CARDIOVASCULAR EFFECTS OF SULFONYLUREAS EXPERIMENTAL AND CLINICAL EXPERIENCES

CARDIOVASCULAR EFFECTS OF SULFONYLUREAS EXPERIMENTAL AND CLINICAL EXPERIENCES PhD thesis Eve Nieszner MD Semmelweis University 2 nd Department of Cardiology National Center of Health Sciences Department of Cardiology and Internal Medicine Budapest Semmelweis University 2002

Introduction Notwithstanding that typ2 Diabetes Mellitus can be treated excellently nowadays the complications of diabetes are still taking place in the front lines of the mortality data High blood sugar in consideration of high diabetic cardiovascular mortality plays an important role in the progressive atherosclerosis as being the main origin of this multiorgan disease In spite of the effective treatment of hyperglycaemy the high number of cardiac death means a great demand for revaluation the risk factors among diabetic patients Beside the needed normoglycaemy, the necessity of interventions for primer prevention and multifactorial treatment has to be underlined However sulfonylurea treatment has arised as a possible new risk factor as possessing special channel blocking effects on ATP dependent potassium channels Besides beta cells they may have an influence on all other ones in extrapancreatogen localisation As K + ATP channels are actors of protection in the cardiovascular system and are mainly metabolically controlled During sulfonylurea treatment their activity is inhibited, so their participation in vasodilation and cardioprotection is supposed to be impeded in the diabetic patients As extrapancreatic localisation of these channels are widespread in the cardiovascular system SU treatment may result in the depression of preconditioning or vasodilation There are only a small information about the activity and potency of K + ATP channels in the cardiovascular system under chronic sulfonylurea treatment Should we need account with a paralysed cardiovascular protection in the diabetic patient treated with sulfonylurea? Does sulfonylurea treatment mean an increased or anlarged hazard?? Aim of study The aim of the study was to investigate the influence of two distinct sulfonylureas (glibenclamide and glimepiride) on the adaptation properties of the cardiovscular system 1/ Myocardial preconditioning and its metabolic modulation was assessed in vivo and in vitro experimental studies to get information about, how these reactions are influenced by sulfonylurea treatement and metabolic circumstances 2/ Clinical relevances were assessed in diabetic patiens treated or untreated with diabetes mellitus

3/ Different sulfonylureas (glibenclamid, glimepirid) and their effects on vasoregulatory adaptation were assessed in coronary patients and in patients with eriferial artery disease Method Alloxan induced (145mM kg -1 ) diabetic (n=189) New Zeland male rabbits (BW:1650±250g) were used in the experiments They were regularly controlled and consumed when their blood sugar reached the pathological range(bs 125mM) In clinical studies healthy (n=26, kor:56±12y) control and diabetic patients (n=43year :63±0,8years) were employed (HbA1C 70%) We possessed their inform concent for diagnostic assessement In vivo animal models : preconditioning were provoked by 2 min of no flow ischaemia, followed by 2 min reperfusion (for two occasions) Myocardial infarction was provoked by 60 min coronary artery ligation after 005-02- 06 10-3 mm kg -1 of glibenclamid or glimepirid treatment both in healthy control and diabetic animals Planymetry was carried out after tetrazolium blue (TTC) vital painting, and histological measurements were done with the help of flurescens signal followed with fluorescens stereo microscope (Eclyps 600, NIKON, VIRGINIA IBM PC,IMAN 20 beta KFKI) In vitro experimental studies: rabbit hearts were perfused retrogradely according to Langendorff-II method (constant 80watercm) and exposed to 2min no flow ischaemia followed by 2min reperfusion (2 times) Infarction was provoked by 20 min ligation of coronary perfusion and 30 min reperfusion and concentration dependent influence of glibenclamide and gliclazid treatment (5-25-250-1224ng/l) on contraction and relaxation in healthy control and diabetic hearts were observed Experimental data were analysed by 3way variance and by regression analysis In human studies the effects of glibenclamid and glimepiride on microcirculation in healthy controls and newly diagnosed diabetics without obliterative

artery disease (n=22) was assessed by a laser Doppler method (He-Ne monocromatics, Perimed 5000,Perisoft 51 IBM PC) Flow mediated vasodilatory capacitiy of the brachial artery was assessed in controls and diabetic patients with and without obliterativ artery disease (n=22) (FMVD, 11MHz, PD) Measuremets were repeated in metabolic modulation (exposition to adenosine (500 g/min iv), L-arginin (01gtskg -1 iv), trimetazidine (60mg po) and NO (po) Vasodilatory response (endothel dependent and independent) to these agents were compared in patients with and without sulfonylurea treatment (glibenclamid or Glimepirid) Transthoracal echocardiography (TTE, Powervision, 2D,PD,35MHz) measurements, diameteres and pulsed Doppler measurements - from the apex of the heart were done to compare the effects of vascular complications and/or different types of treatments in the diabnetic group (Observed parameteres: E/A, prejection period-pep, circumferential shortening-crs, PEP/LVET, periferial stress-esmws) Transoesophageal echocardiography (TEE, Powervision, PD, 45MHz,45-60 0 ) assessment supplied data about the vasodilation capacity and flow velocity in the coronary system of sulfonylurea treated patients (n=23) Treadmill test (Bruce protokol) served as a method for clinical type of preconditoning as being repeated within 60 mins following the first test Developed changes (per centum) in load capacitiy, ischaemic tolerance and time of reconvalescens in the second compared to the first measurement expressed the possibility of preconditioning The effect of metabolic (trimetazidine) and sulfonylurea (glibenclamid and glimepirid ) treatment were assessed Different types of statistical methods were used in analysis(t probe,oneway variance, Bonferroni analysis) Results In vitro studies prconditioning in healthy control rabbits reduces infarcted area (F=30247 p<00005, oneway ANOVA signp<00) and infarctus/risk area (F=23948 p<0001, oneway ANOVA signp<00) Alloxan treatment enlarged the infarcted area in

diabetics (control precond vs diab precond :00005 MD:-0286 SE:046, MCT by Tukey, signp<005)while in controls all of the applied doses enlarged the infarcted area (: area: p 1 <0003 vs p 2 <0002 vs p 3 <0001, infarktus/risk: p 1 <0004 vs p 2 <0002 vs p 3 <0001, MCT by Tukey, signp<005)) in diabetic rabbits a concentration dependent effect of glibenclamide can be observed In vitro experiments non of the glibenclamid doses caused changes in contraction and relaxation, while in substantial metabolic disorder glib evoked a dose-dependenet effect (y=-35399ln(x)+98615 R2=0254, p<005) The direction of sulfonylurea effect depends on the severity of metabolic impairement (control:y=-30958ln(x)+11014 R2=07336 p<0001 vs D1: y= -19644Ln(x)+10839 R2=03471 p<001 vs D2: y= 26956Ln(x)+92067 p<001) While in controls dose dependent effect can not be assessed in spite of the strong influence of preconditioning and sulfonylurea treatment, (F=79907 p<00005 3way ANOVA, signp<005), precondítioning (F=176725 p<00000 3way ANOVA, signp<005), in diabetic rabbits presumable in the consecvences of the more activated potassium channels glibenclamide effect seems to be concentration dependenet and interaction between doses of glibenclamide and metabolic state exist (F=56069 p<00003 3way ANOVA, signp<005) ) The same observation can be won in relaxation parameteres Antioxidant effects of gliclazid as a metabolic inflence of the sulfonylurea without cardiac effect could be observed Results in humans No evidences of different vasodilatory response in microcirculation was observed in the newly diagnosed diabetic and the healthy control patients However in glibenclamid treated patients both basic flow and vasodilator capacity proved diminished (F0- diab vs F0- glib : 156PU/s SE:038 vs 137PU/s SE:063 p=0001 - F glib vs F kont : 2200% SE:112 vs 443% SE:188 p<00005 compbonferroni, signp<005) Glimepirid treatment did not diminished flow or vasodilating capacitiy in microcirculation)

Both endothel dependent and independent vasodilation is reduced in diabetic patient with periferial obliterative disease, while in glimepirid treatment endothel independent reflection is not involved in the pathological reaction L-arginin and trimetazidine according to the metabolic impairement may improve both type of vasodilation (endothel dependent dilatation: contr vs glim vs glib: 99% 25 vs 1348 % 31 vs 251% 23 p<005 independent: 162% 04 vs 2063% 14 vs 463% 17 p<005 Both the existing complications, and the effects of permanent treatments can be involved in the transthoracal echocardiaographical measurements, especially the ESMWS the perferial stress parameter can be used in thismeasurements Transoesophageal echocardiography is the proper method of choice for assessing pathological changes in coronary flow reserv capacity as glibenclamide substantially reduces vasodilatator capacity in patients with no coronary sclerosis (CFR glib vs CFR ins vs CFR glim : 121 vs 225 vs 231 p<005) In the consequences of metabolic effects of Glimepiride coronary flow reserv capacitiy may be preserved in the diabetics treated with glimeopiride unless in the case of hyperlipidaemia By repeated loading test in healthy controls clinicasl typőe of preconditioning can be modellized Diabetic patients preconditioning is determinated simultonosly by metabolic circumstances, sulfonylurea treatment Summary The participation of K + ATP channels in the cardioprotectiv procedure that is in precondotioning is proved Either being a signal or the main participant of this procedure sulfonylurea tretament can modify the activity of K + ATP channels In this way the efficacy of preconditioning can be modified Modification of channel activity and so the influence of preconditioning on myocardial infarction are modified by effects and sulfonylurea treatment as well Both effects can be assessed by clinical diagnostic equipmnets, so it is possibble today to choose the proper, personal therapy,

Articles in connection with the paper 1 Nieszner É, Nádas I, Simon J, Baranyi É, Préda I: Macroangiopathiaban szenvedő cukorbetegek anyagcserehelyzetének értékelése Érbetegségek, 2 11-15 1994 2 Nieszner É, Nádas I, Baranyi É,Tóth K,Vereczkei K, Préda I,: Balkamrafunkció értékelése diabetes mellitus okozta microangio -pathiaban Érbetegségek, 4 5-11 1996 3 Baranyi É, Winkler G, Nieszner É, Tóth J: A nem inzulin dependens cukorbetegek (NIDDM) kezelésének ujabb lehetősége: egyénre szabott szabott szulfonilurea therapia Orvosképzés, 2:122-7 1998 4 Nieszner É, Posa I, Kocsis E, Pogátsa G, Préda I, Koltai MZS: A precondicionálás jelenségének módosulása kezelt és kezeletlen diabetes mellitusban Diabetologia Hungarica, 8(1) : 19-26 2000 5 EKocsis, PPacher, IPósa, ENieszner, G Pogátsa and MZKoltai: Hyperglycaemia alters the endothelium-dependent relaxation of canine coronary arteries Acta Physiol Scand 169; 183-187, 2000 Impact f: 1764 6 Nieszner É, Baranyi É, Simon J, Vereczkei K, Nádas I, Préda I: Kis dózisú ACE gátló kezelés renoprotectív hatásának vizsgálata normo/hypotóniás diabetes mellitusban szenvedő betegekben Medicus Universalis XXXV/1 2002 7 ENieszner, IPósa, EKocsis, G Pogátsa, IPréda, MZKoltai: Influence of diabetic state and that of different sulfonylureas on the size of myocardial infarction with and without ischemic preconditioning in rabbits ExpClinEndocrinolDiabetes 110: 212-218 2002 Impact f: 1617 8 Nieszner É, Vereczkei K, Farkas K, Márkus R, Nádas I, Baeanyi É, Préda I: A glimepiride kedvező hatása a mikrocirculacióban 2 típusú diabetes korai stadiumában Érbetegségek 2:49-57 2002 9 ENieszner*, JRadó,FBányai*, MHorváth, INádas*, FGonda, IPréda*: Haemodynamic benefits for diabetic heart in insulin treated patients Advances in Recent Cardiovascular Research (Proceedings of the 22 nd European Section Meeting of the International Society for Heart Research) CardiovascResearch folyamatban Impact f: 4552

Abstracts in connection with the paper 1 Nieszner É, Nádas I, Simon J, Baranyi É, Préda I: Macroangiopathiaban szenvedő cukorbetegek anyagcserehelyzetének értékelése Magyar Diabetes Társaság XIIKongresszusa, Győr Diabetologia Hungarica IISuppl 2 35o 1994 2 Nieszner É, Nádas I, Baranyi É, Préda I: Diabeteses microangiopathias betegek echocardiographias parametereinek értékelése Magyar Diabetes Társaság XIII Kongresszusa, Keszthely Diabetológia Hungarica IVSuppl219o 1996 3 ÉNieszner, INádas, ÉBaranyi, KTóth, KVereczkei, IPréda: Left ventricular function in diabetic microangiopathy International Union of Angiology European Chapter s Congress, Budapest International Angiology, Vol l5 Suppl1 p73 1996 Impact f: 0,295 4 KVereczkei, LMajor, KTóth, INádas, ÉNieszner, IPréda: Late results of periferial stenting International Union of Angiology European Chaper s Congress, Budapest International Angiology, Vol 15 Suppl l p45 1996 Impact f: 0,295 5 Vereczkei K, Major L, Molnár F, Regős L, Tóth K, Nádas I, Nieszner É, Préda I: Stentbeültetésen átesett betegeink klinikai utánkövetése Magyar Kardiológusok Társasága Tudományos Kongresszusa Cardiologia Hungarica Suppl1 75o 1996 6 Nieszner É, Farkas K, Vereczkei K, Nádas I, Préda I: Szulfanylurea kezelés hatása a periferias microcirculatióra IItipusú diabetes mellitusban Magyar Kardiológusok Társasága Tudományos Kongresszusa CardiolHung Suppl3 57o 1997 7 ÉNieszner, KVereczkei, KFarkas, INádas, IPréda: Effect of Sulfonylurea treatment on periferial microcirculation in NIDDM 7 th International Symposium on Cardiovascular Pharmacotherapy, Jerusalem Cardiovascular Drugs and Therapy 11 Suppl2 p332 1997 Impact f: 1,098 8 KVereczkei, ÉNieszner, KFarkas, INádas, IPréda: Effect of serum glucose level and sulfonylurea treatment on periferial microcirculation in NIDDM International Union of Angiology European Chapter s Congress, Rome, 1997 International Angiology, 19 p111 1997 Impact f: 0,295

9 ENieszner, K Vereczkei, K Farkas, INádas, ÉBaranyi IPréda: Hat die Sulphonylurea Therapie eine nachteilige Wirkung auf die Mikrocirkulation im Diabetes Mellitus? XIV Internationales Donausymposium über Diabetes Mellitus Tschechische Medizinische Gesellschaft JEPyrkiné, Prag, 1997 10 11 12 13 14 15 16 Nieszner É, Vereczkei K, Farkas K, Nádas I, Baranyi É, Préda I: A SU therapia hatása a NO dependens vasodilatiós mechanizmusra Magyar Diabetes Társaság XIV Kongresszusa, Eger Diabetológia Hungarica VISuppl153o1998 Nieszner É, Vereczkei K, Nádas I, Baranyi É, Préda I: Kis dózisú ACE gátló kezelés renoprotectív hatása normotenziós diabetes mellitusban szenvedő betegekben Magyar Kardiológusok Társasága Tudományos Kongresszusa, Balatonfüred Cardiologia HungaricaSuppl1 77o 1998 Nieszner É, Pósa I, Kocsis E, Koltai MZS, Pogátsa G, Préda I: A kóros szénhidrát anyagcsere és a glyburide hatása a szív precondícionálására nyúlban Magyar Kardiológusok Társasága Tudományos Kongresszusa, Balatonfüred Cardiologia Hungarica, Suppl2 59o 1999 Simon J, Nieszner É, Baranyi É, Vilimi B, Tari A, Ferencz A: A microalbuminuria összefüggése a szénhidrát- és lipidanyagcsere laboratóriumi jellemzőivel Magyar Laboratóriumi Diagnosztikai Társaság 49 Nagygyűlése, 1999 Siófok Előadáskivonat 122o E Nieszner, IPosa, MZSKoltai, IPréda, GPogatsa: Effect of sulfonylurea treatment on preconditioning in alloxan diabetic rabbits 8 th International Symposium on Cardiovascular Pharmacotherapy, Amsterdam Cardiovascular Drugs and Therapy13(1):12 1999 Impact f: 1,098 ENieszner, IPosa, MZSKoltai, GPogátsa: Do Sulfonylureas limit protective effect of preconditioning? International Society for Heart Research, XX th European Section Meeting, Maastricht J MolCellCardiol31:(6): A 100 1999 Impact f: 3,255 ENieszner, IPosa, EKocsis, IPréda, GPogatsa, MZSKoltai: Is sulfonylurea treatment determinative on preconditioning in alloxan diabetic rabbits? 35 th Annual Meeting of the EASD, Brussel Diabetologia, 42Suppl1A 282 1999 Impact f: 5,347

17 18 19 20 21 22 23 24 Nieszner É, Baranyi É, Horányi P, Préda I:Gondolatok az idős cukorbetegek komplex ellátásának problémáiról súlyos hypoglikaemiás esetek értékelése során MDT XVKongresszusa, 2000 Tihany Diabetologoa Hungarica SupplI 8: 64o 2000 Rimanóczy É, Baranyi É, Nieszner É, Ferencz A: Anti-GAD-meghatározás: Új diagnosztikai lehetőség a szénhidrátanyagcsere-zavarban szenvedő betegek vizsgálatában és kezelésük elörejelzésében MDT XVKongreasszusa, 2000 Tihany Diabetologoa Hungarica SupplI 8: 72o 2000 Nieszner É, Vereczkei K, Farkas K, Nádas I, Márkus R, Baranyi É,Préda I: Glibenclamid és glimepirid eltérő hatása a reactív hyperaemiara 2típusú diabetes mellitusban MB Nagygyűlés 2000 Budapest MBA Nieszner É, Nádas I, Vereczkei K, Baranyi É, Préda I: A microalbuminuria predictív szerepe a diastoles functió értékelésében diabeteses és egészséges anyagcsereállapotban Magyar Atherosclrosis Társaság Kongresszusa, 2000 Sopron Előadáskivonat ENieszner, I Nádas, KVereczkei, EBaranyi, IPréda: Degree of microalbuminuria is related to diastolic performance in diabetic and non-diabetic patients as well XXIICongress of the ESC, Amsterdam Eur H J 21 Suppl P3745, 2000 Impact: f: 3,84 Pósa I, Kocsis E, Nieszner É, Koltai MZS, Pogátsa G: Haemodinamika és metabolismus:vércukorcsökkentő sulfonylureak hatása eltérő anyagcsereállapotban Magyar Kardiológusok Társasága Tudományos Ülése, Balatonfüred Cardiologia Hungarica Suppl 3 42o, 2001 Nádas I, Nieszner É, Bányai F, Baranyi É, Simon J, Bencze J, Borsányi T, Kerecsen G, Préda I: A microalbuminuria predictív szerepe a balkamrai diastoles functió értékelésében diabetses és egészséges anyagcsereállapotban Magyar Kardiológusok Társasága Tudományos Ülése, Balatonfüred Cardiologia Hungarica Suppl 3 76o, 2001 Nieszner É, Kocsis E, Posa I, Koltai MZS, Préda I: Glibenclamid hatása a kontrakcióra és relaxacióra precondícionalt nyúlszívben Magyar Kardiológusok Társasága Tudományos Ülése, Balatonfüred Cardiologia Hungarica Suppl 3 26o, 2001

25 26 27 28 29 ENieszner, EKocsis, IPosa, MZS Koltai,IPréda: Glibenclamide induced changes in contraction and relaxation in preconditioned rabbit heart International Society for Heart Research, XVIIWorld Congress,Winnipeg J MolCell Cardiol 2001 Impact f: 3,383 Nieszner É, Kocsis E, Posa I, Pogátsa G, Préda I, Tóth M, Koltai MZs:A gliclazid és gléibenclamid hatása a kontractiora és relaxatiora precondícionálással elökezelt nyúlszben Magyar Kardiológusok Társasága Tudományos Ülése, Balatonfüred Cardiologia Hungarica Sullp1É 69o 2002 ENieszner, JRadó, FBányai, MHorváth, INádas, FGonda, IPréda: Haemodinamic benefits for diabetic heart in insulin treated patients 22 nd European Section Meeting of th International Society for Heart Research, Szeged JMolCellCardiol 34: A46, 2002 Impact f: 3,255 Nieszner É, Szabó A, Nádas I, Borbély J, Baranyi É, Préda I: Sulfanylurea csoporton belüli eltérő endothelhatások Magyar Atherosclrosis Társaság Kongresszusa, 2002 Sopron Előadáskivonat Nieszner É, Szabó A, Nádas I, Baranyi É, Borbély J, Préda I: A metabolikus moduláció hatása az artériás endothelfunkcióra MB Nagygyűlés 2002 Budapest MBA, Előadáskionat