Postprandial blood glucose predicts cardiovascular events and all-cause mortality in type 2 diabetes in a 14-year follow-up: lessons from the San Luigi Gonzaga Diabetes Study.

OBJECTIVE: To evaluate whether postprandial blood glucose predicts cardiovascular events and all-cause mortality in type 2 diabetes in a long-term follow-up taking into account A1C and the main cardiovascular risk factors. RESEARCH DESIGN AND METHODS: Consecutive type 2 diabetic patients (n = 505) followed up at our diabetes clinic were evaluated at baseline (1995) for the main cardiovascular risk factors and for five glycemic control parameters (fasting blood glucose, blood glucose 2 h after breakfast, blood glucose 2 h after lunch, blood glucose before dinner, and A1C); all-cause mortality and the first cardiovascular events occurring during the 14-year follow-up were measured. RESULTS: We observed 172 cardiovascular events (34.1% of the population) and 147 deaths (29.1% of the population). Using the Cox analysis with the backward method, we categorized the variables according to the therapeutic targets of the American Diabetes Association. Our observations were as follows. When the five glycemic control parameters were considered together, the predictors were 1) for cardiovascular events, blood glucose 2 h after lunch (hazard ratio 1.507, P = 0.010) and A1C (1.792, P = 0.002); and 2) for mortality, blood glucose 2 h after lunch (1.885, P < 0.0001) and A1C (1.907, P = 0.002). When blood glucose 2 h after lunch and A1C were considered together with the main cardiovascular risk factors, the following glycemic control parameters were predictors: 1) for cardiovascular events, blood glucose 2 h after lunch (1.452, P = 0.021) and A1C (1.732, P = 0.004); and 2) for mortality, blood glucose 2 h after lunch (1.846, P = 0.001) and A1C (1.896, P = 0.004). CONCLUSIONS: In type 2 diabetes, both postprandial blood glucose and A1C predict cardiovascular events and all-cause mortality in a long-term follow-up.

Evaluation of a simple policy for pre- and post-prandial blood glucose self-monitoring in people with type 2 diabetes not on insulin.

BACKGROUND AND AIMS: Since there is no agreement on regimens of self-monitoring of blood glucose (SMBG) in type 2 diabetes not on insulin, we evaluated the effects of a simple SMBG policy taking into account compliance. METHODS AND RESULTS: 273 type 2 diabetic patients not on insulin with HbA1c >7% attending our Diabetes Clinic and already using SMBG were randomized as follows: Group A, one BG profile/month with fasting and post-prandial values; Group B, one BG profile every 2 weeks with pre- and post-prandial values. Patients were followed-up by the same team every 3 months with the same education and treatment policies. At 3 and 6 months, SMBG profiles were evaluated and HbA1c measured. SMBG was carried out as recommended by 73% of Group A and 44% of Group B patients. In compliant patients, HbA1c and BG were unchanged in Group A whereas in Group B fasting, pre-prandial and two out of three post-prandial BG values were reduced and HbA1c decreased from 8.09+/-0.84% to 7.60+/-0.73% (p<0.001). The influence on BG control was similar for the two policies when compliance was not considered. CONCLUSIONS: The more intensive SMBG policy considered is associated with improvements in glycaemic control in compliant subjects.

High glucose rapidly activates the nitric oxide/cyclic nucleotide pathway in human platelets via an osmotic mechanism.

The aim was to evaluate whether high glucose influences the nitric oxide (NO)/cyclic nucleotide pathway in human platelets via osmotic stress and to clarify the role of protein kinase C (PKC) in this phenomenon. The study was carried out on 33 healthy lean male volunteers, aged 28.3+/-1.3 years. NO synthesis was detected as L-citrulline production after L-arginine incubation in platelets incubated for 6 min with 22.0 mM D-glucose and iso-osmolar concentrations of mannitol, L-glucose and fructose. To evaluate the influence of PKC, experiments with D-glucose and mannitol were repeated in the presence of the PKC-beta selective inhibitor LY379196, and NO synthesis was detected after a 6-min incubation with phorbol 12-myristate 13-acetate (PMA), a non-selective PKC activator. Platelet content of guanosine-3',5'-cyclic monophosphate (cGMP) and adenosine-3',5'-cyclic monophosphate (cAMP) was measured by radioimmunoassay in platelets incubated with iso-osmolar concentrations of D-glucose, mannitol, L-glucose and fructose. NO-dependence of cyclic nucleotide enhancements was evaluated by inhibiting NO synthase and guanylate cyclase. Platelet aggregation to ADP and collagen was evaluated in Platelet-Rich Plasma (PRP) in the presence of a 6-min incubation with D-glucose and mannitol, both without and with LY379196 and the guanylate cyclase inhibitor (H-[1,2,4]Oxadiazolo [4,3-a]quinoxaline-1-one)(ODQ). Iso-osmolar concentrations of D-glucose, mannitol, L-glucose and fructose, and PMA increased NO production (p=0.0001). Effects of D-glucose and mannitol were blunted by LY379196. D-glucose and mannitol enhanced platelet cGMP and cAMP (p=0.0001) with a mechanism blunted by NO synthase and guanylate-cyclase inhibition, but did not modify platelet aggregation. In conclusion, glucose activates the NO/cyclic nucleotide pathway in human platelets with an osmotic mechanism mediated by PKC-beta.

Platelet resistance to the antiaggregating effect of N-acetyl-L-cysteine in obese, insulin-resistant subjects.

INTRODUCTION: We investigated whether the platelets from obese subjects are sensitive as those from controls to the antiaggregating effects of N-acetyl-L-cysteine (NAC)-an antioxidant thiol that increases availability of endogenous nitric oxide (NO)-and of superoxide dismutase (SOD) and amifostine which act as scavengers of superoxide anion. MATERIALS AND METHODS: In platelets from obese subjects (n=20, body mass index [BMI]=34.2+/-1.9 kg/m(2), homeostasis model assessment [HOMA] index=5.5+/-1.1) and controls (n=20, BMI=21.4+/-0.6 kg/m(2), HOMA index=1.4+/-0.2), we investigated the effects of NAC on aggregation and on 3',5'-cyclic guanosine monophosphate (cGMP) synthesis and the interplay between NAC and the organic nitrates glyceryl trinitrate (GTN) and sodium nitroprusside (SNP). Similar experiments were carried out with SOD and amifostine. RESULTS: We found that a 3-min platelet exposure to NAC decreased aggregation and increased cGMP in controls, but not in obese subjects. Only more prolonged incubations exerted a small effect also in obese subjects. GTN and SNP increased platelet cGMP in both groups, but their effect was much lower in obese subjects. NAC (3 mmol/l), SOD (150 U/ml), and amifostine (50 micromol/l) enhanced the increase of cGMP elicited by NO donors, but again, the effect was much lower in obese subjects. CONCLUSIONS: Since antioxidants do not restore the effects of NO in platelets from obese subjects, we hypothesize that oxidative stress is not the unique cause of platelet resistance to NO in obesity and suggest that a resistance to the NO action at the guanylate cyclase level could play a role in this phenomenon, potentially involved in the increased atherothrombotic risk linked to obesity.

Comparison between the effects of the rapid recombinant insulin analog aspart and those of human regular insulin on platelet cyclic nucleotides and aggregation.

INTRODUCTION: Insulin aspart is a rapid insulin analog used in clinical practice: aim of the present study is to evaluate in human platelets its influence on: (i). concentrations of guanosine 3':5'-cyclic monophosphate (cGMP) and adenosine 3':5'-cyclic monophosphate (cAMP), mediators of platelet anti-aggregation; (ii). platelet aggregation to adenosine-5 diphosphate. MATERIALS AND METHODS: In human platelets, incubated with human regular insulin or with insulin aspart, we measured: (1). guanosine 3':5-cyclic monophosphate and adenosine 3':5'-cyclic monophosphate concentrations by radioimmunoassays, with and without nitric oxide synthase (NOS) inhibition by N(G)-monomethyl-L-arginine, and phosphatidylinositol-3-kinase inhibition by wortmannin; (ii). aggregation to adenosine-5 diphosphate by Born's method. RESULTS: (i). Human regular insulin and insulin aspart increased both cyclic nucleotides; (ii). these effects were dependent on nitric oxide, being inhibited by N(G)-monomethyl-L-arginine, and mediated by the phosphatidylinositol-3-kinase pathway of insulin signalling, being inhibited by wortmannin; (iii). the effects exerted by insulin aspart on both cyclic nucleotides (ANOVA, p=0.0001) were more prolonged than those exerted by regular insulin; (iv) like human regular insulin, insulin aspart significantly decreased platelet response to ADP (ANOVA, p=0.0001): after 60 min of incubation, the anti-aggregating effect exerted by insulin aspart was significantly greater than that exerted by human regular insulin (p=0.027). CONCLUSIONS: The effects of insulin aspart on platelet cyclic nucleotides and aggregation show kinetic differences compared to those of human regular insulin, resulting in more prolonged effects.

Insulin influences the nitric oxide cyclic nucleotide pathway in cultured human smooth muscle cells from corpus cavernosum by rapidly activating a constitutive nitric oxide synthase.

AIMS: We have evaluated, in cultured human cavernosal smooth muscle cells, the expression and activity of calcium-dependent constitutive nitric oxide synthase (cNOS) and the ability of insulin to induce nitric oxide (NO) production and to increase intracellular cyclic nucleotides guanosine 3',5'-cyclic monophosphate (cGMP) and adenosine 3',5'-cyclic monophosphate (cAMP). METHODS: cNOS mRNA was detected by RT-PCR amplification, cNOS protein by immunofluorescence, cNOS activity as l-[3H]-citrulline production from l-[3H]-arginine and cyclic nucleotides by radioimmunoassay. RESULTS: cNOS mRNA and cNOS protein were found in cultured cells; cNOS activity was increased by 5-min exposure to 1 micro mol/l calcium ionophore ionomycin (from 0.1094+/-0.0229 to 0.2685+/-0.0560 pmol/min per mg cell protein, P=0.011) and to 2 nmol/l insulin (from 0.1214+/-0.0149 to 0.2045+/-0.0290 pmol/min per mg cell protein, P=0.041). Insulin increased both cGMP and cAMP in a dose- and time-dependent manner (i.e. with 2 nmol/l insulin, cGMP rose from 2.71+/-0.10 to 6.80+/-0.40 pmol/10(6) cells at 30 min, P=0.0001; cAMP from 1.26+/-0.06 to 3.02+/-0.30 pmol/10(6) cells at 60 min, P=0.0001). NOS inhibitor N(G)-monomethyl-l-arginine and phosphatidylinositol 3-kinase (PI 3-kinase) inhibitors wortmannin and LY 294002 blunted these effects of insulin. The action of insulin on cyclic nucleotides persisted in the presence of phosphodiesterase inhibition, guanylate cyclase activation by NO donors and adenylate cyclase activation by Iloprost or forskolin. CONCLUSION: Human cavernosal smooth muscle cells, by expressing cNOS activity, are a source of NO and not only its target; in these cells, insulin rapidly activates cNOS through a PI 3-kinase pathway, with a consequent increase of both cyclic nucleotides, thus directly influencing the mechanisms involved in penile vascular tone and interplaying with classical haemodynamic mediators.

Adenosine increases human platelet levels of cGMP through nitric oxide: possible role in its antiaggregating effect.

Adenosine is an endogenous antiaggregating substance that influences the platelet responses through specific A-type receptors that activate adenylate cyclase increasing the levels of 3',5'-cyclic adenosine monophosphate (cAMP). In this study, we investigated whether adenosine can also influence the levels of 3',5'-cyclic guanosine monophosphate (cGMP) and decrease the aggregating response of human platelets to adenosine-5-diphosphate (ADP) through this nucleotide. In platelet samples from healthy volunteers, we evaluated the effect of adenosine on ADP-induced aggregation and cyclic nucleotide synthesis. Some experiments were repeated in the presence of dipyridamole (inhibitor of adenosine uptake and phosphodiesterase activity), N(G)-monomethyl-L-arginine (L-NMMA, nitric synthase inhibitor), ionomycin (calcium ionophore), and ambroxol (2-amino-3,5-dibromo-N-[trans-4-hydroxycyclohexyl]benzylamine, inhibitor of nitric oxide (NO)-dependent activation of guanylate cyclase). Adenosine decreased the response to ADP in a concentration-dependent way (analysis of variance, ANOVA: P<.0001): cAMP levels increased from 30.0 +/- 2.0 (control) to 46.0 +/- 3.0 pmol/10(9) platelets (in the presence of 15 mumol/l adenosine) and cGMP levels increased from 5.6 +/- 1.0 (control) to 10.9 +/- 2.0 pmol/10(9) platelets (in the presence of 15 mumol/l adenosine). Also, nucleotide levels measured at the end of aggregation were higher in platelet samples exposed to adenosine than in controls. Dipyridamole at 40 mumol/l slightly increased adenosine's effects on both nucleotides. L-NMMA blunted the effect of adenosine on cGMP both in unstimulated samples and in aggregated platelets without any effect on cAMP synthesis. Platelet exposure to L-NMMA and ambroxol partially prevented adenosine's effect on ADP-induced aggregation. In conclusion, adenosine, which enhances intraplatelet cAMP levels, was determined to also cause an increase in cGMP concentrations through a mechanism that involves NO synthesis. This effect plays a direct role in the adenosine-induced antiaggregation.