Original Article

Acta Diabetologica

, Volume 50, Issue 3, pp 373-382

First online:

Effect of normalization of fasting glucose by intensified insulin therapy and influence of eNOS polymorphisms on the incidence of restenosis after peripheral angioplasty in patients with type 2 diabetes: a randomized, open-label clinical trial

  • Pier Marco PiattiAffiliated withCardio-Metabolism and Clinical Trials Unit, Department of Internal Medicine and Metabolic and Cardiovascular Science Division, San Raffaele Scientific Institute Email author 
  • , Enrico MaroneAffiliated withVascular Surgery Division, Cardio-Thoraco-Vascular Department and Cardiovascular Science Division, San Raffaele Scientific Institute
  • , Manuela ManteroAffiliated withCardiovascular Department, Multimedica IRCCS
  • , Emanuela SetolaAffiliated withCardio-Metabolism and Clinical Trials Unit, Department of Internal Medicine and Metabolic and Cardiovascular Science Division, San Raffaele Scientific Institute
  • , Elena GalluccioAffiliated withCardio-Diabetes and Core Lab Unit, Department of Internal Medicine and Metabolic and Cardiovascular Science Division, San Raffaele Scientific Institute
  • , Pietro LucottiAffiliated withCardio-Metabolism and Clinical Trials Unit, Department of Internal Medicine and Metabolic and Cardiovascular Science Division, San Raffaele Scientific Institute
  • , Ermal ShehajAffiliated withCardio-Metabolism and Clinical Trials Unit, Department of Internal Medicine and Metabolic and Cardiovascular Science Division, San Raffaele Scientific Institute
  • , Valentina VillaAffiliated withCardio-Metabolism and Clinical Trials Unit, Department of Internal Medicine and Metabolic and Cardiovascular Science Division, San Raffaele Scientific Institute
  • , Francesca PerticoneAffiliated withCardio-Metabolism and Clinical Trials Unit, Department of Internal Medicine and Metabolic and Cardiovascular Science Division, San Raffaele Scientific Institute
    • , Massimo VenturiniAffiliated withDepartment of Radiology and Center for Experimental Imaging, San Raffaele Scientific Institute
    • , Alessio PaliniAffiliated withFlow Cytometry Resource Laboratory, San Raffaele Scientific Institute
    • , Flavio AiroldiAffiliated withCardiovascular Department, Multimedica IRCCS
    • , Ezio FagliaAffiliated withCardiovascular Department, Multimedica IRCCS
    • , Alessandro Del MaschioAffiliated withDepartment of Radiology and Center for Experimental Imaging, San Raffaele Scientific Institute
    • , Antonio ColomboAffiliated withInterventional Cardiology Division, Cardio-Thoraco-Vascular Department and Metabolic and Cardiovascular Science Division, San Raffaele Scientific Institute
    • , Roberto ChiesaAffiliated withVascular Surgery Division, Cardio-Thoraco-Vascular Department and Cardiovascular Science Division, San Raffaele Scientific Institute
    • , Emanuele BosiAffiliated withCardio-Metabolism and Clinical Trials Unit, Department of Internal Medicine and Metabolic and Cardiovascular Science Division, San Raffaele Scientific InstituteCardio-Diabetes and Core Lab Unit, Department of Internal Medicine and Metabolic and Cardiovascular Science Division, San Raffaele Scientific Institute
    • , Lucilla D. MontiAffiliated withCardio-Diabetes and Core Lab Unit, Department of Internal Medicine and Metabolic and Cardiovascular Science Division, San Raffaele Scientific Institute

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Abstract

Primary objective was to evaluate whether an intensified insulin therapy (IIT) incorporating the target of normal fasting glucose and HbA1c levels could halve the incidence of restenosis/amputation/SCA/death at 6 months after peripheral angioplasty compared with standard care (SC) in patients with type 2 diabetes (DMT2) affected by critical limb ischemia (CLI). Forty-six consecutive patients with DMT2 and CLI were randomly assigned to a parallel, open-label study with IIT (basal-bolus glulisine + glargine administrations) or SC (glargine administration + oral antidiabetic drugs). A SNP of eNOS (rs753482-A>C) and circulating CD34+ and CD34+KDR+ progenitor cells were determined. At the end of the study, although HbA1c levels were lower in IIT than in SC (6.9 ± 1.3 % vs. 7.6 ± 1.2 %, p < 0.05), IIT did not reduce the cumulative incidence of restenosis/amputation/SCA/death (52 and 65 %, respectively, odd ratio 0.59; CI 95 %: 0.21–1.62, p = 0.59). rs753482AC+CC as compared with rs753482AA increased the cumulative incidence of restenosis/amputation/SCA/death (79 and 42 %; odd ratio 5.3; CI 95 %: 1.41–19.5, p < 0.02). Baseline CD34+KDR+ were higher in rs753482AA (166.2 ± 154.0 × 106 events) than in rs753482AC+CC (63.1 ± 26.9 × 106 events, p < 0.01). At the end of the study, the highest circulating CD34+KDR+ were found in IIT rs753482AA (246.9 ± 194.0 × 106 events) while the lowest levels were found in SC rs753482AC+CC (70.9 ± 45.0 × 106 events). IIT did not decrease the cumulative incidence of restenosis/amputation/SCA/death in DMT2 and CLI patients. These patients correspond to a class of fragile subjects at high risk of cardiovascular events, and new predictors of restenosis should be contemplated, such as of eNOS polymorphism, (rs753482-A>C SNP) and circulating endothelial progenitor cells.

Keywords

Intensified insulin therapy Type 2 diabetes Critical limb ischemia eNOS polymorphism Endothelial progenitor cells Restenosis Amputation