Differential effects of once-weekly glucagon-like peptide-1 receptor agonist dulaglutide and metformin on pancreatic β-cell and insulin sensitivity during a standardized test meal in patients with type 2 diabetes

This substudy of the AWARD-3 trial evaluated the effects of the once-weekly glucagon-like peptide-1 receptor agonist, dulaglutide, versus metformin on glucose control, pancreatic function and insulin sensitivity, after standardized test meals in patients with type 2 diabetes. Meals were administered at baseline, 26 and 52 weeks to patients randomized to monotherapy with dulaglutide 1.5 mg/week (n = 133), dulaglutide 0.75 mg/week (n = 136), or metformin ≥1500 mg/day (n = 140). Fasting and postprandial serum glucose, insulin, C-peptide and glucagon levels were measured up to 3 h post-meal. β-cell function and insulin sensitivity were assessed using empirical variables and mathematical modelling. At 26 weeks, similar decreases in area under the curve for glucose [AUCglucose (0-3 h)] were observed among all groups. β-cell function [AUCinsulin /AUCglucose (0-3 h)] increased with dulaglutide and was unchanged with metformin (p ≤ 0.005, both doses). Dulaglutide improved insulin secretion rate at 9 mmol/l glucose (p ≤ 0.04, both doses) and β-cell glucose sensitivity (p = 0.004, dulaglutide 1.5 mg). Insulin sensitivity increased more with metformin versus dulaglutide. In conclusion, dulaglutide improves postprandial glycaemic control after a standardized test meal by enhancing β-cell function, while metformin exerts a greater effect on insulin sensitivity.

Low incidence of anti-drug antibodies in patients with type 2 diabetes treated with once-weekly glucagon-like peptide-1 receptor agonist dulaglutide

Therapeutic administration of peptides may result in anti-drug antibody (ADA) formation, hypersensitivity adverse events (AEs) and reduced efficacy. As a large peptide, the immunogenicity of once-weekly glucagon-like peptide-1 (GLP-1) receptor agonist dulaglutide is of considerable interest. The present study assessed the incidence of treatment-emergent dulaglutide ADAs, hypersensitivity AEs, injection site reactions (ISRs), and glycaemic control in ADA-positive patients in nine phase II and phase III trials (dulaglutide, N = 4006; exenatide, N = 276; non-GLP-1 comparators, N = 1141). Treatment-emergent dulaglutide ADAs were detected using a solid-phase extraction acid dissociation binding assay. Neutralizing ADAs were detected using a cell-based assay derived from human endothelial kidney cells (HEK293). A total of 64 dulaglutide-treated patients (1.6% of the population) tested ADA-positive versus eight (0.7%) from the non-GLP-1 comparator group. Of these 64 patients, 34 (0.9%) had dulaglutide-neutralizing ADAs, 36 (0.9%) had native-sequence GLP-1 (nsGLP-1) cross-reactive ADAs and four (0.1%) had nsGLP-1 neutralization ADAs. The incidence of hypersensitivity AEs and ISRs was similar in the dulaglutide versus placebo groups. No dulaglutide ADA-positive patient reported hypersensitivity AEs. Because of the low incidence of ADAs, it was not possible to establish their effect on glycaemic control.

Safety and efficacy of once-weekly dulaglutide versus sitagliptin after 2 years in metformin-treated patients with type 2 diabetes (AWARD-5): a randomized, phase III study

AIMS

To compare the once-weekly glucagon-like peptide-1 (GLP-1) receptor dulaglutide with the dipeptidyl peptidase-4 (DPP-4) inhibitor sitagliptin after 104 weeks of treatment.

METHODS

This AWARD-5 study was a multicentre, double-blind trial that randomized participants to dulaglutide (1.5 or 0.75 mg) or sitagliptin 100 mg for 104 weeks or placebo (reported separately) for 26 weeks. Change in glycated haemoglobin (HbA1c) concentration from baseline was the primary efficacy measure. A total of 1098 participants with HbA1c concentrations ≥7.0% (≥53.0 mmol/mol) and ≤9.5% (≤80.3 mmol/mol) were randomized, and 657 (59.8%) completed the study. We report results for dulaglutide and sitagliptin at the final endpoint.

RESULTS

Changes in HbA1c at 104 weeks were (least squares mean ± standard error) -0.99 ± 0.06% (-10.82 ± 0.66 mmol/mol), -0.71 ± 0.07% (-7.76 ± 0.77 mmol/mol) and -0.32 ± 0.06% (-3.50 ± 0.66 mmol/mol) for dulaglutide 1.5 mg, dulaglutide 0.75 mg and sitagliptin, respectively (p < 0.001, both dulaglutide doses vs sitagliptin). Weight loss was greater with dulaglutide 1.5 mg (p < 0.001) and similar with 0.75 mg versus sitagliptin (2.88 ± 0.25, 2.39 ± 0.26 and 1.75 ± 0.25 kg, respectively). Gastrointestinal adverse events were more common with dulaglutide 1.5 and 0.75 mg versus sitagliptin (nausea 17 and 15% vs 7%, diarrhoea 16 and 12% vs 6%, vomiting 14 and 8% vs 4% respectively). Pancreatic, thyroid, cardiovascular and hypersensitivity safety were similar across groups.

CONCLUSIONS

Dulaglutide doses provided superior glycaemic control and dulaglutide 1.5 mg resulted in greater weight reduction versus sitagliptin at 104 weeks, with acceptable safety.

Dose-finding results in an adaptive, seamless, randomized trial of once-weekly dulaglutide combined with metformin in type 2 diabetes patients (AWARD-5)

AIMS

AWARD-5 was an adaptive, seamless, double-blind study comparing dulaglutide, a once-weekly glucagon-like peptide-1 (GLP-1) receptor agonist, with placebo at 26 weeks and sitagliptin up to 104 weeks. The study also included a dose-finding portion whose results are presented here.

METHODS

Type 2 diabetes (T2D) patients on metformin were randomized 3 : 1 : 1 to seven dulaglutide doses, sitagliptin (100 mg), or placebo. A Bayesian algorithm was used for randomization and dose selection. Patients were adaptively randomized to dulaglutide doses using available data on the basis of a clinical utility index (CUI) of glycosylated haemoglobin A1c (HbA1c) versus sitagliptin at 52 weeks and weight, pulse rate (PR) and diastolic blood pressure (DBP) versus placebo at 26 weeks. The algorithm randomly assigned patients until two doses were selected.

RESULTS

Dulaglutide 1.5 mg was determined to be the optimal dose. Dulaglutide 0.75 mg met criteria for the second dose. Dulaglutide 1.5 mg showed the greatest Bayesian mean change from baseline (95% credible interval) in HbA1c versus sitagliptin at 52 weeks -0.63 (-0.98 to -0.20)%. Dulaglutide 2.0 mg showed the greatest placebo-adjusted mean change in weight [-1.99 (-2.88 to -1.20) kg] and in PR [0.78 (-2.10 to 3.80) bpm]. Dulaglutide 1.5 mg showed the greatest placebo-adjusted mean change in DBP [-0.62 (-3.40 to 2.30) mmHg].

CONCLUSIONS

The Bayesian algorithm allowed for an efficient exploration of a large number of doses and selected dulaglutide doses of 1.5 and 0.75 mg for further investigation in this trial.

Monotherapy with the once-weekly GLP-1 analogue dulaglutide for 12 weeks in patients with Type 2 diabetes: dose-dependent effects on glycaemic control in a randomized, double-blind, placebo-controlled study

AIMS

Evaluate dose-dependent effects of once-weekly dulaglutide, a glucagon-like peptide-1 analogue, on glycaemic control in patients with Type 2 diabetes treated with lifestyle measures with or without previous metformin.

METHODS

This 12-week, double-blind, placebo-controlled, dose-response trial randomized 167 patients who were anti-hyperglycaemic medication-naïve or had discontinued metformin monotherapy [mean baseline HbA(1c) 59 ± 8 to 61 ± 8 mmol/mol (7.6 ± 0.7 to 7.8 ± 0.8%)] to once-weekly injections of placebo or dulaglutide (0.1, 0.5, 1.0 or 1.5 mg).

RESULTS

A significant dose-dependent reduction in HbA(1c) (least squares mean ± SE) was observed across doses (P < 0.001). HbA(1c) reductions in the 0.5, 1.0 and 1.5 mg dulaglutide groups were greater than in the placebo group [-10 ± 1, -11 ± 1 and -11 ± 1 vs. 0 ± 1 mmol/mol (-0.9 ± 0.1, -1.0 ± 0.1 and -1.0 ± 0.1 vs. 0.0 ± 0.1%), respectively, all P < 0.001]. Dose-dependent reductions in fasting plasma glucose were also observed [least squares mean difference (95% CI) ranging from -0.43 (-1.06 to 0.19) mmol/l for dulaglutide 0.1 mg to -1.87 (-2.56 to -1.19) mmol/l for dulaglutide 1.5 mg, P < 0.001]. Dose-dependent weight loss was demonstrated across doses (P = 0.009), but none of the groups were different from placebo. The most common adverse events were nausea and diarrhoea.

CONCLUSIONS

The observed dulaglutide dose-dependent reduction in HbA(1c) and its acceptable safety profile support further clinical development for treatment of Type 2 diabetes.

Cytogenetic effects of 8-Cl-cAMP on human and animal chromosomes

PURPOSE

To assess the cytogenetic effects in vitro and in vivo of a non-cytotoxic antitumor agent with biomodulator activity, 8-chloro-3',5' cyclic adenosine monophosphate (8-ClcAMP).

MATERIALS AND METHODS

Cytogenetic effects of 8-Cl-cAMP where evaluated using the in vitro chromosome cytogenetic assay (CA) on human peripheral blood lymphocytes of healthy individuals and by bone marrow micronucleus assay in adult BALB/c mice.

RESULTS

In the in vitro chromosome CA, 8-Cl-cAMP (in all respective doses; 1.5 and 15 microm) induced mitotic inhibition and premature centromere separation (PCS) but no chromosomal damage in cultured human peripheral blood lymphocytes. In the in vivo test, single intraperitoneal (i.p.) injection of 8-Cl-cAMP in doses of 10, 80 and 150 mg/kg showed a dose-related effect on the frequency of micronuclei, detected in murine polychromatic erythrocytes (PCE).

CONCLUSION

The results of the present study show that genotoxicity of 8-Cl-cAMP has a different matrix of response when comparing results in vitro and in vivo, suggesting that high metabolic activity in vivo is responsible for the clastogenic potential of 8-Cl-cAMP. These comparative results indicate a need of having an available battery of genotoxic tests in order to evaluate possible cytogenetic effects of novel antitumor agents.

Molecular characterization of hsp90 isoforms in colorectal cancer cells and its association with tumour progression

A key role of hsp90 in the activity of various oncogenic proteins and pathways is currently of intense interest. To clarify the molecular basis of biological behaviour of colorectal cancers we analysed the expression characteristics of hsp90 in cytosolic, nuclear and plasma membranous fractions of cancer cells. As determined by Western blot assay all hsp90 isoforms studied, alpha (84 kDa), beta (86 kDa) and hsp90N (75 kDa), were up-regulated and differentially expressed in various stages of colorectal carcinoma. The inducible hsp90alpha isoform is a component of invasive phenotype of cancer cells thus pointing to the importance of hsp90alpha for metastasis generation. The expression of hsp90beta is definitely higher in poorly-differentiated carcinomas than in well-differentiated cancers, suggesting an involvement of hsp90beta in the inhibition of cancer cell differentiation. Especially, the expression of cytosolic hsp90N isoform in malignant cells points to the possibility that induction or overexpression of hsp90N might be causally related to tumour formation. Hsp90N is the plasma-membrane-associated protein in poorly-differentiated colorectal cancers with metastasis. This suggests that the expression of hsp90N is elevated with progressive dedifferentiation often associated with advanced cancer stages. Hsp90 was exclusively localized in the invasive front in a majority of metastatic cancers as visualized by immunohistochemical study. Consistent with these facts, the frequent expression of hsp90alpha and hsp90N on the surface of colorectal cancer cells may enable hsp90 to act as a mediator of metastasis generation. The above results indicate more complex roles for hsp90 in colorectal tumourigenesis. In this way, the hsp90 would be at the crossroads of both signalling and cell migration events.

Deregulated sequential motion of centromeres induced by antitumor agents may lead to genome instability in human peripheral blood lymphocytes

PURPOSE

Segregation of chromosomes in anaphase is preceded by a sequential order of centromere separation. Alteration of the sequence of centromere separation or premature centromere division (PCD) has been found to be significantly higher in populations exposed to various xenobiotics. The purpose of this study was to investigate if PCD induced by various cytostatics can alter the stability of chromosomes and lead to aneuploidy.

MATERIALS AND METHODS

Peripheral blood lymphocytes of 10 healthy, non smoking subjects were exposed to 8-Cl-cAMP at a dose of 1, 5 and 15 microM, paclitaxel at a dose of 0.01, 0.05 and 0.2 microM, and cycloheximide (CX) at a dose of 5, 10 and 25 microg/ml. By using the cytohalasin B (CB)-micronucleus (MN) test in vitro, in combination with fluorescent in situ hybridization (FISH), the presence of MN was analyzed in 1000 binuclear cells for each experimental and negative control group. For analysis of MN content we used the alpha-centromeric probe for chromosome 18.

RESULTS

8-Cl-cAMP and paclitaxel induced an increase in the frequency of MN in peripheral blood lymphocytes. 8-Cl-cAMP and paclitaxel proved clastogenic, i.e. they increased the frequency of MN and induced PCD in all respective doses. CX proved not clastogenic in the respected doses when using the CB-MN test in vitro, although CX is a specific PCD inducer. No correlation of PCD and aneuploidy of chromosome 18 was found in cells exposed to 8-Cl-cAMP and paclitaxel by using FISH. In cells exposed to CX we found PCD of chromosome 18 in binuclear cells and single signals in scarce MN. These findings were not statistically significant compared to the negative control group.

CONCLUSION

Our results show that the properties of the investigated antitumor agents to induce PCD in peripheral blood lymphocytes and, therefore, aneuploidy and genome instability, is highly based on the nature of the alteration of centromere function, i.e. the temporal order of centromere kinetics are more regulated through the sequence of centromere separation than by the segregation processes. We suggest that PCD induced by novel antitumor agents could be included in preclinical and clinical genetic risk assessment analysis.

β-Cell Secretory Function and CD25 + Lymphocyte Subsets In the Early Stage of Type 1 Diabetes Mellitus

Cellular immunologic tests have not been used for diagnostic purposes in individuals at risk for autoimmune insulitis or in patients with partial beta-cell destruction because of a lack of studies that show their predictive value. In this study we initially evaluated 43 patients with recent-onset Type 1 diabetes (disease duration <or= 6 months, 29 ICA positive) with regard to beta-cell secretion stimulation test with glucagon and immunologic parameters, including CD4 +, CD8 +, CD4 + CD25 +, CD8 + CD25 + lymphocyte subsets. At baseline, C-peptide concentration 6 min after stimulation increased on average by 0.18 +/- 0.27 micro g/ml. The percentage of CD4 + cells was 42 +/- 9,4 % (healthy controls 44 +/- 7.3 %, p nonsig.) and percentage of CD8 + was 33 +/- 8.6 % (healthy control 31 +/- 8.3 %, p nonsig.). Relative size of CD4 + CD25 + subpopulation was 7 +/- 5.4 % (healthy control 2 +/- 2 %, p < 0.001). Percentage of activated CD8 + cell subset was also increased (2 +/- 1.4 vs. 1.0 +/- 1.0 %), but not significantly. Functional beta-cell testing was repeated after 6 months and nineteen patients were eligible for analysis. Their response was weaker after 6 months (0.13 +/- 0.1 micro g/ml, p < 0.05 vs. baseline). The average change in C-peptide excursion from baseline to the endpoint was - 0.07 +/- 0.17 micro g/ml. There was no significant correlation between beta-cell functional parameters at baseline (C-peptide6min (baseline)) and the relative size of various T cell subpopulations. Results were identical for the 6-month beta-cell functional data (C-peptide6min (6month)). The change in the excursion of C-peptide between baseline and follow-up visit (C-peptide6min (6month-baseline)) showed mild, negative correlation with relative size of the CD8 + CD25 + subpopulation (r = - 0.511, p = 0.025), which may indicate that the size of this cell subpopulation has predictive value in assessing future functional beta-cell changes.

Interventions in diabetic patients after myocardial infarction

Occurrence of a first acute myocardial infarction (AMI) is associated with further increase in risk of cardiovascular events. This risk is further increase is disproportionate in diabetics, who suffer from very high mortality short and long term after AMI. Factors responsible for the increased risk are only partially understood. Additional, properly designed, prospective epidemiological studies are needed for a better understanding of complicated diabetic macrovascular disease after the occurrence of the first event. These studies are also needed for designing interventional trials that target factors that carry the highest risk of new events. Published studies provide some insight into the issue of efficacy of blood pressure, cholesterol and blood glucose lowering strategies in the diabetic population. It remains unclear how important is the control of triglyceride concentration or other risk factors during various stages of recovery after AMI. The main reason is the lack of clinical trials. Evidence-based approach to patients with diabetes and AMI indicates the importance of tight control of cholesterol, blood pressure and blood glucose concentration. Although other risk factors have not been extensively studied, it is reasonable to assume that other major risk factors, such as hypertriglyceridemia, should be targeted as well. In the meantime, more data need to be collected from prospective epidemiological and interventional protocols, if better control over the cardiovascular risk in this high-risk population is to be achieved.

Retrospective analysis of cardiovascular outcomes in patients with type 2 diabetes mellitus after the first acute myocardial infarction

We retrospectively analyzed survival in patients with type 2 diabetes mellitus (DM) after first acute myocardial infarction (AMI). The study was conducted in 5 sites in Poland and involved 521 patients who survived more than 30 days after AMI. In the 5-year period after the acute event, we investigated the following cardiovascular (CV) outcomes: death (overall mortality), next MI, stroke, hospitalization due to acute coronary symptoms (HACS), and composite outcomes (whichever occurred first). We also assessed: age, smoking habit, obesity, hypertension, dyslipidemia and coronary artery disease (CAD) diagnosed before AMI, and gender. 269 patients (52%) suffered one of the outcomes from the composite CV endpoint. HACS was the first event in 164 cases, MI in 59, death in 32, and stroke in 14 patients. Analyzing the prevalence of individual CV events, we found: HACS in 184 patients (35%), next MI in 79 patients (15%), death in 59 patients (11%), and stroke in 30 patients (6%). Only dyslipidemia, arterial hypertension, and CAD were independent risk factors with an impact on composite CV endpoint. Other analyzed risk factors like smoking and obesity did not have independent effects on the CV risk. In the retrospective analysis, we found that HACS was the most frequent CV event in individuals with type 2 DM after AMI. The CV risk in type 2 diabetics who suffered at least one myocardial infarction was further increased in those with coexisting dyslipidemia, arterial hypertension or CAD. These findings support the current guidelines which recommend aggressive management of CV risk factors including hypertension, dyslipidemia and CAD before a first myocardial infarction.

Apoptotic versus genotoxic potential of anti-tumor agents: a concept of duality in unity

Recent advances in anti-tumor therapy have raised a problem of secondary tumors and tumor resistance. Secondary tumors induced by chemotherapeutic agents as a consequence of primary therapy have poor prognostic outcome. Many new insights into molecular controls of cell cycle progression of normal and cancer cells can provide a useful framework in order to identify potential targets for anti-tumor therapies. One of the most promising strategies is the possibility to modulate apoptosis induced by anti-tumor agents. Cancer cell survival after chemotherapy will depend on specific checkpoints and/or repair pathways that have been lost, leading either to greater susceptibility to anti-tumor agents when the repair of damage is most important for survival or to greater resistance when the apoptotic response is more important. We have proposed a hypothesis that views survival and apoptotic processes (duality) in normal and tumor cells as genetically coupled (unity). We introduce, through a theoretical background, a new pathway of apoptotic inhibition. The proposed process of apoptotic inhibition is induced by mutation fixation in which recombination/repair processes (hRAD genes) play an important role. These coupled processes (duality in unity), to our view, underline tumor resistance by apoptotic inhibition and mutation fixation in normal cells exposed to anti-tumor agents.

A comparison of insulin lispro Mix25 and human insulin 30/70 in the treatment of type 2 diabetes during Ramadan

OBJECTIVE

To compare insulin lispro Mix25 and human insulin 30/70 with regard to their effect on morning and evening postprandial glucose (PPG) control, and on average daily blood-glucose (BG), in patients with Type 2 diabetes who wish to fast during Ramadan.

METHOD

Insulin lispro Mix25 and human insulin 30/70 were compared in an open-label, multicenter, randomised, crossover study involving 151 patients. Each treatment period had a duration of 14 days during which the patients self-monitored their BG before and 2 h after the main meals on any 3 days within the last 5 days of each treatment period.

RESULTS

The 2 h PPG excursion following the main evening meal after sunset was significantly lower with insulin lispro Mix25 (3.4+/-2.9 mmol/l) compared with human insulin 30/70 (4.0+/-3.2 mmol/l, P=0.007). The evening pre-meal fasting BG values were also lower with insulin lispro Mix25 (7.1+/-2.2 mmol/l) versus human insulin 30/70 (7.5+/-2.6 mmol/l, P=0.034). The average daily BG concentration was 9.5+/-2.4 mmol/l during treatment with insulin lispro Mix25 versus 10.1+/-2.5 mmol/l with human insulin 30/70 given in identical doses (P=0.004).

CONCLUSION

When compared with human insulin 30/70, treatment of insulin-requiring Type 2 patients with insulin lispro Mix25 during Ramadan resulted in better average daily glycaemia, and better BG control before and after the evening meal. Insulin lispro Mix25 should be considered as a therapeutic option during Ramadan.

Humalog Mix 25 in patients with type 2 diabetes which do not achieve acceptable glycemic control with oral agents: results from a phase III, randomized, parallel study

BACKGROUND

Humalog Mix 25 (Mix 25) is a premixed insulin mixture of 25% lispro and 75% neutral protamine lispro. Insulin lispro is an analog of human insulin. It is created when the amino acids at positions 28 and 29 of the B-chain of insulin are reversed. The natural sequence in human insulin at this position is proline at B28 and lysine at B29. The pharmacokinetic and pharmacodynamic profiles of insulin lispro indicate that it is more rapid acting, and therefore more physiological mealtime insulin than regular human insulin.

OBJECTIVE

Primary objective of this study was to compare twice daily treatment with insulin lispro low mixture (Mix 25) to oral treatment with glibenclamide in patients with type 2 diabetes, with respect to the mean 2-hour postprandial blood glucose excursions after breakfast and dinner.

SECONDARY OBJECTIVES

to compare the two treatments with regard to the following: hemoglobin A1c, fasting blood glucose, pre-dinner blood glucose, frequency of hypoglycemia, body weight, treatment satisfaction (by questionnaire).

METHODS

The study described is a randomized, open-label, parallel group comparison of two treatment regimens in patients with type 2 diabetes. The study included two periods. The lead-in period lasted 10 +/- 7 days, all patients were taking glibenclamide. The treatment period lasted 16 weeks. Patients were randomized to receive either glibenclamide 15 mg daily or switch to Mix 25 before breakfast and dinner. Study design is illustrated in Fig. 1. Glycemic control was assessed by glycosylated hemoglobin (HbA1c) measurements, 4-point self monitoring blood glucose profiles, and patient reported hypoglycemia. One treatment satisfaction questionnaire (Appendix 1) was completed by each participant.

RESULTS

175 patients were included from the two participating countries (Romania--100 patients and Russia--75 patients). 85 were randomized to receive Mix 25 and 90 to glibenclamide arm. 172 patients were included in the efficacy analysis. Baseline patient characteristics did not show any differences between treatment groups for any of the demographic (age, gender, height, body weight, body mass index) or efficacy parameters (HbA1c or self monitored BG values). The mean age was 59.5 +/- 8.2 years, and 35.5% (61/172) were men. The mean body mass index was 27.2 kg/m2. The mean duration of type 2 diabetes was 10.2 +/- 6.6 years, and the mean duration of sulfonylurea treatment was 5.8 +/- 5.9 years. The mean HbA1c and fasting blood glucose levels were 10.07 +/- 1.4% and 11.6 +/- 2.8 mmol/L, respectively, in the glibenclamide group and 9.85 +/- 1.2% and 12.2 +/- 2.9 mmol/L, respectively, in the Mix 25 group. At the end point, all efficacy parameters were better improved in Mix 25 group (HbA1c, fasting blood glucose, 2-hour postprandial blood glucose). Mean HbA1c was significantly lower in the Mix 25 group than in the GB group (Mix 25, 8.5% +/- 1.3%; GB, 9.4 +/- 1.8%; P = 0.001). For all self-monitored blood glucose values (Fig. 2) a larger decrease from baseline was observed in the Mix 25 group: -1.4% versus -0.7% for HbA1c, (P = 0.004); -2.8 mmol/L versus -1.1 mmol/L for fasting blood glucose, (P < 0.01); -5.1 mmol/L versus -1.7 mmol/L for the morning 2-hour postprandial blood glucose, (P < 0.001); -2.2 mmol/L versus -0.8 mmol/L for the evening preprandial blood glucose, (P < 0.05); and 4.4 mmol/L versus -1.5 mmol/L for the evening 2-hour postprandial blood glucose, (P < 0.001). Percentage of patients experiencing at least 1 episode of hypoglycemia was--as predicted--higher in the Mix 25 group (44.7% versus 10.3%; P = 0.01). Patients expressed more satisfaction with Mix 25 than with GB, as measured by the weighted combined score on a treatment satisfaction questionnaire (2.0 +/- 1.3 vs 0.7 +/- 1.3).

CONCLUSIONS

When glycemic control can no longer be achieved by oral antidiabetic agents, treatment with insulin should be considered as the next therapeutic option. Mix 25 provided good overall glycemic control, as well as patient treatment satisfaction.

Glycemic control with Humalog Mix25 in type 2 diabetes inadequately controlled with glyburide

BACKGROUND

Humalog Mix25 (Mix25) is a premixed insulin mixture of 25% insulin lispro and 75% neutral protamine lispro.

OBJECTIVE

The aim of this study was to quantitate the improvement in glycemic control achieved with Mix25 versus the maximum dose of glyburide (GB) in patients with type 2 diabetes inadequately controlled with GB.

METHODS

In this randomized, parallel, open-label comparative study, patients with type 2 diabetes received either Mix25 before the morning and evening meals for 4 months or GB 15 mg daily for 4 months. Glycemic control was assessed by glycosylated hemoglobin (HbA1c) measurements, 4-point self-monitored blood glucose profiles, and patient-reported hypoglycemia. Patients also completed a treatment satisfaction questionnaire at the end of the study.

RESULTS

All 172 patients were white; 85 were randomized to receive Mix25. The mean age was 59.5 +/- 8.2 years, and 35.5% (61/172) were men. The mean body mass index was 27.2 kg/m2. The mean duration of type 2 diabetes was 10.2 +/- 6.6 years, and the mean duration of sulfonylurea treatment was 5.8 +/- 5.9 years. The mean HbA1c and fasting blood glucose levels were 10.07% +/- 1.4% and 11.6 +/- 2.8 mmol/L, respectively, in the glyburide group and 9.85% +/- 1.2% and 12.2 +/- 2.9 mmol/L, respectively, in the Mix25 group. There were no statistically significant differences between the treatment groups at baseline for any of the demographic or efficacy variables. At end point, mean HbA1c was significantly lower in the Mix25 group than in the GB group (Mix25, 8.5% +/- 1.3%; GB, 9.4% +/- 1.8%; P = 0.001). A larger decrease from baseline in HbA1c and in all self-monitored blood glucose values was observed in the Mix25 group: -1.4% versus -0.7% for HbA1c, P = 0.004; -2.8 mmol/L versus -1.1 mmol/L for fasting blood glucose, P < 0.01; -5.1 mmol/L versus -1.7 mmol/L for the morning 2-hour postprandial blood glucose, P < 0.001; -2.2 mmol/L versus -0.8 mmol/L for the evening preprandial blood glucose, P < 0.05; and -4.4 mmol/L versus -1.5 mmol/L for the evening 2-hour postprandial blood glucose, P < 0.001. Patients expressed more satisfaction with Mix25 than with GB, as measured by the weighted combined score on a treatment satisfaction questionnaire (2.0 +/- 1.3 vs 0.7 +/- 1.3). The mean hypoglycemia rate (events per patient per 30 days) was significantly higher in the Mix25 group at end point (Mix25, 0.30 +/- 0.53; GB, 0.05 +/- 0.20; P < 0.001).

CONCLUSIONS

Compared with maximum-dose GB, twice-daily injections of Mix25 resulted in improved glycemic control and treatment satisfaction, and were associated with a predictably higher rate of hypoglycemia in this group of patients with type 2 diabetes who were inadequately controlled with maximum-dose GB. Although the inclusion of patients who were inadequately controlled with GB was intended to allow a comparison of the 2 treatments with respect to efficacy and tolerability in a real-life setting, a double-blind comparison in treatment-naive individuals may have resulted in a different outcome.

How recombinant insulin analogs improve insulin therapy of diabetes mellitus: pathophysiology, clinical practice and recommendations

According to the latest prognoses, 300 million people are expected to suffer from diabetes (particularly type 2) in 2025; diabetes will become a new epidemics of the coming century. Therefore it is so important to get acquainted with the pathomechanism of diabetes-related disorders and the possibilities of effective treatment. During the last decade, numerous prospective epidemiological studies have been completed, which have considerably extended our knowledge of the pathomechanism of disturbances and their effect on late complications of diabetes. Resistance to insulin has an important role in the etiology of type 2 diabetes. However, there is substantial evidence indicating that impairment or regression of rapid insulin secretion phase at the early stage of the disease is a factor of no lesser importance. The lack of appropriate insulin concentration after the stimulation by food ingestion (first 30 min after the meal), leads to permanent, treatment-resistant hyperglycemia. The postulated attempts to obtain a 'nearly normoglycemic' condition, as well as the results of prospective epidemiological studies proving that achieving this aim improves the prognosis of diabetic patients, prompt the researchers to search for the drugs or treatment schedules, which could effectively restore the impaired insulin secretion, and its early phase in particular, in type 2 diabetes. Human insulin analogs and their pre-formulated commercially available mixtures seem very promising in this respect.

Intramuscular injection of insulin lispro or soluble human insulin: pharmacokinetics and glucodynamics in Type 2 diabetes

AIM

The aim of the study was to compare the pharmacokinetics and glucodynamics of insulin lispro and soluble human insulin following intramuscular (i.m.) injection in patients with Type 2 diabetes with secondary failure of sulphonylureas.

METHODS

Single 15-U i.m. doses of insulin lispro or soluble human insulin were administered to 16 patients in a two-way, randomized, crossover design. Glucodynamic and pharmacokinetic parameters were determined over 6 h after insulin injection using clamp techniques.

RESULTS

Insulin C(max) was significantly higher (971 +/- 217 vs. 659 +/- 141 pmol/l, P < 0.001) and T(max) was significantly shorter (46.9 +/- 27 vs. 94.7 +/- 50.1 min, P = 0.002) with insulin lispro. Glucose infusion rate (GIR) curves showed clear separation 20 min after injection and were significantly greater for insulin lispro during the 40-60, 60-80 and 80-100-minute time intervals. Total glucose infused was only approximately 5% larger with insulin lispro during the 6-h follow-up, due to lower insulinaemia at later time points. The glucose R(max) and TR(max) were not statistically different between insulin treatments.

CONCLUSION

This study shows that i.m. injection of insulin lispro is followed by its more rapid absorption, which results in stronger metabolic effect in the first 2 h when compared with soluble human insulin under the same test conditions. Diabet. Med. 18, 562-566 (2001)

Low arylsulphatase A activity in the development of psychiatric disorders

Previous studies have suggested that arylsulphatase A (ASA) deficiency may be present in psychiatric patients. A number of patients with low ASA activity and various neuropsychiatric symptoms have been observed. Metachromatic leucodystrophy (MLD) is a disease caused by deficiency of the enzyme ASA. Clinically, adult MLD may present as a schizophrenia-like psychosis, deterioration of cognitive functions, personality changes, depression and dementia. However, there are individuals with low ASA activity without clinical symptoms of MLD. This state is described as ASA pseudodeficiency. It remains controversial whether low ASA activity predisposes to or influences the development of psychiatric symptoms. Relatively little attention has been paid to the role of neurodegenerative processes in the pathophysiology of psychiatric disorders. The hypothesis underlying this work is that there is a subclass of mentally ill patients whose psychiatric problems are at least partly caused by an abnormal ASA. The purpose of this particular study was to determine whether an abnormal ASA could be detected in schizophrenic, major depressed and demented patients and control subjects. There were 66 schizophrenic, 59 major depressed and 61 demented patients. The control group consisted of 102 healthy volunteers. Leucocyte ASA activity was determined from blood samples, using p-nitrocatechol sulphate as substrate. Our results show that low ASA activity is more frequently found in psychiatric patients than in control subjects. Our findings indicate that clinical types of major depression and schizophrenia could be connected with low ASA activity. The presence of a decreased ASA activity points to the conclusion that an enzyme deficit entails vulnerability to psychiatric disorders.

Colonic vasoactive intestinal polypeptide (VIP) in ulcerative colitis--a radioimmunoassay and immunohistochemical study

BACKGROUND/AIMS

In this study, we present radioimmunoassay data describing the concentration of Vasoactive Intestinal Polypeptide (VIP) in both plasma and colonic biopsies, as well as immunostaining of VIPergic innervation in mucosal biopsies of normal subjects and patients with ulcerative colitis (UC).

PATIENTS AND METHODS

Thirty three patients with UC and 17 healthy subjects were investigated. All UC patients suffered from active disease. Fasting circulating levels of VIP in plasma as well as tissue concentrations were measured by radioimmunoassay. For the immunohistochemistry, polyclonal antibody against VIP and the streptavidin-biotin peroxidase complex technique were carried out.

RESULTS

Overall plasma VIP concentrations in the UC patients were similar to those in the controls. Significantly decreased concentrations of VIP were found in UC of rectum compared to the normal tissue. However, both plasma VIP values and tissue concentrations were found to be significantly lower in patients expressing minimal or mild active disease according to clinical activity index (AI) and histological activity index (HAI), but marked increase of plasma VIP was clear in UC patients with moderate or severe AI and HAI. There was a trend towards increased tissue concentrations of VIP in the group of patients with moderate or severe AI and HAI. Our immunohistochemical analysis of VIP fibers and nerve cell bodies revealed consistently weaker VIP-immunoreactivity in the rectum in UC patients with minimal or mild HAI. Simultaneously, in the rectal biopsies from UC patients with moderate and severe disease, the fibers in the lamina propria and ganglion cells in the submucous plexus were markedly increased in density and in degree of immunostaining. Very strong immunoreactivity was also found in inflammatory cells of the lamina propria as well as in the epithelial layer of the biopsies from UC patients with obvious disease.

CONCLUSIONS

Our study shows clearly the heterogeneity in the response of VIP plasma level as well as rectum concentration and distribution in UC patients at different stages of the active disease. The possible role of VIP in the colon suggests that further studies of the alterations of this gut peptide may be useful in the understanding of UC pathophysiology.