Comparison of clinical efficacy and safety of weekly glucagon-like peptide-1 receptor agonists dulaglutide and semaglutide in Japanese patients with type 2 diabetes: Randomized, parallel-group, multicentre, open-label trial (COMING study).

AIM: To compare the clinical usefulness of once-weekly glucagon-like peptide-1 receptor agonists dulaglutide and semaglutide at the doses approved for use in Japanese patients with type 2 diabetes. METHODS: In total, 120 patients with glycated haemoglobin (HbA1c) ≥7% were randomly assigned to dulaglutide (n = 59) or semaglutide group (n = 61), and 107 participants (dulaglutide/semaglutide = 53/54) completed the 24-week trial. The primary endpoint was the difference of HbA1c level between the two groups at 24 weeks. RESULTS: HbA1c level at 24 weeks was significantly lower in the semaglutide group (7.9 ± 0.5%-6.7 ± 0.5%) compared with the dulaglutide group (8.1 ± 0.6%-7.4 ± 0.8%) (p < .0001). Reduction in body mass index and visceral fat area were also more significant in the semaglutide group (p < .05, respectively). The achievement rate of HbA1c <7% was higher in the semaglutide group (p < .0001). The parameters such as low-density lipoprotein cholesterol, alanine aminotransferase and γ-glutamyl transpeptidase were decreased in the semaglutide group. Surprisingly, only semaglutide group significantly improved the apolipoprotein B/A1 ratio, which is considered a useful myocardial infarction risk index. Using computed tomography, the liver to spleen ratio was significantly elevated only in the semaglutide group. In contrast, gastrointestinal symptoms were observed in 13.2% of dulaglutide and 46.3% of semaglutide group (p < .01). The Diabetes Treatment-Related Quality of Life scores related to pain and gastrointestinal symptoms were also superior in the dulaglutide group. CONCLUSIONS: This prospective trial showed that semaglutide has more pronounced glucose- and body mass index-lowering effects and reduces liver fat percentage and visceral fat area and that dulaglutide has less gastrointestinal symptoms and superior Diabetes Treatment-Related Quality of Life scores related to pain and gastrointestinal symptoms.

Seven-year Observational Study on the Association between Glycemic Control and the New Onset of Macroangiopathy in Japanese Subjects with Type 2 Diabetes.

Objective To examine the association between glycemic control and the new onset of macroangiopathy in Japanese subjects with type 2 diabetes. Methods We examined seven-year follow-up data for 572 patients. We divided the subjects by the average of seven-year glycemic control based on the guidelines. First, we excluded the subjects with a past history of macroangiopathy and then examined the incidence of the new onset of macroangiopathy. Results The incidence of ischemic heart disease (IHD) was 1.0% per year, and that of cerebral vascular disease (CVD) was 1.0% per year. However, IHD events were not observed at all for five years in the most intensive glycemic control group (HbA1c<6%). Similarly, CVD events were not observed at all for seven years in the most intensive glycemic control group (HbA1c<6%). In addition, the cumulative incidence rate of IHD tended to increase as the glycemic control became poorer (HbA1c<6%, 4.5%; 6%≤HbA1c<7%, 6.0%; 7%≤HbA1c<8%, 7.2%; HbA1c≥8%, 10.7%). Furthermore, a logistic regression analysis showed that the duration of diabetes and HbA1c level were independent risk factors contributing to the onset of IHD, but not to the onset of CVD. Conclusion This seven-year observational study showed the possible association between glycemic control and the onset of macroangiopathy in a total of 572 Japanese subjects with type 2 diabetes.

Azelnidipine, but not amlodipine, reduces urinary albumin excretion and carotid atherosclerosis in subjects with type 2 diabetes: blood pressure control with olmesartan and azelnidipine in Type 2 diabetes (BOAT2 study).

To evaluate the efficacy of azelnidipine and amlodipine on diabetic nephropathy and atherosclerosis, we designed a prospective and randomized controlled clinical study in type 2 diabetic patients with stable glycemic control with fixed dose of anti-diabetic medication. Although there was no difference in blood pressure between both groups, urinary albumin excretion and maximum carotid intima-media thickness were reduced in azelnidipine group, but not in amlodipine group. In addition, inflammatory cytokine levels were decreased only in azelnidipine group which possibly explains such beneficial effects of azelnidipine on urinary albumin excretion and carotid atherosclerosis.

Concomitant use of miglitol and mitiglinide as initial combination therapy in type 2 diabetes mellitus.

AIM: To evaluate the efficacy of miglitol and mitiglinide alone or in combination on the metabolic profile and incretin secretion in Japanese type 2 diabetes patients. METHODS: Patients on diet and exercise with or without metformin, were randomized to receive either miglitol, mitiglinide, or a combination, three times daily for 12 weeks. RESULTS: At 12 weeks, HbA1c decreased significantly (p<0.001) and 1,5-AG increased significantly (p<0.001) in all three groups, with the greatest change seen with combination therapy. Effective improvement of postprandial hyperglycemia was demonstrated by a meal-loading test in all three interventions but serum insulin concentration was not increased by miglitol. In a subset of patients without prior metformin administration, faster and better glycemic control was achieved with the initial combination. After meal loading, serum total GLP-1 significantly increased only with miglitol monotherapy (p<0.05) and serum total GIP significantly decreased (p<0.01) in the arms employing miglitol after 12 weeks. CONCLUSION: Miglitol/mitiglinide combination is more potent than monotherapy in improving glycemic control through the reduction of postprandial glucose excursion and the simultaneous sparing of additional insulin secretion. A marked difference in the effects of miglitol and mitiglinide on incretin secretion was also demonstrated.

Molecular mechanism by which pioglitazone preserves pancreatic beta-cells in obese diabetic mice: evidence for acute and chronic actions as a PPARgamma agonist.

Pioglitazone preserves pancreatic beta-cell morphology and function in diabetic animal models. In this study, we investigated the molecular mechanisms by which pioglitazone protects beta-cells in diabetic db/db mice. In addition to the morphological analysis of the islets, gene expression profiles of the pancreatic islet were analyzed using laser capture microdissection and were compared with real-time RT-PCR of db/db and nondiabetic m/m mice treated with or without pioglitazone for 2 wk or 2 days. Pioglitazone treatment (2 wk) ameliorated dysmetabolism, increased islet insulin content, restored glucose-stimulated insulin secretion, and preserved beta-cell mass in db/db mice but had no significant effects in m/m mice. Pioglitazone upregulated genes that promote cell differentiation/proliferation in diabetic and nondiabetic mice. In db/db mice, pioglitazone downregulated the apoptosis-promoting caspase-activated DNase gene and upregulated anti-apoptosis-related genes. The above-mentioned effects of pioglitazone treatment were also observed after 2 days of treatment. By contrast, the oxidative stress-promoting NADPH oxidase gene was downregulated, and antioxidative stress-related genes were upregulated, in db/db mice treated with pioglitazone for 2 wk, rather than 2 days. Morphometric results for proliferative cell number antigen and 4-hydroxy-2-noneal modified protein were consistent with the results of gene expression analysis. The present results strongly suggest that pioglitazone preserves beta-cell mass in diabetic mice mostly by two ways; directly, by acceleration of cell differentiation/proliferation and suppression of apoptosis (acute effect); and indirectly, by deceleration of oxidative stress because of amelioration of the underlying metabolic disorder (chronic effect).

Gallbladder edema in type 1 diabetic patient due to delayed-type insulin allergy.

A 29-year-old woman was diagnosed as having type 1 diabetes mellitus and received insulin aspart and NPH insulin (NovolinN). On day 22, she had leg edema and right abdominal pain. The serum hepatobiliary enzyme levels were markedly elevated. Computed tomography revealed gallbladder edema. After an injection of human regular insulin and NPH insulin (HumacartN), the elevated liver enzyme levels were no longer observed. Challenge testing demonstrated that protamine was the cause of her allergy. Furthermore, tests revealed increased VEGF levels. This is an extremely rare case with a delayed-type protamine allergy caused by NovolinN resulting in gallbladder edema.

Molecular analysis of db gene-related pancreatic beta cell dysfunction; evidence for a compensatory mechanism inhibiting development of diabetes in the db gene heterozygote.

The db gene homozygous, but not heterozygous, mice develop diabetes with severe beta-cell damage. We investigated the molecular mechanism underlying db gene-associated pancreatic beta-cell dysfunction. Islet morphology, beta-cell function, and gene expression profiles specific for pancreatic islet cells were compared among db gene homozygous(db/db), heterozygous (db/m) and unrelated m/m mice. The beta-cell ratio decreased in db/db mice with age, but not in non-diabetic db/m and m/m mice. The islet insulin content was lower, but the triglyceride content was higher in db/db than other mice. The islet cell specific gene expression profiles analyzed by laser capture microdissection method and morphological findings suggested an augmentation of beta-cell apoptosis, oxidative stress and ER stress in db/db mice. Interestingly, insulin I and II, anti-apoptotic bcl-2, and proliferation promoting ERK-1 gene expressions were significantly upregulated in db/m mice. An impaired glucose tolerance was shown in m/m mice fed a high fat diet, but not in db/m mice, in which a higher insulin response and increased beta-cell mass were observed. Expressions of insulin I and II, bcl-2, and ERK-1 gene were increased in db/m mice, but not in m/m fed a high fat diet. The present results strongly suggest that the db gene heterozygote, but not homozygote, acquires a compensatory mechanism suppressing beta-cell apoptosis and augmenting the capacity of beta-cell function.

MIN6 is not a pure beta cell line but a mixed cell line with other pancreatic endocrine hormones.

MIN6 cells retains glucose-stimulated insulin secretion (GSIS) as isolated islets. We comprehensively evaluated the gene expression and production of other islet hormones in MIN6 cells. Islet hormones were demonstrated by immunohistochemical staining and measured by ELISA. The gene expression profiles of MIN6 cells were compared with those in the mouse islets obtained by the laser capture micro-dissection (LCM). MIN6 cells excreted insulin, glucagon, somatostatin and ghrelin. They expressed mRNAs of insulin I and II, proglucagon, somatostatin, pancreatic polypeptide (PP) and ghrelin which were shown in the mouse pancreatic islet core and periphery obtained by LCM. A variety of genes closely related to the islet hormone producing cells were expressed in MIN6. Confocal laser scanning microscopy revealed that MIN6 cells included not only insulin positive cells but also insulin and glucagon or somatostin double positive cells. Glucagon, somatostatin and ghrelin were detectable in the culture medium. The present study clearly demonstrated that MIN6 produce pancreatic endocrine cells. It would be possible to use this cell line as a model to research the development, cell differentiation and function of pancreatic islets.

Effects of sulfonylurea drugs on adiponectin production from 3T3-L1 adipocytes: implication of different mechanism from pioglitazone.

Adiponectin is a fat-derived cytokine with anti-diabetic and anti-atherogenic properties. In this study, effects of sulfonylureas (SUs) on adiponectin production and the action mechanism were evaluated using 3T3-L1 adipocytes. The cells were incubated with glimepiride, glibenclamide, gliclazide, pioglitazone, metformin and the medium only as the control. In the control, the adiponectin level evaluated as the production rate per 24 h was not changed, while pioglitazone significantly increased the adiponectin level. SUs also increased the adiponectin level, but metformin failed to show any increase in adiponectin production. SUs induced adiponectin gene expression as well as pioglitazone. Pioglitazone significantly increased adipogenesis, but glimepiride did not. The aP2 gene expression was increased by pioglitazone, but not by glimepiride. Forskolin, a protein kinase A stimulator, reduced the adiponectin production stimulated by glimepiride but not by pioglitazone. These observations strongly suggest that SUs stimulate the adiponectin production through a different mechanism from pioglitazone, namely an interaction with protein kinase A activity. The significance of the extrapancreatic action of SUs observed in this study should be further evaluated in the clinical field.

Pharmacokinetics and pharmacodynamics of glimepiride in type 2 diabetic patients: compared effects of once- versus twice-daily dosing.

To compare the pharmacokinetic and pharmacodynamic effects of glimepiride between once- and twice-daily dosing in type 2 diabetic patients. Eight Japanese type 2 diabetic patients, who had been treated with 2 mg glimepiride alone over 4 weeks (age 40-70, body mass index

Analysis of waist circumference in Japanese subjects with type 2 diabetes mellitus: lack of propriety to define the current criteria of metabolic syndrome.

A necessary condition of advocated criteria to determine the metabolic syndrome (MetS) in Japan is waist circumference (WC), which varies among races. In this study, we measured WC and visceral fat area (VFA) in subjects with type 2 diabetes (T2DM) and assessed the propriety of new criteria of MetS in Japan. Four hundred and nineteen patients (M/F: 258/161, age: 60.4+/-0.7 years, BMI: 24.4+/-0.2 kg/m(2)) who received abdominal CT examination were analyzed, and 178 (M/F: 111/67) subjects sufficed the criteria of MetS. Average VFA was significantly larger in subjects with MetS (162+/-3 cm(2) versus 82+/-3 cm(2), p<0.01). The WC and VFA were correlated significantly in both male (r=0.78, p<0.001) and female (r=0.82, p<0.001), and corresponding VFA at 85 cm of WC in male and at 90 cm in female were 125 cm(2) and 120 cm(2). Incidence of cardio- and cerebro-vascular diseases (CVD) was not different between subjects with and without MetS. The present cross-sectional study strongly suggests that the recommended WC is not suitable to define the current criteria of MetS (VFA, > or =100 cm(2)) and its criteria is not appropriate to segregate a risk of CVD in Japanese T2DM subjects. Further prospective analysis should be required to validate the criteria and clinical significance of MetS in T2DM.

Effect of apolipoprotein E4 allele on plasma LDL cholesterol response to diet therapy in type 2 diabetic patients.

OBJECTIVE: The aim of this study was to investigate the effect of apolipoprotein (apo)E4 allele on plasma LDL cholesterol response to calorie-restricted diet therapy in type 2 diabetic patients. RESEARCH DESIGN AND METHODS: Twenty-four diabetic patients with the apoE3/3 genotype and 11 diabetic patients with the apoE4/3 genotype were recruited. Participants were hospitalized for calorie-restricted diet therapy (25.0 kcal. kg body wt(-1). day(-1)) for 14 days. Body weight, fasting plasma glucose (FPG) levels, and plasma lipid levels on hospital days 1 and 14 were compared between the two apoE genotype groups. RESULTS: There were no significant differences in baseline FPG levels, HbA(1c) levels, BMI, and plasma levels of total cholesterol, triglyceride, and HDL cholesterol between the two apoE genotype groups, but baseline plasma levels of LDL cholesterol were significantly higher in the apoE4/3 group than in the apoE3/3 group. Body weight decreased slightly and FPG levels decreased significantly after diet therapy in both apoE genotype groups. In the apoE3/3 group, only plasma levels of triglyceride decreased significantly after diet therapy, whereas in the apoE4/3 group, plasma levels of triglyceride, total cholesterol, and LDL cholesterol decreased significantly after diet therapy. The decrease (percentage of change) in total cholesterol (-16.3 vs. -6.6%) and LDL cholesterol (-15.6 vs. -0.7%) after diet therapy was significantly greater in the apoE4/3 group than in the apoE3/3 group. CONCLUSIONS: Calorie-restricted diet therapy is more effective in reducing plasma LDL cholesterol in type 2 diabetic patients with the apoE4 allele.

The higher immunoreactivity to ACE (angiotensin converting enzyme) in patients with type 2 diabetes mellitus than in non-diabetic individuals.

In a random sample of 200 patients with type 2 diabetes mellitus, immunoreactivities to ACE (angiotensin converting enzyme) were measured by ELISA. Immunoreactivities were positive for 129 (64.5%) patients, and were positive in 30 (83.3%) out of 36 patients in the early stage of clinical diabetic nephropathy. Serum ACE activity in rabbits immunized with ACE decreased to 50% of the control level after 7 months (78.0 +/- 3.8 IU/L/37 degrees C, basal, 42.0 +/- 5.0 at 7 months and 33.3 +/- 3.5 IU/L/37 degrees C at 8 months, respectively). When rabbit serum containing antiACE antibodies was mixed, after heat-treatment at 56 degrees C for 30 min, with normal human serum, the ACE activity was reduced in a concentration-dependent manner. These results suggested that anti-ACE autoantibody may be present in patients with type 2 diabetes mellitus. However, the absence of data on the epitope for the antibody does not allow any conclusion except that the immunoreactivities to ACE are higher in type 2 diabetic patients than in non-diabetic individuals.

Immunization with ACE (Angiotensin Converting Enzyme) develops diabetic changes in the kidney and retina in diabetogenic rats.

In normal New Zealand white rabbits, immunization with rabbit lung ACE (angiotensin converting enzyme) induced atherosclerotic retinal changes, and glomerular changes similar to those seen in diabetic nephropathy. Also, in genetically diabetogenic rats, immunization with the rabbit lung ACE induced diabetic nephropathy and retinopathy.

Apolipoprotein E genetic polymorphism, remnant lipoproteins, and nephropathy in type 2 diabetic patients.

BACKGROUND: We previously showed that the apolipoprotein (apo) Eepsilon2 allele is associated with the progression of diabetic nephropathy. The aim of the present study is to further investigate the association between apo E genetic polymorphism, plasma lipid levels (particularly remnant lipoproteins), and diabetic nephropathy. SUBJECTS AND METHODS: One hundred fifty-eight patients with type 2 diabetes who had a duration of diabetes longer than 10 years were divided into the three apo E groups: apo E2 (n = 22), E3/3 (n = 102), and E4 (n = 34). Plasma levels of lipids and remnant lipoproteins were measured. The effect of apo E2 triglyceride (TG)-rich lipoproteins, including remnant lipoproteins, on the accumulation of cholesteryl esters by human mesangial cells (HMCs) was estimated by measuring the stimulation of radioactive carbon-labeled oleate incorporation into cholesteryl esters. RESULTS: The frequency of overt nephropathy was significantly greater in apo E2 patients with diabetes (59.1%) than apo E3/3 (34.3%) or apo E4 patients (8.8%), and the frequency of normoalbuminuria was significantly greater in apo E4 patients with diabetes (67.6%) than apo E3/3 (34.3%) or apo E2 patients (4.5%). Logistical regression analysis showed that odds ratios of apo E2 and apo E4 genotypes for the presence of overt nephropathy were 10.179 (P = 0.0349) and 0.129 (P = 0.0028), respectively. Plasma TG and remnant-like lipoprotein particle cholesterol levels were significantly greater in apo E2 patients and significantly lower in apo E4 patients than apo E3/3 patients. Apo E2 TG-rich lipoproteins stimulated the accumulation of cholesteryl esters by HMCs significantly more than apo E3/3 or apo E4 TG-rich lipoproteins. CONCLUSION: Apo E2 is a positive factor and apo E4 is a negative factor for diabetic nephropathy. Apo E2 TG-rich lipoproteins, including remnant lipoproteins, affected HMCs. Remnant lipoproteins may have an important role in the progression of diabetic nephropathy.