Diabetic gastroparesis: diagnosis and management

Drug-Drug Interactions Between Glucagon-Like Peptide 1 Receptor Agonists and Oral Medications: A Systematic Review

BACKGROUND

Glucagon-like peptide 1 receptor agonists (GLP1RAs) are used in the treatment of diabetes and obesity. Their slowing effect of gastric emptying might change oral drug absorption, potentially affecting pharmacokinetics, particularly in the case of medications with a narrow therapeutic index.

PURPOSE

The purpose of this systematic review is to summarize data on drug-drug interactions between GLP1RAs and oral drugs.

DATA SOURCES

The PubMed and EMBASE databases were searched up to November, 1st 2023.

STUDY SELECTION

We selected pharmacokinetic studies of any injectable GLP1RA given with an oral medication, and product prescribing sheets reporting data without access to the original study.

DATA EXTRACTION

Two authors independently extracted the data.

DATA SYNTHESIS

Twenty-two reports and six prescribing sheets were included. Treatment with GLP1RAs resulted in unaffected or reduced Cmax and delayed tmax of drugs with high solubility and permeability (warfarin, contraceptive pills, acetaminophen), drugs with high solubility and low permeability (angiotensin converting enzyme inhibitors), drugs with low solubility and high permeability (statins) and drugs with low solubility and permeability (digoxin). However, the use of GLP1RAs did not exert clinically significant changes in the AUC or differences in clinically relevant endpoints.

LIMITATIONS

The major limitations of the studies that are included in this systematic review are the enrollment of healthy subjects and insufficient data in conditions that might affect pharmacokinetics (e.g., kidney dysfunction).

CONCLUSIONS

To conclude, reduced Cmax and delayed tmax of drugs co-administered with GLP1RAs are consistent with the known delayed gastric output by the latter. Nevertheless, the overall drug exposure was not considered clinically significant. Dose adjustments are probably not required for simultaneous use of GLP1RAs with oral medications. Still, results should be carefully generalized to cases of background kidney dysfunction or when using drugs with narrow therapeutic index. The study is registered in PROSPERO: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022332339 .

Diabetic Gastroparesis and its Emerging Therapeutic Options: A Narrative Review of the Literature

Diabetic gastroparesis (DG) is one of the many complications of diabetes mellitus (DM). Even though this condition surfaces years after uncontrolled disease, it affects the quality of life in several ways and causes significant morbidity. Common symptoms experienced by the patients include postprandial nausea, vomiting, abdominal fullness, and pain. Strict glycemic control is essential to evade the effects of DG. The purpose of this review article is to briefly study the pathophysiology, clinical features, diagnostic modalities, and the effects of DG on different aspects of life. Furthermore, it also focuses on the emerging treatment modalities for DG. Tradipitant and relamorelin are two such treatment options that are gaining noteworthy recognition and are discussed in detail in this review article. As observed through various clinical trials, these drugs help alleviate symptoms like nausea, vomiting, abdominal pain, and bloating in patients suffering from DG, thereby targeting the most common and bothersome symptoms of the disease. This leads to an improvement in the quality of life, making it a reliable treatment option for this disease. But while pharmacological intervention is vital, psychological support and lifestyle changes are equally important and are the reason why a multidisciplinary approach is required for the treatment of DG.

Underutilisation of gastric emptying studies and underrecognition of gastroparesis in people with diabetes treated in a hospital setting

Delayed gastric emptying occurs in up to 30% of patients with long-standing diabetes and causes significant morbidity. We performed a retrospective cohort study of 341 patients who had participated in a gastric emptying study from 2018 to 2021 in a large teaching hospital. Given the expected prevalence of gastroparesis in people with diabetes, there were fewer studies than anticipated, which could lead to gastroparesis underrecognition.

Rapid, non-invasive measurement of gastric emptying rate using transcutaneous fluorescence spectroscopy

Gastric emptying rate (GER) signifies the rate at which the stomach empties following ingestion of a meal and is relevant to a wide range of clinical conditions. GER also represents a rate limiting step in small intestinal absorption and so is widely assessed for research purposes. Despite the clinical and physiological importance of gastric emptying, methods used to measure GER possess a series of limitations (including being invasive, slow or unsuitable for certain patient populations). Here, we present a new technique based on transcutaneous (through-the-skin) fluorescence spectroscopy that is fast, non-invasive, and does not require the collection of samples or laboratory-based analysis. Thus, this approach has the potential to allow immediate reporting of clinical results. Using this new method, participants receive an oral dose of a fluorescent contrast agent and a wearable probe detects the uptake of the agent from the gut into the blood stream. Analysis of the resulting data then permits the calculation of GER. We compared our spectroscopic technique to the paracetamol absorption test (a clinically approved GER test) in a clinical study of 20 participants. Results demonstrated good agreement between the two approaches and, hence, the clear potential of transcutaneous fluorescence spectroscopy for clinical assessment of GER.

An early scientific report on acromegaly: solving an intriguing endocrinological (c)old case?

We present and discuss a late-nineteenth century clinical case described by Professor Taruffi in a scientific paper titled "Scheletro con prosopoectasia e tredici vertebre dorsali" (Skeleton with prosopoectasia and thirteen thoracic vertebrae). Taruffi could not explain the disproportionate skeletal and visceral growth, and the case could therefore be considered an unrecognized case of acromegaly. The anatomopathological specimens and the wax model cited in the paper are currently hosted at the "Luigi Cattaneo" Anatomical Wax Collection of Bologna University; however, some inaccuracies and uncertainties as to their attribution to the same case have remained to this day. The skeletal remains were examined macroscopically to investigate any structural abnormalities and pathological changes. In addition, thanks to archival, museum inventory and literature research, we documented the systematic relationship between the paper and the samples and were able to ascribe the abnormally dilated dried stomach, currently displayed in a different showcase, to the same case. This is, to our knowledge, the first case of acromegaly in the history of medical literature which also includes a visceral specimen. As far as we know, there are no reports of the occurrence of severe gastromegaly in patients with acromegaly. In view of this rare association and, to date, endocrinological research, we hypothesize a further pathogenic mechanism by which acromegaly could have induced this massive dilatation. Taruffi's work represents an immensely valuable scientific/artistic heritage and is still cited in contemporary endocrinological literature, demonstrating its relevant contribution to the historical evolution of the disease through the nineteenth and twentieth centuries.

Diabetes and Metabolic Disorders and the Peripheral Nervous System

PURPOSE OF REVIEW

This article provides an up-to-date review of the manifestations of neuropathy seen in the setting of diabetes and other metabolic disorders.

RECENT FINDINGS

Although a number of metabolic disorders cause or are associated with peripheral neuropathy, the neuropathies associated with glucose dysregulation make up the vast majority of cases. Recent investigations have determined major differences in the neuropathies associated with type 1 and type 2 diabetes. Neuropathy in type 1 diabetes is closely linked to glycemic control, whereas neuropathy in type 2 diabetes is linked to dyslipidemia, central obesity, hypertension, insulin resistance, and glucose control. Although length-dependent axonal distal symmetric polyneuropathy is the most common clinical presentation, diabetes is also associated with acute, asymmetric, painless, and autonomic neuropathies.

SUMMARY

The prevalence of diabetes and metabolic syndrome is increasing across the globe. The need to recognize and treat the wide array of clinical manifestations of neuropathy detected in individuals with metabolic disorders will continue to grow. As a consequence, an increasing number of well-trained physicians who can manage these patients is needed. At present, treatment is largely focused on prevention and symptomatic management. Investments into funding for both basic and clinical science are necessary to bring novel therapeutic interventions into clinical practice.

Role of sex hormones and their receptors on gastric Nrf2 and neuronal nitric oxide synthase function in an experimental hyperglycemia model

BACKGROUND

Gastroparesis, a condition of abnormal gastric emptying, is most commonly observed in diabetic women. To date, the role of ovarian hormones and/or gastric hormone receptors on regulating nitrergic-mediated gastric motility remains inconclusive.

AIM

The purpose of this study is to investigate whether sex hormones/their receptors can attenuate altered Nuclear factor (erythroid-derived 2)-like 2 (Nrf2), neuronal Nitric Oxide Synthase (nNOS) expression and nitrergic relaxation in gastric neuromuscular tissues exposed to in-vitro hyperglycemia (HG).

METHODS

Gastric neuromuscular sections from adult female C57BL/6 J mice were incubated in normoglycemic (NG, 5 mM) or hyperglycemic (30 mM or 50 mM) conditions in the presence or absence of selective estrogen receptor (ER) agonists (ERα /PPT or ERβ: DPN); or non-selective sex hormone receptor antagonists (ER/ICI 182,780, or progesterone receptor (PR)/ RU486) for 48 h. mRNA, protein expression and nitrergic relaxation of circular gastric neuromuscular strips were assessed.

RESULTS

Our findings in HG, compared to NG, demonstrate a significant reduction in ER, Nrf2, and nNOS expression in gastric specimens. In addition, in-vitro treatment with sex hormones and/or their agonists significantly (*p < 0.05) restored Nrf2/nNOSα expression and total nitrite production. Conversely, ER, but not PR, antagonist significantly reduced Nrf2/nNOSα expression and nitrergic relaxation.

CONCLUSIONS

Our data suggest that ER's can regulate nitrergic function by improving Nrf2/nNOS expression in experimental hyperglycemia.

The High-Resolution Three-Dimensional Magnetic Detector System 3D-Magma Accurately Measures Gastric and Small Bowel Motility in People with Type 2 Diabetes with Neuropathy

Gastroparesis is an important complication of diabetes. Motility disorders are underdiagnosed and can lead to unexplained hypoglycemia. Currently diagnostic options are limited. All established methods harbor certain disadvantages. The 3D-MAGMA system is capable of reliably measuring gastric and small intestinal motility. The aim of the current study was to determine if 3D-MAGMA is able to detect changes in intestinal motility in people with type 2 diabetes. 18 healthy volunteers and 19 people with type 2 diabetes underwent motility testing by 3D-MAGMA. In the control group the retention time in the stomach was 33.0 [min] compared to 75.3 [min] in the diabetes group. The median time in the duodenum was 12.7 [min] compared to 8.1 [min]. The time for the first 50 cm of the jejunum was 29.9 [min] compared to 28.2 [min]. Discussion and conclusion: 3D-MAGMA is able to detect changes in intestinal motility. Its clinical value might be useful in patients with fluctuating blood glucose levels and unexplained hypoglycemic episodes.

Wireless motility capsule compared with scintigraphy in the assessment of diabetic gastroparesis

BACKGROUND

Gastroparesis is a potentially severe late complication of diabetes mellitus. Today, delayed gastric emptying (GE) is mandatory for establishing the diagnosis. In this study, we compared wireless motility capsule (WMC) with gastric emptying scintigraphy (GES).

METHODS

Seventy-two patients (49 women) with diabetes mellitus (59 type 1) and symptoms compatible with gastroparesis were prospectively included between 2014 and 2018. Patients were simultaneously examined with GES and WMC. Symptoms were assessed with the Patient Assessment of Upper Gastrointestinal Symptom Severity Index (PAGI-SYM) questionnaire. All patients were on intravenous glucose-insulin infusion during testing.

KEY RESULTS

WMC and GES correlated r = .74, P < .001. Compared to GES, WMC at ordinary cutoff for delayed GE (300 minutes) had a sensitivity of 0.92, specificity 0.73, accuracy 0.80, and Cohen's kappa κ = 0.61 (P < .001). By receiver operating characteristics (ROC), the area under the curve was 0.95 (P < .001). A cutoff value for delayed GE of 385 minutes produced sensitivity 0.92, specificity 0.83, accuracy 0.86, and Cohen's kappa κ = 0.72 (P < .001). Inter-rater reliability for GE time with WMC was r = .996, κ = 0.97, both P < .001. There was no difference in symptom severity between patients with normal and delayed GE.

CONCLUSIONS & INFERENCES

Our findings demonstrate the applicability of WMC as a reliable test to assess gastric emptying in diabetic gastroparesis showing very high inter-observer correlation. By elevating the cutoff value for delayed emptying from 300 to 385 minutes, we found higher specificity without reducing sensitivity.

The Role of Diabetes Mellitus in Diseases of the Gallbladder and Biliary Tract

BACKGROUND

The increasing prevalence of diabetes mellitus worldwide continues to pose a heavy burden. Though its gastrointestinal impact is appropriately recognized, the lesser known associations may be overlooked.

OBJECTIVE

We aim to review the negative implications of diabetes on the gallbladder and the biliary tract.

METHODS

A MEDLINE® database search of literature was conducted with emphasis on the previous five years, combining keywords such as "diabetes," "gallbladder," and "biliary".

RESULTS

The association of diabetes to the formation of gallstones, gallbladder cancer, and cancer of the biliary tract are discussed along with diagnosis and treatment.

CONCLUSION

Though we uncover the role of diabetic neuropathy in gallbladder and biliary complications, the specific individual diabetic risk factors behind these developments is unclear. Also, in addition to diabetes control and surgical gallbladder management, the treatment approach also requires further focus.

Comparing radiopaque markers and 13C-labelled breath test in diabetic gastroparesis diagnostics

Purpose: Determining gastric emptying is mandatory in the diagnosis of diabetic gastroparesis. Several methods of investigation exist, but none has proven reliable, inexpensive and accessible. In this study, we aimed to compare gastric emptying of radiopaque markers (ROM) and ¹³carbon-labelled gastric emptying breath tests for solids (GEBT). We also aimed to determine any association between gastric emptying and patient-reported symptoms, glycemic control and the patients’ age, diabetes duration and occurrence of other late complications.

Patients and methods: Forty-five patients (30 women, 15 men) with diabetes mellitus types 1 or 2 (40, 5) and symptoms of gastroparesis were examined with ROM and GEBT. All were interviewed, filled out symptom questionnaires and had HbA1c levels measured.

Results: Forty percent of patients had delayed gastric emptying of ROM, while 55% had delayed gastric emptying of GEBT. Correlation between ROM and GEBT was not significant. Compared to GEBT, sensitivity for a positive ROM test was 0.52, while specificity was 0.74. In women, we found a higher specificity of 0.92, sensitivity 0.47. Difference in HbA1c between patients with positive and negative results was of borderline significance for both tests. GEBT (r=0.41, P=0.008) correlated with HbA1c. Patients with any late complications of diabetes had higher gastric retention of ROM (P=0.028), while patients with polyneuropathy (P=0.014) and diabetic wounds (P=0.004) had slower emptying with GEBT. None of the methods identified significant associations between gastric emptying and symptom scores, age or diabetes duration.

Conclusions: As a measure of gastric emptying, the ROM test has benefits of being affordable and available. Compared to GEBT, the method has low diagnostic reliability. Before continued use, we recommend additional studies validating the test in diabetes patients.

Activation of Nrf2 attenuates delayed gastric emptying in obesity induced diabetic (T2DM) female mice

Diabetic gastroparesis (GP) is a clinical syndrome characterized by delayed gastric emptying (DGE). Loss of Nrf2 (Nuclear factor (erythroid-derived 2)-like 2) led to reduced nNOSα mediated gastric motility and DGE. The molecular signaling of cinnamaldehyde (CNM) mediated Nrf2 activation and its mechanistic role on DGE were further investigated in obese/T2D female mice. Adult female homozygous Nfe2l2-/- (C57BL/6J) and their wild-type (WT) littermates (Nfe2l2+/+) mice were fed with high fat diet (HFD; Obese/T2D model), or normal diet (ND) with or without CNM (50 mg/kg b.w; i.p). Supplementation of CNM attenuated (p < 0.05) DGE in WT female but not in Nrf2 KO Obese/T2D mice. CNM (1) normalized serum estradiol-17β levels, (2) induced gastric Nrf2 and phase II antioxidant enzymes through extracellular signal-regulated kinase, (ERK)/c-Jun N-terminal kinase (JNK)/p38 mitogen-activated protein kinase (MAPK), (3) reduced glucose synthase kinase 3 beta (GSK3β) and aryl hydrocarbon receptor (AhR) and this was associated with (4) increased estrogen receptor expression, BH4 (Cofactor of nNOS) biosynthesis enzyme GCH-1 and nNOSα dimerization in WT Obese/T2 diabetic female mice. In addition, CNM restored impaired nitrergic relaxation in hyperglycemic conditions. These findings emphasize the importance of Nrf2 in maintaining nNOSα mediated GE and may have a translational relevance to treat obese/diabetic gastroparesis in women.

Acupuncture for symptomatic gastroparesis

BACKGROUND

Gastroparesis, a state of delayed gastric emptying in the absence of mechanical obstruction of the stomach, has a substantial impact on people's daily function and quality of life when symptomatic. Current treatment options are based on limited evidence of benefits. Acupuncture is widely used to manage gastrointestinal disorders, although its role in people with symptomatic gastroparesis is unclear. We therefore undertook a systematic review of the evidence.

OBJECTIVES

To assess the benefits and harms of acupuncture, in comparison with no treatment, sham acupuncture, conventional medicine, standard care, or other non-pharmacological active interventions for symptom management in people with gastroparesis.

SEARCH METHODS

On 26 March 2018, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL Plus, PsycINFO, AMED, Korean medical databases (including Korean Studies Information, DBPIA, Korea Institute of Science and Technology Information, Research Information Centre for Health Database, KoreaMed, and the National Assembly Library), and Chinese databases (including the China Academic Journal). We also searched two clinical trials registries for ongoing trials. We imposed no language limitations.

SELECTION CRITERIA

We selected all randomised controlled trials comparing the penetrating type of acupuncture with no treatment, sham acupuncture, conventional medicine, standard care, and other non-pharmacological active interventions for people with symptomatic gastroparesis of any aetiology (i.e. surgical, diabetic, or idiopathic). Trials reporting outcomes at least four weeks from baseline (short-term outcomes) were eligible. We defined long-term outcomes as those measured after 12 weeks from baseline. The primary outcome was improvement of gastroparesis symptoms in the short term. Secondary outcomes were: improvement of symptoms measured after three months, change in the rate of gastric emptying, quality of life, use of medication, and adverse events in the short and long term.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected eligible trials based on predefined selection criteria. Two review authors independently extracted data and evaluated the risk of bias. The review authors contacted investigators to obtain missing information wherever possible.

MAIN RESULTS

We included 32 studies that involved a total of 2601 participants. Acupuncture was either manually stimulated (24 studies) or electrically stimulated (8 studies). The aetiology of gastroparesis was diabetes (31 studies) or surgery (1 study). All studies provided data on the proportion of people with symptoms 'improved', although the definition or categorisation of improvement varied among the studies. Most measured only short-term outcomes (28 studies), and only one study employed validated instruments to assess subjective changes in symptoms or reported data on quality of life or the use of medication. Reporting of harm was incomplete; minor adverse events were reported in only seven trials. Most studies had unclear risk of bias in terms of allocation concealment (29/32), outcome assessor blinding (31/32) and selective reporting (31/32), as well as high risk of bias in terms of participant/personnel blinding (31/32). Acupuncture was compared with sham acupuncture (needling on non-acupuncture points), three different types of gastrokinetic drugs (domperidone, mosapride, cisapride), and a histamine H₂ receptor antagonist (cimetidine).There was low-certainty evidence that symptom scores of participants receiving acupuncture did not differ from those of participants receiving sham acupuncture at three months when measured by a validated scale.There was very low-certainty evidence that a greater proportion of participants receiving acupuncture had 'improved' symptoms in the short term compared to participants who received gastrokinetic medication (4 to 12 weeks) (12 studies; 963 participants; risk ratio (RR) 1.25; 95% confidence interval (CI) 1.17 to 1.33, I² = 8%). Short-term improvement in overall symptom scores favouring acupuncture was also reported in five studies with considerable heterogeneity.Acupuncture in combination with other treatments, including gastrokinetics, non-gastrokinetics and routine care, was compared with the same treatment alone. There was very low-certainty evidence in favour of acupuncture for the proportion of participants with 'improved' symptoms in the short term (4 to 12 weeks) (17 studies; 1404 participants; RR 1.22; 95% CI 1.16 to 1.28; I² = 0%). Short-term improvement in overall symptom scores, favouring acupuncture, were also reported (two studies, 132 participants; MD -1.96, 95% CI -2.42 to -1.50; I² = 0%).Seven studies described adverse events, including minor bleeding and hematoma, dizziness, xerostomia, loose stool, diarrhoea, abdominal pain, skin rash and fatigue. The rest of the trials did not report whether adverse events occurred.Subgroup analyses revealed that short-term benefits in terms of the proportion of people with 'improved' symptoms did not differ according to the type of acupuncture stimulation (i.e. manual or electrical). The sensitivity analysis revealed that use of a valid method of random sequence generation, and the use of objective measurements of gastric emptying, did not alter the overall effect estimate in terms of the proportion of people with 'improved' symptoms. The asymmetric funnel plot suggests small study effects and publication bias towards positive reporting.

AUTHORS' CONCLUSIONS

There is very low-certainty evidence for a short-term benefit with acupuncture alone or acupuncture combined with gastrokinetic drugs compared with the drug alone, in terms of the proportion of people who experienced improvement in diabetic gastroparesis. There is evidence of publication bias and a positive bias of small study effects. The reported benefits should be interpreted with great caution because of the unclear overall risk of bias, unvalidated measurements of change in subjective symptoms, publication bias and small study reporting bias, and lack of data on long-term outcomes; the effects reported in this review may therefore differ significantly from the true effect. One sham-controlled trial provided low-certainty evidence of no difference between real and sham acupuncture in terms of short-term symptom improvement in diabetic gastroparesis, when measured by a validated scale. No studies reported changes in quality of life or the use of medication.Due to the absence of data, no conclusion can be made regarding effects of acupuncture on gastroparesis of other aetiologies. Reports of harm have remained largely incomplete, precluding assessments of the safety of acupuncture in this population. Future research should focus on reducing the sources of bias in the trial design as well as transparent reporting. Harms of interventions should be explicitly reported.

Azithromycin Induces Migrating Motor Complexes in Pediatric Patients Undergoing Antroduodenal Motility Studies

OBJECTIVE

Erythromycin (ERY) is used in the treatment of gastroparesis; however, this medication is associated with serious side effects, such as cardiac arrhythmias and consequent cardiorespiratory arrest. Azithromycin (AZM) has been suggested as an alternative to ERY as a result of its improved safety profile. Intravenous ERY (1 mg/kg) is administered during antroduodenal motility studies to induce migrating motor complexes (MMCs), the presence or absence of which helps diagnose motility disorders like gastroparesis and gastrointestinal dysmotility. However, there are no pediatric studies comparing the effects of AZM and ERY on antroduodenal pressure profiles. The goal of this study is to determine if AZM is comparable in inducing MMCs in pediatric patients undergoing antroduodenal motility studies.

METHODS

We performed a retrospective chart analysis of gastric and small bowel manometric data in 2 adolescent patients, both age 15 years, who were given AZM (1 mg/kg) during antroduodenal motility studies. The pressure profiles obtained during motility studies were compared to those of patients of similar age and symptomology who were given the standard intravenous ERY dose during motility studies. We then compared the total duration of effect, mean amplitude of contractions, number of cycles per minute, and duration of highest antral and duodenal contractions.

RESULTS

Intravenous AZM induces migrating motor contractions in the stomach followed by contractions in the small intestine. The mean amplitude of the stomach contractions was 259 mm Hg in patients who received AZM vs 241 mm Hg in patients who received ERY. The mean amplitude of small intestinal MMCs was 68 mm Hg in patients who received AZI and 72 mm Hg in patients who received ERY. Additionally, the frequency and duration of stomach and small intestinal contractions were also similar in the 2 groups.

CONCLUSIONS

Intravenous AZM has similar prokinetic effects to intravenous ERY. Our study suggests that AZM is a suitable alternative to ERY in inducing MMCs without the concerning side effects related to ERY and may potentially be used in the management of gastroparesis and other small bowel motility disorders. However, larger prospective studies are required to better understand the long-term efficacy of AZM.

A longitudinal study on patients with diabetes and symptoms of gastroparesis - associations with impaired quality of life and increased depressive and anxiety symptoms

AIMS

To examine patient reported outcomes (PRO) in patients previously assessed for diabetic gastroparesis, and to investigate how symptoms of gastroparesis evolve over time. In addition, to further evaluate outcomes in those with versus without diabetic gastroparesis at baseline.

METHODS

Thirty-four patients with diabetes and gastrointestinal (GI) symptoms, diagnosed with or without diabetic gastroparesis in 2011-2013, were included in this follow-up study. PRO were measured with the Patient assessment of upper gastrointestinal symptom severity index (PAGI-SYM), 36-Item Short Form Survey (SF-36), Patient assessment of upper gastrointestinal disorders-quality of life (PAGI-QOL) and Hospital Anxiety and Depression Scale (HADS). Demographic factors and clinical variables were also recorded.

RESULTS

Participants diagnosed with gastroparesis had improved glycemic control (p=0.04) and less GI symptoms (p=0.001), after a follow-up time of 3.2years (mean). Both groups reported severely impaired quality of life (QoL). In total 47% reported symptoms of anxiety, 38% symptoms of depression (scores≥8). GI symptom severity or other PRO could not differentiate between the two groups.

CONCLUSIONS

Patients diagnosed with diabetic gastroparesis, as well as those with gastroparesis symptoms - but normal gastric emptying, suffer from severely impaired QoL and a high burden of anxiety and depressive symptoms.

Diabetic autonomic neuropathy

Diabetes mellitus is the commonest cause of an autonomic neuropathy in the developed world. Diabetic autonomic neuropathy causes a constellation of symptoms and signs affecting cardiovascular, urogenital, gastrointestinal, pupillomotor, thermoregulatory, and sudomotor systems. Several discrete syndromes associated with diabetes cause autonomic dysfunction. The most prevalent of these are: generalized diabetic autonomic neuropathy, autonomic neuropathy associated with the prediabetic state, treatment-induced painful and autonomic neuropathy, and transient hypoglycemia-associated autonomic neuropathy. These autonomic manifestations of diabetes are responsible for the most troublesome and disabling features of diabetic peripheral neuropathy and result in a significant proportion of the mortality and morbidity associated with the disease.

Treating Diabetic Neuropathy: Present Strategies and Emerging Solutions

Diabetic peripheral neuropathies (DPN) are a heterogeneous group of disorders caused by neuronal dysfunction in patients with diabetes. They have differing clinical courses, distributions, fiber involvement (large or small), and pathophysiology. These complications are associated with increased morbidity, distress, and healthcare costs. Approximately 50% of patients with diabetes develop peripheral neuropathy, and the projected rise in the global burden of diabetes is spurring an increase in neuropathy. Distal symmetrical polyneuropathy (DSPN) with painful diabetic neuropathy, occurring in around 20% of diabetes patients, and diabetic autonomic neuropathy (DAN) are the most common manifestations of DPN. Optimal glucose control represents the only broadly accepted therapeutic option though evidence of its benefit in type 2 diabetes is unclear. A number of symptomatic treatments are recommended in clinical guidelines for the management of painful DPN, including antidepressants such as amitriptyline and duloxetine, the γ-aminobutyric acid analogues gabapentin and pregabalin, opioids, and topical agents such as capsaicin. However, monotherapy is frequently not effective in achieving complete resolution of pain in DPN. There is a growing need for head-to-head studies of different single-drug and combination pharmacotherapies. Due to the ubiquity of autonomic innervation in the body, DAN causes a plethora of symptoms and signs affecting cardiovascular, urogenital, gastrointestinal, pupillomotor, thermoregulatory, and sudomotor systems. The current treatment of DAN is largely symptomatic, and does not correct the underlying autonomic nerve deficit. A number of novel potential candidates, including erythropoietin analogues, angiotensin II receptor type 2 antagonists, and sodium channel blockers are currently being evaluated in phase II clinical trials.

Treatment of Diabetic Gastroparesis by Complementary and Alternative Medicines

Gastroparesis is a common gastrointestinal complication in diabetes, induced by hyperglycemia and characterized by delayed gastric emptying and upper abdominal symptoms, such asnausea, vomiting, early satiety, bloating and epigastric pain. Diabetic gastroparesis (DGP) affects life quality and glycemic control, and is a challenge to treat in both Western and Eastern medicine. Routine treatment in Western medicine includes gastric emptying promoted by prokinetic agents, gastric pacemaking, or surgery combined with lifetime hormono-therapy, all of which have unavoidable side effects and limitations, and are very expensive. Complementary and alternative medical treatments like acupuncture, moxibustion, and massage are becoming more and more attractive because of their effectiveness, fewer side effects, and reliable safety. This article aims to introduce representative methods of complementary and alternative medicine to treat DGP, which were searched in English through Pubmed and in Chinese through CNKI (China Knowledge Resource Integrated Database). Several lines of evidence demonstrated the effects of single or combined complementary alternative therapies on DGP outcomes; however, the mechanisms were rarely investigated. Randomized controlled trials are undoubtedly required in future studies.

Physical activity and type 1 diabetes: time for a rewire?

While being physically active bestows many health benefits on individuals with type 1 diabetes, their overall blood glucose control is not enhanced without an effective balance of insulin dosing and food intake to maintain euglycemia before, during, and after exercise of all types. At present, a number of technological advances are already available to insulin users who desire to be physically active with optimal blood glucose control, although a number of limitations to those devices remain. In addition to continued improvements to existing technologies and introduction of new ones, finding ways to integrate all of the available data to optimize blood glucose control and performance during and following exercise will likely involve development of "smart" calculators, enhanced closed-loop systems that are able to use additional inputs and learn, and social aspects that allow devices to meet the needs of the users.

Gastroparesis as the initial presentation of pulmonary adenocarcinoma

Malignancy-associated gastroparesis is an under-reported entity and its diagnosis as a cause of cachexia or gastrointestinal symptoms is often missed in clinical practice. This case report highlights an unusual association of pulmonary adenocarcinoma with gastroparesis at presentation. Malignancy-associated gastroparesis should be added to the differential diagnosis in patients presenting with delayed gastric emptying of unknown aetiology and should prompt further radiological investigations. Early detection and treatment of underlying gastroparesis in patients with cancer is necessary to improve the quality of life and to avoid premature clinical deterioration due to intolerance to oral treatment.

Combination of symptoms, syndrome and disease: Treatment of refractory diabetic gastroparesis

AIM: To assess effect of combination of symptoms, syndrome and disease on treatment of diabetic gastroparesis with severe nausea and vomiting.

METHODS: Professor Tong Xiaolin’s clinical electronic medical records of patients who were treated between January 1, 2006 and October 1, 2012 were used as a database. Patients who met the inclusion criteria were enrolled. General information (name, sex and age), symptoms and blood glucose levels were obtained from the clinic electronic medical record, which was supplemented by a telephone interview. The patient-rated Gastroparesis Cardinal Symptom Index (GCSI) was used to evaluate the severity of the symptoms of gastroparesis. The effects of the treatment were assessed by the change in the severity of the symptoms of gastroparesis and the change in blood glucose between the baseline levels and the post-treatment levels at 1, 2, 4, 8 and 12 wk.

RESULTS: Forty-five patients had a mean GCSI nausea and vomiting severity score of 4.21 ± 0.67 and a total GCSI score of 2.77 ± 0.63 before treatment. There was a significant improvement in the nausea and vomiting score at every return visit compared with the baseline score (1 wk: 3.02 ± 1.04 vs 4.18 ± 0.71, P < 0.001; 2 wk: 2.32 ± 1.25 vs 4.16 ± 0.73, P < 0.001; 4 wk: 2.12 ± 1.26 vs 4.12 ± 0.73, P < 0.001; 8 wk: 1.79 ± 1.09 vs 4.24 ± 0.77, P < 0.001; 12 wk: 0.69 ± 0.92 vs 4.25 ± 0.70, P < 0.001). Twenty-five of the 45 patients had complete resolution of vomiting during the observation period (mean time to resolution was 37.9 ± 27.3 d). The postprandial fullness and early satiety subscale, bloating subscale and total GCSI scores were also improved. Finally, the blood glucose levels improved after treatment, although the change was not significant.

CONCLUSION: Use of the combination of symptoms, syndrome and disease to treat diabetic gastroparesis with refractory nausea and vomiting may be a new treatment option.

Exercising with peripheral or autonomic neuropathy: what health care providers and diabetic patients need to know

Both peripheral and autonomic neuropathies are characterized by a progressive loss of nerve fiber function. Most peripheral neuropathy affects the extremities, particularly the lower legs and the feet, but also the hands, whereas damage to the autonomic nervous system may lead to imbalances between the sympathetic and parasympathetic nerve fibers that innervate the heart and blood vessels, as well as abnormalities in heart rate control and vascular dynamics. To prescribe or engage in exercise that is both safe and effective, health care providers and patients with diabetes mellitus need to increase their understanding of the pathophysiological nature of neuropathies and the physical activity hurdles that may arise from the presence of a neuropathy. With proper care and preventative measures, patients with diabetes mellitus that experience either type of neuropathy can benefit from regular participation in mild to moderate aerobic, resistance, and balance activities, assuming they take any potential alterations into account to ensure that exercise is safe and effective.

Use of secondary prevention pharmacotherapy after first myocardial infarction in patients with diabetes mellitus

Background

Despite recommended pharmacotherapies the use of secondary prevention therapy after myocardial infarction (MI) remains suboptimal. Patients with diabetes mellitus (DM) have worse prognosis after MI compared to patients without DM and aggressive secondary prevention pharmacotherapy in this population is therefore warranted. We examined the changes in use of evidence-based secondary prevention pharmacotherapy in patients with and without DM discharged after first MI.

Methods

All patients aged 30 years or older admitted with first MI in Denmark during 1997–2006 were identified by individual-level linkage of nationwide registries of hospitalizations. Univariate and multivariate logistic regression models were used to identify patient characteristics associated with initiation of acetylsalicylic acid, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, and clopidogrel within 90 days, and statins within 180 days of discharge, respectively.

Results

A total of 78,230 patients were included, the mean age was 68.3 years (SD 13.0), 63.5% were men and 9,797 (12.5%) had diabetes. Comparison of claimed prescriptions in the period 1997–2002 and 2003–2006 showed significant (p < 0.001) increases in claims for acetylsalicylic acid (38.9% vs. 69.7%), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (38.7% vs. 50.4%), β-blockers (69.2% vs. 77.9%), clopidogrel (16.7% vs. 66.3%), and statins (41.3% vs. 77.3%). During 2003–2006, patients with DM claimed significantly less acetylsalicylic acid (odds ratio [OR] 0.81 [95% confidence interval [CI] 0.74–0.88) and clopidogrel (OR 0.91 [95% CI 0.83–1.00]) than patients without DM.

Conclusions

Despite sizeable increase in use of evidence-based secondary prevention pharmacotherapy after MI from 1997 to 2006, these drugs are not used in a substantial proportion of subjects and patients with DM received significantly less antiplatelet therapy than patients without DM. Increased focus on initiation of secondary prevention pharmacotherapy after MI is warranted, especially in patients with DM.

Treatments for severe gastroparesis

Severe gastroparesis is a kind of gastroparesis that is refractory to conventional drug therapy and requires nutritional support and frequently emergency hospitalization. The selection of treatment for severe gastroparesis has always been a dilemma for clinicians. Currently, there have been limited reports on the treatment of severe gastroparesis. This article sums up the primary treatments, drug treatments and other kinds of treatments for severe gastroparesis and discusses the prospects for the treatment of this refractory disease.

Effect of irbesartan on expression of ET-1 and AT1R in gastric tissues of diabetic rats with gastroparesis

AIM: To investigate the therapeutical effect of irbesartan on diabetic gastroparesis (DG) in rats and to explore potential mechanisms involved.

METHODS: Thirty male Sprague-Dawley rats were randomly divided into either a normal control group (NC group, n = 10) or a diabetes mellitus group (DM group, n = 20). Diabetes mellitus was induced with streptozotocin (50 mg/kg i.p.). The DM group was further divided into a diabetic control group (DC group, n = 10) and an irbesartan group (DI group, n = 10). The DI group was given irbesartan 0.012 g/(kg•d) through stomach feeding, while the NC and DC groups were given equal volume of saline by gavage. Six weeks later, all the rats were administered with phenol red solution to measure the rate of gastric emptying. Endothelin (ET-1) content in stomach tissue was measured by radioimmunoassay. Chemical colorimetry was used to measure the activity of nitric oxide synthase (NOS) in the stomach tissue. The expression level of angiotensin receptor (AT1R) mRNA was determined by RT-PCR.

RESULTS: Compared to the NC group, the rate of gastric emptying significantly decline in the other two groups (62.64% ± 4.51% vs 18.65% ± 4.30%, 22.64% ± 2.88%); however, the rate of gastric emptying was significantly higher in the DI group than in the DC group (22.64% ± 2.88% vs 18.65% ± 4.30%). There was a significant difference in ET-1 content among the three groups (NC 18.520 pg/mgpro ± 2.795 pg/mgpro vs DC 26.850 pg/mgpro ± 2.897 pg/mgpro vs DI 21.660 pg/mgpro ± 4.686 pg/mgpro). Compared to the NC group, cNOS activity significantly declined in the DC and DI groups (0.521 pg/mgpro ± 0.057 pg/mgpro vs 0.323 pg/mgpro ± 0.079 pg/mgpro, 0.384 pg/mgpro ± 0.067 pg/mgpro); however, there was no significant change in cNOS activity between the DC and DI groups (0.323 pg/mgpro ± 0.079 pg/mgpro vs 0.384 pg/mgpro ± 0.067 pg/mgpro). iNOS activity in the DI group was significantly lower than that in the DC group (0.246 pg/mgpro ± 0.033 pg/mgpro vs 0.276 pg/mgpro ± 0.021 pg/mgpro), but higher than that in the NC group (0.246 pg/mgpro ± 0.033 pg/mgpro vs 0.209 pg/mgpro ± 0.015 pg/mgpro). The expression of AT1R mRNA in DC group and DI group was up-regulated significantly (0.741 ± 0.010, 0.546 ± 0.005 vs 0.207 ± 0.004) compared with the NC group. After intervention with irbesartan, the level of AT1R mRNA in the DI group was lower than that in the DC group (0.546 ± 0.005 vs 0.741 ± 0.010).

CONCLUSION: Irbesartan can improve, to some extent, gastric emptying in rats with diabetic gastroparesis possibly by altering the levels of ET, NOS, and AT1R mRNAs in the stomach tissue.

Azithromycin for the treatment of gastroparesis

OBJECTIVE

To evaluate the use of azithromycin for the treatment of gastroparesis.

DATA SOURCES

Literature was accessed through PubMed/MEDLINE and Web of Science (both 1966-October 2012) using the terms gastroparesis, diabetic gastroparesis, and azithromycin. Literature was limited to English-language publications. In addition, references from publications identified were reviewed.

STUDY SELECTION AND DATA EXTRACTION

All articles published in English identified from the data sources were evaluated.

DATA SYNTHESIS

The treatment of gastroparesis depends on the severity of the symptoms, but generally includes dietary modifications, prokinetic medications, and antiemetics. The initial treatment for gastroparesis is a prokinetic agent, and because erythromycin has the greatest effect on gastric emptying, it is often used. Limitations to erythromycin include adverse reactions (nausea, vomiting, and abdominal pain), QTc interval prolongation, CYP3A-associated drug interactions, and tachyphylaxis. Azithromycin, another macrolide, has been shown to increase gastrointestinal motility and may have fewer limitations to its use. Azithromycin has fewer drug interactions, less incidence of QTc interval prolongation, a longer half-life, and fewer gastrointestinal adverse effects. Use of azithromycin may be beneficial in patients with gastric and small bowel dysmotility. Two observational studies have supported its use in gastroparesis, but there have been no controlled studies. All studies published have been performed during testing procedures for gastroparesis; thus, longer-term treatment effects and symptom control need to be studied. There is one ongoing prospective controlled trial with preliminary data available only in abstract form.

CONCLUSIONS

Azithromycin may prove to be an alternative prokinetic agent in gastroparesis, but further study is needed before it can be recommended.

Diabetic autonomic neuropathy

Autonomic neuropathy, once considered to be the Cinderella of diabetes complications, has come of age. The autonomic nervous system innervates the entire human body, and is involved in the regulation of every single organ in the body. Thus, perturbations in autonomic function account for everything from abnormalities in pupillary function to gastroparesis, intestinal dysmotility, diabetic diarrhea, genitourinary dysfunction, amongst others. "Know autonomic function and one knows the whole of medicine!" It is now becoming apparent that before the advent of severe pathological damage to the autonomic nervous system there may be an imbalance between the two major arms, namely the sympathetic and parasympathetic nerve fibers that innervate the heart and blood vessels, resulting in abnormalities in heart rate control and vascular dynamics. Cardiac autonomic neuropathy (CAN) has been linked to resting tachycardia, postural hypotension, orthostatic bradycardia and orthostatic tachycardia (POTTS), exercise intolerance, decreased hypoxia-induced respiratory drive, loss of baroreceptor sensitivity, enhanced intraoperative or perioperative cardiovascular lability, increased incidence of asymptomatic ischemia, myocardial infarction, and decreased rate of survival after myocardial infarction and congestive heart failure. Autonomic dysfunction can affect daily activities of individuals with diabetes and may invoke potentially life-threatening outcomes. Intensification of glycemic control in the presence of autonomic dysfunction (more so if combined with peripheral neuropathy) increases the likelihood of sudden death and is a caveat for aggressive glycemic control. Advances in technology, built on decades of research and clinical testing, now make it possible to objectively identify early stages of CAN with the use of careful measurement of time and frequency domain analyses of autonomic function. Fifteen studies using different end points report prevalence rates of 1% to 90%. CAN may be present at diagnosis, and prevalence increases with age, duration of diabetes, obesity, smoking, and poor glycemic control. CAN also cosegregates with distal symmetric polyneuropathy, microangiopathy, and macroangiopathy. It now appears that autonomic imbalance may precede the development of the inflammatory cascade in type 2 diabetes and there is a role for central loss of dopaminergic restraint on sympathetic overactivity. Restoration of dopaminergic tone suppresses the sympathetic dominance and reduces cardiovascular events and mortality by close to 50%. Cinderella's slipper can now be worn!

Emesis in diabetes mellitus

It is estimated that 20-40% of patients with diabetes, particularly those with prolonged duration of type 1 diabetes mellitus with other complications develop gastroparesis .We present in a picture quiz format the interesting case of an elderly lady presenting with diabetic gastroparesis in a tertiary care hospital in India.

Management of diabetes in pregnancy

The link between diabetes and poor pregnancy outcomes is well established. As in the non-pregnant population, pregnant women with diabetes can experience profound effects on multiple maternal organ systems. In the fetus, morbidities arising from exposure to diabetes in utero include not only increased congenital anomalies, fetal overgrowth, and stillbirth, but metabolic abnormalities that appear to carry on into early life, adolescence, and beyond. This article emphasizes the newest guidelines for diabetes screening in pregnancy while reviewing their potential impact on maternal and neonatal complications that arise in the setting of hyperglycemia in pregnancy.

Morphofunctional changes underlying intestinal dysmotility in diabetic RIP-I/hIFNβ transgenic mice

The pathogenetic mechanisms underlying gastrointestinal dysmotility in diabetic patients remain poorly understood, although enteric neuropathy, damage to interstitial cells of Cajal (ICC) and smooth muscle cell injury are believed to play a role. The aim of this study was to investigate the morphological and functional changes underlying intestinal dysmotility in RIP-I/hIFNβ transgenic mice treated with multiple very low doses of streptozotocin (20 mg/kg, i.p., 5 days). Compared with vehicle-treated mice, streptozotocin-treated animals developed type 1 diabetes mellitus, with sustained hyperglycaemia for 3.5 months, polyphagia, polydipsia and increased faecal output without changes in faecal water content (metabolic cages). Diabetic mice had a longer intestine, longer ileal villi and wider colonic crypts (conventional microscopy) and displayed faster gastric emptying and intestinal transit. Contractility studies showed selective impaired neurotransmission in the ileum and mid-colon of diabetic mice. Compared with controls, the ileal and colonic myenteric plexus of diabetic mice revealed ultrastructural features of neuronal degeneration and HuD immunohistochemistry on whole-mount preparations showed 15% reduction in neuronal numbers. However, no immunohistochemical changes in apoptosis-related markers were noted. Lower absolute numbers of neuronal nitric oxide synthase- and choline acetyltransferase-immunopositive neurons and enhanced vasoactive intestinal polypeptide and substance P immunopositivity were observed. Ultrastructural and immunohistochemical analyses did not reveal changes in the enteric glial or ICC networks. In conclusion, this model of diabetic enteropathy shows enhanced intestinal transit associated with intestinal remodelling, including neuroplastic changes, and overt myenteric neuropathy. Such abnormalities are likely to reflect neuroadaptive and neuropathological changes occurring in this diabetic model.

Biomagnetic techniques for evaluating gastric emptying, peristaltic contraction and transit time

Biomagnetic techniques were used to measure motility in various parts of the gastrointestinal (GI) tract, particularly a new technique for detecting magnetic markers and tracers. A coil was used to enhance the signal from a magnetic tracer in the GI tract and the signal was detected using a fluxgate magnetometer or a magnetoresistor in an unshielded room. Estimates of esophageal transit time were affected by the position of the subject. The reproducibility of estimates derived using the new biomagnetic technique was greater than 85% and it yielded estimates similar to those obtained using scintigraphy. This technique is suitable for studying the effect of emotional state on GI physiology and for measuring GI transit time. The biomagnetic technique can be used to evaluate digesta transit time in the esophagus, stomach and colon, peristaltic frequency and gastric emptying and is easy to use in the hospital setting.

Improved kidney graft function after conversion from twice daily tacrolimus to a once daily prolonged-release formulation

BACKGROUND

Tacrolimus once daily (Tac-QD) formulation has been recently introduced to improve patient adherence to immunosuppressive medications. To evaluate long-term effects of conversion from tacrolimus twice daily (Tac-BID) to Tac-QD on kidney graft excretory function, we retrospectively analyzed kidney graft function after the conversion from Tac-BID to Tac-QD over 24 months.

METHODS

We enrolled 72 kidney transplant recipients, including 19 simultaneous pancreas-kidney cases, who were at least 9 months posttransplantation and showed stable graft function for 6 months. We analyzed kidney graft function (glomerular filtration rate [eGFR] by the Modification of Diet in Renal of Disease equation), tacrolimus daily dose and tacrolimus blood trough level changes over 24 months after conversion.

RESULTS

All patients completed the 12 months and 56 patients, 24 months observation. At 3 months, the eGFR increased significantly after conversion from 57.1 to 60.0 mL/min/1.73 m2 (P=.004) and at 24 months to 66.0 mL/min/1.73 m2 (P<.001). Tacrolimus daily dose diminished over time by almost 10%, a difference that reached statistical significance at 18 months. Tacrolimus blood trough levels did not change significantly until 24 months. There was no correlation between eGFR changes during the first 12 months after conversion and changes in tacrolimus blood trough levels (r=-0.118; P=.33).

CONCLUSION

Conversion from Tac-BID to Tac-QD formulation was followed by a clinically significant improvement in kidney graft function upon long-term observation. The improvement seemed to not be related to changes in tacrolimus blood trough levels.

Gender bias in gastroparesis: is nitric oxide the answer?

Accumulating evidence suggests that gender-related differences are prominent in gastric motility functions in both health and disease. Women are more susceptible to gastroparesis than men. Though the mechanism(s) involved are not fully understood, impairment of the nitrergic system is one of the main factors responsible for the disease. Uncoupling of neuronal nitric oxide synthase (nNOS) causes a decreased synthesis of NO leading to a reduction in smooth muscle relaxation. Tetrahydrobiopterin (BH(4)) (an essential cofactor for nNOS) is a key regulator of nNOS activity for stomach dysfunction and gastroparesis. In addition, BH(4) has been shown to be a potent antioxidant and anti-inflammatory agent. Well established by results from our laboratory, a diminished intracellular (BH(4):total biopterin) ratio in diabetic female rats significantly impairs nNOS activity and function. Recent research has been focused on BH(4) biosynthesis and gastroparesis because reduced BH(4) cofactor levels can alter the production of NO by nNOS. Researchers are now paying more attention to the possibility of using BH(4) as a therapeutic strategy in gastroparesis. The purpose of this review is to provide an overview of the regulation and function of nNOS by sex hormones and BH(4) and its potential role in the treatment of gastroparesis.

Obesity and symptoms suggestive of gastroparesis in patients with type 2 diabetes and neuropathy

BACKGROUND

Associated with neuropathy, symptoms suggestive of gastroparesis are common in patients with type 2 diabetes mellitus (T2DM) and include nausea, vomiting, bloating and early satiety. Gastric motor abnormalities have been reported in obese patients, and obesity is associated with T2DM. An association between obesity and gastroparesis symptoms in diabetic patients with neuropathy has not been investigated.

METHODS

In this nested case-control study, 161 patients with neuropathy were identified from within a cross-sectional survey of 380 T2DM patients. Of these, 134 (83.2%, "cases") had at least one cardinal symptom suggestive of gastroparesis. The remaining symptom-free subjects served as controls. Logistic and general linear modeling was used to assess associations between obesity and the presence and number of symptoms.

RESULTS

Subjects were 66.6±10 years of age. Cases were significantly more likely than controls to be obese (89% vs. 77%, P=.04), female (55.6% vs. 33.3%) and hypertensive (90.2% vs. 63%, P=.001) and to report adherence to diet (87.4% vs. 66.7%, P=.007). In a logistic regression model including sex, hypertension, antiaggregant therapy, adherence to diet therapy and an obesity-by-sex interaction term, obesity emerged as a significant independent predictor of any cardinal symptom suggestive of gastroparesis (odds ratio 9.86, 95% confidence interval 1.4-69.2, P=.02). Obesity was also identified as a significant independent predictor of number of cardinal symptoms suggestive of gastroparesis in the general linear model. Obese subjects reported significantly more early satiety (61.5% vs. 35.2%, P=.001), fullness (63.7% vs. 40.8%, P=.004), bloating (70.3% vs. 49.3%, P=.006) and abdominal distention (71.4 vs. 50.7%, P=.007) than nonobese subjects. Further, obese subjects reported more cardinal symptoms suggestive of gastroparesis symptoms (4.2±2.4 vs. 3.1±2.5, P=.01).

CONCLUSIONS

Obesity emerged as a significant independent predictor of cardinal symptoms suggestive of gastroparesis in patients with T2DM and neuropathy. This finding suggests that mechanisms in addition to neuropathy play a role in the generation of symptoms suggestive of gastroparesis in this patient population.

Loss of NRF2 impairs gastric nitrergic stimulation and function

Emerging research suggests that antioxidant gene expression has the potential to suppress the development of gastroparesis. However, direct genetic evidence that definitively supports this concept is lacking. We used mice carrying a targeted disruption of Nfe2l2, the gene that encodes the transcription factor NRF2 and directs antioxidant Phase II gene expression, as well as mice with a targeted disruption of Gclm, the modifier subunit for glutamate-cysteine ligase, to test the hypothesis that defective antioxidant gene expression contributes to development of gastroparesis. Although expression of heme oxygenase-1 remained unchanged, expression of GCLC, GCLM, SOD1, and CAT was down-regulated in gastric tissue from Nrf2(-/-) mice compared to wild-type animals. Tetrahydrobiopterin oxidation was significantly elevated and nitrergic relaxation was impaired in Nrf2(-/-) mouse gastric tissue. In vitro studies showed a significant decrease in NO release in Nrf2(-/-) mouse gastric tissue. Nrf2(-/-) mice displayed delayed gastric emptying. The use of Gclm(-/-) mice demonstrated that the loss of glutamate-cysteine ligase function enhanced tetrahydrobiopterin oxidation while impairing nitrergic relaxation. These results provide genetic evidence that loss of antioxidant gene expression can contribute to the development of gastroparesis and suggest that NRF2 represents a potential therapeutic target.

Effects of GLP-1 and incretin-based therapies on gastrointestinal motor function

Glucagon-like peptide 1 (GLP-1) is a hormone secreted predominantly by the distal small intestine and colon and released in response to enteral nutrient exposure. GLP-1-based therapies are now used widely in the management of type 2 diabetes and have the potential to be effective antiobesity agents. Although widely known as an incretin hormone, there is a growing body of evidence that GLP-1 also acts as an enterogastrone, with profound effects on the gastrointestinal motor system. Moreover, the effects of GLP-1 on gastrointestinal motility appear to be pivotal to its effect of reducing postprandial glycaemic excursions and may, potentially, represent the dominant mechanism. This review summarizes current knowledge of the enterogastrone properties of GLP-1, focusing on its effects on gut motility at physiological and pharmacological concentrations, and the motor actions of incretin-based therapies. While of potential importance, the inhibitory action of GLP-1 on gastric acid secretion is beyond the scope of this paper.

Detecting pre-diabetes and the role of the pharmacist

OBJECTIVE

This study aims to use a pharmacoepidemiological approach to study the drug use of patients during the year prior to diabetes diagnosis (i.e. pre-diabetic patients) and control patients. Drug use might reveal cardiovascular, metabolic and/or endocrinological changes and help to identify indicators for active monitoring of Type 2 diabetes mellitus.

METHODS

A retrospective case-control study compared drug use of patients with a future diagnosis of diabetes (experimental patients) with patients without a diabetes diagnosis (control patients) based on community pharmacy records. An experimental patient had used oral hypoglycaemic drugs during 2005 or 2006. Experimental and control patients were matched in terms of age, gender and quarter of index date. Drugs were selected based on possible co-morbidities of diabetes. Drug use was expressed as a binary variable, indicating whether or not a patient took specific drugs. Drug use was compared between experimental patients during the year prior to diagnosis and control patients using the chi-squared test.

RESULTS

Our dataset covered 5,064 patients (1,688 experimental and 3,376 control patients). A higher probability of taking cardiovascular drugs was observed for specific subgroups of patients with pre-diabetes as compared to control patients: this trend was observed for men as well as for women, for various cardiovascular drug classes, and for different age groups (p<0.05), although it was not always statistically significant for the 29-38 age group. For each selected age and gender group, patients with pre-diabetes had a higher probability of taking a combination of a lipid-modifying agent and an antihypertensive drug than control patients (p<0.005).

CONCLUSIONS

Using community pharmacy data, this study demonstrated that age and a characteristic drug use pattern could contribute to detecting pre-diabetes. There is a potential role for community pharmacists to follow up drug indicators of patients with a view to refer high-risk people for screening by a physician.

Randomised clinical trial: ghrelin agonist TZP-101 relieves gastroparesis associated with severe nausea and vomiting--randomised clinical study subset data

BACKGROUND

Limited therapeutic options exist for severe gastroparesis, where severe nausea and vomiting can lead to weight loss, dehydration and malnutrition due to inadequate caloric and fluid intake. TZP-101 (ulimorelin) is a ghrelin receptor agonist that accelerates gastric emptying and improves upper gastrointestinal symptoms in diabetic patients with gastroparesis.

AIM

To assess effects of TZP-101 in diabetic gastroparesis patients with severe nausea/vomiting and baseline severity scores of ≥3.5 (range: 0-5) on the Gastroparesis Cardinal Symptom Index (GCSI) Nausea/Vomiting subscale.

METHODS

Patients were hospitalised and received four single daily 30-min infusions of one of six TZP-101 doses (range 20-600 μg/kg) or placebo. Efficacy was assessed by symptom improvement.

RESULTS

At baseline, 23 patients had a mean severity score for GCSI Nausea/Vomiting of 4.45±0.44. Statistically significant improvements over placebo occurred in the 80 μg/kg group for end of treatment changes from baseline in GCSI Nausea/Vomiting subscale (reduction in score of -3.82±0.76, P=0.011) and the GCSI Total score (-3.14±0.78, P=0.016) and were maintained at the 30-day follow-up assessment (-2.02±1.63, P=0.073 and -1.99±1.33, P=0.032 respectively). The proportion of days with vomiting was reduced significantly (P=0.05) in the 80 μg/kg group (mean of 1.2 days of vomiting for four treatment days) compared with placebo (mean of 3.2 days of vomiting across 4 treatment days).

CONCLUSIONS

TZP-101 substantially reduced the frequency and severity of nausea and vomiting as well as overall gastroparesis symptoms. The results are consistent with gastrointestinal motility effects of TZP-101, supporting further investigation of TZP-101 in the management of severe gastroparesis.

Gastroparesis in pregnancy: case report and literature review

Gastroparesis is a syndrome characterized by delayed gastric emptying in the absence of mechanical obstruction. The most common underlying aetiology is diabetes mellitus; however, many cases are idiopathic. Pregnancy per se is associated with gastrointestinal neuromuscular dysfunction; however, reports of gastroparesis arising during pregnancy are rare. We report a case of severe gastroparesis and proximal small bowel paresis presenting during pregnancy.

Diabetic gastroparesis-backwards and forwards

Diabetic gastroparesis was once thought to be rare, associated with a poor prognosis, and to affect only patients with type 1 diabetes and irreversible autonomic neuropathy. A landmark study conducted by Horowitz et al. and published in JGH in 1986 paved the way for further studies to examine the pathophysiology, natural history and prognosis of diabetic gastroparesis, as well as its optimal management. This review summarizes the developments in knowledge gained over the last ∼25 years that have led to understanding about normal and disordered gastric emptying in diabetes, with a particular emphasis on the inter-relationship between the rate of gastric emptying and the regulation of blood glucose.

Domperidone treatment for gastroparesis: demographic and pharmacogenetic characterization of clinical efficacy and side-effects

BACKGROUND

Domperidone is a useful alternative to metoclopramide for treatment of gastroparesis due to better tolerability. Effectiveness and side-effects from domperidone may be influenced by patient-related factors including polymorphisms in genes encoding drug-metabolizing enzymes, drug transporters, and domperidone targets.

AIMS

The aim of this study was to determine if demographic and pharmacogenetic parameters of patients receiving domperidone are associated with response to treatment or side-effects.

METHODS

Patients treated with domperidone for gastroparesis provided saliva samples from which DNA was extracted. Fourteen single-nucleotide polymorphisms (SNPs) in seven candidate genes (ABCB1, CYP2D6, DRD2, KCNE1, KCNE2, KCNH2, KCNQ1) were used for genotyping. SNP microarrays were used to assess single-nucleotide polymorphisms in the ADRA1A, ADRA1B, and ADRA1D loci.

RESULTS

Forty-eight patients treated with domperidone participated in the study. DNA was successfully obtained from each patient. Age was associated with effectiveness of domperidone (p=0.0088). Genetic polymorphism in KCNH2 was associated with effectiveness of domperidone (p=0.041). The efficacious dose was associated with polymorphism in ABCB1 gene (p=0.0277). The side-effects of domperidone were significantly associated with the SNPs in the promoter region of ADRA1D gene.

CONCLUSIONS

Genetic characteristics associated with response to domperidone therapy included polymorphisms in the drug transporter gene ABCB1, the potassium channel KCNH2 gene, and α1D--adrenoceptor ADRA1D gene. Age was associated with a beneficial response to domperidone. If verified in a larger population, this information might be used to help determine which patients with gastroparesis might respond to domperidone and avoid treatment in those who might develop side-effects.

Diabetic gastroparesis and its impact on glycemia

Diabetes is the most common cause of gastroparesis and it is now recognized that the relationship between gastric emptying and glycemia is complex and intertwined. Postprandial blood glucose levels influence, and are influenced by, the rate of gastric emptying, highlighting the difficulty in determining which is the cause and which is the effect. Novel diagnostic techniques and therapeutic strategies have been developed for the management of diabetic gastroparesis. This article highlights recent advances in knowledge about diabetic gastroparesis, with an emphasis on the inter-relationships between disordered gastric motor function on glycemia and vice versa, as well as therapeutic strategies for optimizing glycemic control using modulation of gastric emptying.