DPP-4 Inhibitors and Acute Myocardial Infarction:Effects on Platelet Function

DPP-4 Inhibitors in Patients With Type 2 Diabetes and Acute Myocardial Infarction:Effects on Platelet Function

Cardiovascular events are the main cause of mortality in diabetic patients ,on the other hand,during an acute myocardial infarction(AMI),hyperglycemia increases mortality and is related to different pathophysiologic processes. More important evidence regarding the effect of glycemic control on AMI patients prognosis is contradictory,and the potential benefits of dipeptidyl peptidase-4 inhibitors(DPP4-i) in this setting is unknown. The aim of this study is to assess the presence of pleiotropic effects of DPP4-i(sitagliptin or saxagliptin) and their relationship with glycemic control during in-hospital phase of AMI.

Randomized clinical trial,double-blinded,placebo-controlled, in a single center, to assess the influence of DPP4-i on platelet aggregability in type 2 diabetic patients with acute myocardial infarction in use of dual anti platelet therapy (DAPT) . Others exploratory analysis include:glycemic control ,infarct size,genetic analysis and cholesterol metabolism. After giving signed informed consent,eligible subjects will be randomly allocated to receive saxagliptin or placebo, in the first 48 hours (+-24) after the beginning of an AMI. The investigator and subjects will be blinded to trial treatment,and a person not involved in trial conduct will prepare the doses of study drug.The doses will be administered by mouth,in a once daily basis by the investigator. Blood samples will be collected by the investigator according to pre-specified outcomes and time frames. Evaluation of glycemic control by CGM will be carried out by the investigator,including insert and withdrawal of the device. Treatment of the acute event,(AMI) will be done according to routine procedures from coronary care unit. Serious adverse event report taking into consideration all-cause mortality, cardiovascular mortality, hospitalization for heart failure and pancreatitis, will be done according to presence of these events.

diabetes mellitus, platelet function testing, acute coronary syndromes, saxagliptin, sitagliptin, dpp-4 inhibitors

Use of DPP4-i : sitagliptin 50 mg (if glomerular filtration rate-GFR <50 ml/min at randomization) or 100 mg (if GFR>50 ml/min at randomization),during 30 days,once-daily(OD) OR saxagliptin 2,5 mg (if glomerular filtration rate-GFR <50 ml/min at randomization) or 5 mg (if GFR>50 ml/min at randomization),during 30 days,once-daily(OD)

placebo tablets identical to active comparator,administered according to GFR at randomization,during 30 days,OD

sitagliptin OR saxagliptin tablets, 48(+-24) hours after the beginning of an AMI,and both arms in use of dual anti-platelet therapy (DAPT) .

placebo tablets, 48(+-24) hours after the beginning of an AMI,and both arms in use of dual anti-platelet therapy (DAPT) .

Comparison on platelet function between two therapeutic arms in a double-blind randomized fashion. Platelet aggregability will be measured 4(+-2) days after drug exposure,using a point-of-care test (VerifyNow Aspirin) in type 2 diabetic patients with AMI on dual antiplatelet therapy (ASA+ ticagrelor or clopidogrel according to institutional routine).

changes in glycemic control(glycemic variability assessed by standard deviation(SD) of capillary glucose samples).

Evaluated by measurements of capillary glucose samples by point-of care test during the length of coronary care unit(CCU) stay( expected average of 1 week).The glycemic variability will be obtained by calculating the standard deviation(SD).

changes in glycemic control(glycemic variability assessed by continuous glucose monitoring system - CGM).

Changes on platelet aggregability will be compared on pre-specified subgroups: elderly (age >65 yrs-old) versus non-elderly; male versus female; smoking versus non-smoking patients; obese(BMI>30 Kg/m2) versus non-obese; length of diabetes; baseline glucose; glycated hemoglobin(HbA1c) < 9% and >9 %

Rate of capillary glucose <70 mg/dL and <40 mg/dL,evaluated by capillary glucose measurements by point-of-care tests,during CCU stay(expected average of 1 week).

Comparison of the total requirement of correctional insulin between treatment and control arms after drug exposure.

Comparison the incidence of composite end-point between two arms.Composite end-point include: cardiovascular death; unstable angina; stroke ; hospitalization for heart failure; new non fatal myocardial infarction ; coronary revascularization .

Analysis of infarct size between two arms, by peak of creatine kinase(CK-MB) during CCU stay(expected average of 1 week).

Number of participants with adverse effects by analysis on changes of serum level of : alanine transferase; brain natriuretic peptide(BNP); amylase; lipase.

Inclusion Criteria: previous diagnosis of type 2 diabetes mellitus,with treatment including insulin and/or oral antidiabetic agent; subjects without previous diagnosis of diabetes,but HbA1c admission >= 6,5% during current hospital-stay AMI with or without ST-elevation; use of double antiplatelet therapy; signed informed consent term Exclusion Criteria: GFR <30 ml/min; use of DPP4 inhibitors or glucagon- like peptide-1(GLP1) analogue in the past 6 months; use of strong inhibitors of cytochrome P450(CYP3A4/5) ou glucocorticoids; severe systemic decompensation requiring insulin infusion; Killip classification of myocardial infarction grade >2; previous history of pancreatitis

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