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To compare the efficacy and safety of adding low-dose lobeglitazone (0.25 mg/day) or standard-dose lobeglitazone (0.5 mg/day) to patients with type 2 diabetes mellitus (T2DM) with inadequate glucose control on metformin and dipeptidyl peptidase (DPP4) inhibitor therapy.In this phase 4, multicentre, double-blind, randomized controlled, non-inferiority trial, patients with T2DM insufficiently controlled by metformin and DPP4 inhibitor combination therapy were randomized to receive either low-dose or standard-dose lobeglitazone. The primary endpoint was non-inferiority of low-dose lobeglitazone in terms of glycaemic control, expressed as the difference in mean glycated haemoglobin levels at week 24 relative to baseline values and compared with standard-dose lobeglitazone, using 0.5% non-inferiority margin.At week 24, the mean glycated haemoglobin levels were 6.87 ± 0.54% and 6.68 ± 0.46% in low-dose and standard-dose lobeglitazone groups, respectively (p = .031). The between-group difference was 0.18% (95% confidence interval 0.017-0.345), showing non-inferiority of the low-dose lobeglitazone. Mean body weight changes were significantly greater in the standard-dose group (1.36 ± 2.23 kg) than in the low-dose group (0.50 ± 1.85 kg) at week 24. The changes in HOMA-IR, lipid profile and liver enzyme levels showed no significant difference between the groups. Overall treatment-emergent adverse events (including weight gain, oedema and hypoglycaemia) occurred more frequently in the standard-dose group.Adding low-dose lobeglitazone to metformin and DPP4 inhibitor combination resulted in a non-inferior glucose-lowering outcome and fewer adverse events compared with standard-dose lobeglitazone. Therefore, low-dose lobeglitazone might be one option for individualized strategy in patients with T2DM.

Pancreatic β-cells are vulnerable to oxidative stress, which promotes β-cell failure in type 2 diabetes. System χc- is a sodium-independent, cystine/glutamate antiporter that mediates the exchange of extracellular l-cystine and intracellular l-glutamate. The import of l-cystine through this transporter is the rate-limiting step in the glutathione (GSH) biosynthesis pathway that plays a significant role in antioxidative defense. Previously, we reported that 2-deoxy-d-ribose (dRib) induces oxidative damage through GSH depletion in pancreatic β-cells. In the current study, we elucidated the mechanism underlying the oxidative stress-induced β-cell damage. We measured the intracellular l-[14C]cystine uptake, GSH content, reactive oxygen species (ROS) levels, cytotoxicity, and apoptosis in rat insulinoma cell line, RINm5F. Treatment of dRib decreased the intracellular l-[14C]cystine uptake and GSH content and increased the intracellular ROS levels, cytotoxicity, and apoptosis in a time- and dose-dependent manner. Conversely, 2-mercaptoethanol (2-ME), a cystine uptake enhancer, recovered the dRib-induced decrease in l-[14C]cystine uptake, GSH content, and cell viability in a Na+-independent manner. In the case of isolated islets, dRib dose-dependently decreased the intracellular l-[14C]cystine uptake and cell viability; however, dRib-induced cytotoxicity was completely recovered by adding N-acetyl cysteine (NAC). To confirm that system χc- mediates the oxidative stress-induced β-cell damage, we overexpressed xCT (the substrate-specific subunit of system χc-) using a lentiviral vector in RINm5F cells. Overexpression of xCT fully recovered the dRib-induced decrease in l-[14C]cystine uptake and GSH content and prevented the dRib-induced increase in ROS levels, cytotoxicity, and apoptosis. The overexpression of xCT showed a protective effect against dRib-induced oxidative damage in RINm5F cells. Our study showed that dRib depletes intracellular GSH content through inhibition of cystine transport via system χc- in β-cells.

Background: We aimed to investigate the changes in glucagon levels in people with diabetes after the ingestion of a mixed meal and the correlations of variation in glucagon levels with incretin and clinico-biochemical characteristics. Methods: Glucose, C-peptide, glucagon, intact glucagon-like peptide 1 (iGLP-1), and intact glucose-dependent insulinotropic polypeptide (iGIP) were measured in blood samples collected from 317 people with diabetes before and 30 min after the ingestion of a standard mixed meal. The delta (Δ) is the 30-min value minus the basal value. Results: At 30 min after meal ingestion, the glucagon level showed no difference relative to the basal value, whereas glucose, C-peptide, iGLP-1, and iGIP levels showed a significant increase. In univariate analysis, Δglucagon showed not only a strong correlation with HbA1c but also a significant correlation with fasting glucose, Δglucose, and estimated glomerular filtration rate. However, Δglucagon showed no significant correlations with ΔiGLP-1 and ΔiGIP. In the hierarchical multiple regression analysis, HbA1c was the only variable that continued to show the most significant correlation with Δglucagon. Conclusions: People with diabetes showed no suppression of glucagon secretion after meal ingestion. Patients with poorer glycemic control may show greater increase in postprandial glucagon level, and this does not appear to be mediated by incretin.

Metabolic syndrome increases the risk of cardiovascular disease. Recently glucagon-like peptide 1 (GLP-1) agonists proved to be effective in preventing cardiovascular disease (CVD) in patients with type 2 diabetes. We investigated the association of blood incretin levels with metabolic syndrome in patients with type 2 diabetes.This is a cross-sectional study involving 334 people with type 2 diabetes. Intact GLP-1 (iGLP-1) and intact glucose-dependent insulinotropic polypeptide (iGIP) levels were measured in a fasted state and 30 min after ingestion of a standard mixed meal. Metabolic syndrome was diagnosed based on the criteria of the International Diabetes Federation.Two hundred twenty-five (69%) of the subjects have metabolic syndrome. The fasting iGLP-1 level was no different between groups. Thirty-min postprandial iGLP-1 was non-significantly lower in the subjects who had metabolic syndrome. Incremental iGLP-1 (ΔiGLP-1, the difference between 30-min postmeal and fasting iGLP-1 levels) was significantly lower in those with metabolic syndrome. There were no significant differences in fasting iGIP, postprandial iGIP, and ΔiGIP between groups. The ΔiGLP-1, but not ΔiGIP levels decreased significantly as the number of metabolic syndrome components increased. In hierarchical logistic regression analysis, the ΔiGLP-1 level was found to be a significant contributor to metabolic syndrome even after adjusting for other covariates.Taken together, the iGLP-1 increment in the 30 min after meal ingestion is inversely associated with metabolic syndrome in patients with type 2 diabetes. This suggests that postmeal iGLP-1 increment could be useful in assessing cardiovascular risk in type 2 diabetes.

Pancreatic β-cells are vulnerable to oxidative stress, which promotes β-cell failure in type 2 diabetes. System χ

Pancreatic β-cells are vulnerable to oxidative stress, which is related to β-cell failure in type 2 diabetes. System x(c)- is a sodium-independent cystine/glutamate antiporter that mediates the exchange of extracelluar L-cystine and intracellular L-glutamate. The import of L-cystine through this transporter is the limiting state of intracellular glutathione (GSH) synthesis that has a major role in defends against oxidative stress. Our previous study reported that 2-deoxy-D-ribose (dRib) induces oxidative damage through GSH depletion in pancreatic β-cells. The aim of the present study was to elucidate the mechanism underlying oxidative stress-induced β-cell damage. We measured intracellular L-[14C] cysteine uptake, GSH content and reactive oxygen species (ROS) levels, cytotoxicity and apoptosis in rat insulinoma cell line (RINm5F cells). Stimulation with dRib dose- and time-dependently decreased intracellular L-[14C] cystine uptake and GSH content and increased intracellular ROS levels, cytotoxicity and apoptosis. The addition of 2-mercaptoethanol (2-ME), a cystine uptake enhancer, sodium-independently recovered the dRib-induced decreases in L-[14C] cystine uptake, GSH content and cell viability. To determine clearly whether system x(c)- deficiency mediate the oxidative stress-induced β-cell damage, we overexpressed xCT, the substrate-specific subunit of the system x(c)-, by using a lentiviral vector in RINm5F cells. Overexpression of xCT fully recovered the dRib-induced decreases in L-[14C] cystine uptake and GSH content and prevented the dRib-induced ROS rises, cytotoxicity and apoptosis. In summary, overexpression of xCT showed protective effects against oxidative damage in RINm5F cells. It suggests that system x(c)- deficiency play a critical role in oxidative stress-induced β-cell damage. Disclosure S. Yoo: None. J. Bae: None. H. Chin: None. G. Koh: None.

We performed this study to identify factors related to intact incretin levels in patients with type 2 diabetes (T2D).We cross-sectionally analyzed 336 patients with T2D. Intact glucagon-like peptide 1 (iGLP-1) and intact glucose-dependent insulinotropic polypeptide (iGIP) levels were measured in a fasted state and 30 min after ingestion of a standard mixed meal. The differences between 30 and 0 min iGLP-1 and iGIP levels were indicated as ΔiGLP-1 and ΔiGIP.After ingestion of a mixed meal, iGLP-1 (5.5±3.0 to 10.4±7.0 pmol/L; p

Background We aimed to investigate the effectiveness and safety of adding basal insulin to initiating dipeptidyl peptidase-4 (DPP-4) inhibitor and metformin and/or sulfonylurea (SU) in achieving the target glycosylated hemoglobin (HbA1c) in patients with type 2 diabetes mellitus (T2DM). Methods This was a single-arm, multicenter, 24-week, open-label, phase 4 study in patients with inadequately controlled (HbA1c ≥7.5%) T2DM despite the use of DPP-4 inhibitor and metformin. A total of 108 patients received insulin glargine while continuing oral antidiabetic drugs (OADs). The primary efficacy endpoint was the percentage of subjects achieving HbA1c ≤7.0%. Other glycemic profiles were also evaluated, and the safety endpoints were adverse events (AEs) and hypoglycemia. Results The median HbA1c at baseline (8.9%; range, 7.5% to 11.1%) decreased to 7.6% (5.5% to 11.7%) at 24 weeks. Overall, 31.7% subjects (n=33) achieved the target HbA1c level of ≤7.0%. The mean differences in body weight and fasting plasma glucose were 1.2±3.4 kg and 56.0±49.8 mg/dL, respectively. Hypoglycemia was reported in 36 subjects (33.3%, 112 episodes), all of which were fully recovered. There was no serious AE attributed to insulin glargine. Body weight change was significantly different between SU users and nonusers (1.5±2.5 kg vs. -0.9±6.0 kg, P=0.011). Conclusion The combination add-on therapy of insulin glargine, on metformin and DPP-4 inhibitors with or without SU was safe and efficient in reducing HbA1c levels and thus, is a preferable option in managing T2DM patients exhibiting dysglycemia despite the use of OADs.

Our previous study reported that both oxidative stress and protein glycation were the principal mechanisms underlying 2‑deoxy‑D‑ribose (dRib)‑induced pancreatic β‑cell damage. The aim of the present study was to investigate the effects of captopril on dRib‑induced damage in pancreatic β‑cells, as well as to determine the mechanisms underlying these effects. Treatment with dRib increased the levels of cytotoxicity, apoptosis, and intracellular reactive oxygen species in Syrian hamster insulinoma HIT‑T15 cells; however, pretreatment with captopril significantly inhibited the effects of dRib. The intracellular levels of reduced and oxidized glutathione were depleted following treatment with dRib; however, these levels were restored following HIT‑T15 cell treatment with captopril. In rat islets, dRib stimulation suppressed the mRNA expression levels of insulin, and pancreatic and duodenal homeobox 1, as well as insulin content; however, these effects were dose‑dependently reversed by treatment with captopril. Treatment with buthionine sulfoximine, an inhibitor of intracellular glutathione biosynthesis, inhibited the protective effects of captopril on dRib‑mediated glutathione depletion and cytotoxicity in HIT‑T15 cells. Following incubation with albumin, dRib increased the formation of dicarbonyl and advanced glycation end products. Treatment with captopril did not inhibit the dRib‑induced increase in production of dicarbonyl and advanced glycation end products. In conclusion, treatment with captopril reversed dRib‑induced oxidative damage and suppression of insulin expression in β‑cells. The mechanism underlying the protective effects of captopril may involve increased intracellular glutathione production, rather than protein glycation.

Background: Increased low density lipoprotein cholesterol (LDL-C) level and the presence of metabolic syndrome (MetS) are important risk factors for cardiovascular disease (CVD) in type 2 diabetes mellitus (T2DM). Recent studies demonstrated apolipoprotein B (apoB), a protein mainly located in LDL-C, was an independent predictor of the development of CVD especially in patients with T2DM. The aim of this study was to investigate the relationship between apoB and MetS in T2DM patients. Methods: We analyzed 912 patients with T2DM. Fasting blood samples were taken for glycated hemoglobin, high-sensitivity Creactive protein, total cholesterol, triglyceride (TG), high density lipoprotein cholesterol, LDL-C, and apoB. MetS was defined by the modified National Cholesterol Education Program Adult Treatment Panel III criteria. We performed a hierarchical regression analysis with apoB as the dependent variable. Age, sex, the number of components of MetS and LDL-C were entered at model 1, the use of lipid-lowering medications at model 2, and the individual components of MetS were added at model 3. Results: Seventy percent of total subjects had MetS. ApoB level was higher in subjects with than those without MetS (104.5± 53.3 mg/dL vs. 87.7±33.7 mg/dL, P

In patients with type 2 diabetes mellitus (DM), insulin-stimulated glucose uptake is impaired. However, the relationship between serum potassium concentration and insulin resistance is poorly defined. This study aimed to investigate the association between serum potassium concentration and insulin resistance in these patients. Between April 2009 and October 2012, 180 patients with type 2 DM were analyzed. Insulin resistance was estimated using the homeostasis model and assessment (HOMA) index; resistance was defined as an index value of >2. The association between serum potassium concentration and insulin resistance was analyzed using linear regression methods. The incidence of hyperkalemia was also evaluated during follow-up. Mean serum potassium concentration was 4.12 ± 0.47 mEq/l. The median HOMA index score was 2.1 (interquartile range 1.1–3.4). When the patients were compared based on insulin resistance, serum potassium concentration was higher in the patients with insulin resistance compared with the patients without (4.25 ± 0.48 vs. 4.09 ± 0.44 mEq/l, p = 0.015). The variables found to be the determinants of serum potassium concentration included female, renal function, serum sodium level, log aldosterone-to-plasma renin activity ratio, glycosylated hemoglobin, and log HOMA index. Over a mean follow-up period of 2.6 ± 1.1 years, 37 of 180 patients (21 %) experienced episodic hyperkalemia. Patients with insulin resistance experienced episodic hyperkalemia more frequently than those without. Serum potassium concentration is likely to be increased in the patients with poorly controlled type 2 DM with insulin resistance than in those without insulin resistance.

Sialadenitis is a common complication arising from radioactive iodine therapy. F-18-fluoro-2-deoxyglucose positronemission tomography/computed tomography (18F-FDGPET/CT) has been proposed to be useful in detecting not only amalignant lesion but also inflammatory changes. An 18F-FDG uptake pattern can vary according to inflammatorychanges, and the present study reports on a case of late-onset sialadenitis 3 years after the treatment, showing adiffuse and intense 18F-FDGuptakeon 18F-FDGPET/CT. To the best of our knowledge, this is the first report on such an18F-FDG pattern in late-onset sialadenitis after radioiodine therapy.

Background We performed this study to identify factors related to intact incretin levels in patients with type 2 diabetes mellitus (T2DM). Methods We cross-sectionally analyzed 336 patients with T2DM. Intact glucagon-like peptide 1 (iGLP-1) and intact glucose-dependent insulinotropic polypeptide (iGIP) levels were measured in a fasted state and 30 minutes after ingestion of a standard mixed meal. The differences between 30 and 0 minute iGLP-1 and iGIP levels were indicated as ΔiGLP-1 and ΔiGIP. Results In simple correlation analyses, fasting iGLP-1 was positively correlated with glucose, C-peptide, creatinine, and triglyceride levels, and negatively correlated with estimated glomerular filtration rate. ΔiGLP-1 was positively correlated only with ΔC-peptide levels. Fasting iGIP showed positive correlations with glycosylated hemoglobin (HbA1c) and fasting glucose levels, and negative correlations with ΔC-peptide levels. ΔiGIP was negatively correlated with diabetes duration and HbA1c levels, and positively correlated with Δglucose and ΔC-peptide levels. In multivariate analyses adjusting for age, sex, and covariates, fasting iGLP-1 levels were significantly related to fasting glucose levels, ΔiGLP-1 levels were positively related to ΔC-peptide levels, fasting iGIP levels were related to fasting C-peptide levels, and ΔiGIP levels were positively related to ΔC-peptide and Δglucose levels. Conclusion Taken together, intact incretin levels are primarily related to C-peptide and glucose levels. This result suggests that glycemia and insulin secretion are the main factors associated with intact incretin levels in T2DM patients.

2-Deoxy- d -ribose (dRib) is known to induce oxidative damage and apoptosis by depleting GSH content in several types of cells. However, little is known about how dRib depletes intracellular GSH content. We hypothesized that dRib would deplete GSH content through inhibition of cystine uptake via system χc-. HIT-T15 cells were incubated with various concentrations of dRib, 2-mercaptoethanol (2-ME), Sulfasalazine (SASP), and homocysteic acid (HCA). We measured intracellular uptake of l -[14C]cystine, GSH content, and cell viability. Stimulation with dRib dose- and time-dependently decreases intracellular l -[14C]cystine uptake and GSH content. The addition of 2-ME, a cystine uptake enhancer, fully recovered the dRib-induced decreases in l -[14C]cystine uptake, GSH content, and cell viability. The 2-ME promoted the l -[14C]cystine uptake even in the absence of extracellular Na+, probably suggesting the involvement of the system χc-. SASP and HCA, system χc- inhibitors, significantly reduced l -[14C]cystine uptake and GSH content like dRib did, and 2-ME also restored the reductions. These findings suggest that dRib depletes intracellular GSH content through inhibition of cystine transport, and this inhibition may be mediated by system χc-. Additional experiments using a gene overexpression technique is necessary to further clarify the mechanism.

Case Kaposi’s sarcoma (KS) is a malignant vascular tumor that occurs commonly in patients with acquired immunodeficiency syndrome. KS associated with Cushing’s syndrome (CS) is unusual, especially in endogenous CS. Here, we report a case of KS associated with glucocorticoid-replacement therapy after surgical treatment for adrenal CS. A 70-year-old man presented with symptoms and signs of CS with a left adrenal mass. Adrenal CS was confirmed by biochemical studies. After left adrenalectomy, he took oral prednisolone (15 mg/day) to prevent adrenal insufficiency. Ten weeks later, numerous raised purple plaques on the lower extremities were newly detected. The biopsy findings were compatible with KS, but anti-HIV antibodies were negative. After withdrawal of glucocorticoid therapy, the skin lesions regressed completely. Conclusion In this case, KS developed after the use of exogenous corticosteroid but not during endogenous hypercortisolism. This finding suggests that endogenous and exogenous corticosteroid play different roles in the development of KS.