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Perez-Frances M, Bru-Tari E, Cohrs C, Abate MV, van Gurp L, Furuyama K, Speier S, Thorel F, Herrera PL. Regulated and adaptive in vivo insulin secretion from islets only containing β-cells. Nat Metab 2024; 6:1791-1806. [PMID: 39169271 PMCID: PMC11422169 DOI: 10.1038/s42255-024-01114-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/22/2024] [Indexed: 08/23/2024]
Abstract
Insulin-producing β-cells in pancreatic islets are regulated by systemic cues and, locally, by adjacent islet hormone-producing 'non-β-cells' (namely α-cells, δ-cells and γ-cells). Yet whether the non-β-cells are required for accurate insulin secretion is unclear. Here, we studied mice in which adult islets are exclusively composed of β-cells and human pseudoislets containing only primary β-cells. Mice lacking non-β-cells had optimal blood glucose regulation, enhanced glucose tolerance, insulin sensitivity and restricted body weight gain under a high-fat diet. The insulin secretion dynamics in islets composed of only β-cells was comparable to that in intact islets. Similarly, human β-cell pseudoislets retained the glucose-regulated mitochondrial respiration, insulin secretion and exendin-4 responses of entire islets. The findings indicate that non-β-cells are dispensable for blood glucose homeostasis and β-cell function. These results support efforts aimed at developing diabetes treatments by generating β-like clusters devoid of non-β-cells, such as from pluripotent stem cells differentiated in vitro or by reprograming non-β-cells into insulin producers in situ.
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Affiliation(s)
- Marta Perez-Frances
- Department of Genetic Medicine and Development, iGE3 and Centre facultaire du diabète, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Eva Bru-Tari
- Department of Genetic Medicine and Development, iGE3 and Centre facultaire du diabète, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Christian Cohrs
- Institute of Physiology, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
- Paul Langerhans Institute Dresden of the Helmholtz Zentrum München at the University Clinic Carl Gustav Carus of Technische Universität Dresden, Helmholtz Zentrum München, Neuherberg, Germany
| | - Maria Valentina Abate
- Department of Genetic Medicine and Development, iGE3 and Centre facultaire du diabète, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Léon van Gurp
- Department of Genetic Medicine and Development, iGE3 and Centre facultaire du diabète, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Kenichiro Furuyama
- Department of Genetic Medicine and Development, iGE3 and Centre facultaire du diabète, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Center for iPS Cell Research and Application (CiRA), Kyoto University, Kyoto, Japan
| | - Stephan Speier
- Institute of Physiology, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
- Paul Langerhans Institute Dresden of the Helmholtz Zentrum München at the University Clinic Carl Gustav Carus of Technische Universität Dresden, Helmholtz Zentrum München, Neuherberg, Germany
| | - Fabrizio Thorel
- Department of Genetic Medicine and Development, iGE3 and Centre facultaire du diabète, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Pedro L Herrera
- Department of Genetic Medicine and Development, iGE3 and Centre facultaire du diabète, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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2
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Hirsch IB, Parkin CG, Cavaiola TS, Bergenstal RM. Use of continuous glucose monitoring when initiating glucagon-like peptide-1 receptor agonist therapy in insulin-treated diabetes. Diabetes Obes Metab 2024. [PMID: 39193839 DOI: 10.1111/dom.15883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 07/31/2024] [Accepted: 08/02/2024] [Indexed: 08/29/2024]
Abstract
Glucagon-like peptide-1 receptor agonist (GLP-1RA) medications have been shown to be effective in achieving optimal glucose control and reducing all-cause death, cardiovascular death, nonfatal myocardial infarction, hospitalization for heart failure, and end-stage kidney disease in individuals with type 1 (T1D) and type 2 diabetes (T2D). However, use of these medications has been associated with increased hypoglycaemia risk in patients treated with concomitant antihyperglycaemic medications. The risk is particularly high in patients with T1D due to their loss of glucagon counter-regulatory response. This article reviews the effect of GLP-1RA formulations on the development of hypoglycaemia in individuals with T1D and T2D treated with insulin therapy, discusses the benefits of continuous glucose monitoring with GLP-1RA treatment, and presents strategies for safely initiating GLP-1RA therapy in these individuals.
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Affiliation(s)
- Irl B Hirsch
- University of Washington School of Medicine, Seattle, Washington, USA
| | | | | | - Richard M Bergenstal
- International Diabetes Centre, HealthPartners Institute, Minneapolis, Minnesota, USA
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3
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Shapey IM, Alfred J, Sharp R, Whelan P, Szatmary P, Mann K, Dunne DJ, Raraty M, Ghaneh P, Halloran C, Weston P, Sutton R, Baron RD. Glycaemic control following total pancreatectomy: room for improvement? HPB (Oxford) 2024; 26:1075-1078. [PMID: 38762354 DOI: 10.1016/j.hpb.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 05/20/2024]
Affiliation(s)
- Iestyn M Shapey
- Department of Pancreatic Surgery, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Prescot St, Liverpool, L7 8XP, UK; Faculty of Medicine and Health, University of Leeds, Woodhouse, Leeds, LS2 9JT, UK.
| | - Joshua Alfred
- Department of Pancreatic Surgery, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Prescot St, Liverpool, L7 8XP, UK
| | - Rachel Sharp
- Department of Pancreatic Surgery, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Prescot St, Liverpool, L7 8XP, UK
| | - Philip Whelan
- Department of Pancreatic Surgery, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Prescot St, Liverpool, L7 8XP, UK
| | - Peter Szatmary
- Department of Pancreatic Surgery, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Prescot St, Liverpool, L7 8XP, UK; Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, L69 3GE, UK
| | - Kulbir Mann
- Department of Pancreatic Surgery, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Prescot St, Liverpool, L7 8XP, UK
| | - Declan Jf Dunne
- Department of Pancreatic Surgery, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Prescot St, Liverpool, L7 8XP, UK
| | - Michael Raraty
- Department of Pancreatic Surgery, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Prescot St, Liverpool, L7 8XP, UK
| | - Paula Ghaneh
- Department of Pancreatic Surgery, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Prescot St, Liverpool, L7 8XP, UK; Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, L69 3GE, UK
| | - Christopher Halloran
- Department of Pancreatic Surgery, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Prescot St, Liverpool, L7 8XP, UK; Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, L69 3GE, UK
| | - Philip Weston
- Department of Diabetes and Endocrinology, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Prescot St, Liverpool, L7 8XP, UK
| | - Robert Sutton
- Department of Pancreatic Surgery, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Prescot St, Liverpool, L7 8XP, UK; Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, L69 3GE, UK
| | - Ryan D Baron
- Department of Pancreatic Surgery, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Prescot St, Liverpool, L7 8XP, UK
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Horie I, Abiru N. Advances in clinical research on glucagon. Diabetol Int 2024; 15:353-361. [PMID: 39101175 PMCID: PMC11291794 DOI: 10.1007/s13340-024-00705-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 02/19/2024] [Indexed: 08/06/2024]
Abstract
We are now celebrating the 100th anniversary of the discovery of an important pancreatic hormone, glucagon. Glucagon is historically described as a diabetogenic hormone elevating glucose levels via increases in insulin resistance and hepatic gluconeogenesis. The more recently identified actions of glucagon include not only its pathophysiologic effects on glucose metabolism but also its significant roles in amino-acid metabolism in the liver. The possibility that abnormalities in α-cells' secretion of glucagon in metabolic disorders are a compensatory adaptation for the maintenance of metabolic homeostasis is another current issue. However, the clinical research concerning glucagon has been considerably behind the advances in basic research due to the lack of suitable methodology for obtaining precise measurements of plasma glucagon levels in humans. The precise physiology of glucagon secretory dynamics in individuals with metabolic dysfunction (including diabetes) has been clarified since the development in 2014 of a quantitative measurement technique for glucagon. In this review, we summarize the advances in the clinical research concerning glucagon, including those of our studies and the relevant literature.
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Affiliation(s)
- Ichiro Horie
- Department of Endocrinology and Metabolism, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501 Japan
| | - Norio Abiru
- Department of Endocrinology and Metabolism, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501 Japan
- Medical Health Examination Center, Midori Clinic, 32-20 Joei-Machi, Nagasaki, 852-8034 Japan
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5
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She R, Suvitaival T, Andersen HU, Hommel E, Nørgaard K, Wojtaszewski JFP, Legido-Quigley C, Pedersen-Bjergaard U. Metabolic effect of adrenaline infusion in people with type 1 diabetes and healthy individuals. Diabetologia 2024; 67:1095-1106. [PMID: 38427076 PMCID: PMC11058679 DOI: 10.1007/s00125-024-06116-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/03/2024] [Indexed: 03/02/2024]
Abstract
AIMS/HYPOTHESIS As a result of early loss of the glucagon response, adrenaline is the primary counter-regulatory hormone in type 1 diabetes. Diminished adrenaline responses to hypoglycaemia due to counter-regulatory failure are common in type 1 diabetes, and are probably induced by exposure to recurrent hypoglycaemia, however, the metabolic effects of adrenaline have received less research attention, and also there is conflicting evidence regarding adrenaline sensitivity in type 1 diabetes. Thus, we aimed to investigate the metabolic response to adrenaline and explore whether it is modified by prior exposure to hypoglycaemia. METHODS Eighteen participants with type 1 diabetes and nine healthy participants underwent a three-step ascending adrenaline infusion during a hyperinsulinaemic-euglycaemic clamp. Continuous glucose monitoring data obtained during the week before the study day were used to assess the extent of hypoglycaemia exposure. RESULTS While glucose responses during the clamp were similar between people with type 1 diabetes and healthy participants, plasma concentrations of NEFAs and glycerol only increased in the group with type 1 diabetes (p<0.001). Metabolomics revealed an increase in the most common NEFAs (p<0.01). Other metabolic responses were generally similar between participants with type 1 diabetes and healthy participants. Exposure to hypoglycaemia was negatively associated with the NEFA response; however, this was not statistically significant. CONCLUSIONS/INTERPRETATION In conclusion, individuals with type 1 diabetes respond with increased lipolysis to adrenaline compared with healthy participants by mobilising the abundant NEFAs in plasma, whereas other metabolic responses were similar. This may suggest that the metabolic sensitivity to adrenaline is altered in a pathway-specific manner in type 1 diabetes. TRIAL REGISTRATION ClinicalTrials.gov NCT05095259.
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Affiliation(s)
- Rui She
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Eva Hommel
- Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Kirsten Nørgaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Herlev, Denmark
| | | | - Cristina Legido-Quigley
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Institute of Pharmaceutical Science, King's College London, London, UK
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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6
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She R, Al-Sari NH, Mattila IM, Sejling AS, Pedersen J, Legido-Quigley C, Pedersen-Bjergaard U. Decreased branched-chain amino acids and elevated fatty acids during antecedent hypoglycemia in type 1 diabetes. BMJ Open Diabetes Res Care 2023; 11:e003327. [PMID: 37369531 PMCID: PMC10410980 DOI: 10.1136/bmjdrc-2023-003327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
INTRODUCTION Hypoglycemia is a major limiting factor in achieving recommended glycemic targets for people with type 1 diabetes. Exposure to recurrent hypoglycemia results in blunted hormonal counter-regulatory and symptomatic responses to hypoglycemia. Limited data on metabolic adaptation to recurrent hypoglycemia are available. This study examined the acute metabolic responses to hypoglycemia and the effect of antecedent hypoglycemia on these responses in type 1 diabetes. RESEARCH DESIGN AND METHODS Twenty-one outpatients with type 1 diabetes with normal or impaired awareness of hypoglycemia participated in a study assessing the response to hypoglycemia on 2 consecutive days by a hyperinsulinemic glucose clamp. Participants underwent a period of normoglycemia and a period of hypoglycemia during the hyperinsulinemic glucose clamp. Plasma samples were taken during normoglycemia and at the beginning and the end of the hypoglycemic period. Metabolomic analysis of the plasma samples was conducted using comprehensive two-dimensional gas chromatography with time-of-flight mass spectrometry. RESULTS In total, 68 metabolites were studied. On day 1, concentrations of the branched-chain amino acids, leucine (p=3.8×10-3) and isoleucine (p=2.2×10-3), decreased during hypoglycemia. On day 2, during hypoglycemia, five amino acids (including leucine and isoleucine) significantly decreased, and two fatty acids (tetradecanoic and oleic acids) significantly increased (p<0.05). Although more metabolites responded to hypoglycemia on day 2, the responses of the single metabolites were not statistically significant between the 2 days. CONCLUSIONS In individuals with type 1 diabetes, one episode of hypoglycemia decreases leucine and isoleucine concentrations. Antecedent hypoglycemia results in the decrement of five amino acids and increases the concentrations of two fatty acids, suggesting an alteration between the two hypoglycemic episodes, which could indicate a possible adaptation. However, more studies are needed to gain a comprehensive understanding of the consequences of these alterations. TRIAL REGISTRATION NUMBER NCT01337362.
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Affiliation(s)
- Rui She
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Capital Region of Denmark, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Kobenhavn, Capital Region of Denmark, Denmark
| | - Naba Hassan Al-Sari
- Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Capital Region of Denmark, Denmark
| | - Ismo Matias Mattila
- Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Capital Region of Denmark, Denmark
| | - Anne-Sophie Sejling
- Boston Global Development, Novo Nordisk, Søborg, Capital Region of Denmark, Denmark
| | - Jens Pedersen
- Department of Internal Medicine, Herlev Hospital, Herlev, Capital Region of Denmark, Denmark
| | - Cristina Legido-Quigley
- Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Capital Region of Denmark, Denmark
- Institute of Pharmaceutical Science, King's College London, London, UK
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Capital Region of Denmark, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Kobenhavn, Capital Region of Denmark, Denmark
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7
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Liu Z, Zhang L, Qian C, Zhou Y, Yu Q, Yuan J, Lv Y, Zhang L, Chang X, Li Y, Liu Y. Recurrent hypoglycemia increases hepatic gluconeogenesis without affecting glycogen metabolism or systemic lipolysis in rat. Metabolism 2022; 136:155310. [PMID: 36063868 DOI: 10.1016/j.metabol.2022.155310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 08/29/2022] [Accepted: 08/31/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Recurrent hypoglycemia (RH) impairs secretion of counterregulatory hormones. Whether and how RH affects responses within metabolically important peripheral organs to counterregulatory hormones are poorly understood. OBJECTIVE To study the effects of RH on metabolic pathways associated with glucose counterregulation within liver, white adipose tissue and skeletal muscle. METHODS Using a widely adopted rodent model of 3-day recurrent hypoglycemia, we first checked expression of counterregulatory hormone G-protein coupled receptors (GPCRs), their inhibitory regulators and downstream enzymes catalyzing glycogen metabolism, gluconeogenesis and lipolysis by qPCR and western blot. Then, we examined epinephrine-induced phosphorylation of PKA substrates to validate adrenergic sensitivity in each organ. Next, we measured hepatic and skeletal glycogen content, degree of breakdown by epinephrine and abundance of phosphorylated glycogen phosphorylase under hypoglycemia and that of phosphorylated glycogen synthase during recovery to evaluate glycogen turnover. Further, we performed pyruvate and lactate tolerance tests to assess gluconeogenesis. Additionally, we measured circulating FFA and glycerol to check lipolysis. The abovementioned studies were repeated in streptozotocin-induced diabetic rat model. Finally, we conducted epinephrine tolerance test to investigate systemic glycemic excursions to counterregulatory hormones. Saline-injected rats served as controls. RESULTS RH increased counterregulatory hormone GPCR signaling in liver and epidydimal white adipose tissue (eWAT), but not in skeletal muscle. For glycogen metabolism, RH did not affect total content or epinephrine-stimulated breakdown in liver and skeletal muscle. Although RH decreased expression of phosphorylated glycogen synthase 2, it did not affect hepatic glycogen biosynthesis during recovery from hypoglycemia or after fasting-refeeding. For gluconeogenesis, RH upregulated fructose 1,6-bisphosphatase 1 and monocarboxylic acid transporter 1 that imports lactate as precursor, resulting in a lower blood lactate profile during hypoglycemia. In agreement, RH elevated fasting blood glucose and caused higher glycemic excursions during pyruvate tolerance test. For lipolysis, RH did not affect circulating levels of FFA and glycerol after overnight fasting or upon epinephrine stimulation. Interestingly, RH upregulated the trophic fatty acid transporter FATP1 and glucose transporter GLUT4 to increase lipogenesis in eWAT. These aforementioned changes of gluconeogenesis, lipolysis and lipogenesis were validated in streptozotocin-diabetic rats. Finally, RH increased insulin sensitivity to accelerate glucose disposal, which was attributable to upregulated visceral adipose GLUT4. CONCLUSIONS RH caused metabolic adaptations related to counterregulation within peripheral organs. Specifically, adrenergic signaling was enhanced in liver and visceral fat, but not in skeletal muscle. Glycogen metabolism remained unchanged. Hepatic gluconeogenesis was augmented. Systemic lipolysis was unaffected, but visceral lipogenesis was enhanced. Insulin sensitivity was increased. These findings provided insights into mechanisms underlying clinical problems associated with intensive insulin therapy, such as high gluconeogenic flux and body weight gain.
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Affiliation(s)
- Zejian Liu
- Key Laboratory of Human Functional Genomics of Jiangsu Province, Department of Biochemistry and Molecular Biology, Nanjing Medical University, Nanjing, Jiangsu 211166, China
| | - Lingyu Zhang
- Department of Endocrinology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu 211100, China
| | - Chen Qian
- Department of Endocrinology, Zhangjiagang Hospital Affiliated to Soochow University, Zhangjiagang, Suzhou, Jiangsu 215699, China
| | - Ying Zhou
- Department of Endocrinology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu 211100, China
| | - Qiuyu Yu
- Key Laboratory of Human Functional Genomics of Jiangsu Province, Department of Biochemistry and Molecular Biology, Nanjing Medical University, Nanjing, Jiangsu 211166, China
| | - Jiaqi Yuan
- Key Laboratory of Human Functional Genomics of Jiangsu Province, Department of Biochemistry and Molecular Biology, Nanjing Medical University, Nanjing, Jiangsu 211166, China
| | - Yunfan Lv
- Key Laboratory of Human Functional Genomics of Jiangsu Province, Department of Biochemistry and Molecular Biology, Nanjing Medical University, Nanjing, Jiangsu 211166, China
| | - Leheng Zhang
- Key Laboratory of Human Functional Genomics of Jiangsu Province, Department of Biochemistry and Molecular Biology, Nanjing Medical University, Nanjing, Jiangsu 211166, China
| | - Xiaoai Chang
- Key Laboratory of Human Functional Genomics of Jiangsu Province, Department of Biochemistry and Molecular Biology, Nanjing Medical University, Nanjing, Jiangsu 211166, China
| | - Yangyang Li
- Department of Endocrinology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu 211100, China.
| | - Yu Liu
- Department of Endocrinology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu 211100, China.
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Bisgaard Bengtsen M, Møller N. Review: experimentally induced hypoglycemia-associated autonomic failure in humans: determinants, designs and drawbacks. J Endocr Soc 2022; 6:bvac123. [PMID: 36042977 PMCID: PMC9419494 DOI: 10.1210/jendso/bvac123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Indexed: 11/19/2022] Open
Abstract
Context Iatrogenic hypoglycemia remains one of the leading hindrances of optimal glycemic management in insulin-treated diabetes. Recurring hypoglycemia leads to a condition of hypoglycemia-associated autonomic failure (HAAF). HAAF refers to a combination of (i) impaired hormonal counterregulatory responses and (ii) hypoglycemia unawareness to subsequent hypoglycemia, substantially increasing the risk of severe hypoglycemia. Several studies since the 1990s have experimentally induced HAAF, yielding variable results. Objective The aim of this review was to assess the varying designs, clinical outcomes, potential assets, and drawbacks related to these studies. Method A systemic literature search was conducted on PubMed and Embase in winter 2021 to include all human studies attempting to experimentally induce HAAF. In different combinations, the search terms used were “hypoglycemia-associated autonomic failure,” “HAAF,” “hypoglycemia,” “recurring,” “recurrent,” “repeated,” “consecutive,” and “unawareness,” yielding 1565 publications. Inclusion criteria were studies that had aimed at experimentally inducing HAAF and measuring outcomes of hormonal counterregulation and awareness of hypoglycemia. Results The literature search yielded 27 eligible publications, of which 20 were successful in inducing HAAF while statistical significantly impairing both hormonal counterregulation and impairing awareness of hypoglycemia to subsequent hypoglycemia. Several factors were of significance as regards inducing HAAF: Foremost, the duration of antecedent hypoglycemia should be at least 90 minutes and blood glucose should be maintained below 3.4 mmol/L. Other important factors to consider are the type of participants, insulin dosage, and the risk of unintended hypoglycemia prior to the study. Conclusion Here we have outlined the most important factors to take into consideration when designing a study aimed at inducing HAAF, including to take into consideration other disease states susceptible to hypoglycemia, thus hopefully clarifying the field and allowing qualified studies in the future.
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Affiliation(s)
| | - Niels Møller
- Department of Endocrinology and Internal Medicine , Aarhus University Hospital, Denmark
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9
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Story LH, Wilson LM. New Developments in Glucagon Treatment for Hypoglycemia. Drugs 2022; 82:1179-1191. [PMID: 35932416 DOI: 10.1007/s40265-022-01754-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 11/28/2022]
Abstract
Glucagon is essential for endogenous glucose regulation along with the paired hormone, insulin. Unlike insulin, pharmaceutical use of glucagon has been limited due to the unstable nature of the peptide. Glucagon has the potential to address hypoglycemia as a major limiting factor in the treatment of diabetes, which remains very common in the type 1 and type 2 diabetes. Recent developments are poised to change this paradigm and expand the use of glucagon for people with diabetes. Glucagon emergency kits have major limitations for their use in treating severe hypoglycemia. A complicated reconstitution and injection process often results in incomplete or aborted administration. New preparations include intranasal glucagon with an easy-to-use and needle-free nasal applicator as well as two stable liquid formulations in pre-filled injection devices. These may ease the burden of severe hypoglycemia treatment. The liquid preparations may also have a role in the treatment of non-severe hypoglycemia. Despite potential benefits of expanded use of glucagon, undesirable side effects (nausea, vomiting), cost, and complexity of adding another medication may limit real-world use. Additionally, more long-term safety and outcome data are needed before widespread, frequent use of glucagon is recommended by providers.
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Affiliation(s)
- LesleAnn Hayward Story
- Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR, USA
| | - Leah M Wilson
- Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR, USA.
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10
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Acciaroli G, Welsh JB, Akturk HK. Mitigation of Rebound Hyperglycemia With Real-Time Continuous Glucose Monitoring Data and Predictive Alerts. J Diabetes Sci Technol 2022; 16:677-682. [PMID: 33401946 PMCID: PMC9294577 DOI: 10.1177/1932296820982584] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Excess carbohydrate intake during hypoglycemia can lead to rebound hyperglycemia (RH). We investigated associations between RH and use of real-time continuous glucose monitoring (rtCGM) and an rtCGM system's predictive alert. METHODS RH events were series of sensor glucose values (SGVs) >180 mg/dL starting within two hours of an antecedent SGV <70 mg/dL. Events were characterized by their frequency, duration (consecutive SGVs >180 mg/dL × five minutes), and severity (area under the glucose concentration-time curve). To assess the impact of rtCGM, data gathered during the four-week baseline phase (without rtCGM) and four-week follow-up phase (with rtCGM) from 75 participants in the HypoDE clinical trial (NCT02671968) of hypoglycemia-unaware individuals were compared. To assess the impact of predictive alerts, we identified a convenience sample of 24 518 users of an rtCGM system without predictive alerts who transitioned to a system whose predictive alert signals an SGV ≤55 mg/dL within 20 minutes (Dexcom G5 and G6, respectively). RH events from periods of blinded versus unblinded rtCGM wear and from periods of G5 and G6 wear were compared with paired t tests. RESULTS Compared to RH events in the HypoDE baseline phase, the mean frequency, duration, and severity of events fell by 14%, 12%, and 23%, respectively, in the follow-up phase (all P < .05). Compared to RH events during G5 use, the mean frequency, duration, and severity of events fell by 7%, 8%, and 13%, respectively, during G6 use (all P < .001). CONCLUSIONS Rebound hypreglycemia can be objectively quantified and mitigated with rtCGM and rtCGM-based predictive alerts.
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Affiliation(s)
| | - John B. Welsh
- Dexcom, Inc., San Diego, CA, USA
- John B. Welsh, MD, PhD, Dexcom, Inc., 6340
Sequence Drive, San Diego, CA 92121, USA.
| | - Halis Kaan Akturk
- Barbara Davis Center for Diabetes,
University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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11
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Bengtsen MB, Hansen ESS, Tougaard RS, Lyhne MD, Rittig NF, Støy J, Jessen N, Mariager CØ, Stødkilde-Jørgensen H, Møller N, Laustsen C. Hyperpolarized [1- 13 C]pyruvate combined with the hyperinsulinaemic euglycaemic and hypoglycaemic clamp technique in skeletal muscle in a large animal model. Exp Physiol 2021; 106:2412-2422. [PMID: 34705304 PMCID: PMC9298727 DOI: 10.1113/ep089782] [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: 05/23/2021] [Accepted: 10/20/2021] [Indexed: 11/08/2022]
Abstract
New Findings What is the central question of this study? Is it possible to combine the hyperpolarized magnetic resonance technique and the hyperinsulinaemic clamp method in order to evaluate skeletal muscle metabolism in a large animal model? What is the main finding and its importance? The logistical set‐up is possible, and we found substantial increments in glucose infusion rates representing skeletal muscle glucose uptake but no differences in ratios of [1‐13C]lactate to [1‐13C]pyruvate, [1‐13C]alanine to [1‐13C]pyruvate, and 13C‐bicarbonate to [1‐13C]pyruvate, implying that the hyperpolarization technique might not be optimal for detecting effects of insulin in skeletal muscle of anaesthetized animals, which is of significance for future studies.
Abstract In skeletal muscle, glucose metabolism is tightly regulated by the reciprocal relationship between insulin and adrenaline, with pyruvate being at the intersection of both pathways. Hyperpolarized magnetic resonance (hMR) is a new approach to gain insights into these pathways, and human trials involving hMR and skeletal muscle metabolism are imminent. We aimed to combine the hyperinsulinaemic clamp technique and hMR in a large animal model resembling human physiology. Fifteen anaesthetized pigs were randomized to saline (control group), hyperinsulinaemic euglycaemic clamp technique (HE group) or hyperinsulinaemic hypoglycaemic clamp technique (HH group). Skeletal muscle metabolism was evaluated by hyperpolarized [1‐13C]pyruvate injection and hMR at baseline and after intervention. The glucose infusion rate per kilogram increased by a statistically significant amount in the HE and HH groups (P < 0.001). Hyperpolarized magnetic resonance showed no statistically significant changes in metabolite ratios: [1‐13C]lactate to [1‐13C]pyruvate in the HH group versus control group (P = 0.19); and 13C‐bicarbonate to [1‐13C]pyruvate ratio in the HE group versus the control group (P = 0.12). We found evidence of profound increments in glucose infusion rates representing skeletal muscle glucose uptake, but interestingly, no signs of significant changes in aerobic and anaerobic metabolism using hMR. These results imply that hyperpolarized [1‐13C]pyruvate might not be optimally suited to detect effects of insulin in anaesthetized resting skeletal muscle, which is of significance for future studies.
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Affiliation(s)
- Mads Bisgaard Bengtsen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | | | | | - Mads Dam Lyhne
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Nikolaj Fibiger Rittig
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus N, Denmark.,Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus N, Denmark
| | - Julie Støy
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus N, Denmark
| | - Niels Jessen
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus N, Denmark
| | | | | | - Niels Møller
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus N, Denmark
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Bisgaard Bengtsen M, Møller N. Mini-review: Glucagon responses in type 1 diabetes - a matter of complexity. Physiol Rep 2021; 9:e15009. [PMID: 34405569 PMCID: PMC8371343 DOI: 10.14814/phy2.15009] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 07/29/2021] [Indexed: 12/14/2022] Open
Abstract
In recent years the role of altered alpha cell function and glucagon secretion in type 1 diabetes has attracted scientific attention. It is well established that glucagon responses to hypoglycemia are absent in type 1 diabetes, but more uncertain whether it is intact following other physiological and metabolic stimuli compared with nondiabetic individuals. The aim of this review is to (i) summarize current knowledge on glucagon responses during hypoglycemia in normal physiology and type 1 diabetes, and (ii) review human in vivo studies investigating glucagon responses after other stimuli in individuals with type 1 diabetes and nondiabetic individuals. Available data suggest that in type 1 diabetes the absence of glucagon secretion after hypoglycemia is irreversible. This is a scenario specific to hypoglycemia, since other stimuli, including administration of amino acids, insulin withdrawal, lipopolysaccharide exposure and exercise lead to substantial glucagon responses though attenuated compared to nondiabetic individuals in head-to-head studies. The derailed glucagon secretion is not confined to hypoglycemia as individuals with type 1 diabetes, as opposed to nondiabetic individuals display glucagon hypersecretion after meals, thereby potentially contributing to insulin resistance. The complexity of these phenomena may relate to activation of distinct regulatory pathways controlling glucagon secretion i.e., intra-islet paracrine signaling, direct and autonomic nervous signaling.
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Affiliation(s)
- Mads Bisgaard Bengtsen
- Department of Endocrinology and Internal MedicineAarhus University HospitalAarhusDenmark
- Department of Internal MedicineRegional Hospital HorsensHorsensDenmark
| | - Niels Møller
- Department of Endocrinology and Internal MedicineAarhus University HospitalAarhusDenmark
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