1. Journal Club 2011年3月31日 8:30-8:55 ８階 医局
DeFronzo RA, Tripathy D, Schwenke DC, Banerji M, Bray GA, Buchanan TA, Clement SC, Henry RR, Hodis HN, Kitabchi AE, Mack WJ, Mudaliar S, Ratner RE, Williams K, Stentz FB, Musi N, Reaven PD; ACT NOW Study.
Pioglitazone for diabetes prevention in impaired glucose tolerance.
N Engl J Med Mar 24;364(12):
2011年3月31日　8:30-8:55
８階　医局
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

2. Primary Prevention of Type 2 Diabetes Mellitus
● Life style modification
・Malmö feasibility study (Eriksson, 1991)
・Malmö Prfevention Trial (Eriksson, 1998)
・DaQing IGT and Diabetes Study (Pan, 1997)
・Finnish Diabetes Prevnetion Study (Tuomilehto, 2001)
・Japan Diabetes Prevention Study (Kuzuya)
・Stockholm Diabetes Prevention Program (Bjärås)
● Drug intervention
・Diabetes Prevention Program (DPP Research Group, 2002)
・STOP-NIDDM (Chiasson, 2002)
・TRIPOD (Buchanan, 2001)
・EDIT (Holman, 2003)
・NAVIGATOR (Rury R. Holman, 2010) negative
・DREAM (Boche, 2006)
・ACT NOW (DeFronzo，2008)
・ONTARGET (ONTARGET group, 2008)
STOP-NIDDM：Study To Prevent NDDM,
TRIPOD：Troglitazone In Prevention of Diabetes
EDIT：Early Diabetes Intervention Trial,
NAVIGATOR：Natglinide and Valsartan in Impaired Glucose Tolerance Outcome Reaserach
DREAM：Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medications

3. Prevention of Diabetes Mellitus
Trial
publication
follow-up, year
drug
No. of new
on-set of DM
No.(total)
event
per 1000 person-years
control
Thiazolidine
*DPP
2005
0.9
Troglitazone 10
387
28.7
Placebo
Metformin
ILS 37 21 16
391
397
393
105.1
58.8
45.2
TRIPOD
2002
2.5 17
114
59.6
122
121.3
PIPOD
2006
3.0
Pioglitazone 11 86
42.6 -
*DREAM
Rosiglitazone
306
2365
43.1
686
2634
86.8
*ACTNOW
2008
4.0
303
8.3 45
299
37.6
*CANOE
2010
3.9
Met+Rosi 14
103
34.9 41
104
101.1
Other (α-GI, statin, fibrate, glinide)
WOSCOP
2001 5
Pravastation 57
2999
3.8 82
3975
5.5
*STOP- NIDDM
3.3
Acarbose
221
682
98.2
285
125.9
BIP
2004
6.2
Bezafibrate 66
156
68.2 80
147
87.8
*VICTORY
2009 4
Voglibose 50
897
13.9
106
881
30.0
*NAVIGATOR
6.5
Nateglinide
1674
3726
69.1
1580
3747
64.9
Matsuda M.;GEKKAN TOUNYOUBYOU;2,16-22,2010 2:16-22, 　

4. Cardiovascular outcomes from 16 observational studies (4 case-control studies and 12 retrospective cohort studies), including thiazolidinedione users, were evaluated after a detailed review of 189 citations.
BMJ 2011;342:d1309
Meta-analysis of odds ratio for overall mortality with rosiglitazone versus pioglitazone

5. the Texas Diabetes Institute and University of Texas Health Science Center (R.A.D., D.T., N.M.) and KenAnCo Biostatistics (K.W.) — both in San Antonio; Phoenix Veterans Affairs (VA) Health Care System, Phoenix, AZ (D.C.S., P.D.R.); College of Nursing and Health Innovation, Arizona State University, Phoenix (D.C.S.); SUNY Health Science Center at Brooklyn, Brooklyn, NY (M.B.); Pennington Biomedical Research Center– Louisiana State University, Baton Rouge (G.A.B.); University of Southern California Keck School of Medicine, Los Angeles (T.A.B., H.N.H., W.J.M.); Division of Endocrinology and Metabolism, Georgetown University, Washington, DC (S.C.C.); VA San Diego Healthcare System and University of California at San Diego, San Diego (R.R.H., S.M.); University of Tennessee, Division of Endocrinology, Diabetes, and Metabolism, Memphis (A.E.K., F.B.S.); and Medstar Research Institute, Hyattsville, MD (R.E.R.)
N Engl J Med 2011;364:

6. BACKGROUND
Impaired glucose tolerance is associated with increased rates of cardiovascular disease and conversion to type 2 diabetes mellitus. Interventions that may prevent or delay such occurrences are of great clinical importance.

7. METHODS
We conducted a randomized, double-blind, placebo-controlled study to examine whether pioglitazone can reduce the risk of type 2 diabetes mellitus in adults with impaired glucose tolerance. A total of 602 patients were randomly assigned to receive pioglitazone or placebo. The median follow-up period was 2.4 years. Fasting glucose was measured quarterly, and oral glucose tolerance tests were performed annually. Conversion to diabetes was confirmed on the basis of the results of repeat testing.

8. Figure 1. Enrollment, Randomization, and Follow-up of Study Patients.
FPG denotes fasting plasma glucose, and OGTT oral glucose-tolerance test.

12. Figure 3. Incidence Rates, Hazard Ratios, and Tests for Heterogeneity for All Patients and Selected Subgroups. The figure shows incidence rates per 100 person-years and corresponding hazard ratios and confidence intervals for the effects of pioglitazone as compared with placebo on the conversion of impaired glucose tolerance to diabetes. The x axis is interrupted to allow for better visual presentation. BMI denotes body-mass index (the weight in kilograms divided by the square of the height in meters), IFG impaired fasting glucose, and IGT impaired glucose tolerance. To convert the values for glucose to millimoles per liter, multiply by

13. Figure 4. Effects of Pioglitazone as Compared with Placebo.
Over the course of the study, mean percentage changes and standard errors in continuous measures were calculated with the use of a linear, mixed-repeated-measures model fit to all available data for each measure. As compared with placebo, treatment with pioglitazone (dashed lines) had beneficial effects on fasting plasma glucose levels (Panel A), 2-hour plasma glucose levels (Panel B), and HbA1c levels (Panel C) and on systolic and diastolic blood pressure (Panels E and F, respectively), alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels (Panels G and H, respectively), and carotid intima–media thickness (Panel I). Weight gain was greater with pioglitazone than with placebo (Panel D). (Body-mass index was calculated at each examination with the use of height measured at baseline; as a result, the percentage change in BMI is identical to the percentage change in weight.) A total of 365 patients (placebo group, 186; pioglitazone group, 179) completed the follow-up examination at 15 to 18 months for measurement of carotid intima–media thickness, and 336 patients (placebo group, 173; pioglitazone group, 163) completed the final examination for measurement of carotid intima–media thickness. P values are shown for the interaction between time and study group, indicating whether the slopes differ significantly over time.

14. EFFECT OF PIOGLITAZONE AND PLACEBO ON MATSUDA INDEX OF INSULIN SENSITIVITY10
Insulin sensitivity as measured with the Matsuda index increased more with pioglitazone than with placebo (4.31±0.24 to 7.65±0.34 vs. 4.31±0.30 to 5.23±0.31, P<0.001).
P<0.001 8 6
Matsuda Index 4 2
Pre
Post
Pre
Post

15. EFFECT OF PIOGLITAZONE AND PLACEBO ON INSULIN SECRETION / INSULIN RESISTANCE INDEX
The index of insulin secretion factored by insulin resistance, calculated on the basis of the oral glucose-tolerance test (I0–120/ΔG0–120 × Matsuda index), increased more with pioglitazone than with placebo (3.43±0.12 to 5.44±0.31 vs. 3.81±0.30 to 4.20±0.20, P<0.005).
P<0.005 6 5 4
I/G xMatsuda (0-120) 3 2 1
Pre
Post
Pre
Post

16. Effect of Thiazolidinediones on Fat Topography
High FFA
FFA
TZD
Intramuscular Fat
Harold Bays, Lawrence Mandarino, and Ralph A. DeFronzo Role of the Adipocyte, Free Fatty Acids, and Ectopic Fat in Pathogenesis of Type 2 Diabetes Mellitus: Peroxisomal Proliferator-Activated Receptor Agonists Provide a Rational Therapeutic Approach J. Clin. Endocrinol. Metab., Feb 2004; 89:
Subcutaneous Fat
Intrahepatic Fat
Intra-arterial Fat
Intraabdominal Fat
Artery
Bays H, Mandarino L, DeFronzo RA. J Clin Endocrinol Metab. 2004;89:

17. * For the comparison of placebo and pioglitazone regarding frequency of edema, cardiovascular events, and total events, P = 0.007, P = 0.80, and P = 0.03, respectively. The total number of adverse events — excluding edema — did not differ significantly between groups (P = 0.52).
† Edema was defined as an increase above baseline by two or more grades on one or more distinct study visits.
‡ Weight gain was defined as a gain of more than 1 kg.

18. RESULTS
Annual incidence rates for type 2 diabetes mellitus were 2.1% in the pioglitazone group and 7.6% in the placebo group, and the hazard ratio for conversion to diabetes in the pioglitazone group was 0.28 (95% confidence interval, 0.16 to 0.49; P<0.001). Conversion to normal glucose tolerance occurred in 48% of the patients in the pioglitazone group and 28% of those in the placebo group (P<0.001). Treatment with pioglitazone as compared with placebo was associated with significantly reduced levels of fasting glucose (a decrease of 11.7 mg per deciliter vs. 8.1 mg per deciliter [0.7 mmol per liter vs. 0.5 mmol per liter], P<0.001), 2-hour glucose (a decrease of 30.5 mg per deciliter vs mg per deciliter [1.6 mmol per liter vs. 0.9 mmol per liter], P<0.001), and HbA1c (a decrease of 0.04 percentage points vs. an increase of 0.20 percentage points, P<0.001). Pioglitazone therapy was also associated with a decrease in diastolic blood pressure (by 2.0 mm Hg vs. 0.0 mm Hg, P = 0.03), a reduced rate of carotid intima–media thickening (31.5%, P = 0.047), and a greater increase in the level of high-density lipoprotein cholesterol (by 7.35 mg per deciliter vs. 4.5 mg per deciliter [0.4 mmol per liter vs. 0.3 mmol per liter], P = 0.008). Weight gain was greater with pioglitazone than with placebo (3.9 kg vs kg, P<0.001), and edema was more frequent (12.9% vs. 6.4%, P = 0.007).

19. CONCLUSIONS
As compared with placebo, pioglitazone reduced the risk of conversion of impaired glucose tolerance to type 2 diabetes mellitus by 72% but was associated with significant weight gain and edema.
(Funded by Takeda Pharmaceuticals and others; ClinicalTrials.gov number, NCT )

20. Message/Comments ACTNOW研究の結果の報告がかなり遅れていたが今回発表された。
ピオグリタゾンの糖尿病発症予防は72%である。

22. 2009_294臨床研究：FMDとARB
2009_307臨床研究：プロインスリン
2010_334臨床研究：DPP4IとOGTT
2010_342臨床研究：DPP4I長期介入
2010_350臨床研究：DPP4I抗GAD陽性者
2010_351臨床研究：インスリン作用指標と血糖管理
2011_398臨床研究：DPP4I獨協プロトコール

24. Message/Comments
過去２年、埼玉医科大学総合医療センター内分泌・糖尿病内科で行う臨床研究の準備を進めてきたが、やっと倫理委員会の承認や検査会社との契約ができ開始できそうである。