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Oza C, Mandlik R, Khadilkar AV, Gondhalekar KM, Khadilkar VV. Role of Dietary Macronutrient Composition and Fibre Intake in Development of Double Diabetes in Indian Youth. Indian J Endocrinol Metab 2024; 28:213-219. [PMID: 38911111 PMCID: PMC11189281 DOI: 10.4103/ijem.ijem_90_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 12/12/2023] [Accepted: 02/28/2024] [Indexed: 06/25/2024] Open
Abstract
Introduction Insulin resistance (IR) and obesity are common presentations of double diabetes (DD) in subjects with type-1 diabetes (T1D). There is evidence that dietary composition has an impact on developing IR. Objectives were to assess the impact of macronutrient and fibre intake on glycaemic control and the role of macronutrient composition of diet in the development of DD in subjects with T1D. Methods This cross-sectional study included 77 young adults (10-25 years) with T1D. Data related to demography, anthropometry, biochemistry and body composition were collected. Dietary data was collected by fourteen-day food diary. IR was calculated using eGDR, SEARCH and CACTI equations, and metabolic syndrome (MS) was diagnosed using the International Diabetes Federation Consensus Definition. Results Subjects at risk of DD had higher age, leptin levels, percentage carbohydrate consumption in diet and IR. A positive association of insulin sensitivity with fibre intake and %protein intake was noted. Poor glycaemic control, adiponectin/leptin ratio, fibre intake and insulin/carbohydrate ratio were significant negative predictors of IR. Addition of dietary factors to the regression model improved the R square and percentage of subjects identified correctly. Inclusion of dietary parameters significantly improves the prediction of the risk of development of DD in subjects with T1D. Conclusion Good glycaemic control and increased intake of dietary fibre may prevent the development of IR in subjects with T1D and reduce the burden of DD.
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Affiliation(s)
- Chirantap Oza
- Paediatric Growth and Endocrine Department, Hirabai Cowasji Jehangir Medical Research Institute, Pune, Maharashtra, India
| | - Rubina Mandlik
- Paediatric Growth and Endocrine Department, Hirabai Cowasji Jehangir Medical Research Institute, Pune, Maharashtra, India
| | - Anuradha V. Khadilkar
- Paediatric Growth and Endocrine Department, Hirabai Cowasji Jehangir Medical Research Institute, Pune, Maharashtra, India
- Department of Interdisciplinary, School of Health Sciences, Savitribai Phule Pune University, Pune, Maharashtra, India
| | - Ketan M. Gondhalekar
- Paediatric Growth and Endocrine Department, Hirabai Cowasji Jehangir Medical Research Institute, Pune, Maharashtra, India
| | - Vaman V. Khadilkar
- Paediatric Growth and Endocrine Department, Hirabai Cowasji Jehangir Medical Research Institute, Pune, Maharashtra, India
- Department of Interdisciplinary, School of Health Sciences, Savitribai Phule Pune University, Pune, Maharashtra, India
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Bielka W, Przezak A, Molęda P, Pius-Sadowska E, Machaliński B. Double diabetes-when type 1 diabetes meets type 2 diabetes: definition, pathogenesis and recognition. Cardiovasc Diabetol 2024; 23:62. [PMID: 38341550 PMCID: PMC10859035 DOI: 10.1186/s12933-024-02145-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
Currently, the differentiation between type 1 diabetes (T1D) and type 2 diabetes (T2D) is not straightforward, and the features of both types of diabetes coexist in one subject. This situation triggered the need to discriminate so-called double diabetes (DD), hybrid diabetes or type 1.5 diabetes, which is generally described as the presence of the insulin resistance characteristic of metabolic syndrome in individuals diagnosed with T1D. DD not only raises the question of proper classification of diabetes but is also associated with a significantly greater risk of developing micro- and macroangiopathic complications, which was independent of glycaemic control. When considering the global obesity pandemic and increasing incidence of T1D, the prevalence of DD may also presumably increase. Therefore, it is of the highest priority to discover the mechanisms underlying the development of DD and to identify appropriate methods to prevent or treat DD. In this article, we describe how the definition of double diabetes has changed over the years and how it is currently defined. We discuss the accuracy of including metabolic syndrome in the DD definition. We also present possible hypotheses connecting insulin resistance with T1D and propose possible methods to identify individuals with double diabetes based on indirect insulin resistance markers, which are easily assessed in everyday clinical practice. Moreover, we discuss adjuvant therapy which may be considered in double diabetic patients.
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Affiliation(s)
- Weronika Bielka
- Department of Diabetology and Internal Diseases, Pomeranian Medical University, 72-009, Police, Poland.
| | - Agnieszka Przezak
- Department of Diabetology and Internal Diseases, Pomeranian Medical University, 72-009, Police, Poland
| | - Piotr Molęda
- Department of Diabetology and Internal Diseases, Pomeranian Medical University, 72-009, Police, Poland
| | - Ewa Pius-Sadowska
- Department of General Pathology, Pomeranian Medical University, 70-111, Szczecin, Poland
| | - Bogusław Machaliński
- Department of General Pathology, Pomeranian Medical University, 70-111, Szczecin, Poland
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Donga E, Dekkers OM, Corssmit EPM, Romijn JA. Insulin resistance in patients with type 1 diabetes assessed by glucose clamp studies: systematic review and meta-analysis. Eur J Endocrinol 2015; 173:101-9. [PMID: 25899581 DOI: 10.1530/eje-14-0911] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 04/20/2015] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The aim of this study was to perform a systematic review and meta-analysis on insulin resistance in adult patients with type 1 diabetes mellitus compared to healthy controls, assessed by hyperinsulinemic euglycemic clamp studies. DESIGN AND METHODS We conducted a systematic search of publications using PubMed, EMBASE, Web of Science and COCHRANE Library. Hyperinsulinemic euglycemic clamp studies comparing adult patients with type 1 diabetes mellitus to healthy controls were eligible. Primary outcome measures were pooled mean differences of insulin sensitivity of endogenous glucose production (EGP), of glucose uptake and of lipolysis. We estimated mean (standardized) differences and 95% CIs using random effects meta-analysis. RESULTS We included 38 publications in this meta-analysis. The weighed mean differences in EGP during hyperinsulinemia between patients and controls was 0.88 (95% CI: 0.47, 1.29) in the basal state and 0.52 (95% CI: 0.09, 0.95) in insulin stimulated conditions, indicating decreased hepatic insulin sensitivity in patients. Insulin sensitivity of glucose uptake was either reported as M value (M), glucose infusion rate (GIR), glucose disposal rate (GDR) or metabolic clearance rate (MCR). Weighed mean differences were similar for M -3.98 (95% CI: -4.68, -3.29) and GIR -4.61 (95% CI: -5.86, -3.53). Weighed mean difference for GDR was -2.43 (95% CI: -3.03, -1.83) and -3.29 (95% CI: -5.37, -1.22) for MCR, indicating decreased peripheral insulin sensitivity in patients. Insulin mediated inhibition of lipolysis was decreased in patients, reflected by increased non-esterified fatty acid levels. CONCLUSIONS Insulin resistance is a prominent feature of patients with type 1 diabetes mellitus and involves hepatic, peripheral and adipose tissues.
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Affiliation(s)
- Esther Donga
- Department of Endocrinology and Metabolic Diseases C7Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The NetherlandsDepartment of Clinical EpidemiologyLeiden University Medical Center, Leiden, The NetherlandsDepartment of Internal MedicineAmsterdam Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Olaf M Dekkers
- Department of Endocrinology and Metabolic Diseases C7Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The NetherlandsDepartment of Clinical EpidemiologyLeiden University Medical Center, Leiden, The NetherlandsDepartment of Internal MedicineAmsterdam Medical Center, University of Amsterdam, Amsterdam, The Netherlands Department of Endocrinology and Metabolic Diseases C7Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The NetherlandsDepartment of Clinical EpidemiologyLeiden University Medical Center, Leiden, The NetherlandsDepartment of Internal MedicineAmsterdam Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Eleonora P M Corssmit
- Department of Endocrinology and Metabolic Diseases C7Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The NetherlandsDepartment of Clinical EpidemiologyLeiden University Medical Center, Leiden, The NetherlandsDepartment of Internal MedicineAmsterdam Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Johannes A Romijn
- Department of Endocrinology and Metabolic Diseases C7Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The NetherlandsDepartment of Clinical EpidemiologyLeiden University Medical Center, Leiden, The NetherlandsDepartment of Internal MedicineAmsterdam Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Bergman BC, Howard D, Schauer IE, Maahs DM, Snell-Bergeon JK, Eckel RH, Perreault L, Rewers M. Features of hepatic and skeletal muscle insulin resistance unique to type 1 diabetes. J Clin Endocrinol Metab 2012; 97:1663-72. [PMID: 22362823 PMCID: PMC3339891 DOI: 10.1210/jc.2011-3172] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
CONTEXT Type 1 diabetes is known to be a state of insulin resistance; however, the tissues involved in whole-body insulin resistance are less well known. It is unclear whether insulin resistance is due to glucose toxicity in the post-Diabetes Control and Complications Trial era of tighter glucose control. OBJECTIVE We performed this study to determine muscle and liver insulin sensitivity individuals with type 1 diabetes after overnight insulin infusion to lower fasting glucose concentration. DESIGN, PATIENTS, AND METHODS Fifty subjects [25 controls without and 25 individuals with type 1 diabetes (diabetes duration 22.9 ± 1.7 yr, without known end organ damage] were frequency matched on age and body mass index by group and studied. After 3 d of dietary control and overnight insulin infusion to normalize glucose, we performed a three-stage hyperinsulinemic/euglycemic clamp infusing insulin at 4, 8, and 40 mU/m(2) · min. Glucose metabolism was quantified using an infusion of [6,6-(2)H(2)]glucose. Hepatic insulin sensitivity was measured using the insulin IC(50) for glucose rate of appearance (Ra), whereas muscle insulin sensitivity was measured using the glucose rate of disappearance during the highest insulin dose. RESULTS Throughout the study, glucose Ra was significantly greater in individuals compared with those without type 1 diabetes. The concentration of insulin required for 50% suppression of glucose Ra was 2-fold higher in subjects with type 1 diabetes. Glucose rate of disappearance was significantly lower in individuals with type 1 diabetes during the 8- and 40-mU/m(2) · min stages. CONCLUSION Insulin resistance in liver and skeletal muscle was a significant feature in type 1 diabetes. Nevertheless, the etiology of insulin resistance was not explained by body mass index, percentage fat, plasma lipids, visceral fat, and physical activity and was also not fully explained by hyperglycemia.
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Affiliation(s)
- Bryan C Bergman
- Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, P.O. Box 6511, MS 8106, Aurora, Colorado 80045, USA.
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Kacerovsky M, Jones J, Schmid AI, Barosa C, Lettner A, Kacerovsky-Bielesz G, Szendroedi J, Chmelik M, Nowotny P, Chandramouli V, Wolzt M, Roden M. Postprandial and fasting hepatic glucose fluxes in long-standing type 1 diabetes. Diabetes 2011; 60:1752-8. [PMID: 21562079 PMCID: PMC3114392 DOI: 10.2337/db10-1001] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Intravenous insulin infusion partly improves liver glucose fluxes in type 1 diabetes (T1D). This study tests the hypothesis that continuous subcutaneous insulin infusion (CSII) normalizes hepatic glycogen metabolism. RESEARCH DESIGN AND METHODS T1D with poor glycemic control (T1Dp; HbA(1c): 8.5 ± 0.4%), T1D with improved glycemic control on CSII (T1Di; 7.0 ± 0.3%), and healthy humans (control subjects [CON]; 5.2 ± 0.4%) were studied. Net hepatic glycogen synthesis and glycogenolysis were measured with in vivo (13)C magnetic resonance spectroscopy. Endogenous glucose production (EGP) and gluconeogenesis (GNG) were assessed with [6,6-(2)H(2)]glucose, glycogen phosphorylase (GP) flux, and gluconeogenic fluxes with (2)H(2)O/paracetamol. RESULTS When compared with CON, net glycogen synthesis was 70% lower in T1Dp (P = 0.038) but not different in T1Di. During fasting, T1Dp had 25 and 42% higher EGP than T1Di (P = 0.004) and CON (P < 0.001; T1Di vs. CON: P = NS). GNG was 74 and 67% higher in T1Dp than in T1Di (P = 0.002) and CON (P = 0.001). In T1Dp, GP flux (7.0 ± 1.6 μmol ⋅ kg(-1) ⋅ min(-1)) was twofold higher than net glycogenolysis, but comparable in T1Di and CON (3.7 ± 0.8 and 4.9 ± 1.0 μmol ⋅ kg(-1) ⋅ min(-1)). Thus T1Dp exhibited glycogen cycling (3.5 ± 2.0 μmol ⋅ kg(-1) ⋅ min(-1)), which accounted for 47% of GP flux. CONCLUSIONS Poorly controlled T1D not only exhibits augmented fasting gluconeogenesis but also increased glycogen cycling. Intensified subcutaneous insulin treatment restores these abnormalities, indicating that hepatic glucose metabolism is not irreversibly altered even in long-standing T1D.
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Affiliation(s)
- Michaela Kacerovsky
- Karl-Landsteiner Institute for Endocrinology and Metabolism, Vienna, Austria
| | - John Jones
- Department of Life Sciences and Center for Neurosciences and Cell Biology, University of Coimbra, Coimbra, Portugal
- Portuguese Diabetes Association, Rua do Salitre, Lisbon, Portugal
| | - Albrecht I. Schmid
- Karl-Landsteiner Institute for Endocrinology and Metabolism, Vienna, Austria
- MR Center of Excellence, Medical University of Vienna, Vienna, Austria
| | - Cristina Barosa
- Department of Life Sciences and Center for Neurosciences and Cell Biology, University of Coimbra, Coimbra, Portugal
| | - Angelika Lettner
- Karl-Landsteiner Institute for Endocrinology and Metabolism, Vienna, Austria
| | - Gertrud Kacerovsky-Bielesz
- Karl-Landsteiner Institute for Endocrinology and Metabolism, Vienna, Austria
- 1st Medical Department, Hanusch Hospital, Vienna, Austria
| | - Julia Szendroedi
- Karl-Landsteiner Institute for Endocrinology and Metabolism, Vienna, Austria
- 1st Medical Department, Hanusch Hospital, Vienna, Austria
- Institute for Clinical Diabetology, German Diabetes Center (Leibniz Center for Diabetes Research), Düsseldorf, Germany
- Department of Metabolic Diseases, Heinrich-Heine University and University Clinics Düsseldorf, Düsseldorf, Germany
| | - Marek Chmelik
- Karl-Landsteiner Institute for Endocrinology and Metabolism, Vienna, Austria
- MR Center of Excellence, Medical University of Vienna, Vienna, Austria
| | - Peter Nowotny
- Institute for Clinical Diabetology, German Diabetes Center (Leibniz Center for Diabetes Research), Düsseldorf, Germany
| | - Visvanathan Chandramouli
- Department of Medicine, University Hospitals Case Medical Center, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Michael Wolzt
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Michael Roden
- Karl-Landsteiner Institute for Endocrinology and Metabolism, Vienna, Austria
- 1st Medical Department, Hanusch Hospital, Vienna, Austria
- Institute for Clinical Diabetology, German Diabetes Center (Leibniz Center for Diabetes Research), Düsseldorf, Germany
- Department of Metabolic Diseases, Heinrich-Heine University and University Clinics Düsseldorf, Düsseldorf, Germany
- Corresponding author: Michael Roden,
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Kacerovsky M, Brehm A, Chmelik M, Schmid AI, Szendroedi J, Kacerovsky-Bielesz G, Nowotny P, Lettner A, Wolzt M, Jones JG, Roden M. Impaired insulin stimulation of muscular ATP production in patients with type 1 diabetes. J Intern Med 2011; 269:189-99. [PMID: 21205021 DOI: 10.1111/j.1365-2796.2010.02298.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE in type 2 diabetic patients and their first-degree relatives, insulin resistance (IR) is associated with impairment of insulin-stimulated myocellular glucose-6-phosphate (g6p) and unidirectional flux through ATP synthase (fATP), suggesting the presence of inherited abnormal mitochondrial oxidative fitness. We hypothesized that patients with long-standing type 1 diabetes may also exhibit insulin resistance as well as lower fATP. DESIGN this single-centre trial was registered at ClinicalTrials.gov (NCT00481598). SUBJECTS we included eight nonobese type 1 diabetic patients (mean diabetes duration: 17 years) with near-target glycaemic control [haemoglobin A1c (HbA1c): 6.8 ± 0.4%] during treatment with continuous subcutaneous insulin infusion pumps and eight healthy volunteers (HbA1c: 5.4 ± 0.2%) of comparable age, body mass and level of physical activity. OUTCOME MEASURES myocellular fATP, g6p and intramyocellular lipid content (IMCL) were measured with (1) H/(31) P magnetic resonance spectroscopy during fasting and hyperinsulinaemic-euglycaemic clamp tests. RESULTS fasting fATP, g6p and IMCL did not differ between groups. During stimulation by insulin, type 1 diabetic patients exhibited approximately 50% (P < 0.001) lower whole-body glucose disposal along with approximately 42% (P = 0.003) lower intramyocellular g6p and approximately25% (P = 0.024) lower fATP. Insulin-stimulated fATP correlated positively with whole-body insulin sensitivity (R = 0.706, P = 0.002) and negatively with HbA1c (R = -0.675, P = 0.004). CONCLUSIONS despite documented near-target glycaemic control for 1 year, nonobese patients with long-standing type 1 diabetes can exhibit insulin resistance. This associates with lower insulin-stimulated flux through muscular ATP synthase which could result from glucose toxicity.
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Affiliation(s)
- M Kacerovsky
- Karl-Landsteiner Institute for Endocrinology and Metabolism, Medical University of Vienna, Vienna, Austria
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Stadler M, Anderwald C, Pacini G, Zbýň Š, Promintzer-Schifferl M, Mandl M, Bischof M, Gruber S, Nowotny P, Luger A, Prager R, Krebs M. Chronic peripheral hyperinsulinemia in type 1 diabetic patients after successful combined pancreas-kidney transplantation does not affect ectopic lipid accumulation in skeletal muscle and liver. Diabetes 2010; 59:215-8. [PMID: 19833878 PMCID: PMC2797924 DOI: 10.2337/db09-0354] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE So far it is unclear whether chronic peripheral hyperinsulinemia per se might contribute to ectopic lipid accumulation and consequently insulin resistance. We investigated the effects of systemic instead of portal insulin release in type 1 diabetic patients after successful pancreas-kidney transplantation (PKT) with systemic venous drainage on the intracellular lipid content in liver and soleus muscle, endogenous glucose production (EGP), and insulin sensitivity. RESEARCH DESIGN AND METHODS In nine PKT patients and nine matching nondiabetic control subjects, intrahepatocellular lipids (IHCLs) and intramyocellular lipids (IMCLs) were measured using (1)H nuclear magnetic resonance spectroscopy. Fasting EGP was measured using d-[6,6-(2)H(2)]glucose tracer dilution. A 3-h 75-g oral glucose tolerance test (OGTT) allowed us to assess kinetics of glucose, free fatty acids, insulin, and C-peptide concentrations in plasma and to calculate the clamp-like index (CLIX) for insulin sensitivity and the hepatic insulin resistance (HIR) index. RESULTS The PKT patients displayed approximately twofold increased fasting insulin (20 +/- 6 vs. 9 +/- 3 microU/ml; P < 0.0002) compared with that in nondiabetic control subjects and approximately 10% increased fasting glucose (P < 0.02) concentrations, but during the OGTT areas under the concentration curves of C-peptide and insulin were similar. IHCL (PKT, 2.9 +/- 2.5%; nondiabetic control subjects, 4.4 +/- 6.6%), IMCL (PKT, 1.0 +/- 0.4%; nondiabetic control subjects, 1.0 +/- 0.5%), CLIX (PKT, 8 +/- 2; nondiabetic control subjects, 7 +/- 3), HIR (PKT, 25.6 +/- 13.2; nondiabetic control subjects, 35.6 +/- 20 [mg * min(-1) * kg(-1)] x [microU/ml]), and EGP (PKT, 1.6 +/- 0.2; nondiabetic control subjects, 1.7 +/- 0.2 mg * min(-1) * kg(-1)) were comparable between PKT patients and nondiabetic control subjects. IHCL was negatively correlated with CLIX in all participants (r = -0.55; P < 0.04). CONCLUSIONS Despite fasting peripheral hyperinsulinemia because of systemic venous drainage, type 1 diabetic patients after PKT show similar IHCL, IMCL, insulin sensitivity, and fasting EGP in comparison with nondiabetic control subjects. These results suggest that systemic hyperinsulinemia per se does not cause ectopic lipid accumulation in liver and skeletal muscle.
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Affiliation(s)
- Marietta Stadler
- Hietzing Hospital, 3rd Medical Department of Metabolic Diseases and Nephrology, Vienna, Austria
- Karl Landsteiner Institute of Metabolic Diseases and Nephrology, Vienna, Austria
| | - Christian Anderwald
- Medical University of Vienna, Department of Internal Medicine III, Division of Endocrinology and Metabolism, Vienna, Austria
- Corresponding author: Christian Anderwald,
| | - Giovanni Pacini
- Metabolic Unit, Institute of Biomedical Engineering, National Research Council, Padova, Italy
| | - Štefan Zbýň
- Medical University of Vienna, Department of Radiology, MR Center–High Field MR, Vienna, Austria
| | - Miriam Promintzer-Schifferl
- Medical University of Vienna, Department of Internal Medicine III, Division of Endocrinology and Metabolism, Vienna, Austria
| | - Martina Mandl
- Medical University of Vienna, Department of Internal Medicine III, Division of Endocrinology and Metabolism, Vienna, Austria
| | - Martin Bischof
- Medical University of Vienna, Department of Internal Medicine III, Division of Endocrinology and Metabolism, Vienna, Austria
| | - Stephan Gruber
- Medical University of Vienna, Department of Radiology, MR Center–High Field MR, Vienna, Austria
| | - Peter Nowotny
- Medical University of Vienna, Department of Internal Medicine III, Division of Endocrinology and Metabolism, Vienna, Austria
| | - Anton Luger
- Medical University of Vienna, Department of Internal Medicine III, Division of Endocrinology and Metabolism, Vienna, Austria
| | - Rudolf Prager
- Hietzing Hospital, 3rd Medical Department of Metabolic Diseases and Nephrology, Vienna, Austria
- Karl Landsteiner Institute of Metabolic Diseases and Nephrology, Vienna, Austria
| | - Michael Krebs
- Medical University of Vienna, Department of Internal Medicine III, Division of Endocrinology and Metabolism, Vienna, Austria
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Mégarbane B, Deye N, Bloch V, Sonneville R, Collet C, Launay JM, Baud FJ. Intentional overdose with insulin: prognostic factors and toxicokinetic/toxicodynamic profiles. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:R115. [PMID: 17963523 PMCID: PMC2556768 DOI: 10.1186/cc6168] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2007] [Accepted: 10/28/2007] [Indexed: 08/29/2023]
Abstract
Introduction Prognostic factors in intentional insulin self-poisoning and the significance of plasma insulin levels are unclear. We therefore conducted this study to investigate prognostic factors in insulin poisoning, in relation to the value of plasma insulin concentration. Methods We conducted a prospective study, and used logistic regression to explore prognostic factors and modelling to investigate toxicokinetic/toxicodynamic relationships. Results Twenty-five patients (14 female and 11 male; median [25th to 75th percentiles] age 46 [36 to 58] years) were included. On presentation, the Glasgow Coma Scale score was 9 (4 to 14) and the capillary glucose concentration was 1.4 (1.1 to 2.3) mmol/l. The plasma insulin concentration was 197 (161 to 1,566) mIU/l and the cumulative amount of glucose infused was 301 (184 to 1,056) g. Four patients developed sequelae resulting in two deaths. Delay to therapy in excess of 6 hours (odds ratio 60.0, 95% confidence interval 2.9 to 1,236.7) and ventilation for longer than 48 hours (odds ratio 28.5, 95% confidence interval 1.9 to 420.6) were identified as independent prognostic factors. Toxicokinetic/toxicodynamic relationships between glucose infusion rates and insulin concentrations fit the maximum measured glucose infusion rate (Emax) model (Emax 29.5 [17.5 to 41.1] g/hour, concentration associated with the half-maximum glucose infusion rate [EC50] 46 [35 to 161] mIU/l, and R2 range 0.70 to 0.98; n = 6). Conclusion Intentional insulin overdose is rare. Assessment of prognosis relies on clinical findings. The observed plasma insulin EC50 is 46 mIU/l.
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Affiliation(s)
- Bruno Mégarbane
- Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière, Réanimation Médicale et Toxicologique, INSERM U705, CNRS, UMR 7157, Université Paris 7, 2 Rue Ambroise Paré, 75010, Paris, France.
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Promintzer M, Krebs M, Todoric J, Luger A, Bischof MG, Nowotny P, Wagner O, Esterbauer H, Anderwald C. Insulin resistance is unrelated to circulating retinol binding protein and protein C inhibitor. J Clin Endocrinol Metab 2007; 92:4306-12. [PMID: 17726077 DOI: 10.1210/jc.2006-2522] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Recent data suggest that circulating retinol-binding protein (RBP) might be involved in the pathogenesis of insulin resistance. Moreover, protein C inhibitor (PCI), which specifically binds retinoic acid, was found to be increased in myocardial infarction survivors who are also insulin resistant. OBJECTIVE The objective of this study was to investigate the association of insulin resistance with RBP factors and PCI active antigen. DESIGN AND SETTING This was a clinical study. PATIENTS Nondiabetic humans with high (IS; n = 20, 14 females, six males, aged 47.2 +/- 1.9 yr, body mass index 26 +/- 1 kg/m(2)) and low (IR; n = 20, 14 females, six males, aged 45.5 +/- 1.7 yr, body mass index 28 +/- 1 kg/m(2)) insulin-stimulated glucose-disposal (M) participated in this study. MAIN OUTCOME MEASURES M was measured by 2-h hyperinsulinemic (40 mU.min(-1).m(-2))-isoglycemic clamp tests. Measurements of RBP were performed using a nephelometric method and validated using quantitative Western blotting. RESULTS M (80-120 min) was higher in IS (10.9 +/- 0.6 mg.min(-1).kg(-1)) than IR (4.0 +/- 0.2; P < 10(-12)). Fasting plasma RBP concentrations were comparable between IS and IR measured by both nephelometry (IS: 4.4 +/- 0.3; IR: 4.6 +/- 0.3 mg/dl, P = 0.6) and quantitative Western blot (IS 7.9 +/- 0.5, IR 8.3 +/- 0.6 mg/dl; P = 0.6). Fasting plasma PCI active antigen was similar in both groups. Plasma RBP and PCI were not significantly related to M. RBP was positively correlated with uric acid (r = 0.488, P = 0.003), triglycerides (r = 0.592, P < 0.001), prealbumin (r = 0.63, P < 0.0001), and vitamin A (r = 0.75, P < 10(-6)). CONCLUSIONS Our data demonstrate that healthy, insulin-resistant humans do not show altered plasma retinol binding factors, such as RBP and PCI. Both do not significantly correlate with insulin sensitivity. Thus, our findings do not support the hypothesis of insulin sensitivity modulation by proteins involved in retinol transport.
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Affiliation(s)
- Miriam Promintzer
- Department of Internal Medicine III, Medical University of Vienna, A-1090 Vienna, Austria
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Christopher MJ, Rantzau C, Alford FP. The relationship between peripheral glucose utilisation and insulin sensitivity in the regulation of hepatic glucose production: studies in normal and alloxan-diabetic dogs. Diabetes Metab Res Rev 2006; 22:155-67. [PMID: 16222656 DOI: 10.1002/dmrr.594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Hepatic glucose overproduction (HGP) of diabetes could be primary or could occur in response to the metabolic needs of peripheral (skeletal muscle (SkM)) tissues. This question was tested in normal and diabetic dogs. METHODS HGP, SkM glucose uptake (Rd(tissue)), metabolic clearance of glucose (MCRg) and glycolytic flux (GF(exog)), and SkM biopsies were measured in the same dogs before and after alloxan-induced diabetes. Normal dogs were exposed to (1) an extended 20-h fast, (2) low- and high-dose glucose infusions (GINF) at basal insulinaemia, and chronic diabetic dogs were exposed to (3) hyperglycaemia, (4) phlorizin-induced normoglycaemia, and (5) poor and good diabetic control. RESULTS (1) Prolonged fast: HGP, Rd(tissue), and GF(exog) fell in parallel (p < 0.05). (2) Low-dose GINF: plasma glucose, insulin, Rd(tissue), MCRg, and GF(exog) were unchanged, but HGP fell by approximately 40%, paralleling the supplemental GINF. (3) High-dose GINF at basal insulin: plasma glucose doubled and synchronous changes in HGP, Rd(tissue), MCRg, and GF(exog) occurred; IC(glucose), G6P, and glycogen were unchanged. (4) Hyperglycaemic diabetes: HGP was raised (p < 0.05), matching urinary glucose loss (UGL) and decreased MCR(g), and maintaining normal basal Rd(tissue) and GF(exog). SkM IC(glucose) was increased and glycogen decreased (both p < 0.05). (5) Phlorizin-induced normoglycaemia in diabetic dogs: HGP rose, matching the increased UGL, while maintaining normal Rd(tissue) and GF(exog). Intramuscular substrates normalised. (6) Whole body and SkM metabolism normalised with correction of the insulin resistance and good diabetic control. CONCLUSION HGP reflects whether SkM is in a state of relative glucose 'excess' or absolute/relative glucose 'deprivation'.
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Affiliation(s)
- M J Christopher
- Endocrinology and Diabetes, St Vincent's Hospital, Melbourne, Australia
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11
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Staehr P, Hother-Nielsen O, Landau BR, Chandramouli V, Holst JJ, Beck-Nielsen H. Effects of free fatty acids per se on glucose production, gluconeogenesis, and glycogenolysis. Diabetes 2003; 52:260-7. [PMID: 12540595 DOI: 10.2337/diabetes.52.2.260] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Insulin-independent effects of a physiological increase in free fatty acid (FFA) levels on fasting glucose production, gluconeogenesis, and glycogenolysis were assessed by administering [6,6-(2)H(2)]-glucose and deuteriated water ((2)H(2)O) in 12 type 1 diabetic patients, during 6-h infusions of either saline or a lipid emulsion. Insulin was either fully replaced (euglycemic group, n = 6), or underreplaced (hyperglycemic group, n = 6). During saline infusions, plasma FFA levels remained unchanged. Glucose concentrations decreased from 6.7 +/- 0.4 to 5.3 +/- 0.4 mmol/l and 11.9 +/- 1.0 to 10.5 +/- 1.0 mmol/l in the euglycemic and hyperglycemic group, respectively. Accordingly, glucose production declined from 84 +/- 5 to 63 +/- 5 mg x m(-2) x min(-1) and from 84 +/- 5 to 68 +/- 4 mg x m(-2) x min(-1), due to declining rates of glycogenolysis but unaltered rates of gluconeogenesis. During lipid infusions, plasma FFA levels increased twofold. In the euglycemic group, plasma glucose increased from 6.8 +/- 0.3 to 7.8 +/- 0.8 mmol/l. Glucose production declined less in the lipid study than in the saline study due to a stimulation of gluconeogenesis by 6 +/- 1 mg x m(-2) x min(-1) and a decline in glycogenolysis that was 6 +/- 2 mg x m(-2) x min(-1) less in the lipid study than in the saline study. In contrast, in the hyperglycemic group, there were no significant effects of elevated FFA on glucose production, gluconeogenesis, or glycogenolysis. In conclusion, a physiological elevation of plasma FFA levels stimulates glycogenolysis as well as gluconeogenesis and causes mild fasting hyperglycemia. These effects of FFA appear attenuated in the presence of hyperglycemia.
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Affiliation(s)
- Peter Staehr
- Medical Department M, Odense University Hospital, Denmark.
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12
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Georg P, Kautzky-Willer A, Mahdjoobian K, Hofer A, Prager R, Pacini G, Ludvik BH. Influence of metabolic control on splanchnic glucose uptake, insulin sensitivity, and the time required for glucose absorption in patients with type 1 diabetes. Diabetes Care 2002; 25:2042-7. [PMID: 12401754 DOI: 10.2337/diacare.25.11.2042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The relationship between splanchnic glucose uptake (SGU) after oral glucose administration and metabolic control in type 1 diabetic patients is controversial. We estimated SGU as well as peripheral glucose uptake and the time required for glucose absorption by a validated method, the oral glucose (OG) clamp, in type 1 diabetic patients with different levels of long-term glycemic control. RESEARCH DESIGN AND METHODS An OG clamp (which combines a hyperinsulinemic clamp [120 mU. m(-2). min(-1)] with an OR load [75 g] during steady-state glucose uptake) was performed in eight type 1 diabetic patients with good metabolic control (DG) (HbA(1c) 6.1 +/- 0.2%, BMI 23.1 +/- 0.7 kg/m(2)), eight type 1 diabetic patients with poor metabolic control (DP) (HbA(1c) 8.5 +/- 0.3%, BMI 25.4 +/- 1.4 kg/m(2)), and eight healthy matched control subjects (C) (HbA(1c) 5.1 +/- 0.1%, BMI 25 +/- 1.3 kg/m(2)) to determine SGU, glucose uptake, and glucose absorption. RESULTS Glucose uptake calculated from 120 to 180 min during the clamp was 9.13 +/- 0.55 mg. kg(-1). min(-1) in C, 8.18 +/- 0.71 mg. kg(-1). min(-1) in DG, and 7.42 +/- 0.96 mg. kg(-1). min(-1) in DP (NS). Glucose absorption was 140 +/- 6 min in C, 156 +/- 4 min in DG, and 143 +/- 7 min in DP (NS). The respective calculated SGU was 14.5 +/- 5.6% in C, 17.8 +/- 3.1% in DG, and 18.8 +/- 4.2% in DP (NS) and did not correlate with HbA(1c) values. CONCLUSIONS Peripheral glucose uptake, SGU after oral glucose administration, and the glucose absorption time were not different in type 1 diabetic patients independent of glycemic control when compared with healthy subjects.
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Affiliation(s)
- Petra Georg
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, University of Vienna, Vienna, Austria
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13
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Anderwald C, Bernroider E, Krssak M, Stingl H, Brehm A, Bischof MG, Nowotny P, Roden M, Waldhäusl W. Effects of insulin treatment in type 2 diabetic patients on intracellular lipid content in liver and skeletal muscle. Diabetes 2002; 51:3025-32. [PMID: 12351443 DOI: 10.2337/diabetes.51.10.3025] [Citation(s) in RCA: 125] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Insulin resistance is frequently associated with increased lipid content in muscle and liver. Insulin excess stimulates tissue lipid accumulation. To examine the effects of insulin and improved glycemia on insulin sensitivity and intracellular lipids, we performed stepped (1, 2, and 4 mU x min(-1) x kg(-1)) hyperinsulinemic-euglycemic clamps in eight type 2 diabetic and six nondiabetic control subjects at baseline and after 12 and 67 h of insulin-mediated near-normoglycemia (118 +/- 7 mg/dl). Intrahepatocellular lipids (IHCLs) and intramyocellular lipids (IMCLs) of soleus (IMCL-S) and tibialis anterior muscle (IMCL-TA) were measured with (1)H nuclear magnetic resonance spectroscopy. At baseline, nondiabetic subjects had an approximate twofold higher insulin sensitivity (P < 0.02) and lower IHCLs than diabetic patients (5.8 +/- 1.2 vs. 18.3 +/- 4.2%, P < 0.03), in whom IMCL-TA negatively correlated with insulin sensitivity (r = -0.969, P < 0.001). After a 67-h insulin infusion in diabetic patients, IMCL-S and IHCLs were increased (P < 0.05) by approximately 36 and approximately 18%, respectively, and correlated positively with insulin sensitivity (IMCL-S: r = 0.982, P < 0.0005; IHCL: r = 0.865, P < 0.03), whereas fasting glucose production, measured with D-[6,6-(2)H(2)]glucose, decreased by approximately 10% (P < 0.04). In conclusion, these results indicate that IMCLs relate to insulin resistance in type 2 diabetic patients at baseline and that insulin-mediated near-normoglycemia for approximately 3 days reduces fasting glucose production but stimulates lipid accumulation in liver and muscle without affecting insulin sensitivity.
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Affiliation(s)
- Christian Anderwald
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, University of Vienna, Austria
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14
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Bischof MG, Bernroider E, Krssak M, Krebs M, Stingl H, Nowotny P, Yu C, Shulman GI, Waldhäusl W, Roden M. Hepatic glycogen metabolism in type 1 diabetes after long-term near normoglycemia. Diabetes 2002; 51:49-54. [PMID: 11756322 DOI: 10.2337/diabetes.51.1.49] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We tested the impact of long-term near normoglycemia (HbA(1c) <7% for >1 year) on glycogen metabolism in seven type 1 diabetic and seven matched nondiabetic subjects after a mixed meal. Glycemic profiles (6.2 +/- 0.10 vs. 5.9 +/- 0.07 mmol/l; P < 0.05) of diabetic patients were approximated to that of nondiabetic subjects by variable insulin infusion. Rates of hepatic glycogen synthesis and breakdown were calculated from the glycogen concentration time curves between 7:30 P.M. and 8:00 A.M. using in vivo (13)C nuclear magnetic resonance spectroscopy. Glucose production was determined with D-[6,6-(2)H(2)]glucose, and the hepatic uridine-diphosphate glucose pool was sampled with acetaminophen. Glycogen synthesis and breakdown as well as glucose production were identical in diabetic and healthy subjects: 7.3 +/- 0.9 vs. 7.1 +/- 0.7, 4.2 +/- 0.5 vs. 3.8 +/- 0.3, and 8.7 +/- 0.5 vs. 8.4 +/- 0.7 micromol x kg(-1) x min(-1), respectively. Although portal vein insulin concentrations were doubled, the flux through the indirect pathway of glycogen synthesis remained higher in type 1 diabetic subjects: approximately 70 vs. approximately 50%; P < 0.05. In conclusion, combined long- and short-term intensified insulin substitution normalizes rates of hepatic glycogen synthesis but not the contribution of gluconeogenesis to glycogen synthesis in type 1 diabetes.
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Affiliation(s)
- Martin G Bischof
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, University of Vienna Medical School, Vienna, Austria
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15
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Bischof MG, Krssak M, Krebs M, Bernroider E, Stingl H, Waldhäusl W, Roden M. Effects of short-term improvement of insulin treatment and glycemia on hepatic glycogen metabolism in type 1 diabetes. Diabetes 2001; 50:392-8. [PMID: 11272152 DOI: 10.2337/diabetes.50.2.392] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Insufficiently treated type 1 diabetic patients exhibit inappropriate postprandial hyperglycemia and reduction in liver glycogen stores. To examine the effect of acute improvement of metabolic control on hepatic glycogen metabolism, lean young type 1 diabetic (HbA1c 8.8 +/- 0.3%) and matched nondiabetic subjects (HbA1c 5.4 +/- 0.1%) were studied during the course of a day with three isocaloric mixed meals. Hepatic glycogen concentrations were determined noninvasively using in vivo 13C nuclear magnetic resonance spectroscopy. Rates of net glycogen synthesis and breakdown were calculated from linear regression of the glycogen concentration time curves from 7:30-10:30 P.M. and from 10:30 P.M. to 8:00 A.M., respectively. The mean plasma glucose concentration was approximately 2.4-fold higher in diabetic than in nondiabetic subjects (13.6 +/- 0.4 vs. 5.8 +/- 0.1 mmol/l, P < 0.001). Rates of net glycogen synthesis and net glycogen breakdown were reduced by approximately 74% (0.11 +/- 0.02 vs. 0.43 +/- 0.04 mmol/l liver/min, P < 0.001) and by approximately 47% (0.10 +/- 0.01 vs. 0.19 +/- 0.01 mmol/l liver/min, P < 0.001) in diabetic patients, respectively. During short-term (24-h) intensified insulin treatment, the mean plasma glucose level was not different between diabetic and nondiabetic subjects (6.4 +/- 0.1 mmol/l). Net glycogen synthesis and breakdown increased by approximately 92% (0.23 +/- 0.04 mmol/l liver/min, P = 0.017) and by approximately 40% (0.14 approximately 0.01 mmol/l liver/min, P = 0.011), respectively. In conclusion, poorly controlled type 1 diabetic patients present with marked reduction in both hepatic glycogen synthesis and breakdown. Both defects in glycogen metabolism are improved but not normalized by short-term restoration of insulinemia and glycemia.
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Affiliation(s)
- M G Bischof
- Department of Internal Medicine III, University of Vienna Medical School, Austria
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16
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The effects of free fatty acids on glucose transport and phosphorylation in human skeletal muscle. ACTA ACUST UNITED AC 2000. [DOI: 10.1097/00060793-200008000-00006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fasching P, Roden M, Stühlinger HG, Kurzemann S, Zeiner A, Waldhäusl W, Laggner AN. Estimated glucose requirement following massive insulin overdose in a patient with type 1 diabetes. Diabet Med 1994; 11:323-5. [PMID: 8033534 DOI: 10.1111/j.1464-5491.1994.tb00279.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A well-documented case of a 35-year-old male Type 1 diabetic patient who was admitted as an emergency after having injected 1500 international units (IU) of insulin (750 IU regular insulin,750 IU NPH-insulin) subcutaneously as a suicidal attempt is reported. Computing disappearance rates of glucose from its infused amounts necessary to maintain euglycaemia during 65 h after the insulin injection in analogy to experimental hyperinsulinaemic euglycaemic clamp examinations, a glucose consumption of 55.6 mumol kg-1 min-1 was found at peak serum insulin concentrations of about 14,400 pmol l-1. The insulin-induced glucose dynamics resemble closely those seen in healthy persons and Type 1 diabetic subjects during a 10 mU kg-1 min-1 euglycaemic clamp. This information may be useful in the handling of similar cases of insulin intoxication.
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Affiliation(s)
- P Fasching
- Department of Medicine III, University Hospital, Vienna, Austria
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