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Sosale A, Sosale B, Kesavadev J, Chawla M, Reddy S, Saboo B, Misra A. Steroid use during COVID-19 infection and hyperglycemia - What a physician should know. Diabetes Metab Syndr 2021; 15:102167. [PMID: 34186344 PMCID: PMC8189750 DOI: 10.1016/j.dsx.2021.06.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/02/2021] [Accepted: 06/04/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIMS The COVID-19 pandemic continues to challenge us. Despite several strides in management, steroids remain the mainstay for treating moderate to severe disease and with it arises challenges such as hyperglycemia. The review aims to enhance awareness amongst physicians on steroid use and hyperglycemia. METHODS An advisory document describing various strategies for hyperglycemia management was prepared in the public interest by DiabetesIndia. RESULTS The review provides awareness on steroids and hyperglycemia, adverse outcomes of elevated blood glucose levels and, advice at the time of discharge. CONCLUSIONS The article emphasizes enhancing awareness on effective management of hyperglycemia during COVID-19.
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Affiliation(s)
| | | | | | | | - Sanjay Reddy
- Center For Diabetes & Endocrine Care (CDE), Bangalore, India.
| | - Banshi Saboo
- Diabetologist, Diacare, Diabetes Care & Hormone Clinic, Ahmedabad, India.
| | - Anoop Misra
- Fortis-C-DOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology, Chairman, National Diabetes, Obesity and Cholesterol Foundation (N-DOC), President, Diabetes Foundation India (DFI), India.
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2
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Akin S, Kubat GB, Guray U, Akin Y, Demirel HA. Possible value of galectin-3 on follow-up of cardiac remodeling during glucocorticoid treatment. J Biochem Mol Toxicol 2021; 35:e22717. [PMID: 33484019 DOI: 10.1002/jbt.22717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/01/2020] [Accepted: 12/03/2020] [Indexed: 11/07/2022]
Abstract
Glucocorticoids are among the most prescribed drugs globally due to their potent anti-inflammatory and immunosuppressive properties. Although they have positive effects on the treatment of various disease states; long-term administration is associated with high blood pressure, insulin resistance, and susceptibility to type 2 diabetes. The heart attempts to cope with increased blood pressure and a decrease in glucose utilization by developing pathological cardiac remodeling. However, in this process, cardiac fibrosis formation and deterioration in heart structure and functions occur. Galectin-3, a member of the β-galactoside binding lectins, is consistently associated with inflammation and fibrosis in the pathogenesis of various disease states including insulin resistance and heart failure. Galectin-3 expression is markedly increased in activated macrophages and a subset of activated fibroblasts and vascular cells. Also, failing and remodeling myocardium show increased Gal-3 expression and elevated Gal-3 levels are related to heart failure severity and prognosis. Furthermore, Gal-3-related pathways are recently suggested as therapeutic targets both pharmacologically and genetically to increase insulin sensitivity in vivo. The objective of this review is to provide a summary of our current understanding of the role of glucocorticoid-associated insulin resistance, which is important for some cardiac events, and the potential role of galectin in this pathophysiological process.
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Affiliation(s)
- Senay Akin
- Department of Exercise and Sport Physiology, Faculty of Sport Sciences, Hacettepe University, Ankara, Turkey
| | - Gokhan B Kubat
- Department of Exercise and Sport Physiology, Faculty of Sport Sciences, Hacettepe University, Ankara, Turkey.,Department of Pathology, Gulhane Training and Research Hospital, Ankara, Turkey
| | - Umit Guray
- Department of Cardiology, Ankara City Hospital, Ankara, Turkey
| | - Yesim Akin
- Department of Cardiology, Faculty of Medicine, Karabuk University, Karabuk, Turkey
| | - Haydar A Demirel
- Department of Exercise and Sport Physiology, Faculty of Sport Sciences, Hacettepe University, Ankara, Turkey.,Department of Sports Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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van Steen SC, Rijkenberg S, van der Voort PHJ, DeVries JH. The association of intravenous insulin and glucose infusion with intensive care unit and hospital mortality: a retrospective study. Ann Intensive Care 2019; 9:29. [PMID: 30742240 PMCID: PMC6370891 DOI: 10.1186/s13613-019-0507-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 02/04/2019] [Indexed: 12/12/2022] Open
Abstract
Background We assessed the association of intravenous insulin and glucose infusion with intensive care unit (ICU) and hospital mortality. Methods For this retrospective association study, we used data from all patients admitted to a medical-surgical ICU between January 2012 and September 2017. We excluded patients admitted < 24 h, patients with a diabetic ketoacidosis, patients with a therapy restriction upon ICU admission and readmissions. Using multivariate logistic regression, we examined the relation between intravenous insulin and glucose infusion and ICU and hospital mortality for all patients. Additionally, we used the same model to analyze the outcomes for patients admitted > 72 h. Results Of 9507 eligible patients, 3966 were included. After correction for potential confounders, intravenous insulin was associated with ICU and hospital mortality in patients admitted > 24 h (n = 3966) (odds ratio (OR) 1.09 [95% CI 1.05–1.13] and 1.09 [95% CI 1.06–1.13] per 0.1 IU/kg added, respectively). Likewise, intravenous glucose was associated with ICU mortality (OR 1.01 [95% CI 1.00–1.01]) but not with hospital mortality and (OR 1.00 [95% CI 1.00–1.01]) per g/day added, respectively. In patients admitted > 72 h (n = 1550), insulin dose was associated with both ICU and hospital mortality (p = 0.002 and p < 0.001, respectively), but glucose infusion was not (p = 0.08 and p = 0.2, respectively). Conclusions Intravenous insulin administration is associated with an increased risk of ICU and hospital mortality, after correction for potential confounders. Parenteral glucose administration was limited in amount but was still associated with ICU mortality. However, based on these results, it is unknown whether this association is an epiphenomenon, or represents a true harm of insulin and glucose administration. Electronic supplementary material The online version of this article (10.1186/s13613-019-0507-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sigrid C van Steen
- Department of Endocrinology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care, OLVG Hospital, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands
| | - Saskia Rijkenberg
- Department of Intensive Care, OLVG Hospital, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands
| | - Peter H J van der Voort
- Department of Intensive Care, OLVG Hospital, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands. .,TIAS, School for Business and Society, Tilburg University, Tilburg, The Netherlands.
| | - J Hans DeVries
- Department of Endocrinology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Antolic A, Wood CE, Keller-Wood M. Chronic maternal hypercortisolemia in late gestation alters fetal cardiac function at birth. Am J Physiol Regul Integr Comp Physiol 2017; 314:R342-R352. [PMID: 29092858 DOI: 10.1152/ajpregu.00296.2017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Studies in our laboratory have shown that modest chronic increases in maternal cortisol concentrations over the last 0.20 of gestation impair maternal glucose metabolism and increase the incidence of perinatal stillbirth. Previous studies had found that an increase in maternal cortisol concentrations from 115 to 130 days of gestation in sheep increased both proliferation in fetal cardiomyocytes and apoptosis in the fetal cardiac Purkinje fibers. We hypothesized that the adverse effects of excess cortisol may result in defects in cardiac conduction during labor and delivery. In the present study, we infused cortisol (1 mg·kg-1·day-1) into late gestation pregnant ewes and continuously monitored fetal aortic pressure and ECG through labor and delivery. We found that, although the fetuses of cortisol infused ewes had normal late gestation patterns of arterial pressure and heart rate, there was a significant decrease in fetal aortic pressure and heart rate on the day of birth, specifically in the final hour before delivery. Significant changes in the fetal ECG were also apparent on the day of birth, including prolongation of the P wave and P-R interval. We speculate that chronic exposure to glucocorticoids alters cardiac metabolism or ion homeostasis, contributing to cardiac dysfunction, precipitated by active labor and delivery.
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Affiliation(s)
- Andrew Antolic
- Department of Pharmacodynamics, University of Florida , Gainesville, Florida
| | - Charles E Wood
- Department of Physiology and Functional Genomics, University of Florida , Gainesville, Florida
| | - Maureen Keller-Wood
- Department of Pharmacodynamics, University of Florida , Gainesville, Florida
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5
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Ramkissoon CM, Aufderheide B, Bequette BW, Vehi J. A Review of Safety and Hazards Associated With the Artificial Pancreas. IEEE Rev Biomed Eng 2017; 10:44-62. [DOI: 10.1109/rbme.2017.2749038] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Impact of Glucocorticoid Excess on Glucose Tolerance: Clinical and Preclinical Evidence. Metabolites 2016; 6:metabo6030024. [PMID: 27527232 PMCID: PMC5041123 DOI: 10.3390/metabo6030024] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 07/28/2016] [Accepted: 07/29/2016] [Indexed: 12/28/2022] Open
Abstract
Glucocorticoids (GCs) are steroid hormones that exert important physiological actions on metabolism. Given that GCs also exert potent immunosuppressive and anti-inflammatory actions, synthetic GCs such as prednisolone and dexamethasone were developed for the treatment of autoimmune- and inflammatory-related diseases. The synthetic GCs are undoubtedly efficient in terms of their therapeutic effects, but are accompanied by significant adverse effects on metabolism, specifically glucose metabolism. Glucose intolerance and reductions in insulin sensitivity are among the major concerns related to GC metabolic side effects, which may ultimately progress to type 2 diabetes mellitus. A number of pre-clinical and clinical studies have aimed to understand the repercussions of GCs on glucose metabolism and the possible mechanisms of GC action. This review intends to summarize the main alterations that occur in liver, skeletal muscle, adipose tissue, and pancreatic islets in the context of GC-induced glucose intolerance. For this, both experimental (animals) and clinical studies were selected and, whenever possible, the main cellular mechanisms involved in such GC-side effects were discussed.
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Dexamethasone-induced insulin resistance: kinetic modeling using novel PET radiopharmaceutical 6-deoxy-6-[(18)F]fluoro-D-glucose. Mol Imaging Biol 2015; 16:710-20. [PMID: 24819311 DOI: 10.1007/s11307-014-0737-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE An insulin-resistant rat model, induced by dexamethasone, was used to evaluate a Michaelis-Menten-based kinetic model using 6-deoxy-6-[(18)F]fluoro-D-glucose (6-[(18)F]FDG) to quantify glucose transport with PET. PROCEDURES Seventeen, male, Sprague-Dawley rats were studied in three groups: control (Ctrl), control + insulin (Ctrl + I), and dexamethasone + insulin (Dex + I). PET scans were acquired for 2 h under euglycemic conditions in the Ctrl group and under hyperinsulinemic-euglycemic conditions in the Ctrl + I and Dex + I groups. RESULTS Glucose transport, assessed according to the 6-[(18)F]FDG concentration, was highest in skeletal muscle in the Ctrl + I, intermediate in the Dex + I, and lowest in the Ctrl group, while that in the brain was similar among the groups. Modeling analysis applied to the skeletal muscle uptake curves yielded values of parameters related to glucose transport that were greatest in the Ctrl + I group and increased to a lesser degree in the Dex + I group, compared to the Ctrl group. CONCLUSION 6-[(18)F]FDG and the Michaelis-Menten-based model can be used to measure insulin-stimulated glucose transport under basal and an insulin resistant state in vivo.
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Kusenda M, Kaske M, Piechotta M, Locher L, Starke A, Huber K, Rehage J. Effects of Dexamethasone-21-Isonicotinate on Peripheral Insulin Action in Dairy Cows 5 days after Surgical Correction of Abomasal Displacement. J Vet Intern Med 2012. [DOI: 10.1111/jvim.12010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- M. Kusenda
- Clinic for Cattle; University of Veterinary Medicine Hannover; 30173 Hannover Germany
| | - M. Kaske
- Clinic for Cattle; University of Veterinary Medicine Hannover; 30173 Hannover Germany
| | - M. Piechotta
- Clinic for Cattle; University of Veterinary Medicine Hannover; 30173 Hannover Germany
| | - L. Locher
- Clinic for Cattle; University of Veterinary Medicine Hannover; 30173 Hannover Germany
| | - A. Starke
- Clinic for Cattle; University of Veterinary Medicine Hannover; 30173 Hannover Germany
| | - K. Huber
- Department of Physiology; University of Veterinary Medicine Hannover; 30173 Hannover Germany
| | - J. Rehage
- Clinic for Cattle; University of Veterinary Medicine Hannover; 30173 Hannover Germany
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Laskewitz AJ, van Dijk TH, Grefhorst A, van Lierop MJ, Schreurs M, Bloks VW, Reijngoud DJ, Dokter WH, Kuipers F, Groen AK. Chronic prednisolone treatment aggravates hyperglycemia in mice fed a high-fat diet but does not worsen dietary fat-induced insulin resistance. Endocrinology 2012; 153:3713-23. [PMID: 22653558 DOI: 10.1210/en.2011-1891] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Synthetic glucocorticoids such as prednisolone have potent antiinflammatory actions. Unfortunately, these drugs induce severe adverse effects in patients, many of which resemble features of the metabolic syndrome, such as insulin resistance. In this study, we investigated whether adverse effects of prednisolone on glucose homeostasis are aggravated in mice with compromised insulin sensitivity due to a high-fat diet by applying various methods to analyze changes in insulin sensitivity in mice. C57BL/6J mice were fed a high-fat diet for 6 wk and treated with either prednisolone (10 mg/kg · d) or vehicle for the last 7 d. Insulin sensitivity and blood glucose kinetics were analyzed with state-of-the-art stable isotope procedures in different experimental conditions. Prednisolone treatment aggravated fasting hyperglycemia and hyperinsulinemia caused by high-fat feeding, resulting in a higher homeostatic assessment model of insulin resistance. In addition, prednisolone-treated high-fat diet-fed mice appeared less insulin sensitive by detailed analysis of basal glucose kinetics. Remarkably, using hyperinsulinemic-euglycemic or hyperglycemic clamp techniques, neither hepatic nor peripheral insulin resistance was worsened in the group that was treated with prednisolone. Yet analysis of hepatic glucose metabolism revealed that prednisolone did alter glycogen balance by reducing glycogen synthase flux under hyperinsulinemic as well as hyperglycemic conditions. In addition to elevated insulin levels, prednisolone-treated mice showed a major rise in plasma leptin and fibroblast growth factor 21 levels. Our data indicate that prednisolone-induced adverse effects on glucose metabolism in high-fat diet-fed mice do not reflect impaired insulin sensitivity but may be caused by other changes in the hormonal regulatory network controlling glucose metabolism such as fibroblast growth factor 21 and leptin.
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Affiliation(s)
- Anke J Laskewitz
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, 9700 RB, Groningen, The Netherlands
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Abstract
The effects of glucocorticoid on lipid metabolism of broiler chicken (Gallus gallus domesticus) skeletal muscle were investigated. Male Arbor Acres chickens (35 days old) were subjected to dexamethasone treatment for 3 days. We found that dexamethasone retards body growth while facilitating lipid accumulation. In M. pectoralis major (PM), dexamethasone increased the expression of glucocorticoid receptor (GR), fatty acid transport protein 1 (FATP1), heart fatty acid-binding protein (H-FABP) and long-chain acyl-CoA dehydrogenase (LCAD) mRNA and decreased the expression of liver carnitine palmitoyltransferase 1 (L-CPT1), adenosine-monophosphate-activated protein kinase (AMPK) α2 and lipoprotein lipase (LPL) mRNA. LPL activity was also decreased. In M. biceps femoris (BF), the levels of GR, FATP1 and L-CPT1 mRNA were increased. AMPKα (Thr172) phosphorylation and CTP1 activity of skeletal muscle were decreased by dexamethasone. In fed chickens, dexamethasone enhanced very low-density lipoprotein receptor (VLDLR) expression and AMPK activity in muscle, but it impaired the expression of LPL and L-CPT1 mRNA and LPL activity in PM and augmented the expression of GR, LPL, H-FABP, L-CPT1, LCAD and AMPKα2 mRNA in BF. Adipose triglyceride lipase (ATGL) protein expression was not affected by dexamethasone. In conclusion, in the fasting state, dexamethasone-induced-retarded fatty acid utilisation may be involved in the augmented intramyocellular lipid accumulation in both glycolytic (PM) and oxidative (BF) muscle tissues. In the fed state, dexamethasone promoted the transcriptional activity of genes related to lipid uptake and oxidation in muscles. Unmatched lipid uptake and utilisation are suggested to be involved in the augmented intramyocellular lipid accumulation.
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Affiliation(s)
- X J Wang
- Department of Animal Science, Shandong Agricultural University, Taian, Shandong 271018, PR China
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11
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El Youssef J, Castle JR, Branigan DL, Massoud RG, Breen ME, Jacobs PG, Bequette BW, Ward WK. A controlled study of the effectiveness of an adaptive closed-loop algorithm to minimize corticosteroid-induced stress hyperglycemia in type 1 diabetes. J Diabetes Sci Technol 2011; 5:1312-26. [PMID: 22226248 PMCID: PMC3262697 DOI: 10.1177/193229681100500602] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
To be effective in type 1 diabetes, algorithms must be able to limit hyperglycemic excursions resulting from medical and emotional stress. We tested an algorithm that estimates insulin sensitivity at regular intervals and continually adjusts gain factors of a fading memory proportional-derivative (FMPD) algorithm. In order to assess whether the algorithm could appropriately adapt and limit the degree of hyperglycemia, we administered oral hydrocortisone repeatedly to create insulin resistance. We compared this indirect adaptive proportional-derivative (APD) algorithm to the FMPD algorithm, which used fixed gain parameters. Each subject with type 1 diabetes (n = 14) was studied on two occasions, each for 33 h. The APD algorithm consistently identified a fall in insulin sensitivity after hydrocortisone. The gain factors and insulin infusion rates were appropriately increased, leading to satisfactory glycemic control after adaptation (premeal glucose on day 2, 148 ± 6 mg/dl). After sufficient time was allowed for adaptation, the late postprandial glucose increment was significantly lower than when measured shortly after the onset of the steroid effect. In addition, during the controlled comparison, glycemia was significantly lower with the APD algorithm than with the FMPD algorithm. No increase in hypoglycemic frequency was found in the APD-only arm. An afferent system of duplicate amperometric sensors demonstrated a high degree of accuracy; the mean absolute relative difference of the sensor used to control the algorithm was 9.6 ± 0.5%. We conclude that an adaptive algorithm that frequently estimates insulin sensitivity and adjusts gain factors is capable of minimizing corticosteroid-induced stress hyperglycemia.
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Boersma G, Scheurink A, Wielinga P, Steimer T, Benthem L. The passive coping Roman Low Avoidance rat, a non-obese rat model for insulin resistance. Physiol Behav 2009; 97:353-8. [DOI: 10.1016/j.physbeh.2009.03.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2008] [Revised: 02/09/2009] [Accepted: 03/05/2009] [Indexed: 10/21/2022]
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Abstract
Intensive research investigating the relation between the management of glycemia and outcome in patients receiving neurocritical care has underlined the possible benefits and adverse events related to glucose control. Here, we review experimental and clinical studies investigating the effects of hypoglycemia and hyperglycemia on the brain that advance current knowledge on managing glycemia in patients receiving neurocritical care.
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Caperuto LC, Anhê GF, Cambiaghi TD, Akamine EH, do Carmo Buonfiglio D, Cipolla-Neto J, Curi R, Bordin S. Modulation of bone morphogenetic protein-9 expression and processing by insulin, glucose, and glucocorticoids: possible candidate for hepatic insulin-sensitizing substance. Endocrinology 2008; 149:6326-35. [PMID: 18703636 DOI: 10.1210/en.2008-0655] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Bone morphogenetic protein 9 (BMP-9), a member of the TGF-beta superfamily predominantly expressed in nonparenchymal liver cells, has been demonstrated to improve glucose homeostasis in diabetic mice. Along with this therapeutic effect, BMP-9 was proposed as a candidate for the hepatic insulin-sensitizing substance (HISS). Whether BMP-9 plays a physiological role in glucose homeostasis is still unknown. In the present study, we show that BMP-9 expression and processing is severely reduced in the liver of insulin-resistant rats. BMP-9 expression and processing was directly stimulated by in situ exposition of the liver to the combination of glucose and insulin and oral glucose in overnight fasted rats. Additionally, prolonged fasting (72 h) abrogated refeeding-induced BMP-9 expression and processing. Previous exposition to dexamethasone, a known inductor of insulin resistance, reduced BMP-9 processing stimulated by the combination of insulin and glucose. Finally, we show that neutralization of BMP-9 with an anti-BMP-9 antibody induces glucose intolerance and insulin resistance in 12-h fasted rats. Collectively, the present results demonstrate that BMP-9 plays an important role in the control of glucose homeostasis of the normal rat. Additionally, BMP-9 is expressed and processed in an HISS-like fashion, which is impaired in the presence of insulin resistance. BMP-9 regulation according to the feeding status and the presence of diabetogenic factors reinforces the hypothesis that BMP-9 might exert the role of HISS in glucose homeostasis physiology.
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Affiliation(s)
- Luciana Chagas Caperuto
- Department of Biological Sciences, Federal University of São Paulo, 04023-900 São Paulo, Brazil
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15
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Abstract
Glycemic control clearly improves outcome in critically ill patients. Remaining questions are how tight the control must be to obtain the most benefit without increasing the risk for severe hypoglycemia, and whether an acuity level exists in which this benefit is not clearly visualized. In other words, is this benefit only seen in severely ill patients? The authors believe that clinical trials with ICU lengths of stay of 3 days or less make showing a clinical benefit difficult. Rather, they believe that clinical benefit is seen in higher acuity patients whose ICU length of stay is directly related to the reversal of the inflammatory systemic response rather than the disease or injury alone. Finally, the issue remains of how to obtain a TGC in the 80 to 110 mg/dL range without achieving a less-than-acceptable incidence of hypoglycemia. The answer may well lie with the introduction of continuous glucose monitors that will allow measurements to be obtained every 15 to 30 minutes without introducing an increased workload to the nursing staff. Many of these devices, such as the Optiscanner, which measures plasma glucose continuously, are on the horizon and should be approved by the FDA in 2008.
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Affiliation(s)
- Grant V Bochicchio
- University of Maryland School of Medicine, Room T1R59, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Baltimore, MD 21201, USA.
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Novelli M, Pocai A, Chiellini C, Maffei M, Masiello P. Free fatty acids as mediators of adaptive compensatory responses to insulin resistance in dexamethasone-treated rats. Diabetes Metab Res Rev 2008; 24:155-64. [PMID: 18058844 DOI: 10.1002/dmrr.785] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Chronic low-dose dexamethasone (DEX) treatment in rats is associated to insulin resistance with compensatory hyperinsulinaemia and reduction in food intake. We tested the hypothesis that the elevation in circulating free fatty acids (FFAs) induced by DEX is the common mediator of both insulin resistance and insulin hyperproduction. METHODS For this purpose, an anti-lipolytic agent was administered during DEX treatment to lower lipacidaemia for several hours prior to glucose and insulin tolerance tests. Leptin expression in adipose tissue (by Northern blot) and plasma leptin levels (by radioimmunoassay) were also investigated to verify whether a rise in circulating leptin could be responsible for the anorectic effect of DEX. RESULTS Our data show that a transient pharmacological reduction of elevated plasma FFA levels abates the post-loading hyperinsulinaemia and counteracts the insulin resistance induced by DEX, supporting the hypothesis that the chronic elevation in FFAs is the common mediator of DEX-induced changes. Despite enhanced leptin expression in white adipose tissue, DEX-treated rats show no significant increase in plasma leptin levels. This suggests that the anorectic effect of DEX should be mediated, at least partially, by other factors, possibly related to the influence of concomitantly elevated plasma FFA and insulin levels on the hypothalamic centers regulating feeding. CONCLUSIONS Our results sustain the idea that a prolonged increase in plasma FFA levels plays an important role in the adaptive regulation of glucose and energy homeostasis, not only by potentiating insulin secretion but also by providing a signal of 'nutrient abundance' capable of restraining food intake.
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Affiliation(s)
- Michela Novelli
- Department of Experimental Pathology, University of Pisa, and Ospedale di Cisanello, Italy
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17
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Qi D, Rodrigues B. Glucocorticoids produce whole body insulin resistance with changes in cardiac metabolism. Am J Physiol Endocrinol Metab 2007; 292:E654-67. [PMID: 17077342 DOI: 10.1152/ajpendo.00453.2006] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Insulin resistance is viewed as an insufficiency in insulin action, with glucocorticoids being recognized to play a key role in its pathogenesis. With insulin resistance, metabolism in multiple organ systems such as skeletal muscle, liver, and adipose tissue is altered. These metabolic alterations are widely believed to be important factors in the morbidity and mortality of cardiovascular disease. More importantly, clinical and experimental studies have established that metabolic abnormalities in the heart per se also play a crucial role in the development of heart failure. Following glucocorticoids, glucose utilization is compromised in the heart. This attenuated glucose metabolism is associated with altered fatty acid supply, composition, and utilization. In the heart, elevated fatty acid use has been implicated in a number of metabolic, morphological, and mechanical changes and, more recently, in "lipotoxicity". In the present article, we review the action of glucocorticoids, their role in insulin resistance, and their influence in modulating peripheral and cardiac metabolism and heart disease.
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Affiliation(s)
- Dake Qi
- Division of Pharmacology and Toxicology, Faculty of Pharmaceutical Sciences, The University of British Columbia, 2146 East Mall, Vancouver, BC, Canada V6T 1Z3
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18
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Piroli GG, Grillo CA, Reznikov LR, Adams S, McEwen BS, Charron MJ, Reagan LP. Corticosterone impairs insulin-stimulated translocation of GLUT4 in the rat hippocampus. Neuroendocrinology 2007; 85:71-80. [PMID: 17426391 DOI: 10.1159/000101694] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2007] [Accepted: 02/27/2007] [Indexed: 01/14/2023]
Abstract
BACKGROUND Exposure to stress levels of glucocorticoids produces physiological responses that are characteristic of type 2 diabetes, such as peripheral insulin resistance and impairment in insulin-stimulated trafficking of glucose transporter 4 (GLUT4) in muscle and fat. In the central nervous system, stress produces neuroanatomical and neurochemical changes in the hippocampus that are associated with cognitive impairments. METHODS In view of these observations, the current studies examined the effects of short-term (1 week) exposure of stress levels of glucocorticoids upon insulin receptor (IR) expression and signaling, including GLUT4 translocation, in the rat hippocampus. RESULTS One week of corticosterone (CORT) treatment produced insulin resistance in response to peripheral glucose challenge. In the hippocampus, IR expression was unchanged in CORT-treated rats as compared with vehicle-treated rats. However, insulin-stimulated phosphorylation of the IR, total Akt levels and total GLUT4 levels were reduced in CORT-treated rats when compared to controls. In addition, insulin-stimulated translocation of hippocampal GLUT4 to the plasma membrane was completely abolished in CORT-treated rats. CONCLUSIONS These results demonstrate that in addition to eliciting peripheral insulin resistance, short-term CORT administration impairs insulin signaling in the rat hippocampus, effects that may contribute to the deleterious consequences of hypercortisolemic/hyperglycemic states observed in type 2 diabetes.
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Affiliation(s)
- Gerardo G Piroli
- Department of Pharmacology, Physiology and Neuroscience, University of South Carolina School of Medicine, Columbia, SC 29208, USA
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Abstract
OBJECTIVE To critically review recent evidence on pathophysiology, diagnosis, and control of acute and chronic hyperglycemia in medical and surgical intensive care unit (ICU) patients. DATA SOURCE AND STUDY SELECTION A MEDLINE/PubMed search (1966 through February 2006) with manual cross-referencing was conducted, including all relevant articles published on blood glucose control in intensive care patients. An emphasis was placed on more recent clinical trials investigating the effects of tight glycemic control in ICU patients and on basic science studies investigating the pathophysiology and systemic effects of transient hyperglycemia in nondiabetic patients. DATA EXTRACTION AND SYNTHESIS Original articles, selected reviews, letters to the editor, and chapters of selected textbooks were extracted. The reviewed information was then analyzed with respect to the prevalence of hyperglycemia in ICU patients, the pathophysiology of hyperglycemia in nondiabetics, and evidence on glycemic control in various subgroups of ICU patients. The risk of iatrogenic hypoglycemia in the ICU and potential future research directions are discussed at the end of the review. CONCLUSIONS Recent evidence shows direct improvements in patient mortality and in-hospital morbidity with strict control of even short-term elevations of glucose levels in certain subgroups of ICU patients. However, precisely defined target glucose levels, subgroup analyses of different patient populations and treatment interventions, and the avoidance of hypoglycemic episodes during insulin therapy remain incompletely resolved and warrant future investigation.
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Affiliation(s)
- Matthias Turina
- Department of Surgery, Price Institute of Surgical Research, University of Louisville School of Medicine, Louisville, KY, USA
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Taylor JH, Beilman GJ. Hyperglycemia in the intensive care unit: no longer just a marker of illness severity. Surg Infect (Larchmt) 2005; 6:233-45. [PMID: 16128630 DOI: 10.1089/sur.2005.6.233] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Hyperglycemia is a common occurrence in critically ill patients. Recent evidence has demonstrated improved survival in patients in surgical intensive care units (SICUs) receiving "tight glycemic control." The mechanisms of this survival advantage are not well understood. METHODS A review of the English language literature pertaining to potential mechanisms affecting outcome in critically ill patients receiving insulin therapy, including recently published human trials evaluating mortality outcomes. RESULTS This review discusses the results of clinical trials of "tight glycemic control," considers mechanisms of hyperglycemia in critical illness, and reviews potential mechanisms of improved outcome related in the critically ill patient. CONCLUSIONS A number of human studies have demonstrated improved outcomes in critically ill patient populations receiving insulin therapy with a target of euglycemia, suggesting at least part of the benefit of this therapy is normal blood sugar and not the effects of insulin. An important population not studied to date is patients in the medical ICU. However, aggressive control of hyperglycemia now remains an important component of care for all surgical patients in the ICU.
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Affiliation(s)
- Jodie H Taylor
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, 55455, USA
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Abstract
Stress hyperglycemia is common and likely to be associated with at least some of the same complications as hyperglycemia in true diabetes mellitus, such as poor wound healing and a higher infection rate. The predominant cause is the intense counterregulatory hormone and cytokine responses of critical illness, often compounded by excessive dextrose administration, usually as TPN. Although randomized data suggesting benefit of controlling hyperglycemia in hospitalized patients are paltry, prospective controlled trials are feasible and should be initiated. In the interim, the practice at the authors' institution is to use insulin to lower plasma glucose concentrations to a safe range of 150 mg/dL to 200 mg/dL in all patients.
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Affiliation(s)
- K C McCowen
- Departments of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
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Benthem L, Keizer K, Wiegman CH, Strubbe JH, Steffens AB, Kuipers F, Scheurink AJ. Excess portal venous long-chain fatty acids induce syndrome X via HPA axis and sympathetic activation. Am J Physiol Endocrinol Metab 2000; 279:E1286-93. [PMID: 11093916 DOI: 10.1152/ajpendo.2000.279.6.e1286] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We tested the hypothesis that excessive portal venous supply of long-chain fatty acids to the liver contributes to the development of insulin resistance via activation of the hypothalamus-pituitary-adrenal axis (HPA axis) and sympathetic system. Rats received an intraportal infusion of the long-chain fatty acid oleate (150 nmol/min, 24 h), the medium-chain fatty acid caprylate, or the solvent. Corticosterone (Cort) and norepinephrine (NE) were measured as indexes for HPA axis and sympathetic activity, respectively. Insulin sensitivity was assessed by means of an intravenous glucose tolerance test (IVGTT). Oleate infusion induced increases in plasma Cort (Delta = 13.5 +/- 3.6 microg/dl; P < 0.05) and NE (Delta = 235 +/- 76 ng/l; P < 0.05), whereas caprylate and solvent had no effect. The area under the insulin response curve to the IVGTT was larger in the oleate-treated group than in the caprylate and solvent groups (area = 220 +/- 35 vs. 112 +/- 13 and 106 +/- 8, respectively, P < 0.05). The area under the glucose response curves was comparable [area = 121 +/- 13 (oleate) vs. 135 +/- 20 (caprylate) and 96 +/- 11 (solvent)]. The results are consistent with the concept that increased portal free fatty acid is involved in the induction of visceral obesity-related insulin resistance via activation of the HPA axis and sympathetic system.
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Affiliation(s)
- L Benthem
- Department of Animal Physiology, University of Groningen, NL-9700AB Groningen, The Netherlands.
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Strolin-Benedetti M, Brogin G, Bani M, Oesch F, Hengstler JG. Association of cytochrome P450 induction with oxidative stress in vivo as evidenced by 3-hydroxylation of salicylate. Xenobiotica 1999; 29:1171-80. [PMID: 10598750 DOI: 10.1080/004982599238038] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
1. Previous studies have shown that formation of 2,3-dihydroxybenzoate (2,3-DHB) from salicylate in vivo is a sensitive and specific marker of *OH radical generation, since 2,3-DHB is formed exclusively by *OH radicals, whereas both *OH radicals and cytochrome P450 (CYP) contribute to the production of 2,5-DHB. In the present study the salicylate-hydroxylation assay was used to examine whether CYP induction by the administration of dexamethasone, phenobarbital or beta-naphthoflavone to the male rat led to oxidative stress in vivo. 2. Dexamethasone was used under conditions that induced an approximately 50-fold induction of CYP P4503A expression in liver microsomal protein. Treatment with dexamethasone caused a 17.2-fold increase in 2,3-DHB plasma concentration compared with control animals. An increase in total hydroxylated salicylate (2,3-DHB plus 2,5-DHB) of 133.5 micromol/l plasma was produced, of which--assuming that the attack by *OH in position 3 or 5 of salicylate occurs at a similar rate--10.9 micromol/l were due to *OH radical attack and 122.6 micromol/l due to metabolism by CYP. 3. Phenobarbital led to a 4.7-fold increase in 2,3-DHB plasma concentration under conditions that induced CYP P4502B and 3A. An increase in total hydroxylated salicylate of 34.3 micromol/l plasma was observed, 2.0 micromol/l due to *OH radical attack and 32.3 micromol/l due to metabolism by cytochrome P450. 4. In contrast to dexamethasone and phenobarbital, beta-naphthoflavone did not cause a significant increase in 2,3-DHB plasma concentrations. 5. SKF 525A, a mixed-function oxidase inhibitor, caused a significant reduction of mean 2,5-DHB plasma concentration by 35% (p < 0.001), whereas 2,3-DHB was not significantly reduced, indicating that in contrast to the situation after induction by dexamethasone or phenobarbital, *OH radical generation by constitutive CYP contributes only to a minor degree to total in vivo *OH radical generation. 6. This study shows for the first time, to the authors' knowledge, that induction of some (but not all) P450s is associated with the production of hydroxyl radicals in vivo.
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Thomas CR, Turner SL, Jefferson WH, Bailey CJ. Prevention of dexamethasone-induced insulin resistance by metformin. Biochem Pharmacol 1998; 56:1145-50. [PMID: 9802324 DOI: 10.1016/s0006-2952(98)00151-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This study investigates the effect of the antidiabetic drug metformin on dexamethasone-induced hyperglycaemia and insulin resistance in mice. Normal mice were treated with dexamethasone (2.5 mg/kg/day p.o.) plus metformin (250 mg/kg/day p.o.) and pair-fed to those receiving dexamethasone alone. Metformin reduced the extent of dexamethasone-induced hyperglycaemia and decreased insulin resistance as indicated by an improved insulin-hypoglycaemia test. Metformin-treated mice also showed increased basal glucose uptake into isolated diaphragm (by 38%), soleus (by 19%) and deep (red) quadriceps (by 31%). Measurements in the quadriceps showed that the increase in glucose uptake occurred without increasing either the mRNA levels or total cellular membrane abundance of the GLUT1 or GLUT4 glucose transporter isoforms. Thus metformin can ameliorate dexamethasone-induced hyperglycaemia and insulin resistance in part by increasing glucose disposal into skeletal muscle. Since this was achieved in quadriceps muscle without increasing mRNA or total membrane abundance of GLUT1 or GLUT4, it is possible that metformin might influence the intrinsic activity of glucose transporters, as well as altering their intracellular translocation.
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Affiliation(s)
- C R Thomas
- Department of Medicine, ST. Thomas' Hospital, London, UK
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Schneiter P, Tappy L. Kinetics of dexamethasone-induced alterations of glucose metabolism in healthy humans. THE AMERICAN JOURNAL OF PHYSIOLOGY 1998; 275:E806-13. [PMID: 9815000 DOI: 10.1152/ajpendo.1998.275.5.e806] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Six healthy human subjects were studied during three 75-g oral, [13C]glucose tolerance tests to assess the kinetics of dexamethasone-induced impairment of glucose tolerance. On one occasion, they received dexamethasone (4 x 0.5 mg/day) during the previous 2 days. On another occasion, they received a single dose (0. 5 mg) of dexamethasone 150 min before ingestion of the glucose load. On the third occasion, they received a placebo. Postload plasma glucose was significantly increased after both 2 days dexamethasone and single dose dexamethasone compared with control (P < 0.05). This corresponded to a 20-23% decrease in the metabolic clearance rate of glucose, whereas total glucose turnover ([6,6-2H]glucose), total (indirect calorimetry) and exogenous glucose oxidation (13CO2 production), and suppression of endogenous glucose production were unaffected by dexamethasone. Plasma insulin concentrations were increased after 2 days of dexamethasone but not after a single dose of dexamethasone. In a second set of experiments, the effect of a single dose of dexamethasone on insulin sensitivity was assessed in six healthy humans during a 2-h euglycemic hyperinsulinemic clamp. Dexamethasone did not significantly alter insulin sensitivity. It is concluded that acute administration of dexamethasone impairs oral glucose tolerance without significantly decreasing insulin sensitivity.
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Affiliation(s)
- P Schneiter
- Faculty of Medicine, Institute of Physiology, University of Lausanne, 1005 Lausanne, Switzerland
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