EFFICACY OF SITAGLIPTIN IN RETARDING THE PROGRESSION OF

ALBUMINURIA AND ASSESSING ITS SAFETY AND EFFICACY IN

PATIENTS WITH DIABETIC NEPHROPATHY

Dissertation submitted to

THE TAMILNADU

DR. M.G.R. MEDICAL UNIVERSITY

In partial fulfilment for the award of the degree of

DOCTOR OF MEDICINE

IN

PHARMACOLOGY

INSTITUTE OF PHARMACOLOGY

MADRAS MEDICAL COLLEGE

CHENNAI - 600 003

MAY 2018

CERTIFICATE

This is to certify that the dissertation entitled, “EFFICACY OF

SITAGLIPTIN IN RETARDING THE PROGRESSION OF

ALBUMINURIA AND ASSESSING ITS SAFETY AND EFFICACY IN

PATIENTS WITH DIABETIC NEPHROPATHY” submitted by

Dr.R.Keerthana, in partial fulfilment for the award of the degree of Doctor of

Medicine in Pharmacology by The Tamilnadu Dr.M.G.R. Medical University,

Chennai is an original bonafide record of the work done by her in the Institute

of Pharmacology, Madras Medical College during the academic year 2015-2018.

I forward this dissertation to the Tamilnadu Dr. M.G.R Medical university,

Chennai, Tamil Nadu,India.

The Dean, The Director & Professor,

Madras Medical College, Institute of pharmacology,

RGGGH , Madras Medical College,

Chennai. Chennai – 600 003.

CERTIFICATE OF THE GUIDE

This is to certify that the dissertation entitled, “EFFICACY OF

SITAGLIPTIN IN RETARDING THE PROGRESSION OF ALBUMINURIA

AND ASSESSING ITS SAFETY AND EFFICACY IN PATIENTS WITH

DIABETIC NEPHROPATHY” submitted by Dr.R.Keerthana, in partial fulfilment

for the award of the degree of Doctor of Medicine in Pharmacology by The Tamilnadu

Dr.M.G.R. Medical University, Chennai is an original Bonafide record of the work

done by her under my guidance and supervision in the Institute of Pharmacology,

Madras Medical College during the academic year 2015-2018. I recommend this

dissertation to the Tamilnadu Dr. M..G.R Medical university, Chennai, Tamil Nadu

India.

PLACE: Dr.S. Purushothaman M.D,

DATE: Associate Professor

Institute of pharmacology

Madras Medical College

Chennai – 3.

CERTIFICATE OF THE CO-GUIDE

This is to certify that the dissertation entitled, “EFFICACY OF

SITAGLIPTIN IN RETARDING THE PROGRESSION OF ALBUMINURIA

AND ASSESSING ITS SAFETY AND EFFICACY IN PATIENTS WITH

DIABETIC NEPHROPATHY” submitted by Dr.R.Keerthana, in partial fulfilment

for the award of the degree of Doctor of Medicine in Pharmacology by The Tamilnadu

Dr.M.G.R. Medical University, Chennai is an original Bonafide record of the work

done by her under my guidance and supervision in the Institute of Diabetology,

Madras Medical College, RGGGH, Chennai during the academic year 2015-2018. I

recommend this dissertation to the Tamilnadu Dr.M.G.R Medical university, Chennai,

Tamilnadu.

PLAC : Dr.P.DHARMARAJAN,M.D,D.DIAB,

DATE : Director & Professor,

Institute of Diabetology,

MMC & RGGGH,

Chennai – 3

DECLARTION

I, Dr.R.KEERTHANA, Solemnly declare that the dissertation titled,

‘EFFICACY OF SITAGLIPTIN IN RETARDING THE PROGRESSION

OF ALBUMINURIA AND ASSESSING ITS SAFETY AND EFFICACY IN

PATIENTS WITH DIABETIC NEPHROPATHY – A RANDOMISED

OPEN LABEL COMPARATIVE STUDY’ has been done by me and submitted

to Tamil Nadu Dr. MGR Medical university, Chennai in partial fulfilment of the

rules and regulations for the M.D degree examination in Pharmacology.

PLACE: Dr.R.Keerthana

Date:

ACKNOWLEDGEMENT

I owe my thanks to the Dean, Dr.R.Narayananbabu M.D, DCH,

Madras Medical College & Rajiv Gandhi Government General Hospital,

Chennai for permitting me to utilise the facilities and conducting this study and

the members of ethical committee for their role.

I am very Grateful to the Vice Principal, Dr.Sudha Seshayyan, M.D.,

Madras Medical College & Rajiv Gandhi Government General Hospital,

Chennai for granting me permission and complete cooperation to do this study.

I am extremely Grateful to Professor Dr.K.M.S. Susila, M.D,

Director , Institute of Pharmacology, Madras Medical College, and Professor

Dr.B.Vasanthi M.D, Institute of Pharmacology,MMC, Chennai for their

remarkable guidance, valuable suggestions and support.

I am very thankful to Dr.S. Purushothaman M.D., Associate

Professor of Pharmacology, Madras Medical College for his valuable guidance,

untiring support and continuous encouragement throughout the dissertation

work.

I record my sincere thanks to Professor Dr.P.Dharmarajan M.D,D.DIAB,

Director and Professor of Diabetology for granting me permission and complete

cooperation to do this study in the Institute of Diabetology, Madras Medical

college.

I am very thankful to Professor Dr.K.M. Sudha M.D Institute of

Pharmacology, Madras Medical College for her encouragement that

strengthened me to accomplish my work.

I am grateful to Assistant Professors of the Institute of

Pharmacology, Dr.S.Deepa M.D, Dr.G.Meeradevi M.D, Dr.S.Suganeshwari

M.D, Dr.VishnuPriya M.D, Dr.Ramesh Kannan, M.D, Dr.Meenakshi M.D. and

Dr.A.C.Yegneshwaran, who supported and provided the necessary information

during the study.

I also take this opportunity to thank my husband Dr.A.Rajesh, M.ch, for

helping me out with my problems at various points of time with regard to my

study. I also extend my sincere thanks to all other staff members and colleagues

of this Institute of Pharmacology for their wholehearted support and valuable

suggestions throughout the study.

Last but not least, I am always grateful to my parents and the Almighty

for supporting throughout my life since my birth. I also wish to thank the

patients who voluntarily participated in the study.

PLAGIARISM CERTIFICATE

This is to certify that this dissertation work titled “EFFICACY OF

SITAGLIPTIN IN RETARDING THE PROGRESSION OF ALBUMINURIA

AND ASSESSING ITS SAFETY AND EFFICACY IN PATIENTS WITH

DIABETIC NEPHROPATHY” of the candidate DR.R. KEERTHANA with

registration Number 201516002 for the award of the Degree of Doctor of Medicine in

the branch of Pharmacology. I personally verified the urkund.com website for the

purpose of plagiarism Check. I found that the uploaded thesis file contains from

introduction to conclusion pages and result shows Twelve percentage (12%) of

plagiarism in the dissertation.

PLACE: Dr.S. Purushothaman M.D,

DATE: Associate Professor

Institute of pharmacology

Madras Medical College

Chennai – 3.

PLAGIARISM CERTIFICATE

TABLE OF CONTENTS

S.NO TOPICS PAGE NO

1. INTRODUCTION 1

2. REVIEW OF LITERATURE 5

3. AIM & OBJECTIVES 43

4. METHODOLOGY 45

5. RESULTS 57

6. DISCUSSION 76

7. CONCLUSION 81

8. BIBILOGRAPHY 82

9. APPENDICES 94

INTRODUCTION

1

INTRODUCTION

Diabetes mellitus is a growing epidemic and is the most common cause of

chronic kidney disease. This is due to increase in the prevalence of diabetes and now

the patients live longer due to availability of medical facilities. Diabetic nephropathy

is a clinical diagnosis based upon the detection of proteinuria in a patient with diabetes

in the absence of another obvious cause such as infection.1 Many of these patients will

also be hypertensive, have retinopathy and in advanced stage of renal impairment.

Exposure of tissues to chronic hyperglycemia is the initiating factor for microvascular

complication.2 Microalbuminuria is an important early sign of diabetic nephropathy

and it is associated with hypoglycemia.3

Diabetic nephropathy is a clinical syndrome characterized by

1) Persistent albuminuria >200 mcg /min or > 300mg/24 hour that is confirmed on

at least two occasions,

2) Progressive decline in Glomerular Filtration Rate

3) Elevated arterial pressure.4

In early stage of diabetic nephropathy, endothelial dysfunction is

the main pathogenic process as indicated by increased leakage of albumin through

glomerular barrier5. Insulin resistance that i.e. hyperinsulinemia, hyperglycemia,

hypertension is the main cause for endothelial dysfunction and development of diabetic

nephropahy6. Hyperglycemia produces more reactive oxygen species (ROS) such as

superoxide, it may lead to oxidative stress and increased lipid peroxidation. Oxidative

2

stress further triggers the deposition of extracellular matrix and fibrosis in the kidney

leading to complication. So, improvement in endothelial function and glycemic control

is an essential therapeutic goal of antidiabetic medication and prevention of

complications. Intensive hyperglycemic control and blood pressure control decreases

the incidence and progression of albuminuria7 in diabetic individuals.

SITAGLIPTIN- Dipeptidyl peptidase 4(DPP4) inhibitor a novel

class of antidiabetic drug (ADD). It increases the half-life of endogenous glucagon

like peptide-1 (GLP-1) by inhibiting the enzyme DPP4 which causes degradation of

GLP-1.So by inhibition of DDP4 enzyme it prolongs the action of GLP-1.8 Stimulation

of GLP1 receptor in turn increases insulin secretion, preserves β cell function promotes

its proliferation, and inhibit glucagon release from α cells leading to improved glucose

control.9 Studies have shown that GLP-1 has anti-inflammatory properties and Its

efficacy for the management of diabetic kidney disease is known in animal

models10.DPP4 inhibitors have been proved to have cyto-protective effects on such

organs, including the heart, kidney11 and retina that are involved in series of T2DM

complications. Thus, Sitagliptin slows the degradation and inactivation of GLP-1 and

could therefore be beneficial in diabetic nephropathy.

The role of Renin Angiotensin Aldosterone system has been implicated in

the development and progression of diabetic nephropathy. The use of Angiotensin

converting enzyme (ACE) inhibitors or Angiotensin Receptor blockers (ARBs) prevent

the progression of microalbuminuria into overt albuminuria.

3

The objective of this study is to investigate the effect of sitagliptin along

with other Anti diabetic drugs and Angiotensin Converting Enzyme inhibitor or

Angiotensin Receptor Blockers to determine whether it will reduce the albumin levels

in the urine and evaluate its efficacy, safety of glycemic profile in Diabetic

Nephropathy patients.

4

REVIEW OF LITERATURE

5

REVIEW OF LITERATURE

Diabetes is one of the most common endocrine disorders. It is a disorder of

metabolism of carbohydrate, fat and protein due to absolute or relative deficiency in

insulin secretion and its action.

Classification of diabetes mellitus5

1) TYPE1 diabetes mellitus

Beta cell destruction usually leading to absolute insulin deficiency

a) Autoimmune

b) Idiopathic

2) Type 2 diabetes mellitus

a) Predominantly insulin resistance

b) Predominantly insulin secretory defects

3) OTHER SPECIFIC TYPES OF DIABETES

a) Genetic defects in beta cell dysfunction e.g. MODY 1 – 15

b) Genetic defects in insulin action, e.g. Type A insulin resistance

c) Disease of exocrine pancreas

e.g. Fibro calculus Pancreatopathy

d) Endocrinopathies, e.g. acromegaly, Cushing’s

e) Drugs or chemical induced e.g. steroids

f) Infections e.g. congenital rubella

6

g) Uncommon forms of immune mediated diabetes

e.g. stiff man syndrome

h) Other genetic syndrome

4) Gestational diabetes

RISK FACTOR FOR TYPE 2 DIABETES MELLITUS 13

a. Family history of diabetes

b. Hypertension

c. Dyslipidaemia

d. Polycystic ovarian syndrome

e. Obesity & Diet

e. Age > 50 years

7

PATHOGENESIS:

TYPE1 DIABETES MELLITUS: 14,15

GENETIC SUSCEPTABILITY

ENVIRONMENTAL TRIGGER

(VIRUS, TOXINS)

AUTO IMMUNITY (GAD, IAA, ICA)

PROGRESSIVE

BETA CELL DESTRUCTION

TYPE 1 DIABETES MELLITUS

T1DM is mainly due to genetic and environmental influences. It most

commonly results from autoimmune destruction of insulin-producing β-cells in the

pancreas. Eisenbarth proposed that one or more environmental factors, such as

enteroviruses, dietary factors or toxins, might trigger the development of T-cell

8

dependent autoimmunity in genetically susceptible individuals.16 Autoimmunity is

manifested by detectable antibodies to Islet cell antibody (ICA512), Insulinoma

associated antibody (IA-2), insulin autoantibody (IAA) and glutamic acid

decarboxylase (GAD). Insulitis with gradual β-cell destruction leads to pre-diabetes

and finally to overt DM. These patients are susceptible to other autoimmune diseases,

such as Hashimoto’s thyroiditis, celiac disease, Addison’s disease, and myasthenia

gravis, a genetic locus in the major histocompatibility (HLA) region are associated

with increased susceptibility to developing T1DM, including the alleles DR3/4, DQ

0201/0302, DR 4/4, and DQ 0300/0302.

The risk of T1DM is approximately 5% if there is an affected first-degree

relative and slightly higher if the affected parent is the father rather than the mother. To

date, interventional trials have failed to delay the onset or prevent T1DM in those

genetically at risk. Ongoing research by international networks is exploring ways to

prevent, delay or reverse the progression of T1DM (e.g. Trial Net, TRIGR) 17

PATHOGENESIS OF TYPE 2 DIABETES MELLITUS:

Type 2 DM will be characterized by impaired insulin secretion,

insulin resistance, excessive hepatic glucose production, and abnormal fat metabolism.

Obesity, particularly visceral or central (as evidenced by the hip-waist ratio), is very

common in type 2 DM. (> 80% of patients are obese) In the early stages of the

disorder, glucose tolerance remains near-normal, despite insulin resistance, because the

pancreatic beta cells compensate by increasing insulin output. As insulin resistance and

compensatory hyperinsulinemia progress, certain individuals are unable to sustain the

9

hyper insulinemic state. It leads to impaired Glucose Tolerance which is characterized

by elevations in postprandial glucose. A further deterioration in insulin secretion and

an increase in hepatic glucose production lead to overt diabetes with fasting

hyperglycaemia. Ultimately, beta cell failure develops. Although both insulin

resistance and impaired insulin secretion contribute to the pathogenesis of type 2

DM, the relative contribution of each varies from individual to individual.

❖ Figure1: Pathogenesis of Type 2 DM -ominous octet

10

CLINICAL FEATURES OF DIABETES MELLITUS18

Clinical presentation may be acute, subacute or asymptomatic and with or without

one of the complications of diabetes.

ACUTE PRESENTATION

Young people often present with a 2 to 6-week history the classic triad of symptoms:

• POLYURIA: Due to the osmotic diuresis, that result when blood glucose levels

exceed the renal threshold.

• THIRST: Due to the resulting loss of fluid and electrolytes

•WEIGHT LOSS: Due to fluid depletion and the accelerated breakdown of fat and

muscle secondary to insulin deficiency. Ketonuria is often present in young people

and may progress to ketoacidosis if these early symptoms are not recognized and

treated early.

SUBACUTE PRESENTATION:

The onset may be over several months or years, particularly in older patients.

Thirst, polyuria and weight loss are typically present and also, they have complaining

of tiredness, visual blurring, pruritus vulvae or balanitis that is due to Candida

infection. Some may present with Complications as the presenting feature. These

include staphylococcal skin infections, retinopathy, polyneuropathy causing tingling

and numbness in the feet, erectile dysfunction, arterial disease resulting in myocardial

infarction or peripheral gangrene.

11

ASYMPTOMATIC DIABETES

Glycosuria or a raised blood glucose may be detected on routine examination in

individual who have no symptoms of ill-health. This is more common in older people,

who have a raised renal threshold for glucose.

DIAGNOSIS:

WHO DIAGNOSTIC CRITERIA FOR DIABETES

Fasting plasma glucose > 126 mg/dl

Random plasma glucose > 200 mg/dl

HbA1C > 6.5

GLUCOSE TOLERANCE TEST -WHO CRITERIA

Timing of test Normal

mg/dl

Impaired glucose

tolerance mg/dl

Impaired fasting

glucose mg/dl

Diabetes mg/dl

Fasting <100 100- 126 100- 126 >126

2 hr after 75 gm

glucose load

<140 140-199 <140 >200

TREATMENT:

Diabetes care is best provided by a multidisciplinary team of health

professionals with expertise in diabetes, working in collaboration with the patient and

12

family. Ideally, blood glucose should be maintained at near-normal levels (Pre-prandial

levels of 90-130 mg / dl and hemoglobin A1C [HbA1c] levels < 7%).

Life style modification:

Medical Nutrition therapy is advised for all individuals with diabetes

to maintain body weight, to consume nutritious food. Diabetic treatment is not

complete without exercise. Exercise is being recognised as a part of the treatment of

diabetes. The beneficial effect of exercise on glycaemic control due to increased tissue

sensitivity to insulin. Current guidelines recommend that patients with DM should

perform at least 150 min per week of moderate-intensity aerobic exercise and should

perform resistance exercise 3 times per week 19.

ANTI DIABETIC AGENTS78:

Biguanides:

METFORMIN – is the only biguanide currently available. It reduces the rate

of gluconeogenesis, hepatic glucose output and increase the insulin sensitivity. It does

not affect insulin secretion, does not induce hypoglycemia and does not predispose to

weight gain. It is particularly helpful in the overweight, although normal-weight

individuals with combination of other antidiabetic drugs. Adverse effects – lactic

acidosis is rare, may occur in kidney disease.20

Sulfonylureas:

Sulfonylureas act on the β cell to promote insulin secretion at any glucose

concentration, that is insulin release is provoked even at low glucose concentration.

13

Their action is to bind to the sulfonylurea receptor on the cell membrane, which closes

ATP-sensitive potassium channels, leading to depolarization promotes influx of

calcium, a signal for insulin release. They are ineffective in patients without a

functional β-cell mass, and are usually avoided in pregnancy. Sulfonylureas are cheap

and highly effective than all other ADA. Adverse effects are hypoglycemia, weight

gain. They should be used with care in patients with liver disease, and patients with

renal impairment should use sulfonylureas primarily excreted by the liver.

Meglitinides:

Repaglinide and Nateglinide are meglitinides – insulin secretagogues.

Meglitinides are the non-sulfonylurea moiety of glibenclamide. As with the

Drug name Features

TOLBUTAMIDE 0.5 gm tab Weaker, shorter acting, flexible dosage,

safer in elderly

GLIBENCLAMIDE 2.5,5 mg tab Potent, slow acting, higher incidence of

hypoglycaemia

GLIPIZIDE 5mg tab Fast and short acting, hypoglycaemia and

weight gain less likely, preferable in

elderly

GLICLAZIDE 20,40,80 mg tab Antiplatelet action, generates only

inactive metabolite, daily dose > 80 mg to

be divided.

GLIMEPRIDE 1,2 mg tab Long acting, only inactive metabolite,

lower incidence of hypoglycaemia.

14

sulfonylureas, they act via closure of the K+-ATP channel in the β cells. They are

short-acting agents that promote insulin secretion in response to meals. Repaglinide is

indicated in type 2 DM with uncontrolled post prandial hyperglycemia / to supplement

metformin or another ADA. It should be avoided in liver disease.

Thiazolidinedione (PPAR-γ agonist):

The thiazolidinedione (known as the glitazones) reduce insulin resistance

by interaction with peroxisome proliferator-activated receptor-gamma (PPAR-γ), a

nuclear receptor that regulates large numbers of genes, including those involved in

lipid metabolism and insulin action. It enhances the transcription of insulin responsive

genes. Glitazone reverses insulin resistance by enhancing GLUT4 expression and

translocation. Entry of glucose into muscle and fat is improved. The only drug

currently available is Pioglitazone. It also lowers serum triglycerides level and raises

HDL level because it acts through PPAR α Receptor.it is mainly used in type 2 DM

and used to supplement other Antidiabetic drugs.21

α GLUCOSIDASE INHIBITORS:

Drugs available are Acarbose, Miglitol, Voglibose. They slow down

and decrease digestion and absorption of carbohydrates. Mild antihyperglycemic used

mainly in post prandial hyperglycemia, as adjuvant therapy. It produces abdominal

discomfort and loose stools due to unabsorbed carbohydrates.22 If Hypoglycemia

occurred in patient taking α-glucosidase inhibitor, monosaccharides should be given

e.g.(glucose)

15

Dipeptidyl Peptidase4 (DPP4) inhibitors:

These drugs enhance the effect of incretin. DPP4 enzyme rapidly

inactivates the incretin hormone GLP-1, GIP (Glucose dependent insulinotropic

hormone). DPP4 inhibitors prevents degradation of incretin hormone and prolongs its

action. Currently available drugs are Sitagliptin, Vildagliptin, Saxagliptin, Linagliptin,

Alogliptin, Teneligliptin. Used in Type2 DM as monotherapy/adjuvant therapy.

❖ Figure2: Effects of DPP4 inhibitors

GLUCAGON- LIKE PEPTIDE -1 (GLP) ANALOGUES:

GLP-1 is an important incretin released from the gut in response to

ingested glucose. It induces insulin release from pancreatic β cells, inhibits

glucagon release from α cells, slows gastric emptying and suppresses appetite by

activating specific GLP-1 receptors, which are expressed on β and α cells, central and

peripheral neurones, gastrointestinal mucosa, etc. Characteristically GLP-1 induces

16

insulin release only at high glucose concentration. GLP-1 based therapy appears to be

the most effective measure for preserving β cell function in type 2 DM.GLP-1 is

rapidly degraded by Dipeptidyl peptidase-4 enzyme,23 so drugs should be resistant to

DDP4 enzyme. Exenatide, liraglutide and lixisenatide are injectable analogues of

glucagon-like peptide-1(GLP-1). Advantage of this drug is improving glucose control

and weight reduction. Adverse effects include nausea, acute pancreatitis and acute

kidney injury.

SODIUM GLUCOSE CO TRANSPORTER 2 INHIBITOR:

Glucose is freely filtered by the renal glomeruli and is reabsorbed in the

proximal tubules by the action of sodium-glucose cotransporters (SGLT). Sodium-

glucose co-transporter 2 (SGLT2) accounts for about 90% of glucose reabsorption and

its inhibition causes glycosuria in people with diabetes, lowering plasma glucose

levels. The SGLT2 inhibitors canagliflozin, dapagliflozin, and empagliflozin are

approved for clinical use.

OTHER DRUGS:

Pramlintide is a synthetic analogue of Islet Amyloid Polypeptide (lAPP or amylin).

When given subcutaneously, it delays gastric emptying, suppresses glucagon secretion,

and decreases appetite. It is approved for use both in type 1 diabetes and in insulin-

treated type 2 diabetes.

17

BROMOCRIPTINE

A dopamine agonist has been approved by FDA for the treatment of diabetes.

Taken early in the morning it is thought to act on the hypothalamic dopaminergic

control of the circadian rhythm of hormone (GH, prolactin, ACTH, etc.) release and

reset it to reduce insulin resistance. Bromocriptine can be taken alone to supplement

diet+ exercise or added to metformin or SU or both. Started at 0.8 mg OD and

increased up to 4.8 mg OD (as needed) it has been shown to marginally improve

glycaemic control and lower HbA1c by up to 0.5%.24

Colesevelam a bile acid-binding resin that lowers cholesterol, can reduce blood

glucose absorption by reducing release of gastrointestinal peptides.25

Orlistat is a lipase inhibitor that reduces the absorption of fat from the diet. It benefits

diabetes indirectly by promoting weight loss in patients under careful dietary

supervision on a low-fat diet. It is mainly used in obese with type 2 DM26. Adverse

effect is steatorrhea.

INSULIN PREPARATIONS:27

Human insulins are commonly used nowadays. It is produced by Human recombinant

DNA technology. Its structure is same as that of normal human insulin. Some insulins

have been modified through Genetic engineering to produce insulin analogues.

(Insulin lispro, insulin aspart, insulin glulisine)

18

CLASSIFICATION OF INSULINS:

Insulin Regimens:

Insulin regimen should cover basal control by inhibiting hepatic glucose

output, lipolysis and protein breakdown, as well as supply extra amount to meet

postprandial needs for disposal of absorbed glucose and amino acids.

Split mixed regimen:

The total daily dose of a 30:70 or 50:50 mixture of regular and NPH insulin is usually

split into two (split-mixed regimen) and injected subcutaneously before breakfast and

before dinner. This is conventional method.

HUMAN INSULIN

REGULAR- SHORT ACTING NEUTRAL PROTAMINE HAGEDORN(NPH) OR

ISOPHANE INSULIN

INSULIN ANALOGUES

RAPID ACTING

INSULIN LISPRO

INSULIN ASPART

INSULIN

GLULISINE

LONG ACTING

INSULIN GLARGINE

INSULIN DETEMIR

INSULIN DEGLUDEC

19

Basal Bolous regimen :

It is a intensive regimen with short-acting insulin at every meal and a

long -acting insulin analogue before breakfast or before bedtime. Intensive regimens

more completely meet the round-the-clock euglycaemia. , the risk of microvascular

disease appears to be related to the glycaemia control. The large multicentric Diabetes

Control and Complications Trial (DCCT) among type 1 patients has established that

intensive insulin therapy markedly reduces the occurrence of complications like

diabetic retinopathy, neuropathy, nephropathy and slows progression in comparison to

conventional regimens which attain only intermittent euglycaemia.

Diabetes related complications affect many systems of the body and are

responsible for major morbidity and mortality. Complications can be divided into

vascular and nonvascular and are similar for type1 and type 2 DM. The vascular

complications can be subdivided into microvascular and macrovascular

complications. The microvascular complications are retinopathy, neuropathy,

nephropathy. The macrovascular complications are coronary artery disease,

cerebrovascular disease, peripheral vascular disease.5 Microvascular complications

are diabetic specific, are seen more with diabetic patients.

20

❖ Figure3: schematic representation of the management of T2DM

21

DIABETIC NEPHROPATHY:

Diabetic nephropathy (DN) or diabetic kidney disease is a syndrome characterized

by the presence of Albuminuria, progressive loss of glomerular filtration rate (GFR)

and elevated arterial pressure.

The main pathophysiological mechanism causing diabetic nephropathy are

I. Metabolic pathway

II. Haemodynamic and Hormonal pathway

I.METABOLIC PATHWAYS:

The biochemical factors implicated in the pathogenesis of DN clarify that

hyperglycemia leads to increased glycolysis which then upregulates four distinct

pathways: the polyol pathway, hexosamine pathway, production of advanced glycation

end products (AGEs), and activation of protein kinase C (PKC).

Glycolysis is the biochemical pathway in which glucose is broken down to

make energy. In a normoglycemic Individuals glycolysis proceeds down in its well

described pathway. But in diabetic state, glucotoxicity leads to activation of excess

superoxide which then inhibits the enzyme Glyceraldehyde 3-phosphate

dehydrogenase (GADPH). This prevents normal glycolysis and increased levels of

glucose upregulate the polyol pathway whereas increased levels of fructose-6

phosphate upregulate the hexosamine pathway. Increased levels of glyceraldehyde-3

phosphate upregulate both advanced glycation end(AGE) products and DAG, the latter

being a cofactor PKC activation.

22

❖ Figure4: Glycolysis pathway

1.ADVANCED GLYCATION END PRODUCTS:

High blood glucose level in diabetes leads to non-Enzymatic glycation of tissue

protein producing Amadori products. These products slowly converted to Advanced

Glycated End Products (AGE) which accumulate in tissue especially in arterial wall,

glomerular basement membrane and serum, causing injury and inflammation via

stimulation of pro-inflammatory factors, such as complement and cytokines.

23

2.POLYOL PATHWAY:

Aldose reductase is present in the papillae, glomerular epithelial cells, distal

tubular cells and probably mesangial cells of normal kidney. Their primary function is

the generation of sorbitol (sugar alcohol). This excess glucose is converted to sorbitol

by enzyme Aldose reductase. Aldose reductase needs NADPH. So, depletion of

NADPH leads to generation of more free radicals. Sorbitol is then oxidised to fructose

by the enzyme sorbitol dehydrogenase. This step requires NADH. Increased sorbitol

interferes with inositol signalling and depletion of intracellular NADPH store leading

onto oxidative injury. This causes changes in vascular permeability, cell proliferation

and capillary structure via stimulation of protein kinase C and transforming growth

factor beta (TGF-β).29

3.HEXOSAMINE PATHWAY:

In glycolysis, fructose-6-phosphate is converted to glucosamine-6-phosphate by the

glutamine fructose-6 phosphate amido transferase (GFAT). Then glucosamine-6

phosphate is used as a substrate to increase inflammatory cytokines TNF-α, TGF-β.

These inflammatory cytokines promote renal cell hypertrophy, increase mesangial

matrix expansion.30

4.PROTEIN KINASE C PATHWAY:

Hyperglycaemia converts glyceraldehyde-3 phosphate into dihydroxy acetone

phosphate (DHAP) and Diacyl glycerol (DAG) which is a cofactor for PKC

24

activation.31 PKC activation also increases VGEF, TGF and Type IV collagen which

contribute to GBM thickening and extra cellular matrix expansion.32

In advanced diabetic nephropathy, there is extensive mesangial expansion due

to increased extracellular matrix production, with the formation of spherical,

eosinophilic nodules with a central hypocellular or acellular area, known as

Kimmelstiel–Wilson nodules.33

❖ Figure 5: schematic representation of metabolic pathway

25

Biochemical abnormalities of extra cellular matrix:

The rate of synthesis of matrix and glomerular basement membrane thickness are

increased in diabetic nephropathy.

90% of Glomerular basement membrane is made up of Glycosaminoglycans (GAG)

polysaccharides especially heparan sulphate and the reminder by sialo proteins.

Heparan sulphate together with sialic acid contributes to the negative charge of

glomerular capillary wall.34 The sialo proteins which are highly negatively charged

coat the glomerular epithelial cells, foot process, epithelial slit and diaphragm.

In diabetics, synthesis of heparin sulphate and the total GAG content of the

glomerular are reduced. This leads to loss of negative charge of glomerular basement

membrane which is responsible for fusion of foot process and subsequent obliteration

of slit and diaphragm. So, loss of negative charge of GBM leads to Albuminuria in

diabetic nephropathy.35

II. HAEMODYNAMIC AND HORMONAL EVENTS:

Persistent elevations in blood glucose alter renal hemodynamic through activation of

several vasoactive hormonal pathways, including the renin-angiotensin-aldosterone

system40, endothelin, and urotensin36.These hormones then in turn can activate

second messenger signalling pathways37, including protein kinase C, transcription

factors, including NF-κB, and cytokines, including TGF-β, VEGF38, and PDGF, all of

which can lead to the development of albuminuria, glomerulosclerosis, and tubulo

interstitial fibrosis characteristic of diabetic nephropathy.39

26

❖ Figure6: Pathologic changes of diabetic nephropathy

Three major histologic changes develop in the glomeruli of persons with

diabetic nephropathy. First, mesangial expansion is directly produced by

hyperglycemia, Second, thickening of the glomerular basement membrane, Third,

glomerular sclerosis is caused by intra glomerular hypertension induced by dilatation

of the afferent renal artery or from ischemic injury induced by hyaline narrowing of the

vessels supplying the glomeruli.

RISK FACTORS FOR DIABETIC NEPHROPATHY:

1.Increasing age

2.Poor glycaemic control

3.Systolic Hypertension41

27

4.Dyslipidaemia43

5.Microalbuminuria44

6.Family history of nephropathy45

7.Smoking 42

SCREENING OF DIABETIC NEPHROPATHY:

Screening should be started five years after the diagnosis of Type 1 DM and

for Type 2 DM at the time of diagnosis and annually. Microalbuminuria is the earliest

sign of diabetic nephropathy46. Once Microalbuminuria is detected the rate of further

progression to macro albuminuria and ESRD can be prevented by tight control of

blood sugar, blood pressure, lipids, dietary protein restriction, cessation of smoking,

RASS (Renin Angiotensin Aldosterone System) inhibitors47.

Screening tests are Microalbuminuria, estimated Glomerular filtration rate (eGFR)48.

CALCULATION OF eGFR:

The Glomerular filtration rate can be done by measuring serum creatinine and

using the GFR estimation formulae. The abbreviated modification of diet in renal

disease (MDRD) and chronic kidney disease epidemiology collaboration (CKD -EPI)

formulae are more accurate but need computer software for calculation.

The Cockcroft and Gault equation is easily calculated and is ideal for bedside.

The value is multiplied by 0.85 to estimate the GFR in women.

Creatinine Clearance = (140 – age) x weight / (serum creatinine x 72)

28

Serum creatinine can be affected by age, gender, ethnicity, dietary protein intake and

lean body mass and remain within the reference range despite marked renal impairment

in low muscle mass.so eGFR is better option for screening.

The estimation of eGFR enable us to categorise the stage of CKD.

STAGES OF DIABETIC NEPHROPATHY

DESIGNATION CHARACTERISTICS eGFR (ml/min)

STAGE 1 Hyperfunction and

hypertrophy

Large kidney, Glomerular Hyperfiltration

Albumin excretion may be increased

>90

STAGE 2 Silent Stage Thickened basement membrane and mesangial

expansion

60-89

STAGE 3 Incipient stage Persistent Microalbuminuria,

Hypertension

30-59

STAGE 4 Overt Diabetic

nephropathy

Macro-albuminuria, Hypertension,

fall in GFR

15-29

STAGE 5 End Stage Renal

Disease

Uraemia <15or dialysis

29

GLOMERULAR CLASSIFICATION OF DIABETIC NEPHROPATHY

CLASS DESCRIPTION INCLUSION CRITERIA

I Mild or nonspecific LM

changes and EM-proven GBM

thickening

Biopsy does not meet any of the criteria

mentioned below for class II, III or IV

GBM>395nm in female and >430nm in males

>9 years old

II a Mild Mesangial expansion No criteria for class III or IV

Mild mesangial expansion in >25% of the

observed mesangium

II b Severe Mesangial expansion No criteria for class III or IV

Severe mesangial expansion in >25% of the

observed mesangium

III Nodular sclerosis

(Kimmelstiel-Wilson lesion)

No criteria for class IV

At least one convincing Kimmelsteil-Wilson

lesion

IV Advanced diabetic

glomerulosclerosis

Global glomerular sclerosis in >50% of

glomeruli

Lesions from classes I through III

30

DEFINITIONS OF ABNORMAL ALBUMIN EXCRETION

Urinary Albumin

Excretion Rate

(mg/day)

URINARY

Albumin Excretion

Rate(µg/min)

Urine albumin excretion

ratio(mg/mg)

Normal <30 <20 <0.02

Microalbuminuria 30-300 20-200 0.02-0.2

Macro albuminuria >300 >200 >0.2

CLINICAL PRESENTATION:

Early stage of disease especially when picked up during screening,

diabetic nephropathy is asymptomatic. If there is established nephropathy, there may

be a history of fatigue, foamy urine and pedal oedema18 secondary to

hypoalbuminemia, There may be any associated diabetic retinopathy, peripheral

vascular disease, Hypertension or Coronary artery disease.

MANAGEMENT:

The appropriate aim is to prevent the development of diabetic nephropathy.

Both the Diabetes Control and Complications Trial (DCCT) in type 1 diabetes 49 and

the UKPDS in type 2 diabetes50 demonstrated that in individuals with the lower the

blood glucose level, the lower the risk of developing microalbuminuria51

31

Primary prevention:

Prevent kidney disease from occurring at all by modifying, removing or

avoiding risk factors that predispose to diabetes and renal disease.

Secondary prevention:

Identify the factors that hasten the progression of kidney disease and

preventing and removing such factors.

Tertiary prevention:

Proper early management DKD.

GLYCAEMIC CONTROL:

Control hyperglycaemia is very difficult in a diabetic nephropathy.

Hyperglycaemic and Hypoglycaemic episodes are very common. Metformin is

contraindicated in nephropathy for the fear of Lactic acidosis. It is not recommended

when serum creatinine >1.5 mg/dl52.Sulphonylureas that are excreted unchanged by the

kidney or long acting like Glibenclamide are not recommended. Glipizide, Gliclazide

are short acting and metabolised and excreted in the bile. Insulin is degraded by the

kidneys, so insulin dose should be reduced in nephropathy. Sitagliptin, Saxagliptin,

Vildagliptin are mainly excreted by kidneys.so it needs dose reduction according to

eGFR. Linagliptin is excreted by enterohepatic circulation. So, does not need dosage

reduction in nephropathy.

32

Blood pressure control:

ACE inhibitors should be advised when microalbuminuria is detected regardless

of the presence or absence of hypertension in diabetes patients. ACE inhibitors not

only lower systemic blood pressure but also decrease intra glomerular pressure. In a

prospective study of type 2 diabetic patients with microalbuminuria but normal blood

pressure, patients were randomized to enalapril 5 mg/day or no treatment.51 After 4

years, urinary albumin excretion had increased in the untreated patients from 93.9 to

150.0 mg per 24 hours. In the enalapril-treated group during this 4-year period,

however, albumin excretion decreased significantly from 115.4 to 75.3 mg per 24

hours. There was no change in creatinine clearance, blood pressure, or HbA1c in either

group, suggesting that the beneficial effect of the ACE inhibitor was independent of its

systemic antihypertensive action 52.

But in normotensive, normoalbuminuric patients and the role of ACE

inhibitors in preventing diabetic nephropathy is doubtful.53

ACE inhibitors are the first-choice anti hypertensives in patients with

diabetes. Angiotensin receptor blocker (ARB) can be used to preventing the

progression of albuminuria54. Combination of ACE inhibitor and ARBs has become

controversial. Diuretics, Calcium channel blocker, Beta blockers, alpha blockers may

be used in the treatment of hypertension in diabetic nephropathy5.

33

DIETARY RESTRICTION:

Vegetable source proteins are preferred than animal protein. Low protein intake

retards the progression of nephropathy. Recommended protein 0.8g/kg/day. Salt

restriction <70 meq /day enhances the antiproteinuric effect of ARBs. Potassium

restriction also adviced1.

LIPID LOWERING:

Dyslipidemia is an important risk factor in progression of diabetic nephropathy43.

Patients with DM with CKD risk of coronary artery disease is higher.so statins are

recommended. Atorvastatin has only mild renal elimination. statins can be continued

during the stages of dialysis and transplantation. Fenofibrate can be used but it needs

dose reduction.

END STAGE RENAL DISEASE:

When GFR < 60ml/min patient should be referred to nephrologist. Earlier referral

may be necessary situations like fluid management, Hypertension, Renal bone disease

and anaemia. Despite all efforts if the GFR continues to steadily decline and reaches

<20 ml/min it is prudent to start Renal Replacement Therapy.

34

Novel therapies for diabetic nephropathy

• Inhibitors of growth factors

➢ Insulin-like growth factor-1

➢ Transforming growth factor

➢ Vascular endothelial growth factor

➢ Endothelin-1 antagonists.

Biochemical:

➢ Protein kinase C inhibitors

➢ Inhibition of formation of advanced glycation end-products (AGE)

➢ AGE cross link breakers

➢ Blockade of receptor for AGE.

35

SITAGLIPTIN

Sitagliptin is a pyrazine derived competitive inhibitor of Dipeptidyl peptidase-4

enzyme.

Molecular formula: C16H18F6N5O5P

The International Union of Pure and Applied Chemistry (IUPAC) name:

3R)-3-amino-1-[3-(trifluoromethyl)-6,8-dihydro-5H-(1,2,4) triazolo (4,3-apyrazin-7-

yl)-4-(2,4,5-trifluorophenyl) butan-1-one; phosphoric acid.

Sitagliptin - an active inhibitor of DPP-4 enzyme as indirectly acting as insulin

secretogogues. This is the first DPP-4 inhibitor introduced in USA in 2006 and now

available worldwide. The HbA1c lowering effect is equivalent to metformin. Further

lowering of HbA1c occurs when it is added to other ADDs.

PHARMACOKINETICS:

Sitagliptin is well absorbed orally, is little metabolised and is largely excreted

unchanged in urine with a t ½ averaging 12 hours. It is excreted in urine in part by

tubular secretion of the drug. Hepatic metabolism is limited and mediated largely by

the cytochrome CYP3A4 isoform and to a lesser degree by CYP2C8.The metabolites

36

have insignificant activity56. Dose reduction is needed in moderate to severe renal

disease but not liver disease.

Normal Dose – 100 mg once daily.

In renal disease dose of sitagliptin:

Cr Cl - > 50ml/min – no dose adjustment

Cr Cl - 30 – 50ml/min - 50mg once daily

Cr Cl - <30ml/min – 25mg once daily

PHARMACODYNAMICS:

Incretin based therapies represent one of the promising options in type 2 DM with

low risk of hypoglycaemia and weight neutral. Sitagliptin increases endogenous

concentration of GLP-1 by preventing its degradation. It promotes glucose mediated

insulin release so it has low risk of hypoglycaemia and suppress glucagon release

leading to improvement in glucose control.

ADVERSE EFFECTS:

Sitagliptin is well tolerated. Side effects are nausea, loose stools, head ache,

rashes, Nasopharyngitis and cough occurs in some patient due to prevention of

substance P degradation. Pancreatitis is rare. Sitagliptin should be immediately

discontinued if pancreatitis or allergic and hypersensitivity reactions occur56.

37

DIPEPTIDYL PEPTIDASE-4 ENZYME:

Dipeptidyl peptidase-4 (DPP4) or adenosine deaminase complexing protein

2 (ADCP 2) or T-cell activation antigen CD26 is a serine exopeptidase belonging to the

S9B protein family that cleaves N terminal or C terminal amino acid residues from

polypeptides and proteins55. DPP-4 enzyme is a serine protease- expressed on the

surface of many cell type, including the kidney, lung, liver, intestine, spleen and

endothelial cells on the surface of T lymphocyte. The substrates of DPP-4 are proline

or alanine containing peptides and include growth factors, chemokines, neuropeptides,

vasoactive peptides. This enzyme also associated with immune regulation, signal

transduction and apoptosis. Upregulation of DPP-4 expression in renal glomeruli

occurs during inflammation and usually accompanies the development of diabetes-

induced glomerulosclerosis58. Appearance DPP4 in urine may be an early marker of

renal damage before the onset of albuminuria57.

38

❖ Figure7- A schematic representation showing the roles of DPP-4

inhibition on diabetic microangiopathy.

Experimental evidence indicates that DPP4-I affects inflammation, vascular

responses, lipids, blood pressure, and bone marrow function. In combination with

increased levels of GLP-1 and improved glucose control, these effects can mediate

protection from microvascular diabetes complications.

EFFECT OF SITAGLIPTIN IN DIABETIC NEPHROPATHY:

Increased levels of GLP is the cause for renal effects of DPP4 inhibition.

GLP-1 receptor is expressed in pancreas, other numerous tissues including glomerular

endothelial cells, mesangial cells, podocytes and proximal tubular cells. Studies

revealed GLP-1 receptor expression was decreased in diabetic compared with

39

nondiabetic mice59. Studies have shown that GLP-1 has anti-inflammatory properties

and decreases AGEs production by protein kinase A (PKA) activation61. Inhibition of

production of angiotensin II, PAI-1, ICAM-1, and VCAM-1and the stimulation of

nitricoxide60(NO) production seems to be both GLP-1 dependent and independent

effects.

In uncontrolled hyperglycaemia there will be an upregulation of DPP4 expression.

DPP-4 cleavage substrates are high mobility group protein-B1 (HMGB1), Meprin β,

neuropeptide Y (NPY), and peptide YY (PYY) which have been seen in kidney62.

HMGB1 is a known ligand for advanced glycation end products receptor (RAGE), as

well as Toll-like receptor 2 (TLR2) and TLR4, which are involved in the inflammatory

process of diabetic nephropathy leading to NF-κB activation62. Meprin β was

associated with several types of renal pathology63. Both NPY and PYY have been

important mediators of various kidney functions including natriuresis64,65 Experimental

studies were also shown that DPP-4 participates in the extracellular catabolism of

proteins in the kidney such as degradation proline-containing peptides66. So DPP4

enzyme inhibition is beneficial in diabetic nephropathy.

Preclinical data suggested that DPP4 inhibitors have nephroprotective

properties. The study with sitagliptin evaluated its effects on metabolic profile and

renal lesions in rat model of diabetic nephropathy. Sitagliptin administered rat lowered

glycaemia and ameliorated glomerular, tubulo interstitial and vascular lesions67. It also

reduces kidney lipid peroxidation as measured by decreased malonaldehyde content.

40

Sterptozocin induced diabetic rat has been used in an experimental

study with Linagliptin. Diabetes was induced in endothelial nitric oxide synthase

(eNOS) knockout mice which have been used as an experimental model for diabetic

nephropathy.69 The effect of Linagliptin on the progression of diabetic nephropathy

alone and combination with ARBs was evaluated. After 12 weeks of the study,

combined treatment with Linagliptin and telmisartan74 significantly reduced

albuminuria compared with monotherapy with linagliptin70.

The experimental model of renal ischemia or reperfusion injury, vildagliptin was

administered intravenously 15 minutes before surgery, and animals were sacrificed

after 2,12,48 hours of reperfusion71. DPP4 inhibition dose dependently reduced serum

creatinine, tubular necrosis, serum malonaldehyde levels and mRNA expression of pro

inflammatory chemokine. These data suggested that nephroprotection by DPP-4

inhibition was mediated by antiapoptotic, anti-inflammatory and anti-oxidative

changes.

clinical data suggested that 36 patients with HbA1c >6.5 % despite life style

measures and antidiabetic treatment were enrolled and treated by sitagliptin 50 mg/day

for 6 months. sitagliptin significantly lowered HbA1c and systolic and diastolic blood

pressure75. significant reduction in C-reactive protein and VCAM-1 also observed.

Albuminuria after 6 months of sitagliptin treatment measured by urine albumin

creatinine ratio significantly lowered.

82 subjects have been enrolled to the 52-week, prospective, single-

arm study where sitagliptin added-on to sulphonylureas (glimepiride or gliclazide) with

41

or without metformin. The primary endpoint has a change in HbA1c. The secondary

endpoints have been changes in BMI, blood pressure, UACR and hypoglycemia. After

52 weeks sitagliptin treatment reduced HbA1c by 0.8% and UACR from to 76.2 ±95.6

to 33.0 ±48.1mg/g along with slight reduction in BMI and blood pressure76.

Experimental and clinical studies suggested that DPP4 inhibitors have possible

protective effect on diabetic kidney disease, with special focus on the progression of

albuminuria.

42

AIM & OBJECTIVE

43

AIM OF THE STUDY:

To evaluate the efficacy of sitagliptin in retarding the progression of

albuminuria and assessing its safety and efficacy in patients with diabetic nephropathy

OBJECTIVES:

PRIMARY OBJECTIVE:

To study the efficacy of SITAGLIPTIN, Dipeptidyl Peptidase 4 inhibitors in

retarding the progression of albuminuria in diabetic nephropathy when given along

with other Anti diabetic drugs and RAAS - Renin Angiotensin Aldosterone System

inhibitors.

SECONDARY OBJECTIVE:

To assess the glycemic profile and safety of sitagliptin in patients with diabetic

nephropathy.

44

METHODOLOGY

45

METHODOLOGY

STUDY DESIGN:

This study was a Randomized, open label and a Comparative study

STUDY TYPE:

This was an Interventional study.

STUDY CENTRE:

Institute of Pharmacology, Madras Medical College (MMC) in collaboration

with the institute of Diabetology, Rajiv Gandhi Government General hospital

(RGGGH), MMC, Chennai.

STUDY POPULATION:

Adult diabetic patients with albuminuria attending out-patients department of

diabetology, RGGGH, Madras Medical College.

SAMPLE SIZE:

Total number of patients 60

• 30 patients-sitagliptin+ standard treatment,

• 30 patients - standard treatment

STANDARD TREATMENT:

Dose of antidiabetic drugs (Metformin, sulfonylureas, insulin) have been

adjusted according to their blood sugar level. If the patient taking ACE inhibitor

46

Tab. Enalapril it should be continued, otherwise Tab. Enalapril 2.5 mg was added

according to their UACR, blood pressure and continued throughout the study, in both

control and study group.

STUDY PERIOD:

August 2016 to may2017

STUDY DURATION

24 weeks treatment period per patient

PRIMARY OUTCOME:

• Reduction in albuminuria level

SECONDARY OUTCOME:

• Reduction in HbA1c

• Reduction in Fasting blood sugar level

• Reduction in Post prandial blood glucose level

INCLUSION CRITERIA:

1) Diabetes with HbA1c > 6.5% on medications.

2) Albuminuria UACR >30 mg/gm

3) BP <140/ 90mmHg with or without Medications

(RAAS inhibitors and others)

4) eGFR > 60 ml/min/1.73 m2

5) Patient willing to participate and give written informed consent.

47

EXCLUSION CRITERIA:

1) eGFR < 60 ml/min/1.73 m2

2) BP > 140/ 90 mm Hg

3) Patient with Hyperlipidemia TGL > 500 mg/dl, LDL > 250 mg/dl

4) Patient with cardiac and liver failure.

5) Patient who did not give written consent.

6) Smoking.

STUDY PROCEDURE:

The study was conducted after obtaining permission from the Institutional Ethics

committee, Madras Medical College.

Patient was explained about study procedure and purpose. Informed consent

will be obtained from the patients who are willing to participate in the trial in the

prescribed format in the regional language. The demographic details of the patients

were be obtained.

SCREENING:

Patients will be screened by History, Vitals, General and Systemic examinations

and Lab investigations.168 patients were screened.

RECRUITMENT:

Patient who fulfil the inclusion and exclusion criteria will be recruited for the

study.60 patients recruited for the study.

48

RANDOMISATION:

The enrolled patients were randomized to Control (Group A) and Study (Group B)

by simple randomization by odd numbers group A and even numbers group B.

TREATMENT PLAN:

CONTROL GROUP A:

Anti-Diabetic Drugs

Tab. Enalapril 2.5mg

STUDY GROUP B:

Tab. Sitagliptin100mg od

other Anti Diabetic Drugs

Tab. Enalapril 2.5mg

The study medication was issued for 2weeks. After assessing the

compliance of the patient at the end of 2 weeks, study medication was issued for the

subsequent 4 weeks. The same procedure was repeated till the completion of study.

ADVICE:

The subjects of both the groups were asked to continue meal plan, exercise and

their Anti-dyslipidemia agents and multi vitamins

BASELINE – INVESTIGATION

➢ Blood Pressure

➢ Body weight

➢ Complete blood count

➢ Fasting and Post Prandial blood sugar

➢ HbA1C

49

➢ Renal Function test

• Blood urea

• Serum creatinine

➢ Lipid profile

• Total cholesterol

• HDL

• LDL

• VLDL

• Triglycerides

➢ Liver function test

• Serum bilirubin

• SGOT

• SGPT

• Serum bilirubin

• Total protein

• Serum albumin

➢ Chest x ray PA view

➢ ECG

➢ Urine analysis

➢ UACR – Urine Albumin Creatinine Ratio

➢ e GFR

➢ Blood Pressure

➢ Body weight

All the baseline investigations were done at the start of the study and at the end of

the study. Fasting Blood sugar, Postprandial blood sugar were done 4th ,12th, 24th

week.

50

STUDY FLOW CHART:

SCREENING

RANDOMISATION

CONTROL GROUP

(n=30)

Standard treatment

ADDs + ACE inhibitors

ENROLLMENT

STUDY GROUP

(n=30)

T. SITAGLIPTIN 100 mg /day +

Standard treatment

TREATMENT PERIOD - 24 WEEKS

STATISTICAL ANALYSIS

51

STUDY VISITS:

Screening and Baseline Investigations:

1. Demographic details obtained.

2. Complete medical history recorded.

3. Vitals recorded and clinical examination performed.

4. Enrolment was done.

5. Written informed consent obtained.

6. Laboratory Baseline investigations were done.

VISIT 1 (0week)

1. Randomization of patient has been done.

2. Physical & Clinical examination were done.

3. Vitals were recorded.

4. Drugs were issued for Control group and Study group patients.

5. Instructions given to return the empty blister in the subsequent visit

6.To report any adverse event if occurs.

7. Informed consent form was obtained.

VISIT- 2 (2 week)

1.Received empty blisters

2.Vitals were recorded.

3.Drugs were issued for 2 weeks.

4. Instructions given to return the empty blister in the subsequent

visit

5. Patients were advised to report any adverse event occurs.

52

VISIT -3 (4 week)

1.FBS & PPBS were checked.

2.Empty blisters received from the patient.

3.Vitals were recorded.

4. Body weight was recorded.

5.Drugs were issued for 4 weeks.

6. Instructions given to return the empty blister in the subsequent

visit

7. Patients were advised to report any adverse event occurs.

VISIT – 4 (8 week)

1. Empty blisters received from the patient.

2. Vitals were recorded.

3. Body weight was recorded

4. Drugs were issued for 4 weeks.

5. Instructions given to return the empty blister in the subsequent

Visit

6. Patients were advised to report any adverse event occurs.

VISIT 4 (12 week)

1. Empty blisters received from the patient.

2. Vitals were recorded.

3. Body weight was recorded.

4. FBS & PPBS were checked.

5. Drugs were issued for 4 weeks.

53

6. Instructions given to return the empty blister in the subsequent

Visit

7. Patients were advised to report any adverse event occurs.

VISIT 5 (16 week)

1. Empty blisters received from the patient.

2. Vitals were recorded.

3. Body weight was recorded.

4. Drugs were issued for 4 weeks.

5. Instructions given to return the empty blister in the subsequent

Visit

6. Patients were advised to report any adverse event occurs.

VISIT 6 (20 week)

1. Empty blisters received from the patient.

2. Vitals were recorded.

3. Body weight was recorded.

4. Drugs were issued for 4 weeks.

5. Instructions given to return the empty blister in the subsequent

Visit

6. Patients were advised to report any adverse event occurs.

VISIT 7 (24 week)

1. Empty blisters received from the patient.

2. Vitals were recorded.

3. Clinical examination was done.

54

4. Body weight was recorded.

5. Patients were advised to report any adverse event occurs.

6. HbA1C, UACR, FBS, PPBS were checked.

7. Other laboratory investigations repeated.

• Fasting lipid Profile

• Hb%

• Blood Urea

• Serum creatinine

• SGOT

• SGPT

• Serum Alkaline phosphatase

• Serum bilirubin

• Serum Albumin

Patients advised to continue their routine medications at the end of 24 weeks.

INSTRUCTIONS TO PATIENTS:

The patients were instructed clearly about the regular intake of the medicines. They

were also given proper advice to report for assessment and collection of drugs. They

were counselled to report any adverse reactions if occurs.

COMPLIANCE:

Patient’s compliance was monitored by the empty blister returned at each visit.

ADVERSE EVENTS:

Any adverse event reported by the patient or observed by the physician during

the study was recorded. The onset of adverse event, and its causal relationship to the

55

study drug and the action taken for the adverse effect was recorded. Appropriate

medical care was provided for the adverse event.

WITHDRAWAL:

During the study period, the subject can withdraw their voluntary consent and opt

out of study. Similarly, the subjects can be withdrawn from the study if any adverse

event is reported by patient or observed by the physician.

STATISTICAL ANALYSIS:

The obtained data were analyzed statistically using SPSS software version 21.

The biochemical parameters were analyzed statistically in both the groups. The

differences within the groups before and after treatment were analyzed using student’s

paired t-test whereas the difference between the Control and Study group were

analyzed using students independent t-test.

P value of < 0.05 is considered as statistically significant.

56

RESULTS

57

RESULTS

This study was conducted to evaluate the effect of sitagliptin along with ACE

inhibitors in patients having albuminuria with early stage of diabetic nephropathy.

➢ 168 patients were screened of which 60 patients were enrolled and completed

the study.

➢ There were no dropouts in the study

TABLE :1 AGE DISTRIBUTION

❖ Table 1 shows age distribution.

❖ Age group 61-70 years had more number of patients followed by 51-60 years.

FIGURE 1: AGE DISTRIBUTION

❖ Figure 1 depicts Age distribution in both the group

0

5

10

15

20

41-5051-60

61-7071-80

2

7

19

2

1

8

18

3NO

OF

PATI

ENTS

AGE

AGE DISTRIBUTION

CONTROL STUDY

AGE IN

YEARS

CONTROL STUDY

NO

%

% NO % NO %

41-50 2 6.6 1 3.3

51-60 7 23.3 8 26.6

61-70 19 63.3 18 60

70-80 2 6.6 3 10

58

TABLE 2: MEAN AGE DISTRIBUTION

➢ Table 2 shows mean age distribution.

➢ Mean control age was 63.21 and study age was 63.46.

FIGURE 2: MEAN AGE DISTRIBUTION

❖ Figure 2 is the graphical representation of table2

❖ Figure 2 is the graphical representation of table2

GROUP NO OF

PATIENTS

AGE

IN YEARS

SD

CONTROL 30 63.21 5.99

STUDY 30 63.46 5.61

P VALUE O.740

0

20

40

60

80

63.21 63.46

AG

E IN

YEA

RS

MEAN AGE DISTRIBUTIONT

CONTROL STUDY

59

TABLE 3: SEX DISRIBUTION

SEX

DISTRIBUTION

CONTROL STUDY

NO

OF PATIENTS

% NO OF

PATIENTS

%

MALE 24 80 21 70

FEMALE 6 20 9 30

TOTAL NO OF

PATIENTS

30 100 30 100

➢ Table 3 shows sex distribution of population.

➢ Males were more in number compared to females in both group

FIGURE 3: SEX DISTRIBUTION

❖ Figure 3 depicts table 3

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CONTROL STUDY

8070

2030

SEX DISTRIBUTION

MALE FEMALE

60

TABLE4 : EFFECT ON BODY WEIGHT

➢ Table 4 shows the effect on mean body weight both control and study group at

baseline and 24 weeks.

➢ In control group mean Body weight was increased from 69.76 to 71.13 at 24

weeks. P value was significant 0.004

➢ There was no statistical significant difference within the study group and

between the group at baseline and 24 weeks.

FIGURE 4:EFFECT ON BODY WEIGHT

❖ Figure 4 is the graphical representation of table 4

69.76 68.9371.1368.16

0

10

20

30

40

50

60

70

80

WEI

GH

T IN

KG

S

CONTROL STUDY

EFFECT ON BODY WEIGHT

0WEEKS

24WEEKS

GROUP

0 WEEKS 24 WEEKS

P value MEAN SD MEAN SD

CONTROL 69.76 12.94 71.13 12.22 0.004

STUDY 68.93 8.43 68.16 8.35 0.133

P value 0.638 0.277

61

TABLE:5 DISTRIBUTION OF ALBUMINURIA

Microalbuminuria Macro albuminuria

CONTROL 23 7

STUDY 24 6

➢ Table 5 shows distribution of albuminuria in both control and study group

➢ In both groups microalbuminuria population was higher.

Figure:5 DISTRIBUTION OF ALBUMINURIA

❖ Figure 5 is the graphical representation of table 5.

2324

76

0

5

10

15

20

25

30

CONTROL TEST

NO

OF

PA

TIEN

TS

ALBUMINURIA DISTRIBUTION

MICROALBUMINURIA MACROALBUMINURIA

62

Table 6: URINE ALBUMIN CREATININE RATIO

➢ Table 6 shows mean UCAR value of control and study group at baseline and 24

weeks.

➢ UCAR value was significantly reduced in study group (from 302.10 to 143.83)

compared to control group (from 324.36 to 290.93) P value was significant in both

groups.

FIGURE6: URINE ALBUMIN CREATININE RATIO

❖ Figure 6 is the graphical representation of the table 6.

324.36302.1290.3

143.83

0

50

100

150

200

250

300

350

CONTROL STUDY

UA

CR

mg

/gm

URINE ALBUMIN CREATININE RATIO

0 WEEKS 24 WEEKS

GROUP

0 weeks 24 weeks

P value MEAN SD MEAN SD

CONTROL 324.36 237.64 290.93 213.98 0.007

STUDY 302.10 222.42 143.83 98.03 0.001

P value 0.709 0.001

63

Table 7: Estimated Glomerular Filtration Rate –eGFR

❖ Table 7 shows mean eGFR of both control and study group.

❖ eGFR was increased in study group from baseline to 24 weeks (100.43 to

102.46).

❖ Statistical analysis within the control group revealed no significant.

❖ Statistical analysis between the group at 24 weeks was significant. P value-

0.006

Figure7: Estimated Glomerular Filtration Rate - eGFR

❖ Figure 7 is the graphical representation of the table 7

101.76

100.43

102.96

104.46

98

99

100

101

102

103

104

105

CONTROL STUDY

eG

FR m

l/m

in

eGFR

OWEEKS 24 WEEKS

GROUP

0 WEEKS 24 WEEKS

P value MEAN SD MEAN SD

CONTROL 101.76 11.09 102.96 10.94 0.574

STUDY 100.43 10.32 104.46 9.86 0.001

P value 0.632 0.006

64

TABLE 8: FASTING BLOOD SUGAR

GROUP 0 WEEKS 24 WEEKS P value

MEAN SD MEAN SD

CONTROL 192.30 23 125.43 7.48 0.001

STUDY 192.56 26.55 109.43 7.20 0.001

P VALUE 0.965 0.001

❖ Table 8 shows mean fasting blood sugar level of both groups at base line and 24

weeks.

❖ There was a significant reduction in the mean FBS level in the study group

(109.43mg/dl) compared to control group (125.43mg/dl) at the end of 24 weeks.

❖ There was a statistically significant difference between the groups at the end of 24

weeks (P< 0.001)

Figure8: FASTING BLOOD SUGAR

❖ Figure 8 is the graphical representation of table 8.

192.3 192.56

125.43109.43

0

50

100

150

200

250

CONTROL STUDY

BLO

OD

SU

GA

R L

EVEL

mg/

dl

FASTING BLOOD SUGAR

0 WEEKS

24 WEEKS

65

TABLE 9: POSTPRANDIAL BLOOD SUGAR

GROUP 0 WEEKS 24 WEEKS P value

MEAN SD MEAN SD

CONTROL 278.10 7.99 205.53 6.98 0.001

STUDY 277.16 7.85 186.76 6.07 0.001

P VALUE 0.650 0.001

❖ Table 9 shows mean Post prandial blood sugar level of both groups at base line

and 24 weeks.

❖ There was a significant reduction in the mean PPBS level in the study group

(186.76mg/dl) compared to control group (205.33 mg/dl) at the end of 24 weeks.

❖ Statistical analysis within the group showed a significant reduction in both the

group at the end of 24 weeks.

❖ There was a statistically significant difference between the groups at the end of 24

weeks (P< 0.001)

FIGURE 9: POST PRANDIAL BLOOD SUGAR

❖ Figure 9 depicts table 9

278.1 277.16

205.33186.76

0

50

100

150

200

250

300

CONTROL TEST

BLO

OD

SU

GA

R L

EVEL

S

POST PRANDIAL BLOOD SUGAR

0 WEEKS 24 WEEKS

66

Table10: HbA1C

❖ Table 10 shows mean HbA1C level in both control and study group.

❖ There was a significant reduction in mean HbA1C in the study group (7.02%)

compared to control group (7.50%)

❖ Statistical analysis within and between the group showed a significant

reduction.

❖ There was a statistically significant difference between the groups at the end of

the 24 weeks (P<0.001)

Figure 10: HbA1C

❖ Figure 10 is the graphical representation of table 10.

8.53 8.48

7.57.02

0

1

2

3

4

5

6

7

8

9

CONTROL TEST

HB

A1

C V

ALU

E

HBA1C

0 WEEKS 24 WEEKS

GROUP

0 WEEKS 24 WEEKS

P value MEAN SD MEAN SD

CONTROL 8.53 0.22 7.5 0.58 0.006

STUDY 8.48 0.22 7.02 0.38 0.001

P value 0.108 0.001

67

TABLE 11: SYSTOLIC BLOOD PRESSURE (SBP)

❖ Table 11 showed SBP of both group at 0 weeks and 24 weeks.

❖ Mean SBP was significantly reduced in study (120.6) group than control

(124.53) group.

❖ Statistical analysis showed significant reduction within the study group (p<

0.005). No significant difference in control group at the end of 24 weeks.

❖ Statistical analysis between the group showed significant reduction in the study

group (P<0.001)

FIGURE 11: SYSTOLIC BLOOD PRESSURE

❖ Figure 11 is the graphical representation of Table 11

126.26

122.46

124.53

120.6

117

118

119

120

121

122

123

124

125

126

127

CONTROL TEST

SYST

OLI

C B

P m

mH

g

SYSTOLIC BLOOD PRESSURE

0 WEEKS

24 WEEKS

GROUP

0 WEEKS 24 WEEKS

P value MEAN SD MEAN SD

CONTROL 126.26 4.47 124.53 3.05 0.111

STUDY 124.86 5.95 120.6. 4.18 0.005

P value 0.308 0.001

68

TABLE 12: DIASTOLIC BLOOD PRESSURE

❖ Table12 showed DBP measurement in control and study group at 0 ,24 weeks

❖ DBP was significantly reduced in study group (78.60) than control (79.20) group.

❖ Statistical analysis within the study group revealed significant reduction in DBP

(p<0.013) at 24 weeks.

❖ Statistical analysis between the group revealed no significant difference at 24

weeks.

FIGURE 12: DIASTOLIC BLOOD PRESSURE

❖ Figure 12 depicts table 12

80.85

79.479.2

78.6

77

77.5

78

78.5

79

79.5

80

80.5

81

81.5

CONTROL TEST

DIA

STO

LIC

BP

mm

Hg

DIASTOLIC BLOOD PRESSURE

0 WEEKS 24 WEEKS

GROUP

0 WEEKS 24 WEEKS

P value MEAN SD MEAN SD

CONTROL 80.85 7.38 79.20 6.24 0.143

STUDY 79.40 6.77 78.60 4.79 0.013

P value 0.782 0.221

69

TABLE 13: BIOCHEMICAL INVESTIGATIONS (CONTROL GROUP)

❖ Table 13 shows Biochemical investigations of control group at baseline and 24

weeks.

❖ Statistical analysis within the group and between the group did not show any

significance.

INVESTIGATIONS

CONTROL GROUP

P value 0 WEEKS 24 WEEKS

Mean SD MEAN

Blood urea 30.13 4.34 29.86 3.79 0.326

Serum creatinine 0.69 0.15 0.66 0.09 0.286

Total cholesterol 176.13 31.20 175.41 28.87 0.673

Triglycerides 165.43 13.24 164.63 12.23 0.263

Serum LDL 146.03 10.74 147.10 11.60 0.098

VLDL 30.10 2.35 30.20 2.01 0.443

HDL 42.70 2.24 41.78 7.42 0.305

Serum bilirubin 0.58 0.0917 0.57 0.105 0.527

SGOT 27.30 2.87 26.53 2.93 0.111

SGPT 27.90 1.53 27.60 1.03 0.222

Serum alkaline

phosphatase

40.81 4.15 40.46 2.93 0.278

Serum albumin 4.33 0.379 4.30 0.453 0.446

70

TABLE 14: BIOCHEMICAL INVESTIGATION OF STUDY GROUP

❖ Table 14 shows Biochemical investigations study group at baseline and

24weeks.

❖ Statistical analysis within the group and between the group did not show any

significance

INVESTIGATIONS

STUDY GROUP

P value 0 WEEKS 24 WEEKS

MEAN SD MEAN SD

Blood urea 31.63 2.6 30.93 2.31 0.186

Serum creatinine 0.67 0.14 0.65 0.09 0.206

Total cholesterol 173.961 23.08 70.73 17.55 0.336

Triglycerides 161.50 10.42 160.66 9.5 0.410

Serum LDL 146.03 8.61 147.10 9.01 0.098

VLDL 30.03 1.85 29.90 1.39 0.475

HDL 42.30 2.30 41.26 4.50 0.235

Serum bilirubin 0.583 0.105 0.586 0.122 0.902

SGOT 26.73 1.85 26.63 1.27 0.762

SGPT 27.36 1.44 27.30 1.11 0.774

Serum alkaline

phosphatase

41.46 4.73 40.80 3.29 0.98

Serum albumin 4.25 0.427 4.37 0.327 0.281

71

TABLE 15: INCIDENCE OF ADRs

➢ Table 15 shows the incidence of ADRs presented by the patients in both the

groups.

➢ In control group, 8 ADRs were reported and in Study group 3 ADRs were

reported.

FIGURE 15: INCIDENCE OF ADRs

❖ Figure 15 depicts Table 15

0%

10%

20%

30%

CONTROL

STUDY

26%

10.00%

PER

CEN

TAG

E O

F A

DR

s

INCIDENCE OF ADRs

CONTROL STUDY

Incidence of

ADR

8 (26 %) 3 (10 %)

72

TABLE 16: ADVERSE DRUG REACTION PATTERN

ADR Control group Study group

Hypoglycaemia 4 (13.3%) 1 (3.3%)

Cough 1 (3.3%) 1 (3.3%)

Dizziness 1 (3.3%) 0

Myalgia 2 (6.6%) 1 (3.3%)

❖ Table 16 shows the adverse drug reaction of the both control and study

group.

❖ Adverse drug reactions were reported more with control group (26%) than

study group (10%)

❖ Hypoglycaemia was reported more with control (13.3%) group than study

(3.3%) group

FIGURE 16: ADVERSE DRUG REACTION

❖ Figure 16 is the graphical representation of the table

13%

3%3% 3%3%

0.00%

6.60%

3%

0%

2%

4%

6%

8%

10%

12%

14%

CONTROL STUDY

% O

F A

DR

s

Axis Title

ADVERSE DRUG REACTIONS

HYPOGLYCAEMIA COUGH DIZZINESS MYALGIA

73

TABLE 17: SEVERITY ASSESSMENT OF ADR

SEVERITY CONTROL GROUP STUDY GROUP

MILD 8 3

MODERATE - -

SEVERE - -

➢ Table 17 shows severity assessment of Adverse Drug Reactions.

➢ Severity assessment was done using Modified Hartwig and Siegel scale.

➢ Adverse Drug Reactions were mild in both the group.

74

TABLE 18: CAUSALITY ASSESSMENT OF INDIVIDUAL ADR IN

CONTROL GROUP

❖ Table 18 shows causality assessment of individual ADR in control group.

❖ Causality assessment was done using WHO causality assessment scale.

❖ Adverse drug reactions were categorized as PROBABLE except myalgia came

under POSSIBLE

TABLE 19: CAUSALITY ASSESSMENT OF INDIVIDUAL ADR IN STUDY GROUP

❖ Table 19 shows causality assessment of individual ADR in study group.

❖ Causality assessment was done using WHO causality assessment scale

❖ All adverse drug reactions were categorized as probable, Myalgia side effect

came under possible.

ADR

Certain

Probable

Possible

Un-

likely

un -

classified

Un -

classifiable

Total

Hypoglycaemia 4 4

Dizziness 1 1

Cough 1 1

Myalgia 2 2

ADR

Certain

Probable

Possible

Un-

likely

un -

classified

Un -

classifiable

Total

Hypoglycaemia 1 1

Dizziness 0 0

Cough 1 1

Myalgia 1 1

75

DISCUSSION

76

DISCUSSION

Diabetes is the most common cause of CKD both in type 1 and type2 DM.

Early initiation of strict glycemic control and blood pressure control has been proven to

reduce the risk of diabetic nephropathy. Screening of diabetic nephropathy should be

done regularly in diabetic patients. Microalbuminuria is an important early sign of

diabetic nephropathy. So, Type 2 DM patients should be screened for albuminuria

annually. Screening tests are UCAR and eGFR. Serum creatinine can be affected by

age, gender, ethnicity, dietary protein intake and lean body mass and remain within the

reference range despite marked renal impairment in low muscle mass. The sensitivity

of serum creatinine for early detection of kidney disease is poor. With

Microalbuminuria and eGFR values we can find early stage of diabetic nephropathy.

According to current American Diabetic Association guidelines the primary

intervention in patients with detected albuminuria is the blockade of renin angiotensin

aldosterone system with ACE inhibitor or Angiotensin receptor blocker74.

Sitagliptin, an Incretin-based therapy is most recently approved agents for

the treatment of type 2 diabetes owing to their good effectiveness with low risk of

hypoglycemia and weight neutral. One of the recently emerged interesting features of

dipeptidyl peptidase-4 (DPP-4) inhibitors is its possible protective effect on the

diabetic kidney disease. Mechanisms underlying possible nephroprotective properties

of DPP-4 inhibitors include reduction of oxidative stress and inflammation and

improvement in endothelial dysfunction. Effects of DPP-4 inhibitors may be both

glucagon-like peptide-1 (GLP-1) dependent and independent.

77

DPP4 inhibitors lower blood glucose levels by raising the half-life of short-

lived endogenous incretins, such as GLP-1 and GIP. In diabetes DPP4 enzyme

expression will be more. The ability of DPP-4 to cleave a host cell membrane substrate

that exert enzymatic properties by interacting with other membrane proteins/receptors

suggests it may be a novel and exciting therapeutic target in diabetic nephropathy.

This study demonstrated the effect of sitagliptin in patients having diabetic

nephropathy with persistent albuminuria and its glycaemic control in that patients.

More number of male patients from 61-70 years of age group were fulfil the criteria

and included in the study. Mean control age was 63.21± 5.99 and mean study age was

63.46 ± 5.61. Number of male patients in control group was 24, in study group 21.

Number of female patients in control group 6 and in study group 9.

Both group of patients received oral anti diabetic drugs like sulphonylureas

(Glimepiride, Glibenclamide, Glipizide), metformin and enalapril 2.5 mg OD dose.

Study group patients received test along with standard treatment.

In control group mean body weight was increased from 69.76 kg to

71.13 kg at the end of 24 weeks which was statistically significant. Body weight was

not affected in Sitagliptin treated group, even though they were taking sulphonyl urea.

Sitagliptin has weight neutral effect, when it combined with other ADD it prevent

weight gain.

The result of the present study showed that the administration of sitagliptin

significantly decreased the mean Urinary albumin excretion ratio in persistent

albuminuria patient from the baseline 302.10 mg/gm to 143.83. In control UCAR value

78

reduced from 324.10 to 290.93. Both group of patients received ACE inhibitors, better

reduction was seen in sitagliptin treated group. This was the primary outcome of the

study. Estimated glomerular filtration rate mean value was 100.43 ml/min/1.732 m2 at

baseline and 104.46 ml/min/1.732 m2 at 24 weeks in the study group. P value was

statistically significant.

In this study group mean HbA1C decreased from 8.48% at baseline to

7.02% at 6 months. This 1.4% reduction may be more significant considering the fact

that the mean Baseline HbA1C in the lower limit.

A reduction in mean fasting blood glucose was observed at 6 months

(from 192.56 ± 26.25 to 109.43 ± 7.20) and a reduction in mean post prandial blood

sugar at 6 months (from 277.16 ± 7.85 to 186.76 ± 6.07). Comparing to control group,

sitagliptin treated group had better reduction in the blood sugar levels.

Sitagliptin treatment for 6 months significantly reduced mean systolic blood

pressure from 124.86 ±5.95 mmHg from baseline to 120.6 ± 4.18 mmHg at 6 months.

Statistical analysis showed significant reduction in the study group at the end of 24

weeks. The antihypertensive effect of GLP-1 is attributed to the GLP-1 dependent

increases in salt and water excretion77. So significant reduction in blood pressure with

sitagliptin in this study has been contribute to some extent to lowering urinary albumin

excretion. There was no significant change in the diastolic BP from base line and end

of the study.

Triglyceride, total cholesterol, HDL cholesterol, and LDL-cholesterol were not

altered by sitagliptin treatment. There was no statistically significant difference within

79

the group and between the group at baseline and end of the study. Serum bilirubin,

SGOT, SGPT, serum alkaline phosphate, serum albumin levels were not altered at

baseline and 24 weeks of the study in both control and study group.

The number of adverse events observed were less in patients receiving

sitagliptin than control group. According to WHO causality assessment scale, in the

study group the Adverse Drug Reactions like hypoglycemia, cough observed were

categorized as probable and myalgia noted under possible. Based on the Modified

Hartwig and Siegel severity assessment scale, all the reactions reported were mild.

This explicit that sitagliptin did not increase the occurrence of adverse events.

The limitations of our study are that it was done for a shorter period and also

sitagliptin was given in combination with ACE inhibitors and other ADD. The role of

ACE-inhibitors on albuminuria reduction was already established. The therapeutic

effects of sitagliptin in albuminuria can be evaluated by administering sitagliptin as a

monotherapy. Sitagliptin can be used in patients with end stage renal failure with dose

adjustment. This study demonstrated the effect of sitagliptin in stage I diabetic

nephropathy. Further studies are needed to prove its effect on albuminuria to be done

in larger group of patients with various stages of nephropathy for longer duration.

80

CONCLUSION

81

CONCLUSION

From the findings of this present study, we concluded that in patients with

persistent albuminuria on stage I diabetic nephropathy, Sitagliptin 100mg significantly

reduced albuminuria without decreasing estimated Glomerular filtration rate. It reduced

Fasting blood sugar, post prandial blood sugar, HbA1C level and associated significant

reduction in systolic blood pressure. Sitagliptin was well tolerated. These findings

suggested that Sitagliptin may be an appropriate treatment option for patients with

early stage of diabetic nephropathy.

82

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Appendices

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APPENDIX-1 LIST ABBREVATIONS USED

AGEs:

ADD:

Advanced glycation end-products

Anti-Diabetic Drug

CKD: Chronic kidney disease

DKD: Diabetic kidney disease

DPP-4: Dipeptidyl peptidase-4

eNOS: Endothelial nitric oxide synthase

GLP-1: Glucagon like peptide-1

HMGB1: High mobility group protein-B1

ICAM-1: Intercellular adhesion molecule-1

GLP-1R: GLP-1 receptor

NF-κB: Nuclear factor-Κb

NO: Nitric oxide

NPY: Neuropeptide Y

PAI-1: Plasminogen activator inhibitor-1

PKA: Protein Kinase A

PKC: Protein Kinase C

PYY: Peptide YY

RAAS: Renin-angiotensin-aldosterone system

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RAGE: Advances glycation end products receptor

TGF-β Transforming growth factor β

TNF-α: Tumor necrosis factor-α

UACR: Urinary albumin creatinine ratio

VCAM-1: Vascular cell adhesion molecule-1

VEGF: Vascular endothelial growth factor.

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APPENDIX-2

CASE-PROFORMA

INVESTIGATIONS First visit Last visit

Complete blood Count

TC:

DC:

Hb%

FBS

PPBS

HbA1C

Total cholesterol

Triglycerides

HDL

Blood Urea

Serum creatinine

e GFR

Total protein

Urine Albumin

creatinine ratio

Name:

AGE/SEX:

OP NUMBER

CONTACT NO:

ADDRESS:

DIAGNOSIS:

Duration of diabetes:

Alcohol: Smoking:

Current treatment:

Parameters O week 4th week 8th week 12th week 16th week 20th week 24th week

Blood pressure

Weight

FBS

PPBS

COMPLAINTS

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APPENDIX – 3

INFORMATION TO PARTICIPANTS

Title: “Efficacy of Sitagliptin in retarding the progression of albuminuria and

assessing its safety and efficacy in patients with Diabetic nephropathy” – A

Randomized, Open Label, Comparative study”

Principal Investigator: Name of Participant:

This study is being conducted in Diabetology OPD at Rajiv Gandhi Govt.

General Hospital, Chennai. You are invited to take part in this study. The information

in this document is meant to help you decide whether or not to take part in this study.

Please feel free to ask if you have any queries or concerns.

What is the purpose of this study?

Diabetes mellitus is the most common cause of chronic kidney disease.

Microalbuminuria is an important early sign of diabetic nephropathy. Mostly chronic

diabetes and uncontrolled hyperglycemia patient may develop microalbuminuria with

hypertension. The role of ACE inhibitors in albuminuria was proven. So, in this study

we know the efficacy of sitagliptin -DPP4 inhibitor in albuminuria and assessing its

efficacy and safety in diabetic nephropathy patient. We have obtained permission

from the Institutional Ethics Committee.

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The study design:

All patients in the study will be divided into 2 groups A & B. You will be

assigned to either of the groups. Group A will receive standard treatment & Group B

will receive standard treatment + sitagliptin.

Study Procedures: The study involves evaluation of decrease in albuminuria, FBS,

PPBS, HbA1C. The planned scheduled visits involve every 4th week for up to 24 weeks

after your initial visit. At each visit, the study physician will examine you. Urine tests

will be carried out twice (at screening and at the end of study) and Blood test will be

done thrice during the study and total of about 20 ml blood will be collected. These

tests are essential to monitor your condition, and to assess the safety and efficacy of the

treatment given to you. In addition, if you notice any adverse events, you should report

it. This will enable correct assessment of the study results.

Possible benefits to you –Sitagliptin along with standard treatment will cause

reduction in albuminuria and blood sugar levels. Possible benefits to other people -

The results of the research may provide benefits to the society in terms of advancement

of medical knowledge and/or therapeutic benefit to future patients

Confidentiality of the information obtained from you

You have the right to confidentiality regarding the privacy of your medical

information. (Like physical examinations, investigations). By signing this document,

you will be allowing the research team investigators, other study personnel, and

Institutional Ethics Committee to view your data, if required. The information from

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this study, if published in scientific journals or presented at scientific meetings, will not

reveal your identity.

How will your decision to not participate in the study affect you?

Your decision not to participate in this research study will not affect your medical care

or your relationship with the investigator or the institution. You will be taken care of

and you will not lose any benefits to which you are entitled.

Can you decide to stop participating in the study once you start?

The participation in this research is purely voluntary and you have the right to

withdraw from this study at any time without giving any reasons. However, it is

advisable that you talk to the research team prior to stopping the

treatment/discontinuing of procedures etc. The expenditure for the treatment and

investigation for this study will not be collected from you

Signature of Investigator Signature of Participant

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APPENDIX-4

INFORMED CONSENT FORM

“Efficacy of Sitagliptin in retarding the progression of albuminuria and assessing

its safety and efficacy in patients with Diabetic nephropathy” – A Randomized,

Open Label, Comparative study

Name of the Participant:

I, _____________________________ have read the information in this form (or

it has been read to me). I was free to ask any questions and they have been answered. I

am over 18 years of age and, exercising my free power of choice, hereby give my

consent to be included as a participant in this study.

1. I have read and understood this consent form and the information provided to me.

2. I have had the consent document explained to me.

3. I have been explained about the nature of the study.

4. I have been explained about my rights and responsibilities by the investigator.

5. I am aware of the fact that I can opt out of the study at any time without having to

give any reason and this will not affect my future treatment in this hospital.

6. I hereby give permission to the investigators to release the information obtained

from me as result of participation in this study to the sponsors, regulatory authorities,

Govt. agencies, and IEC.I understand that they are publicly presented.

7. I have understood that my identity will be kept confidential if my data are publicly

presented

8. I have had my questions answered to my satisfaction.

9. I have decided to be in the research study.

I am aware that if I have any question during this study, I should contact the

investigator. By signing this consent form I attest that the information given in this

document has been clearly explained to me and understood by me, I will be given a

copy of this consent document.

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1. Name and signature / thumb impression of the participant (or legal representative if

participant incompetent)

Name ___________________Signature/Guardian_________________ Date_______

2.Name and Signature of impartial witness (required for illiterate patients):

Name ______________________ Signature_________________ Date_______

Address and contact number of the impartial witness:

3. Name and Signature of the investigator or his representative obtaining consent:

Name _____________________ Signature_________________ Date ________

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