Balancing benefits and risks in patients receiving incretin-based therapies: focus on cardiovascular and pancreatic side effects

Generation and characterisation of C-terminally stabilised PYY molecules with potential in vivo NPYR2 activity

BACKGROUND

Activation of neuropeptide Y2 receptors (NPYR2) by the N-terminally truncated, dipeptidyl peptidase-4 (DPP-4) generated, Peptide YY (PYY) metabolite, namely PYY(3-36), results in satiating actions. However, PYY(3-36) is also subject to C-terminal enzymatic cleavage, which annuls anorectic effects.

METHODS

Substitution of l-Arg³⁵ with d-Arg³⁵ in the DPP-4 stable sea lamprey PYY(1-36) peptide imparts full C-terminal stability. In the current study, we have taken this molecule and introduced DPP-4 susceptibility by Iso³ substitution.

RESULTS

As expected, [Iso³]sea lamprey PYY(1-36) and [Iso³](d-Arg³⁵)sea lamprey PYY(1-36) were N-terminally degraded to respective PYY(3-36) metabolites in plasma. Only [Iso³](d-Arg³⁵)sea lamprey PYY(1-36) was C-terminally stable. Both peptides possessed similar insulinostatic and anti-apoptotic biological actions to native PYY(1-36) in beta-cells. Unlike native PYY(1-36) and [Iso³](d-Arg³⁵)sea lamprey PYY(1-36), [Iso³]sea lamprey PYY(1-36) displayed some proliferative actions in Npyr1 knockout beta-cells. In addition, [Iso³]sea lamprey PYY(1-36) induced more rapid NPYR2-dependent appetite suppressive effects in mice than its C-terminally stable counterpart. Twice daily administration of either peptide to high fat fed (HFF) mice resulted in significant body weight reduction and improvements in circulating triglyceride levels. [Iso³]sea lamprey PYY(1-36) treatment also prevented elevations in glucagon. Both peptides, and especially [Iso³]sea lamprey PYY(1-36), improved glucose tolerance. The treatment interventions also partially reversed the deleterious effects of sustained high fat feeding on pancreatic islet morphology.

CONCLUSION

The present study confirms that sustained NPYR2 receptor activation by [Iso³](d-Arg³⁵)sea lamprey induced significant weight lowering actions. However, identifiable benefits of this peptide over [Iso³]sea lamprey PYY(1-36), which was not protected against C-terminal degradation, were not pronounced.

Clinical pharmacology of glucagon-like peptide-1 receptor agonists

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are an important asset in the armamentarium for the treatment of type 2 diabetes mellitus (type 2 DM). Incretin failure is a critical etiopathogenetic feature of type 2 DM, which, if reversed, results in improved glycaemic control. GLP-1 RAs are injectable peptides that resemble the structure and function of endogenous incretin GLP-1, but as they are not deactivated by the dipeptidyl peptidase-4 (DPP-4), their half-life is prolonged compared with native GLP-1. Based on their ability to activate GLP-1 receptor, GLP-1 RAs are classified as short-acting (exenatide twice-daily and lixisenatide once-daily), and long-acting (liraglutide once-daily and the once-weekly formulations of exenatide extended-release, dulaglutide, and albiglutide). Semaglutide, another long-acting, once-weekly GLP-1 RA, was recently approved by the FDA and EMA. Although all of these agents potently reduce haemoglobin A1C (HbA1c), there are unique features and fundamental differences among them related to fasting and postprandial hyperglycaemia reduction, weight loss potency, cardiovascular protection efficacy, and adverse events profile. It is imperative that current evidence be integrated and applied in the context of an individualised patient-centred approach. This should include not only glucose management but also targeting as many as possible of the pathophysiologic mechanisms responsible for type 2 DM development and progression.

Glucagon-like peptide 1 in the pathophysiology and pharmacotherapy of clinical obesity

Though the pathophysiology of clinical obesity is undoubtedly multifaceted, several lines of clinical evidence implicate an important functional role for glucagon-like peptide 1 (GLP-1) signalling. Clinical studies assessing GLP-1 responses in normal weight and obese subjects suggest that weight gain may induce functional deficits in GLP-1 signalling that facilitates maintenance of the obesity phenotype. In addition, genetic studies implicate a possible role for altered GLP-1 signalling as a risk factor towards the development of obesity. As reductions in functional GLP-1 signalling seem to play a role in clinical obesity, the pharmacological replenishment seems a promising target for the medical management of obesity in clinical practice. GLP-1 analogue liraglutide at a high dose (3 mg/d) has shown promising results in achieving and maintaining greater weight loss in obese individuals compared to placebo control, and currently licensed anti-obesity medications. Generally well tolerated, provided that longer-term data in clinical practice supports the currently available evidence of superior short- and long-term weight loss efficacy, GLP-1 analogues provide promise towards achieving the successful, sustainable medical management of obesity that remains as yet, an unmet clinical need.

Leaf Extract from Lithocarpus polystachyus Rehd. Promote Glycogen Synthesis in T2DM Mice

The purpose of this study was to investigate the effects of leaf extract from Lithocarpus polystachyus Rehd. on type II diabetes mellitus (T2DM) and the active ingredients of this effect. In addition, this study determined, for the first time, the underlying molecular and pharmacological mechanisms of the extracts on hyperglycemia using long-term double high diet-fed and streptozotocin (STZ) induced type II diabetic mice. In the present study, leaf extract, phloridzin and trilobatin were assessed in vivo (gavage) and in vitro (non-invasive micro-test technique, NMT) in experimental T2DM mice. The biochemical parameters were measured including blood glucose and blood lipid level, liver biochemical indexes, and hepatic glycogen. The relative expression of glycometabolism-related genes was detected. The effect of leaf extracts on physiological glucose flux in liver tissue from control and T2DM mice was also investigated. Body weight of experimental T2DM mice increased significantly after the first week, but stabilized over the subsequent three weeks; body weight of all other groups did not change during the four weeks’ study. After four weeks, all treatment groups decreased blood glucose, and treatment with leaf extract had numerous positive effects: a) promoted in glucose uptake in liver, b) increased synthesis of liver glycogen, c) reduced oxidative stress, d) up-regulation of glucokinase (GK), glucose transporter 2 (GLUT2), insulin receptor (IR) and insulin receptor substrate (IRS) expression in liver, e) down-regulation of glucose-6-phosphatase (G-6-P) expression, and f) ameliorated blood lipid levels. Both treatment with trilobatin or phloridzin accelerated liver glycogen synthesis, decreased oxidative stress and increased expression of GK. IRS and phosphoenolpyruvate carboxykinase (PEPCK) were both up-regulated after treatment with trilobatin. Expression of GLUT2, PEPCK and G-6-P were also increased in liver tissue after treatment with phloridzin. Our data indicate that leaf extract from L. polystachyus Rehd. has a preferable hypoglycemic effects than trilobatin or phloridzin alone. Leaf extract significantly increased glucose uptake and hepatic glycogen synthesis while also inducing a decline of hepatic gluconeogenesis and oxidative stress in T2DM mice. From this study, we draw conclusions that L. polystachyus promoted glycogen synthesis in T2DM mice, and that the active compounds were not only the trilobatin or phloridzin.

[Lixisenatide in patients with type 2 diabetes and obesity: Beyond glycaemic control]

Objetivo

Evaluar la tolerancia a lixisenatida y sus efectos sobre el peso y el control metabólico de pacientes con diabetes tipo 2 y obesidad.

Diseño

Estudio prospectivo.

Emplazamiento

Consultas de atención especializada de Endocrinología y Nutrición en Almería, Granada y Málaga.

Participantes

Pacientes con diabetes tipo 2 y obesidad.

Intervenciones

Respuesta y tolerancia al tratamiento con lixisenatida.

Mediciones principales

Se analizaron datos clínicos y analíticos con medidas de cambio intrasujeto antes-después del tratamiento.

Resultados

Evaluamos 104 pacientes (51% mujeres) con diabetes tipo 2 y obesidad (Almería 18,3%; Granada 40,4%; Málaga 41,3%). Edad media 58,4 ± 10,5 años y duración media de diabetes 11,2 ± 6,7 años. El tiempo medio desde la visita basal a la revisión tras inicio de tratamiento con lixisenatida fue de 3,8 ± 1,6 meses. Encontramos mejoría significativa del peso (p < 0,001), índice de masa corporal (p < 0,001), circunferencia de cintura (p = 0,002), presión arterial sistólica (p < 0,001) y diastólica (p = 0,001), glucemia en ayunas (p < 0,001), HbA1c (p = 0,022), colesterol total (p < 0,001), colesterol LDL (p = 0,046) y triglicéridos (p = 0,020). No se observó alteración de cifras de amilasa en relación con el tratamiento con lixisenatida, y el 7,9% no lo toleraron.

Conclusiones

Lixisenatida consigue: 1) mejoría significativa de parámetros antropométricos y control glucémico (glucemia basal y HbA1c); 2) descenso significativo de la presión arterial y del perfil lipídico, y 3) seguridad y buena tolerancia en la mayoría de los pacientes. Además, encontramos una significativa intensificación del tratamiento antihipertensivo e hipolipemiante.

No Change in Serum Incretins Levels but Rise of Leptin Levels After Smoking Cessation: a Pilot Study

The mechanisms behind the changes of body weight after smoking cessation are only partially understood. To this end, we explored the possible effects of smoking cessation on incretin hormones, leptin and selected anthropometric, biochemical and other hormonal parameters. Twenty-two non-obese male adult smokers attending an ambulatory smoking cessation program in Prague, Czech Republic, were examined at the baseline. Thirteen patients (mean age 37.92±2.66 years, mean body mass index 25.56±0.69 kg/m2) successfully quit smoking and were examined three months after smoking cessation; relapsed smokers were not followed up. The patients underwent 2-h liquid meal test with Fresubin and repeated blood sampling for measurements of blood glucose, gastric inhibitory polypeptide (GIP), glucagon-like peptide 1 (GLP-1), amylin, insulin, leptin, peptide-YY (PYY) and pancreatic polypeptide (PP). Three months after smoking cessation, body weight increased (4.35±3.32 kg, p<0.001). Leptin levels increased significantly in all repeated samples, while levels of GIP, GLP-1, amylin, insulin, PYY and PP remained unchanged. In conclusions, smoking cessation increased leptin levels probably owing to weight gain while it did not influence incretin levels.

Urinary metabolomic profiling in mice with diet-induced obesity and type 2 diabetes mellitus after treatment with metformin, vildagliptin and their combination

Metformin, vildagliptin and their combination are widely used for the treatment of diabetes, but little is known about the metabolic responses to these treatments. In the present study, NMR-based metabolomics was applied to detect changes in the urinary metabolomic profile of a mouse model of diet-induced obesity in response to these treatments. Additionally, standard biochemical parameters and the expression of enzymes involved in glucose and fat metabolism were monitored. Significant correlations were observed between several metabolites (e.g., N-carbamoyl-β-alanine, N1-methyl-4-pyridone-3-carboxamide, N1-methyl-2-pyridone-5-carboxamide, glucose, 3-indoxyl sulfate, dimethylglycine and several acylglycines) and the area under the curve of glucose concentrations during the oral glucose tolerance test. The present study is the first to present N-carbamoyl-β-alanine as a potential marker of type 2 diabetes mellitus and consequently to demonstrate the efficacies of the applied antidiabetic interventions. Moreover, the elevated acetate level observed after vildagliptin administration might reflect increased fatty acid oxidation.