The effect of atromid on serum cholesterol and glucose tolerance in diabetes mellitus

JOURNAL OF ATHEROSCLEROSIS RESEARCH

679

T H E E F F E C T OF ATROMID ON SERUM C H O L E S T E R O L AND GLUCOSE T O L E R A N C E IN D I A B E T E S M E L L I T U S S. C. H E R R I O T , I. W. P E R C Y - R O B B , J. A. S T R O N G AND C. G. T H O M S O N

The Western General Hospital and the Department of Medwine, University of Edznburgh, Edinburgh (Scotland)

INTRODUCTION

The high incidence of vascular complications in diabetes mellitus is one of the most serious aspects of the disease, since vascular disease constitutes the most important single cause of mortality 1. The relationship between cholesterol metabolism and arterial degenerative disease is problematical. Arterial disease and a raised blood cholesterol concentration are both common in diabetes mellitus, and any effective method of reducing the blood cholesterol in this disease m a y be worth a trial. THORP AND WARING2 described a series of aryloxyisobutyric acids found to be active in rats in reducing total lipid cholesterol in both blood and liver. THORP3 has also described the effect of combining androsterone, an adrenal androgen, with CPIB (ethyl-a-p-chlorophenoxy-isobutyrate), and showed that the capacity of parenteral androsterone to lower the serum cholesterol is maintained when it is given by mouth, but only if accompanied b y CPIB. Studies b y OLIVER4 in a series of cases of myocardial infarction showed that Atromid (a combination of androsterone and CPIB) depressed the serum concentration of cholesterol, triglycerides and uric acid in all but one of 20 patients with hypereholesterolaemia. This paper describes an investigation of the effect of Atromid in diabetes mellitus, both on the serum cholesterol concentration and on carbohydrate metabolism. MATERIALS AND METHODS

Atromid was used in capsules containing 244.5 mg CPIB with 5.5 mg androsterone. Serum free and total cholesterol concentrations were determined in duplicate by the method of SEARCY AND BERGQUIST 5. Carbohydrate metabolism was studied by the intravenous glucose tolerance test as described b y BOYD et al. 6. True capillary blood glucose was determined b y a method using glucose oxidase 7. The 8 patients studied were selected from those attending the diabetic clinic in this hospital. They were all "maturity-onset" diabetic women, and, with one exception, were overweight. Excepting their obesity, their diabetic control was regarded as satisfactory. Four were stabilised on diet alone and 4 on diet and chlorpropamide. J. Atheroscler. Res., 3 (1963) 679-688

680

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EFFECT OF ATROMID IN DIABETES MELLITUS

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Clinical details of the patients are recorded in Table I. During this investigation they continued to attend as out-patients on the same regimen as they had previously observed, and they tested their urine regularly for reducing substances b y the clinitest method and recorded the results. At stated intervals they attended the hospital at about 9 a.m., fasting, and having taken their dose of chlorpropamide where appropriate. After resting briefly, fasting venous blood samples were taken for serum cholesterol estimations. Three capillary blood samples were then removed at intervals of 5 min, and 25 g of glucose in 50 % solution was given b y intravenous injection over 3 min. Further samples of capillary blood were taken at timed intervals up to 90 min from the midpoint of the time of injection of glucose. The results obtained have been expressed as the increment index s. Cholesterol estimations and an intravenous glucose tolerance test were carried out twice, at intervals of one week, before starting treatment with Atromid. Thereafter while the patient's management remained otherwise unchanged, Atromid was given in three daily doses each of 750 mg. The patients returned for review after intervals of 4, 8 and 12 weeks, when the previous tests were repeated, and the treatment with Atromid was then withdrawn. After further intervals of 1 and 4 weeks, the tests were repeated to provide the means of comparison after treatment with the findings before and during treatment. RESULTS

Cholesterol The findings in each case are shown in Table II. The results are also shown of an analysis of significance carried out to compare the data obtained after 4, 8 and 12 weeks of treatment, and after withdrawal of treatment, with the control results before treatment (the mean of two duplicate estimations performed at intervals of one week). In each instance, the free and total cholesterol concentration during the period of treatment with Atromid and one week after withdrawing treatment differs significantly from the mean result before treatment, but the results obtained 4 weeks after stopping treatment show no significant difference from the control results. These findings are shown diagramatically in Fig. 1. For this purpose, the results obtained at each interval were expressed as a percentage of the mean control value for the individual. Thereafter the means of these percentage values were calculated with their standard errors. The analysis of significance again shows that the fall in serum free and total cholesterol concentration during the period of treatment is statistically significant, while the results after treatment fail to show any statistically significant difference from the control values.

Intravenous glucose tolerance tests The results after calculation as increment indices, with an analysis of significance, are shown in Table I I I . Although the mean increment index at each interval during

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J. Atheroscler. Res., 3 1963) 679-688

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EFFECT OF ATROMID IN DIABETES MELLITUS TABLE III INTRAVENOUS GLUCOSE TOLERANCE TESTS IN 8 DIABETICS TREATED WITH ATROMID

Increment ,ndices* Case No.

during and after treatment w#h Atromid** (weeks) before treatment

8

4

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1.96 1.64

1.93 3.16

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1.36 1.50

-2.34

2.02 1.74

1.27 2.42

1.07 2.06

1.21 1.84

5

1.84 1.41 3.64 0.90

1.73 1.36 3.59 1.38

1.47 2.07 1.94 1.44

1.90

1.70

1

Diet only 6 7 8

Mean S.E.

1.21 1.58 2.30 1.56

3.49 1.18

1.18 --

1.38

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2.78 0.67

2.42 1.49

1.75

2.08

1.89

2.17

1.71

1.92

0.28

0.07 0.84 0,5-0.4

0.16 0.58 0.6-0.5

0.37 1.34 0.3-0.2

0.27 0.29 0.8-0.7

0.25 0.65 0.6-0.5

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Fig. 1. Changes in serum flee and total cholesterol concentrations during and alter treatment with A t r o m i d . The v a l u e s shown r e p r e s e n t t h e m e a n of i n d i v i d u a l c h a n g e s i n t u r n e x p r e s s e d as a ' p e r c e n t a g e of t h e m e a n v a l u e s o b t a i n e d before s t a r t i n g t r e a t m e n t .

J. Atheroscler. Res., 3 (1963) 679-688

684

s . C . HERRIOT, I. W. PERCY-ROBB, J. A. STRONG, C. G. THOMSON

treatment with Atromid was slightly greater than the mean of two control values, these differences were not statistically significant when the data obtained from all 8 patients were calculated together. T

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Fig. 2. Changes in increment index of 8 patients during a n d after t r e a t m e n t with Atromid. The values shown represent the m e a n of individual changes in t u r n expressed as a percentage of the m e a n values obtained before starting treatment. 20C

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16 1 21 0.4- 0.3

Fig. 3. Changes in increment index of 4 patients (cases Nos. 1-4) during and after t r e a t m e n t with Atromid. These 4 patients remained on t r e a t m e n t with chlorpropamide before and t h r o u g h o u t the study. The values shown represent the m e a n of individual changes in t u r n expressed as a percentage of the m e a n values obtained before starting treatment.

J. Atheroscler. Res., 3 (1963) 679-688

EFFECT OF ATROMID IN DIABETES MELLITUS

685

These findings have also been expressed as a percentage of the mean initial value for each patient, and the means and standard error for the entire group of 8 patients at each time interval were then calculated. The findings are shown in Fig. 2, and it ,-p I

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Fig. 4. C h a n g e s in i n c r e m e n t i n d e x of 4 p a t i e n t s (cases Nos. 5-8) d u r i n g a n d after t r e a t m e n t w i t h A t r o m i d . T h e s e 4 p a t i e n t s received d i e t a r y t r e a t m e n t o n l y for t h e i r d i a b e t e s before a n d t h r o u g h o u t t h e s t u d y . T h e v a l u e s s h o w n r e p r e s e n t t h e m e a n of i n d i v i d u a l c h a n g e s in t u r n e x p r e s s e d as a p e r c e n t a g e of t h e m e a n v a l u e s o b t a i n e d before s t a r t i n g t r e a t m e n t .

is apparent that the mean percentage increase in the increment index at each time interval failed to differ significantly from the mean initial value. Inspection of the data however suggested that the changes in the increment index tended to be greater in the 4 patients treated with chlorpropamide and by diet than in the 4 patients treated b y diet alone. The findings and the analysis of significance of each of these two groups are shown in s u m m a r y form in Figs. 3 and 4. It m a y be noted however that in one instance only, namely after 8 weeks treatment in the 4 patients receiving chlorpropamide, is the difference statistically significant.

DISCUSSION

Serum cholesterol

These limited studies in a small group of stable diabetics, none of whom required insulin, show that both free and total serum cholesterol concentrations can be reduced by treatment with Atromid just as has been shown in non-diabetic hypercholesterolaemic patients 4. The two groups of patients studied, namely those receiving and those not receiving chlorpropamide, while adequately matched in other respects, were not well matched J. Atheroscler. Res., 3 (1963) 679-688

686

S . C . HERRIOT, I. W. PERCY-ROBB, J. A. STRONG, C. G. THOMSON

so far as their initial serum cholesterol concentrations were concerned. The percentage fall in serum cholesterol was greater in those patients receiving chlorpropamide, but this m a y have been because the mean initial serum free and total cholesterol concentration in this group of patients (Table I) was greater than in the group of patients treated b y diet alone. Since the fall in serum cholesterol tends to be greater when the initial concentration is high, the differences in the response to treatment by these two groups of patients m a y have been due to factors caused by the method of selecting the patients for study. The possibility also exists that patients requiring chlorpropamide as treatment have higher serum cholesterol concentrations than those responding to treatment b y diet alone, or further, that treatment with chlorpropamide might raise the serum cholesterol concentration.

Glucose tolerance The method chosen of testing glucose tolerance was selected because it seemed more likely to reveal small changes in carbohydrate tolerance than might have been shown b y other methods. Further, the increment index provides a numerical expression for glucose tolerance which could be used in comparative tests. Most of the data obtained in this study were also analysed by the method described b y LUNDBAEK 9, but comparison of the results did not indicate that this was greatly superior to the increment index. The differences, apparent in Figs. 3 and 4, suggest that some form of synergism exists between chlorpropamide and Atromid, but cannot be accepted as established on the basis of these data. The changes found in the 4 patients receiving chlorpropamide were statistically significant after 8 weeks only. When the glucose tolerance tests were analysed b y the method of LUNDBAEK 9, the differences in the same group of patients were statistically significant after 12 weeks treatment with Atromid (0.05 > P > 0.02). Examination of the correlation between the percentage fall in the total serum cholesterol concentration and the percentage rise in the k index described by LIINBBAEK9 at various intervals during treatment gave a correlation coefficient of ~0.084 for 29 pairs of observations. I t thus appears unlikely that the effects of Atromid on the serum cholesterol concentration and on carbohydrate tolerance are in any way closely related.

Side effects No untoward effects were noted b y these patients during the period of treatment with Atromid, with the exception of one patient (case No. 3) who required admission to hospital for the treatment of acute glaucoma. She continued treatment with Atromid, and it was generally felt that the glaucoma and her treatment with Atromid were unlikely to be causally related. I t will be seen from Table I that 5 of the 8 patients studied gained weight during the period of treatment. No oedema was noted in these patients, and the nature of the gain in weight is not known. I t is possible that this was due to water retention J. Atheroscler. Res., 3 (1963) 6 7 9 - 6 8 8

EFFECT OF ATROMID IN DIABETES MELLITUS

687

only, or it m a y have been due to an increase in adipose and other tissue. OLIVER10 noted considerable gains in weight in patients under treatment with Atromid. In view of its implications for the patient with incipient cardiac failure, and for the diabetic patient, the nature of this gain in weight obviously merits further investigation. SUMMARY

Eight "maturity-onset" female diabetics stabilised on treatment b y diet alone or with the addition of chlorpropamide have been studied before, during and after treatment with Atromid in a dose of 2.25 g daily given for a period of 12 weeks. The serum free and total cholesterol concentration and the increment index determined b y an intravenous glucose tolerance test were examined twice at intervals of one week before treatment, at intervals of 4, 8 and 12 weeks from the start of treatment and at intervals of 1 and 4 weeks after treatment had been withdrawn. Significant reductions in the concentration of free and total serum cholesterol were noted during treatment. The mean increment index rose during treatment, to a greater extent in those patients treated with chlorpropamide and diet than in those treated b y diet alone. No untoward side effects attributable to the drug were noted. The effects of Atromid on the diabetic state in the type of patient described in this study should present no obstacle to the administration of the drug to similar patients if its use is considered to be indicated on other grounds. The nature of the gain in weight occurring in some patients treated with this drug requires further study. R~SUM~ Huit femmes chez qui les accidents diab~tiques avaient commenc~ au d~but de la maturitd, stabilisdes par le r6gime avec ou sans supplement de ehlorpropamide, ont dtd observ~es avant, pendant et apr~s traitement par l'Atromide, administrd pendant une p~riode de 12 semaines h la dose de 2.25 g par jour. La teneur du s~rum en cholesterol fibre et total et l'indice d'augmentation d~termind par un test de toldrance au glucose intraveineux ont ~t~ examines deux fois 5. des intervalles d'une semaine avant, ~ des intervalles de 4, 8 et 12 semaines ~ partir du d~but, et ~ des intervalles de l ~ 4 semaines apr~s arr~t du traitement. On a notd de significatives r~ductions des taux du cholestdrol s~rique total et fibre pendant le traitement. L'indice de l'augmentation moyenne a atteint chez les sujets soumis au r~gime plus chlorpropamide un chiffre plus ~l~v~ que chez ceux trait~s par le r~gime seul. I1 n'a pas dt6 constat6 d'effets secondaires nuisibles qui seraient dus au m6dicament. Les effets de l'Atromide sur l'6tat diab6tique pr6sentent chez le type de malade d6crit dans cette 6tude, ne sauraient mettre obstacle ~ l'administration de la drogue des sujets semblables quand son emploi paralt ~tre indiqu6 sur d'autres bases. J. Atheroscler. Res., 3 (1963) 679-688

688

S . C . HERRIOT, I. W. PERCY-ROBB, J. A. STRONG, C. G. THOMSON

L a n a t u r e de l ' a u g m e n t a t i o n d u poids qui s u r v i e n t chez quelques sujets trait4s p a r cette drogue d e m a n d e des 4tudes prolong4es.

ZUSAMMENFASSUNG

A c h t F r a u e n m i t sp~tt a u f t r e t e n d e r Diabetes, die m i t t e l s einer B e h a n d l u n g von ausschliesslich Di~t oder Digit plus C h t o r p r o p a m i d stabilisiert waren, w u r d e n vor, w ~ h r e n d u n d n a c h der B e h a n d l u n g m i t einer Tagesdosis von 2.25 g A t r o m i d , 12 W o c h e n lang b e o b a c h t e t . Die freie u n d die G e s a m t c h o l e s t e r i n - K o n z e n t r a t i o n im S e r u m u n d der d u r c h eine intraven6se G l u k o s e - T o l e r a n z t e s t b e s t i m m t e Z u n a h m e i n d e x w u r d e n zweireal geprtift: in I n t e r v a l l e n von einer W o c h e v o r der B e h a n d l u n g , von 4-, 8- u n d 12-w6chentlich a b Beginn der B e h a n d l u n g , u n d in I n t e r v a l l e n von 1 u n d 4 W o c h e n n a c h B e e n d i g u n g der Behandlung. Signifikante V e r m i n d e r u n g e n in der K o n z e n t r a t i o n des freien u n d G e s a m t c h o l esterins im S e r u m w u r d e n wAhrend der B e h a n d h m g notiert. Der m i t t l e r e Z u n a h m e i n d e x stieg w~thrend der B e h a n d l u n g bei P a t i e n t e n die ausser der Digit auch Chlorp r o p a l n i d b e k a m e n mehr, als bei denen die n u r auf Di~t angewiesen waren. Keine, d e m Mittel z u s c h r e i b b a r e n ungtinstigen N e b e n w i r k u n g e n w u r d e n b e m e r k t . Der Effekt von A t r o m i d auf den d i a b e t i s c h e n Z u s t a n d bei d e m hier beschriebenen P a t i e n t e n t y p u s sollte die V e r a b r e i c h u n g des Mittels an Xhnliche P a t i e n t e n n i c h t beeintr~chtigen, wenn seine A n w e n d u n g aus a n d e r e n Griinden indiziert ist. Die bei einigen m i t diesem Mittel b e h a n d e l t e n P a t i e n t e n a u f t r e t e n d e Gewichtsz u n a h m e erfordert weiteres S t u d i u m . REFERENCES 1 S. WARREN AND P. M. LE COMPTE, The Pathology of Diabetes Mellitus, Lea and Febiger, Philadelphia, 1952, p. 129. 2 j. M. THORP AND W. S. WARING, Nature, 194 (1962) 948.

3 j. M. THORP, Lancet, i (1962) 1323. 4 M. F. OLIVER, Lancet, i (1962) 1321. 5 R. L. SEARCY AND L. M. BERGQUIST, Clin. Chim. Acta, 5 (1960) 192.

6 D. H. A. BOYD, B. CLAPP AND M. FINNEGAN,Brit. J. Cancer, 16 (1962) 577. 7 D. KEILIN AND E. F. HARTREE, B,ochem. J., 42 (1948) 230. s L. J. P. DUNCAN, Quart. j . Exptl. Physiol., 41 (1956) 85. 9 K. LUNDBAEK, Br,t. Med. J., i (1962) 1507. 10 M. F. OLIVER, J. Atheroscler. Res., 3 (1963) 427. J. Atheroscler. Res., 3 (1963) 679-688