1
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Unhapipatpong C, Hiranyatheb P, Phanachet P, Warodomwichit D, Sriphrapradang C, Shantavasinkul PC. Postprandial hypoglycemia after ileocolic interposition and Billroth-II gastrojejunostomy: A case report. Clin Case Rep 2023; 11:e7060. [PMID: 36950668 PMCID: PMC10025248 DOI: 10.1002/ccr3.7060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/03/2023] [Accepted: 02/22/2023] [Indexed: 03/24/2023] Open
Abstract
Postprandial reactive hypoglycemia, or late dumping syndrome, is a common but underrecognized complication from bypass surgery. We report an unusual case of postprandial reactive hypoglycemia in a patient with a severe esophageal stricture from corrosive agent ingestion who underwent ileocolic interposition and an antecolic Billroth-II gastrojejunostomy. A 22-year-old male patient with a one-year history of corrosive ingestion was referred to the hospital for a surgical correction of severe esophageal stricture. After the patient underwent ileocolic interposition and an antecolic Billroth-II gastrojejunostomy, he experienced multiple episodes of gastroesophageal refluxsymptoms during nasogastric feeding and had onset of hypoglycemic symptoms. His plasma glucose level was 59 mg/dL. After we had intraoperatively re-inserted a jejunostomy tube bypassing the ileocolic interposition, and reintroduced enteral nutrition, his hypoglycemic symptoms resolved. We performed a mixed meal tolerance test by nasogastric tube, but the results did not show postprandial hypoglycemia. Although the specific mechanism is unclear, this case suggests gastroesophageal reflux to the ileal interposition may have caused a state of exaggerated hyperinsulinemic response and rebound hypoglycemia. To the best of our knowledge, we are the first to report case of postprandial hypoglycemia after ileocolic interposition, which may have been caused by exaggerated hyperinsulinemic response due to gastroesophageal reflux to the ileal interposition. This syndrome should be considered in the patient who has had ileocolic interposition surgery and has developed postprandial hypoglycemia.
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Affiliation(s)
- Chanita Unhapipatpong
- Department of Medicine, Division of Clinical NutritionKhon Kaen HospitalKhon KaenThailand
| | - Pitichote Hiranyatheb
- Department of Surgery, Division of General Surgery, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - Pariya Phanachet
- Department of Medicine, Division of Nutrition and Biochemical Medicine, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - Daruneewan Warodomwichit
- Department of Medicine, Division of Nutrition and Biochemical Medicine, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - Chutintorn Sriphrapradang
- Department of Medicine, Division of Endocrinology and Metabolism, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - Prapimporn Chattranukulchai Shantavasinkul
- Department of Medicine, Division of Nutrition and Biochemical Medicine, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
- Graduate Program in Nutrition, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
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2
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Langeskov EK, Kristensen K. Population pharmacokinetic of paracetamol and atorvastatin with co-administration of semaglutide. Pharmacol Res Perspect 2022; 10:e00962. [PMID: 35799471 PMCID: PMC9263537 DOI: 10.1002/prp2.962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 04/02/2022] [Indexed: 11/09/2022] Open
Abstract
Semaglutide is a glucagon-like-peptide-1 (GLP-1) analogue marketed for once-weekly subcutaneous administration for type 2 diabetes mellitus. Like other long-acting GLP-1 analogues, semaglutide reduces gastric emptying and, potentially, alters the rate of absorption of orally co-administered drugs. The objective of the current analysis was to evaluate the effects on the gastric emptying rate caused by semaglutide on pharmacokinetic model parameters of paracetamol and atorvastatin in healthy subjects. Non-linear mixed effect modeling was used to estimate population pharmacokinetic model parameters of paracetamol and atorvastatin after single doses with or without semaglutide. The absorption rate (ka) of paracetamol decreased by 53% when co-administered with semaglutide. For atorvastatin, ka and transit compartment rate (ktr) decreased by 72% and 91%, respectively. Thus, gastric emptying, measured as T50, i.e., drug disappearance from the absorption compartments, showed an additional 5-min delay for paracetamol and a 67-min delay for atorvastatin when co-administered with semaglutide. Semaglutide affected pharmacokinetic model parameters of paracetamol and atorvastatin, and minor quantitative differences in gastric emptying between placebo vs. semaglutide administration were observed. However, these effects of semaglutide were considered not to be of clinical relevance.
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Affiliation(s)
- Emilie K Langeskov
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Kim Kristensen
- Discovery & Development PKPD, Novo Nordisk A/S, Måløv, Denmark
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3
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Holst JJ. Glucagon-like peptide-1: Are its roles as endogenous hormone and therapeutic wizard congruent? J Intern Med 2022; 291:557-573. [PMID: 34982496 DOI: 10.1111/joim.13433] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Glucagon-like peptide-1 (GLP-1) is a peptide derived from differential processing of the precursor for the hormone glucagon. It is secreted predominantly by endocrine cells in the gut epithelium in response to nutrient stimulation. Studies from the last 35 years have given us an idea about its physiological functions. On the basis of some of its many actions, it has also been developed into a pharmaceutical agent for the treatment of obesity and type 2 diabetes (T2DM). It is currently positioned as the most effective anti-obesity agent available and is recommended in both national and international guidelines as an effective second-in line treatment for T2DM, in particular in patients with increased cardiovascular risk. In this review, I first discuss whether the processing of proglucagon may also result in GLP-1 formation in the pancreas and in glucagon in the gut. Next, I discuss the relationship between the physiological actions of GLP-1 and the therapeutic effects of the GLP-1 receptor agonists, which are far from being congruent and generally poorly understood. These relationships illustrate both the difficulties and the benefits of bridging results obtained in the laboratory with those emerging from the clinic.
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Affiliation(s)
- Jens J Holst
- NovoNordisk Foundation Center for Basic Metabolic Research and Department of Biomedical Sciences, The Panum Institute, University of Copenhagen, Copenhagen, Denmark
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4
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Danowitz M, De Leon DD. The Role of GLP-1 Signaling in Hypoglycemia due to Hyperinsulinism. Front Endocrinol (Lausanne) 2022; 13:863184. [PMID: 35399928 PMCID: PMC8987579 DOI: 10.3389/fendo.2022.863184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/01/2022] [Indexed: 01/05/2023] Open
Abstract
Incretin hormones play an important role in the regulation of glucose homeostasis through their actions on the beta cells and other tissues. Glucagon-like peptide-1 (GLP-1) and glucose dependent insulinotropic polypeptide (GIP) are the two main incretins and are secreted by enteroendocrine L- and K-cells, respectively. New evidence suggests that incretin hormones, particularly GLP-1, play a role in the pathophysiology of hyperinsulinemic hypoglycemia. In individuals with acquired hyperinsulinemic hypoglycemia after gastrointestinal surgery, including Nissen fundoplication and gastric bypass surgery, the incretin response to a meal is markedly increased and antagonism of the GLP-1 receptor prevents the hyperinsulinemic response. In individuals with congenital hyperinsulinism due to inactivating mutations in the genes encoding the beta cell KATP channels, the GLP-1 receptor antagonist, exendin-(9-39), increases fasting plasma glucose and prevents protein-induced hypoglycemia. Studies in human and mouse islets lacking functional KATP channels have demonstrated that the effect on plasma glucose is at least in part mediated by inhibition of insulin secretion resulting from lower cytoplasmic cAMP levels. The understanding of the role of incretin hormones in the pathophysiology of hyperinsulinemic hypoglycemia is important for the exploration of the GLP-1 receptor as a therapeutic target for these conditions. In this article, we will review incretin physiology and evidence supporting a role of the incretin hormones in the pathophysiology of hyperinsulinemic hypoglycemia, as well as results from proof-of concept studies exploring a therapeutic approach targeting the GLP-1 receptor to treat hyperinsulinemic hypoglycemia.
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Affiliation(s)
- Melinda Danowitz
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Diva D. De Leon
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
- *Correspondence: Diva D. De Leon,
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5
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Ja'arah D, Al Zoubi MS, Abdelhady G, Rabi F, Tambuwala MM. Role of Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists in Hypoglycemia. CLINICAL MEDICINE INSIGHTS-ENDOCRINOLOGY AND DIABETES 2021; 14:11795514211051697. [PMID: 34690504 PMCID: PMC8527576 DOI: 10.1177/11795514211051697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 09/20/2021] [Indexed: 01/21/2023]
Abstract
A relatively recent addition to the arsenal of antidiabetic drugs used for the
treatment of type 2 diabetes mellitus (T2DM) has been the “incretin mimetics,” a
group of drugs that work on the glucagon-like peptide-1 (GLP-1) receptor and
enhance insulin secretion from the pancreatic β-cells in a glucose-dependent
manner, more potently in hyperglycemic conditions, while suppressing glucagon
secretion at the same time. Therefore, it was assumed that this class of drugs
would have a lower risk of hypoglycemia than insulin secretagogues like
sulphonylureas. However, GLP-1 receptor agonists have been proposed to cause
hypoglycemia in healthy normoglycemic subjects implying that their action is not
as glucose-dependent as once thought. Other studies concluded that they might
not induce hypoglycemia and the risk is dependent on other individual factors.
However, the FDA announced that the 12 GLP-1 receptor agonists currently
available on the market had potential safety signs and evaluated the need for
regulatory action. This review provides an overview of the studies that
investigated the possible hypoglycemic effect of GLP-1 receptor agonists. In
addition, the current review describes other adverse effects of GLP-1 receptor
agonist treatment.
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Affiliation(s)
- Daria Ja'arah
- Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid, Jordan
| | - Mazhar Salim Al Zoubi
- Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid, Jordan
| | - Gamal Abdelhady
- Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid, Jordan
| | - Firas Rabi
- Department of Clinical Sciences, Faculty of Medicine, Yarmouk University, Irbid, Jordan
| | - Murtaza M Tambuwala
- School of Pharmacy and Pharmaceutical Science, Ulster University, Coleraine, UK
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6
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Della Pepa G, Vetrani C, Lupoli R, Massimino E, Lembo E, Riccardi G, Capaldo B. Uncooked cornstarch for the prevention of hypoglycemic events. Crit Rev Food Sci Nutr 2021; 62:3250-3263. [PMID: 33455416 DOI: 10.1080/10408398.2020.1864617] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Hypoglycemia is a pathological condition characterized by a low plasma glucose concentration associated with typical autonomic and/or neuroglycopenic symptoms, and resolution of these symptoms with carbohydrate consumption. Hypoglycemia is quite common in clinical practice, particularly in insulin-treated patients with diabetes and in other inherited or acquired conditions involving the regulation of glucose metabolism. Beyond symptoms that might strongly affect the quality of life, hypoglycemia can lead to short- and long-term detrimental consequences for health. Hypoglycemia can be prevented by appropriate changes in dietary habits or by relevant modifications of the drug treatment. Several dietary approaches based on the intake of various carbohydrate foods have been tested for hypoglycemia prevention; among them uncooked cornstarch (UCS) has demonstrated a great efficacy. In this narrative review, we have summarized the current evidence on the UCS usefulness in some conditions characterized by high hypoglycemic risk, focusing on some inherited diseases -i.e. glycogen storage diseases and other rare disorders - and acquired conditions such as type 1 diabetes, postprandial hypoglycemia consequent to esophageal-gastric or bariatric surgery, and insulin autoimmune syndrome. We also considered the possible role of UCS during endurance exercise performance. Lastly, we have discussed the dose requirement, the side effects, the limitations of UCS use, and the plausible mechanisms by which UCS could prevent hypoglycemia.
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Affiliation(s)
- Giuseppe Della Pepa
- Department of Clinical Medicine and Surgery, University of Naples Federico II School of Medicine and Surgery, Naples, Italy
| | - Claudia Vetrani
- Department of Clinical Medicine and Surgery, University of Naples Federico II School of Medicine and Surgery, Naples, Italy
| | - Roberta Lupoli
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II School of Medicine and Surgery, Naples, Italy
| | - Elena Massimino
- Department of Clinical Medicine and Surgery, University of Naples Federico II School of Medicine and Surgery, Naples, Italy
| | - Erminia Lembo
- Department of Clinical Medicine and Surgery, University of Naples Federico II School of Medicine and Surgery, Naples, Italy
| | - Gabriele Riccardi
- Department of Clinical Medicine and Surgery, University of Naples Federico II School of Medicine and Surgery, Naples, Italy
| | - Brunella Capaldo
- Department of Clinical Medicine and Surgery, University of Naples Federico II School of Medicine and Surgery, Naples, Italy
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7
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Lindgren O, Ahrén B. Consequences on islet and incretin hormone responses to dinner by omission of lunch in healthy men. Endocrinol Diabetes Metab 2020; 3:e00141. [PMID: 32704562 PMCID: PMC7375076 DOI: 10.1002/edm2.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 03/31/2020] [Accepted: 04/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Omission of breakfast results in higher glucose and lower insulin and incretin hormone levels after both lunch and dinner. Whether omission of lunch has a similar impact on the following meal is not known. AIM This study therefore explored whether omission of lunch ingestion affects glucose, islet and incretin hormones after dinner ingestion in healthy subjects. MATERIALS & METHODS Twelve male volunteers (mean age 22 years, BMI 22.5 kg/m2) underwent two test days in random order with standard breakfast and dinner on both days with provision or omission of standard lunch in between. RESULTS The results showed that throughout the 300 minutes study period, glucose, insulin, glucagon and GIP levels after dinner ingestion did not differ between the two tests. In contrast, C-peptide, and GLP-1 levels were 26%-35% higher at later time points after dinner ingestion when lunch had been omitted (P < .05). CONCLUSION We conclude that omission of lunch increases GLP-1 and insulin secretion and possibly also insulin clearance resulting in unchanged glucose and insulin levels after dinner ingestion.
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Affiliation(s)
- Ola Lindgren
- Department of Clinical Sciences LundLund UniversityLundSweden
| | - Bo Ahrén
- Department of Clinical Sciences LundLund UniversityLundSweden
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8
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Ahmad A, Kornrich DB, Krasner H, Eckardt S, Ahmad Z, Braslow A, Broggelwirth B. Prevalence of Dumping Syndrome After Laparoscopic Sleeve Gastrectomy and Comparison with Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg 2020; 29:1506-1513. [PMID: 30635813 DOI: 10.1007/s11695-018-03699-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Dumping syndrome is a well-known side effect of laparoscopic gastric bypass (LRYGB), and it is commonly believed that dumping syndrome is less likely to occur after laparoscopic sleeve gastrectomy (LSG), due to the preservation of the pyloric sphincter. However, it is not uncommon for patients undergoing LSG at our center to report symptoms suggestive of dumping syndrome. OBJECTIVE To assess the prevalence of symptoms of dumping syndrome after LSG compared with LRYGB. SETTING A single surgical group at a high-volume (700 cases per year) Bariatric and Metabolic Surgery Center of Excellence. METHODS One thousand four hundred seventy-one LRYGB (366) and LSG (1105) patients received a questionnaire to assess symptoms of dumping syndrome, utilizing a modified version of the Sigstad scoring system. Dumping syndrome was considered to be present when the questionnaire score exceeded a threshold value. RESULTS A total of 360 responses were received (249 LSG, 111 LRYGB). 26.5% (66) LSG and 41.4% (46) LRYGB exceeded the threshold for dumping syndrome (p < 0.01). 84.8% (56) LSG and 84.7% (39) LRYGB reported early dumping syndrome (p > 0.05). Thirty-six percent (24) LSG and 28% (13) LRYGB reported late dumping syndrome (p > 0.05). Twenty-seven percent (62) LSG and 44.4% (44) LRYGB reported at least one symptom of dumping syndrome with sweets (p < 0.05). 34.3% (85) LSG and 35.5% (39) LRYGB reported symptoms when drinking with or within 30 min of a meal (p > 0.05). 14.5% (36) LSG and 17.3% (19) LRYGB reported symptoms after alcohol consumption (p > 0.05). CONCLUSION Dumping syndrome after LSG is prevalent but has not been widely reported. This finding may impact clinicians and patients in their choice of procedure and has relevance in post-operative education and care.
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Affiliation(s)
- Arif Ahmad
- Mather Hospital Northwell Health, 625 Belle Terre Road, Port Jefferson, NY, 11777, USA.
| | | | - Helaine Krasner
- Mather Hospital Northwell Health, 625 Belle Terre Road, Port Jefferson, NY, 11777, USA
| | - Sarah Eckardt
- Mather Hospital Northwell Health, 625 Belle Terre Road, Port Jefferson, NY, 11777, USA
| | - Zoha Ahmad
- Mather Hospital Northwell Health, 625 Belle Terre Road, Port Jefferson, NY, 11777, USA
| | - AnnaMarie Braslow
- Mather Hospital Northwell Health, 625 Belle Terre Road, Port Jefferson, NY, 11777, USA
| | - Barbara Broggelwirth
- Mather Hospital Northwell Health, 625 Belle Terre Road, Port Jefferson, NY, 11777, USA
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9
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Holst JJ, Albrechtsen NJW, Rosenkilde MM, Deacon CF. Physiology of the Incretin Hormones,
GIP
and
GLP
‐1—Regulation of Release and Posttranslational Modifications. Compr Physiol 2019; 9:1339-1381. [DOI: 10.1002/cphy.c180013] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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10
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Gastric Emptying and Distal Gastrectomy Independently Enhance Postprandial Glucagon-Like Peptide-1 Release After a Mixed Meal and Improve Glycemic Control in Subjects Having Undergone Pancreaticoduodenectomy. Pancreas 2019; 48:953-957. [PMID: 31268979 DOI: 10.1097/mpa.0000000000001361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES New-onset diabetes frequently resolves after pancreaticoduodenectomy (PD). Glucagon-like peptide-1 (GLP-1) conceivably is involved as its release is enhanced by rapid gastric emptying and distal bowel exposure to nutrients. We aimed at studying factors associated with GLP-1 release after PD. METHODS Fifteen PD subjects with distal gastrectomy (Whipple) and 15 with pylorus preservation were evaluated. A test meal containing 1 g paracetamol to measure gastric emptying was ingested. Blood for the measurement of paracetamol, glucose, insulin, and GLP-1 was drawn at baseline and 10, 20, 30, 60, 90, 120, 150, and 180 minutes thereafter. The Matsuda index of insulin sensitivity was calculated. RESULTS In univariate analysis, gastric emptying correlated with GLP-1. Glucagon-like peptide-1 responses to the modes of operation did not differ. Multiple regression analysis confirmed gastric emptying and Whipple versus pylorus-preserving pancreaticoduodenectomy as independent predictors of GLP-1 release. The Matsuda index of insulin sensitivity correlated with GLP-1 concentrations and inversely with body mass index. Patients after Whipple procedure revealed lower glycated hemoglobin as compared with pylorus-preserving pancreaticoduodenectomy. CONCLUSIONS Following PD, the postprandial GLP-1 release seems to be enhanced by rapid gastric emptying and to improve insulin sensitivity. Partial gastrectomy versus pylorus preservation enhanced the release of GLP-1, conceivably because of greater distal bowel exposure to undigested nutrients.
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11
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Larraufie P, Roberts GP, McGavigan AK, Kay RG, Li J, Leiter A, Melvin A, Biggs EK, Ravn P, Davy K, Hornigold DC, Yeo GSH, Hardwick RH, Reimann F, Gribble FM. Important Role of the GLP-1 Axis for Glucose Homeostasis after Bariatric Surgery. Cell Rep 2019; 26:1399-1408.e6. [PMID: 30726726 PMCID: PMC6367566 DOI: 10.1016/j.celrep.2019.01.047] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/14/2018] [Accepted: 01/11/2019] [Indexed: 02/07/2023] Open
Abstract
Bariatric surgery is widely used to treat obesity and improves type 2 diabetes beyond expectations from the degree of weight loss. Elevated post-prandial concentrations of glucagon-like peptide 1 (GLP-1), peptide YY (PYY), and insulin are widely reported, but the importance of GLP-1 in post-bariatric physiology remains debated. Here, we show that GLP-1 is a major driver of insulin secretion after bariatric surgery, as demonstrated by blocking GLP-1 receptors (GLP1Rs) post-gastrectomy in lean humans using Exendin-9 or in mice using an anti-GLP1R antibody. Transcriptomics and peptidomics analyses revealed that human and mouse enteroendocrine cells were unaltered post-surgery; instead, we found that elevated plasma GLP-1 and PYY correlated with increased nutrient delivery to the distal gut in mice. We conclude that increased GLP-1 secretion after bariatric surgery arises from rapid nutrient delivery to the distal gut and is a key driver of enhanced insulin secretion.
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Affiliation(s)
- Pierre Larraufie
- Metabolic Research Laboratories, Wellcome Trust MRC Institute of Metabolic Science, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Geoffrey P Roberts
- Metabolic Research Laboratories, Wellcome Trust MRC Institute of Metabolic Science, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Anne K McGavigan
- Metabolic Research Laboratories, Wellcome Trust MRC Institute of Metabolic Science, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Richard G Kay
- Metabolic Research Laboratories, Wellcome Trust MRC Institute of Metabolic Science, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Joyce Li
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Andrew Leiter
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Audrey Melvin
- Metabolic Research Laboratories, Wellcome Trust MRC Institute of Metabolic Science, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Emma K Biggs
- Metabolic Research Laboratories, Wellcome Trust MRC Institute of Metabolic Science, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Peter Ravn
- Department of Antibody Discovery and Protein Engineering, MedImmune, Granta Park, Cambridge CB21 6GH, UK
| | - Kathleen Davy
- Department of Cardiovascular and Metabolic Disease, MedImmune, Granta Park, Cambridge, UK
| | - David C Hornigold
- Department of Cardiovascular and Metabolic Disease, MedImmune, Granta Park, Cambridge, UK
| | - Giles S H Yeo
- Metabolic Research Laboratories, Wellcome Trust MRC Institute of Metabolic Science, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Richard H Hardwick
- Cambridge Oesophago-gastric Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Frank Reimann
- Metabolic Research Laboratories, Wellcome Trust MRC Institute of Metabolic Science, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Fiona M Gribble
- Metabolic Research Laboratories, Wellcome Trust MRC Institute of Metabolic Science, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK.
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12
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Holst JJ, Madsbad S, Bojsen-Møller KN, Svane MS, Jørgensen NB, Dirksen C, Martinussen C. Mechanisms in bariatric surgery: Gut hormones, diabetes resolution, and weight loss. Surg Obes Relat Dis 2018; 14:708-714. [PMID: 29776493 PMCID: PMC5974695 DOI: 10.1016/j.soard.2018.03.003] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 03/04/2018] [Indexed: 12/11/2022]
Abstract
Gastric bypass surgery leads to profound changes in the secretion of gut hormones with effects on metabolism, appetite, and food intake. Here, we discuss their contributions to the improvement in glucose tolerance and the weight loss that results from the operations. We find that the improved glucose tolerance is due the following events: a negative energy balance and resulting weight loss, which improve first hepatic and later peripheral insulin sensitivity, in combination with increased postprandial insulin secretion elicited particularly by exaggerated glucagon-like peptide-1 responses. The weight loss is due to loss of appetite resulting in reduced energy intake, and we find it probable that this process is driven by exaggerated secretion of appetite-regulating gut hormones including, but probably not limited to, glucagon-like peptide-1 and peptide-YY. The increased secretion is due to an accelerated exposure to and absorption of nutrients in the small intestine. This places the weight loss and the gut hormones in key positions with respect to the metabolic improvements after bypass surgery.
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Affiliation(s)
- Jens Juul Holst
- NNF Center for Basic Metabolic Research and Dept. Biomedical Sciences, the Panum Institute, University of Copenhagen, Copenhagen, Denmark.
| | - Sten Madsbad
- NNF Center for Basic Metabolic Research and Dept. Biomedical Sciences, the Panum Institute, University of Copenhagen, Copenhagen, Denmark; Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Kirstine N Bojsen-Møller
- NNF Center for Basic Metabolic Research and Dept. Biomedical Sciences, the Panum Institute, University of Copenhagen, Copenhagen, Denmark; Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Maria Saur Svane
- NNF Center for Basic Metabolic Research and Dept. Biomedical Sciences, the Panum Institute, University of Copenhagen, Copenhagen, Denmark; Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Nils Bruun Jørgensen
- NNF Center for Basic Metabolic Research and Dept. Biomedical Sciences, the Panum Institute, University of Copenhagen, Copenhagen, Denmark; Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Carsten Dirksen
- NNF Center for Basic Metabolic Research and Dept. Biomedical Sciences, the Panum Institute, University of Copenhagen, Copenhagen, Denmark; Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christoffer Martinussen
- NNF Center for Basic Metabolic Research and Dept. Biomedical Sciences, the Panum Institute, University of Copenhagen, Copenhagen, Denmark; Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
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13
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Amagai M, Tsuchiya H, Chiba Y, Suzuki J, Nagakura J, Shigematsu E, Yamakawa T, Terauchi Y. Incretin Kinetics Before and After Miglitol in Japanese Patients With Late Dumping Syndrome. J Clin Med Res 2017; 9:879-885. [PMID: 28912925 PMCID: PMC5593436 DOI: 10.14740/jocmr3135w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 07/28/2017] [Indexed: 11/11/2022] Open
Abstract
Background In patients with late dumping syndrome following gastrectomy, it has been reported that hypoglycemia occurs due to inhibition of glucagon secretion as a result of excessive insulin production facilitated by an increase in glucagon-like peptide-1 (GLP-1). Methods To determine the kinetics of incretins in Japanese patients with late dumping syndrome, an oral glucose tolerance test was carried out before and after miglitol administration, and the kinetics of insulin and incretins were analyzed. Results After miglitol administration, there was improvement of hypoglycemia and early phase insulin secretion, with persistent excessive insulin secretion being minimized. These findings revealed that miglitol inhibited rapid excessive influx of carbohydrates into the blood and persistent elevation of GLP-1, resulting in improvement of early phase insulin secretion and minimizing persistent excessive insulin secretion. Conclusions Eating frequent small meals is generally effective for late dumping syndrome, but patients often find it difficult to continue such a regimen. Based on the present analysis of incretin kinetics, miglitol may be a useful treatment option for late dumping syndrome.
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Affiliation(s)
- Mari Amagai
- Department of Endocrinology and Diabetes, Yokosuka City Hospital, Yokosuka, Japan.,These authors contributed equally to this work
| | - Hirohisa Tsuchiya
- Department of Endocrinology and Diabetes, Yokosuka City Hospital, Yokosuka, Japan.,These authors contributed equally to this work
| | - Yukari Chiba
- Department of Endocrinology and Diabetes, Yokosuka City Hospital, Yokosuka, Japan
| | - Jun Suzuki
- Department of Endocrinology and Diabetes, Yokohama City University Medical Center, Yokohama, Japan
| | - Jo Nagakura
- Department of Endocrinology and Diabetes, Yokohama City University Medical Center, Yokohama, Japan
| | - Erina Shigematsu
- Department of Diabetes and Endocrinology, National Hospital Organization Yokohama Medical Center, Yokohama, Japan
| | - Tadashi Yamakawa
- Department of Endocrinology and Diabetes, Yokohama City University Medical Center, Yokohama, Japan
| | - Yasuo Terauchi
- Department of Endocrinology and Metabolism, Yokohama City University School of Medicine, Yokohama, Japan
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Takebayashi K, Inukai T. Effect of Sodium Glucose Cotransporter 2 Inhibitors With Low SGLT2/SGLT1 Selectivity on Circulating Glucagon-Like Peptide 1 Levels in Type 2 Diabetes Mellitus. J Clin Med Res 2017; 9:745-753. [PMID: 28811850 PMCID: PMC5544478 DOI: 10.14740/jocmr3112w] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 07/01/2017] [Indexed: 02/07/2023] Open
Abstract
Sodium glucose cotransporter 2 (SGLT2) inhibitors are a new class of antidiabetic drugs that improve glycemic control by inhibiting reabsorption of glucose filtered through the renal glomerulus. Use of drugs in this class has increased because of their effect of decreasing body weight and a low risk for hypoglycemia, in addition to a relatively strong glucose-lowering effect. SGLT2 inhibitors such as canagliflozin and sotagliflozin (a SGLT1/SGLT2 dual inhibitor) also have a mild or moderate intestinal and renal SGLT1 inhibitory effect because of their relatively weak selectivity for SGLT2 over SGLT1. Recent evidence shows that these SGLT2 inhibitors with low SGLT2/SGLT1 selectivity elevate the level of circulating glucagon like peptide-1 (GLP-1), an incretin hormone that promotes insulin secretion in pancreatic β cells. This effect probably occurs partly via inhibition of intestinal SGLT1, and the elevation of active GLP-1 levels is especially apparent when these drugs are co-administered with dipeptidyl peptidase 4 (DPP4) inhibitors. These findings suggest that a combination of canagliflozin or sotagliflozin and a DPP4 inhibitor can provide a beneficial effect associated with elevation of circulating active GLP-1 and may serve as a treatment for patients with type 2 diabetes.
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Affiliation(s)
- Kohzo Takebayashi
- Department of Internal Medicine, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
| | - Toshihiko Inukai
- Department of Internal Medicine, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
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Vukovic R, Milenkovic T, Djordjevic M, Mitrovic K, Todorovic S, Sarajlija A, Hussain K. Postprandial hyperinsulinemic hypoglycemia in a child as a late complication of esophageal reconstruction. J Pediatr Endocrinol Metab 2017; 30:791-795. [PMID: 28672750 DOI: 10.1515/jpem-2017-0139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 06/02/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Postprandial hyperinsulinemic hypoglycemia (PHH) is an increasingly recognized complication of gastric bypass surgery in obese adults, distinct from the "dumping syndrome". CASE PRESENTATION Upon birth, primary repair of esophageal atresia was performed, and at the age of 14 months definite esophageal reconstruction was performed. At the age of 3 years, recurrent brief episodes of symptomatic hypoglycemia started. At the age of 5.7 years the girl was admitted to our clinic and investigations indicated hyperinsulinemic hypoglycemia. Oral glucose tolerance test (OGTT) and continuous glucose monitoring results revealed frequent postprandial hypoglycemic events, which were always preceded by early postprandial hyperglycemia. It was concluded that the patient had PHH caused by a delayed and hyperinsulinemic response to carbohydrate intake as a result of esophagogastric surgery. Treatment with acarbose was titrated using flash glucose monitoring, which resulted in satisfactory glucose regulation. CONCLUSIONS This is the first described case of a child with PHH following esophageal reconstruction.
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Trindade EM, Gebara TSES, Cambi MPC, Baretta GAP. NUTRITIONAL ASPECTS AND THE USE OF NUTRITIONAL SUPPLEMENTS BY WOMEN WHO UNDERWENT GASTRIC BYPASS. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2017; 30:11-13. [PMID: 28489160 PMCID: PMC5424678 DOI: 10.1590/0102-6720201700010004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 12/15/2016] [Indexed: 01/22/2023]
Abstract
Background Bariatric surgery is deemed one of the most effective procedures for the treatment of obesity and it aims at the reduction and maintenance of weight loss in long term, as the control of the related comorbidities. Aim Quantify the occurrence of alterations of the gastrointestinal tract, suggestive signs of nutritional deficiencies and the use of supplements in a group of women undergoing bariatric surgery. Methods The sample consisted of women aged 20-65 years submitted to Roux-en-Y gastric bypass with monitoring equal to or higher than 24 months. For the qualitative analysis, the Feeding Frequency Questionnaire was used. Results In the postoperative period, alopecia was the most reported (79.3%), followed by changes in the texture of the nails, both considered predictive of nutritional deficiencies. Changes in the gastrointestinal tract were described in 86.2%, and episodes of dumping were reported in 65.5%. Qualitative analysis has shown reduced daily consumption of sources of animal and plant proteins. Conclusion After bariatric surgery can occur flatulence, vomiting and dumping syndrome as the most frequent representative symptoms of digestive functional disorders. Alopecia and nail changes are the most important signs of nutritional deficiency. The use of dietary supplements in the postoperative period is scarce and sporadic.
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Steiner E, Kazianka L, Breuer R, Hacker M, Wadsak W, Mitterhauser M, Stimpfl T, Reiter B, Karanikas G, Miholic J. **-Postprandial pancreatic [ 11C]methionine uptake after pancreaticoduodenectomy mirrors basal beta cell function and insulin release. Eur J Nucl Med Mol Imaging 2016; 44:509-516. [PMID: 27389029 PMCID: PMC5591624 DOI: 10.1007/s00259-016-3451-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 06/22/2016] [Indexed: 12/18/2022]
Abstract
Purpose [S-methyl-11C]-L-methionine ([11C]MET) uptake in the pancreas might be a central indicator of beta cell function. Since gastric emptying was recently shown to influence glycemic control in subjects after pancreaticoduodenectomy (PD, the surgical treatment of neoplasms of the pancreas head), we looked for imaginable relationships between gastric emptying, pre- and postprandial insulin concentrations, and [11C]MET uptake. Methods Nineteen tumor-free survivors after PD (age mean ± SD: 61 ± 8.7 yrs.; 10 male, 9 female) and 10 healthy controls (age: 27 ± 8.7 yrs.; 7 male, 3 female) were given a mixed test meal. One gram of paracetamol was ingested with the meal to evaluate the speed of gastric emptying. Insulin, glucose, and paracetamol plasma concentrations were measured before and over 180 minutes after ingestion. Beta cell function was calculated from fasting glucose and insulin plasma concentrations. Simultaneously, 800 MBq of [11C]MET were administered and the activity (maximum tissue standardized uptake values [SUVmax]) over the pancreas was measured at 15, 30, and 60 minutes after injection. Total integrated SUVmax (area under the curve [AUC]) and incremental SUVmax were calculated. Results The uptake of [11C]MET in the pancreas was significantly higher (p < 0.0001) in controls compared to the PD group. Gastric emptying was significantly slower in controls compared to pancreatectomy subjects (p < 0.0001). Paracetamol AUC30 correlated with the SUVmax increment between 15 and 30 minutes (R2 = 0.27, p = 0.0263), suggesting a relationship between gastric emptying and the uptake of [11C]MET. Total integrated SUVmax correlated with insulin AUC60 (R2 = 0.66,p < 0.0001) in patients after PD. Multivariate regression analysis revealed insulin AUC60 and beta cell function, calculated from the fasting insulin to glucose ratio, as independent predictors of 11C-methionine uptake, i.e. total integrated SUVmax, in patients after PD (R2 = 0.78, p < 0.0001). Conclusion Postprandial [11C]MET uptake may represent basal and postprandial beta cell function. The findings suggest a possible usefulness of this imaging procedure for further studying beta cell function.
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Affiliation(s)
- Emanuel Steiner
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Lukas Kazianka
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Robert Breuer
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Marcus Hacker
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, A-1090, Austria
| | - Wolfgang Wadsak
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, A-1090, Austria
| | - Markus Mitterhauser
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, A-1090, Austria
| | - Thomas Stimpfl
- Clinical Institute of Laboratory Medicine, Forensic Toxicology, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Birgit Reiter
- Clinical Institute of Laboratory Medicine, Forensic Toxicology, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Georgios Karanikas
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Divisional Head PET-PET/CT (Nuclear Medicine), Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria.
| | - Johannes Miholic
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
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Shantavasinkul PC, Torquati A, Corsino L. Post-gastric bypass hypoglycaemia: a review. Clin Endocrinol (Oxf) 2016; 85:3-9. [PMID: 26840207 DOI: 10.1111/cen.13033] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 11/27/2015] [Accepted: 01/28/2016] [Indexed: 12/27/2022]
Abstract
Bariatric surgery is a highly effective treatment for severe obesity, resulting in substantial weight loss and normalizing obesity-related comorbidities. However, long-term consequences can occur, such as postbariatric surgery hypoglycaemia. This is a challenging medical problem, and the number of patients presenting with it has been increasing. Roux-en-Y gastric bypass (RYGB) is the most popular bariatric procedure, and it is the surgery most commonly associated with the development of postbariatric surgery hypoglycaemia. To date, the pathogenesis of this condition has not been completely established. However, various factors - particularly increased postprandial glucagon-like peptide (GLP)-1 secretion - have been considered as crucial mediator. The mechanisms responsible for diabetic remission after bariatric surgery may be responsible for the development of hypoglycaemia, which typically occurs 1-3 h after a meal and is concurrent with inappropriate hyperinsulinaemia. Carbohydrate-rich foods usually provoke hypoglycaemic symptoms, which can typically be alleviated by strict dietary modifications, including carbohydrate restriction and avoidance of high glycaemic index foods and simple sugars. Few patients require further medical intervention, such as medications, but some patients have required a pancreatectomy. Because this option is not always successful, it is no longer routinely recommended. Clinical trials are needed to further determine the pathophysiology of this condition as well as the best diagnostic and treatment approaches for these patients.
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Affiliation(s)
- Prapimporn C Shantavasinkul
- Division of Nutrition and Biochemical Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Alfonso Torquati
- Center for Weight Loss and Bariatric Surgery, Department of General Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Leonor Corsino
- Department of Medicine, Division of Endocrinology, Metabolism and Nutrition, Duke University, Durham, NC, USA
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Holst JJ, Gribble F, Horowitz M, Rayner CK. Roles of the Gut in Glucose Homeostasis. Diabetes Care 2016; 39:884-92. [PMID: 27222546 DOI: 10.2337/dc16-0351] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 03/22/2016] [Indexed: 02/05/2023]
Abstract
The gastrointestinal tract plays a major role in the regulation of postprandial glucose profiles. Gastric emptying is a highly regulated process, which normally ensures a limited and fairly constant delivery of nutrients and glucose to the proximal gut. The subsequent digestion and absorption of nutrients are associated with the release of a set of hormones that feeds back to regulate subsequent gastric emptying and regulates the release of insulin, resulting in downregulation of hepatic glucose production and deposition of glucose in insulin-sensitive tissues. These remarkable mechanisms normally keep postprandial glucose excursions low, regardless of the load of glucose ingested. When the regulation of emptying is perturbed (e.g., pyloroplasty, gastric sleeve or gastric bypass operation), postprandial glycemia may reach high levels, sometimes followed by profound hypoglycemia. This article discusses the underlying mechanisms.
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Affiliation(s)
- Jens Juul Holst
- The Novo Nordisk Foundation Center for Basic Metabolic Research and Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Fiona Gribble
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, U.K
| | - Michael Horowitz
- Discipline of Medicine, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Chris K Rayner
- Discipline of Medicine, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Holst JJ, Madsbad S. Mechanisms of surgical control of type 2 diabetes: GLP-1 is key factor. Surg Obes Relat Dis 2016; 12:1236-42. [PMID: 27313194 DOI: 10.1016/j.soard.2016.02.033] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 02/23/2016] [Indexed: 01/07/2023]
Abstract
GLP-1 secretion in response to meals is dramatically increased after gastric bypass operations. GLP-1 is a powerful insulinotropic and anorectic hormone, and analogs of GLP-1 are widely used for the treatment of diabetes and recently approved also for obesity treatment. It is, therefore, reasonable to assume that the exaggerated GLP-1 secretion contributes to the antidiabetic and anorectic effects of gastric bypass. Indeed, human experiments with the GLP-1 receptor antagonist, Exendin 9-39, have shown that the improved insulin secretion, which is responsible for part of the antidiabetic effect of the operation, is reduced and or abolished after GLP-1 receptor blockade. Also the postoperative improvement of glucose tolerance is eliminated and or reduced by the antagonist, pointing to a key role for the exaggerated GLP-1 secretion. Indeed, there is evidence that the exaggerated GLP-1 secretion is also responsible for postprandial hypoglycemia sometimes observed after bypass. Other operations (biliopancreatic-diversion and or sleeve gastrectomy) appear to involve different and/or additional mechanisms, and so does experimental bariatric surgery in rodents. However, unlike bypass surgery in humans, the rodent operations are generally associated with increased energy metabolism pointing to an entirely different mechanism of action in the animals.
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Affiliation(s)
- Jens Juul Holst
- NNF Center for Basic Metabolic Research and Department of Biomedical Research, the Panum Institute, Copenhagen, Denmark.
| | - Sten Madsbad
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
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Lupoli R, Cotugno M, Griffo E, Nosso G, Riccardi G, Capaldo B. Role of the Entero-Insular Axis in the Pathogenesis of Idiopathic Reactive Hypoglycemia: A Pilot Study. J Clin Endocrinol Metab 2015; 100:4441-6. [PMID: 26502359 DOI: 10.1210/jc.2015-3309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
CONTEXT Idiopathic reactive hypoglycemia (IRH) is characterized by recurrent episodes of symptomatic hypoglycemia occurring within 4 hours after meals. The underlying mechanisms remain obscure. OBJECTIVE This study aimed to investigate the response of the glucoregulatory and gastrointestinal hormones to an oral glucose load (OGTT) in individuals with documented IRH. DESIGN AND SETTING This was a cross-sectional study composed of outpatients referred to "Federico II" University of Naples. PATIENTS We enrolled subjects with IRH documented by a mixed meal under ordinary life conditions and healthy subjects as controls. MAIN OUTCOME MEASURE We measured plasma glucose, insulin, glucagon-like peptide 1 (GLP-1), GIP, and glucagon response to a 75-g OGTT in cases and controls. RESULTS Ten IRH and eight control subjects were enrolled. During the OGTT, mean plasma glucose tended to be lower in IRH than in control subjects, reaching a statistically significant difference at 240 minutes (T240) (43 ± 1.6 vs 72 ± 0.3 mg/dL; P = .001). Accordingly, the insulin response was higher in IRH than in control subjects (P < .019) with a statistically significant difference (46%) at T90 (P = .045) and was associated with significantly lower glucagon levels in the late phase of the OGTT: at T120 (P = .031) and T180 (P = .048) in IRH than in control subjects. A greater GLP-1 response was found among IRH compared with control subjects (P = .005); GLP-1 peak was 2-fold higher in IRH individuals (9.77 ± 2.52 pmol/L) than in the control group (4.19 ± 0.53 pmol/L; P = .041). In the IRH group, GLP-1 peak inversely correlated with the nadir of plasma glucose (r = -0.66; P = .039). A multivariate analysis confirmed that GLP-1 peak independently predicted the plasma glucose nadir (β = -0.593; P = .026). CONCLUSIONS GLP-1 may play a significant role in the pathogenesis of idiopathic IRH.
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Affiliation(s)
- Roberta Lupoli
- Department of Clinical Medicine and Surgery, "Federico II" University, 80131 Naples, Italy
| | - Mariella Cotugno
- Department of Clinical Medicine and Surgery, "Federico II" University, 80131 Naples, Italy
| | - Ettore Griffo
- Department of Clinical Medicine and Surgery, "Federico II" University, 80131 Naples, Italy
| | - Gabriella Nosso
- Department of Clinical Medicine and Surgery, "Federico II" University, 80131 Naples, Italy
| | - Gabriele Riccardi
- Department of Clinical Medicine and Surgery, "Federico II" University, 80131 Naples, Italy
| | - Brunella Capaldo
- Department of Clinical Medicine and Surgery, "Federico II" University, 80131 Naples, Italy
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Abstract
Although GLP-1 (glucagon like peptide-1) based therapies (GLP-1 agonists and dipeptidyl peptidase-4 inhibitors) is currently playing a cornerstone role in the treatment of type 2 diabetes, dilemma does exist about some of its basic physiology. So far, we know that GLP-1 is secreted by the direct actions of luminal contents on the L cells in distal jejunum and proximal ileum. However, there is growing evidence now, which suggest that other mechanism via "neural" or "upper gut" signals may be playing a second fiddle and could stimulate GLP-1 secretion even before the luminal contents have reached into the proximities of L cells. Therefore, the contribution of direct and indirect mechanism to GLP-1 secretion remains elusive. Furthermore, no clear consensus exists about the pattern of GLP-1 secretion, although many believe it is monophasic. One of the most exciting issues in incretin science is GLP-1 level and GLP-1 responsiveness. It is not exactly known as to what happens to endogenous GLP-1 with progressive worsening of dysglycemia from normal glucose tolerance to impaired glucose to frank diabetes and furthermore with increasing duration of diabetes. Although, conventional wisdom suggests that there may be a decrease in endogenous GLP-1 level with the worsening of dysglycemia, literature showed discordant results. Furthermore, there is emerging evidence to suggest that GLP-1 response can vary with ethnicity. This mini review is an attempt to put a brief perspective on all these issues.
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Affiliation(s)
- Awadhesh Kumar Singh
- Senior Consultant Endocrinologist, G.D Diabetes Hospital, Kolkata, West Bengal, India
- Sun Valley Diabetes Hospital, Guwahati, Assam, India
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Harmuth S, Wewalka M, Holst JJ, Nemecek R, Thalhammer S, Schmid R, Sahora K, Gnant M, Miholić J. Distal gastrectomy in pancreaticoduodenectomy is associated with accelerated gastric emptying, enhanced postprandial release of GLP-1, and improved insulin sensitivity. J Gastrointest Surg 2014; 18:52-9. [PMID: 24002756 DOI: 10.1007/s11605-013-2283-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 07/02/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This study aims to investigate the relationship between gastric emptying, postprandial GLP-1 and insulin sensitivity after pancreaticoduodenectomy (PD). BACKGROUND Abnormal glucose regulation is highly prevalent in patients with pancreatic neoplasm and resolves in some after PD, the cause of which is unclear. The procedure is carried out with pylorus preservation (PPPD) or with distal gastrectomy (Whipple procedure). Accelerated gastric emptying and ensuing enhanced release of glucagon-like peptide-1 (GLP-1) conceivably play a role in glucose metabolism after PD. It was the purpose of this study to shed light on the relationship between gastric emptying, GLP-1 and glycemic control after PPPD and the Whipple procedure. METHODS A 75-g oral glucose tolerance test was carried out in 13 patients having undergone PPPD and in 13 after the Whipple procedure, median age 61 (range, 32-70) years, following an interval of 23 (range, 5-199) months. Gastric emptying was measured by the paracetamol absorption method. Plasma concentrations of glucose, insulin, GLP-1 and paracetamol were measured at baseline, 10, 20, 30 60, 90, 120, 150 and 180 min. Homeostasis model assessment-estimated insulin resistance (HOMA-IR) and oral glucose insulin sensitivity were calculated from glucose and insulin concentrations. RESULTS Patients with Whipple procedure as compared to PPPD had accelerated gastric emptying (p = 0.01) which correlated with early (0-30 min) integrated GLP-1 (AUC30; r (2) = 0.61; p = 0.02) and insulin sensitivity (r (2) = 0.41; p = 0.026) and inversely with HOMA-IR (r (2) = 0.17; p = 0.033). Two of 13 Whipple patients (15 %) as compared to seven of 13 after PPPD (54 %) had postload glucose concentrations (i.e. 120 min postmeal) ≥200 mg/dl (p < 0.05). None of 13 (0 %) after Whipple procedure but four of 13 patients (31 %) after PPPD had fasting glucose concentrations ≥126 mg/dl (p < 0.05) CONCLUSIONS: Gastric emptying was accelerated after Whipple procedure as compared to patients who have undergone PPPD, resulting in higher postprandial GLP-1 concentrations and insulin sensitivity and improved glycemic control.
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Affiliation(s)
- Stefan Harmuth
- Department of Surgery, Allgemeines Krankenhaus (AKH), Medical University of Vienna, Währinger Gürtel 18, 1090, Vienna, Austria
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Abstract
Hypoglycemia remains a common problem for patients with diabetes and is associated with substantial morbidity and mortality. This article summarizes our current knowledge of the epidemiology, pathogenesis, risk factors, and complications of hypoglycemia in patients with diabetes and discusses prevention and treatment strategies.
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Affiliation(s)
- Mazen Alsahli
- Division of Endocrinology, Department of Medicine, Southlake Regional Health Center, 309-531 Davis Drive, Newmarket, Ontario L3Y 6P5, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, 1 King's College Cir, Toronto, Ontario M5S 1A8, Canada
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Idorn T, Knop FK, Jørgensen M, Holst JJ, Hornum M, Feldt-Rasmussen B. Postprandial responses of incretin and pancreatic hormones in non-diabetic patients with end-stage renal disease. Nephrol Dial Transplant 2013; 29:119-27. [PMID: 24078334 DOI: 10.1093/ndt/gft353] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Patients with end-stage renal disease (ESRD) have glucometabolic disturbances resulting in a high prevalence of prediabetes. The underlying pathophysiology remains unclear, but may prove important for the strategies employed to prevent progression to overt diabetes. Meal-induced release of the insulinotropic gut-derived incretin hormones and pancreatic hormones play a critical role in the maintenance of a normal postprandial glucose tolerance. METHODS We studied patients with ESRD and either normal (n = 10) or impaired (n = 10) glucose tolerance, and control subjects (n = 11). Plasma concentrations of glucose, insulin, glucagon, glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP) and paracetamol were measured repeatedly during a standardized 4-h liquid meal including 1.5 g paracetamol (added for evaluation of gastric emptying). RESULTS Fasting glucose and postprandial glucose responses were comparable between groups (P > 0.082). Patients with ESRD exhibited higher fasting levels of GIP and glucagon compared with controls (P < 0.001). Baseline-corrected GLP-1 and glucagon responses were enhanced (P < 0.002), baseline-corrected insulin responses and insulin excursions were reduced (P < 0.035), and paracetamol excursions were delayed (P < 0.024) in patients with ESRD compared with controls. None of the variables differed between the two ESRD subgroups. CONCLUSIONS Non-diabetic patients with ESRD were characterized by reduced postprandial insulin responses despite increased secretion of the insulinotropic incretin hormone GLP-1. Fasting levels and baseline-corrected responses of glucagon were elevated and gastric emptying was delayed in the ESRD patients. These perturbations seem to be caused by uraemia per se and may contribute to the disturbed glucose metabolism in ESRD patients.
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Affiliation(s)
- Thomas Idorn
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Plamboeck A, Veedfald S, Deacon CF, Hartmann B, Wettergren A, Svendsen LB, Meisner S, Hovendal C, Knop FK, Vilsbøll T, Holst JJ. Characterisation of oral and i.v. glucose handling in truncally vagotomised subjects with pyloroplasty. Eur J Endocrinol 2013; 169:187-201. [PMID: 23704713 PMCID: PMC3709640 DOI: 10.1530/eje-13-0264] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Glucagon-like peptide 1 (GLP1) is rapidly inactivated by dipeptidyl peptidase 4 (DPP4), but may interact with vagal neurons at its site of secretion. We investigated the role of vagal innervation for handling of oral and i.v. glucose. DESIGN AND METHODS Truncally vagotomised subjects (n=16) and matched controls (n=10) underwent 50 g-oral glucose tolerance test (OGTT)±vildagliptin, a DPP4 inhibitor (DPP4i) and isoglycaemic i.v. glucose infusion (IIGI), copying the OGTT without DPP4i. RESULTS Isoglycaemia was obtained with 25±2 g glucose in vagotomised subjects and 18±2 g in controls (P<0.03); thus, gastrointestinal-mediated glucose disposal (GIGD) - a measure of glucose handling (100%×(glucoseOGTT-glucoseIIGI/glucoseOGTT)) - was reduced in the vagotomised compared with the control group. Peak intact GLP1 concentrations were higher in the vagotomised group. Gastric emptying was faster in vagotomised subjects after OGTT and was unaffected by DPP4i. The early glucose-dependent insulinotropic polypeptide response was higher in vagotomised subjects. Despite this, the incretin effect was equal in both groups. DPP4i enhanced insulin secretion in controls, but had no effect in the vagotomised subjects. Controls suppressed glucagon concentrations similarly, irrespective of the route of glucose administration, whereas vagotomised subjects showed suppression only during IIGI and exhibited hyperglucagonaemia following OGTT. DPP4i further suppressed glucagon secretion in controls and tended to normalise glucagon responses in vagotomised subjects. CONCLUSIONS GIGD is diminished, but the incretin effect is unaffected in vagotomised subjects despite higher GLP1 levels. This, together with the small effect of DPP4i, is compatible with the notion that part of the physiological effects of GLP1 involves vagal transmission.
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Affiliation(s)
- Astrid Plamboeck
- Diabetes Research Division, Department of Internal Medicine, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark.
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Incretin dysfunction in type 2 diabetes: Clinical impact and future perspectives. DIABETES & METABOLISM 2013; 39:195-201. [DOI: 10.1016/j.diabet.2013.03.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 03/08/2013] [Accepted: 03/11/2013] [Indexed: 01/21/2023]
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Lee W, Ahn SH, Lee JH, Park DJ, Lee HJ, Kim HH, Yang HK. Comparative study of diabetes mellitus resolution according to reconstruction type after gastrectomy in gastric cancer patients with diabetes mellitus. Obes Surg 2012; 22:1238-43. [PMID: 22179701 DOI: 10.1007/s11695-011-0580-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND This study was conducted to investigate diabetes mellitus (DM) resolution after gastrectomy according to reconstruction type in gastric cancer patients. METHODS Two hundred twenty-nine gastric cancer patients with DM who underwent gastrectomy with curative intent from May 2003 to December 2009 were enrolled. Changes in fasting blood sugar concentration and the dosage of oral hyperglycemic agents or insulin were compared between reconstruction types. RESULTS The numbers of patients who underwent distal gastrectomy with a Billroth I (BI), Billroth II (BII), Roux-en-Y gastrojejunostomy (RYGJ), or total gastrectomy with Roux-en-Y esophagojejunostomy (RYEJ) were 119 (51.7%), 54 (23.5%), 40 (17.4%), and 16 (6.9%), respectively. DM remitted in 45 (19.7%) patients: 18 BI patients (15.1%), 11 BII patients (20.3%), 8 RYGJ patients (20.0%), and 8 RYEJ patients (50.0%). DM improved in 85 (37.1%) patients: 41 BI patients (34.4%), 25 BII patients (46.2%), 15 RYGJ patients (37.5%), and 4 RYEJ patients (25.0%). The DM remission or improvement rate was higher in the duodenal bypass group (BII, RYGJ, RYEJ) than in the BI group (67.2% vs. 49.5%, P = 0.022), and the DM remission rate was higher in the RYEJ group than in the distal gastrectomy group (50.0% vs. 17.3%, P = 0.002). CONCLUSIONS Many gastric cancer patients with DM who received a gastrectomy showed remission or improvement of DM. The duodenal bypass group had higher DM remission or improvement rate than the BI group, and the RYEJ group had the highest DM remission rate.
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Affiliation(s)
- Woohyung Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
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Wang G, Agenor K, Pizot J, Kotler DP, Harel Y, Van Der Schueren BJ, Quercia I, McGinty J, Laferrère B. Accelerated gastric emptying but no carbohydrate malabsorption 1 year after gastric bypass surgery (GBP). Obes Surg 2012; 22:1263-7. [PMID: 22527599 DOI: 10.1007/s11695-012-0656-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Following gastric bypass surgery (GBP), there is a post-prandial rise of incretin and satiety gut peptides. The mechanisms of enhanced incretin release in response to nutrients after GBP is not elucidated and may be in relation to altered nutrient transit time and/or malabsorption. METHODS Seven morbidly obese subjects (BMI = 44.5 ± 2.8 kg/m(2)) were studied before and 1 year after GBP with a D: -xylose test. After ingestion of 25 g of D: -xylose in 200 mL of non-carbonated water, blood samples were collected at frequent time intervals to determine gastric emptying (time to appearance of D: -xylose) and carbohydrate absorption using standard criteria. RESULTS One year after GBP, subjects lost 45.0 ± 9.7 kg and had a BMI of 27.1 ± 4.7 kg/m(2). Gastric emptying was more rapid after GBP. The mean time to appearance of D: -xylose in serum decreased from 18.6 ± 6.9 min prior to GBP to 7.9 ± 2.7 min after GBP (p = 0.006). There was no significant difference in absorption before (serum D: -xylose concentrations = 35.6 ± 12.6 mg/dL at 60 min and 33.9 ± 9.1 mg/dL at 180 min) or 1 year after GBP (serum D: -xylose = 31.5 ± 18.1 mg/dL at 60 min and 27.2 ± 11.9 mg/dL at 180 min). CONCLUSIONS These data confirm the acceleration of gastric emptying for liquid and the absence of carbohydrate malabsorption 1 year after GBP. Rapid gastric emptying may play a role in incretin response after GBP and the resulting improved glucose homeostasis.
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Affiliation(s)
- Gary Wang
- New York Obesity Nutrition Research Center, New York, NY, USA
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32
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Myint KS, Greenfield JR, Farooqi IS, Henning E, Holst JJ, Finer N. Prolonged successful therapy for hyperinsulinaemic hypoglycaemia after gastric bypass: the pathophysiological role of GLP1 and its response to a somatostatin analogue. Eur J Endocrinol 2012; 166:951-5. [PMID: 22408121 DOI: 10.1530/eje-11-1065] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Spontaneous hyperinsulinaemic hypoglycaemia following gastric bypass surgery (GBS) is increasingly recognised. However, its pathophysiology remains unclear. Some patients require pancreatectomy. Medical therapy with calcium channel blockers, acarbose and diazoxide has been reported to be beneficial but has variable adherence and response. METHOD We demonstrate the role of GLP1, counter-regulatory hormones and the subsequent response of GLP1 to somatostatin analogue therapy in a 42-year-old woman with persistent neuroglycopaenia 6 years after GBS. Plasma GLP1, insulin and glucose were measured for 5 h on three settings: i) a 75 g oral glucose tolerance test (OGTT); ii) a standard liquid test meal (LTM); and iii) an OGTT 30 min after a s.c. injection of 100 μg octreotide. RESULTS In comparison with obese non-diabetic controls, the patient had an elevated fasting and a markedly enhanced GLP1 response during the OGTT, followed by an exaggerated insulin response and a subsequent low glucose level. The GLP1 response to a LTM was similar but greater. Octreotide given prior to the OGTT attenuated both the GLP1 and insulin responses and abolished hypoglycaemia. Octreotide therapy significantly improved the patient's neuroglycopaenic symptoms. The hormone profile was reassessed after 6 months following the LTM preceded by octreotide injection. Peak GLP1 and insulin responses were less pronounced than pretreatment responses and without hypoglycaemia. The patient was treated with lanreotide and had remained symptom-free and euglycaemic for 4 years. CONCLUSION An exaggerated incretin response following altered gastrointestinal anatomy was the likely cause of hypoglycaemia in our GBS patient. Somatostatin successfully suppressed this response acutely and in the long term, thereby avoiding pancreatectomy and its sequelae.
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Affiliation(s)
- K S Myint
- Department of Endocrinology, Institute of Metabolic Science, Cambridge University NHS Trust, Cambridge CB2 0QQ, UK.
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Abstract
The incretin hormones, glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1), are gut peptides which are secreted by endocrine cells in the intestinal mucosa. Their plasma concentrations increase quickly following food ingestion, and carbohydrate, fat, and protein have all been shown to stimulate GLP-1 and GIP secretion. Although neural and hormonal mechanisms have also been proposed to regulate incretin hormone secretion, direct stimulation of the enteroendocrine cells by the presence of nutrients in the intestinal lumen is probably the most important factor in humans. The actions of the incretin hormones are crucial for maintaining normal islet function and glucose homeostasis. Furthermore, it is also now being recognized that incretin hormones may have other actions in addition to their glucoregulatory effects. Studies have shown that GLP-1 and GIP levels and actions may be perturbed in disease states, but interpretation of the precise relationship between disease and incretins is difficult. The balance of evidence seems to suggest that alterations in secretion and/or action of incretin hormones arise secondarily to the development of insulin resistance, glucose intolerance, and/or increases in body weight rather than being causative factors. However, these impairments may contribute to the deterioration of glycemic control in diabetic patients.
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Affiliation(s)
- Carolyn F Deacon
- Department of Biomedical Sciences, University of Copenhagen, DK-2200 Copenhagen N, Denmark.
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Tam CS, Berthoud HR, Bueter M, Chakravarthy MV, Geliebter A, Hajnal A, Holst J, Kaplan L, Pories W, Raybould H, Seeley R, Strader A, Ravussin E. Could the mechanisms of bariatric surgery hold the key for novel therapies? report from a Pennington Scientific Symposium. Obes Rev 2011; 12:984-94. [PMID: 21729236 PMCID: PMC4048708 DOI: 10.1111/j.1467-789x.2011.00902.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Bariatric surgery is the most effective method for promoting dramatic and durable weight loss in morbidly obese subjects. Furthermore, type 2 diabetes is resolved in over 80% of patients. The mechanisms behind the amelioration in metabolic abnormalities are largely unknown but may be due to changes in energy metabolism, gut peptides and food preference. The goal of this meeting was to review the latest research to better understand the mechanisms behind the 'magic' of bariatric surgery. Replication of these effects in a non-surgical manner remains one of the ultimate challenges for the treatment of obesity and diabetes. Promising data on energy metabolism, gastrointestinal physiology, hedonic response and food intake were reviewed and discussed.
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Affiliation(s)
- C S Tam
- Pennington Biomedical Research Center, Baton Rouge, LA 70808, USA
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Coate KC, Kraft G, Lautz M, Smith M, Neal DW, Cherrington AD. A high-fat, high-fructose diet accelerates nutrient absorption and impairs net hepatic glucose uptake in response to a mixed meal in partially pancreatectomized dogs. J Nutr 2011; 141:1643-51. [PMID: 21775526 PMCID: PMC3159053 DOI: 10.3945/jn.111.145359] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The aim of this study was to elucidate the impact of a high-fat, high-fructose diet (HFFD; fat, 52%; fructose, 17%), in the presence of a partial (~65%) pancreatectomy (PPx), on the response of the liver and extrahepatic tissues to an orally administered, liquid mixed meal. Adult male dogs were fed either a nonpurified, canine control diet (CTR; fat, 26%; no fructose; n = 5) or a HFFD (n = 5) for 8 wk. Diets were provided in a quantity to maintain neutral or positive energy balance in CTR or HFFD, respectively. Dogs underwent a sham operation or PPx at wk 0, portal and hepatic vein catheterization at wk 6, and a mixed meal test at wk 8. Postprandial glucose concentrations were significantly greater in the HFFD group (14.5 ± 2.0 mmol/L) than in the CTR group (9.2 ± 0.5 mmol/L). Impaired glucose tolerance in HFFD was due in part to accelerated gastric emptying and glucose absorption, as indicated by a more rapid rise in arterial plasma acetaminophen and the rate of glucose output by the gut, respectively, in HFFD than in CTR. It was also attributable to lower net hepatic glucose uptake (NHGU) in the HFFD group (5.5 ± 3.9 μmol · kg(-1) · min(-1)) compared to the CTR group (26.6 ± 7.0 μmol · kg(-1) · min(-1)), resulting in lower hepatic glycogen synthesis (GSYN) in the HFFD group (10.8 ± 5.4 μmol · kg(-1) · min(-1)) than in the CTR group (30.4 ± 7.0 μmol · kg(-1) · min(-1)). HFFD also displayed aberrant suppression of lipolysis by insulin. In conclusion, HFFD feeding accelerates gastric emptying and diminishes NHGU and GSYN, thereby impairing glucose tolerance following a mixed meal challenge. These data reveal a constellation of deleterious metabolic consequences associated with consumption of a HFFD for 8 wk.
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Affiliation(s)
- Katie Colbert Coate
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN,To whom correspondence should be addressed. E-mail:
| | - Guillaume Kraft
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Margaret Lautz
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Marta Smith
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Doss W. Neal
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN,Diabetes Research and Training Center, Vanderbilt University School of Medicine, Nashville, TN
| | - Alan D. Cherrington
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN,Diabetes Research and Training Center, Vanderbilt University School of Medicine, Nashville, TN
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Octreotide-treated diabetes accompanied by endogenous hyperinsulinemic hypoglycemia and protein-losing gastroenteropathy. Case Rep Med 2011; 2011:381203. [PMID: 21826148 PMCID: PMC3150201 DOI: 10.1155/2011/381203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Revised: 05/11/2011] [Accepted: 06/14/2011] [Indexed: 01/24/2023] Open
Abstract
Occurrence of hypoglycemia in diabetes patients is very rare. We report here a case of frequent hypoglycemic attacks caused by inappropriate endogenous hyperinsulinemia in a female patient with poorly controlled diabetes and protein-losing gastroenteropathy. The blood glucose profiles of the patient were unstable. Results of the fasting test performed to investigate the cause of hypoglycemia suggested endogenous hyperinsulinism. Repeated selective arterial calcium injection tests suggested that hyperinsulinemia might be extrapancreatic in origin. However, efforts to detect a responsible lesion such as insulinoma were unsuccessful. Octreotide was used for the treatment of hypoglycemia and protein-losing gastroenteropathy. After treatment, although her leg edema caused by hypoalbuminemia persisted, hypoglycemia almost disappeared.
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Abstract
Gastric resection, whether partial or total gastrectomy, often results in nutrition-related complications including weight loss, diet intolerances, and micronutrient deficiencies. The physiology of normal and postgastrectomy digestion is the basis for most of the current diet recommendations after gastric surgery. A careful review reveals that there is not sufficient literature to support a standard postgastrectomy diet. Rather, individualized diet manipulation for symptom relief is recommended. This review highlights the physiology behind common postgastrectomy complications, provides guidelines for the medical and nutrition management of these complications, and presents a basic approach to postgastrectomy gastrointestinal symptoms.
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Affiliation(s)
- Christie Rogers
- Nutrition Support Services, University of Virginia Health System, Charlottesville, VA 22908, USA.
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Holst JJ, Knop FK, Vilsbøll T, Krarup T, Madsbad S. Loss of incretin effect is a specific, important, and early characteristic of type 2 diabetes. Diabetes Care 2011; 34 Suppl 2:S251-7. [PMID: 21525464 PMCID: PMC3632188 DOI: 10.2337/dc11-s227] [Citation(s) in RCA: 194] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Jens J Holst
- Department of Biomedical Sciences, Panum Institute, Copenhagen, Denmark.
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Kielgast U, Holst JJ, Madsbad S. Antidiabetic actions of endogenous and exogenous GLP-1 in type 1 diabetic patients with and without residual β-cell function. Diabetes 2011; 60:1599-607. [PMID: 21441444 PMCID: PMC3292336 DOI: 10.2337/db10-1790] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To investigate the effect of exogenous as well as endogenous glucagon-like peptide 1 (GLP-1) on postprandial glucose excursions and to characterize the secretion of incretin hormones in type 1 diabetic patients with and without residual β-cell function. RESEARCH DESIGN AND METHODS Eight type 1 diabetic patients with (T1D+), eight without (T1D-) residual β-cell function, and eight healthy matched control subjects were studied during a mixed meal with concomitant infusion of GLP-1 (1.2 pmol/kg/min), saline, or exendin 9-39 (300 pmol/kg/min). Before the meal, half dose of usual fast-acting insulin was injected. Plasma glucose (PG), glucagon, C-peptide, total GLP-1, intact glucose-dependent insulinotropic polypeptide (GIP), free fatty acids, triglycerides, and gastric emptying rate (GE) by plasma acetaminophen were measured. RESULTS Incretin responses did not differ between patients and control subjects. Infusion of GLP-1 decreased peak PG by 45% in both groups of type 1 diabetic patients. In T1D+ patients, postprandial PG decreased below fasting levels and was indistinguishable from control subjects infused with saline. In T1D- patients, postprandial PG remained at fasting levels. GLP-1 infusion reduced GE and glucagon levels in all groups and increased fasting C-peptide in T1D+ patients and control subjects. Blocking endogenous GLP-1 receptor action increased endogenous GLP-1 secretion in all groups and increased postprandial glucose, glucagon, and GE in T1D+ and T1D- patients. The insulinogenic index (the ratio of insulin to glucose) decreased in T1D+ patients during blockade of endogenous GLP-1 receptor action. CONCLUSIONS Type 1 diabetic patients have normal incretin responses to meals. In type 1 diabetic patients, exogenous GLP-1 decreases peak postprandial glucose by 45% regardless of residual β-cell function. Endogenous GLP-1 regulates postprandial glucose excursions by modulating glucagon levels, GE, and β-cell responsiveness to glucose. Long-term effects of GLP-1 in type 1 diabetic patients should be investigated in future clinical trials.
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Affiliation(s)
- Urd Kielgast
- Department of Endocrinology, Hvidovre University Hospital, Copenhagen, Denmark.
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40
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Abstract
The two incretin hormones glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) are key factors in the regulation of islet function and glucose metabolism, and incretin-based therapy for type 2 diabetes has gained considerable interest during recent years. Regulation of incretin hormone secretion is less well characterized. The main stimulus for incretin hormone secretion is presence of nutrients in the intestinal lumen, and carbohydrate, fat as well as protein all have the capacity to stimulate GIP and GLP-1 secretion. More recently, it has been established that a diurnal regulation exists with incretin hormone secretion to an identical meal being greater when the meal is served in the morning compared to in the afternoon. Finally, whether incretin hormone secretion is altered in disease states is an area with, so far, controversial results in different studies, although some studies have demonstrated reduced incretin hormone secretion in type 2 diabetes. This review summarizes our knowledge on regulation of incretin hormone secretion and its potential changes in disease states.
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Affiliation(s)
- Bo Ahrén
- Department of Clinical Sciences in Lund, Division of Medicine, Lund University, Lund, Sweden
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Perugini RA, Malkani S. Remission of type 2 diabetes mellitus following bariatric surgery: review of mechanisms and presentation of the concept of 'reversibility'. Curr Opin Endocrinol Diabetes Obes 2011; 18:119-28. [PMID: 21522001 DOI: 10.1097/med.0b013e3283446c1f] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Roux-en-Y gastric bypass (RYGB) leads to remission of type 2 diabetes mellitus (T2DM) in a majority of patients. This is prompting investigation of RYGB, and other bariatric operations as interventional therapies for T2DM. RECENT FINDINGS The impact of RYGB is due to an increase in the release of gastrointestinal hormones in response to a meal [glucagon-like peptide, peptide YY, oxyntomodulin]. This effect involves the parasympathetic nervous system. These same hormones are responsible for an early increase in β-cell secretion of insulin, leading to early remission of T2DM following RYGB. Progressive weight loss leads to a later improvement in peripheral insulin sensitivity, which is required for later remissions, and is responsible for re-emergence of T2DM in individuals who regain weight in long-term follow-up. As the success of bariatric surgery has prompted the emergence of the concept that T2DM is reversible, we offer a theory to predict reversibility of diabetes after bariatric surgery that is based on baseline beta cell function. SUMMARY This review will improve the understanding of the physiology of bariatric surgery and its impact on T2DM, stimulate investigations into new avenues to treat T2DM, and allow better selection of nonobese individuals for interventional therapy of T2DM.
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Affiliation(s)
- Richard A Perugini
- Department of Surgery, University of Massachusetts Medical Center, Worcester, Massachusetts 01655-0333, USA.
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Murai J, Koga M, Saito H, Mukai M, Matsumoto S, Kasayama S. Profiles of atherosclerotic risk factors in gastrectomized men. Endocr J 2011; 58:657-62. [PMID: 21666338 DOI: 10.1507/endocrj.k10e-401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Postprandial hyperglycemia is an established risk factor for atherosclerotic vascular diseases, and it is frequently observed in gastrectomized subjects. This study sought to examine whether other atherosclerotic risk factors are also common among gastrectomized subjects. The study population comprised of 44 non-diabetic men who previously underwent gastrectomy. The age- and body mass index-matched control population comprised of 278 non-diabetic men without gastrectomy. In addition to traditional atherosclerotic risk factors for atherosclerosis, high sensitivity C-reactive protein (hsCRP) and brachial-ankle pulse wave velocity (baPWV) were also compared between the groups. Fasting plasma glucose was not different between both groups, while glycated hemoglobin (HbA1c) was significantly higher in the gastrectomized men than in the control men. Systolic and diastolic blood pressures and high density lipoprotein cholesterol (HDL-C) were significantly higher, whereas low density lipoprotein cholesterol (LDL-C) was lower in the gastrectomized men than in the control men. baPWV, hsCRP, triglycerides and insulin resistance (as per the homeostasis model assessment) were not different between groups. While levels of certain atherosclerotic risk factors, including HbA1c and blood pressure are higher among gastrectomized men, HDL-C and LDL-C were actually favorable. Additionally, levels of more emerging risk factors, such as hsCRP and baPWV were not altered among gastrectomized men.
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Affiliation(s)
- Jun Murai
- Department of Internal Medicine, Kinki Central Hospital, Itami, Japan
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Nauck MA, Vardarli I, Deacon CF, Holst JJ, Meier JJ. Secretion of glucagon-like peptide-1 (GLP-1) in type 2 diabetes: what is up, what is down? Diabetologia 2011; 54:10-8. [PMID: 20871975 DOI: 10.1007/s00125-010-1896-4] [Citation(s) in RCA: 328] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2010] [Accepted: 07/30/2010] [Indexed: 01/08/2023]
Abstract
The incretin hormones gastric inhibitory polypeptide and especially glucagon-like peptide (GLP) have an important physiological function in augmenting postprandial insulin secretion. Since GLP-1 may play a role in the pathophysiology and treatment of type 2 diabetes, assessment of meal-related GLP-1 secretory responses in type 2 diabetic patients vs healthy individuals is of great interest. A common view states that GLP-1 secretion in patients with type 2 diabetes is deficient and that this applies to a lesser degree in individuals with impaired glucose tolerance. Such a deficiency is the rationale for replacing endogenous incretins with GLP-1 receptor agonists or re-normalising active GLP-1 concentrations with dipeptidyl peptidase-4 inhibitors. This review summarises the literature on this topic, including a meta-analysis of published studies on GLP-1 secretion in individuals with and without diabetes after oral glucose and mixed meals. Our analysis does not support the contention of a generalised defect in nutrient-related GLP-1 secretory responses in type 2 diabetes patients. Rather, factors are identified that may determine individual incretin secretory responses and explain some of the variations in published findings of group differences in GLP-1 responses to nutrient intake.
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Affiliation(s)
- M A Nauck
- Diabeteszentrum Bad Lauterberg, Bad Lauterberg im Harz, Germany.
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Sato T, Narita T, Hosoba M, Kakei M, Nanjo H, Uchinami H, Satoh K, Yamamoto Y, Yamada Y. A case of insulinoma following total gastrectomy--effects of an alpha-glucosidase inhibitor on suppressing GIP and GLP-1 elevations. Diabetes Res Clin Pract 2010; 88:e4-6. [PMID: 20122751 DOI: 10.1016/j.diabres.2010.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Revised: 12/18/2009] [Accepted: 01/04/2010] [Indexed: 10/19/2022]
Abstract
A 61-year-old woman with fasting hypoglycemia following total gastrectomy was diagnosed as insulinoma. GIP and GLP-1 levels after a mixed meal were extremely increased. Administration of miglitol, an alpha-glucosidase inhibitor, suppressed the GIP and GLP-1 elevations.
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Affiliation(s)
- Takehiro Sato
- Department of Endocrinology, Diabetes and Geriatric Medicine, Akita University Graduate School of Medicine, Hondo, Akita, Japan
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45
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Management of postgastric bypass noninsulinoma pancreatogenous hypoglycemia. Surg Endosc 2010; 24:2547-55. [DOI: 10.1007/s00464-010-1001-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Accepted: 01/03/2010] [Indexed: 01/07/2023]
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A rehabilitation program for patients with gastroesophageal cancer--a pilot study. Support Care Cancer 2010; 18 Suppl 2:S35-40. [PMID: 20177712 DOI: 10.1007/s00520-010-0828-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Accepted: 01/25/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE Gastroesophageal carcinoma has a 5-year survival rate of 20%. Esophagogastrectomy is a significant life-altering operation which interferes with a patient's ability to eat food as a normal social interaction. Dumping syndrome, delayed gastric emptying, and reflux are encountered after surgery. In addition, loss of appetite and body weight occurs. Fatigue is universally encountered. We conducted this study to evaluate whether a structured cancer nutrition and rehabilitation program has an effect on the symptoms and quality of life of patients with gastroesophageal cancer. MATERIALS AND METHODS Fifty-three patients with histologically documented gastroesophageal carcinoma were evaluated before and after an 8-week multidisciplinary program consisting of physicians, oncology nurse, dietitian, physical and occupational therapists, social worker, and psychologist. Twenty-two patients completed all the following questionnaires pre- and post-program: The Edmonton Symptom Assessment Scale (ESAS), Patient-Generated Subjective Global Assessment (PG-SGA), Brief Fatigue Inventory (BFI), and the Distress Thermometer. RESULT There were 42 male and 11 female patients. The median age was 63 years (22-80 years). Thirty patients had gastric cancer and 23 had esophageal cancer. On the ESAS, appetite, strength, shortness of breath, and constipation all improved (p = 0.01). The PG-SGA score decreased significantly (p = 0.05). Fatigue and general activity as measured on the BFI improved significantly. The 6-min walk increased from 384 to 435 m (p = 0.01). CONCLUSION The Cancer Nutrition and Rehabilitation program offers a multidimensional, holistic treatment approach emphasizing the patient as an individual. Participation in a cancer rehabilitation program ameliorates symptoms, improves nutrition, decreases global distress, and increases physical activities.
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Carr RD, Larsen MO, Jelic K, Lindgren O, Vikman J, Holst JJ, Deacon CF, Ahrén B. Secretion and dipeptidyl peptidase-4-mediated metabolism of incretin hormones after a mixed meal or glucose ingestion in obese compared to lean, nondiabetic men. J Clin Endocrinol Metab 2010; 95:872-8. [PMID: 20008019 DOI: 10.1210/jc.2009-2054] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) are cleaved by dipeptidyl peptidase-4 (DPP-4); plasma activity of DPP-4 may be increased in obesity. The impact of this increase on incretin hormone secretion and metabolism is not known. OBJECTIVE The aim of the study was to assess incretin hormone secretion and degradation in lean and obese nondiabetic subjects. DESIGN, SETTINGS, AND PARTICIPANTS We studied the ingestion of a mixed meal (560 kcal) or oral glucose (2 g/kg) in healthy lean (n = 12; body mass index, 20-25 kg/m(2)) or obese (n = 13; body mass index, 30-35 kg/m(2)) males at a University Clinical Research Unit. MAIN OUTCOME MEASURES We measured the area under the curve of plasma intact (i) and total (t) GIP and GLP-1 after meal ingestion and oral glucose. RESULTS Plasma DPP-4 activity was higher in the obese subjects (38.5 +/- 3.0 vs. 26.7 +/- 1.6 mmol/min . microl; P = 0.002). Although GIP secretion (AUC(tGIP)) was not reduced in obese subjects after meal ingestion or oral glucose, AUC(iGIP) was lower in obese subjects (8.5 +/- 0.6 vs. 12.7 +/- 0.9 nmol/liter x 300 min; P < 0.001) after meal ingestion. GLP-1 secretion (AUC(tGLP-1)) was reduced in obese subjects after both meal ingestion (7.3 +/- 0.9 vs. 10.0 +/- 0.6 nmol/liter x 300 min; P = 0.022) and oral glucose (6.6 +/- 0.8 vs. 9.6 +/- 1.1 nmol/liter x 180 min; P = 0.035). iGLP-1 was reduced in parallel to tGLP-1. CONCLUSIONS 1) Release and degradation of the two incretin hormones show dissociated changes in obesity: GLP-1 but not GIP secretion is lower after meal ingestion and oral glucose, whereas GIP but not GLP-1 metabolism is increased after meal ingestion. 2) Increased plasma DPP-4 activity in obesity is not associated with a generalized augmented incretin hormone metabolism.
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Affiliation(s)
- Richard D Carr
- Department of Clinical Sciences Lund, B11 BMC, SE-2221 84 Lund, Sweden
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Lerche S, Soendergaard L, Rungby J, Moeller N, Holst JJ, Schmitz OE, Brock B. No increased risk of hypoglycaemic episodes during 48 h of subcutaneous glucagon-like-peptide-1 administration in fasting healthy subjects. Clin Endocrinol (Oxf) 2009; 71:500-6. [PMID: 19094067 DOI: 10.1111/j.1365-2265.2008.03510.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE It is uncertain whether the ability to avoid hypoglycaemia during fasting is preserved, and the risk of reactive hypoglycaemia after an oral glucose stimulus following a prolonged fasting period is increased at augmented glucagon-like peptide-1 (GLP-1) levels. DESIGN A randomized, double-blind placebo-controlled cross-over study in eight healthy men to assess the safety, in terms of hypoglycaemia, of a continuously infused pharmacological dose of native GLP-1 during long-term fasting. After an overnight fast the fasting period continued for 48 h and was followed by a 3-h oral glucose tolerance test (OGTT). GLP-1(7-36 amide) or placebo was continuously infused subcutaneously and titrated to a dose of 4.8 pmol/kg per min. RESULTS Two subjects in the GLP-1 group and one subject in the placebo group were withdrawn due to protocol specified plasma glucose (PG) < or = 2.8 mm and neuroglycopaenic symptoms. The infusion of GLP-1 resulted in pharmacological levels of intact GLP-1. During the fasting period PG, insulin and C-peptide levels declined and glucagon, GH and free fatty acid (FFA) levels increased with no differences between GLP-1 and placebo. During OGTT circulating levels of insulin and C-peptide were higher with GLP-1 infusion. However, PG was similar during GLP-1 vs. placebo infusions. GLP-1 infusion increased norepinephrine and cortisol levels during OGTT. CONCLUSION The counter-regulatory response during 48 h of subcutaneous GLP-1 infusion was preserved despite long-term fasting with no apparent increased risk of hypoglycaemic episodes. No reactive hypoglycaemia was observed when the fast was followed by an OGTT. Thus use of long-acting GLP-1 analogues may not increase the risk of hypoglycaemia.
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Affiliation(s)
- Susanne Lerche
- Institute of Pharmacology, University of Aarhus, University Park 1240, Aarhus C, Denmark.
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Palladino AA, Sayed S, Levitt Katz LE, Gallagher PR, De León DD. Increased glucagon-like peptide-1 secretion and postprandial hypoglycemia in children after Nissen fundoplication. J Clin Endocrinol Metab 2009; 94:39-44. [PMID: 18957502 PMCID: PMC2630870 DOI: 10.1210/jc.2008-1263] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Postprandial hypoglycemia (PPH) is a frequent complication of Nissen fundoplication in children. The mechanism responsible for the PPH is poorly understood, but involves an exaggerated insulin response to a meal and subsequent hypoglycemia. We hypothesize that increased glucagon-like peptide-1 (GLP-1) secretion contributes to the exaggerated insulin surge and plays a role in the pathophysiology of this disorder. OBJECTIVE The aim of the study was to characterize glucose, insulin, and GLP-1 response to an oral glucose load in children with symptoms of PPH after Nissen fundoplication. DESIGN Ten patients with suspected PPH and a history of Nissen fundoplication and eight control subjects underwent a standard oral glucose tolerance test at The Children's Hospital of Philadelphia. Blood glucose (BG), insulin, and intact GLP-1 levels were obtained at various time points. PARTICIPANTS Children ages 4 months to 13 years old were studied. MAIN OUTCOME MEASURES Change scores for glucose, insulin, and intact GLP-1 were recorded after an oral glucose tolerance test. RESULTS All cases had hypoglycemia after the glucose load. Mean BG at nadir (+/- sd) was 46.7 +/- 11 mg/dl for cases (vs. 85.9 +/- 21.3 mg/dl; P < 0.0005). Mean change in BG from baseline to peak (+/- sd) was 179.3 +/- 87.4 mg/dl for cases (vs. 57.8 +/- 39.5 mg/dl; P = 0.003). Mean change in BG (+/- sd) from peak to nadir was 214.4 +/- 85.9 mg/dl for cases (vs. 55.9 +/- 41.1 mg/dl, P < 0.0005). Mean change in insulin (+/- sd) from baseline to peak was 224.3 +/- 313.7 microIU/ml for cases (vs. 35.5 +/- 22.2 microIU/ml; P = 0.012). Mean change in GLP-1 (+/- sd) from baseline to peak was 31.2 +/- 24 pm (vs. 6.2 +/- 9.5 pm; P = 0.014). CONCLUSIONS Children with PPH after Nissen fundoplication have abnormally exaggerated secretion of GLP-1, which may contribute to the exaggerated insulin surge and resultant hypoglycemia.
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Affiliation(s)
- Andrew A Palladino
- The Children's Hospital of Philadelphia, Abramson Research Center, Room 802A, 3615 Civic Center Boulevard, Philadelphia, Pennsylvania 19104, USA
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Mahmood SA, Lindequist U. A pilot study on the effect of Catha edulis Frosk., (Celastraceae) on metabolic syndrome in WOKW rats. AFRICAN JOURNAL OF TRADITIONAL, COMPLEMENTARY, AND ALTERNATIVE MEDICINES 2008; 5:271-7. [PMID: 20161948 DOI: 10.4314/ajtcam.v5i3.31283] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study investigated the effect of Catha edulis (khat) on some important parameters of the metabolic syndrome in Wistar Ottawa Karlsburg W (WOKW) rat. The animals were fed with the standard chow containing 5% air dried pulverized khat leaves for 14 days; followed by the standard chow for 16 days. The khat leaves were sorted into green (khat light; KL) and crimson (khat dark; KD) leaves. The control rats were fed on standard chow. Blood glucose (G), serum insulin, serum leptin and serum lipids (triglycerides, total cholesterol, HDL-, LDL-, and VLDL cholesterol) were determined. Feeding with khat leaves reduced the body weight and the triglyceride level of the animals. The effect of KD on these parameters was stronger than that of KL. KD lowered the blood glucose concentration and the leptin content whereas KL was inactive. The khat intake had no significant influence on serum insulin, total serum cholesterol, HDL-, LDL- and VLDL-cholesterol.
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Affiliation(s)
- Samira Abdulla Mahmood
- Department of Pharmacology, Faculty of Medicine and Health Sciences, Aden University, Aden, Yemen.
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