Antiobesity and Antidiabetic β-agonists: Lessons Learned and Questions to be Answered

β3-Adrenergically induced glucose uptake in brown adipose tissue is independent of UCP1 presence or activity: Mediation through the mTOR pathway

Objective

Today, the presence and activity of brown adipose tissue (BAT) in adult humans is generally equated with the induced accumulation of [2-¹⁸F]2-fluoro-2-deoxy-d-glucose ([¹⁸F]FDG) in adipose tissues, as investigated by positron emission tomography (PET) scanning. In reality, PET-FDG is currently the only method available for in vivo quantification of BAT activity in adult humans. The underlying assumption is that the glucose uptake reflects the thermogenic activity of the tissue.

Methods

To examine this basic assumption, we here followed [¹⁸F]FDG uptake by PET and by tissue [³H]-2-deoxy-d-glucose uptake in wildtype and UCP1(−/−) mice, i.e. in mice that do or do not possess the unique thermogenic and calorie-consuming ability of BAT.

Results

Unexpectedly, we found that β₃-adrenergically induced (by CL-316,243) glucose uptake was UCP1-independent. Thus, whereas PET-FDG scans adequately reflect glucose uptake, this acute glucose uptake is not secondary to thermogenesis but is governed by an independent cellular signalling, here demonstrated to be mediated via the previously described KU-0063794-sensitive mTOR pathway.

Conclusions

Thus, PET-FDG scans do not exclusively reveal active BAT deposits but rather any tissue possessing an adrenergically-mediated glucose uptake pathway. In contrast, we found that the marked glucose uptake-ameliorating effect of prolonged β₃-adrenergic treatment was UCP1 dependent. Thus, therapeutically, UCP1 activity is required for any anti-diabetic effect of BAT activation.

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β₃-adrenergically glucose uptake in BAT is UCP1-independent.

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Glucose uptake is not secondary to thermogenesis but is through the mTOR pathway.

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Both glucose uptake and thermogenesis are needed to fully effect glucose homeostasis.

The rediscovery of BAT in adult humans using imaging

Human brown adipose tissue has been acknowledged in newborns and children but in adults the first printed publications are from the beginning of 20th century. Further evidence of the existence of adult brown fat was published throughout the century but only very recently the functionality of active brown adipose tissue in vivo in adulthood was confirmed. This was contributed mainly by advanced imaging technology, namely hybrid positron emission tomography (PET) and computed tomography (CT), being able to combine functional and anatomical imaging data. Functionality is most commonly measured with glucose analog, 18F-fluoro-2-deoxy-d-glucose (FDG) but other tracers for other functions than glucose uptake have been introduced as well. Growing body of evidence has increased the knowledge of the role of brown adipose tissue in human metabolism and energy expenditure, providing a promising option for the management of body weight balance and disturbed glucose and lipid metabolism.

Nitric oxide mechanisms of nebivolol

β-blockers are among the most widely used drugs in the prevention and treatment of cardiovascular disease, although they are associated with increased peripheral resistance. Third-generation β-blockers avoid this adverse effect by inducing vasodilation through different mechanisms. In particular, nebivolol, a highly selective blocker of β1-adrenergic receptors, is the only β-blocker known to induce vascular production of nitric oxide, the main endothelial vasodilator. The specific mechanism of nebivolol is particularly relevant in hypertension, where nitric oxide dysfunction occurs. Indeed, nebivolol is able to reverse endothelial dysfunction. Nebivolol induces nitric oxide production via activation of β3-adrenergic receptors, which can explain the good metabolic profile observed after treatment with this drug. Moreover, nebivolol can also stimulate the β3-adrenergic receptor-mediated production of nitric oxide in the heart, and this stimulation can result in a greater protection against heart failure. In conclusion, nebivolol has a unique profile among antihypertensive drugs, adding to a very high selectivity against β1 adrenergic receptors, and an agonist action on β3 receptors and nitric oxide (NO), which has led to clinically significant improvements in hypertensive patients.

Antiobesity pharmacotherapy in the management of type 2 diabetes

Obesity is a well-known risk factor for the development of Type 2 diabetes mellitus. The management of the obese diabetic patient remains a challenge for the clinician but, in any case, weight reduction should be considered as a key objective. In this respect, several antiobesity drugs have demonstrated potential. However, while fenfluramine and dexfenfluramine have been shown to promote weight loss and to directly improve insulin sensitivity, being two mechanisms contributing to better blood glucose control in obese Type 2 diabetic patients, they were recently withdrawn due to safety problems. Sibutramine, a new selective norepinephrine and serotonin reuptake inhibitor, promotes weight loss by decreasing food intake, an effect which leads to a mild improvement (significant in patients losing > or =5% of initial body weight) of blood glucose control in obese diabetic patients. Similarly, orlistat, a selective gastrointestinal lipase inhibitor which increases faecal fat losses, enhances diet-induced weight reduction and improves both blood glucose control and vascular risk profile, especially dyslipidaemia, in obese Type 2 diabetic patients. Further studies are required to better identify good responders to pharmacotherapy and specify the role of antiobesity agents in the overall long-term management of obese subjects with Type 2 diabetes. Other novel pharmacological approaches deserve further consideration, for instance beta-3 agonists aiming to increase energy expenditure, drugs interfering with tumor necrosis factor-alpha (TNF-alpha) or free fatty acid release by the adipose tissue or agents that slow gastric emptying. However, until now, results regarding efficacy and/or safety have been disappointing or preliminary in humans.

A beta-3 adrenergic agonist (BRL-37,344) decreases food intake

This study evaluated the effect of peripheral injections of a beta3 adrenergic agonist, BRL-37,344 on food intake and whether this inhibition could be blocked by a nonspecific beta-adrenergic antagonist, propranolol, given peripherally or into the central nervous system. When BRL-37,344 was injected intraperitoneally (i.p.) into lean and obese Zucker rats, food intake was decreased. The reduction of food intake by BRL-37,344 was attenuated when propranolol was administered i.p. prior to giving the beta adrenergic agonist. When propranolol was administered into the third cerebral ventricle, it increased food intake in lean rats, but not the fatty rats. Propranolol administered into the third cerebral ventricle attenuated the effect on food intake of i.p. injection of BRL-37,344. These studies support the hypothesis that there are peripheral beta-3 adrenergic receptors that can reduce food intake and that there are central beta2 or beta3 adrenergic receptors that mediate the peripheral effect of the beta3 agonist.

Effects on energy utilization of a beta3-adrenergic agonist in rats fed on a cafeteria diet

The antiobesity potential of a new beta3-adrenergic agonist (Trecadrine) was assessed in a cafeteria model of obesity through body composition, thermogenesis and oxygen consumption indicators. Animals fed on a cafeteria diet for 75 days increased body weight and fat content, while muscle mass as a percentage of body weight was reduced in relation to control fed rats. In addition, in vitro brown adipose tissue (BAT) and white adipose tissue (WAT) oxygen consumption was increased in these obese animals as compared with controls. Trecadrine administration reduced weight gain, BAT and WAT stores as well as the respiratory quotient, which was accompanied by an increase in WAT and BAT oxygen consumption and rectal temperature. Moreover, muscle mass as a percentage of body weight maintained the same values as non-obese animals, while an increase in absolute muscle weight was found in Trecadrine-treated obese rats. However, liver weights and in vitro oxygen consumption remained unaltered after cafeteria feeding and Trecadrine administration. Since chronic administration of Trecadrine had no effect on food intake, the stimulation of thermogenesis and oxygen consumption by the beta3-adrenergic agonist in white and brown adipose tissue are apparently responsible for the rise in energy expenditure as well as for the lower weight gain and fat deposition in obese treated rats. Thus, Trecadrine exhibits some promise as a potential treatment for obesity.

Biphasic effects of the beta-adrenoceptor agonist, BRL 37344, on glucose utilization in rat isolated skeletal muscle

1. The effects of the selective beta 3-adrenoceptor agonist, BRL 37344 (BRL) on glucose uptake and phosphorylation (i.e. glucose utilization; GU) and glycogen synthesis in rat isolated soleus and extensor digitorium longus (EDL) muscle preparations in vitro were investigated by use of 2-deoxy-[3H]-glucose (GU) and [U-14C]-glucose (glycogen synthesis). 2. Low concentrations of BRL (10(-11)-10(-9) M) significantly increased GU, with maximal increases of 30% in soleus and 24% in EDL at 10(-11) M. Neither the selective beta 1-adrenoceptor antagonist, atenolol (10(-8)-10(-6) M), nor the selective beta 2-adrenoceptor antagonist, ICI 118551 (10(-8)-10(-6) M) had any effect on the stimulation of GU induced by 10(-11) M BRL. 3. High concentrations of BRL (10(-6)-10(-5) M) caused significant inhibition (up to 30%) of GU in both soleus and EDL muscles. The inhibition of 10(-6) M BRL was blocked completely by 10(-6) and 10(-7) M ICI 118551 in soleus, and by 10(-6)-10(-8) M ICI 118551 in EDL; atenolol (10(-8)-10(6) M) had no effect. 4. Another selective beta 3-adrenoceptor agonist, CL 316,243, also caused a significant stimulation of muscle GU, with maximal increases of 43% at 10(-9) M in soleus and 45% at 10(-10) M in EDL. The stimulation of GU declined with further increases in the concentration of CL 316,243, but no inhibition of GU was seen, even at the highest concentration (10(-5) M) tested. 5. BRL at 10(-5) M inhibited completely insulin-stimulated glycogen synthesis in both soleus and EDL, but this inhibitory effect of BRL was abolished by 10(-6) M ICI 118551. BRL at 10(-11) M (with or without 10(-6) M ICI 118551) had no effect on insulin-stimulated glycogen synthesis. 6. It is concluded that: (i) low (< nM) concentrations of BRL stimulate GU via an atypical beta-adrenoceptor that is resistant to conventional beta 1-adrenoceptor and beta 2-adrenoceptor antagonists; (ii) the stimulation of GU is negated by the activation of beta 2-adrenoceptors that occurs at higher (> nM) concentrations of BRL; (iii) inhibition of GU via beta 2-adrenoceptor activation is associated with inhibition of glycogen synthesis, possibly due to activation of glycogenolysis; (iv) the opposing effects of beta 2-adrenoceptor and atypical beta-adrenoceptor activation on GU suggest that in skeletal muscle these adrenoceptors are linked to different post-receptor pathways.

Evaluation of drugs for treating obesity

Criteria for the evaluation of new drugs to treat obesity are important as guides for designing clinical trials to test these agents. These criteria must be developed in relation to the realities of obesity, which is a chronic disease associated with morbidity and mortality that is increased by visceral fat deposits. The observation that patients regain weight after stopping drug treatment for obesity argues for the proposition that drugs work only when taken and NOT that the drugs are ineffective. The analogy between the development of treatments for obesity to those for the treatment of hypertension is used to highlight potential areas for new developments. Several features of an ideal drug for the treatment of obesity are suggested. Criteria for evaluating new drugs include both primary and secondary endpoints. The primary endpoint for an anti-obesity drug should be weight loss, possibly by category of success. Losses of total body fat or visceral fat might be alternative primary endpoints. Secondary endpoints include reduction in risk factors for associated diseases and improvement in the quality of life. In trials where vigorous placebo designs including highly aggressive behavior modification or very-low-calorie diets were used, it may be difficult or impossible to detect a response to a drug.

Beta-agonists as antiobesity, antidiabetic and nutrient partitioning agents

In the past decade, the antiobesity, antidiabetic and nutrient partitioning activities of beta-agonists have been extensively studied. The data generated from these compounds in experimental and farm animals have convincingly proved that body fat content and body weight can be modified to some degree by a metabolic agent without decreasing food consumption. Marginal antiobesity and antidiabetic activities in humans have been demonstrated with a few mixed beta-agonists under certain conditions, but their utility is limited by side effects. The concept of a beta 3-receptor rose from the study of these compounds and has been verified by the cloning and expression of this receptor from several species. Rat beta 3-selective agonists have so far shown no antiobesity efficacy in humans. The resolution of several issues is critical for the discovery and development of efficacious antiobesity and antidiabetic agents with minimum side effects. Ultimately, the further investigation of these beta-agonists and beta-receptors should lead to a better understanding of the relationship between energy metabolism and feeding behavior.