Efficacy and Safety of Adding Sitagliptin in Type 2 Diabetes Patients on Insulin: Age-Stratified Comparison at One Year in the ASSIST-K Study.

BACKGROUND: Sitagliptin, the first dipeptidyl peptidase-4 inhibitor, has demonstrated efficacy and safety as monotherapy and as add-on therapy to oral antidiabetic agents or insulin. However, there have been few reports about sitagliptin in elderly patients. The ASSIST-K observational study was performed in patients with type 2 diabetes mellitus (T2DM) receiving sitagliptin as add-on therapy to insulin. Changes of hemoglobin A1c (HbA1c), body weight, and the estimated glomerular filtration rate (eGFR), as well as adverse events, were investigated over 12 months in age-stratified groups. METHODS: Among outpatients with T2DM treated at member institutions of Kanagawa Physicians Association, those starting sitagliptin as add-on therapy to insulin were followed for 12 months. HbA1c (National Glycohemoglobin Standardization Program), body weight, and eGFR were the efficacy endpoints, while adverse events were investigated to assess safety. Patients were stratified into three age groups (≤ 64 years, 65 - 74 years, and ≥ 75 years) for comparison of the endpoints. RESULTS: Among 937 patients on insulin before starting sitagliptin, 821 patients were analyzed after excluding those without HbA1c data at baseline and 12 months. The two groups of elderly patients (65 - 74 years and ≥75 years) had more complications and their HbA1c was lower at initiation of sitagliptin therapy. The dose of sitagliptin, daily number of insulin injections, and number of concomitant oral antidiabetic agents were all lower in the elderly patients. HbA1c showed a significant decrease after initiation of sitagliptin in all age groups, and there were no significant intergroup differences in the change of HbA1c at 12 months. Body weight did not change significantly in any group. eGFR decreased significantly in all groups, with no significant intergroup differences at 12 months. Regarding adverse events, there were no significant intergroup differences in the incidence of severe hypoglycemia, gastrointestinal symptoms, or constipation. CONCLUSIONS: Despite baseline differences in demographic factors and medications, sitagliptin showed good efficacy and safety in all age groups of patients receiving it as add-on therapy to insulin during routine management of T2DM. Adding sitagliptin to insulin achieves similar efficacy and safety outcomes at 12 months in both elderly and non-elderly T2DM patients.

Factors Predicting Therapeutic Efficacy of Combination Treatment With Sitagliptin and Insulin in Type 2 Diabetic Patients: The ASSIST-K Study.

BACKGROUND: It is unclear whether dipeptidyl peptidase-4 inhibitors decrease hemoglobin A1c (HbA1c) in a glucose-dependent manner in patients on insulin therapy who have impaired insulin secretion. This study investigated factors influencing the efficacy of sitagliptin when used concomitantly with insulin to treat type 2 diabetes mellitus (T2DM) in the real-world setting. METHODS: A retrospective study was conducted of 1,004 T2DM patients at 36 Japanese clinics associated with the Diabetes Task Force of the Kanagawa Physicians Association. Eligible patients had been on insulin for at least 6 months, with a baseline HbA1c of 7.0% (53 mmol/mol) or higher. Baseline characteristics and laboratory data from 495 patients were subjected to multiple regression analysis to identify factors influencing the change of HbA1c. RESULTS: Most patients (n = 809) received sitagliptin at a dose of 50 mg. In the 1,004 patients, HbA1c decreased by 0.74% (6 mmol/mol) and body weight increased by 0.1 kg after 6 months of combination therapy. Multiple regression analysis showed that a higher baseline HbA1c, older age, and lower body mass index influenced the change of HbA1c after 6 months. Hypoglycemic symptoms occurred in 7.4%, but none were severe. CONCLUSIONS: These results emphasize the importance of a higher HbA1c at the commencement of sitagliptin therapy in patients on insulin. Glucose-dependent suppression of glucagon secretion by sitagliptin may be useful in patients with impaired insulin secretion. Sitagliptin can be used concomitantly with insulin irrespective of the insulin regimen, duration of insulin treatment, and concomitant medications.

Safety and efficacy of adding sitagliptin to insulin in patients with type 2 diabetes: the ASSIST-K study.

We retrospectively studied more than 1000 patients with type 2 diabetes attending 36 Japanese clinics to investigate the efficacy and safety of adding sitagliptin to various insulin regimens. We found that the treatment with add-on sitagliptin for 6-months was effective, irrespective of the type or dose of concomitant insulin.

Vascular endothelial growth factor gene expression is correlated with glomerular neovascularization in human diabetic nephropathy.

BACKGROUND: In diabetic nephropathy (DN) small vessels are frequently observed around the glomerular vascular pole in addition to normal afferent and efferent arterioles; this is regarded as neovascularization . Because vascular endothelial growth factor (VEGF) promotes vascular generation, the authors investigated the relationship between glomerular VEGF gene expression and structural glomerular changes in the early stage of human DN. METHODS: Kidney specimens were obtained from 18 type 2 DN patients by open renal biopsy. Additional vessels were distinguished by light microscopy as either afferent or efferent arterioles. Glomerular VEGF messenger RNA expression was determined by using in situ hybridization. The mesangial matrix area was quantified, and the ratio of the mesangial matrix area to the whole glomerular area was calculated to determine the mesangial matrix index (MMI). RESULTS: There were significantly more glomeruli with extra vessels in DN than in normal kidneys. The degree of neovascularization was significantly increased in DN and correlated with the magnitude of VEGF messenger RNA expression (r 2 = 0.46, P = 0.010) and MMI (r 2 = 0.45, P = 0.0093). CONCLUSION: These findings suggest that glomerular VEGF may be involved in structural changes in human DN at an early stage.

High expression of PKC-MAPK pathway mRNAs correlates with glomerular lesions in human diabetic nephropathy.

BACKGROUND: Activation of protein kinase C (PKC) is a major signaling pathway for transforming growth factor (TGF)-beta to induce extracellular matrix (ECM) production in diabetic nephropathy (DN). PKC also activates mitogen-activated protein kinase (MAPK), which is called the PKC-MAPK pathway. The PKC-MAPK pathway is probably responsible for PKC-related abnormalities in diabetic glomeruli. To confirm the involvement of this pathway, we determined the localization and expression of mRNAs in glomeruli by in situ hybridization method. METHODS: In the present study, we examined expression of PKCbeta1, MAPK/ERK kinase (MEK) 1, MEK2, extracellular signal-regulated protein kinase (ERK) 1, ERK2, and TGF-beta1 mRNAs using renal tissue samples from kidneys affected by DN (N= 21) and from normal human kidney (NHK; N= 6). We also performed an immunohistochemical study using anti-phosphorylated MEK1/2 (P-MEK) and ERK1/2 (P-ERK) antibodies. The glomerular severity of DN was classified into three groups according to mesangial expansion: D1 (N= 4), D2 (N= 13), and D3 (N= 4). We analyzed differences and correlations between variables. RESULTS: In the glomeruli, the number of cells that stained for these mRNAs in DN was significantly higher than in NHK. The expression of PKC-MAPK pathway mRNAs tended to be inversely proportional to the degree of mesangial expansion. The P-MEK and P-ERK signal intensity were parallel to its mRNA expression pattern. Furthermore, there were significant correlations among the P-MEK, P-ERK signal intensity, PKCbeta1 mRNA expression. CONCLUSION: Our results suggest that high expression of PKC-MAPK pathway mRNAs plays an important role in the development and/or progression of early tissue damage in DN.

Glomerular expression of platelet-derived growth factor (PDGF)-A, -B chain and PDGF receptor-alpha, -beta in human diabetic nephropathy.

BACKGROUND: Mesangial expansion is thought to be a major cause of diabetic nephropathy (DN). Platelet-derived growth factor (PDGF) plays an important role in the production of extracellular matrix proteins in renal diseases. The present study was designed to determine the expression of PDGF and PDF receptor (PDGFR) mRNA in the renal tissues of type 2 diabetic patients with DN. METHODS: We examined open renal biopsies of 20 type 2 diabetic patients with DN, and 10 normal human kidneys (NHK). Histopathologically, the severity of DN was classified as grade I (DN I, n = 10; mild mesangial expansion) or grade II (DN II, n = 10; moderate mesangial expansion). We evaluated the expression and localization of PDGF-A, -B, and PDGFR-Alpha, -Beta using in situ hybridization, and quantified PDGF and PDGFR mRNA expression by counting all nuclei, and nuclei surrounded by PDGF-positive cytoplasm and PDGFR-positive cytoplasm, in at least ten randomly selected cross-sections of nonsclerotic glomeruli. RESULTS: In all glomeruli, PDGF and PDGFR mRNAs were expressed mainly in glomerular resident cells, predominantly glomerular mesangial and epithelial cells. The percentages of cells positive for PDGF-A and PDGFR-Alpha mRNA in DN were similar to those in NHK. In contrast, the percentages of PDGF-B and PDGFR-Beta mRNA-positive cells in DN were significantly higher than those in NHK, and were significantly higher in DN I than in DN II: The percentages of cells positive for PDGF-B correlated with the PDGFR-Beta mRNA level. CONCLUSIONS: Our results suggest that the expression of PDGF-B and PDGFR-Beta is an important factor in histologically early glomerular lesions of DN. Mesangial expansion is thought to be a major cause of diabetic nephropathy (DN). Platelet-derived growth factor (PDGF) plays an important role in the production of extracellular matrix proteins in renal diseases. The present study was designed to determine the expression of PDGF and PDGF receptor (PDGFR) mRNA in the renal tissues of type 2 diabetic patients with DN.

Expression of human nephrin mRNA in diabetic nephropathy.

BACKGROUND: Diabetic nephropathy (DN) is associated with functional changes in the filtration barrier, and microalbuminuria is a strong predictor of the development of overt DN. Nephrin is a novel podocyte-specific protein which localizes at the slit diaphragm. This study examines the expression of nephrin mRNA in the kidneys of type 2 diabetics with DN. METHODS: Renal tissues were obtained from 13 type 2 diabetics with DN. We also examined samples from five patients with minimal change nephrotic syndrome (MCNS) and five normal kidneys (normals) as control. The severity of DN was classified into two grades based on histopathological findings. DN grade 1 (DN1 = seven patients) presented mild mesangial expansion, and DN grade 2 (DN2 = six patients) moderate mesangial expansion. Nephrin mRNA was quantitated and localized by in situ hybridization. RESULTS: Cells positive for nephrin mRNA were detected exclusively in glomerular epithelial cells. The percentage of cells positive for nephrin mRNA in DN2 was significantly lower than in MCNS and normal kidneys. Furthermore, there was an inverse correlation between the percentage of cells positive for nephrin mRNA and extent of proteinuria. CONCLUSION: The low expression of nephrin mRNA may be closely linked to development and/or progression of proteinuria in human diabetic nephropathy.

Trace analysis of explosives in soil: pressurized fluid extraction and gas and liquid chromatography-mass spectrometry.

Soil samples are collected from the former Open Burn/Open Detonation Unit, Makua Military Reservation, on the island of Oahu, Hawaii. The soil is the Helemano series. The soil samples are fortified with eight explosives for development of the analytical method. These analytes are 2-amino-4,6-dinitrotoluene; 1,3-dinitrobenzene; 2,4-dinitrotoluene (DNT); hexahydro-1,3,5-trinitro-1,3,5-triazine (RDX); nitrobenzene (NB); octogen; 1,3,5-trinitrobenzene; and 2,4,6-trinitrotoluene. The analytes are recovered with pressurized fluid extraction and measured with liquid chromatography (LC), LC-mass spectrometry (MS), and gas chromatography-MS. Average recoveries of the seven analytes, except for NB, range from 67% to 110% from freshly fortified samples. The procedure fails to extract NB in soil. The average recoveries decrease from 67-110% to 41-81% as the soil is aged for 1 day to 6 months after fortification of the soil with the seven explosives. The field samples are analyzed for the presence of explosives, of which DNT and RDX are indeed detected. The results obtained with this procedure agree well with those obtained by an independent laboratory following the standard U.S. Environmental Protection Agency (EPA) method SW-846 8330. Compared with the EPA method, this new method provides MS confirmation of the analytes, and the extraction requires approximately 15 min, rather than 18 h by the EPA method.

Glomerular expression of connective tissue growth factor mRNA in various renal diseases.

Connective tissue growth factor (CTGF) is a cysteine-rich member of a new family of growth regulators. It is an important factor in the pathogenesis of mesangial matrix accumulation and progressive glomerulosclerosis. The present study was designed to elucidate the role of CTGF in diabetic nephropathy (DN), immunoglobulin A nephropathy (IgA-N), membranous nephropathy (MN), and minimal change nephrotic syndrome (MCNS). We evaluated the expression and localization of CTGF mRNA in surgically excised renal tissue samples from 10 patients with DN, 10 with IgA-N, 10 with MN, 10 with MCNS, and 10 normal human kidney (NHK) tissue samples, by using high-resolution in situ hybridization with digoxigenin-labelled oligonucleotide. To quantify CTGF mRNA expression, we counted all nuclei, and nuclei surrounded by CTGF-positive cytoplasm, in at least 10 randomly selected cross-sections of non-sclerotic glomeruli, and expressed the results as a percentage of total glomerular cells. In all glomeruli, CTGF mRNA was expressed mainly in glomerular intrinsic cells, including glomerular mesangial and epithelial cells and some cells of Bowman's capsule. The percentage of cells positive for CTGF mRNA was significantly higher in DN and IgA-N than in MN, MCNS and NHK. However, there was no significant difference in the percentage of CTGF mRNA-positive cells between DN and IgA-N. Our study indicates that CTGF may play an important role in the development and progression of glomerulosclerosis in DN and IgA-N, which are both accompanied by mesangial matrix expansion and comprise two major causes of end-stage renal failure.