Efficacy and Safety of Adjunctive Cilostazol to Clopidogrel-Treated Diabetic Patients With Symptomatic Lower Extremity Artery Disease in the Prevention of Ischemic Vascular Events

Background

Type 2 diabetes mellitus is a risk factor for lower extremity arterial disease. Cilostazol expresses antiplatelet, anti‐inflammatory, and vasodilator actions and improves the claudication intermittent symptoms. We investigated the efficacy and safety of adjunctive cilostazol to clopidogrel‐treated patients with type 2 diabetes mellitus exhibiting symptomatic lower extremity arterial disease, in the prevention of ischemic vascular events and improvement of the claudication intermittent symptoms.

Methods and Results

In a prospective 2‐arm, multicenter, open‐label, phase 4 trial, patients with type 2 diabetes mellitus with intermittent claudication receiving clopidogrel (75 mg/d) for at least 6 months, were randomly assigned in a 1:1 ratio, either to continue to clopidogrel monotherapy, without receiving placebo cilostazol (391 patients), or to additionally receive cilostazol, 100 mg twice/day (403 patients). The median duration of follow‐up was 27 months. The primary efficacy end point, the composite of acute ischemic stroke/transient ischemic attack, acute myocardial infarction, and death from vascular causes, was significantly reduced in patients receiving adjunctive cilostazol compared with the clopidogrel monotherapy group (sex‐adjusted hazard ratio [HR], 0.468; 95% CI, 0.252–0.870; P=0.016). Adjunctive cilostazol also significantly reduced the stroke/transient ischemic attack events (sex‐adjusted HR, 0.38; 95% CI, 0.15–0.98; P=0.046) and improved the ankle‐brachial index and pain‐free walking distance values (P=0.001 for both comparisons). No significant difference in the bleeding events, as defined by Bleeding Academic Research Consortium criteria, was found between the 2 groups (sex‐adjusted HR, 1.080; 95% CI, 0.579–2.015; P=0.809).

Conclusions

Adjunctive cilostazol to clopidogrel‐treated patients with type 2 diabetes mellitus with symptomatic lower extremity arterial disease may lower the risk of ischemic events and improve intermittent claudication symptoms, without increasing the bleeding risk, compared with clopidogrel monotherapy.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02983214.

Improvement of metabolic control after 3-month use of real-time continuous glucose monitoring in patients with type 1 diabetes: a multicenter study in Greece

PURPOSE

To assess the efficacy of a real-time continuous glucose monitoring (RT-CGM) system added to insulin pump therapy for 3 months, in sub-optimally controlled adults with type 1 diabetes mellitus (T1D).

METHODS

This was a prospective, multicenter, non-randomized, post-market release study. A total of 43 adult patients with T1D on insulin pump therapy and inadequate glycemic control (HbA1c > 7.0%) participated in the study. The primary endpoint was the change from baseline HbA1c levels. Secondary objectives were to evaluate the impact of the RT-CGM system on glucose variability, daily insulin requirements, and the frequency of hypoglycemic and ketoacidosis events.

RESULTS

At 3 months, the baseline HbA1c values decreased from 8.0 (7.6, 8.7) to 7.1 (6.7, 8.0) % (p < 0.001). Nineteen participants (44.2%) had a posttreatment HbA1c level ≤ 7%. Average total daily insulin requirements, as well as the average number of insulin boluses per day, increased significantly after the use of the RT-CGM system. The number of hypoglycemic events recorded did not differ between the first week and last week of RT-CGM usage, while no severe hypoglycemic episodes, ketoacidosis events, or hospitalizations related to diabetes occurred during the 3-month follow-up period.

CONCLUSION

Addition of a RT-CGM system to insulin pump therapy for 3 months in inadequately controlled patients with T1D resulted in improved HbA1c levels, without increasing the risk of hypoglycemic events.

WHICH FACTORS MAY AFFECT THE QUALITY OF LIFE IN PATIENTS WITH TYPE 1 DIABETES MELLITUS USING THE MEDTRONIC VEO CONTINUOUS SUBCUTANEOUS INSULIN INFUSION PUMP?

Continuous Subcutaneous Insulin Infusion (CSII) is considered an effective therapeutic approach to the treatment of patients with Type 1 Diabetes Mellitus (T1DM). Literature offers limited information regarding the quality of life (QoL) in patients using CSII. The aim of the study was to investigate the impact of diabetes related factors on the QoL of patients with T1DM on CSII treatment, in a Greek urban population. A cross-sectional study was conducted on 80 patients with T1DM using CSII. [(Mean±SD) age: 35.9±11.4 years, duration of diabetes: 24.2±10.3 years, BMI: 24.6±3.5kg/m2, duration of Insulin pump use: 7.1±3.9 years, HbA1c: 7.7±1.1%, gender: 37 males-43 females)]. QoL was assessed using the patient self-administered EuroQol EQ 5D validated in Greek. Correlation and regression analyses were performed to examine the relationship between EQ index - EQ VAS scores and diabetes related factors. Hypoglycemia Awareness was measured using Clarke and Gold Score questionnaires, Hypoglycemic Episodes were expressed as number of episodes per week and the Fear of Hypoglycemia was measured using the worry subscale of the Hypoglycemia Fear Survey (HFS-W). Results were as follows: Gold score: 2.8±1.5, Clarke score: 2.8±2.1, Hypoglycemia Fear Score: 20.6±11.2, Number of hypoglycemic Episodes per week: 4.3±2.9, VAS score: 68.7±18.1, EQ index: 0.79±0.24. In univariate analyses QoL was negatively correlated with Hypoglycemic episodes, HbA1c, Hypoglycemia Fear Score and Hypoglycemia Awareness status. After regression analysis, only HbA1c and the number of hypoglycemic episodes per week remained independently related to QoL scores. Prevention of hypoglycemia and glycemic control should be emphasized in order to improve QoL in patients with T1DM with CSII.

Effect of atorvastatin on baroreflex sensitivity in subjects with type 2 diabetes and dyslipidaemia

In this prospective study, we examined the effect of atorvastatin treatment on baroreflex sensitivity (BRS) in subjects with type 2 diabetes. A total of 79 patients with type 2 diabetes with dyslipidaemia were recruited. A total of 46 subjects were enrolled to atorvastatin 10 mg daily and low-fat diet and 33 patients to low-fat diet only. BRS was assessed non-invasively using the sequence method at baseline, 3, 6 and 12 months. Treatment with atorvastatin increased BRS after 12 months (from 6.46 ± 2.79 ms/mmHg to 8.05 ± 4.28 ms/mmHg, p = 0.03), while no effect was seen with low-fat diet. Further sub-analysis according to obesity status showed that BRS increased significantly only in the non-obese group (p = 0.036). A low dose of atorvastatin increased BRS in non-obese subjects with type 2 diabetes and dyslipidaemia after 1-year treatment. This finding emphasizes the beneficial effect of atorvastatin on cardiovascular system, beyond the lipid-lowering effects.

Incretin-based therapies for type 2 diabetes mellitus: effects on insulin resistance

Insulin resistance has been associated with the development of type 2 diabetes, obesity, hypertension, dyslipidemia, atherosclerosis, and thus with increased cardiovascular morbidity and mortality. Insulin resistance precedes the onset of type 2 diabetes by many years. Targeting the pathophysiologic defects that characterize the onset of diabetes is more likely to achieve a durable glucose control and to delay disease progression. Incretins are gut-derived peptides that stimulate in a glucose-dependent mechanism insulin secretion and action. Glucose-like peptide 1 (GLP-1) analogues and dipeptidyl peptidase-4 (DPP-4) inhibitors both decrease fasting and postprandial glucose levels. In addition, GLP-1 analogues promote weight loss and exert a favorable effect on several cardiovascular risk factors. Data from human and experimental studies implicate that GLP-1 analogues and to a less extend DPP-4 inhibitors enhance insulin sensitivity. This review summarizes the current knowledge regarding the impact of GLP-1 analogues and DPP-4 inhibitors on insulin resistance.

The role of the osteoprotegerin/RANKL/RANK system in diabetic vascular disease

Over the last years our knowledge on the mechanisms involved in the pathogenesis of cardiovascular disease has been enriched by the discovery of new molecules emerging as novel risk factors. Osteoprotegerin (OPG) is a soluble glycoprotein, member of the tumor necrosis factor (TNF)-related superfamily, involved in bone resorption. It was first described as a key regulator of bone homeostasis and vascular calcification in mice. Clinical studies have suggested that serum OPG is associated with vascular calcification in humans. The role of OPG in the development of macroangiopathy in diabetes is not yet clear. It is possible that the increased OPG levels in diabetes reflect a compensatory response to arterial injury and that it is not involved in the pathogenesis of atherosclerosis. Whether harmful or not, determination of serum OPG levels has been suggested as a prognostic biomarker of cardiovascular disease. In addition, increased OPG levels have been reported in diabetic patients with microvascular complications. The potential of OPG administration for therapeutic reasons is challenging for future investigators. This review summarizes the current knowledge on the association between OPG and macrovascular as well microvascular complications of diabetes.

[Effect of induced hyperglycemia on contrast sensitivity function in insulin-dependent diabetic patients]

Acute hyperglycemia in diabetes mellitus is often associated with transient subjective visual disturbances that have not yet been objectively evaluated. We used a contrast sensitivity (CS) test to assess functional visual disturbances in provoked hyperglycemia in 20 patients with well-controlled insulin-dependent diabetes (40 eyes) with no evidence of diabetic retinopathy and with intact visual acuity (age: 32 +/- 8.2 years, duration of diabetes: 11.4 +/- 7.3 years). The CS function was measured by using the CSV-1000 CS test, which is rapid and easily comprehended by the patient and encompasses four spatial frequencies, 3 (A), 6 (B), 12 (C) and 18 (D) cycles/degree. At each frequency, eight pairs of circular targets differing stepwise in contrast were presented simultaneously. The number of targets seen by each patient in the four spatial frequencies at euglycemic (116 +/- 14.7 mg/dl) and hyperglycemic (274 +/- 52 mg/dl) levels, expressed as the CS score, was recorded and afterwards analyzed. The differences in mean CS scores at the individual frequencies at euglycemic versus hyperglycemic levels were statistically significant (p < 0.001). Visual acuity remained stable during hyperglycemia. There was no significant difference in the amount of CS reduction between the group of patients that had had diabetes for a duration of more than 10 years and the group who had had diabetes for less than 10 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Biologic activities of biosynthetic human insulin in healthy volunteers and insulin-dependent diabetic patients monitored by the artificial endocrine pancreas

This study investigates and compares biosynthetic human insulin (BHI) and purified pork insulin, in healthy volunteers and in insulin-dependent diabetic patients, in terms of biologic action, capacity for controlling diabetic patients, and the requirements of the patients on each insulin. The possible importance of this new insulin in the improved long-term control of diabetic patients led to the experimental design of this protocol.

The validity of C-peptide measurement in the diagnosis of factitious hypoglycemia

The case is presented of a 32-year-old obese diabetic nurse, with a history of recent hypoglycemic episodes. Estimation of immunologically measurable insulin during hypoglycemia after an overnight fast revealed high values, while simultaneous determination of serum C-peptide failed to show an increase. This combination is considered pathognomonic for factitious hyperinsulinism. After the hidden vial was discovered and presented to her, the patient finally admitted that she had been surreptitiously injecting insulin.

[A field study with the combination of Pindolol and Clopamid in antihpertensive therapy (author's transl)]

In a field study comprising 678 patients with arterial hypertension efficacy and tolerance of the stable combination VKB 105 consisting of 10 mg Pindolol (Visken) and 5 mg Clopamid (Brinaldix) were investigated. Treatment with 1--2 tablets of VKB per day resulted in a successful therapy in 94% of all patients corresponding on the average to a reduction in blood pressure to 145/85 mm Hg within 14 days. In mean arterial pressures ranging between 120 and 170 mm Hg a positive linear relationship between the individual initial value and the hypotensive effect of the combination could be observed. A controlled omission trial disclosed qualitatively the respective contribution to the effect of the two components Pindolol and Clopamid. With a systematic case control of the serum potassium under the combined therapy with VKB 105 and during a monotherapy with Clopamid and antihypokalaemic effect of Pindolol could be demonstrated diminishing the tendency for potassium loss. The result revealed a far-reaching potassium neutrality of diuresis-depending stimulation of renin by the beta-receptor blocker. In 61 patients altogether subjective side-effects could be recorded, such as vertigo (5%), palpitations (2.8%), fatigue (2%), insomina (1.9%), nausea (1.7%) and vomiting (0.8%). Laboratory controls gave no indication for clinically relevant changes.