Inflammatory Markers and Anti- Inflammatory Effects of Insulin

Size: px

Start display at page:

Download "Inflammatory Markers and Anti- Inflammatory Effects of Insulin"

Candace Merritt
5 years ago
Views:

Inflammatory Markers and Anti- Inflammatory Effects of Insulin Paresh Dandona, BSc, MD, DPhil, FRCP, FACP, FACC, FACE Distinguished Professor of Medicine and Pharmacology School of Medicine and

1 Inflammatory Markers and Anti- Inflammatory Effects of Insulin Paresh Dandona, BSc, MD, DPhil, FRCP, FACP, FACC, FACE Distinguished Professor of Medicine and Pharmacology School of Medicine and Biomedical Sciences Division Head, Endocrinology and Metabolism State University of New York at Buffalo Founder and Medical Director, Diabetes-Endocrinology Center of Western New York Head, Division of Endocrinology Kaleida Health/Millard Fillmore Hospital, Buffalo, New York

2 2 % CV Events at 8 Years Higher CRP Levels are Associated with Adverse Events CRP <1 CRP >3 CRP 1 3 Cumulative Rate of Recurrent MI or Coronary Death Lowering CRP with Statin Therapy is Beneficial CRP 2 mg/l CRP <2 mg/l Follow-up (Years) Adapted from Ridker PM et al. Circulation 2003;107: Ridker PM et al. N Engl J Med 2005;352: Copyright Massachusetts Medical Society. All rights reserved. 7/21/2009 1:52 PM [Insert Title Here].ppt

3 3 Clinical Relevance of Achieved LDL-C C and Achieved CRP Combined after Treatment with Statin Therapy: PROVE IT TIMI TIMI 22 Recurrent MI or Coronary Death (%) Follow-up (Years) Ridker PM et al. N Engl J Med 2005;352: Copyright 2005 Massachusetts Medical Society. All rights reserved. 7/21/2009 1:52 PM [Insert Title Here].ppt LDL 70 mg/dl, CRP 2 mg/l LDL 70 mg/dl, CRP <2 mg/l LDL <70 mg/dl, CRP 2 mg/l LDL <70 mg/dl, CRP <2 mg/l LDL <70 mg/dl, CRP <1 mg/l

4 4 JUPITER: Primary endpoint Placebo Cumulative incidence 0.04 HR 0.56 ( ) P < Rosuvastatin Years 7/21/2009 1:52 PM [Insert Title Here].ppt Ridker PM et al. N Engl J Med. 2008;359:

5 5 JUPITER: MI, stroke, or CV death Cumulative incidence 0.04 HR 0.53 ( ) P < Placebo 0.02 Rosuvastatin Years 7/21/2009 1:52 PM [Insert Title Here].ppt Ridker PM et al. N Engl J Med. 2008;359:

6 JUPITER: Clinical events according to magnitude of reduction in LDL-C or hscrp MI, stroke, admission for UA, arterial revascularization, or CV death 6 N Rate Rosuvastatin better Rosuvastatin worse Placebo LDL-C achieved 70 mg/dl P < LDL-C achieved <70 mg/dl Placebo LDL-C reduction <50% P < LDL-C reduction 50% Placebo hscrp achieved 2 mg/l P < hscrp achieved <2 mg/l Placebo hscrp reduction <50% P < hscrp reduction 50% Hazard ratio (95% CI) 7/21/2009 1:52 PM [Insert Title Here].ppt Ridker PM et al. Lancet. 2009;373:

7 7 JUPITER: Importance of achieving dual LDL-C and hscrp reduction Cumulative incidence of MI, stroke, admission for UA, arterial revascularization, or CV death 0.08 Cumulative incidence Placebo Follow-up (years) Rosuvastatin (LDL-C 70 mg/dl or hscrp 2 mg/l) Rosuvastatin (LDL-C <70 mg/dl and hscrp <2 mg/l) 7/21/2009 1:52 PM [Insert Title Here].ppt Ridker PM et al. Lancet. 2009;373:

8 8 Summary of Studies of the Effect of C-Reactive Protein (CRP) Genotype Combination and Apolipoprotein E Genotype on the Risk of Ischemic Heart Disease (IHD) Zacho J et al. N Engl J Med 2008;359: /21/2009 1:52 PM [Insert Title Here].ppt

9 9 Summary of Studies of the Effect of C-Reactive Protein (CRP) Genotype Combination on the Risk of Ischemic Cerebrovascular Disease (ICVD) Zacho J et al. N Engl J Med 2008;359: /21/2009 1:52 PM [Insert Title Here].ppt

10 Effect of Insulin on NE-Induced Venoconstriction A B A. Normal vein before cuff inflation B. The same vein after inflation C D C. Constriction induced by norepinephrine D. Attenuation of the norepinephrine effect by insulin Grover A, et al. Hypertension. 1995;25:

11 Effect of Insulin on NE-Induced Venoconstriction: Controls Diameter of Vein (%) Relative to Basal Inflated % 97% 74% 67% 60% 77% 80% P< % 97% 20 0 Basal Grover A, et al. Hypertension. 1995;25: Inflated NE (ng/min) NE ( ng/min) + Insulin ( U/min)

12 Effect of Methylene Blue (MB) Diameter of Vein (mm) NE ( ng/min) NE ( ng/min) + NE ( ng/min) + Insulin (32 U/min) IN (32 U/min) + MB (0.125 g/min) Grover, et al. Hypertension. 1995;25: Mean ± SEM

13 Inability of Insulin to Inhibit Platelet Aggregation in Diabetics CD 50 of Insulin (µu/ml) Control IDDM NIDDM 400 nm U46619 Agonist P<0.001 Dandona P. Presented at :American Diabetes Association 57th Scientific Session; June, Boston, Mass.

14 Factor VIII Ulex Europaeus CD31 EN4 -Actin Negative Control Aljada A, Dandona P. Metabolism. 2000;49:

15 Direct Measurement of NO From HUVEC A Nitric Oxide (nm) 50 0 B Current (pa) 50 pa 200 sec Basal Insulin Dose (nm) ,000 50,000 A) A representative standard curve is shown (r 2 =0.99). B) Representative output generated from an experiment where NO production was measured in response to increasing concentrations of insulin. Current generated by the NO electrode is recorded as a function of time. The concentrations of insulin shown represent cumulative concentrations. Zeng G, Quon MJ. J Clin Invest. 1996;98:

Induction of enos in Endothelial Cells by Insulin A) B) 140 KD- EC NOS LPS-Stimulated Monocytes µu/ml 0 µu/ml 0 Insulin µu/ml 25 Insulin µu/ml 25 µu/ml µu/ml µu/ml 0 µu/ml 0 0 130 kda- 0 25 0 Insulin

16 Induction of enos in Endothelial Cells by Insulin A) B) 140 KD- EC NOS LPS-Stimulated Monocytes µu/ml 0 µu/ml 0 Insulin µu/ml 25 Insulin µu/ml 25 µu/ml µu/ml µu/ml 0 µu/ml kda Insulin ( U/ml, Mean SD) A) Western blot showing the induction of enos in human aortic endothelial cells by insulin. The induction is observed at 25 U/mL. B) No i-nos bands were observed in HAEC induced with different concentrations of insulin even at very high X-ray film exposure. % Change From Baseline enos Protein Levels Adapted from: Aljada A, Dandona P. Metabolism. 2000;49: *P<0.05 * * *

17 NF- B B Activation Cell Membrane Activation Signals Inflammatory Proteins I B Kinases Degradation NF- B Cytoplasm mrna Barnes and Karin. N Engl J Med. 1997;336: Inflammatory Gene Nucleus

Effects of Glucocorticoids on NF- B B Activation Cytokine Receptor Cytokine Cell Membrane Glucocorticoid Inflammatory Proteins Cytoplasm Protein NF- B

18 Effects of Glucocorticoids on NF- B B Activation Cytokine Receptor Cytokine Cell Membrane Glucocorticoid Inflammatory Proteins Cytoplasm Protein NF- B Glucocorticoid Receptor mrna Glucocorticoid Response Element I B Gene Coding Sequence Inflammatory Gene Nucleus Barnes and Karin. N Engl J Med. 1997;336:

19 Plasma Insulin and Glucose Concentrations Following Insulin or Glucose or Saline Infusions* Insulin (μu/ml) *P<0.05 * Time (hours) *Insulin infusion in 10 obese human subjects. * Insulin Infusion Dextrose Infusion Saline Infusion Plasma Glucose (mg/dl) Insulin Infusion Dextrose Infusion Saline Infusion Time (hours) Adapted from: Dandona P, et al. J Clin Endocrinol Metab. 2001;86:

20 ROS Generation by MNC in Obese Subjects Following Insulin or Dextrose or Saline Infusions %ROS Generation By MNC *P< Time (hours) Adapted from: Dandona P, et al. J Clin Endocrinol Metab. 2001;86: * * Insulin Infusion Dextrose Infusion Saline Infusion *

21 phox Relative Expression of p47 phox Subunit Protein Levels Relative Expression of p47 phox Subunit in MNC Following Insulin Infusion (Upper Gel) or Dextrose Infusion (Lower Gel) Time (hours): p47 phox Time (hours): p47 phox % Change In p47phox Subunit *P<0.05 Densitometry * Insulin Infusion Dextrose Infusion * Mean SE Time (hours) Adapted from: Dandona P, et al. J Clin Endocrinol Metab. 2001;86:

Relative NF- B B Binding to Double-Stranded Oligonucleotide- Containing NF- B B DNA Binding Site Following Insulin or Dextrose Infusion Gel Shift Assay % Change In Intranuclear NFkB 140 120

22 Relative NF- B B Binding to Double-Stranded Oligonucleotide- Containing NF- B B DNA Binding Site Following Insulin or Dextrose Infusion Gel Shift Assay % Change In Intranuclear NFkB Insulin Infusion Dextrose Infusion * * Insulin Infusion Dextrose Infusion Time (hours) *P<0.05 Adapted from Dandona P, et al. J Clin Endocrinol Metab. 2001;86:

23 Plasma sicam-1 1 Concentrations Following Insulin or Dextrose or Saline Infusions Insulin Infusion Dextrose Infusion Saline Infusion 110 *P<0.05 % Change in sicam-1 (ng/ml) 90 * * Time (hours) Adapted from Dandona P, et al. J Clin Endocrinol Metab. 2001;86:

24 Plasma MCP-1 1 Concentrations Following Insulin or Dextrose or Saline Infusions % Change In MCP Insulin Infusion Dextrose Infusion Saline Infusion *P< Time (hours) Adapted from Dandona, et al. J Clin Endocrinol Metab. 2001;86: * *

25 Plasma MMP-2 2 and MMP-9 9 Concentrations Following Insulin or Dextrose Infusions Insulin Infusion Dextrose Infusion Insulin Infusion Dextrose Infusion % Change in MMP * *P<0.05 * % Change in MMP *P<0.05 * * Time (hours) Time (hours) Dandona P, Aljada A, et al. Diabetes Care. 2003;26:

26 Plasma TF and PAI-1 1 Concentrations Following Insulin or Dextrose Infusions % Change in Plasma TF Insulin Infusion Dextrose Infusion *P<0.05 * * % Change in Plasma PAI Insulin Infusion Dextrose Infusion * * *P<0.05 * Time (hours) Time (hours)

27 Plasma VEGF Concentrations Following Insulin or Dextrose Infusions Insulin Infusion Dextrose Infusion 120 *P<0.05 % Change in VEGF 80 * * Time (hours) Dandona P, Aljada A, et al. Diabetes Care. 2003;26:

28 Toll-Like Receptors (TLRs) Family

29 Effect of Insulin Infusion in T2DM on TLR4 Expression % Change in TLR4 mrna Expression 140 Insulin Dextrose *# Hours *# * P < 0.05 by One Way RM ANOVA # P < 0.05 by Two Way RM ANOVA

30 Effect of Insulin Infusion in T2DM on TLR2 Expression 160 % Change in TLR2 mrna Expression Insulin Dextrose * *# Hours * P < 0.05 by One Way RM ANOVA # P < 0.05 by Two Way RM ANOVA

31 GIK- MI- Glucose Control Insulin Glucose (mg/dl) h 2h 4h 6h 24h 48h Time (hours)

32 GIK- MI- Insulin Insulin (µu/ml) Control Insulin * 20 0h 2h 4h 6h 24h 48h Time (hours) *p< 0.05, TWANOVA, p<0.05, paired t-test

33 GIK- MI- Plasma CRP Increase in CRP (ng/ml) from baseline Control Baseline: 2700ng/ml Insulin Baseline: 3800ng/ml * -0 0h 2h 4h 6h 24h 48h Time (hours) *p< 0.01, TWANOVA, p< 0.05, t-test

34 GIK MI Serum Amyloid A Increase in SAA (ng/ml) from baseline 30x x x Control Baseline : 12 x 10 3 Insulin Baseline: 19 x 10 3 * 0h 2h 4h 6h 24h 48h Time (hours) *p< 0.01, TWANOVA, p< 0.05, t-test

35 GIK- MI- Plasma PAI-1 Increase in PAI-1 (ng/ml) From Baseline Control Baseline: 47ng/ml Insulin Baseline: 54 ng/ml 0h 2h 4h 6h 24h 48h Time (hours) * *p< 0.05, TWANOVA

36 GIK- MI- p47 phox Subunit % Increase in P47 phox Protein in MNC Control Insulin * 0 0h 2h 4h 6h 24h 48h Time (hours) *p< 0.05, TWANOVA, p<0.05, t-test, p< 0.05, paired t - test

37 GIK- MI- Inferior Wall CK Control Insulin CK (U/L) * 0 0h 2h 4h 6h 8h 16h 24h 48h Time (hours) *p<0.01, Log CK, TWANOVA

38 GIK- MI- Inferior Wall CKMB 500 CKMB (U/L) Control Insulin * - 0h 2h 4h 6h 8h 16h 24h 48h Time (hours) *p<0.01, Log CKMB, TWANOVA

39 GIK- MI- Myoglobin Change in Myoglobin(ng/ml) from baseline insulin control 0h 2h 4h 6h 24h 48h Time (hours) *

40 GIK- MI- FFA 2.0 Free Fatty Acids (micromol/l) control Insulin * 0.6 0h 2h 4h 6h 24h 48h Time (hours)

42 Effects of Insulin Infusion Clamp on Inflammatory Responses During CABG 250 CRP (mg/l) Control GIK * 50 GIK = glucose-insulin-potassium; CABG = coronary artery bypass graft. Visser L et al. Br J Anaesth. 2004;109: Baseline Reperfusion 2-h Reperfusion ICU 6-8 PM POD1 6-8 AM POD1 6-8 PM POD2 6-8 AM POD2 6-8 PM Time dependence of CRP production. Data are presented as mean (SEM). *P<0.05 between groups; 2-way ANOVA for repeated measurements with Bonferroni correction; P<0.05 between groups at separate time points. Note that at some measurement points the error bars are too small to be visible on the scale used.

44 Admission Glucose Dependent Mortality in the CREATE-ECLA < to 144 >144

45 Glucose Levels CONTROL (mg/dl) GIK (mg/dl) Baseline hrs hrs

46 Estimated 30 day mortality versus Baseline Blood Glucose Level in i CREATE-ECLA ECLA Estimated 30 Day Mortality versus Baseline Blood Glucose Level 30 day mortaility = 13.4% at BG = 187mg/dl 13 Mortaility (%) day mortaility = 10.8% at BG = 145mg/dl % mortality = * {1-1.03*exp( *BG) } Based on JAMA 1/26/05-Vol 293, No 4, pg Blood Glucose (mmol/l) Chaudhuri A et al: Targeting Glucose in AMI: Has GIK missed the target? (Diabetes Care, 2007)

47 Hyperglycemia related mortality in CREATE ECLA based on relationship of admission glucose to mortality in controls. Control GIK Time BG* (mg/dl) % Mortality BG* (mg/dl) % Mortality h h Chaudhuri A et al: Targeting Glucose in AMI: Has GIK missed the target? (in press), 2007

48 Observed vs Estimated Mortality based on blood glucose during the 24 hrs in CREATE ECLA % 9.7% 9.9% 10.0% Control GIK Observed Estimated Chaudhuri A et al: Targeting Glucose in AMI: Has GIK missed the target? (Diabetes Care, 2007

54 INTENSIVE Study: Intensive Insulin Therapy and Size of Infarct as a Visual Endpoint by Cardiac MRI Men or Women y/o Primary AWMI Glucose 140 mg/dl <6 hours of symptoms Intensive Insulin Therapy (n = 294) BG goal Primary Endpoint: Final Myocardial Infarct Size at Day 60 (DE- CMR) DE-CMR = Delayed Enhancement Cardiovascular Magnetic Resonance Standard Care (n = 294) BG goal <180 I Revascularization Hour 0 96 hours Day 60 Randomization TIMI flow, TMPG, STR Inflammatory Markers MACE : Major Adverse Coronary Events TIMI = thrombolysis in MI; TMPG = TIMI myocardial perfusion grade; STR = ST segment recovery.

56 Insulin Infusion Suppresses LPS- Induced Increase in NO 2 /NO 3 Concentrations % Change in Plasma NO 2 /NO Ins/Sal *# LPS *# *# *# Time (Hours) LPS+ Saline LPS+Insulin * P < 0.05 by One Way RM ANOVA # P < 0.05 by Two Way RM ANOVA

57 Insulin Infusion Suppresses LPS- Induced Increase in ROS Generation by PMN % Change in ROS Generation (PMN) LPS (2ng/Kg) LPS (2ng/Kg)+ Ins Time (Hours) * P < 0.05 by One Way RM ANOVA # P < 0.05 by Two Way RM ANOVA

58 Insulin Infusion Suppresses LPS- Induced Increase in Plasma TBARS 400 % Change in Plasma TBARS LPS LPS+Ins Time (Hours) * P < 0.05 by One Way RM ANOVA # P < 0.05 by Two Way RM ANOVA

59 Insulin Infusion Suppresses LPS- Induced Increase in MIF Concentrations % Change in MIF Concentrations 260 Endotoxin Endotoxin+Insulin Time (Hours) * P < 0.05 by One Way RM ANOVA # P < 0.05 by Two Way RM ANOVA

60 Insulin Infusion Suppresses LPS- Induced Increase in Myoglobin Concentrations 220 % Change in Myoglobin Concentrations Endotoxin Endotoxin+Insulin Time (Hours) * P < 0.05 by One Way RM ANOVA # P < 0.05 by Two Way RM ANOVA

61 Insulin Infusion Suppresses LPS- Induced Increase in FFA Concentrations Endotoxin Endotoxin+Insulin Plasma FFA (% Change) Time (Hours) * P < 0.05 by One Way RM ANOVA # P < 0.05 by Two Way RM ANOVA

62 Effect of Low Dose Insulin Infusion in T2DM on Amyloid- Precursor mrna Expression in MNC 140 % Change in APP mrna Expression Insulin Dextrose Saline *# Hours * P < 0.05 by One Way RM ANOVA # P < 0.05 by Two Way RM ANOVA

63 Effect of Low Dose Insulin Infusion in T2DM on IL4 mrna Expression in MNC % Change in IL-4 mrna Expression 140 Insulin Dextrose Saline *# *# Infusion time (hours) * P < 0.05 by One Way RM ANOVA # P < 0.05 by Two Way RM ANOVA

64 Effect of Low Dose Insulin Infusion in T2DM on ADAM-33 Expression in MNC 140 % Change in ADAM33 mrna Expression Insulin Dextrose Saline * *# Hours * P < 0.05 by One Way RM ANOVA # P < 0.05 by Two Way RM ANOVA

65 Effect of Low Dose Insulin Infusion in T2DM on CCR2 mrna Expression in MNC 120 Insulin Dextrose % Change in CCR-2 mrna Expression *# *# Hours * P < 0.05 by One Way RM ANOVA # P < 0.05 by Two Way RM ANOVA

66 Effect of Low Dose Insulin Infusion in T2DM on CCR5 mrna Expression in MNC % Change in CCR5 mrna Expression 140 Insulin Dextrose *# *# Infusion time (hours) * P < 0.05 by One Way RM ANOVA # P < 0.05 by Two Way RM ANOVA

67 Effect of Low Dose Insulin Infusion in T2DM on Plasma MCP-1 Concentrations 130 % Change in plasma MCP-1 concentrations Insulin Dextrose Saline * *# Hours * P < 0.05 by One Way RM ANOVA # P < 0.05 by Two Way RM ANOVA

68 Effect of Low Dose Insulin Infusion in T2DM on Plasma Eotaxin Concentrations Eotaxin Concentrations (% Change) 120 Insulin 115 Dextrose Saline Hours * P < 0.05 by One Way RM ANOVA # P < 0.05 by Two Way RM ANOVA

69 Effect of Low Dose Insulin Infusion in T2DM on Plasma RANTES Concentrations Plasma RANTES Concentrations (ng/ml) 45 Insulin Dextrose Saline Hours * P < 0.05 by One Way RM ANOVA # P < 0.05 by Two Way RM ANOVA

70 Effect of Low Dose Insulin Infusion in T2DM on Plasma MMP-9 Concentrations % Change in MMP-9 Plasma concentrations Insulin Dextrose Saline * *# Hours * P < 0.05 by One Way RM ANOVA # P < 0.05 by Two Way RM ANOVA

71 Effect of Low Dose Insulin Infusion in T2DM on Plasma NO 2 /NO 3 Concentrations 140 % Change in Plasma NO 2 /NO Insulin saline Dextrose *# Hours * P < 0.05 by One Way RM ANOVA # P < 0.05 by Two Way RM ANOVA

John J.P. Kastelein MD PhD Professor of Medicine Dept. of Vascular Medicine Academic Medial Center / University of Amsterdam

Latest Insights from the JUPITER Study John J.P. Kastelein MD PhD Professor of Medicine Dept. of Vascular Medicine Academic Medial Center / University of Amsterdam Inflammation, hscrp, and Vascular Prevention