The Effect of Metformin and Glimepiride on Platelet Count and Indices Among Diabetic Patients Attending Jaber Abu Aliz Diabetic Center in Khartoum State

detect the effect of two on platelet and indices platelet PLCR large cell


Results
The results showed that both types of treatment have reduced platelets indices but the reduction in Glimepiride was insigni cant except in PDW when compared with control. Also both have no effect on platelet count. Both treatments have insigni cant variation on measured parameters when considering age, gender, dose and treatment duration though signi cant variation in Glimepiride study population was detected due to associated complications and HbA1C level.

Conclusion
It is concluded that both types of drugs reduce platelet indices which have a good prognostic effect on the Pro-thrombotic state and accelerated atherosclerosis which is associated with type 2 Diabetic patients. Metformin have better effect on platelet indices than Glimepiride. Further case control trails are required.
Background DM is a chronic disease characterized by increased blood glucose level (1) . Approximately 90-95% of diabetic patients are type 2 DM which is caused by insulin resistance (2) . Chronic complications of DM are vascular or nonvascular. Vascular complications are further subdivided into macro vascular (coronary artery disease, peripheral vascular disease, and cerebrovascular disease) or micro vascular (retinopathy, neuropathy, and nephropathy) (2,3) .
Automated blood counters rapidly measure Platelet count and indices (MPV, PDW, and P-LCR) which are features of platelet activation. MPV (Mean platelet volume) determine the platelet volume and reported by analyzing the platelet distribution curve, PDW (platelet distribution width) is an indicator for variation in the platelet size and it is calculated at 20% relative height in platelet size distribution curve. P-LCR (platelet-large cell ratio) is discriminate of the circulating larger platelets (> 12 fL), which is measured by xed discriminator at12 fL and reported as percentage (4) .
The platelets have important roles in normal homeostasis and atherosclerosis process (5,6) . MPV is increased in patients at a high risk for athero-thrombotic diseases (7) . DM has been considered as a 'pro thrombotic state' with increased in thrombocytes reactivity (8,9) . MPV is increased in patients with type 2 DM (10) Researchers also found that PDW and PLCR were all increased in diabetic patients. PDW was decreased in those without complications in contrast to those with micro vascular complications of DM (11) . An increased MPV is a risk marker for platelet activation (7) .
However, whether oral hypoglycemic drugs (Metformin and Glimepiride) can effectively prevent thrombosis or reduce Micorvascular and Macrovascular complications or not currently, there is no available study on the effect of diabetes mellitus hypoglycemic drugs on platelets count and indices among Sudanese population.
This study was conducted to explore the effect of diabetes mellitus treatments (Metformin and Glimepiride) on platelet count and indices (MPV, PLCR, PDW).Beside the effect of Age, sex, dose and duration of the drug used, associated complications, HbA1C level were also explored.

Methods
A cross-sectional descriptive study was carried out on a group of 96 Sudanese patients diagnosed with Type 2 diabetes, 50 under Metformin and 46 under Glimepiride treatment who attended Jaber Abu Aliz Diabetic Center in Khartoum State during the period of 6 months from March to September 2020 .An age, and sex-matched control group consisting of 50 healthy control were also tested. Excluding Non-Sudanese ,Subjects with renal failure, cancer, hepatic ,malaria infected or treated patients in last 7days, hematological disorders, pregnancy and a history of drug used affect platelets count or indices (aspirin, warfarin, heparin, statin, anticoagulant medications) and those younger than 18 years were excluded from the study.
Approvals have been taken from Khartoum State Ministry of Health Research Department, and verbal consent has been taken from each participant volunteer. The samples have collected from participants under COVID 19 outbreak Precautions by administered written questionnaire.
On 5 ml EDTA anticoagulated venous blood sample, platelet count and indices were measured by automatic blood counter (Sysmex KX-21N) for type2 DM patients and controls, and also HbA1C was measured by Ichroma II for DM patient's blood samples.

Result
The mean, standard deviation and P-value of the measured platelet count and indices of the study population and compared with the control group are shown in table (1).   Statistically insigni cance difference was detected on platelet count between patients took Metformin, Glimepiride and healthy controls. Both drugs have reduced platelet indices (MPV, PLCR, PDW) when compared with the control group but platelet indices were much more reduced in patients using Metformin than those taking Glimepiride as oral hypoglycemic drug as shown in (Table 1).
There was insigni cant difference in platelet count and indices among those using Metformin in term of sex, age, dose, drug duration, associated complications and HbA1C level as shown in (Table 2). But among those using Glimepiride as oral hypoglycemic drug, there was increased platelet count and decreased platelet indices in patients with foot ulcers than patients without complications. Also increased platelet indices in patients with HbA1C level less than 6% in contrast to those with HbA1C more than 7%.
Glimepiride diabetic patients from 15 to 20 years old have increased platelet count (488.7) than patients used Glimepiride less than 15 years (247.3), less than 10 years (298.3) and less than 5 years (285.7).
There was insigni cant difference in term of age, gender, and dose in Glimepiride users as shown in (Table 3).

Discussion
A patient with DM has accelerated atherosclerosis (12,13) . The interference effects of oral hypoglycemic drugs (Metformin, Glimepiride) on the platelet count and indices are very important because platelets have direct impact in the pro thrombotic condition which characterizes patients with DM. Platelets of DM patients are characterized by problems in regulation of several signaling pathways leading to the acceleration of adhesion, activation and aggregation (13) . Thus, Platelet count, MPV, P-LCR and PDW were measured as a marker of production rate and platelet activation.
Both Metformin and Glimepiride have been found to have anti-thrombotic effect. Metformin has more anti thrombotic effect than Glimepiride. Patients used Metformin have reduced platelet indices when compared with Glimepiride and non-diabetic population. Diabetes Mellitus DM by exert a favorable effect on platelet function (16) .
The mechanism that Metformin inhibits the platelet activation is described by Xin et al., they found Metformin prevent platelet activation by inhibiting extracellular mitochondrial DNA (mtDNA) release (17) .
Regarding Glimepiride mechanism of preventing thrombosis is reported by Yukio et al. they found that cyclooxygenase pathway is inhibited by Glimepiride, while the activities of 12-lipoxygenase and phospholipase A2 were unaffected thus, prevent the formation of thromboxane A2 from Arachidonic acid metabolism of human platelets .The main function of thromboxane A2 is platelet activation and aggregation (18) .
we compared different DM Patients groups using Glimepiride and Metformin according to (age, sex, dose, associated complications, duration of drug used, Hb A1C level), stable anti thrombotic effect was found among Metformin users because there were no signi cant differences in platelet count and indices (MPV, P-LCR and PDW) in term of above prescribed variables in contrast of Glimepiride which has variable a favorable anti thrombosis effect.
Mardia et al. found a high platelet count, PDW and PCT levels in DM patients with diabetic foot ulcers in contrast to DM patients without diabetic foot ulcers. It indicates that platelets are activated and increased its ability for aggregation (19) . In our ndings Patients with diabetic foot using glimepiride showed high anti thrombotic effect with relatively increased platelet count and deceased indices than patients without complications. These results may explain that Glimepiride is not a drug of choice during diabetic foot complications when compared to Metformin because regardless the high platelet counts, platelet inactivation is insu cient.
BackSterner et al. found that increased platelet counts are a common nding in DM patients with nephropathy (20) . The in vivo generation of advanced glycation end products (AGEs) in the kidney is time dependent reported by Soulis et al. (21) . they supported our nding regarding increased platelet count in DM patients used Glimepiride for more than 15 to 20 years.
Our results showed that platelet indices were decreased in patients with HbA1C more than 7% and increased in the patients with HbA1C less than 6%. Singer et al. they found that Long termed uncontrolled DM type2 patients even after Intensive glycemic control didn't seem to have decreased platelet activation which characterized DM (22) .Kodiatte et al. Reported that DM Patients have MPV positively correlated with HbA1c (23) which is contradicted with our ndings because we have patient's glycemic control history just for the last 3 months not for entire drug using period which is a limitation in our study.

Conclusion
Increased Platelet indices (MPV, PLCR, and PDW) are signs of platelet activation and aggregation which play important role in the Prothrombatic state and accelerated atherosclerosis which characterize Diabetic type 2 patients .They were reduced among an oral hypoglycemic study group (Metformin and Glimepiride) than a non-diabetic population so Metformin and Glimepiride has good prognostic effect on the known Pro thrombatic state and accelerated atherosclerosis of DM but this effect were much more reduced among those using Metformin than patients taking Glimepiride as an oral hypoglycemic drug .
Also we concluded the platelet activation signs (increased MPV, PLCR and PDW) were reduced among those using Glimepiride with associated foot complications and platelet activation is important factor in wound healing in contrast to those taking Metformin. In other words Glimepiride is not drug of choice during diabetic foot Ulcers. Metformin is better for use during diabetic foot ulcers. However these results need further case control trails.