PracticeUpdate Diabetes June 2019

AACE 2019 19

Estimation of VonWillebrand Factor a Possible Diagnostic Aid in Identifying CV Risk Factors in PatientsWith Type 2 Diabetes Such estimation should be explored in a real- world setting. A striking correlation of elevated von Willebrand factor in type 2 dia- betes has been observed, as well as an absence of such a direct correlation with brachial-ankle pulse wave velocity. Estimation of von Willebrand factor in type 2 diabetes should be explored in large-scale, ran- domized, controlled trials. This outcome of a prospective cohort study was reported at AACE 2019. Vipin Talwar, MD, of the Golden Endocrine Hospital in Jalandhar, India, and colleagues set out to identify the role and correlation of von Willebrand fac- tor with other cardiovascular risk factors in patients with type 2 diabetes. Correlates were compared with those in the nondiabetic population. Overall, 46 patients were matched 1:1 in two groups (n=23 with diabetes, n=23 without diabetes). Von Willebrand factor, brachial-ankle pulse wave velocity, and other risk fac- tors, such as lipid profile, albuminuria, hypertension, body mass index, and HbA1c, were evaluated. Unpaired t-test and Mann Whitney test were utilized for the statistical analysis. Mean brachial-ankle pulse wave velocity in the group with diabetes was higher (1434 cm/s) than that in the group without diabetes (1315  cm/s). Sim- ilarly, mean von Willebrand factor in patients with diabetes (297 IU/dL) was higher than in those without diabetes (202 IU/dL). A weak correlation of von Willebrand factor was seen (r = 0.29; P = .01) with urinary proteins in both groups. No statistical correlation was observed with brachial-ankle pulse wave veloc- ity and other risk factors, including HbA1c, body mass index, cholesterol, and low-density lipoprotein cholesterol in patients with and without diabetes. The results demonstrated that von Willebrand factor is a marker of endothe- lial dysfunction and is elevated in patients with type 2 diabetes. No such remarkable correlation was observed with brachial-ankle pulse wave veloc- ity and other risk enhancers. A targeted drug design and development program to decrease elevated von Willebrand factor would help mitigate enhanced cardiovascular risk and improve cardiovascular outcomes in patients with type 2 diabetes. Dr. Talwar explained that brachial-ankle pulse wave velocity is a measure- ment used to estimate arterial stiffness. Brachial-ankle pulse wave velocity reflects the stiffness of both the aorta and peripheral artery. Traditional risk factors such as dyslipidemia, altered body mass index, and hypertension are known to raise risk of coronary artery disease. Von Wil- lebrand factor is a large multimeric glycoprotein present in plasma and is considered an accurate predictor of vascular risk. Dr. Talwar concluded that a striking correlation for elevated von Willebrand factor in type 2 diabetes was observed, as well as an absence of such direct correlation with brachial-ankle pulse wave velocity. Estimation of von Willebrand factor in patients with type 2 diabetes should be explored in a real-world setting. Results of the present study may be the basis for further, large-scale, randomized, controlled explorations of this evidence. www.practiceupdate.com/c/82852

More patients who took sitagliptin + other oral dia- betics reached target HbA1c <7% than those who took sitagliptin along with insulin (15%). Sitagliptin works to competitively inhibit the DPP4 enzyme. This enzyme breaks down the incretins glucagon-like peptide-1 and gastric inhibitory poly- peptide released in response to a meal. By preventing the breakdown of glucagon-like peptide-1 and gastric inhibitory polypeptide, DPP4 enzyme inhibitors are able to increase the secretion of insulin and suppress the release of glucagon by pancreatic α cells. This suppression drives blood glucose levels toward normal. As the blood glucose level approaches normal, amounts of insulin released and glucagon sup- pressed diminishes, preventing an “overshoot” and subsequent hypoglycemia. Such hypoglycemia is seen with other oral hypoglycemic agents. Sitagliptin has been shown to lower HbA1c level by about 0.7% points vs placebo. It is slightly less effec- tive than metformin when used as monotherapy. Sitagliptin does not cause weight gain and is asso- ciated with less hypoglycemia than sulfonylureas. Sitagliptin is recommended in combination with other drugs after the combination of diet/exercise and metformin fails. Sitagliptin was approved in 2006. Dr. Manikandan concluded that the DPP4 inhibitor sitagliptin was proven effective. Most patients who received sitagliptin achieved HbA1c goals. www.practiceupdate.com/c/82853 globulin 4. Dulaglutide binds to glucagon-like pep- tide 1 receptors, slowing gastric emptying and increasing insulin secretion by pancreatic ß cells. Simultaneously, the compound reduces elevated glucagon secretion by inhibiting pancreatic α cells. Such secretion is known to be inappropriate in the diabetic patient. Glucagon-like peptide-1 is normally secreted by L cells of the gastrointestinal mucosa in response to a meal. Dulaglutide was approved in 2014 to treat type 2 diabetes and can be used once weekly. Dr. Bhattacharyya explained that prediabetes is a state of insulin resistance that progresses to diabe- tes at a rate of 5% to 10% per year. Published evidence suggests glucagon-like pep- tide-1 receptor agonists to be promising in preventing progression of prediabetes to diabetes. They pro- mote regression to normoglycemia. Dr. Bhattacharyya concluded that, in a real-world setting, dulaglutide monotherapy was well tolerated and demonstrated a significant improvement in glycemic outcomes and body weight in obese Indian adults with prediabetes. Themonotherapy demonstrated a potential to reduce the risk of diabetes in obese adults with prediabetes. Further investigation in a larger, appropriately pow- ered clinical trial is warranted, however. www.practiceupdate.com/c/82851

VOL. 3 • NO. 2 • 2019