Pathophysiologic heterogeneity in the development of type 2 diabetes mellitus in Korean subjects

Linagliptin improves glycemic control after 1 year as add-on therapy to basal insulin in Asian patients with type 2 diabetes mellitus

OBJECTIVE

To evaluate the efficacy and long-term safety of linagliptin added to basal insulin in Asian patients with type 2 diabetes mellitus (T2DM) inadequately controlled by basal insulin with/without oral agents.

RESEARCH DESIGN AND METHODS

This was a post hoc analysis of Asian patients from a global ≥52 week study in which patients on basal insulin were randomized (1:1) to double-blind treatment with linagliptin 5 mg once daily or placebo (NCT00954447). Basal insulin dose remained stable for 24 weeks, after which adjustments could be made according to the investigator's discretion to improve glycemic control. The primary endpoint was the mean change in glycated hemoglobin (HbA1c) from baseline to 24 weeks.

RESULTS

Data were available for 154 Asian patients (80 linagliptin, 74 placebo). Baseline HbA1c (standard deviation [SD]) was 8.6 (0.9)% (70 [10] mmol/mol). The placebo-corrected mean change (standard error [SE]) in HbA1c from baseline was -0.9 (0.1)% (-10 [1] mmol/mol) (95% confidence interval [CI]: -1.2, -0.7; p<0.0001) at Week 24 and -0.9 (0.1)% (-10 [1] mmol/mol) (95% CI: -1.1, -0.6; p<0.0001) at Week 52. The frequency of adverse events (linagliptin 81.3%, placebo 91.9%) and hypoglycemia (Week 24: linagliptin 25.0%, placebo 25.7%; treatment end: linagliptin 28.8%, placebo 35.1%) was similar between groups. By Week 52, changes (SE) in mean body weight were similar in both groups (linagliptin -0.67 [0.26] kg, placebo -0.38 [0.25] kg).

CONCLUSIONS

This study was limited by the post hoc nature of the analysis and the small number of patients in the subgroup. However, the results suggest that linagliptin significantly improves glycemic control in Asian patients with T2DM inadequately controlled by basal insulin, without increasing the risk for hypoglycemia or weight gain. ClinicalTrials identifier: NCT00954447.

Efficacy and safety of linagliptin as monotherapy or add-on treatment in Asian patients with suboptimal glycemic control: a pooled analysis

AIMS

To evaluate the efficacy and safety of the dipeptidyl peptidase (DPP)-4 inhibitor linagliptin in Asian patients with type 2 diabetes mellitus (T2DM), a rapidly increasing population.

METHODS

Data were pooled for Asian patients receiving linagliptin orally once daily, as monotherapy or added to existing oral antidiabetes therapies, in multinational randomized placebo-controlled clinical trials. Efficacy data were taken from four pivotal trials with 24-week durations to allow for robust efficacy assessment. Safety data were pooled from a wider group of 10 trials with varying durations to capture the largest possible incidence of adverse events (AEs). The primary efficacy endpoint was change from baseline to week 24 in HbA1c. AEs were analyzed descriptively.

RESULTS

Mean baseline HbA1c (±SD) in this population was 8.2 ± 0.9%. Placebo-corrected mean change in HbA1c after 24 weeks was -0.79% (95% confidence interval [CI]: -0.92 to -0.67; p < 0.0001). Placebo-corrected mean change in fasting plasma glucose was -17.8 ± 2.4 mg/dL (95% CI: -22.6, -13.0; p < 0.0001). In a small subgroup, mean post-prandial glucose was reduced by a placebo-corrected -56.9 ± 14.0 mg/dL (95% CI: -85.2, -28.5). AEs occurred in 58.0% of linagliptin patients (serious AEs in 2.4%) and 58.2% of placebo patients (serious AEs in 3.0%).

CONCLUSIONS

This study was limited by the post hoc nature of the analysis, and because the pooling did not differentiate between geographically distant Asian regions. Nonetheless, this analysis provides evidence that linagliptin was efficacious and well tolerated as monotherapy or added to other oral antidiabetes therapies in Asian patients with T2DM.

Impaired glucose metabolism in hypertensive patients with/without the metabolic syndrome

BACKGROUND

In hypertension clinics, screening patients for the metabolic syndrome (MetS) is common practice, while performing the cumbersome oral glucose tolerance test (OGTT) is not. How large is the underestimation of diabetes and prediabetes that ensues is unknown.

METHODS

We recruited N=1397 patients with essential arterial hypertension who underwent a 75-g OGTT and were classified as normally glucotolerant (NGT) or having impaired glucose metabolism (IGM), and as affected or not by MetS (ATPIII criteria). The agreement between the OGTT and the ATPIII criteria in attributing a high cardiovascular risk was estimated by matching the categories of MetS and no-MetS with NGT and IGM.

RESULTS

n=677/1397 patients (48%) satisfied criteria for MetS, while n=757/1397 (54%) had an IGM. MetS and IGM were both present in n=512/1397 patients (36.6%), and both absent in n=475/1397 (34%). Further n=410/1397 patients (29%) were discordant for the two conditions: n=165/410 (40%) had the MetS but were NGT, and n=245/410 (60%) had IGM but no MetS. Among IGM patients, n=168/757 (22%; of which 45 had no MetS) received a new diagnosis of diabetes based on OGTT criteria. Among all discordant patients, those with IGM and no MetS were more commonly males (p<0.001), and had older age (p<0.001) and lower body mass index (p<0.05).

CONCLUSIONS

Among patients with hypertension, the estimate of the prevalence of diabetes and prediabetes, hence of the global cardiovascular risk, can be seriously flawed unless an OGTT is performed. Our results support a wider use of the OGTT in the management of hypertension.

Risk equations for the development of worsened glucose status and type 2 diabetes mellitus in a Swedish intervention program

Background

Several studies investigated transitions and risk factors from impaired glucose tolerance (IGT) to type 2 diabetes mellitus (T2D). However, there is a lack of information on the probabilities to transit from normal glucose tolerance (NGT) to different pre-diabetic states and from these states to T2D. The objective of our study is to estimate these risk equations and to quantify the influence of single or combined risk factors on these transition probabilities.

Methods

Individuals who participated in the VIP program twice, having the first examination at ages 30, 40 or 50 years of age between 1990 and 1999 and the second examination 10 years later were included in the analysis. Participants were grouped into five groups: NGT, impaired fasting glucose (IFG), IGT, IFG&IGT or T2D. Fourteen potential risk factors for the development of a worse glucose state (pre-diabetes or T2D) were investigated: sex, age, education, perceived health, triglyceride, blood pressure, BMI, smoking, physical activity, snus, alcohol, nutrition and family history. Analysis was conducted in two steps. Firstly, factor analysis was used to find candidate variables; and secondly, logistic regression was employed to quantify the influence of the candidate variables. Bootstrap estimations validated the models.

Results

In total, 29 937 individuals were included in the analysis. Alcohol and perceived health were excluded due to the results of the factor analysis and the logistic regression respectively. Six risk equations indicating different impacts of different risk factors on the transition to a worse glucose state were estimated and validated. The impact of each risk factor depended on the starting or ending pre-diabetes state. High levels of triglyceride, hypertension and high BMI were the strongest risk factors to transit to a worsened glucose state.

Conclusions

The equations could be used to identify individuals with increased risk to develop any of the three pre-diabetic states or T2D and to adapt prevention strategies.

Adolescent build plotting on body composition chart and the type of diabetes mellitus

Although the prevalence of type 2 diabetes is increasing, there are cases difficult to categorize into certain type in pediatric diabetic patients. The aims of this study were to detect and choose a proper treatment modality for atypical cases of diabetes mellitus, using the body composition chart. We conducted a retrospective study from August 2005 to 2012 with patients who visited Konkuk University Medical Center, and were diagnosed with diabetes mellitus. The medical records were reviewed for the anthropometric data and indices of body composition. The subjects were grouped by the type of diabetes and gender. We constructed a body composition chart plotting fat free mass index and fat mass index (FMI). Body mass index and all body composition indices were higher in type 2 diabetes, in each gender in analysis with Mann-Whitney test. Significant determinant of diabetes type was revealed as FMI and contributing factors on FMI were analyzed with regression analysis. Six atypical cases were identified by a body composition chart including non-obese type 2 diabetes showing suboptimal growth with lower BMI related to relatively lower insulin secretion and type 1 diabetes with insulin resistance resulted from obesity. Body composition chart analysis might be useful in characterization of diabetes type and detection of atypical cases and early adjustment of diabetes management strategy.

Influence of gastrectomy for stomach cancer on type 2 diabetes mellitus for patients with a body mass index less than 30 kg/m(2)

Purpose

The impressive effect of LRYGBP on mildly obese patients (30 kg/m² < BMI < 35 kg/m²) with T2DM raises the argument for lowering the threshold for surgical intervention to non-obesity (BMI < 30 kg/m²). The goal of this study was to evaluate the effect of gastrectomy on non-obese patients with T2DM and what preoperative clinical factors are associated with postoperative long term improvement.

Methods

In this retrospective review, we analyzed the change in diabetic status in 75 patients with gastric cancer undergoing three different gastrectomies in a single institution from June 1996 to September 2009. Pre- and postoperative fasting blood glucose, serum hemoglobin A1c and diabetic medication requirements were compared. The demographic data and other biochemical markers were also collected.

Results

At an average follow-up of 35.0 ± 25.9 months, we collected the data of 75 patients and evaluated the change of diabetes status. There was no resolution of diabetes in Billroth-I (B-I) group, and 45.2% of patients improved whereas the resolution rate of Billroth-II (B-II) and RY group was 22.2% and 23.5% and 85.2% and 88.2%, respectively. The improvement rate of diabetes mellitus (DM) status was 7.46 times higher in B-II than in B-I patients. The method of reconstruction is the most powerful factor and severity and duration of diabetes showed significant clinical factors for the improvement of the disease after surgery.

Conclusion

According to these results, foregut-bypass procedure may improve the type 2 DM better than can be explained by the effect of weight loss only. Diabetes remission is significantly higher in those with duration of diabetes less than 5 years.

Efficacy and safety of vildagliptin/pioglitazone combination therapy in Korean patients with diabetes

AIM: To assess the efficacy and safety of vildagliptin/pioglitazone combination therapy in Korean patients with type 2 diabetes mellitus (T2DM).

METHODS: This was a post hoc analysis in Korean patients, from a 24-wk, randomized, active-controlled, double-blind, parallel-group, multicenter study. Eligible patients were aged between 18 and 80 years, drug naive, and had been diagnosed with T2DM [hemoglobin A_1c (HbA_1c): 7.5%-11.0% and fasting plasma glucose (FPG): < 270 mg/dL (< 15 mmol/L)]. Patients were randomized (1:1:1:1) to receive the vildagliptin/pioglitazone combination at 100/30 mg q.d. (high-dose) or 50/15 mg q.d. (low-dose), vildagliptin 100 mg q.d., or pioglitazone 30 mg q.d. monotherapies. The primary outcome measure was change in HbA_1c from baseline to endpoint.

RESULTS: The distribution of baseline demographic and clinical parameters was well balanced between treatment groups. The overall mean age, body mass index, HbA_1c, FPG, and duration of disease were 50.8 years, 24.6 kg/m², 8.6%, 10.1 mmol/L, and 2.2 years, respectively. Adjusted mean changes (± standard error) in HbA_1c from baseline (~8.7%) to week 24 endpoint were -2.03% ± 0.16% (high-dose, N = 34), -1.88% ± 0.15% (low-dose, N = 34), -1.31% ± 0.21% (vildagliptin, N = 36), and -1.52% ± 0.16% (pioglitazone, N = 36). The high-dose combination therapy demonstrated greater efficacy than monotherapies [vildagliptin (P = 0.029) and pioglitazone (P = 0.027)]. Percentage of patients achieving HbA_1c < 7% and ≤ 6.5% was the highest in the high-dose group (76% and 68%) followed by low-dose (58% and 47%), vildagliptin (59% and 37%), and pioglitazone (53% and 28%) groups. The overall incidence of adverse events was comparable.

CONCLUSION: In Korean patients, first-line treatment with high-dose combination therapy improved glycemic control compared to pioglitazone and vildagliptin monotherapies, consistent with results published for the overall study population.

1,5-Anhydroglucitol reflects postprandial hyperglycemia and a decreased insulinogenic index, even in subjects with prediabetes and well-controlled type 2 diabetes

To examine the serum 1,5-anhydroglucitol (AG) levels as a surrogate measure of postprandial hyperglycemia (PPH) and insulin secretion in a wide range of hyperglycemia, we compared the relationship between the glycemic index during a 75g oral glucose tolerance test (OGTT) and the insulinogenic index and 1,5-AG according the overall glycemic state. Fasting serum 1,5-AG levels were lower in the type 2 diabetic group (18.0+/-7.0microg/mL) than in the normal glucose tolerance (NGT, 25.4+/-4.0microg/mL), impaired fasting glucose (IFG, 24.6+/-6.2microg/mL), and impaired glucose tolerance (IGT, 22.1+/-6.2microg/mL) groups and were clearly correlated with glycemic values from the OGTT. 120-min post-challenge plasma glucose (PPG(120)) emerged as an independent predictor for 1,5-AG levels after multiple linear regression analysis (beta=-0.554, P<0.001). Additionally, 1,5-AG levels were significantly correlated with PPG(120) in each quartile of A1C, and the coefficients increased with higher A1C quartiles. Subjects with low 1,5-AG levels had both increased insulin resistance and decreased insulin secretion. Decreased 1,5-AG levels are closely correlated with PPH and decreased insulin secretion capacity across a wide range of glycemia, even in relatively well-controlled diabetes.

Ethnic difference in patients with type 2 diabetes mellitus in inter-East Asian populations: a systematic review and meta-analysis focusing on fasting serum insulin

AIMS

To investigate ethnic difference by focusing on fasting serum insulin (FSI) in inter-East Asian patients with type 2 diabetes.

METHODS

Data sources included MEDLINE and EMBASE between 2001 and 2006. We conducted a search for articles containing mean or geometric mean values of FSI in East Asian patients with type 2 diabetes. The Monte Carlo method was used for simulation of the mean and standard deviation of individual measures in each ethnic group; calculation of the median ratio and 95% confidence interval of individual measures between ethnic groups.

RESULTS

The initial search identified a total of 996 journal articles. After reviewing the titles and abstracts of these articles, 201 studies were selected for further screening and the complete papers on these studies were then reviewed in detail. Of these, seven articles fully met our pre-determined criteria and were included in the meta-analysis. Results of the meta-analysis revealed that FSI level is significantly lower in Japanese patients than in Korean and Chinese patients.

CONCLUSIONS

Results from our review of ethnic differences in dietary habit in the inter-East Asian population suggested that difference in dietary component was one of the most influential factors for the ethnic difference.