Drug treatment of non-insulin-dependent diabetes mellitus in the 1990s. Achievements and future developments

Diabetic Pneumopathy- A Novel Diabetes-associated Complication: Pathophysiology, the Underlying Mechanism and Combination Medication

BACKGROUND

The "diabetic lung" has been identified as a possible target organ in diabetes, with abnormalities in ventilation control, bronchomotor tone, lung volume, pulmonary diffusing capacity, and neuroadrenergic bronchial innervation.

OBJECTIVE

This review summarizes studies related to diabetic pneumopathy, pathophysiology and a number of pulmonary disorders including type 1 and type 2 diabetes.

METHODS

Electronic searches were conducted on databases such as Pub Med, Wiley Online Library (WOL), Scopus, Elsevier, ScienceDirect, and Google Scholar using standard keywords "diabetes," "diabetes Pneumopathy," "Pathophysiology," "Lung diseases," "lung infection" for review articles published between 1978 to 2023 very few previous review articles based their focus on diabetic pneumopathy and its pathophysiology.

RESULTS

Globally, the incidence of diabetes mellitus has been rising. It is a chronic, progressive metabolic disease. The "diabetic lung" may serve as a model of accelerated ageing since diabetics' rate of respiratory function deterioration is two to three-times higher than that of normal, non-smoking people.

CONCLUSION

Diabetes-induced pulmonary dysfunction has not gained the attention it deserves due to a lack of proven causality and changes in cellular properties. The mechanism underlying a particular lung illness can still only be partially activated by diabetes but there is evidence that hyperglycemia is linked to pulmonary fibrosis in diabetic people.

Bioprospecting of Sea Anemones (Cnidaria, Anthozoa, Actiniaria) for β-Defensin-like α-Amylase Inhibitors

Diabetes mellitus is one of the most serious diseases of our century. The drugs used are limited or have serious side effects. The search for new sources of compounds for effective treatment is relevant. Magnificamide, a peptide inhibitor of mammalian α-amylases, isolated from the venom of sea anemone Heteractis magnifica, can be used for the control of postprandial hyperglycemia in diabetes mellitus. Using the RACE approach, seven isoforms of magnificamide were detected in H. magnifica tentacles. The exon-intron structure of magnificamide genes was first established, and intron retention in the mature peptide-encoding region was revealed. Additionally, an α-amylase inhibitory domain was discovered in the mucins of some sea anemones. According to phylogenetics, sea anemones diverge into two groups depending on the presence of β-defensin-like α-amylase inhibitors and/or mucin-inhibitory domains. It is assumed that the intron retention phenomenon leads to additional diversity in the isoforms of inhibitors and allows for its neofunctionalization in sea anemone tentacles. Bioprospecting of sea anemones of the order Actiniaria for β-defensin-like α-amylase inhibitors revealed a diversity of inhibitory sequences that represents a starting point for the design of effective glucose-lowering drugs.

Vernonia amygdalina stimulates muscle glucose uptake and modulates redox activities and functional chemistry in oxidative hepatic injury

The ethyl acetate, ethanol, and aqueous extracts sequentially obtained from the leaves of Vernonia amygdalina were investigated for their antidiabetic and antioxidant protective effect in oxidative hepatic injury. The extracts showed significant (p < .05) free radical scavenging and reducing power activities. They significantly (p < .05) elevated reduced glutathione level, superoxide dismutase, and catalase activities, with concomitant depletion of malondialdehyde level. The ethanol and aqueous extracts caused a removal of oxidative-included chemical functional group at 1,500-1,200 (amide II)/cm region, with the inclusion of a functional group at 3,000-2,800 (carboxylic acid)/cm region. The extracts significantly (p < .05) inhibited the activities of α-glucosidase and α-amylase and stimulated glucose uptake in rat muscles. Gas chromatography-mass spectrometric (GC-MS) analysis revealed phytol as the predominant compound, with ethanol having the highest concentration. Based on the IC₅₀ values, the ethanol extract exhibited the best activities, followed by the ethyl acetate extract, while the aqueous extract was the least. These results suggest the antioxidative and antidiabetic properties of V. amygdalina as evident by their modulation of antioxidant biomarkers and oxidative-induced chemistry changes and stimulate muscle glucose uptake. PRACTICAL APPLICATIONS: Vernonia amygdalina (bitter leaf) is amongst the common leafy vegetables in West Africa reported for its various medicinal and nutritional properties. It is utilized as a food ingredient as well as supplement for the treatment and management of type 2 diabetes. The ability of its extracts to stimulate glucose uptake and protect against diabetic-induced changes in the chemical functional groups of the liver gives more credence to its reported antidiabetic properties. Being a common leafy vegetable, V. amygdalina can be a cheap source of nutraceutical for the treatment and management of type 2 diabetes and its complications.

Sinapic Acid Ameliorates the Progression of Streptozotocin (STZ)-Induced Diabetic Nephropathy in Rats via NRF2/HO-1 Mediated Pathways

Diabetic neuropathy (DN) is a complicated inauspicious outcome of diabetes, like other abnormalities of diabetes the cause of DN is still vague and it may be the result of various pathological conditions leading up to end-stage renal failure. The present study examines the efficacy of sinapic acid (SA) in streptozotocin (STZ)-induced DN nephropathy and the linked pathway. Twenty-four rats were equally divided randomly into four categories: Normal control (NC), STZ, STZ + SA 20 mg/kg bw, and STZ + SA 40 mg/kg bw. After 8 weeks they were evaluated for ratio of renal index, the fasting blood glucose (FBG), blood urea nitrogen (BUN), 24 h urea protein, serum creatinine (SCr), reduced glutathione peroxidase (GPx), superoxide dismutase (SOD), lipid peroxidation (MDA), tumor necrosis factor α (TNFα), interleukin (IL)-6, as well as lipid profile total cholesterol (TC), total triglycerides (TG), very low density lipoprotein (VLDL), low density lipoprotein (LDL), and high density lipoprotein (HDL) levels. Additionally, histomorphology and ultrastructure of the kidneys were also assessed. Protein expression levels of transforming growth factor-β1 (TGF-β1), nuclear factor erythroid 2-related factor 2 (Nrf2), heme oxygenase-1 (HO-1), IκBα protein (IkBα), anti-apoptotic protein BCl2, nuclear factor kappa B (NF-kB), and Bax were examined. We observed that SA 20 mg/kg bw and 40 mg/kg bw pretreatment significantly and dose-dependently upregulated the protein expression of HO-1, Nrf2, IKBα, and Bcl-2 but downregulated the protein expression of NF-κB, proposing that the nephroprotective mechanism of SA is due to its antioxidant and anti-inflammatory activity; SA prevents the release of cytokines and inflammatory markers (TNFα and IL-6), upregulates antioxidant defense enzymes, and reduces lipid peroxidation, as well as nitric oxide, and anti-apoptotic activity, which may be influenced by the regulation of TNF-α, IL-6, Bcl-2, NF-kB, and BaX via the Nrf2/HO-1 pathway in STZ induced DN. Thus, our results suggest that SA ameliorates the development of STZ-induced DN in rats via NRF2/HO-1 mediated pathways. Further comprehensive studies are required for complete elucidation of the fundamental mechanisms.

Galangin controls streptozotocin-caused glucose homeostasis and reverses glycolytic and gluconeogenic enzyme changes in rats

Galangin is a natural compound with anticancer, anti-inflammatory, and antioxidant properties. However, the ameliorating effect of streptozotocin (STZ)-induced glucose homeostasis has not yet been evaluated. Hence, this study was aimed at exploring the role of galangin in STZ-induced glucose homeostasis, glycolytic and gluconeogenic enzyme changes in rats. STZ-treated rats were characterised by increased plasma glucose and glycosylated haemoglobin and decreased plasma insulin and haemoglobin compared with the normal cage. Administration of galangin to STZ-treated rats effectively reversed the adverse biochemical and haematological changes. Significant alterations in glycogen levels as well as glycolytic and gluconeogenic enzyme activities were witnessed in STZ-treated rats, and these changes were reversed upon treatment with galangin. The compound exerts potent anti-hyperglycemic effects by regulating the glucose homeostasis and reversing the glycolytic and gluconeogenic enzyme changes in rats. However, the exact mechanism through which galangin prevents diabetic complications needs to be studied in detail.

Biosynthesis of the anti-diabetic metabolite montbretin A: glucosylation of the central intermediate mini-MbA

Type 2 diabetes (T2D) affects over 320 million people worldwide. Healthy lifestyles, improved drugs and effective nutraceuticals are different components of a response against the growing T2D epidemic. The specialized metabolite montbretin A (MbA) is being developed for treatment of T2D and obesity due to its unique pharmacological activity as a highly effective and selective inhibitor of the human pancreatic α-amylase. MbA is an acylated flavonol glycoside found in small amounts in montbretia (Crocosmia × crocosmiiflora) corms. MbA cannot be obtained in sufficient quantities for drug development from its natural source or by chemical synthesis. To overcome these limitations through metabolic engineering, we are investigating the genes and enzymes of MbA biosynthesis. We previously reported the first three steps of MbA biosynthesis from myricetin to myricetin 3-O-(6'-O-caffeoyl)-glucosyl rhamnoside (mini-MbA). Here, we describe the sequence of reactions from mini-MbA to MbA, and the discovery and characterization of the gene and enzyme responsible for the glucosylation of mini-MbA. The UDP-dependent glucosyltransferase CcUGT3 (UGT703E1) catalyzes the 1,2-glucosylation of mini-MbA to produce myricetin 3-O-(glucosyl-6'-O-caffeoyl)-glucosyl rhamnoside. Co-expression of CcUGT3 with genes for myricetin and mini-MbA biosynthesis in Nicotiana benthamiana validated its biological function and expanded the set of genes available for metabolic engineering of MbA.

Effects of endurance training on hippocampus DJ-1, cannabinoid receptor type 2 and blood glucose concentration in diabetic rats

AIMS/INTRODUCTION

To investigate the effect of endurance training on hippocampus DJ-1 and cannabinoid receptor type 2 (CB2 ) protein and blood glucose concentration in diabetic rats.

MATERIALS AND METHODS

A total of 32 rats were randomly divided into diabetic (D), diabetic and exercise (DE), exercise (E) and control (C) groups. The endurance training was carried out five times per week for 6 weeks. The hippocampus DJ-1 and CB2 were measured using an enzyme-linked immunosorbent assay method.

RESULTS

The level of DJ-1 in the D group was significantly higher than the other groups (P ≤ 0.01). However, the level of DJ-1 was not significantly different between the C, E and DE groups. In addition, the level of CB2 was significantly lower in the D group compared with the other groups (P ≤ 0.01). Blood glucose was significantly higher in the D group compared with the DE group (P ≤ 0.05). Furthermore, a significant positive correlation between the level of DJ-1 and blood glucose was observed (r = 0.67, P ≤ 0.001). There was also a significant inverse correlation between the level of CB2 and blood glucose (r = -0.77, P ≤ 0.001).

CONCLUSIONS

The results of this study suggest that the level of DJ-1 and CB2 might change in response to diabetes, and regular aerobic exercise could mediate the effect of DJ-1 and CB2 on diabetes-induced neurodegenerative diseases.

Zuo Gui Wan Alters Expression of Energy Metabolism Genes and Prevents Cell Death in High-Glucose Loaded Mouse Embryos

Background

Zuo Gui Wan (ZGW) is a classic formula in traditional chinese medicine (TCM). Previous studies have shown that it is beneficial for impaired glucose tolerance (IGT) of adults and the offspring as well. This study aimed to understand the molecular mechanisms of the efficacy of ZGW on IGT.

Methods

We used high-glucose loaded 2-cell stage mouse embryos as a model and took advantage of single-cell RNA sequencing technology to analyze the transcriptome of the model with or without ZGW. Differential gene expression analysis was performed with DESeq2.

Results

High glucose can downregulate genes in the ribosome pathway, while ZGW can reverse this inhibition and as a result prevent embryo cell death caused by high glucose. Furthermore, high glucose can affect sugar metabolism and influence mitochondrial function, but ZGW can promote sugar metabolism via the tricarboxylic acid cycle mainly through upregulating the genes in the respiratory chain and oxidative phosphorylation.

Conclusions

ZGW had a protective effect on embryonic cell death caused by glucose loading. The reversion of inhibition of ribosome pathway and regulation of mitochondrial energy metabolism are main effects of ZGW on high-glucose loaded embryos. This research not only revealed the global gene regulation changes of high glucose affecting 2-cell stage embryos but also provided insight into the potential molecular mechanisms of ZGW on the IGT model.

Salutary potential of ethanolic extract of avocado fruit on anomalous carbohydrate metabolic key enzymes in hepatic and renal tissues of hyperglycaemic albino rats

OBJECTIVE

To assess the beneficial potential of ethanolic extract of avocado fruit on abnormal carbohydrate metabolic key enzymes in hepatic and renal tissues in streptozotocin (STZ) induced hyperglycemic albino rats.

METHODS

Twenty-four male albino rats were randomly divided into four groups with six in each group by simple random sampling method. Group 1 as control rats; Group 2 as STZ induced diabetic rats; Group 3 as diabetic rats treated with avocado fruit extract (AFE), 300 mg/kg as aqueous suspension orally for 30 days; Group 4 as diabetic rats treated with gliclazide (5 mg/kg) in aqueous solution orally for 30 days. The rats were fasted overnight and sacrificed by cervical dislocation and the blood was collected for various biochemical analysis and excision of hepatic and kidney were done for histological analysis. Levels of fasting blood glucose, plasma insulin and glycosylated hemoglobin were estimated. The activities of key enzymes in carbohydrate metabolism such as hexokinase, pyruvate kinase, glucose-6- phosphatase, fructose-1, 6-bisphosphatase, glucose-6-phosphate dehydrogenase, glycogen synthase and glycogen phosphorylase were assayed by standard methods described in the methodology.

RESULTS

Oral administration of AFE significantly improved the altered levels of blood glucose, plasma insulin, glycosylated hemoglobin, and modulated the activities of carbohydrate metabolizing enzymes (P<0.05, respectively). The glycogen content in hepatic tissues was significantly increased in diabetic rats treated with AFE (P<0.05, respectively).

CONCLUSION

AFE plays a pivotal role to maintain normoglycemia in diabetes by modulating the activities of carbohydrate metabolic enzymes.

In vivo assessment of antidiabetic and antioxidative activity of natural phytochemical isolated from fruit-pulp of Eugenia jambolana in streptozotocin-induced diabetic rats

OBJECTIVES

Eugenia jambolana (E. jambolana) is well known for its antidiabetic potential. The aim of the present study was to investigate the antidiabetic and antioxidative effect of an active compound (FIIc) isolated from fruit-pulp of E. jambolana in streptozotocin (45 mg/kg body weight)-induced diabetic rats.

METHODS

FIIc was isolated from the crude aqueous extract of fruit-pulp by ion-exchange column chromatography and high-performance column chromatography. Detailed UV, NMR, and IR spectra suggested that FIIc is α-hydroxy succinamic acid. FIIc was orally administered to diabetic rats at a dose of 10, 15, and 20 mg/kg body weight (mg/kg bwt.) to determine its effective dose. Thereafter, effective dose was administered to 8 weeks to determine its antidiabetic and antioxidative activity by estimation of glycemic index, lipid profile, key enzymes of carbohydrate metabolism, and oxidative stress parameters.

RESULTS

Administration of 15 mg/kg dose daily for 8 weeks led to significant (P < 0.001) fall in fasting blood glucose. Treatment with FIIc (15 mg/kg bwt.) showed significant improvement (P < 0.001) in all the biochemical parameters.

DISCUSSION

The results demonstrate that FIIc possesses significant antidiabetic and antioxidative activity.

Antidiabetic, antihyperlipidemic and antioxidant properties of ethanol extract of Grewia asiatica Linn. bark in alloxan-induced diabetic rats

BACKGROUND

Inspite of introduction of oral hypoglycemic agents, diabetes and its related complications remains to be a major clinical problem. The aim of this study was to investigate the antidiabetic, antihyperlipidemic and antioxidant activities of Grewia asiatica (Linn) stem bark in alloxan induced diabetic rats.

METHODS

Diabetes was induced by a single dose of intraperitoneal injection of alloxan (110 mg/kg) in Norwegian Long Evans rats. Ethanol extract of barks from Grewia asiatica (GAE 200 and 400 mg/kg) and metformin (150 mg/kg) were orally administered once daily for 15 days. Blood glucose levels and body weights of rats were measured on 0, 5, 10 and 15 days of oral treatment. At the end of the experiment the rats were sacrificed and blood sample were collected for the measurement of total cholesterol (TC), triglycerides (TG), very low density lipoproteins (VLDL), low density lipoproteins (LDL), high density lipoproteins (HDL), SGOT and CK-MB. Analysis of liver glycogen content and histopathlogy of pancreas were carried out. In vitro DPPH free radical scavenging activity, total phenolic and total flavonoid content of GAE were also determined.

RESULTS

After 15 days of oral administration of GAE at doses of 200 and 400 mg/kg increased survival rate and showed a significant attenuation in blood glucose and lipid profile in diabetic rats. Oral ingestion of GAE significantly reduced the SGOT and CK-MB levels and restored liver glycogen content when compared to diabetic control. The effects of GAE on SGOT, CK-MB and liver glycogen content were dose-dependent. The diabetic rats treated with GAE showed significant improvement in normal cellular population size of islets. Phytochemical screening of GAE revealed the presence of flavonoid, steroid, tannin and phenolic compounds. Total phenolic content was 44.65 ± 3.17 mg of gallic acid equivalent per gm of GAE extract and the total flavonoid content was 39.11 ± 4.65 mg of quercetin equivalent per gm of GAE extract. In DPPH scavenging assay, IC50 values of GAE and ascorbic acid were found 76.45 and 12.50 μg/ml, respectively.

CONCLUSION

We demonstrated that ethanol extract of barks from G. asiatica possess glucose, lipid lowering efficacy, restored liver glycogen and protects pancreas from oxidative damage in alloxan-induced diabetic rats. Thus, the results of the present study provide a scientific rationale for the use of G. asiatica in the management of diabetes and its related complications.

Influence of metformin intake on the risk of bladder cancer in type 2 diabetes patients

AIM

The aim of this study was to look at the influence of metformin intake and duration, on urinary bladder cancer (UBC) risk, with sulfonylurea (SU) only users as control using a new user design (inception cohort).

METHODS

We conducted a retrospective cohort study using data from the UK Clinical Practice Research Datalink (CPRD) including all patients with at least one prescription of oral anti-diabetic drugs (ADD) and/or insulin. The risk of UBC in different groups of ADD users (metformin alone (one), metformin in combination (two) with other ADD medication (glinides, glitazones, DPP-4-inhibitors, SUs, insulin or more than one combination), all metformin users (1 + 2) was compared with SU only users using Cox proportional hazards models. The estimates were adjusted for age, gender, smoking status, BMI and diabetes duration.

RESULTS

The inception cohort included 165,398 participants of whom 132,960 were metformin users and 32,438 were SU only users. During a mean follow-up time of more than 5 years 693 patients developed UBC, 124 of the control group and 461 of the all metformin users. There was no association between metformin use and UBC risk (HR = 1.12, 95% CI 0.90, 1.40) compared with SU only users, even after adjustment for diabetes duration (HR = 1.13, 95% CI 0.90, 1.40). We found a pattern of decreasing risk of UBC with increasing duration of metformin intake, which was statistically not significant.

CONCLUSION

Metformin has no influence on the risk of UBC compared with SU in type 2 diabetes patients using a new user design.

Herbal therapy: A review of emerging pharmacological tools in the management of diabetes mellitus in Africa

BACKGROUND

Diabetes mellitus is a chronic physiological glucose metabolic disorder. It has affected millions of people all over the world thereby having a significant impact on quality of life. The management of diabetes includes both nonpharmacological and conventional interventions. Drawbacks in conventional therapy have led to seeking alternative therapy in herbal medicine. Therefore, the need to review, elucidate and classify their mode of action in therapy for diabetes disease arises.

MATERIALS AND METHODS

Comprehensive literature reports were used to review all conventional agents and herbal therapy used in the management of diabetes. An online database search was conducted for medicinal plants of African origin that have been investigated for their antidiabetic therapeutic potentials.

RESULTS

The results showed that of the documented sixty five plants used, fourteen inhibit intestinal absorption of glucose, three exhibit insulin-mimetic properties, seventeen stimulate insulin secretion from pancreatic beta cells, twelve enhance peripheral glucose uptake, one promotes regeneration of beta-cell of islets of Langerhans, thirteen ameliorate oxidative stress and twenty induces hypoglycemic effect (mode of action is still obscure). Thirteen of these plants have a duplicate mode of actions while one of them has three modes of actions. These agents have a similar mechanism of action as the conventional drugs.

CONCLUSION

In conclusion, antidiabetic activities of these plants are well established; however, the molecular modulation remains unknown. It is envisaged that the use of herbal therapy will promote good health and improve the status of diabetic patients.

Structure Activity Related, Mechanistic, and Modeling Studies of Gallotannins containing a Glucitol-Core and α-Glucosidase

Gallotannins containing a glucitol core, which are only produced by members of the maple (Acer) genus, are more potent α-glucosidase inhibitors than the clinical drug, acarbose. While this activity is influenced by the number of substituents on the glucitol core (e.g. more galloyl groups leads to increased activity), the mechanisms of inhibitory action are not known. Herein, we investigated ligand-enzyme interactions and binding mechanisms of a series of 'glucitol-core containing gallotannins (GCGs)' against the α-glucosidase enzyme. The GCGs included ginnalins A, B and C (containing two, one, and one galloyl/s, respectively), maplexin F (containing 3 galloyls) and maplexin J (containing 4 galloyls). All of the GCGs were noncompetitive inhibitors of α-glucosidase and their interactions with the enzyme were further explored using biophysical and spectroscopic measurements. Thermodynamic parameters (by isothermal titration calorimetry) revealed a 1:1 binding ratio between GCGs and α-glucosidase. The binding regions between the GCGs and α-glucosidase, probed by a fluorescent tag, 1,1'-bis(4-anilino-5-napththalenesulfonic acid, revealed that the GCGs decreased the hydrophobic surface of the enzyme. In addition, circular dichroism analyses showed that the GCGs bind to α-glucosidase and lead to loss of the secondary α-helix structure of the protein. Also, molecular modeling was used to predict the binding site between the GCGs and the α-glucosidase enzyme. This is the first study to evaluate the mechanisms of inhibitory activities of gallotannins containing a glucitol core on α-glucosidase.

Antihyperglycemic and antioxidant activity of Clitorea ternatea Linn. on streptozotocin-induced diabetic rats

Ethanol extract of Clitorea ternatea Linn. (EECT) was evaluated for its antihyperglycemic and antioxidative activity in normal and streptozotocin-induced diabetic rats. Antihyperglycemic activity of EECT was studied in normal fasted and glucose fed hyperglycemic and epinephrine induced hyperglycemic rats by estimating fasting serum glucose (FSG) by glucose oxidisae or peroxidase enzymatic method. Antioxidant activity of EECT was studied by assaying lipid peroxide/Thiobarbituric acid reactive substances (TBARS), superoxide dismutase (SOD), total nitric oxide, catalase (CAT) and glutathione levels in diabetic rats. The EECT (200 and 400 mg/kg) showed significant antihyperglycemic activity by decreasing FSG in all hyperglycemic models except epinephrine induced hyperglycemic rats; in which improvement in FSG was observed only with EECT in 400 mg/kg dose, whereas significant decrease in TBARS (P < 0.001), nitric oxide (P < 0.001) and significant increase in SOD (P < 0.001), CAT (P < 0.01) and reduced glutathione levels (P < 0.001) was observed in animals treated with EECT (200 and 400 mg/kg) compared to diabetic control group. The results indicated that EECT has remedial effects on hyperglycemia and oxidative stress in diabetic rats.

Comparison of acarbose and voglibose in diabetes patients who are inadequately controlled with basal insulin treatment: randomized, parallel, open-label, active-controlled study

We studied the efficacy and safety of acarbose in comparison with voglibose in type 2 diabetes patients whose blood glucose levels were inadequately controlled with basal insulin alone or in combination with metformin (or a sulfonylurea). This study was a 24-week prospective, open-label, randomized, active-controlled multi-center study. Participants were randomized to receive either acarbose (n=59, 300 mg/day) or voglibose (n=62, 0.9 mg/day). The mean HbA1c at week 24 was significantly decreased approximately 0.7% from baseline in both acarbose (from 8.43% ± 0.71% to 7.71% ± 0.93%) and voglibose groups (from 8.38% ± 0.73% to 7.68% ± 0.94%). The mean fasting plasma glucose level and self-monitoring of blood glucose data from 1 hr before and after each meal were significantly decreased at week 24 in comparison to baseline in both groups. The levels 1 hr after dinner at week 24 were significantly decreased in the acarbose group (from 233.54 ± 69.38 to 176.80 ± 46.63 mg/dL) compared with the voglibose group (from 224.18 ± 70.07 to 193.01 ± 55.39 mg/dL). In conclusion, both acarbose and voglibose are efficacious and safe in patients with type 2 diabetes who are inadequately controlled with basal insulin. (ClinicalTrials.gov number, NCT00970528).

Effect of iridoid glucoside on plasma lipid profile, tissue fatty acid changes, inflammatory cytokines, and GLUT4 expression in skeletal muscle of streptozotocin-induced diabetic rats

The present study was designed to examine the antihyperlipidaemic potential of iridoid glucoside isolated from Vitex negundo leaves in STZ-induced diabetic rats. The levels of cholesterol (TC), triglycerides, lipoproteins, free fatty acids, phospholipids, fatty acid composition, proinflammatory cytokines, muscle glycogen content, and glucose transporter 4 (GLUT4) expression were estimated in control and diabetic rats. Oral administration of iridoid glucoside at a dose of 50 mg/kg body weight per day to STZ-induced diabetic rats for a period of 30 days resulted in a significant reduction in plasma and tissue (liver and kidney) cholesterol, triglycerides, free fatty acids, and phospholipids. In addition, the decreased plasma levels of high-density lipoprotein-cholesterol and increased plasma levels of low density lipoprotein- and very low density lipoprotein-cholesterol in diabetic rats were restored to near normal levels following treatment with iridoid glucoside. The fatty acid composition of the liver and kidney was analyzed by gas chromatography. The altered fatty acid composition in the liver and kidney of diabetic rats was also restored upon treatment with iridoid glucoside. Moreover, the elevated plasma levels of proinflammatory cytokines and decreased levels of muscle glycogen and GLUT4 expression in the skeletal muscle of diabetic rats were reinstated to their normal levels via enhanced secretion of insulin from the remnant β cells of pancreas by the administration of iridoid glucoside. The effect produced by iridoid glucoside on various parameters was comparable with that of glibenclamide, a well-known antihyperglycemic drug.

An evidence-based systematic review of vanadium by the Natural Standard Research Collaboration

An evidence-based systematic review of vanadium by the Natural Standard Research Collaboration consolidates the safety and efficacy data available in the scientific literature using a validated, reproducible grading rationale. This article includes written and statistical analysis of clinical trials, plus a compilation of expert opinion, folkloric precedent, history, pharmacology, kinetics/dynamics, interactions, adverse effects, toxicology, and dosing.

Evaluation of vitamin B12 effects on DNA damage induced by pioglitazone

Pioglitazone is a prototype of thiazolidinediones, used for the treatment of type 2 diabetes mellitus. Previous studies suggest that pioglitazone might cause DNA damage by generation of oxidative species. In this study, we investigated the mutagenic effects of pioglitazone using sister chromatid exchanges (SCEs), and chromosomal aberrations (CAs) assays in cultured human lymphocytes. In addition, oxidative DNA damage was evaluated in cells culture by measuring 8-hydroxy-2'-deoxyguanosine (8-OH-dG) marker. We also investigated the possible protective effects of vitamin B12, which is associated with DNA repair, on DNA damage induced by pioglitazone. Treatment of the human lymphocytes with pioglitazone (100μM) significantly increases the frequency of SCEs and CAs (p<0.01). In addition, significant elevation in 8-OH-dG release from lymphocytes was observed after treatment with pioglitazone (p<0.01). On the other hand, pretreatment of cultures with vitamin B12 (13.5μg/ml) protected lymphocytes from the genotoxic effect of pioglitazone. Therefore, we conclude that pioglitazone is genotoxic, and it induces chromosomal and oxidative DNA damage in cultured lymphocytes and this toxicity is prevented by pretreatment with vitamin B12.

Antihyperglycemic and antioxidative effects of the hydro-methanolic extract of the seeds of Caesalpinia bonduc on streptozotocin-induced diabetes in male albino rats

BACKGROUND

No satisfactory effective treatment is available yet to cure diabetes mellitus. Though, synthetic drugs are used but there are several drawbacks. The attributed antihyperglycemic effects of many traditional plants are due to their ability for the management of diabetes mellitus.

MATERIALS AND METHODS

A hydromethanolic extract was administered orally at a dose of 250 mg/kg of body weight per day for 21 days. Its effects on the fasting blood glucose (FBG) level, activities of key carbohydrate metabolic enzymes like hexokinase, glucose-6-phosphatase, and glucose-6-phosphate dehydrogenase, and antioxidant enzymes like catalase and superoxide dismutase along with the effect on the lipid peroxidation level in hepatic tissues were measured. Glycogen levels were also assessed in hepatic and skeletal muscles and some toxicity parameters, such as serum glutamate oxaloacetate transaminase, glutamate pyruvate transaminase, and alkaline phosphates activities were measured.

RESULTS

Treatment of the hydromethanolic extract of the seeds of Caesalpinia bonduc resulted in a significant (P < 0.05) recovery in the activities of carbohydrate metabolic enzymes along with correction in FBG and glycogen levels as compared with the untreated diabetic group. The extract also resulted in a significant (P < 0.05) recovery in the activities of toxicity assessment enzyme parameters. Activities of antioxidant enzymes like catalase and superoxide dismutase along with the lipid peroxidation levels were also recovered significantly (P < 0.05) after the treatment of the extract. The corrective effects produced by the extract were compared with the standard antidiabetic drug, glibenclamide.

CONCLUSION

Our findings provide that the extract shows possible antihyperglycemic and antioxidative activities.

Effect of iridoid glucoside on streptozotocin induced diabetic rats and its role in regulating carbohydrate metabolic enzymes

Vitex negundo is a medicinal plant used to treat many ailments. An active compound of iridoid glucoside was isolated from V. negundo leaves and its efficacy was investigated in streptozotocin induced diabetic rats with special reference to carbohydrate metabolizing enzymes. The optimum dose of iridoid glucoside was determined by oral glucose tolerance test. The effects of iridoid glucoside were compared with glibenclamide Administration of iridoid glucoside (50mg/kg body weight) to diabetic rats for 30 days resulted in significant reduction in the levels of plasma glucose, glycosylated hemoglobin and increase in the levels of insulin and hemoglobin. Administration of iridoid glucoside showed a significant increase in the levels of glycolytic enzymes and glycogen content and decrease in the levels of gluconeogenic enzymes in the liver of diabetic treated rats. Further, iridoid glucoside showed antihyperlipidemic activity as evidenced by significant reduction in serum total cholesterol, triglyceride, low density lipoprotein and very low density lipoprotein coupled together with elevation of high density lipoprotein in diabetic rats. A significant decrease was observed in the activities of aspartate aminotransferase, alanine aminotransferase and decrease in the levels of serum urea and creatinine in diabetic treated rats when compared to diabetic untreated rats. Treatment of iridoid glucoside alleviated body weight loss in diabetic rats. The effect produced by iridoid glucoside on various parameters was comparable to that of glibenclamide. These results indicate that iridoid glucoside possess antihyperlipidemic effect in addition to its antidiabetic effect.

Antidiabetic effect of Raphanus sativus root juice

CONTEXT

Many plants have been explored scientifically and systematically and claimed to be useful for the treatment of diabetes mellitus by various research groups worldwide. The present study is a further effort in the direction of developing a novel oral antidiabetic agent of high potential with minimal or no side effects.

OBJECTIVE

This study screened the glycemic attributes of Raphanus sativus L. (Brassicaceae) root juice in normal as well as sub- and mild-diabetic models.

MATERIALS AND METHODS

The variable doses of 100, 200, 300, and 400 mg kg(-1) body weight (bw) of the extract were administered orally to normal and streptozotocin (STZ)-induced sub- and mild-diabetic rats in order to define its glycemic potential. Glibenclamide was used as a reference drug.

RESULTS

The dose of 300 mg kg(-1)bw was identified as the most effective dose which lowers the blood glucose level (BGL) by 33.4% (p < 0.001) at 6 h during fasting blood glucose (FBG) studies in normal rats. However, the glucose tolerance test (GTT) revealed the maximum reduction of 15.9% (p < 0.001) in BGL at 3 h in normal rats with the same dose, whereas the reduction observed was by 23.8 and 28.3% (p < 0.001) in sub- and mild-diabetic rats, respectively, at the same interval of time.

DISCUSSION AND CONCLUSION

This evidence clearly indicates that Raphanus sativus root juice possesses good hypoglycemic potential coupled with antidiabetic efficacy.

Pharmacokinetics of dipeptidylpeptidase-4 inhibitors

Type 2 diabetes (T2DM) is a complex disease combining defects in insulin secretion and insulin action. New compounds have been developed for improving glucose-induced insulin secretion and glucose control, without inducing hypoglycaemia or weight gain. Dipeptidylpeptidase-4 (DPP-4) inhibitors are new oral glucose-lowering agents, so-called incretin enhancers, which may be used as monotherapy or in combination with other antidiabetic compounds. Sitagliptin, vildaglipin and saxagliptin are already on the market in many countries, either as single agents or in fixed-dose combined formulations with metformin. Other DPP-4 inhibitors, such as alogliptin and linagliptin, are currently in late phase of development. The present paper summarizes and compares the main pharmacokinetics (PK) properties, that is, absorption, distribution, metabolism and elimination, of these five DPP-4 inhibitors. Available data were obtained in clinical trials performed in healthy young male subjects, patients with T2DM, and patients with either renal insufficiency or hepatic impairment. PK characteristics were generally similar in young healthy subjects and in middle-aged overweight patients with diabetes. All together gliptins have a good oral bioavailability which is not significantly influenced by food intake. PK/pharmacodynamics characteristics, that is, sufficiently prolonged half-life and sustained DPP-4 enzyme inactivation, generally allow one single oral administration per day for the management of T2DM; the only exception is vildagliptin for which a twice-daily administration is recommended because of a shorter half-life. DPP-4 inhibitors are in general not substrates for cytochrome P450 (except saxagliptin that is metabolized via CYP 3A4/A5) and do not act as inducers or inhibitors of this system. Several metabolites have been documented but most of them are inactive; however, the main metabolite of saxagliptin also exerts a significant DPP-4 inhibition and is half as potent as the parent compound. Renal excretion is the most important elimination pathway, except for linagliptin whose metabolism in the liver appears to be predominant. PK properties of gliptins, combined with their good safety profile, explain why no dose adjustment is necessary in elderly patients or in patients with mild to moderate hepatic impairment. As far as patients with renal impairment are concerned, significant increases in drug exposure for sitagliptin and saxagliptin have been reported so that appropriate reductions in daily dosages are recommended according to estimated glomerular filtration rate. The PK characteristics of DPP-4 inhibitors suggest that these compounds are not exposed to a high risk of drug-drug interactions. However, the daily dose of saxagliptin should be reduced when coadministered with potent CYP 3A4 inhibitors. In conclusion, besides their pharmacodynamic properties leading to effective glucose-lowering effect without inducing hypoglycaemia or weight gain, DPP-4 inhibitors show favourable PK properties, which contribute to a good efficacy/safety ratio for the management of T2DM in clinical practice.

Metformin decreases IGF1-induced cell proliferation and protein synthesis through AMP-activated protein kinase in cultured bovine granulosa cells

Although its mechanism of action is still unclear, metformin is an anti-diabetic drug effective to restore cyclicity and spontaneous ovulation in women with polycystic ovary syndrome. It may also reduce the risk of cancer. We have recently shown that metformin treatment decreases steroidogenesis through AMP-activated kinase (AMPK) in granulosa cells of various species. Here, we investigated the effects and the molecular mechanisms of metformin in IGF1-induced proliferation and protein synthesis in cultured bovine granulosa cells. Treatment with metformin (10 mM) for 24 h reduced cell proliferation and the levels of cyclin D2 and E, and increased the associations cyclin D2/p21 and cyclin D2/p27 without affecting cell viability in response to IGF1 (10(-8) M). It also decreased IGF1-induced protein synthesis and phosphorylation of P70S6 kinase and ribosomal S6 protein. Interestingly, metformin treatment for 1 h decreased MAPK3/1 (ERK1/2) and P90RSK phosphorylation without affecting AKT phosphorylation in response to IGF1. Adenovirus-mediated expression of dominant-negative AMPK totally abolished the effects of metformin on cell proliferation and phosphorylation of P70S6K in response to IGF1. It also eliminated the inhibitory effects of metformin on MAPK3/1 and P90RSK phosphorylation. Taken together, our results strongly suggest that metformin reduces cell growth, protein synthesis, MAPK3/1, and P90RSK phosphorylation in response to IGF1 through an AMPK-dependent mechanism in cultured bovine granulosa cells.

Antihyperglycemic and hypolipidemic activity of aqueous extract of Cassia auriculata L. leaves in experimental diabetes

ETHNOPHARMACOLOGICAL RELEVANCE

Cassia auriculata L. (Caesalpiniaceae) is widely used from ancient period to treat diabetes mellitus. The leaves of Cassia auriculata are having potential in the development of drug for diabetes due to its antihyperglycemic and lipid-lowering activity.

AIM OF THE STUDY

The present study was to evaluate antihyperglycemic and hypolipidemic activity of aqueous extract of Cassia auriculata leaves (CLEt) in streptozotocin (STZ)-induced mild diabetic (MD) and severe diabetic (SD) rats.

MATERIALS AND METHODS

Male Albino rats were rendered diabetic by STZ (45 mg/kg, intraperitoneally). CLEt was orally administered to MD and SD rats at 100, 200 and 400 mg/kg doses for 1 day to determine antihyperglycemic activity. The 400 mg/kg dose was administered daily for 3 weeks to assess glycemic control and hypolipidemic effect.

RESULTS

CLEt showed dose dependant fall in fasting blood glucose (FBG). After 5h of extract administration at 400mg/kg dose, FBG was reduced by 13.9% and 17.4% in MD and SD rats respectively. After 3 weeks treatment, CLEt produced significant reduction in FBG and glycosylated haemoglobin (GHb) in both MD and SD rats. Serum lipid levels were reversed towards normal in extract fed MD and SD rats.

CONCLUSIONS

The results demonstrate that CLEt possesses potent antihyperglycemic and hypolipidemic activity in both MD and SD rats.

New therapeutic approaches in type 2 diabetes

Type 2 diabetes is a progressive chronic disease resulting from a dynamic interaction between defects in insulin secretion and insulin action. New molecules have recently been launched and many others are under clinical investigation. Besides classical sulfonylureas and glinides, new insulin secretagogues are now available, which target the incretin gut hormone glucagon-like peptide-1 (GLP-1). Indeed, oral incretin enhancers acting as antagonists of the enzyme DPP-4 (dipeptidylpeptidase-4), which inactivates natural GLP-1,and injectable incretin mimetics (exenatide) or analogues (liraglutide), which reproduce the actions of GLP-1 while resisting to DPP-4, represent new opportunities to stimulate insulin secretion, without increasing the risk of hypoglycaemia and weight gain. Among insulin sensitizers, metformin remains unequivocally the first drug of choice for the treatment of type 2 diabetes, whereas promising drugs as thiazolidinediones (glitazones) were recently challenged because of various safety issues. When insulin is required, insulin analogues, both short-acting and basal ones, may offer some advantages regarding better control of postprandial hyperglycaemia, reduced risk of hypoglycaemia and/or lower weight gain in patients with type 2 diabetes. Emphasis should be put on early detection and intensive management of type 2 diabetes, individualized glucose lowering treatments and goals, stepwise pharmacological strategy avoiding therapeutic inertia, and multiple cardiovascular risk--targeted approach.

Adult metformin ingestions reported to Texas poison control centers, 2000–2006

Metformin is an oral hypoglycemic agent used in the management of type 2 diabetes mellitus. Limited information exists on adult metformin ingestions reported to poison control centers. The distribution of adult metformin ingestions reported to Texas poison control centers during 2000–2006 was determined for various factors. In addition, triage guidelines for the management of isolated ingestions were drafted. Of 1528 total metformin ingestions, 58% involved coingestants. Of the 264 ingestions of metformin alone, where the final medical outcome was known, dose ingested was reported for 66%. The mean reported dose was 4739 mg (range 500–60,000 mg). Ingestions of ≤2500 mg and >5000 mg reported doses differed with respect to the proportion involving suspected attempted suicide (6% versus 81%), serious final medical outcome (3% versus 19%), and referral to a health care facility (3% versus 83%). Using 5000 mg as a threshold dose for referral to a health care facility, 91% of cases not already at or en route to a health care facility were managed according drafted triage guidelines.

Assessment of genotoxicity in rats treated with the antidiabetic agent, pioglitazone

Pioglitazone (PIO), a member of the thiazolidinedione class of antidiabetic agents, specifically targets insulin resistance. Drugs of this class act as ligands for the gamma subtype of the peroxisome proliferator-activated receptor. Although troglitazone, another drug in this class, displayed unacceptable hepatotoxicity, PIO was approved for human use by the U.S. Food and Drug Administration. To our knowledge, there are no published reports on the genotoxicity of PIO; however, the package insert indicates that it has minimal genotoxicity. In this study, we used the comet assay to investigate the DNA damage in the peripheral blood and liver cells of rats treated with PIO. Sixteen male Sprague-Dawley rats were randomly distributed into four groups, and dosed daily for 14 days by oral gavage with 0, 10, 20, and 40 mg/kg/day PIO. A dose-dependent increase in DNA damage, as assessed by % tail DNA, was observed in both hepatocytes and blood lymphocytes of the PIO-treated groups, with significant increases detected between the rats treated with all the doses of PIO and the control, and between the rats treated with different PIO doses (P < 0.005 to P < 0.0001). Treating nuclei from the exposed animals with an enzyme cocktail containing Fpg and Endonuclease III prior to performing the comet assay increased the level of DNA damage, which reflects oxidized purine and pyrimidine. Taken together, our data indicate that PIO is able to dose-dependently induce DNA damage in both the liver and blood lymphocytes of rats, which is partially due to the generation of oxidative lesions.

Antihyperglycemic property of Tragia cannabina in streptozotocin-induced diabetic rats

The present study was performed to investigate the efficacy of an ethanol extract of the roots of Tragia cannabina for antihyperglycemic and antioxidant effects in streptozotocin (STZ)-induced diabetic rats. Male Wistar rats were administered T. cannabina (250 mg/kg) orally for 21 days, and blood glucose level was measured weekly. At the end of 21 days, concentrations of serum lipids such as total cholesterol, triglycerides, and high-density lipoprotein (HDL) and protein markers such as total protein, albumin, globulin, and albumin:globulin ratio (A:G) were estimated. Also, levels of enzymes such as serum glutamate oxaloacetate transaminase (SGOT), serum glutamate pyruvate transaminase (SGPT), and alkaline phosphatase (ALP) were determined. Antioxidant activity of the extract was evaluated by estimating lipid peroxides (LPO), superoxide dismutase (SOD), and catalase in liver of normal control and STZ- and extract-treated rats. Histopathological changes of liver and kidney were also studied in STZ-induced diabetic animals and normal controls. All these effects produced by the extract were compared with glibenclamide, a standard antidiabetic drug. Oral administration of T. cannabina for 21 days resulted in a significant reduction in blood glucose level, lipid concentration, and SGOT, SGPT, ALP, and LPO levels accompanied by an increase in the levels of SOD and catalase in liver tissues of STZ-induced diabetic rats. Altered levels of protein markers also reverted back to normal. Histopathological changes of liver and kidney were returned to normal. The effects produced by the extract were comparable to that of glibenclamide. In conclusion, the T. cannabina showed significant antihyperglycemic and antioxidant effects in STZ-induced diabetic rats.

Metallokinetic characteristics of antidiabetic bis(allixinato)oxovanadium(IV)-related complexes in the blood of rat

The antidiabetic effect of vanadium is a widely accepted phenomenon; some oxovanadium(IV) complexes have been found to normalize high blood glucose levels in both type 1 and type 2 diabetic animals. In light of the future clinical use of these complexes, the relationship among their chemical structures, physicochemical properties, metallokinetics, and antidiabetic activities must be closely investigated. Recently, we found that among bis(3-hydroxypyronato)oxovanadium(IV) [VO(3hp)(2)] related complexes, bis(allixinato)oxovanadium(IV) [VO(alx)(2)] exhibits a relatively strong hypoglycemic effect in diabetic animals. Next, we examined its metallokinetics in the blood of rats that received five VO(3hp)(2)-related complexes by the blood circulation monitoring-electron paramagnetic resonance method. The metallokinetic parameters were obtained from the blood clearance curves based on a two-compartment model; most parameters, such as area under the concentration curve and mean residence time, correlated significantly with the in vitro insulinomimetic activity in terms of 1/IC(50) (IC(50) is the 50% inhibitory concentration of the complex required for the release of free fatty acids in adipocytes) and the lipophilicity of the complex (log P (com)). The oxovanadium(IV) concentration was significantly higher and the species resided longer in the blood of rats that received VO(alx)(2) than in the blood of rats that received VO(3hp)(2) or bis(kojato)oxovanadium(IV); VO(alx)(2) also exhibited higher log P (com) and 1/IC(50) values. On the basis of these results, we propose that the introduction of lipophilic groups at the C2 and C6 positions of the 3hp ligand is an effective method to enhance the hypoglycemic effect of the complexes, as supported by the observed in vivo exposure and residence in the blood.

Drug-drug and food-drug pharmacokinetic interactions with new insulinotropic agents repaglinide and nateglinide

This review describes the current knowledge on drug-drug and food-drug interactions with repaglinide and nateglinide. These two meglitinide derivatives, commonly called glinides, have been developed for improving insulin secretion of patients with type 2 diabetes mellitus. They are increasingly used either in monotherapy or in combination with other oral antihyperglycaemic agents for the treatment of type 2 diabetes. Compared with sulfonylureas, glinides have been shown to (i) provide a better control of postprandial hyperglycaemia, (ii) overcome some adverse effects, such as hypoglycaemia, and (iii) have a more favourable safety profile, especially in patients with renal failure. The meal-related timing of administration of glinides and the potential influence of food and meal composition on their bioavailability may be important. In addition, some food components (e.g. grapefruit juice) may cause pharmacokinetic interactions. Because glinides are metabolised via cytochrome P450 (CYP) 3A4 isoenzyme, they are indeed exposed to pharmacokinetic interactions. In addition to CYP3A4, repaglinide is metabolised via CYP2C8, while nateglinide metabolism also involves CYP2C9. Furthermore, both compounds and their metabolites may undergo specialised transport/uptake in the intestine, another source of pharmacokinetic interactions. Clinically relevant drug-drug interactions are those that occur when glinides are administered together with other glucose-lowering agents or compounds widely coadministered to diabetic patients (e.g. lipid-lowering agents), with drugs that are known to induce (risk of lower glinide plasma levels and thus of deterioration of glucose control) or inhibit (risk of higher glinide plasma levels leading to hypoglycaemia) CYP isoenzymes concerned in their metabolism, or with drugs that have a narrow efficacy : toxicity ratio. Pharmacokinetic interactions reported in the literature appear to be more frequent and more important with repaglinide than with nateglinide. Rifampicin (rifampin) reduced repaglinide area under the plasma concentration-time curve (AUC) by 32-85% while it reduced nateglinide AUC by almost 25%. Reported increases in AUCs with coadministration of drugs inhibiting CYP isoenzymes never exceeded 80% for repaglinide (except with ciclosporin and with gemfibrozil) and 50% for nateglinide. Ciclosporin more than doubled repaglinide AUC (+144%), a finding that should raise caution when using these two drugs in combination. The most impressive pharmacokinetic interaction was reported with combined administration of gemfibrozil (a strong CYP2C8 inhibitor) and repaglinide (8-fold increase in repaglinide AUC). Although no studies have been performed in patients with type 2 diabetes, the latter combination should be avoided in clinical practice.

Pharmacokinetic interactions with thiazolidinediones

Type 2 diabetes mellitus is a complex disease combining defects in insulin secretion and insulin action. New compounds called thiazolidinediones or glitazones have been developed for reducing insulin resistance. After the withdrawal of troglitazone because of liver toxicity, two compounds are currently used in clinical practice, rosiglitazone and pioglitazone. These compounds are generally used in combination with other pharmacological agents. Because they are metabolised via cytochrome P450 (CYP), glitazones are exposed to numerous pharmacokinetic interactions. CYP2C8 and CYP3A4 are the main isoenzymes catalysing biotransformation of pioglitazone (as with troglitazone), whereas rosiglitazone is metabolised by CYP2C9 and CYP2C8. For both rosiglitazone and pioglitazone, the most relevant interactions have been described in healthy volunteers with rifampicin (rifampin), which results in a significant decrease of area under the plasma concentration-time curve [AUC] (54-65% for rosiglitazone, p<0.001; 54% for pioglitazone, p<0.001), and with gemfibrozil, which results in a significant increase of AUC (130% for rosiglitazone, p<0.001; 220-240% for pioglitazone, p<0.001). The relevance of such drug-drug interactions in patients with type 2 diabetes remains to be evaluated. However, in the absence of clinical data, it is prudent to reduce the dosage of each glitazone by half in patients treated with gemfibrozil. Conversely, rosiglitazone and pioglitazone do not seem to significantly affect the pharmacokinetics of other compounds. Although some food components have also been shown to potentially interfere with drugs metabolised with the CYP system, no published study deals specifically with these possible CYP-mediated food-drug interactions with glitazones.

Trends in the prescribing of oral agents for the management of type 2 diabetes mellitus in the United States, 1990-2001: does type of insurance influence access to innovation?

PURPOSE

The objectives of the present study were (1) to discern trends in the prescribing of oral pharmacotherapy for the management of type 2 diabetes mellitus (DM) in the United States during the years 1990 through 2001 and (2) to examine the mediating role of primary health insurance coverage on patients' access to pharmaceutical innovation for the management of type 2 DM.

METHODS

Data from the US National Ambulatory Medical Care Survey (NAMCS) for the years 1990 through 2001 were used for this analysis.

RESULTS

National estimates of the number of office-based visits documenting a diagnosis of type 2 DM and the prescribing of an oral medication for glycemic control increased from 7 871 283 in 1990 to 13 730 886 in 2001 (a 74.4% increase). A significantly higher proportion of patients covered by private health insurance were prescribed a newer agent, either alone or as part of a combination regimen of oral agents, as compared to patients covered by either Medicare or Medicaid (chi(2) < or = .001).

CONCLUSIONS

Over the time frame of 1995 through 2001, access to pharmaceutical innovation for the management of type 2 DM was mediated by the patient's primary source of health insurance coverage. Future research will need to discern the effect of observed differences in the prescribing of oral agents for the management of type 2 DM on both clinical and economic outcomes and, in light of ongoing discussion regarding health care reform in the United States, to foster clinically rational and equitable access to pharmaceutical innovation.

Genotoxicity in rats treated with the antidiabetic agent, rosiglitazone

Rosiglitazone (RSG), a member of the thiazolidinedione class of antidiabetic agents, improves glycemic control by increasing insulin sensitivity. The therapeutic mode of action of RSG involves its activity as a highly selective and potent agonist for peroxisome proliferator-activated receptor-gamma. Although other drugs in this class have displayed unacceptable hepatotoxicity, RSG was approved for human use. The package insert indicates that RSG has minimal genotoxicity, but information on the genotoxicity of RSG is not available in the published literature. In this study, we used the single cell gel electrophoresis (SCGE)/Comet assay to investigate the DNA damage in peripheral blood and liver cells of rats treated with RSG. Sixteen male Sprague-Dawley rats were randomly distributed into four groups, and dosed daily by oral gavage with 0.0, 0.5, 1.0, and 2.0 mg/kg/day RSG. The rats dosed with 2.0 mg/kg/day RSG received an approximately 10-times the area under the curve concentration of the maximum recommended human daily dose. After 14 days of treatment, the rats were euthanized, and peripheral blood and liver were collected and processed for the Comet assay. A dose-dependent increase in DNA damage (as assessed by % tail DNA and Olive Tail Moment) was observed in the hepatocytes of RSG-treated groups, with significant increases detected between rats treated with all the doses of RSG and the control, and between rats treated with different RSG doses (P < 0.05 - P < 0.0001). In contrast, DNA damage was detected in peripheral blood lymphocytes only in rats treated with the higher RSG doses (1.0 and 2 mg/kg/day). Taken together, the data indicate that RSG is able to induce primary DNA damage in rats, with greater damage being detected in liver cells than lymphocytes.

Drug interactions of clinical importance with antihyperglycaemic agents: an update

Because management of type 2 diabetes mellitus usually involves combined pharmacological therapy to obtain adequate glucose control and treatment of concurrent pathologies (especially dyslipidaemia and arterial hypertension), drug-drug interactions must be carefully considered with antihyperglycaemic drugs. Additive glucose-lowering effects have been extensively reported when combining sulphonylureas (or the new insulin secretagogues, meglitinide derivatives, i.e. nateglinide and repaglinide) with metformin, sulphonylureas (or meglitinide derivatives) with thiazolidinediones (also called glitazones) and the biguanide compound metformin with thiazolidinediones. Interest in combining alpha-glucosidase inhibitors with either sulphonylureas (or meglitinide derivatives), metformin or thiazolidinediones has also been demonstrated. These combinations result in lower glycosylated haemoglobin (HbA(1c)), fasting glucose and postprandial glucose levels than with either monotherapy. Even if modest pharmacokinetic interferences have been reported with some combinations, they do not appear to have important clinical consequences. No significant adverse effects, except a higher risk of hypoglycaemic episodes that may be attributed to better glycaemic control, occur with any combination. Challenging the classical dual therapy with sulphonylurea plus metformin, there is a recent trend to use alternative dual combinations (sulphonylurea plus thiazolidinedione or metformin plus thiazolidinedione). In addition, triple therapy with the addition of a thiazolidinedione to the metformin-sulphonylurea combination has been recently evaluated and allows glucose targets to be reached before insulin therapy is considered. This triple therapy appears to be safe, with no deleterious drug-drug interactions being reported so far.Potential interferences may also occur between glucose-lowering agents and other drugs, and such drug-drug interactions may have important clinical implications. Relevant pharmacological agents are those that are widely coadministered in diabetic patients (e.g. lipid-lowering agents, antihypertensive agents); those that have a narrow efficacy/toxicity ratio (e.g. digoxin, warfarin); or those that are known to induce (rifampicin [rifampin]) or inhibit (fluconazole) the cytochrome P450 (CYP) system. Metformin is currently a key compound in the pharmacological management of type 2 diabetes, used either alone or in combination with other antihyperglycaemics. There are no clinically relevant metabolic interactions with metformin, because this compound is not metabolised and does not inhibit the metabolism of other drugs. In contrast, sulphonylureas, meglitinide derivatives and thiazolidinediones are extensively metabolised in the liver via the CYP system and thus, may be subject to drug-drug metabolic interactions. Many HMG-CoA reductase inhibitors (statins) are also metabolised via the CYP system. Even if modest pharmacokinetic interactions may occur, it is not clear whether drug-drug interactions between oral antihyperglycaemic agents and statins may have clinical consequences regarding both efficacy and safety. In contrast, a marked pharmacokinetic interference has been reported between gemfibrozil and repaglinide and, to a lesser extent, between gemfibrozil and rosiglitazone. This leads to a drastic increase in plasma concentrations of each antihyperglycaemic agent when they are coadministered with the fibric acid derivative, and an increased risk of adverse effects. Some antihypertensive agents may favour hypoglycaemic episodes when co-prescribed with sulphonylureas or meglitinide derivatives, especially ACE inhibitors, but this effect seems to result from a pharmacodynamic drug-drug interaction rather than from a pharmacokinetic drug-drug interaction. No, or only modest, interferences have been described with glucose-lowering agents and other pharmacological compounds such as digoxin or warfarin. The effects of inducers or inhibitors of CYP isoenzymes on the metabolism and pharmacokinetics of the glucose-lowering agents of each pharmacological class has been tested. Significantly increased (with CYP inhibitors) or decreased (with CYP inducers) plasma levels of sulphonylureas, meglitinide derivatives and thiazolidinediones have been reported in healthy volunteers, and these pharmacokinetic changes may lead to enhanced or reduced glucose-lowering action, and thus hypoglycaemia or worsening of metabolic control, respectively. In addition, some case reports have evidenced potential drug-drug interactions with various antihyperglycaemic agents that are usually associated with a higher risk of hypoglycaemia.