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Antidiabetic drugs
CLIFFORD J BAILEY, CAROLINE DAY
A
chieving good glycaemic control is an important
part of the treatment strategy to minimise
300
vascular complications in diabetes. An expanding
range of differently acting oral antidiabetic agents
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Br J Cardiol 2003;10:128–36
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Introduction 1995 2000 2010 2025
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The prevalence of diabetes mellitus continues to rise and is set to Year
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reach 300 million people worldwide by the year 2025 (figure 1).1
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Data sourced from Zimmet et al. 20011
In most European countries 3–5% of the adult population has
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diabetes, with the vast majority (> 95%) of these patients having
type 2 (non-insulin dependent) diabetes.
Macrovascular complications are commonplace amongst dia-
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betic patients, particularly those with type 2 diabetes (table 1). mellitus
Diabetes increases the risk of ischaemic heart disease by up to
four-fold,2,3 hence the increasing overlap of cardiology and dia- Mortality
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betology. Indeed, type 2 diabetes is one of several cardiovascular ● Death rate > 2-fold
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action.14 Initially insulin resistance is compensated by the adaptive
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Figure 2. Development of type 2 diabetes: changes in glucose
metabolism during a typical progression through obesity and capacity of the pancreatic beta cells to increase insulin concentra-
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impaired glucose tolerance leading to type 2 diabetes tions, preventing any serious disturbance to glucose homeostasis.
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Adaptation of the beta cells depends upon various genetic con-
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straints such as the total beta-cell mass, rates of replication, neo-
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genesis and apoptosis of beta cells, and the activity of key bio-
chemical components of these cells. Environmental influences,
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Pancreas
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Key: * = in Europe thiazolidinediones are not indicated with insulin
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The treatment algorithm
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The first step in any treatment algorithm should be a package
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of dietary and healthy living advice (figure 3). Since this under-
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pins treatment throughout life it should be reinforced at every
Table 4. Actions of oral antidiabetic agents currently available in the UK
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opportunity, although only a small proportion of patients
Class Examples Main mode of action (< 20%) actually achieve good control with such measures
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Sulphonylureas Chlorpropamide, Stimulate insulin alone. Disease progression dictates that most patients will
glibenclamide, gliclazide, secretion (typically require oral drug therapy within three years of diagnosis.8,9 The
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glimepiride, glipizide, acting 6–24 hour) oral antidiabetic agents currently available in the UK and their
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gliquidone, tolbutamide main modes of action are listed in table 4. Continued progres-
Meglitinidesa Repaglinide, nateglinide Stimulate insulin sion of the natural history of type 2 diabetes, mainly due to
secretion (rapid-onset,
ongoing loss of beta-cell function, requires that most patients
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Alpha-glucosidase Acarbose Slow rate of drugs before beta-cell failure deteriorates into absolute
inhibitor carbohydrate digestion hypoinsulinaemia. Indeed, newly diagnosed type 2 diabetic
Key: a = also termed ‘prandial insulin releasers’; b = also termed ‘glitazones’ patients who remain markedly hyperglycaemic (e.g. fasting
plasma glucose > 12 mmol/L or HbA1C > 10%) after dietary
intervention are unlikely to achieve good control (e.g. HbA1C <
6.5%) with one oral antidiabetic agent. These patients may be
1% decrease in HbA1C (at any level down to euglycaemia) candidates for starting oral antidiabetic therapy with (or mov-
decreased diabetes-related morbidity and mortality by about ing promptly to) a combination of two differently acting
21% over 10 years.11 agents. When oral agents fail to achieve or maintain adequate
Since type 2 diabetes is part of the Metabolic Syndrome of control it is recommended to switch to insulin therapy, in some
atherothrombotic risk factors linked to insulin resistance and (ini- cases supplemented with an oral agent. In the USA about one-
tially) hyperinsulinaemia,4,5,14 it is pertinent to consider the dia- third of patients with type 2 diabetes receive insulin.
betologist’s versions of desirable targets for blood lipids and Use of an anti-obesity agent (e.g. sibutramine or orlistat), or
blood pressure (BP) (table 3).17 NICE guidelines for type 2 diabetes various dietary adjuncts such as fibre preparations (e.g. guar
are similar: offer a statin if total cholesterol is > 5 mmol/L, and con- gum), minerals (e.g. magnesium and trivalent chromium) or anti-
sider a fibrate if the triglyceride remains > 2.3 mmol/L.19 For type oxidants (e.g. vitamins C and E), is supported by some specialists,
2 diabetes NICE recommends a BP < 140/80 mmHg.19 The high but these adjuncts do not hold a generally accepted position in
risk of coronary heart disease and the need for especially stringent the treatment algorithm.
targets in diabetic patients are well appreciated.20 Indeed, in the
UKPDS a sustained lowering of systolic BP by 10 mmHg decreased Choice of antidiabetic drugs
the occurrence of diabetic complications by 24%.12 Different antidiabetic agents target different aspects of the path-
Daily dosage (mg) Duration of action* Activity of metabolites Main elimination route Tablet strength (mg)
a
Sulphonylureas
Chlorpropamide 100–500 Long Active Urine > 90% 100, 250
Glibenclamide 2.5–15 Intermediate–long Active Bile > 50% 2.5, 5.0 (scored)
Glimepiride 1–6 Intermediate–long Active Urine ~60% 1,2,3,4 (all scored)
Gliclazide MRb 30–120 Intermediate–long Inactive Urine ~65% 30 (scored)
Gliclazide 40–320 Intermediate Inactive Urine ~65% 80 (scored)
Glipizide 2.5–20 Short–intermediate Inactive Urine ~70% 2.5, 5.0 (scored)
Gliquidone 15–180 Short–intermediate Inactive Bile ~95% 30 (scored)
Tolbutamidec 500–2000 Short Inactive Urine ~100% 500
Meglitinidesc
Repaglinide 0.5–16 Very short Inactive Bile ~90% 0.5, 1, 2
Nateglinided 60–540 Very short Inactive Urine ~80% 60, 120, 180
Biguanide
Metforminc 500–3,000 Short–intermediate Not metabolised Urine ~100% 500, 850
Thiazolidinedionesd
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Rosiglitazone 4–8 Intermediate–long Very weakly active Urine ~65% 4, 8
Pioglitazone 15–30 Intermediate–long Active Bile > 70% 15, 30
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Alpha-glucosidase inhibitor
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Acarbosec 50–300 Short Inactivee Urine ~35%e 50, 100
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Key: * = very short < 6 hour; short < 12 hour; intermediate 12–24 hour; long 18 – > 24 hour
a
= large dosages should be divided and related to meal pattern
b
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= gliclazide MR (Diamicron MR) is a modified release formulation: 30 mg of the MR formulation is approximately therapeutically equivalent to 80 mg of standard
gliclazide
c
= should be taken immediately before meals
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= first-line drug therapy excluded in UK: use in combination therapy only
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e
= degraded mainly in intestine. Some metabolites absorbed but very little parent drug absorbed
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Main exclusions - ? Liver, renala Renal, liver, hypoxiab CHF g, liverh, oedema, anaemia GI i
c
Tolerability Injection - GI - GI c
Safety Hypoglycaemiad Hypoglycaemiad LAe Oedema, anaemia -
d
Monitor - - Creatinine, vitamin B12 or haemoglobinf LFT h ? LFT j
Key: a = if liver or renal disease, select sulphonylurea with appropriate pharmacokinetics and monitor accordingly. Caution drug interactions; b = excluded by renal
impairment, serious liver disease and any condition predisposing to hypoxia; c = take with meals and titrate slowly to reduce gastrointestinal symptoms; d = monitor
glucose with all antidiabetic drugs, especially during titration to avoid hypoglycaemia (‘hypo’); e = rare risk of lactic acidosis (LA); f = check creatinine and vitamin B12 or
haemoglobin annually; g = CHF (congestive heart disease/failure) h = check liver function (e.g. serum alanine transaminase) before treatment and at intervals thereafter;
i
= avoid if intestinal disease; j = check liver function (e.g. serum alanine transaminase) if taking high dose
ogenic process (figure 4). Historically, sulphonylureas have been UKPDS.9,23 Acarbose and repaglinide are less widely used as initial
most widely used to start oral drug therapy for non-obese type therapy, but may be preferred in individuals with mostly post-
2 patients, while metformin has been preferred for obese prandial hyperglycaemia or irregular eating patterns.
patients. More recently there has been interest in a wider use of Thiazolidinediones and nateglinide can be added in as second-
metformin: this reflects growing acceptance that insulin resis- line agents for oral combination therapy. General information on
tance is an early pathogenic feature of most cases of type 2 dia- the use of antidiabetic agents is summarised in tables 5–7.
betes, and evidence that initial therapy with metformin reduced For all oral antidiabetic drugs it is customary to check first for
macrovascular complications in overweight patients during the contraindications, start with a low dose and titrate up slowly
while monitoring blood glucose concentrations. Sulphonylureas Potential interaction with other protein-bound drugs should be
and metformin usually produce a maximum effect before the remembered. Sulphonylurea therapy is likely to cause weight
maximum dose is reached, so a titration step that gives no added gain, but there is little effect on lipids (tables 6 and 7).
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benefit can be reversed. As noted previously, early recourse to
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combination therapy is justified if monotherapy is inadequate. Meglitinides (prandial insulin releasers)
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The same procedure of checks and titration is again applied. The Repaglinide and nateglinide are rapid-acting and short-acting
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main exclusions and precautions for use of antidiabetic drugs are insulin releasers.28 They can be taken immediately before or dur-
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summarised in table 6.24 ing a meal so that their duration of action coincides with the
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period of meal digestion. These agents stimulate insulin release
Sulphonylureas in a similar manner to sulphonylureas, but they bind to a differ-
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Sulphonylureas reduce hyperglycaemia mainly by stimulating ent site (the benzamido site) on SUR-1.
insulin secretion.25 They bind to the sulphonylurea receptor-1 Repaglinide is a derivative of meglitinide, which is the non-
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(SUR-1) in the plasma membrane of the pancreatic beta cells. sulphonylurea portion of glibenclamide. Nateglinide is a pheny-
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SUR-1 is part of the complex containing the ATP-sensitive Kir 6.2 lalanine derivative that is structurally similar to meglitinide.
potassium channel (K-ATP channel).26 Binding of a sulphonylurea Repaglinide and nateglinide are rapidly absorbed (peak concen-
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to SUR-1 closes the K-ATP channel, preventing potassium efflux. tration within 1 hour) followed by rapid elimination (plasma half-
This favours membrane depolarisation and the opening of volt- life [t1/2] < 1 hour) mainly through hepatic metabolism.
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age-dependent calcium channels. The influx of calcium raises Repaglinide metabolites are eliminated mostly into the bile, and
intracellular calcium concentrations and activates calcium-depen- nateglinide metabolites into the urine. With these features,
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dent proteins that control the exocytosis of insulin. The surge of meglitinides are suited to mealtime administration so that insulin
insulin released into the portal vein suppresses excessive output release corresponds with glucose absorption to reduce the extent
of glucose by the liver in type 2 diabetes, and the extended rise of postprandial hyperglycaemia (hence the term prandial insulin
in plasma insulin concentrations facilitates peripheral glucose dis- releasers). The short duration of action should also reduce the
posal. Minor direct extra-pancreatic effects of sulphonylureas risk of interprandial hypoglycaemia and suit individuals with
have been reported to assist glucose-lowering, for example irregular feeding habits.28
glimepiride may facilitate translocation of glucose transporters Meglitinides can be slightly more effective than sulphony-
into the plasma membrane.27 lureas in lowering postprandial hyperglycaemia. Although there
The blood glucose-lowering efficacy of sulphonylureas has is some carry-over reduction in basal glucose, meglitinides are
been affirmed in many trials.8,9,25 Typically the reduction in blood less effective in lowering basal hyperglycaemia. The overall glu-
glucose is initially 2–3 mmol/L (decrease in HbA1C by 1–2% after cose-lowering efficacy of repaglinide can be similar to gliben-
two months). The effectiveness of sulphonylureas is obviously clamide, but the shorter acting nateglinide has less carry-over
dependent on the patient having adequate residual beta-cell effect on basal glycaemia and is not licensed as first-line therapy.
function. In general a similar efficacy can be achieved by appro- Repaglinide and nateglinide can be combined with metformin to
priate titration and dosing schedule with any sulphonylurea, and give an additive glucose-lowering effect.28
choice is based on pharmacokinetic features that determine the Repaglinide and nateglinide can cause weight gain and,
rate of onset and duration of action, metabolism and route of being protein bound, they have the potential to interact with
elimination (table 5). other protein-bound drugs.
Sulphonylureas are well tolerated, but the risk of hypogly-
caemia must be appreciated, especially with long-acting prepa- Metformin
rations and in patients with irregular life-styles who skip meals. The biguanide metformin lowers blood glucose concentrations
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reduced in hyperinsulinaemic patients, demonstrating the ame- often occurs, causing excessive flatulence, diarrhoea and abdom-
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lioration of insulin resistance. Metformin does not cause overt inal discomfort. Rarely, serum transaminases are increased in
hypoglycaemia, hence it is regarded as ‘antihyperglycaemic’ patients on a high dose of acarbose.
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rather than ‘hypoglycaemic’.30 Also, metformin does not cause
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weight gain and may enhance weight loss in overweight Thiazolidinediones
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patients. The lipid profile is often improved by metformin, usual- Thiazolidinediones (TZDs), also termed ‘glitazones,’ are insulin
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ly involving a reduction of triglyceride concentrations and some- sensitisers. Two TZDs – rosiglitazone and pioglitazone – were
times a reduction in LDL-cholesterol in hyperlipidaemic patients. introduced in Europe in 2000. TZDs improve insulin action main-
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Improvements of some parameters of vascular function have ly by activation of the nuclear peroxisome proliferator-activated
been noted with metformin, such as a decrease in PAI-1 and receptor-gamma (PPARγ).33 PPARγ is strongly expressed in adipose
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increased fibrinolysis. In the UKPDS, overweight patients starting tissue where it promotes lipogenesis and the differentiation of
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antidiabetic therapy with metformin incurred lower mortality new adipocytes. PPARγ is weakly expressed in skeletal muscle,
and fewer micro- and macrovascular complications than patients liver and various other tissues. Stimulation of PPARγ by TZDs
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started with a sulphonylurea or insulin.9,23,31 increases transcription of certain genes that are also sensitive to
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Metformin can be used in combination with a sulphonylurea insulin. These genes include those which code for lipoprotein
to produce an additive glucose-lowering effect, but introducing lipase, fatty acid transporters, acyl CoA synthase, glycerol kinase
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the risk of hypoglycaemia. The risk of hypoglycaemia is likely to and the glucose transporter Glut4. This facilitates fatty acid
be less when metformin is combined with a meglitinide, and less uptake, lipogenesis and glucose uptake, particularly in subcuta-
still when combined with a thiazolidinedione or acarbose. neous adipose deposits.
The principal exclusion for metformin is renal impairment While this tends to promote adiposity, associated changes in
(table 6) since the drug is excreted unchanged in the urine (table the glucose-fatty acid (Randle) cycle improve glucose utilisation
5). Excess accumulation of metformin promotes hyperlactataemia by muscle and reduce the energy supply for hepatic glucose pro-
and carries the rare possibility of lactic acidosis. Thus, conditions duction. Although changes in the glucose-fatty acid cycle appear
giving rise to hypoxia such as heart failure, or advanced liver dis- to mediate much of the blood glucose-lowering effect of TZDs,
ease exclude use of metformin.30,31 Gastrointestinal side effects are a direct stimulation of PPARγ in muscle and liver, and possibly
prone to occur during the initiation of metformin therapy. Thus, it actions that are independent of PPARγ, may also be involved. In
is important to start with a low dose, titrate up slowly and take Europe TZDs are licensed for oral combination therapy (not first-
the drug with meals. The gastrointestinal disturbances often line therapy).
resolve with time and usually remit with a reduction in dosage. By The blood glucose-lowering effect of TZDs is similar to met-
improving insulin action metformin can reinstate ovulation in formin when used as a second agent. However, the onset of
anovulatory polysystic ovary syndrome. action is slower and may take two to three months to produce
maximum efficacy. TZDs require adequate insulin to achieve their
Acarbose glucose-lowering potential, and may reduce insulin concentra-
Acarbose competitively inhibits the activity of alpha-glucosidase tions, but in Europe they are not licensed for use with insulin.
enzymes (glycoamylase > sucrase > maltase > isomaltase) at the TZDs typically lower free fatty acid concentrations, often lower
brush border of the small intestine, and weakly inhibits alpha- triglyceride levels, and raise high density lipoprotein. Pioglitazone
amylase.32 Thus, acarbose slows the rate of digestion of complex can lower low density lipoprotein (LDL) while rosiglitazone may
carbohydrates, and extends the digestive process further along increase LDL, although this appears to reflect an increase in
the intestinal tract. In turn, this slows the appearance of glucose larger (more buoyant and less atherogenic) LDL subfractions.
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although hypoglycaemia can occur in combination with an Insulin
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insulin-releasing agent (sulphonylurea or meglitinide). When oral agents are unable to achieve or sustain adequate gly-
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PPARγ is found in macrophages and vascular tissue and TZDs caemic control, or symptoms become severe, it is customary to
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are presently being investigated for possible effects to decrease switch to insulin. The need for insulin indicates that the natural
macrovascular disease and renal vascular disease that are inde-
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pendent of their glucose-lowering effects. (figure 2). Some of these patients may, in fact, have a very slow-
ly developing form of type 1 diabetes. Around 5–10% of
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Combinations patients on one or more oral therapies will require insulin each
If monotherapy with one oral antidiabetic agent does not pro- year, and the potential advantages of insulin at this stage miti-
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duce the desired glycaemic target, or glycaemic control deterio- gate against any delay in making the switch.
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rates to values outside the desired range, oral combination Insulin acts on the liver to reduce hepatic glucose output, and
therapy is indicated. The second agent must act by a different on peripheral tissues, especially skeletal muscle, to increase glu-
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mechanism to the first in order to achieve an additive glucose- cose uptake and metabolism. The choice of insulin regimen, and
lowering effect. The efficacy of oral combination therapy is also the procedure for initiation and titration are still vigorously debat-
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dependent upon adequate remaining beta-cell function. If beta- ed.35 Popular options are twice-daily injection of an intermediate-
cell function is already almost completely lost, hyperglycaemia is acting insulin or a mixture of a short-acting insulin with an inter-
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either severe or rising quickly, often accompanied by uninten- mediate-acting insulin (table 9). Basal insulin replacement with a
tional weight loss. Under these circumstances it is unlikely that single-daily injection of a long-acting insulin is often insufficient to
any combination of currently available oral antidiabetic agents achieve good glycaemic control due to the ‘dome’ profile of cir-
will provide more than a very temporary respite, and the patient culating insulin. A single-daily injection of the newly available sol-
should be switched to insulin. uble long-acting analogue, glargine, produces fairly constant cir-
The most widely used oral antidiabetic drug combinations are culating insulin concentrations for most of a 24-hour period. A
shown in table 8. Metformin, sulphonylureas, repaglinide and long-acting insulin at bedtime with an oral agent during the day-
acarbose are presently licensed for first-line oral therapy. A TZD time is successful and convenient for many patients.36 Metformin,
or nateglinide can be added as second-line therapy. The for example, can improve glycaemic control and reduce insulin
European regulatory recommendations are somewhat tortuous. requirement in insulin-treated patients, while reducing the weight
Currently they specify that a TZD can only be used with met- gain induced by insulin.37 Where lifestyle is irregular and/or a par-
formin or a sulphonylurea if a metformin-sulphonylurea combi- ticularly intensive regimen is required, multiple daily injections of a
nation proves to be inappropriate, e.g. if metformin is not toler- rapid acting insulin analogue can be given with meals, supported
ated or the sulphonylurea is deemed responsible for episodes of with a long-acting insulin given in the evening. Pen injection
hypoglycaemia. Also nateglinide is only for combination with devices, pre-mixed insulins and routine self-monitoring of blood
metformin. glucose are valuable aids for the patient to take day-to-day
It is important to consider exclusions, contraindications and responsibility and make adjustments to their regimen.
interactions for both agents before instituting oral combination Large doses of insulin can be required to overcome the insulin
therapy, and to titrate up the second agent with the usual mon- resistance of type 2 diabetes, and disharmony between the dose
itoring of glycaemic control. Early use of two differently acting regimen and lifestyle carries a risk of serious hypoglycaemia.24
oral agents may beneficially produce additional efficacy at lower Although insulin can directly accentuate insulin resistance, this is
dosages. Hence, it may be appropriate to temporarily lower the usually offset in the long term through reduced glucotoxicity.
Examples Aspart, Lispro Actrapid, Humulin S Mixtard, Humulin M2/3/5 Insulatard, Humulin I Ultratard, Lente Glargine
Duration of action (hours) 1–4 4–8 8–16 8–16 16–30 > 24 hours
Key: * = times for onset and duration of action are approximate ranges that vary between individuals, with dose and site of subcutaneous injection and
pathophysiological state
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Although the switch to insulin is often perceived with horror ● Intensive treatment reduces complications
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by the patient, most adapt quickly. Remember with the advent
● Most patients eventually need a combination of two
of glargine (which is soluble, i.e. clear) the old characterisation of
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insulins into clear (short-acting) and cloudy (long-acting) is now differently acting oral agents and/or insulin
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redundant. The possibility of a non-injection delivery method,
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such as an aerosol, is particularly appealing, but this is still in the
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trial stages.
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nised (if difficult to achieve) route to ameliorate insulin resistance ischaemia. In theory this could reduce arrhythmia during mild
and improve glycaemic control. Weight reduction also benefits ischaemia, but increase myocardial damage during more severe
other associated cardiovascular risk factors such as dyslipidaemia ischaemia. Recent studies have noted that the sulphonylurea
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and hypertension, and justifies the persistent reinforcement of receptors of K-ATP channels in cardiac and vascular smooth mus-
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diet and lifestyle messages to diabetic patients.38 cle (SUR-2A/B) lack the high affinity sulphonylurea binding site of
To facilitate weight loss, the intestinal lipase inhibitor orlistat SUR-1. However, SUR-2A/B retain the benzamido site. Thus,
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can reduce fat absorption by up to 30%.39 Although steator- sulphonylureas that have a benzamido moiety (glibenclamide,
rhoea and associated bowel problems can be limiting, orlistat has glipizide, glimepiride) and meglitinides can bind to SUR-2A/B.
been shown to improve weight loss in conjunction with a low Nevertheless lower affinity and shorter duration of binding at the
calorie diet by around 10% (compared with about 6% on place- benzamido site suggest that therapeutic concentrations of these
bo). Obese type 2 diabetic patients who achieved this weight loss agents are unlikely to exert a clinically significant impact. Several
showed an improved HbA1C by about 0.5%.40 Similar success studies, including the UKPDS, have not shown a detrimental
has been achieved with sibutramine, a satiety-inducing sero- effect of sulphonylureas on cardiac events. Concern that tolbu-
tonin-noradrenaline re-uptake inhibitor.41 tamide adversely affected cardiac events in type 2 diabetic
patients during the controversial American University Group
Cardiovascular issues about antidiabetic drugs Diabetes Program (UGDP) cannot be attributed to an effect on
Several controversial issues regarding the cardiovascular effects SUR-2A/B since tolbutamide does not possess a benzamido moi-
of antidiabetic drugs remain unresolved. Potential benefits of the ety.
acute vasodilatatory response to insulin are well recognised, and As mentioned earlier, initiation of oral antidiabetic drug ther-
use of insulin-glucose infusion has been shown to improve sur- apy with metformin reduced macrovascular events in overweight
vival after a myocardial infarction, especially in type 2 diabetes type 2 diabetic patients during the UKPDS to a greater extent
(Diabetes mellitus Insulin-Glucose infusion in Acute Myocardial than explained by glycaemic control alone.9,23 This could be relat-
Infarction [DIGAMI] study). It is still unclear whether chronic ed to reduced insulin resistance, although metformin may have
hyperinsulinaemia can promote extra growth of vascular smooth independent effects on vascular function and thrombolysis, as
muscle to aggravate the clinical course of atherosclerosis. The well as reducing cardiovascular risk from effects on blood lipids
balance of evidence suggests that therapeutic concentrations of and obesity. Whether the TZDs, which also reduce insulin resis-
insulin probably do not adversely affect the vascular wall in dia- tance, will offer a similar protective effect is now under investi-
betes.42 gation in several long-term trials with hard end points. Various
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ing natural history. Consequently different therapies are required
281:2005-12.
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at different stages of the disease process. Intensive use of avail- 22. Campbell IW, Bailey CJ. New approaches to glycaemic control in type 2
able therapies directed against different pathogenic aspects of diabetes. Mod Diabetes Management 2001;2:6-10.
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the disease is strongly encouraged to return blood glucose and 23. Bailey CJ, Campbell IW. United Kingdom Prospective Diabetes Study:
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24. Krentz AJ, Ferner RE, Bailey CJ. Comparative tolerability profiles of oral
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25. Groop LC. Sulfonylureas in NIDDM. Diabetes Care 1992;15:737-54.
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