dulaglutide 0.75 mg once weekly, with comparable safety and tolerability, in Japanese people with T2D.
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Affiliation(s)
- Tomoaki Morioka
- Department of Metabolism, Endocrinology, and Molecular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Masakazu Takeuchi
- Japan Drug Development and Medical Affairs, Eli Lilly Japan K.K., Kobe, Japan
| | - Akichika Ozeki
- Japan Drug Development and Medical Affairs, Eli Lilly Japan K.K., Kobe, Japan
| | - Masanori Emoto
- Department of Metabolism, Endocrinology, and Molecular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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Li Q, Wu C, Sun S, Yang L, Li Y, Niu Y, Zhang L, Li W, Yu Y. Liraglutide does not increase heart rate of diabetic patients during acute myocardial infarction. J Diabetes 2024; 16:e13517. [PMID: 38173120 PMCID: PMC11212302 DOI: 10.1111/1753-0407.13517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 11/06/2023] [Accepted: 11/18/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Glucagon-like peptide 1 receptor agonists have been shown to reduce all-cause and cardiovascular mortality in patients with Type 2 diabetes mellitus (T2DM). The probable increase in heart rate hinders its early usage in acute myocardial infarction patients. In our study, we aimed to find out whether the use of liraglutide in patients with acute myocardial infarction as early as at the time of hospitalization would increase the heart rate. METHODS This was an observational retrospective study. From December 2020 to August 2021, 200 patients with acute myocardial infarction were included in our study and divided into three groups: T2DM + liraglutide group (n = 46), T2DM + non-liraglutide group (n = 42), and non-T2DM group (n = 112). The primary outcomes were the differences in heart rate. Secondary outcomes were differences in systolic and diastolic blood pressure. RESULTS There were no significant differences in heart rate among the three groups at admission, the day before the first shot of liraglutide, and before discharge. There was also no significant difference in heart rate between diabetic patients with acute myocardial infarction and those on liraglutide during the hospital stay. And there were no differences of beta-blocker dosages among the three groups. Liraglutide did not affect the blood pressure during acute myocardial infarction. CONCLUSIONS Liraglutide did not increase the heart rate in diabetic patients during acute myocardial infarction and did not lead to an increase in the dose of beta-blockers in the patients. It also had no effect on blood pressure and showed better efficacy in lowering glucose levels without additional hypoglycemic events.
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Affiliation(s)
- Qianyi Li
- Department of CardiologyXinhua Hospital, School of Medicine, Shanghai Jiao Tong UniversityShanghaiChina
| | - Chunxuan Wu
- Department of CardiologyXinhua Hospital, School of Medicine, Shanghai Jiao Tong UniversityShanghaiChina
| | - Shiqun Sun
- Department of CardiologyXinhua Hospital, School of Medicine, Shanghai Jiao Tong UniversityShanghaiChina
| | - Lingchao Yang
- Department of CardiologyXinhua Hospital, School of Medicine, Shanghai Jiao Tong UniversityShanghaiChina
| | - Yanyan Li
- Department of CardiologyXinhua Hospital, School of Medicine, Shanghai Jiao Tong UniversityShanghaiChina
| | - Yixin Niu
- Department of EndocrinologyXinhua Hospital, School of Medicine, Shanghai Jiao Tong UniversityShanghaiChina
| | - Li Zhang
- Department of CardiologyXinhua Hospital, School of Medicine, Shanghai Jiao Tong UniversityShanghaiChina
| | - Wei Li
- Department of CardiologyXinhua Hospital, School of Medicine, Shanghai Jiao Tong UniversityShanghaiChina
| | - Ying Yu
- Department of CardiologyXinhua Hospital, School of Medicine, Shanghai Jiao Tong UniversityShanghaiChina
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Clayton TL. Obesity and hypertension: Obesity medicine association (OMA) clinical practice statement (CPS) 2023. OBESITY PILLARS (ONLINE) 2023; 8:100083. [PMID: 38125655 PMCID: PMC10728712 DOI: 10.1016/j.obpill.2023.100083] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 08/06/2023] [Indexed: 12/23/2023]
Abstract
Background This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) provides an overview of the mechanisms and treatment of obesity and hypertension. Methods The scientific support for this CPS is based upon published citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership. Results Mechanisms contributing to obesity-related hypertension include unhealthful nutrition, physical inactivity, insulin resistance, increased sympathetic nervous system activity, renal dysfunction, vascular dysfunction, heart dysfunction, increased pancreatic insulin secretion, sleep apnea, and psychosocial stress. Adiposopathic factors that may contribute to hypertension include increased release of free fatty acids, increased leptin, decreased adiponectin, increased renin-angiotensin-aldosterone system activation, increased 11 beta-hydroxysteroid dehydrogenase type 1, reduced nitric oxide activity, and increased inflammation. Conclusions Increase in body fat is the most common cause of hypertension. Among patients with obesity and hypertension, weight reduction via healthful nutrition, physical activity, behavior modification, bariatric surgery, and anti-obesity medications mostly decrease blood pressure, with the greatest degree of weight reduction generally correlated with the greatest degree of blood pressure reduction.
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Affiliation(s)
- Tiffany Lowe Clayton
- Diplomate of American Board of Obesity Medicine, WakeMed Bariatric Surgery and Medical Weight Loss USA
- Campbell University School of Osteopathic Medicine, Buies Creek, NC 27546, Levine Hall Room 170 USA
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Goldney J, Sargeant JA, Davies MJ. Incretins and microvascular complications of diabetes: neuropathy, nephropathy, retinopathy and microangiopathy. Diabetologia 2023; 66:1832-1845. [PMID: 37597048 PMCID: PMC10474214 DOI: 10.1007/s00125-023-05988-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/17/2023] [Indexed: 08/21/2023]
Abstract
Glucagon-like peptide-1 receptor agonists (GLP-1RAs, incretin mimetics) and dipeptidyl peptidase-4 inhibitors (DPP-4is, incretin enhancers) are glucose-lowering therapies with proven cardiovascular safety, but their effect on microvascular disease is not fully understood. Both therapies increase GLP-1 receptor agonism, which is associated with attenuation of numerous pathological processes that may lead to microvascular benefits, including decreased reactive oxygen species (ROS) production, decreased inflammation and improved vascular function. DPP-4is also increase stromal cell-derived factor-1 (SDF-1), which is associated with neovascularisation and tissue repair. Rodent studies demonstrate several benefits of these agents in the prevention or reversal of nephropathy, retinopathy and neuropathy, but evidence from human populations is less clear. For nephropathy risk in human clinical trials, meta-analyses demonstrate that GLP-1RAs reduce the risk of a composite renal outcome (doubling of serum creatinine, eGFR reduction of 30%, end-stage renal disease or renal death), whereas the benefits of DPP-4is appear to be limited to reductions in the risk of albuminuria. The relationship between GLP-1RAs and retinopathy is less clear. Many large trials and meta-analyses show no effect, but an observed increase in the risk of retinopathy complications with semaglutide therapy (a GLP-1RA) in the SUSTAIN-6 trial warrants caution, particularly in individuals with baseline retinopathy. Similarly, DPP-4is are associated with increased retinopathy risk in both trials and meta-analysis. The association between GLP-1RAs and peripheral neuropathy is unclear due to little trial evidence. For DPP-4is, one trial and several observational studies show a reduced risk of peripheral neuropathy, with others reporting no effect. Evidence in other less-established microvascular outcomes, such as microvascular angina, cerebral small vessel disease, skeletal muscle microvascular disease and autonomic neuropathies (e.g. cardiac autonomic neuropathy, gastroparesis, erectile dysfunction), is sparse. In conclusion, GLP-1RAs are protective against nephropathy, whereas DPP-4is are protective against albuminuria and potentially peripheral neuropathy. Caution is advised with DPP-4is and semaglutide, particularly for patients with background retinopathy, due to increased risk of retinopathy. Well-designed trials powered for microvascular outcomes are needed to clarify associations of incretin therapies and microvascular diseases.
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Affiliation(s)
- Jonathan Goldney
- Diabetes Research Centre, College of Life Sciences, University of Leicester, Leicester, UK.
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester, UK.
| | - Jack A Sargeant
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester, UK
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Melanie J Davies
- Diabetes Research Centre, College of Life Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester, UK
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
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Huang YL, Xu XZ, Liu J, Wang PY, Wang XL, Feng HL, Liu CJ, Han X. Effects of new hypoglycemic drugs on cardiac remodeling: a systematic review and network meta-analysis. BMC Cardiovasc Disord 2023; 23:293. [PMID: 37296380 PMCID: PMC10251583 DOI: 10.1186/s12872-023-03324-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND In recent years, the incidence of diabetes mellitus has been increasing annually, and cardiovascular complications secondary to diabetes mellitus have become the leading cause of death in diabetic patients. Considering the high incidence of type 2 diabetes (T2DM) combined with cardiovascular disease (CVD), some new hypoglycemic agents with cardiovascular protective effects have attracted extensive attention. However, the specific role of these regimens in ventricular remodeling remains unknown. The purpose of this network meta-analysis was to compare the effects of sodium glucose cotransporter type 2 inhibitor (SGLT-2i), glucagon-like peptide 1 receptor agonist (GLP-1RA) and dipeptidyl peptidase-4 inhibitor (DPP-4i) on ventricular remodeling in patients with T2DM and/or CVD. METHODS Articles published prior to 24 August 2022 were retrieved in four electronic databases: the Cochrane Library, Embase, PubMed, and Web of Science. This meta-analysis included randomized controlled trials (RCTs) and a small number of cohort studies. The differences in mean changes of left ventricular ultrasonic parameters between the treatment and control groups were compared. RESULTS A total of 31 RCTs and 4 cohort studies involving 4322 patients were analyzed. GLP-1RA was more significantly associated with improvement in left ventricular end-systolic diameter (LVESD) [MD = -0.38 mm, 95% CI (-0.66, -0.10)] and LV mass index (LVMI) [MD = -1.07 g/m2, 95% CI (-1.71, -0.42)], but significantly decreased e' [MD = -0.43 cm/s 95% CI (-0.81, -0.04)]. DPP-4i was more strongly associated with improvement in e' [MD = 3.82 cm/s, 95% CI (2.92,4.7)] and E/e'[MD = -5.97 95% CI (-10.35, -1.59)], but significantly inhibited LV ejection fraction (LVEF) [MD = -0.89% 95% CI (-1.76, -0.03)]. SGLT-2i significantly improved LVMI [MD = -0.28 g/m2, 95% CI (-0.43, -0.12)] and LV end-diastolic diameter (LVEDD) [MD = -0.72 ml, 95% CI (-1.30, -0.14)] in the overall population, as well as E/e' and SBP in T2DM patients combined with CVD, without showing any negative effect on left ventricular function. CONCLUSION The results of the network meta-analysis provided high certainty to suggest that SGLT-2i may be more effective in cardiac remodeling compared to GLP-1RA and DPP-4i. While GLP-1RA and DPP-4i may have a tendency to improve cardiac systolic and diastolic function respectively. SGLT-2i is the most recommended drug for reversing ventricular remodeling in this meta-analysis.
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Affiliation(s)
- Yi-Lin Huang
- Department of Geriatrics, Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhongmen Road, Nanjing, 210001, Jiangsu, China
| | - Xiao-Zhuo Xu
- Department of Geriatrics, Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhongmen Road, Nanjing, 210001, Jiangsu, China
| | - Jing Liu
- Department of Geriatrics, Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhongmen Road, Nanjing, 210001, Jiangsu, China
| | - Pin-Yao Wang
- Department of Geriatrics, Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhongmen Road, Nanjing, 210001, Jiangsu, China
| | - Xue-Li Wang
- Department of Geriatrics, Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhongmen Road, Nanjing, 210001, Jiangsu, China
| | - Hong-Lin Feng
- Department of Geriatrics, Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhongmen Road, Nanjing, 210001, Jiangsu, China
| | - Cheng-Jiang Liu
- Department of General Medicine, Affiliated Anqing First People's Hospital of Anhui Medical University, Anqing, Anhui, China
| | - Xu Han
- Department of Geriatrics, Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhongmen Road, Nanjing, 210001, Jiangsu, China.
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Roh E, Choi KM. Hormonal Gut-Brain Signaling for the Treatment of Obesity. Int J Mol Sci 2023; 24:ijms24043384. [PMID: 36834794 PMCID: PMC9959457 DOI: 10.3390/ijms24043384] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 02/03/2023] [Accepted: 02/06/2023] [Indexed: 02/10/2023] Open
Abstract
The brain, particularly the hypothalamus and brainstem, monitors and integrates circulating metabolic signals, including gut hormones. Gut-brain communication is also mediated by the vagus nerve, which transmits various gut-derived signals. Recent advances in our understanding of molecular gut-brain communication promote the development of next-generation anti-obesity medications that can safely achieve substantial and lasting weight loss comparable to metabolic surgery. Herein, we comprehensively review the current knowledge about the central regulation of energy homeostasis, gut hormones involved in the regulation of food intake, and clinical data on how these hormones have been applied to the development of anti-obesity drugs. Insight into and understanding of the gut-brain axis may provide new therapeutic perspectives for the treatment of obesity and diabetes.
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Affiliation(s)
- Eun Roh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang 14068, Republic of Korea
| | - Kyung Mook Choi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul 02841, Republic of Korea
- Correspondence: or
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Diabetes-Induced Cardiac Autonomic Neuropathy: Impact on Heart Function and Prognosis. Biomedicines 2022; 10:biomedicines10123258. [PMID: 36552014 PMCID: PMC9775487 DOI: 10.3390/biomedicines10123258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/07/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022] Open
Abstract
Cardiovascular autonomic neuropathy (CAN) is a severe complication of the advance stage of diabetes. More than 50% of diabetic patients diagnosed with peripheral neuropathy will have CAN, with clinical manifestations including tachycardia, severe orthostatic hypotension, syncope, and physical exercise intolerance. Since the prevalence of diabetes is increasing, a concomitant increase in CAN is expected and will reduce quality of life and increase mortality. Autonomic dysfunction is associated with reduced baroreflex sensitivity and impairment of sympathetic and parasympathetic modulation. Various autonomic function tests are used to diagnose CAN, a condition without adequate treatment. It is important to consider the control of glucose level and blood pressure as key factors for preventing CAN progression. However, altered biomarkers of inflammatory and endothelial function, increased purinergic receptor expression, and exacerbated oxidative stress lead to possible targets for the treatment of CAN. The present review describes the molecular alterations seen in CAN, diagnosis, and possible alternative treatments.
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