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Senthilkumaran M, Koch C, Herselman MF, Bobrovskaya L. Role of the Adrenal Medulla in Hypoglycaemia-Associated Autonomic Failure-A Diabetic Perspective. Metabolites 2024; 14:100. [PMID: 38392992 PMCID: PMC10890365 DOI: 10.3390/metabo14020100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/25/2024] Open
Abstract
Hypoglycaemia-associated autonomic failure (HAAF) is characterised by an impairment in adrenal medullary and neurogenic symptom responses following episodes of recurrent hypoglycaemia. Here, we review the status quo of research related to the regulatory mechanisms of the adrenal medulla in its response to single and recurrent hypoglycaemia in both diabetic and non-diabetic subjects with particular focus given to catecholamine synthesis, enzymatic activity, and the impact of adrenal medullary peptides. Short-term post-transcriptional modifications, particularly phosphorylation at specific residues of tyrosine hydroxylase (TH), play a key role in the regulation of catecholamine synthesis. While the effects of recurrent hypoglycaemia on catecholamine synthetic enzymes remain inconsistent, long-term changes in TH protein expression suggest species-specific responses. Adrenomedullary peptides such as neuropeptide Y (NPY), galanin, and proenkephalin exhibit altered gene and protein expression in response to hypoglycaemia, suggesting a potential role in the modulation of catecholamine secretion. Of note is NPY, since its antagonism has been shown to prevent reductions in TH protein expression. This review highlights the need for further investigation into the molecular mechanisms involved in the adrenal medullary response to hypoglycaemia. Despite advancements in our understanding of HAAF in non-diabetic rodents, a reliable diabetic rodent model of HAAF remains a challenge.
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Affiliation(s)
- Manjula Senthilkumaran
- Health and Biomedical Innovation, Clinical and Health Sciences, University of South Australia, Adelaide, SA 5000, Australia
| | - Coen Koch
- Health and Biomedical Innovation, Clinical and Health Sciences, University of South Australia, Adelaide, SA 5000, Australia
| | - Mauritz Frederick Herselman
- Health and Biomedical Innovation, Clinical and Health Sciences, University of South Australia, Adelaide, SA 5000, Australia
| | - Larisa Bobrovskaya
- Health and Biomedical Innovation, Clinical and Health Sciences, University of South Australia, Adelaide, SA 5000, Australia
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Hashmi HZ, Khowaja A, Moheet A. Experimental pharmacological approaches to reverse impaired awareness of hypoglycemia-a review. Front Pharmacol 2024; 15:1349004. [PMID: 38323079 PMCID: PMC10844401 DOI: 10.3389/fphar.2024.1349004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 01/04/2024] [Indexed: 02/08/2024] Open
Abstract
The colossal global burden of diabetes management is compounded by the serious complication of hypoglycemia. Protective physiologic hormonal and neurogenic counterregulatory responses to hypoglycemia are essential to preserve glucose homeostasis and avert serious morbidity. With recurrent exposure to hypoglycemic episodes over time, these counterregulatory responses to hypoglycemia can diminish, resulting in an impaired awareness of hypoglycemia (IAH). IAH is characterized by sudden neuroglycopenia rather than preceding cautionary autonomic symptoms. IAH increases the risk of subsequent sudden and severe hypoglycemic episodes in patients with diabetes. The postulated causative mechanisms behind IAH are complex and varied. It is therefore challenging to identify a single effective therapeutic strategy. In this review, we closely examine the efficacy and feasibility of a myriad of pharmaceutical interventions in preventing and treating IAH as described in clinical and preclinical studies. Pharmaceutical agents outlined include N-acetyl cysteine, GABA A receptor blockers, opioid receptor antagonists, AMP activated protein kinase agonists, potassium channel openers, dehydroepiandrosterone, metoclopramide, antiadrenergic agents, antidiabetic agents and glucagon.
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Affiliation(s)
- Hiba Z. Hashmi
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Ameer Khowaja
- Northeast Endocrinology Associates, San Antonio, TX, United States
| | - Amir Moheet
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
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3
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Macon EL, Devore MH, Lin YK, Music MB, Wooten M, McMullen CA, Woodcox AM, Marksbury AR, Beckner Z, Patel BV, Schoeder LA, Iles AN, Fisher SJ. Current and future therapies to treat impaired awareness of hypoglycemia. Front Pharmacol 2023; 14:1271814. [PMID: 37942482 PMCID: PMC10628050 DOI: 10.3389/fphar.2023.1271814] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/05/2023] [Indexed: 11/10/2023] Open
Abstract
In order to achieve optimal glycemic control, intensive insulin regimes are needed for individuals with Type 1 Diabetes (T1D) and insulin-dependent Type 2 Diabetes (T2D). Unfortunately, intensive glycemic control often results in insulin-induced hypoglycemia. Moreover, recurrent episodes of hypoglycemia result in both the loss of the characteristic warning symptoms associated with hypoglycemia and an attenuated counterregulatory hormone responses. The blunting of warning symptoms is known as impaired awareness of hypoglycemia (IAH). Together, IAH and the loss of the hormonal response is termed hypoglycemia associated autonomic failure (HAAF). IAH is prevalent in up to 25% in people with T1D and up to 10% in people with T2D. IAH and HAAF increase the risk of severe hypoglycemia 6-fold and 25-fold, respectively. To reduce this risk for severe hypoglycemia, multiple different therapeutic approaches are being explored that could improve awareness of hypoglycemia. Current therapies to improve awareness of hypoglycemia include patient education and psychoeducation, the use of novel glycemic control technology, pancreas/islet transplantation, and drug therapy. This review examines both existing therapies and potential therapies that are in pre-clinical testing. Novel treatments that improve awareness of hypoglycemia, via improving the counterregulatory hormone responses or improving hypoglycemic symptom recognition, would also shed light on the possible neurological mechanisms that lead to the development of IAH. To reduce the risk of severe hypoglycemia in people with diabetes, elucidating the mechanism behind IAH, as well as developing targeted therapies is currently an unmet need for those that suffer from IAH.
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Affiliation(s)
- Erica L. Macon
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Micah H. Devore
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Yu Kuei Lin
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Megan B. Music
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Mason Wooten
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Colleen A. McMullen
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Andrea M. Woodcox
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Ashlee R. Marksbury
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Zachary Beckner
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Bansi V. Patel
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Lily A. Schoeder
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Ashley N. Iles
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Simon J. Fisher
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
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Sanchez-Rangel E, Deajon-Jackson J, Hwang JJ. Pathophysiology and management of hypoglycemia in diabetes. Ann N Y Acad Sci 2022; 1518:25-46. [PMID: 36202764 DOI: 10.1111/nyas.14904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In the century since the discovery of insulin, diabetes has changed from an early death sentence to a manageable chronic disease. This change in longevity and duration of diabetes coupled with significant advances in therapeutic options for patients has fundamentally changed the landscape of diabetes management, particularly in patients with type 1 diabetes mellitus. However, hypoglycemia remains a major barrier to achieving optimal glycemic control. Current understanding of the mechanisms of hypoglycemia has expanded to include not only counter-regulatory hormonal responses but also direct changes in brain glucose, fuel sensing, and utilization, as well as changes in neural networks that modulate behavior, mood, and cognition. Different strategies to prevent and treat hypoglycemia have been developed, including educational strategies, new insulin formulations, delivery devices, novel technologies, and pharmacologic targets. This review article will discuss current literature contributing to our understanding of the myriad of factors that lead to the development of clinically meaningful hypoglycemia and review established and novel therapies for the prevention and treatment of hypoglycemia.
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Affiliation(s)
- Elizabeth Sanchez-Rangel
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jelani Deajon-Jackson
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Janice Jin Hwang
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA.,Division of Endocrinology, Department of Internal Medicine, University of North Carolina - Chapel Hill, Chapel Hill, North Carolina, USA
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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: 0] [Impact Index Per Article: 0] [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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Jokiaho AJ, Winchester M, Donovan CM. N-Hydroxyethyl-1-Deoxynojirimycin (Miglitol) Restores the Counterregulatory Response to Hypoglycemia Following Antecedent Hypoglycemia. Diabetes 2022; 71:1063-1072. [PMID: 35179550 DOI: 10.2337/db21-0859] [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] [Received: 09/22/2021] [Accepted: 02/15/2022] [Indexed: 11/13/2022]
Abstract
Antecedent hypoglycemia suppresses the counterregulatory responses to subsequent hypoglycemic episodes, which can be prevented by normalizing portal-mesenteric vein (PMV) glycemia alone during the antecedent bout. Since the sodium-glucose transporter 3 receptor has been implicated in PMV glucosensing, we hypothesized that PMV infusion of the sodium-glucose cotransporter 3 receptor agonist N-hydroxyethyl-1-deoxynojirimycin (miglitol) would rescue the sympathoadrenal response to subsequent hypoglycemia. Rats underwent hyperinsulinemic-hypoglycemic clamps on 2 consecutive days without miglitol infusion (antecedent hypoglycemia without miglitol [HYPO]) or with miglitol infused upstream in the PMV, perfusing the glucosensors, or adjacent to the liver, bypassing PMV glucosensors, on day 1 or day 2. Control animals underwent day 1 euglycemic clamps, followed by hypoglycemic clamps on day 2. Peak epinephrine (EPI) responses for HYPO on day 2 were significantly blunted when compared with controls. Miglitol infusion on day 1 proved ineffective in restoring the EPI response following antecedent hypoglycemia, but day 2 miglitol infusion restored EPI responses to control levels. As norepinephrine and glucagon demonstrated similar responses, day 2 administration of miglitol effectively restored the counterregulatory response following antecedent hypoglycemia. In subsequent experiments, we demonstrate similar results with reduced miglitol infusion doses, approaching those currently prescribed for type 2 diabetes (correcting for rodent size), as well as the efficacy of oral miglitol administration in restoring the counterregulatory responses following antecedent hypoglycemia.
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Affiliation(s)
- Anne J Jokiaho
- Department of Biological Sciences, University of Southern California, Los Angeles, CA
| | - Matthew Winchester
- Department of Biological Sciences, University of Southern California, Los Angeles, CA
| | - Casey M Donovan
- Department of Biological Sciences, University of Southern California, Los Angeles, CA
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Zhang Y, Öz G, Moheet A, Kumar A, Alvear A, Mangia S, Eberly L, Seaquist ER. Heterogeneity in epinephrine response to experimental hypoglycemia in type 1 diabetes and controls. J Endocr Soc 2022; 6:bvac046. [PMID: 35475026 PMCID: PMC9032637 DOI: 10.1210/jendso/bvac046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Indexed: 11/29/2022] Open
Abstract
Context The epinephrine response (Epi) to a first episode of hypoglycemia (HG) has been proposed to be predictive of Epi in subsequent HG and to provide insight into the risk for developing HG-associated autonomic failure (HAAF) in healthy controls (HCs). Objective To determine if Epi and symptom response (SR) to the first episode of HG predicts who will develop HAAF after exposure to recurrent HG in volunteers with type 1 diabetes (T1D) and in HCs. Design Review of data collected between 2013 and 2019. Setting Academic clinical research unit. Patients or Participants Volunteers with T1D and HCs. Interventions Subjects participated in a preinduction protocol where they were exposed to three 2-hour episodes of clamped HG over 2 days. Data collected during clamp 1 were compared with data collected during clamp 3. Main outcome measure Difference in Epi and SR. Results Using the standard definition of HAAF in which HG-induced Epi during clamp 3 is at least 20% lower than during clamp 1, 21/28 HCs and 13/19 volunteers with T1D developed HAAF. Epi during clamp 1 was significantly higher in those subjects who developed HAAF than in those who did not in both groups (P = 0.02). If HAAF is defined as achieving a 20% reduction in HG-induced SR measured during clamp 3 compared with clamp 1, 10/27 HCs and 10/19 volunteers with T1D developed SR-based HAAF. Conclusion There was heterogeneity in the response to the preinduction protocol. Epi during clamp 1 was higher than in clamp 3 in HCs and in those with T1D who developed HAAF.
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Affiliation(s)
- Yuan Zhang
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Gülin Öz
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Amir Moheet
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Anjali Kumar
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Alison Alvear
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Silvia Mangia
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Lynn Eberly
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Elizabeth R Seaquist
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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van Meijel LA, Tack CJ, de Galan BE. Effect of short-term use of dapagliflozin on impaired awareness of hypoglycaemia in people with type 1 diabetes. Diabetes Obes Metab 2021; 23:2582-2589. [PMID: 34338413 PMCID: PMC9292159 DOI: 10.1111/dom.14505] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 07/11/2021] [Accepted: 07/26/2021] [Indexed: 12/12/2022]
Abstract
AIM Impaired awareness of hypoglycaemia (IAH) affects about 25% of patients with type 1 diabetes (T1DM). IAH can be reversed by strict avoidance of hypoglycaemia for at least 3 weeks. Adjunctive treatment with sodium glucose cotransporter 2 inhibitors may reduce the risk of hypoglycaemia through reduction of glucose variability. We tested the hypothesis that short-term use of dapagliflozin may improve awareness of hypoglycaemia in people with T1DM and IAH. MATERIALS AND METHODS Fifteen patients with T1DM and IAH were included in this randomized double-blind, placebo-controlled cross-over trial (age 49.7 ± 14.6 years, 40% men, disease duration 24.1 ± 14.2 years, glycated haemoglobin 7.5 ± 0.8% (58.6 ± 8.4 mmol/mol). They were treated with dapagliflozin 10 mg once daily or matching placebo, with a washout period of 2 weeks. At the end of each treatment period, participants underwent a modified hyperinsulinaemic normoglycaemic-hypoglycaemic glucose clamp (glucose nadir 2.5 mmol/L). Blinded continuous glucose monitors were used in the final treatment weeks. RESULTS Treatment with dapagliflozin significantly improved glycated haemoglobin [-0.32 ± 0.10 vs. 0.22 ± 0.13% (-4.1 ± 0.9 vs. 2.3 ± 1.4 mmol/mol), dapagliflozin vs. placebo, p = .007] and glucose variability (standard deviation, 2.6 ± 0.2 vs. 3.1 ± 0.3 mmol/L, p = .029), but did not affect the frequency of hypoglycaemia. During the hypoglycaemic clamp, dapagliflozin did not affect symptom responses (8.0 ± 3.4 vs. 5.2 ± 1.6, p = .31), but significantly reduced the need for exogenous glucose to maintain hypoglycaemia (3.2 ± 0.3 vs. 4.1 ± 0.4 mg/kg/min, p = .022). CONCLUSIONS Eight weeks of treatment with dapagliflozin did not restore hypoglycaemic awareness in people with T1DM and impaired awareness of hypoglycaemia, but ameliorated some clinical aspects.
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Affiliation(s)
- Lian A. van Meijel
- Department of Internal MedicineRadboud University Medical CenterNijmegenThe Netherlands
- Department of Internal MedicineMaxima Medical CenterVeldhovenThe Netherlands
| | - Cees J. Tack
- Department of Internal MedicineRadboud University Medical CenterNijmegenThe Netherlands
| | - Bastiaan E. de Galan
- Department of Internal MedicineRadboud University Medical CenterNijmegenThe Netherlands
- Department of Internal MedicineMaastricht University Medical CenterMaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
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Koekkoek LL, Kool T, Eggels L, van der Gun LL, Lamuadni K, Slomp M, Diepenbroek C, Serlie MJ, Kalsbeek A, la Fleur SE. Activation of nucleus accumbens μ-opioid receptors enhances the response to a glycaemic challenge. J Neuroendocrinol 2021; 33:e13036. [PMID: 34528311 PMCID: PMC9286654 DOI: 10.1111/jne.13036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/10/2021] [Accepted: 08/20/2021] [Indexed: 11/30/2022]
Abstract
Opioids are known to affect blood glucose levels but their exact role in the physiological control of glucose metabolism remains unclear. Although there are numerous studies investigating the peripheral effects of opioid stimulation, little is known about how central opioids control blood glucose and which brain areas are involved. One brain area possibly involved is the nucleus accumbens because, as well as being a key site for opioid effects on food intake, it has also been implicated in the control of blood glucose levels. Within the nucleus accumbens, μ-opioid receptors are most abundantly expressed. Therefore, in the present study, we investigated the role of μ-opioid receptors in the nucleus accumbens in the control of glucose metabolism. We show that infusion of the μ-opioid receptor agonist [d-Ala2 , N-MePhe4 , Gly-ol]-enkephalin (DAMGO) in the nucleus accumbens by itself does not affect blood glucose levels, but it enhances the glycaemic response after both an insulin tolerance test, as well as a glucose tolerance test. These findings indicate that the nucleus accumbens plays a role in the central effects of opioids on glucose metabolism, and highlight the possibility of nucleus accumbens μ-opioid receptors as a therapeutic target for enhancing the counter-regulatory response.
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Affiliation(s)
- Laura L. Koekkoek
- Amsterdam University Medical Center, Location AMCLaboratory of EndocrinologyDepartment of Clinical ChemistryAmsterdam NeuroscienceAmsterdam Gastroenterology, Endocrinology and MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam University Medical Center, Location AMCDepartment of Endocrinology and MetabolismAmsterdam NeuroscienceAmsterdam Gastroenterology, Endocrinology and MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
- Metabolism and Reward GroupAn Institute of the Royal Netherlands Academy of Arts and SciencesNetherlands Institute for NeuroscienceAmsterdamThe Netherlands
| | - Tess Kool
- Amsterdam University Medical Center, Location AMCLaboratory of EndocrinologyDepartment of Clinical ChemistryAmsterdam NeuroscienceAmsterdam Gastroenterology, Endocrinology and MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam University Medical Center, Location AMCDepartment of Endocrinology and MetabolismAmsterdam NeuroscienceAmsterdam Gastroenterology, Endocrinology and MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
- Metabolism and Reward GroupAn Institute of the Royal Netherlands Academy of Arts and SciencesNetherlands Institute for NeuroscienceAmsterdamThe Netherlands
| | - Leslie Eggels
- Amsterdam University Medical Center, Location AMCLaboratory of EndocrinologyDepartment of Clinical ChemistryAmsterdam NeuroscienceAmsterdam Gastroenterology, Endocrinology and MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam University Medical Center, Location AMCDepartment of Endocrinology and MetabolismAmsterdam NeuroscienceAmsterdam Gastroenterology, Endocrinology and MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
- Metabolism and Reward GroupAn Institute of the Royal Netherlands Academy of Arts and SciencesNetherlands Institute for NeuroscienceAmsterdamThe Netherlands
| | - Luna L. van der Gun
- Amsterdam University Medical Center, Location AMCLaboratory of EndocrinologyDepartment of Clinical ChemistryAmsterdam NeuroscienceAmsterdam Gastroenterology, Endocrinology and MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam University Medical Center, Location AMCDepartment of Endocrinology and MetabolismAmsterdam NeuroscienceAmsterdam Gastroenterology, Endocrinology and MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
- Metabolism and Reward GroupAn Institute of the Royal Netherlands Academy of Arts and SciencesNetherlands Institute for NeuroscienceAmsterdamThe Netherlands
| | - Khalid Lamuadni
- Amsterdam University Medical Center, Location AMCLaboratory of EndocrinologyDepartment of Clinical ChemistryAmsterdam NeuroscienceAmsterdam Gastroenterology, Endocrinology and MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam University Medical Center, Location AMCDepartment of Endocrinology and MetabolismAmsterdam NeuroscienceAmsterdam Gastroenterology, Endocrinology and MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
- Metabolism and Reward GroupAn Institute of the Royal Netherlands Academy of Arts and SciencesNetherlands Institute for NeuroscienceAmsterdamThe Netherlands
| | - Margo Slomp
- Amsterdam University Medical Center, Location AMCLaboratory of EndocrinologyDepartment of Clinical ChemistryAmsterdam NeuroscienceAmsterdam Gastroenterology, Endocrinology and MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam University Medical Center, Location AMCDepartment of Endocrinology and MetabolismAmsterdam NeuroscienceAmsterdam Gastroenterology, Endocrinology and MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
- Metabolism and Reward GroupAn Institute of the Royal Netherlands Academy of Arts and SciencesNetherlands Institute for NeuroscienceAmsterdamThe Netherlands
| | - Charlene Diepenbroek
- Amsterdam University Medical Center, Location AMCLaboratory of EndocrinologyDepartment of Clinical ChemistryAmsterdam NeuroscienceAmsterdam Gastroenterology, Endocrinology and MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam University Medical Center, Location AMCDepartment of Endocrinology and MetabolismAmsterdam NeuroscienceAmsterdam Gastroenterology, Endocrinology and MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
- Metabolism and Reward GroupAn Institute of the Royal Netherlands Academy of Arts and SciencesNetherlands Institute for NeuroscienceAmsterdamThe Netherlands
| | - Mireillle J. Serlie
- Amsterdam University Medical Center, Location AMCDepartment of Endocrinology and MetabolismAmsterdam NeuroscienceAmsterdam Gastroenterology, Endocrinology and MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
| | - Andries Kalsbeek
- Amsterdam University Medical Center, Location AMCLaboratory of EndocrinologyDepartment of Clinical ChemistryAmsterdam NeuroscienceAmsterdam Gastroenterology, Endocrinology and MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam University Medical Center, Location AMCDepartment of Endocrinology and MetabolismAmsterdam NeuroscienceAmsterdam Gastroenterology, Endocrinology and MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
- Hypothalamic Integration MechanismsAn Institute of the Royal Netherlands Academy of Arts and SciencesNetherlands Institute for NeuroscienceAmsterdamThe Netherlands
| | - Susanne E. la Fleur
- Amsterdam University Medical Center, Location AMCLaboratory of EndocrinologyDepartment of Clinical ChemistryAmsterdam NeuroscienceAmsterdam Gastroenterology, Endocrinology and MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam University Medical Center, Location AMCDepartment of Endocrinology and MetabolismAmsterdam NeuroscienceAmsterdam Gastroenterology, Endocrinology and MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
- Metabolism and Reward GroupAn Institute of the Royal Netherlands Academy of Arts and SciencesNetherlands Institute for NeuroscienceAmsterdamThe Netherlands
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10
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Sohn EH, Gibbons CH, Freeman R, Lee AY, Jung MS, Kim S. Validation of the Korean version of the Boston Autonomic Symptom Questionnaire. J Clin Neurol 2021; 17:463-469. [PMID: 34184455 PMCID: PMC8242302 DOI: 10.3988/jcn.2021.17.3.463] [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: 11/16/2020] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE The Boston Autonomic Symptom Questionnaire (BASQ) is a quantitative tool using a numeric rating scale to assess the symptoms of systemic dysautonomia, including cardiovascular, gastrointestinal, urinary, sudomotor, vasomotor, and sexual functions. The aim of this study was to validate the Korean version of the BASQ (KBASQ). METHODS Prospectively enrolled subjects who submitted to autonomic function tests, including tests for cardiovagal, adrenergic, and sudomotor functions, also completed the KBASQ and the Korean version of the Orthostatic Grading Scale (KOGS), a validated questionnaire or assessing orthostatic symptoms.Twenty-eight subjects completed the KBASQ twice to assess test-retest reliability. We classified the subjects to dysautonomia or normal control group according to dysautonomic symptoms and the results of autonomic function tests. RESULTS This study enrolled 225 subjects aged 54.0±18.1 years (mean±standard deviation), with a male/female ratio of 1/1.03. The internal validity of the KBASQ was excellent (Cronbach's α=0.922), and that of each of its subscales ranged from excellent to acceptable (Cronbach's α=0.709-0.952). The test-retest reliability was good, with correlation coefficients ranging from 0.354 to 0.917. The subcategory scores for the KBASQ were significantly higher in the dysautonomia group than in the normal control group. There were significant correlations among the items in the KBASQ and KOGS. There was also a significant correlation between KBASQ scores and the results of the autonomic function tests. CONCLUSIONS The internal validity and reliability of the KBASQ were good, indicating that it may be a useful screening tool for the systematic evaluation of autonomic symptoms in patients with dysautonomia.
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Affiliation(s)
- Eun Hee Sohn
- Department of Neurology, Chungnam National University Hospital, Daejeon, Korea.
| | - Christopher H Gibbons
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ae Young Lee
- Department of Neurology, Chungnam National University Hospital, Daejeon, Korea
| | - Mi Sook Jung
- College of Nursing, Chungnam National University, Daejeon, Korea
| | - Sooyoung Kim
- Department of Neurology, Chungnam National University Hospital, Daejeon, Korea
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11
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Farrell CM, McCrimmon RJ. Clinical approaches to treat impaired awareness of hypoglycaemia. Ther Adv Endocrinol Metab 2021; 12:20420188211000248. [PMID: 33796253 PMCID: PMC7968015 DOI: 10.1177/20420188211000248] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 02/12/2021] [Indexed: 01/25/2023] Open
Abstract
Impaired awareness of hypoglycaemia (IAH) affects between 25% and 30% of all people with type 1 diabetes (T1D) and markedly increases risk of severe hypoglycaemia. This greatly feared complication of T1D impairs quality of life and has a recognised morbidity. People with T1D have an increased propensity to hypoglycaemia as a result of fundamental physiological defects in their ability to respond appropriately to a fall in blood glucose levels. With repeated exposure to low glucose, many then develop a condition referred to as IAH, where there is a reduced ability to perceive the onset of hypoglycaemia and take appropriate corrective action. The management of individuals with IAH relies initially on its identification in the clinic through a detailed exploration of the frequency of hypoglycaemia and an assessment of the individual's ability to recognise these episodes. In this review article, we will address the clinical strategies that may help in the management of the patient with IAH once identified, who may or may not also suffer from problematic hypoglycaemia. The initial focus is on how to identify such patients and then on the variety of approaches involving educational programmes and technological approaches that may be taken to minimise hypoglycaemia risk. No single approach can be advocated for all patients, and it is the role of the health care professional to identify the clinical strategy that best enables their patient to achieve this goal.
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Affiliation(s)
- Catriona M. Farrell
- Division of Systems Medicine, School of Medicine, University of Dundee, Dundee, UK
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12
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Lin YK, Fisher SJ, Pop‐Busui R. Hypoglycemia unawareness and autonomic dysfunction in diabetes: Lessons learned and roles of diabetes technologies. J Diabetes Investig 2020; 11:1388-1402. [PMID: 32403204 PMCID: PMC7610104 DOI: 10.1111/jdi.13290] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/01/2020] [Accepted: 05/07/2020] [Indexed: 12/18/2022] Open
Abstract
Impaired awareness of hypoglycemia (IAH) is a reduction in the ability to recognize low blood glucose levels that would otherwise prompt an appropriate corrective therapy. Identified in approximately 25% of patients with type 1 diabetes, IAH has complex pathophysiology, and might lead to serious and potentially lethal consequences in patients with diabetes, particularly in those with more advanced disease and comorbidities. Continuous glucose monitoring systems can provide real-time glucose information and generate timely alerts on rapidly falling or low blood glucose levels. Given their improvements in accuracy, affordability and integration with insulin pump technology, continuous glucose monitoring systems are emerging as critical tools to help prevent serious hypoglycemia and mitigate its consequences in patients with diabetes. This review discusses the current knowledge on IAH and effective diagnostic methods, the relationship between hypoglycemia and cardiovascular autonomic neuropathy, a practical approach to evaluating cardiovascular autonomic neuropathy for clinicians, and recent evidence from clinical trials assessing the effects of the use of CGM technologies in patients with type 1 diabetes with IAH.
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Affiliation(s)
- Yu Kuei Lin
- Division of Metabolism, Endocrinology and DiabetesDepartment of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Simon J Fisher
- Division of Endocrinology, Metabolism and DiabetesDepartment of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Rodica Pop‐Busui
- Division of Metabolism, Endocrinology and DiabetesDepartment of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
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13
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Sankar A, Khodai T, McNeilly AD, McCrimmon RJ, Luckman SM. Experimental Models of Impaired Hypoglycaemia-Associated Counter-Regulation. Trends Endocrinol Metab 2020; 31:691-703. [PMID: 32563715 DOI: 10.1016/j.tem.2020.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/14/2020] [Accepted: 05/26/2020] [Indexed: 01/24/2023]
Abstract
Impaired awareness of hypoglycaemia (IAH) affects around a quarter of patients with diabetes who receive insulin treatment. This condition is characterised by a progressive reduction in symptomatic and behavioural responses to hypoglycaemia, increasing risk of deeper drops in blood glucose, unconsciousness, and collapse. Thus, patients with IAH experience severe hypoglycaemic episodes more frequently, resulting in significant morbidity and mortality. IAH is thought to develop as a consequence of whole-body adaptations to repeated insulin-induced hypoglycaemia (RH), with widespread deficits in the hypoglycaemia counter-regulatory response (CRR). Despite this important insight, the precise pathophysiology by which RH leads to an attenuated CRR is unknown. Studies into the underlying mechanisms of IAH have employed a variety of protocols in humans and experimental species. The use of animal models has many investigational benefits, including the unprecedented increase in the availability of transgenic strains. However, modelling impaired hypoglycaemia-associated counter-regulation remains challenging and appropriate interpretation of findings across species and protocols even more so. Here, we review the experimental modelling of IAH and impaired hypoglycaemia-associated counter-regulation, with a focus on understanding species-specific variation in glucose homeostasis. This review will aid investigators in interpreting outputs from different studies in IAH and aid progress in the field.
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Affiliation(s)
- Adhithya Sankar
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Tansi Khodai
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Alison D McNeilly
- Division of Systems Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Rory J McCrimmon
- Division of Systems Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Simon M Luckman
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
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14
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Rickels MR. Hypoglycemia-associated autonomic failure, counterregulatory responses, and therapeutic options in type 1 diabetes. Ann N Y Acad Sci 2019; 1454:68-79. [PMID: 31389033 DOI: 10.1111/nyas.14214] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/06/2019] [Accepted: 07/19/2019] [Indexed: 12/12/2022]
Abstract
Hypoglycemia remains a major barrier to the achievement of target levels of glycemic control for most individuals with insulin-dependent type 1 diabetes (T1D). Both the loss of β cells and an accompanying defect in the α cell response to hypoglycemia predispose patients with T1D to the development of low blood glucose. Increased glucose variability, exposure to hypoglycemia, and impaired awareness of hypoglycemia all contribute to increased risk of experiencing severe hypoglycemia, which is explained by progressive impairment in epinephrine secretion and autonomic symptom generation in response to hypoglycemia leading to defective glucose counterregulation and hypoglycemia unawareness that characterize hypoglycemia-associated autonomic failure (HAAF). Interruption of HAAF requires interfering with the mechanisms of brain adaptation to low blood glucose that affect central glucose sensing and the autonomic response to hypoglycemia, or avoidance of hypoglycemia that may allow for eventual recovery of counterregulatory and autonomic symptom responses. Strategies for hypoglycemia avoidance that include continuous glucose monitoring may reduce, but do not eliminate, clinically significant hypoglycemia, with ongoing counterregulatory defects and impaired awareness of hypoglycemia. Complete avoidance of hypoglycemia can be achieved following pancreatic islet transplantation and allows for the restoration of counterregulatory and autonomic symptom responses that evidences the potential for reversing HAAF in T1D.
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Affiliation(s)
- Michael R Rickels
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.,Institute for Diabetes, Obesity and Metabolism, the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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15
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Kakall ZM, Kavurma MM, Cohen EM, Howe PR, Nedoboy PE, Pilowsky PM. Repetitive hypoglycemia reduces activation of glucose-responsive neurons in C1 and C3 medullary brain regions to subsequent hypoglycemia. Am J Physiol Endocrinol Metab 2019; 317:E388-E398. [PMID: 31013147 PMCID: PMC6732467 DOI: 10.1152/ajpendo.00051.2019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The impaired ability of the autonomic nervous system to respond to hypoglycemia is termed "hypoglycemia-associated autonomic failure" (HAAF). This life-threatening phenomenon results from at least two recent episodes of hypoglycemia, but the pathology underpinning HAAF remains largely unknown. Although naloxone appears to improve hypoglycemia counterregulation under controlled conditions, hypoglycemia prevention remains the current mainstay therapy for HAAF. Epinephrine-synthesizing neurons in the rostroventrolateral (C1) and dorsomedial (C3) medulla project to the subset of sympathetic preganglionic neurons that regulate peripheral epinephrine release. Here we determined whether or not C1 and C3 neuronal activation is impaired in HAAF and whether or not 1 wk of hypoglycemia prevention or treatment with naloxone could restore C1 and C3 neuronal activation and improve HAAF. Twenty male Sprague-Dawley rats (250-300 g) were used. Plasma epinephrine levels were significantly increased after a single episode of hypoglycemia (n = 4; 5,438 ± 783 pg/ml vs. control 193 ± 27 pg/ml, P < 0.05). Repeated hypoglycemia significantly reduced the plasma epinephrine response to subsequent hypoglycemia (n = 4; 2,179 ± 220 pg/ml vs. 5,438 ± 783 pg/ml, P < 0.05). Activation of medullary C1 (n = 4; 50 ± 5% vs. control 3 ± 1%, P < 0.05) and C3 (n = 4; 45 ± 5% vs. control 4 ± 1%, P < 0.05) neurons was significantly increased after a single episode of hypoglycemia. Activation of C1 (n = 4; 12 ± 3%, P < 0.05) and C3 (n = 4; 19 ± 5%, P < 0.05) neurons was significantly reduced in the HAAF groups. Hypoglycemia prevention or treatment with naloxone did not restore the plasma epinephrine response or C1 and C3 neuronal activation. Thus repeated hypoglycemia reduced the activation of C1 and C3 neurons mediating adrenal medullary responses to subsequent bouts of hypoglycemia.
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Affiliation(s)
- Zohra M Kakall
- The Heart Research Institute, Newtown, New South Wales, Australia
- Department of Physiology, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Mary M Kavurma
- The Heart Research Institute, Newtown, New South Wales, Australia
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - E Myfanwy Cohen
- The Heart Research Institute, Newtown, New South Wales, Australia
- Department of Physiology, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Peter R Howe
- School of Biomedical Sciences and Pharmacy, University of Newcastle and Institute for Resilient Regions, University of Southern Queensland, Springfield, Queensland, Australia
| | - Polina E Nedoboy
- The Heart Research Institute, Newtown, New South Wales, Australia
- Department of Physiology, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Paul M Pilowsky
- Department of Physiology, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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16
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Chrétien B, Dolladille C, Hamel-Sénécal L, Sassier M, Faillie JL, Miremont-Salamé G, Lelong-Boulouard V, Le Boisselier R, Fedrizzi S, Alexandre J, Humbert X. Comparative study of hypoglycaemia induced by opioids. Is it a class effect? Expert Opin Drug Saf 2019; 18:987-992. [PMID: 31317815 DOI: 10.1080/14740338.2019.1646246] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective: Drug-induced hypoglycaemia has been described with the use of tramadol and methadone. The authors aimed to determine if drug-induced hypoglycaemia could be a class effect for opioids. Methods: The authors performed a disproportionality analysis in VigiBase®, the WHO global individual case safety report database with nine opioids (codeine, fentanyl, hydromorphone, methadone, morphine, oxycodone, tramadol, buprenorphine and nalbuphine) using the broad Standardised MedDRA Query for hypoglycaemia. The authors also carried out a descriptive study of opioid-induced hypoglycaemia in the French PharmacoVigilance DataBase (FPVDB) using the MedDRA Preferred Term 'hypoglycaemia'. Results: The global adjusted Reporting Odds Ratio (aROR) value for the 9 opioids was 1.53 (95% CI 1.52-1.54). The aROR ranged from 1.09 to 1.97 depending on the opioid, but all were statistically significant. A sex ratio of 0.74 was found for the reports of opioid-induced hypoglycaemia in Vigibase®. The authors also found 133 reports of hypoglycaemia in the FPVDB related to opioids. Among the reports, 55 were glycaemic imbalances in diabetics occurring shortly after the start of opioid treatment. Conclusion: This work highlighted a significant association between all opioids and hypoglycaemia, thereby indicating that opioid-induced hypoglycaemia is probably a class effect. Women and/or diabetics seem to be more at risk for developing opioid-induced hypoglycaemia.
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Affiliation(s)
- Basile Chrétien
- Department of Pharmacology, Caen University Hospital , Caen , France.,Pharmacovigilance Center, Caen University Hospital , Caen , France.,Addictovigilance Center, Caen University Hospital , Caen , France
| | | | - Léa Hamel-Sénécal
- Department of Pharmacology, Caen University Hospital , Caen , France.,Pharmacovigilance Center, Caen University Hospital , Caen , France.,Addictovigilance Center, Caen University Hospital , Caen , France
| | - Marion Sassier
- Department of Pharmacology, Caen University Hospital , Caen , France.,Pharmacovigilance Center, Caen University Hospital , Caen , France
| | - Jean Luc Faillie
- Pharmacovigilance Center, Montpellier University Hospital , Montpellier , France
| | | | - Véronique Lelong-Boulouard
- Department of Pharmacology, Caen University Hospital , Caen , France.,INSERM UMR 1075, COMETE-MOBILITES "Vieillissement, Pathologie, Santé", Normandie University, UNICAEN, UFR Santé , Caen , France
| | - Reynald Le Boisselier
- Department of Pharmacology, Caen University Hospital , Caen , France.,Addictovigilance Center, Caen University Hospital , Caen , France
| | - Sophie Fedrizzi
- Department of Pharmacology, Caen University Hospital , Caen , France.,Pharmacovigilance Center, Caen University Hospital , Caen , France
| | - Joachim Alexandre
- Department of Pharmacology, Caen University Hospital , Caen , France.,Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, Normandie University, UNICAEN, Caen University Hospital , Caen , France
| | - Xavier Humbert
- General Practice Department, Normandie University, UNICAEN, EA4650 , Caen , France
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17
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Stanley S, Moheet A, Seaquist ER. Central Mechanisms of Glucose Sensing and Counterregulation in Defense of Hypoglycemia. Endocr Rev 2019; 40:768-788. [PMID: 30689785 PMCID: PMC6505456 DOI: 10.1210/er.2018-00226] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 01/17/2019] [Indexed: 12/12/2022]
Abstract
Glucose homeostasis requires an organism to rapidly respond to changes in plasma glucose concentrations. Iatrogenic hypoglycemia as a result of treatment with insulin or sulfonylureas is the most common cause of hypoglycemia in humans and is generally only seen in patients with diabetes who take these medications. The first response to a fall in glucose is the detection of impending hypoglycemia by hypoglycemia-detecting sensors, including glucose-sensing neurons in the hypothalamus and other regions. This detection is then linked to a series of neural and hormonal responses that serve to prevent the fall in blood glucose and restore euglycemia. In this review, we discuss the current state of knowledge about central glucose sensing and how detection of a fall in glucose leads to the stimulation of counterregulatory hormone and behavior responses. We also review how diabetes and recurrent hypoglycemia impact glucose sensing and counterregulation, leading to development of impaired awareness of hypoglycemia in diabetes.
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Affiliation(s)
- Sarah Stanley
- Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Amir Moheet
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Elizabeth R Seaquist
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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18
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Kakall ZM, Nedoboy PE, Farnham MMJ, Pilowsky PM. Activation of µ-opioid receptors in the rostral ventrolateral medulla blocks the sympathetic counterregulatory response to glucoprivation. Am J Physiol Regul Integr Comp Physiol 2018; 315:R1115-R1122. [PMID: 30281326 DOI: 10.1152/ajpregu.00248.2018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Activation of neurons in the rostral ventrolateral medulla (RVLM) following glucoprivation initiates sympathoadrenal activation, adrenaline release, and increased glucose production. Here, we aimed to determine the role of RVLM µ-opioid receptors in the counterregulatory response to systemic glucoprivation. Experiments were performed in pentobarbital sodium anesthetized male Sprague-Dawley rats ( n = 30). Bilateral activation of RVLM µ-opioid receptors with [d-Ala2, N-Me-Phe4, Gly5-ol]-enkephalin (DAMGO) (8 mM, 50 nl) depressed adrenal sympathetic nerve activity for ~60 min ( n = 6; Δ49.9 ± 5.8%, P < 0.05). The counterregulatory response to glucoprivation (measured by adrenal sympathetic efferent nerve activity) induced by 2-deoxyglucose (2-DG) ( n = 6; Δ63.6 ± 16.5%, P < 0.05) was completely blocked 60 min after DAMGO microinjections ( n = 6; Δ10.2 ± 3.5%, P < 0.05). Furthermore, DAMGO pretreatment attenuated the increase in blood glucose levels after 2-DG infusion ( n = 6; 6.1 ± 0.7mmol/l vs. baseline 5.2 ± 0.3mmol/l, P > 0.05) compared with 2-DG alone ( n = 6; 7.6 ± 0.4mmol/l vs. baseline 6.0 ± 0.4mmol/l, P < 0.05). Thus, activation of RVLM µ-opioid receptors attenuated the neural efferent response to glucoprivation and reduced glucose production.
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Affiliation(s)
- Zohra M Kakall
- Department of Physiology, Sydney Medical School, The University of Sydney , Sydney, NSW , Australia.,Heart Research Institute , Sydney, NSW , Australia
| | - Polina E Nedoboy
- Department of Physiology, Sydney Medical School, The University of Sydney , Sydney, NSW , Australia.,Heart Research Institute , Sydney, NSW , Australia
| | - Melissa M J Farnham
- Department of Physiology, Sydney Medical School, The University of Sydney , Sydney, NSW , Australia.,Heart Research Institute , Sydney, NSW , Australia
| | - Paul M Pilowsky
- Department of Physiology, Sydney Medical School, The University of Sydney , Sydney, NSW , Australia.,Heart Research Institute , Sydney, NSW , Australia
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19
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Seaquist ER. Beyond the brain: do peripheral mechanisms develop impaired awareness of hypoglycemia? J Clin Invest 2018; 128:3739-3741. [PMID: 30080180 PMCID: PMC6118580 DOI: 10.1172/jci122449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
The mechanisms responsible for the development of the impaired awareness of hypoglycemia often seen in insulin-treated patients with diabetes remain uncertain, but cerebral adaptations to recurrent hypoglycemia are frequently hypothesized. In this issue of the JCI, Ma et al. demonstrate that neuropeptide Y (NPY) secretion from adrenal chromaffin cells persists during exposure to recurrent hypoglycemia and activation of the sympathetic nerves at the same time that epinephrine secretion is reduced. This results in the inhibition of tyrosine hydroxylase, the rate-limiting enzyme for catecholamine synthesis. These observations suggest that a peripheral mechanism downstream from the brain contributes to the development of impaired awareness of hypoglycemia.
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20
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McNeilly AD, McCrimmon RJ. Impaired hypoglycaemia awareness in type 1 diabetes: lessons from the lab. Diabetologia 2018; 61:743-750. [PMID: 29417183 PMCID: PMC6448989 DOI: 10.1007/s00125-018-4548-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 10/20/2017] [Indexed: 01/28/2023]
Abstract
Hypoglycaemia remains the most common metabolic adverse effect of insulin and sulfonylurea therapy in diabetes. Repeated exposure to hypoglycaemia leads to a change in the symptom complex that characterises hypoglycaemia, culminating in a clinical phenomenon referred to as impaired awareness of hypoglycaemia (IAH). IAH effects approximately 20-25% of people with type 1 diabetes and increases the risk of severe hypoglycaemia. This review focuses on the mechanisms that are responsible for the much higher frequency of hypoglycaemia in people with diabetes compared with those without, and subsequently how repeated exposure to hypoglycaemia leads to the development of IAH. The mechanisms that result in IAH development are incompletely understood and likely to reflect changes in multiple aspects of the counterregulatory response to hypoglycaemia, from adaptations within glucose and non-glucose-sensing cells to changes in the integrative networks that govern glucose homeostasis. Finally, we propose that the general process that incorporates many of these changes and results in IAH following recurrent hypoglycaemia is a form of adaptive memory called 'habituation'.
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Affiliation(s)
- Alison D McNeilly
- Division of Molecular and Clinical Medicine, Mailbox 12, Level 5, Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, UK
| | - Rory J McCrimmon
- Division of Molecular and Clinical Medicine, Mailbox 12, Level 5, Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, UK.
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21
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Lontchi-Yimagou E, You JY, Carey M, Gabriely I, Shamoon H, Hawkins M. Potential approaches to prevent hypoglycemia-associated autonomic failure. J Investig Med 2018; 66:641-647. [PMID: 29141871 PMCID: PMC6338223 DOI: 10.1136/jim-2017-000582] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2017] [Indexed: 01/27/2023]
Abstract
Clear health benefits are associated with intensive glucose control in type 1 diabetes mellitus (T1DM). However, maintaining near-normal glycemia remains an elusive goal for many patients, in large part owing to the risk of severe hypoglycemia. In fact, recurrent episodes of hypoglycemia lead to 'hypoglycemia-associated autonomic failure' (HAAF), characterized by defective counter-regulatory responses to hypoglycemia. Extensive studies to understand the mechanisms underlying HAAF have revealed multiple potential etiologies, suggesting various approaches to prevent the development of HAAF. In this review, we present an overview of the literature focused on pharmacological approaches that may prevent the development of HAAF. The purported underlying mechanisms of HAAF include: 1) central mechanisms (opioid receptors, ATP-sensitive K+(KATP) channels, adrenergic receptors, serotonin selective receptor inhibitors, γ-aminobuyric acid receptors, N-methyl D-aspartate receptors); 2) hormones (cortisol, estrogen, dehydroepiandrosterone (DHEA) or DHEA sulfate, glucagon-like peptide-1) and 3) nutrients (fructose, free fatty acids, ketones), all of which have been studied vis-à-vis their ability to impact the development of HAAF. A careful review of the current literature reveals many promising therapeutic approaches to treat or reduce this important limitation to optimal glycemic control.
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Affiliation(s)
- Eric Lontchi-Yimagou
- Diabetes Research and Training Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jee Young You
- Diabetes Research and Training Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Michelle Carey
- Diabetes Research and Training Center, Albert Einstein College of Medicine, Bronx, New York, USA
- Center for Drug Evaluation and Research (CDER), US Food and Drug Administration (FDA), Silver Spring, Maryland, USA
| | - Ilan Gabriely
- Diabetes Research and Training Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Harry Shamoon
- Diabetes Research and Training Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Meredith Hawkins
- Diabetes Research and Training Center, Albert Einstein College of Medicine, Bronx, New York, USA
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22
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The effects of recurrent hypoglycaemia and opioid antagonists on the adrenal catecholamine synthetic capacity in a rat model of HAAF. Auton Neurosci 2018; 210:76-80. [DOI: 10.1016/j.autneu.2017.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 12/15/2017] [Accepted: 12/15/2017] [Indexed: 01/11/2023]
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23
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Carey M, Gospin R, Goyal A, Tomuta N, Sandu O, Mbanya A, Lontchi-Yimagou E, Hulkower R, Shamoon H, Gabriely I, Hawkins M. Opioid Receptor Activation Impairs Hypoglycemic Counterregulation in Humans. Diabetes 2017; 66:2764-2773. [PMID: 28860128 PMCID: PMC5652610 DOI: 10.2337/db16-1478] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 08/24/2017] [Indexed: 01/08/2023]
Abstract
Although intensive glycemic control improves outcomes in type 1 diabetes mellitus (T1DM), iatrogenic hypoglycemia limits its attainment. Recurrent and/or antecedent hypoglycemia causes blunting of protective counterregulatory responses, known as hypoglycemia-associated autonomic failure (HAAF). To determine whether and how opioid receptor activation induces HAAF in humans, 12 healthy subjects without diabetes (7 men, age 32.3 ± 2.2 years, BMI 25.1 ± 1.0 kg/m2) participated in two study protocols in random order over two consecutive days. On day 1, subjects received two 120-min infusions of either saline or morphine (0.1 μg/kg/min), separated by a 120-min break (all euglycemic). On day 2, subjects underwent stepped hypoglycemic clamps (nadir 60 mg/dL) with evaluation of counterregulatory hormonal responses, endogenous glucose production (EGP, using 6,6-D2-glucose), and hypoglycemic symptoms. Morphine induced an ∼30% reduction in plasma epinephrine response together with reduced EGP and hypoglycemia-associated symptoms on day 2. Therefore, we report the first studies in humans demonstrating that pharmacologic opioid receptor activation induces some of the clinical and biochemical features of HAAF, thus elucidating the individual roles of various receptors involved in HAAF's development and suggesting novel pharmacologic approaches for safer intensive glycemic control in T1DM.
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Affiliation(s)
- Michelle Carey
- Diabetes Research and Training Center, Albert Einstein College of Medicine, Bronx, NY
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Rebekah Gospin
- Diabetes Research and Training Center, Albert Einstein College of Medicine, Bronx, NY
| | - Akankasha Goyal
- Diabetes Research and Training Center, Albert Einstein College of Medicine, Bronx, NY
| | - Nora Tomuta
- Diabetes Research and Training Center, Albert Einstein College of Medicine, Bronx, NY
| | - Oana Sandu
- Diabetes Research and Training Center, Albert Einstein College of Medicine, Bronx, NY
| | - Armand Mbanya
- Diabetes Research and Training Center, Albert Einstein College of Medicine, Bronx, NY
| | - Eric Lontchi-Yimagou
- Diabetes Research and Training Center, Albert Einstein College of Medicine, Bronx, NY
| | - Raphael Hulkower
- Diabetes Research and Training Center, Albert Einstein College of Medicine, Bronx, NY
| | - Harry Shamoon
- Diabetes Research and Training Center, Albert Einstein College of Medicine, Bronx, NY
| | - Ilan Gabriely
- Diabetes Research and Training Center, Albert Einstein College of Medicine, Bronx, NY
| | - Meredith Hawkins
- Diabetes Research and Training Center, Albert Einstein College of Medicine, Bronx, NY
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Naik S, Belfort-DeAguiar R, Sejling AS, Szepietowska B, Sherwin RS. Evaluation of the counter-regulatory responses to hypoglycaemia in patients with type 1 diabetes during opiate receptor blockade with naltrexone. Diabetes Obes Metab 2017; 19:615-621. [PMID: 27987236 PMCID: PMC6015737 DOI: 10.1111/dom.12855] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 11/30/2016] [Accepted: 12/12/2016] [Indexed: 12/16/2022]
Abstract
AIMS Hypoglycaemia is the major limiting factor in achieving optimal glycaemic control in people with type 1 diabetes (T1DM), especially intensively treated patients with impaired glucose counter-regulation during hypoglycaemia. Naloxone, an opiate receptor blocker, has been reported to enhance the acute counter-regulatory response to hypoglycaemia when administered intravenously in humans. The current study was undertaken to investigate the oral formulation of the long-acting opiate antagonist, naltrexone, and determine if it could have a similar effect, and thus might be useful therapeutically in treatment of T1DM patients with a high risk of hypoglycaemia. MATERIALS AND METHODS We performed a randomized, placebo-controlled, double-blinded, cross-over study in which 9 intensively treated subjects with T1DM underwent a 2-step euglycaemic-hypoglycaemic-hyperinsulinaemic clamp on 2 separate occasions. At 12 hours and at 1 hour before the clamp study, participants received 100 mg of naltrexone or placebo orally. Counter-regulatory hormonal responses were assessed at baseline and during each step of the hyperinsulinaemic-clamp. RESULTS Glucose and insulin levels did not differ significantly between the naltrexone and placebo visits; nor did the glucose infusion rates required to keep glucose levels at target. During hypoglycaemia, naltrexone, in comparison with the placebo group, induced an increase in epinephrine levels ( P = .05). However, no statistically significant differences in glucagon, cortisol and growth hormone responses were observed. CONCLUSION In contrast to the intravenous opiate receptor blocker naloxone, overnight administration of the oral long-acting opiate receptor blocker, naltrexone, at a clinically used dose, had a limited effect on the counter-regulatory response to hypoglycaemia in intensively treated subjects with T1DM.
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MESH Headings
- Adult
- Blood Glucose/analysis
- Connecticut/epidemiology
- Cross-Over Studies
- Delayed-Action Preparations/adverse effects
- Delayed-Action Preparations/therapeutic use
- Diabetes Mellitus, Type 1/blood
- Diabetes Mellitus, Type 1/drug therapy
- Double-Blind Method
- Drug Monitoring
- Epinephrine/blood
- Epinephrine/metabolism
- Female
- Glucose Clamp Technique
- Glycated Hemoglobin/analysis
- Humans
- Hypoglycemia/chemically induced
- Hypoglycemia/epidemiology
- Hypoglycemia/prevention & control
- Hypoglycemic Agents/adverse effects
- Hypoglycemic Agents/blood
- Hypoglycemic Agents/pharmacokinetics
- Hypoglycemic Agents/therapeutic use
- Insulin, Regular, Human/adverse effects
- Insulin, Regular, Human/blood
- Insulin, Regular, Human/pharmacokinetics
- Insulin, Regular, Human/therapeutic use
- Male
- Naltrexone/adverse effects
- Naltrexone/therapeutic use
- Nausea/chemically induced
- Risk
- Sensory System Agents/adverse effects
- Sensory System Agents/therapeutic use
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Affiliation(s)
- Sarita Naik
- Department of Internal Medicine and Endocrinology, Yale University School of Medicine, New Haven, Connecticut
- Department of Diabetes and Endocrinology, University College Hospital, London, UK
| | - Renata Belfort-DeAguiar
- Department of Internal Medicine and Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | - Anne-Sophie Sejling
- Department of Internal Medicine and Endocrinology, Yale University School of Medicine, New Haven, Connecticut
- Department of Cardiology, Nephrology and Endocrinology, Nordsjaellands Hospital, Hillerød, Denmark
| | - Barbara Szepietowska
- Department of Internal Medicine and Endocrinology, Yale University School of Medicine, New Haven, Connecticut
- Heart Research Follow-Up Program, University of Rochester Medical Center, Rochester, New York
| | - Robert S Sherwin
- Department of Internal Medicine and Endocrinology, Yale University School of Medicine, New Haven, Connecticut
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Kim JL, La Gamma EF, Estabrook T, Kudrick N, Nankova BB. Whole genome expression profiling associates activation of unfolded protein response with impaired production and release of epinephrine after recurrent hypoglycemia. PLoS One 2017; 12:e0172789. [PMID: 28234964 PMCID: PMC5325535 DOI: 10.1371/journal.pone.0172789] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 02/09/2017] [Indexed: 12/25/2022] Open
Abstract
Recurrent hypoglycemia can occur as a major complication of insulin replacement therapy, limiting the long-term health benefits of intense glycemic control in type 1 and advanced type 2 diabetic patients. It impairs the normal counter-regulatory hormonal and behavioral responses to glucose deprivation, a phenomenon known as hypoglycemia associated autonomic failure (HAAF). The molecular mechanisms leading to defective counter-regulation are not completely understood. We hypothesized that both neuronal (excessive cholinergic signaling between the splanchnic nerve fibers and the adrenal medulla) and humoral factors contribute to the impaired epinephrine production and release in HAAF. To gain further insight into the molecular mechanism(s) mediating the blunted epinephrine responses following recurrent hypoglycemia, we utilized a global gene expression profiling approach. We characterized the transcriptomes during recurrent (defective counter-regulation model) and acute hypoglycemia (normal counter-regulation group) in the adrenal medulla of normal Sprague-Dawley rats. Based on comparison analysis of differentially expressed genes, a set of unique genes that are activated only at specific time points after recurrent hypoglycemia were revealed. A complementary bioinformatics analysis of the functional category, pathway, and integrated network indicated activation of the unfolded protein response. Furthermore, at least three additional pathways/interaction networks altered in the adrenal medulla following recurrent hypoglycemia were identified, which may contribute to the impaired epinephrine secretion in HAAF: greatly increased neuropeptide signaling (proenkephalin, neuropeptide Y, galanin); altered ion homeostasis (Na+, K+, Ca2+) and downregulation of genes involved in Ca2+-dependent exocytosis of secretory vesicles. Given the pleiotropic effects of the unfolded protein response in different organs, involved in maintaining glucose homeostasis, these findings uncover broader general mechanisms that arise following recurrent hypoglycemia which may afford clinicians an opportunity to modulate the magnitude of HAAF syndrome.
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Affiliation(s)
- Juhye Lena Kim
- The Regional Neonatal Center, Maria Fareri Children’s Hospital at Westchester Medical Center, Valhalla, New York, United States of America
| | - Edmund F. La Gamma
- The Regional Neonatal Center, Maria Fareri Children’s Hospital at Westchester Medical Center, Valhalla, New York, United States of America
- Departments of Pediatrics, Biochemistry and Molecular Biology, Division of Newborn Medicine, New York Medical College, Valhalla, New York, United States of America
| | - Todd Estabrook
- New York Medical College School of Medicine, Valhalla, New York, United States of America
| | - Necla Kudrick
- The Regional Neonatal Center, Maria Fareri Children’s Hospital at Westchester Medical Center, Valhalla, New York, United States of America
| | - Bistra B. Nankova
- Departments of Pediatrics, Biochemistry and Molecular Biology, Division of Newborn Medicine, New York Medical College, Valhalla, New York, United States of America
- * E-mail:
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Mikeladze M, Hedrington MS, Joy N, Tate DB, Younk LM, Davis I, Davis SN. Acute Effects of Oral Dehydroepiandrosterone on Counterregulatory Responses During Repeated Hypoglycemia in Healthy Humans. Diabetes 2016; 65:3161-70. [PMID: 27486235 PMCID: PMC5033266 DOI: 10.2337/db16-0406] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 07/15/2016] [Indexed: 11/13/2022]
Abstract
We tested the hypothesis that acute administration of oral dehydroepiandrosterone (DHEA) during episodes of repeated hypoglycemia can prevent the development of hypoglycemia-associated neuroendocrine and autonomic failure in healthy humans. Twenty-seven individuals (16 men, 11 women) participated in two separate randomized, single-blind, 2-day protocols. Day 1 consisted of morning and afternoon 2-h hypoglycemic clamps (2.9 mmol/L) with 800 mg of DHEA or placebo administered before each clamp. Day 2 consisted of a single 2-h hypoglycemic clamp (2.9 mmol/L) following either DHEA (1,600 mg) or placebo. A 3-tritiated glucose was used to determine glucose kinetics during hypoglycemia on day 2. Antecedent hypoglycemia with placebo resulted in significant reductions of epinephrine, norepinephrine, glucagon, growth hormone, cortisol, endogenous glucose production, and lipolytic and symptom responses. During hypoglycemia on day 2, DHEA prevented blunting of all neuroendocrine, autonomic nervous system (ANS), metabolic, and symptom counterregulatory responses following hypoglycemia on day 1. In summary, DHEA can acutely preserve a wide range of key neuroendocrine, ANS, and metabolic counterregulatory homeostatic responses during repeated hypoglycemia. We conclude that DHEA may have acute effects to protect against hypoglycemia-associated neuroendocrine and autonomic failure in healthy humans.
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Affiliation(s)
- Maia Mikeladze
- Department of Medicine, University of Maryland, Baltimore, MD
| | | | - Nino Joy
- Department of Medicine, University of Maryland, Baltimore, MD
| | - Donna B Tate
- Department of Medicine, University of Maryland, Baltimore, MD
| | - Lisa M Younk
- Department of Medicine, University of Maryland, Baltimore, MD
| | - Ian Davis
- Department of Medicine, University of Maryland, Baltimore, MD
| | - Stephen N Davis
- Department of Medicine, University of Maryland, Baltimore, MD
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Senthilkumaran M, Zhou XF, Bobrovskaya L. Challenges in Modelling Hypoglycaemia-Associated Autonomic Failure: A Review of Human and Animal Studies. Int J Endocrinol 2016; 2016:9801640. [PMID: 27843452 PMCID: PMC5097810 DOI: 10.1155/2016/9801640] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 09/01/2016] [Accepted: 09/18/2016] [Indexed: 01/19/2023] Open
Abstract
Recurrent insulin-induced hypoglycaemia is a major limitation to insulin treatment in diabetes patients leading to a condition called hypoglycaemia-associated autonomic failure (HAAF). HAAF is characterised by reduced sympathoadrenal response to subsequent hypoglycaemia thereby predisposing the patients to severe hypoglycaemia that can lead to coma or even death. Despite several attempts being made, the mechanism of HAAF is yet to be clearly established. In order for the mechanism of HAAF to be elucidated, establishing a human/animal model of the phenomenon is the foremost requirement. Several research groups have attempted to reproduce the phenomenon in diabetic and nondiabetic humans and rodents and reported variable results. The success of the phenomenon is marked by a significant reduction in plasma adrenaline response to subsequent hypoglycaemic episode relative to that of the antecedent hypoglycaemic episode. A number of factors such as the insulin dosage, route of administration, fasting conditions, blood sampling methods and analyses, depth, duration, and number of antecedent hypoglycaemic episodes can impact the successful reproduction of the phenomenon and thus have to be carefully considered while developing the protocol. In this review, we have outlined the protocols followed by different research groups to reproduce the phenomenon in diabetic and nondiabetic humans and rodents including our own observations in rats and discussed the factors that have to be given careful consideration in reproducing the phenomenon successfully.
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Affiliation(s)
- Manjula Senthilkumaran
- School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, SA 5000, Australia
| | - Xin-Fu Zhou
- School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, SA 5000, Australia
| | - Larisa Bobrovskaya
- School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, SA 5000, Australia
- *Larisa Bobrovskaya:
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Moheet A, Mangia S, Kumar A, Tesfaye N, Eberly LE, Bai Y, Kubisiak K, Seaquist ER. Naltrexone for treatment of impaired awareness of hypoglycemia in type 1 diabetes: A randomized clinical trial. J Diabetes Complications 2015; 29:1277-82. [PMID: 26345338 PMCID: PMC4871128 DOI: 10.1016/j.jdiacomp.2015.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 08/06/2015] [Accepted: 08/07/2015] [Indexed: 01/05/2023]
Abstract
AIMS Impaired awareness of hypoglycemia (IAH) is a limiting factor in the treatment of type 1 diabetes (T1D) and is a challenging condition to reverse. The objective of this study was to test the hypothesis that naltrexone therapy in subjects with T1D and IAH will improve counterregulatory hormone response and recognition of hypoglycemia symptoms during hypoglycemia. METHODS We performed a pilot randomized double blind trial of 4weeks of naltrexone therapy (n=10) or placebo (n=12) given orally in subjects with T1D and IAH. Outcome measures included hypoglycemia symptom scores, counterregulatory hormone levels and thalamic activation as measured by cerebral blood flow using MRI during experimental hypoglycemia in all subjects before and after 4weeks of intervention. RESULTS After 4weeks of therapy with naltrexone or placebo, no significant differences in response to hypoglycemia were seen in any outcomes of interest within each group. CONCLUSIONS In this small study, short-term treatment with naltrexone did not improve recognition of hypoglycemia symptoms or counterregulatory hormone response during experimental hypoglycemia in subjects with T1D and IAH. Whether this lack of effect is related to the small sample size or due to the dose, the advanced stage of study population or the drug itself should be the subject of future investigation.
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Affiliation(s)
- Amir Moheet
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, MN, United States.
| | - Silvia Mangia
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, MN, United States
| | - Anjali Kumar
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Nolawit Tesfaye
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Lynn E Eberly
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Yun Bai
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Kristine Kubisiak
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Elizabeth R Seaquist
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
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Martín-Timón I, del Cañizo-Gómez FJ. Mechanisms of hypoglycemia unawareness and implications in diabetic patients. World J Diabetes 2015; 6:912-926. [PMID: 26185599 PMCID: PMC4499525 DOI: 10.4239/wjd.v6.i7.912] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 12/30/2014] [Accepted: 04/02/2015] [Indexed: 02/05/2023] Open
Abstract
Hypoglycemia unawareness (HU) is defined at the onset of neuroglycopenia before the appearance of autonomic warning symptoms. It is a major limitation to achieving tight diabetes and reduced quality of life. HU occurs in approximately 40% of people with type 1 diabetes mellitus (T1DM) and with less frequency in T2DM. Though the aetiology of HU is multifactorial, possible mechanisms include chronic exposure to low blood glucose, antecedent hypoglycaemia, recurrent severe hypoglycaemia and the failure of counter-regulatory hormones. Clinically it manifests as the inability to recognise impeding hypoglycaemia by symptoms, but the mechanisms and mediators remain largely unknown. Prevention and management of HU is complex, and can only be achieved by a multifactorial intervention of clinical care and structured patient education by the diabetes team. Less know regarding the impact of medications on the development or recognition of this condition in patients with diabetes. Several medications are thought to worsen or promote HU, whereas others may have an attenuating effect on the problem. This article reviews recent advances in how the brain senses and responds to hypoglycaemia, novel mechanisms by which people with insulin-treated diabetes develop HU and impaired counter-regulatory responses. The consequences that HU has on the person with diabetes and their family are also described. Finally, it examines the evidence for prevention and treatment of HU, and summarizes the effects of medications that may influence it.
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Davis SN, Tate D, Hedrington MS. Mechanisms of hypoglycemia and exercise-associated autonomic dysfunction. TRANSACTIONS OF THE AMERICAN CLINICAL AND CLIMATOLOGICAL ASSOCIATION 2014; 125:281-292. [PMID: 25125745 PMCID: PMC4112662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
It is well established that diabetes can lead to multiple microvascular and macrovascular complications. Several large scale randomized multicenter studies have shown that intensifying glucose control decreases microvascular and, to a certain extent, macrovascular complications of diabetes. However, intensifying glucose control in both type 1 and type 2 diabetes increases the risk of developing hypoglycemia, one of the most feared complications of people with the disease. The mechanisms responsible for intensive therapy causing increased hypoglycemia in patients with diabetes have been extensively investigated. It is now known that a single episode of hypoglycemia can blunt the body's normal counterregulatory defenses against subsequent hypoglycemia or exercise. Similarly, a single bout of exercise can also blunt counterregulatory responses against subsequent hypoglycemia. Both neuroendocrine and autonomic nervous system responses are reduced by prior hypoglycemia and/or exercise. Work from several laboratories has identified multiple physiologic mechanisms involved in the pathogenesis of this hypoglycemia and exercise-associated counterregulatory failure. By continuing to study these mechanisms, some promising approaches to amplify counterregulatory responses to hypoglycemia are being discovered.
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Affiliation(s)
- Stephen N. Davis
- Correspondence and reprint requests: Stephen N. Davis, MBBS, FRCP, FACP,
22 S. Greene Street, Room N3W42, Baltimore, MD 21201410-328-2488410-328-8688
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Affiliation(s)
- Philip E Cryer
- Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, St. Louis, MO 63110, USA.
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32
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Morton AP. Is reduction in peak heart rate while exercising a sign of hypoglycaemia in athletes with diabetes mellitus? Response to Sacre et al. Diagnostic accuracy of heart-rate recovery after exercise in the assessment of diabetic cardiac autonomic neuropathy. Diabet Med 2013; 30:753-4. [PMID: 23215826 DOI: 10.1111/dme.12093] [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: 10/05/2012] [Accepted: 12/05/2012] [Indexed: 11/27/2022]
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Klement J, Pais I, Strube J, Lehnert H, Peters A, Hallschmid M, Born J. NMDA receptor blockade by memantine does not prevent adaptation to recurrent hypoglycaemia in healthy men. Diabetes Obes Metab 2013; 15:310-5. [PMID: 23072263 DOI: 10.1111/dom.12027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Revised: 08/27/2012] [Accepted: 10/09/2012] [Indexed: 11/28/2022]
Abstract
AIMS Recurrent hypoglycaemia leads to an attenuation of hypoglycaemic symptoms and hormonal counterregulatory responses. This phenomenon poses a severe problem in the treatment of patients with diabetes mellitus, but the underlying neuroendocrine mechanisms are unclear. On the basis of animal experimental findings, we hypothesized that counterregulatory attenuation represents a basic adaptive learning process relying on synaptic long-term potentiation or depression. If so, attenuation should be prevented by blocking glutamatergic N-methyl-D-aspartate (NMDA) receptors. METHODS Sixteen healthy young men participated in two conditions, separated by 4 weeks. Participants received the NMDA antagonist memantine over 5 days (15 mg/day) in one condition and placebo in the other one. After 3 days of drug administration, participants underwent two hypoglycaemic clamps on day 4 and another one on day 5. We assessed blood concentrations of counterregulatory hormones (cortisol, ACTH, epinephrine, norepinephrine, growth hormone and glucagon) as well as subjective symptoms of hypoglycaemia and word-list recall as an indicator of short-term memory. RESULTS Counterregulatory responses of all hormones as well as neuroglycopenic and autonomic symptom ratings showed robust attenuation following the third as compared to the first hypoglycaemia (p < 0.05). NMDA receptor antagonization by memantine impaired memory function but did not alter any neuroendocrine measure of counterregulatory attenuation (p > 0.17). CONCLUSIONS Attenuation of the endocrine as well as symptomatic counterregulatory response to recurrent hypoglycaemia is not prevented by the NMDA receptor blocker memantine. Our results do not support the view that adaptation to repeated hypoglycaemia relies on NMDA receptor-mediated plastic processes involving long-term potentiation or depression.
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Affiliation(s)
- J Klement
- Department of Internal Medicine I, University of Lübeck, Lübeck, Germany.
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Reno CM, Litvin M, Clark AL, Fisher SJ. Defective counterregulation and hypoglycemia unawareness in diabetes: mechanisms and emerging treatments. Endocrinol Metab Clin North Am 2013; 42:15-38. [PMID: 23391237 PMCID: PMC3568263 DOI: 10.1016/j.ecl.2012.11.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
For people with diabetes, hypoglycemia remains the limiting factor in achieving glycemic control. This article reviews recent advances in how the brain senses and responds to hypoglycemia. Novel mechanisms by which individuals with insulin-treated diabetes develop hypoglycemia unawareness and impaired counterregulatory responses are outlined. Prevention strategies for reducing the incidence of hypoglycemia are discussed.
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Affiliation(s)
- Candace M. Reno
- Division of Endocrinology, Metabolism, & Lipid Research, Department of Medicine, Washington University, St. Louis, MO
| | - Marina Litvin
- Division of Endocrinology, Metabolism, & Lipid Research, Department of Medicine, Washington University, St. Louis, MO
| | - Amy L. Clark
- Division of Endocrinology and Diabetes, Department of Pediatrics, Washington University, St. Louis, MO
| | - Simon J. Fisher
- Division of Endocrinology, Metabolism, & Lipid Research, Department of Medicine, Washington University, St. Louis, MO
- Department of Cell Biology and Physiology, Washington University, St. Louis, MO
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Abstract
This paper is the thirty-fourth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2011 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration (Section 16); and immunological responses (Section 17).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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