Rosiglitazone belongs to a category of drugs referred to as thiazolidinesdiones which are antidiabetic drugs. They enhance the response of tissues to insulin ( Rang, Dale & A ; Ritter, 1999 ) .This drug is used to handle type two diabetes mellitus and it is presently being marketed by GlaxoSmithKline. Rosiglitazone is an agonist ( drugs that activate receptors by bring forthing a conformational alteration to the receptors ) which acts on peroxisome proliferator activated receptor I? ( PPAR-I? ) . The map of this receptor includes cistron look transition, blood glucose decrease as a consequence of increased sensitiveness for insulin in the peripheral tissues ( Vamecq & A ; Latruffe, 1999 and Campbell, 2005 ) .
Type 2 diabetes is increasing in prevalence. Mortality from cardiovascular disease ranges from two crease to eight crease higher in people with diabetes compared to those without diabetes ( Lago, Singh & A ; Nesto, 2007 ) . There have been controversial articles written about the increased hazard of myocardial infarction associated with rosigligtazone. These article will be looking at grounds provided from cardinal randomised clinical tests and experimental surveies with respects to the cardiovascular safety of rosiglitazone.
Clinical Trial Data
Three cardinal surveies were identified during literature testing. These surveies included ADOPT, RECORD and DREAM tests which are discussed below:
ADOPT [ A Diabetes Outcome Progression Trial ] ( Viberti et al. , 2002 )
This survey was a prospective randomised controlled test that was developed to compare the efficaciousness of rosiglitazone, gylburide and Glucophage, three antidiabetic agents that are presently available as first line intervention of type 2 diabetes with respects to their glucose control, I?- cell map and cardiovascular hazard. The survey population was aged between 30-75 old ages diagnosed with type 2 diabetes within 3 old ages of survey showing. The survey design comprises of a pre-screening stage, testing stage, a tally in period which was four hebdomads and a intervention period of 4 old ages. This survey showed that the rate of congestive bosom failure associated with rosiglitazone as compared to metformin was similar ( at 95 % assurance interval 0.66, 1.38, the jeopardy ratio was 0.96 ) and the rate of congestive bosom failure associated with rosiglitazone as compared to gylburide was higher ( statistically important ) at 95 % Confidence interval 0.78, 1.73, the jeopardy ratio was 1.16 ( Kahn et al. , 2006 ) .
Study Limitation:
Kahn et Al ( 2006 ) did province that the “ survey was non designed to measure cardiovascular disease outcomes as the protocol excluded patients with known history of congestive bosom failure ” ( p2440 ) . At the terminal of this test, bosom failure was the lone result that was reviewed and besides the survey was limited by the backdown rate.
RECORD [ The Rosiglitazone Evaluated for Cardiac Outcomes and Regulation of Glycaemia in Diabetes ] ( Home et al. , 2007 )
This survey was conducted in response to a recent meta analysis by Nissen & A ; Wolski ( 2007 ) who raised concern about the increased hazard of myocardial infarction and decease from cardiovascular causes linked to rosiglitazone usage in the intervention of type 2 diabetes. This survey was a randomized, multicenter unfastened label noninferiority test in which patients with type 2 diabetes with unequal glucose control with Glucophage or sulfonylurea entirely where indiscriminately allocated rosiglitazone or combination of Glucophage or sulfonylurea. The primary result of this survey was hospitalization or decease from a cardiovascular cause. The survey population included patients with age runing from 40 to 75 old ages affecting patients with type 2 diabetes. This revealed that rosiglitazone was linked to a little non important addition in the hazard of the primary result. The jeopardy ratio was 1.08 ( 95 % assurance interval, 0.89 to 1.31 ) . Home et Al ( 2007 ) states that “ there was no statistically important difference between the rosiglitazone group and the control group for the secondary terminal points for acute myocardial infarction, fatal cardiovascular decease and shot ” ( p28 ) . The jeopardy ratio for fatal cardiovascular causes was 0.80 ( 95 % CI, 0.52 to 1.24 ) . These consequences were indispensable in replying the Nissen & A ; Wolski safety analysis concern ( Home et al, 2007 ) .
Study Restrictions
The fact that the test was unfastened label was a restriction. The survey drug randomization was non concealed. In add-on, the primary result compositing all hospitalizations and deceases from a cardiovascular cause was a weak pick for the survey design.
DREAM TRIAL [ Diabetes Reduction Assessment with Altace and rosiglitazone medicines ] ( Dagenais, 2008 )
This survey looked at the consequence of Altace and rosiglitazone on the cardiovascular and nephritic results in people with hampered glucose tolerance or hampered fasting glucose. Both impaired glucose tolerance and impaired fasting glucose are risks factors for cardiovascular disease and kidney disease. The survey population included patients age greater than or less than 30 old ages of age with stated hazard factors above but do non hold cardiovascular disease or nephritic disease. These patients were randomised to have either Altace versus placebo and or rosiglitazone versus placebo. This survey revealed that rosiglitazone did non cut down the overall hazard of cardiovascular disease but significantly increased the hazard of bosom failure. The jeopardy ratio was 7.04 [ 95 % Confidence interval 1.60 to31.0. This addition in hazard is non statistically important ( Dagenais, 2008 ) .
Experimental Studies Data
A figure of experimental surveies runing from cohorts to meta analysis were identified during literature testing refering to rosiglitazone and increased hazard of cardiovascular events and rosiglitazone supplying a protective consequence with longer usage. A few of the findings of these articles will be discussed below get downing with the Nissen and Wolski article which started the contention.
Consequence of Rosiglitazone on the hazard of myocardial infarction and decease from cardiovascular result ( Nissen & A ; Wolski, 2007 )
These writers perform a meta analysis of 42 clinical tests undertaken by marketing mandate holders. The writers searched published literature, Food and Drug Administration web site and clinical test register looked after by GlaxoSmithKline. Inclusion standards in the analysis included surveies with more than 24 hebdomads continuance and usage randomised control groups non having rosiglitazone and result day of the month for both myocardial infarction and decease from cardiovascular causes. The average age of patients was 56 old ages. Overall, there were 86 myocardial infarctions in the rosiglitazone group and 72 myocardial infarctions in the control group. 39 deceases from cardiovascular causes in the rosiglitazone and 22 in the control group were reported. This survey revealed that rosiglitazone group compared to the control group had an uneven ratio for myocardial infarction as 1.43 ( 95 % assurance interval, 1.03 to 1.98 ) . The uneven ratio for decease from cardiovascular causes was 1.64 ( 95 % assurance interval 0.98 to 2.74 ) . These consequences showed that rosiglitazone has a statistically important addition in hazard of myocardial infarction and besides an increased for decease from cardiovascular causes ( Nissen & A ; Wolski, 2007 ) .
Study Restrictions:
Information from all surveies available was non included in this survey. Surveies which did non describe myocardial infarction were non included in the Nissen survey which did non organize portion of the follow activities. Inclusion of the surveies describing myocardial infarction will decrease the magnitude of increased association between rosiglitazone and myocardial infarction reported. This survey most significantly did non hold entree to the beginning informations for 42 surveies analysed hence analysis was made on table degree informations made available by the company ( Margolis, Hofstad & A ; Strom, 2008 ) .
Long term hazard of cardiovascular events with rosiglitazone- a meta-analysis ( Singh, Loke & A ; Furberg, 2007 )
The writers of this article performed a systematic reappraisal of long term cardiovascular hazard of rosiglitazone including myocardial infarction, bosom failure and cardiovascular decease. They searched MEDLINE, clinical test registry, FDA web site, GSK clinical tests registry. Inclusion standards included surveies affecting randomised test where rosiglitazone is used for bar or intervention of type 2 diabetes with at least 12 months of follow up. The consequence of this survey showed that rosiglitazone statistically significantly increased the hazard of myocardial infarction. The comparative hazard was 1.42 ( 95 % assurance interval, 1.06 to1.91 ) . There was a statistically important addition for bosom failure with rosiglitazone. The comparative hazard was 2.09 ( 95 % assurance interval, 1.52 to 2.88 ) . There was no important addition in the hazard of cardiovascular decease. The comparative hazard was 0.90 ( 95 % assurance interval, 0.63 to 1.26 ) . This survey showed that rosiglitazone usage for a period of 12 months is associated with a important hazard if myocardial infarction and bosom failure without a important addition hazard of cardiovascular decease ( Singh, Loke & A ; Furberg, 2007 ) .
Study Restrictions
There were limited informations from randomised control tests of rosiglitazone hence the hazard ratios were imprecise. The assurance intervals were broad due to the little Numberss. There was unavailable information on the clip to event informations for myocardial infarction and bosom failure which could impact the computation of the jeopardy ratio. In this survey it was hard to find if the harmful effects were immediate or a lag clip to injury was involved ( Singh, Loke & A ; Furberg, 2007 ) .
Coronary bosom disease results in patients having antidiabetic agents- ( McAfee et al, 2007 )
This cohort survey compared the hazard of myocardial infarction and coronary revascularisation in type two diabetic patients treated with rosiglitazone, Glucophage or sulfonylurea. Datas from a big US insurance company was used. Hospitalisation for myocardial infarction or coronary revascularisation was identified. The beginning population was derived from ingenix research database. The survey groups were divided into 3. The monotherapy survey group which involves patient on rosiglitazone, Glucophage or sulfonylurea in whom neither the survey drug nor insulin had been given in the predating six months and none of the 3 drugs named above or insulin have been dispensed within 30 yearss following the initial drug dispense. The double therapy survey group involves patient on rosiglitazone and Glucophage or rosiglitazone and sulfonylurea or Glucophage plus sulfonylurea in whom the same drug brace or insulin had non been used in the six months predating the first dispense of the 2nd drug administered in the brace. Last in the 3rd group, combination with insulin survey group, patients on rosiglitazone and insulin or other unwritten antidiabetic agents in whom the same drug combination had non been used in six months predating the first dispensing of the 2nd drug. The consequences showed that there was no difference between the hazards of composite result with rosiglitazone monotherapy compared to metformin monotherapy. The jeopardy ratio was 1.07, 95 % assurance interval was 0.85 to 1.34. In add-on, there was no difference between the hazards of the composite result with rosiglitazone monotherapy compared with sulfonylurea. The jeopardy ratio was 0.82, 95 % assurance interval was 0.67 to 1.02. ( McAfee et al. , 2007 ) .
Study Restrictions
The statistical power of the survey was limited by the rareness of the results peculiarly in combination with insulin cohorts. In add-on, there were few aged patients in this survey population which may impact the ability to generalize the consequences to the aged ( McAfee et al. , 2007 ) .
Decision
In reexamining the information from the randomized clinical test surveies above ( ADOPT, DREAM and RECORD ) , the informations for ADOPT suggested that there was no statistically significance difference with respects to congestive bosom failure between rosiglitazone and Glucophage but significance addition was associated with rosiglitazone when compared to gylburide. As stated antecedently, this survey was non design to mensurate cardiovascular events and the lone focal point was on bosom failure. In footings of bosom failure, this drug is associated with a little hazard of bosom failure which is shown across all surveies. The DREAM test showed that rosiglitazone did non cut down the overall hazard of cardiovascular event as stated antecedently but an addition hazard of bosom failure was identified. Type 2 diabetes is a contradictory factor for cardiovascular disease hence this patients are predispose to cardiovascular events.
The RECORD test as documented by Home et Al ( 2007 ) showed that rosiglitazone was linked to a “ little non important addition ” with respects to its primary result ( hospitalization for cardiovascular events ) and there was no statistically important addition between rosiglitazone and the control group for the secondary terminal points ( myocardial infarction and cardiovascular deceases ) as opposed to meta analysis of 42 clinical tests reported by Nissen and Wolski ( 2007 ) and Singh et al. , ( 2007 ) who both commented on the important addition of myocardial infarction and bosom failure associated with rosiglitazone. Nissen and Wolski ( 2007 ) and Singh et al. , ( 2007 ) both differ with respects to cardiovascular mortality. Nissen and Wolski reported an addition in hazard while Singh et Al reported a non important addition hazard in cardiovascular mortality. McAfee et al. , ( 2007 ) consequences shows that there was no important addition in hazard and suggested a protective action for rosiglitazone.
All this surveies had assorted restrictions as stated antecedently, in my position, rosiglitazone is likely associated with increased bosom failures but non adequate grounds has been provided with respects to cardiovascular mortality as the studies are conflicting therefore each patient ‘s safety profile should be assessed before administrating rosiglitazone and drug backdown is non supported.
