Journal Club

埼玉医科大学　総合医療センター　内分泌・糖尿病内科Department of Endocrinology and Diabetes,

Saitama Medical Center, Saitama Medical University

松田　昌文Matsuda, Masafumi

2011 年 8 月 11 日　 8:30-8:55８階　医局

Abdul-Ghani MA, Abdul-Ghani T, Stern MP, Karavic J, Tuomi T, Bo I, Defronzo RA, Groop L.Two-Step Approach for the Prediction of Future Type 2 Diabetes Risk.Diabetes Care. 2011 Jul 25. [Epub ahead of print]

Shimoda M, Kanda Y, Hamamoto S, Tawaramoto K, Hashiramoto M, Matsuki M, Kaku K.The human glucagon-like peptide-1 analogue liraglutide preserves pancreatic beta cells via regulation of cell kinetics and suppression of oxidative and endoplasmic reticulum stress in a mouse model of diabetes.Diabetologia. 2011 May;54(5):1098-108. Epub 2011 Feb 22.

Matsuda M.;GEKKAN TOUNYOUBYOU;2,16-22,2010 2:16-22, 2010. 　

Prevention of Diabetes MellitusTrial

publication

follow-up, year

drugNo. of new

on-set of DMNo.(total)

eventper 1000

person-yearscontrol

No. of newon-set of DM

No.(total)event

per 1000 person-years

Thiazolidine

*DPP 2005 0.9 Troglitazone 10 387 28.7Placebo

MetforminILS

372116

391397393

105.158.845.2

TRIPOD 2002 2.5 Troglitazone 17 114 59.6 Placebo 37 122 121.3

PIPOD 2006 3.0 Pioglitazone 11 86 42.6 -

*DREAM 2006 3.0 Rosiglitazone 306 2365 43.1 Placebo 686 2634 86.8

*ACTNOW 2008 4.0 Pioglitazone 10 303 8.3 Placebo 45 299 37.6

*CANOE 2010 3.9 Met+Rosi 14 103 34.9 Placebo 41 104 101.1

Other (α-GI, statin, fibrate, glinide)

WOSCOP 2001 5 Pravastation 57 2999 3.8 Placebo 82 3975 5.5

*STOP- NIDDM 2002 3.3 Acarbose 221 682 98.2 Placebo 285 686 125.9

BIP 2004 6.2 Bezafibrate 66 156 68.2 Placebo 80 147 87.8

*VICTORY 2009 4 Voglibose 50 897 13.9 Placebo 106 881 30.0

*NAVIGATOR 2010 6.5 Nateglinide 1674 3726 69.1 Placebo 1580 3747 64.9

Trial publicationfollow-

up, yeardrug

No. of newon-set of DM

No.(total)event

per 1000 person-years

controlNo. of new

on-set of DMNo.(total)

eventper 1000

person-years

antihypertensive drug

CAPPP 1999 6.1 ACEI 337 5183 10.7 β blocker 380 5230 11.9

STOP-2 1999 4.0 ACEI 93 1970 11.8β blockerDiuretic

CCB

97

95

1960

1935

12.4

12.1

HOPE 2001 4.5 ACEI 102 2837 8.0 Placebo 155 2883 11.9

ALLHAT 2002 4.0 ACE 119 4096 7.3 CCBDiuretic

154302

39546766

9.711.2

PEACE 2004 4.8 ACEI 335 3432 20.3 Placebo 399 3472 23.9

ANBP-2 2005 4.1 ACEI 138 2800 12.0 Diuretic 200 2826 17.3

AASK 2006 3.8 ACEI 45 410 28.9 β blockerCCB

7032

405202

45.541.7

*DREAM 2006 3.0 ACEI 449 2623 57.1 Placebo 489 2646 61.6

LIFE 2002 4.8 ARB 242 4020 12.5 β blocker 320 3979 16.8

*ALPINE 2003 1.0 ARB 1 196 5.1 Diuretic 8 196 40.8

CHARM 2003 3.1 ARB 163 2715 19.4 Placebo 202 2721 23.9

SCOPE 2003 3.7 ARB 93 2167 11.6 Placebo 115 2175 14.3

VALUE 2004 4.2 ARB 690 5087 32.3 CCB 845 5074 39.7

CASE-J 2007 3.2 ARB 38 1343 8.8 CCB 59 1342 13.7

*ProFESS 2008 2.5 ARB 125 7306 6.8 Placebo 151 7283 8.3

*ONTARGET 2008 4.7 ARB 399 8542 10.0 ACEI 366 8576 9.2

*ONTARGET 2008 4.7 ARB+ACEI 323 8502 8.1 ACEI 366 8576 9.2

*TRANSCEND 2008 4.7 ARB 319 2954 26.4 Placebo 395 2972 28.8

*HIJ-CREATE 2009 4.2 ARB 7 645 2.6 Placebo 18 624 6.9

*Kyoto Heart 2009 3.27 ARB+X 58 1116 51.6 X 86 998 76.7

*NAVIGATOR 2010 6.5 ARB 1532 3748 62.9 Placebo 1722 3725 71.1

Matsuda M.; Endocrinology ＆ Diabetology;26,1,35-41,2008.

Prevention of Diabetes Mellitus

Ann Intern Med. 2002;136:575-581

the San Antonio Diabetes Prediction Model (SADPM)

In this equation, p the probability of developing diabetes over the 7.5 year follow-up period;

age is in years; sex = 1 if female, 0 if male; MA = 1 if Mexican American, 0 if non-Hispanic white; FG fasting glucose in mg/dL; SBP systolic blood pressure in mm Hg; HDL high-density lipoprotein cholesterol level in mg/dL; BMI body mass index in kg/m2; and family history =1 if at least one parent or sibling has diabetes or 0 if not.

DOI: 10.2337/dc10-2201DIABETES CARE

the 1Division of Diabetes, University of Texas Health Science Center at San Antonio, San Antonio, Texas; the 2Division of Clinical Epidemiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas; and the 3Department of Clinical Sciences, Diabetes, and Endocrinology, and Lund University Diabetes Center, Lund University, Malmo, Sweden.

OBJECTIVE—To develop a model for the prediction of T2DM risk on the basis of a multivariatelogistic model and 1-h plasma glucose concentration (1-h PG).

The Botnia project was instituted in 1990 in order to investigate and explain these connections at three care centers in Osthrobothnia; Närpes, Korsholm and Malax-Korsnäs. At a later state the project was expanded to also cover Jakobstad and Vasa, along with other areas in Finland and southern Sweden. Until today, approximately 11000 people from 1400 families have participated in the project.

The San Antonio Heart Study is a population-based study in Mexican Americans and non-Hispanic whites. The baseline examination was conducted in 1984–93, with a 7-year follow-up in 1991–94

RESEARCH DESIGNANDMETHODS—The model was developed in a cohort of 1,562 nondiabetic subjects from the San Antonio Heart Study (SAHS) and validated in 2,395 nondiabetic subjects in the Botnia Study. A risk score on the basis of anthropometric parameters, plasma glucose and lipid profile, and blood pressure was computed for each subject. Subjects with a risk score above a certain cut point were considered to represent high-risk individuals, and their 1-h PG concentration during the oral glucose tolerance test was used to further refine their future T2DM risk.

http://en.wikipedia.org/wiki/Positive_predictive_value

Suppose the fecal occult blood (FOB) screen test is used in 2030 people to look for bowel cancer:

RESULTS—We used the San Antonio Diabetes Prediction Model (SADPM) to generate the initial risk score. A risk-score value of 0.065 was found to be an optimal cut point for initial screening and selection of high-risk individuals. A 1-h PG concentration .140 mg/dL in high risk individuals (whose risk score was .0.065) was the optimal cut point for identification of subjects at increased risk. The two cut points had 77.8, 77.4, and 44.8% (for the SAHS) and 75.8, 71.6, and 11.9% (for the Botnia Study) sensitivity, specificity, and positive predictive value, respectively, in the SAHS and Botnia Study.

CONCLUSIONS—A two-step model, based on the combination of the SADPM and 1-h PG, is a useful tool for the identification of high-risk Mexican-American and Caucasian individuals.

Message/Comments

糖尿病を予測できるか？　米国サンアントニオで作ったモデルをスェーデンやフィンランドであてはまるかをやった！　

一般的検査でハイリスクだと OGTT をやるという２ステップ。

日本人にあてはまるかは？（ OGTT をやっている健診センターは 10 年くらいデータがあればすぐ論文書けるでしょう）

ヒト GLP-1 アナログ製剤リラグルチド

7

36

9

Lys

His Ala Thr Thr SerPheGlu Gly AspVal

Ser

SerTyrLeuGluGlyAlaAla GlnLys

Phe

Glu

Ile Ala Trp Leu GlyVal Gly Arg

T½=1.5–2.1 min

DPP-4 により切断され、不活化

Knudsen et al. J Med Chem 2000;43:1664–9; Degn et al. Diabetes 2004;53:1187–94

ヒト GLP-1

• 皮下からゆっくりと吸収される• DPP-4 に切断されにくい• 血中半減期の大幅な延長 (T½=13 hrs)

7 9

36

C-16 脂肪酸( パルミチン酸 )

His Ala Thr Thr SerPheGlu Gly AspVal

Ser

SerTyrLeuGluGlyAlaAla GlnLys

Phe

Glu

Ile Ala Trp Leu GlyVal Gly Arg

Glu

Arg

リラグルチド

ヒト GLP-1 と 97% の相同性を保つ

ヒト GLP-1 アナログ（ 1 日 1 回の皮下注射）

db/db mouse

C57BLKS/J +Leprdb/+Leprdb

Diabetes Division, Kawasaki Medical School

misty mouse

C57BLKS/J m+/m+

Division of Diabetes, Endocrinology and Metabolism, Department of Internal Medicine, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama 701-0192, Japan

Diabetologia (2011) 54:1098–1108

Aims/hypothesis We investigated the molecular mechanism by which the human glucagon-like peptide-1 analogue liraglutide preserves pancreatic beta cells in diabetic db/db mice.

Methods Male db/db and m/m mice aged 10 weeks received liraglutide or vehicle for 2 days or 2 weeks. In addition to morphological and biochemical analysis of pancreatic islets, gene expression profiles in the islet core area were investigated by laser capture microdissection and real-time RT-PCR.

eIF2α Eukaryotic translation initiation factor 2 αER Endoplasmic reticulumERK Extracellular signal-regulated kinaseGLP-1 Glucagon-like peptide-1GSIS Glucose-stimulated insulin secretionHES1 Hairy and enhancer of split-14HNE 4-Hydroxy-2-noneal modified proteinMAPK Mitogen-activated protein kinasePCNA Proliferative cell nuclear antigenPI3K Phosphoinositide 3-kinase

Abbreviations

They received a subcutaneous injection of liraglutide (200 μg/kg) or vehicle (PBS) twice daily (09:00 and 16:00 hours).

2 weeks db/db

2 days db/db

Fig. 3 Islet morphology and function in db/db mice treated with vehicle (black bars) or liraglutide (white bars) for 2 days or 2 weeks. a Haematoxylin–eosin staining, followed by double immunohistochemical staining with antibodies against glucagon and somatostatin. Scale bars 100 μm. b Beta cell mass, measured as described; n=5 (a, b). c Immunohistochemical staining with antibodies against PCNA, quantified (d) as ratio. e, f 4-HNE and (g, h) TUNEL assays and quantification as indicated. c–h n=3 for each assay, scale bars 100 μm. The proportion of cells positive for PCNA (c, d) and 4-HNE (e, f) was measured in each islet and expressed as average proportion for a minimum of 50 islets from each experimental animal. *p<0.05, **p<0.01

the proportion of antibody-positive cells (to PCNA) was measured to evaluate the proliferative effect on pancreatic islets.

Fig. 3 Islet morphology and function in db/db mice treated with vehicle (black bars) or liraglutide (white bars) for 2 days or 2 weeks. e, f 4-HNE and (g, h) TUNEL assays and quantification as indicated. c–h n=3 for each assay, scale bars 100 μm. The proportion of cells positive for PCNA (c, d) and 4-HNE (e, f) was measured in each islet and expressed as average proportion for a minimum of 50 islets from each experimental animal. DNase-treated cells were used as a positive control in the TUNEL assay (g, h), with results of the TUNEL assay expressed as the average number of TUNEL-positive cells per islet by assessing a minimum of 50 islets from each experimental animal. *p<0.05, **p<0.01

Fig. 3 Islet morphology and function in db/db mice treated with vehicle (black bars) or liraglutide (white bars) for 2 days or 2 weeks.

i Islet insulin content and (j) islet triacylglycerol content; n=5. k GSIS was assessed by use of lower and higher glucose concentrations (3 mmol/l and 16.7 mmol/l); n=5. *p<0.05, **p<0.01

The genes analysed in the present study were those associated with cell differentiation (Hlxb-9 [also known as Mnx1], Hes1, Neurod [also known as Neurod1] and Pdx1),cell proliferation (CycD and Erk-1 [also known as Mapk3]), endoplasmic reticulum (ER) stress (Xbp1),antioxidative stress (Cat and Gpx), lipid synthesis (Srebp-1c [also known as Srebf1] and Fas) and cell apoptosis (Bcl2, Casp8, Casp3 and Cad).

To quantify gene expression, 2ΔCt was calculated using 18S rRNA as an internal control.

Bcl-2 (B-cell lymphoma 2) : anti-apoptotic

Fig. 4 Gene expression in the core area of islets in db/db mice treated with vehicle (black bars) or liraglutide (white bars). a–f Expression of genes involved in cell differentiation and proliferation after 2 weeks and (g–l) 2 days of treatment. a, g Hlxb-9, (b, h) Hes1, (c, i) Neurod, (d, j) Pdx1, (e, k) Erk1, (f, l) CycD. m–t Expression of genes involved in pro-apoptosis and anti-apoptosis after 2 weeks (m–p) and 2 days (q–t) of treatment. m, q Bcl2, (n, r) Casp8, (o, s) Casp3, (p, t) Cad.n=4 for each group; *p<0.05, **p<0.01; †p<0.005; ‡p<0.0001; §p=0.08

cell differentiation cell proliferation

2 weeks

2 days

2 weeks

cell apoptosis

Fig. 4 Gene expression in the core area of islets in db/db mice treated with vehicle (black bars) or liraglutide (white bars). Expression of genes involved in pro-apoptosis and anti-apoptosis after 2 weeks (m–p) and 2 days (q–t) of treatment. m, q Bcl2, (n, r) Casp8, (o, s) Casp3, (p, t) Cad. u–dd Expression of genes involved in anti-oxidative stress, ER stress and lipid synthesis after 2 weeks (u–y) and 2 days (z–dd) of treatment. u, z Gpx, (v, aa) Cat, (w, bb) Xbp1, (x, cc) Fas, (y, dd) Srebp-1c. n=4 for each group; *p<0.05, **p<0.01; †p<0.005; ‡p<0.0001; §p=0.08

2 weeks

2 days

2 days

cell apoptosis

ER stress antioxidative stress lipid synthesis

2 weeks m/m

2 weeks m/m

cell differentiation cell proliferation

cell apoptosis

ER stress antioxidative stress lipid synthesis

Results Liraglutide treatment for 2 weeks improved metabolic variables and insulin sensitivity in db/db mice. Liraglutide also increased glucose-stimulated insulin secretion (GSIS) and islet insulin content in both mouse strains and reduced triacylglycerol content in db/db mice. Expression of genes involved in cell differentiation and proliferation in both mouse strains was regulated by liraglutide, which, in db/db mice, downregulated genes involved in pro-apoptosis, endoplasmic reticulum (ER) stress and lipid synthesis, and upregulated genes related to anti-apoptosis and anti-oxidative stress. In the 2 day experiment, liraglutide slightly improved metabolic variables in db/db mice, but GSIS, insulin and triacylglycerol content were not affected. In db/db mice, liraglutide increased gene expression associated with cell differentiation, proliferation and anti-apoptosis, and suppressed gene expression involved in pro-apoptosis; it had no effect on genes related to oxidative stress or ER stress. Morphometric results for cell proliferation, cell apoptosis and oxidative stress in db/db mice islets were consistent with the results of the gene expression analysis.

Conclusions/interpretation Liraglutide increases beta cell mass not only by directly regulating cell kinetics, but also by suppressing oxidative and ER stress, secondary to amelioration of glucolipotoxicity.

Message/Comments

GLP-1 アナログ製剤が膵臓 β 細胞にどのように影響するか興味があるところである。