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Oktavian P, Budi DS, Wibowo IN, Rusuldi RCR, Kusumawardhani AD, Wafa IA, Rahman HR, Pratama NR, Mudjanarko SW. Automated glycemic control with a bionic pancreas for type 1 diabetes mellitus: A systematic review and meta-analysis. Diabetes Metab Syndr 2023; 17:102847. [PMID: 37639999 DOI: 10.1016/j.dsx.2023.102847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/17/2023] [Accepted: 08/20/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND AND AIMS The use of a bionic pancreas with automated insulin delivery systems to prevent complications of diabetes mellitus shows conflicting results. We aimed to comprehensively discuss the potential use of a bionic pancreas in patients with type 1 diabetes (T1D). METHODS A systematic database search was conducted on October 24, 2022, for articles investigating the use of a bionic pancreas in patients with T1D. The hemoglobin A1c (HbA1c) level, mean glucose level, glucose coefficient of variability, time-in-range (TIR), and adverse events were investigated. RESULTS Nine studies were included in this review. The data from these studies suggested that the use of a bionic pancreas could reduce the HbA1c (mean difference [MD] = -0.40% [95% confidence interval {CI} = -0.59 to -0.21], I2 = 0%, p < 0.0001) and mean glucose levels (MD = -21.06 [95% CI = -24.66 to -17.46], I2 = 45%, p < 0.00001) and improve the TIR (MD = 14.41% [95% CI = 10.99 to 17.83], I2 = 60%, p < 0.00001). The most common adverse events reported were nausea and vomiting. CONCLUSIONS The use of a bionic pancreas shows potential in preventing complications of T1D by improving the TIR and decreasing the HbA1c and mean glucose levels. Furthermore, serious adverse events with the use of a bionic pancreas and standard of care show insignificant results, suggesting a good safety profile.
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Affiliation(s)
- Puguh Oktavian
- Faculty of Medicine Universitas Airlangga, Surabaya, Indonesia
| | | | | | | | | | - Ifan Ali Wafa
- Faculty of Medicine Universitas Airlangga, Surabaya, Indonesia
| | | | | | - Sony Wibisono Mudjanarko
- Division of Endocrinology, Metabolism, and Diabetes, Department of Internal Medicine, Dr. Soetomo General Academic Hospital, Faculty of Medicine Universitas Airlangga, Surabaya, Indonesia.
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2
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Furió-Novejarque C, Sanz R, Ritschel TKS, Reenberg AT, Ranjan AG, Nørgaard K, Díez JL, Jørgensen JB, Bondia J. Modeling the effect of glucagon on endogenous glucose production in type 1 diabetes: On the role of glucagon receptor dynamics. Comput Biol Med 2023; 154:106605. [PMID: 36731362 DOI: 10.1016/j.compbiomed.2023.106605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/19/2023] [Accepted: 01/22/2023] [Indexed: 01/26/2023]
Abstract
This paper validates a glucoregulatory model including glucagon receptors dynamics in the description of endogenous glucose production (EGP). A set of models from literature are selected for a head-to-head comparison in order to evaluate the role of glucagon receptors. Each EGP model is incorporated into an existing glucoregulatory model and validated using a set of clinical data, where both insulin and glucagon are administered. The parameters of each EGP model are identified in the same optimization problem, minimizing the root mean square error (RMSE) between the simulation and the clinical data. The results show that the RMSE for the proposed receptors-based EGP model was lower when compared to each of the considered models (Receptors approach: 7.13±1.71 mg/dl vs. 7.76±1.45 mg/dl (p=0.066), 8.45±1.38 mg/dl (p=0.011) and 8.99±1.62 mg/dl (p=0.007)). This raises the possibility of considering glucagon receptors dynamics in type 1 diabetes simulators.
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Affiliation(s)
- Clara Furió-Novejarque
- Instituto Universitario de Automática e Informática Industrial, Universitat Politècnica de València, C/Camí de Vera, s/n, València, 46022, Spain.
| | - Ricardo Sanz
- Instituto Universitario de Automática e Informática Industrial, Universitat Politècnica de València, C/Camí de Vera, s/n, València, 46022, Spain.
| | - Tobias K S Ritschel
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Anker Engelunds Vej 1, Kgs. Lyngby, 2800, Denmark.
| | - Asbjørn Thode Reenberg
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Anker Engelunds Vej 1, Kgs. Lyngby, 2800, Denmark.
| | - Ajenthen G Ranjan
- Steno Diabetes Center Copenhagen, Borgmester Ib Juuls Vej 83, Herlev, 2730, Denmark; Danish Diabetes Academy, Søndre Blvd. 29, Odense, 5000, Denmark.
| | - Kirsten Nørgaard
- Steno Diabetes Center Copenhagen, Borgmester Ib Juuls Vej 83, Herlev, 2730, Denmark.
| | - José-Luis Díez
- Instituto Universitario de Automática e Informática Industrial, Universitat Politècnica de València, C/Camí de Vera, s/n, València, 46022, Spain; Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, Av. Monforte de Lemos, 3-5, Madrid, 28029, Spain.
| | - John Bagterp Jørgensen
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Anker Engelunds Vej 1, Kgs. Lyngby, 2800, Denmark.
| | - Jorge Bondia
- Instituto Universitario de Automática e Informática Industrial, Universitat Politècnica de València, C/Camí de Vera, s/n, València, 46022, Spain; Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, Av. Monforte de Lemos, 3-5, Madrid, 28029, Spain.
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3
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Wu Z, Yardley JE, Messier V, Legault L, Grou C, Rabasa-Lhoret R. Comparison of Nocturnal Glucose After Exercise Among Dual-Hormone, Single-Hormone Algorithm-Assisted Insulin Delivery System and Usual Care in Adults and Adolescents Living with Type 1 Diabetes: A Pooled Analysis. Diabetes Technol Ther 2022; 24:754-762. [PMID: 35653732 DOI: 10.1089/dia.2022.0149] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: Available studies comparing the efficacy of dual-hormone (DH)-algorithm-assisted insulin delivery (AID), single-hormone (SH)-AID and usual care on postexercise overnight glucose in people with type 1 diabetes (T1D) have had different outcomes. By pooling data from all available studies, we aim to draw stronger conclusions. Methods: Data were pooled from two three-arm, open-label, randomized, controlled, crossover studies. Forty-one adults [median (Q1, Q3) age: 34.0 years (29.5, 51.0), mean HbA1c: 7.5% ± 1.0%] and 17 adolescents with T1D [age: 14.0 (13.0, 16.0), HbA1c: 7.8% ± 0.8%] underwent DH-AID, SH-AID, and usual care. Each intervention involved evening aerobic exercise (60-min). The primary outcome, time in range% (TIR%) overnight (00:00-06:00) postexercise based on continuous glucose monitoring, was compared among treatments using linear mixed effect model or generalized linear mixed model. Results: Among adults, mean TIR% was 94.0% ± 11.9%, 83.1% ± 20.5%, and 65.1% ± 37.0% during DH-AID, SH-AID, and usual care intervention, respectively (P < 0.05 for all between-group comparisons). DH-AID was superior to SH-AID and usual care, and SH-AID was superior to usual care regarding hypoglycemia and hyperglycemia prevention, but not glycemic variability. Among adolescents, DH-AID and SH-AID reduced dysglycemia, but not glycemic variability, better than usual care. Glycemic outcomes were similar between DH-AID and SH-AID. Conclusion: AID systems allow improved postexercise nocturnal glycemic management than usual care for both adults and adolescents. DH-AID was better than SH-AID among adults, but not adolescents.
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Affiliation(s)
- Zekai Wu
- Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
- Montreal Clinical Research Institute, Montreal, Quebec, Canada
| | - Jane E Yardley
- Augustana Faculty, University of Alberta, Camrose, Alberta, Canada
- Physical Activity and Diabetes Laboratory, Alberta Diabetes Institute, Edmonton, Alberta, Canada
- Faculty of Kinesiology, Sport and Recreation, University of Alberta, Edmonton, Alberta, Canada
- Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | | | - Laurent Legault
- McGill University Health Centre, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Caroline Grou
- Montreal Clinical Research Institute, Montreal, Quebec, Canada
| | - Rémi Rabasa-Lhoret
- Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
- Montreal Clinical Research Institute, Montreal, Quebec, Canada
- Department of Nutrition, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
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4
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Teigen IA, Riaz M, Åm MK, Christiansen SC, Carlsen SM. Vasodilatory effects of glucagon: A possible new approach to enhanced subcutaneous insulin absorption in artificial pancreas devices. Front Bioeng Biotechnol 2022; 10:986858. [PMID: 36213069 PMCID: PMC9532737 DOI: 10.3389/fbioe.2022.986858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/25/2022] [Indexed: 11/18/2022] Open
Abstract
Patients with diabetes mellitus type 1 depend on exogenous insulin to keep their blood glucose concentrations within the desired range. Subcutaneous bihormonal artificial pancreas devices that can measure glucose concentrations continuously and autonomously calculate and deliver insulin and glucagon infusions is a promising new treatment option for these patients. The slow absorption rate of insulin from subcutaneous tissue is perhaps the most important factor preventing the development of a fully automated artificial pancreas using subcutaneous insulin delivery. Subcutaneous insulin absorption is influenced by several factors, among which local subcutaneous blood flow is one of the most prominent. We have discovered that micro-doses of glucagon may cause a substantial increase in local subcutaneous blood flow. This paper discusses how the local vasodilative effects of micro-doses of glucagon might be utilised to improve the performance of subcutaneous bihormonal artificial pancreas devices. We map out the early stages of our hypothesis as a disruptive novel approach, where we propose to use glucagon as a vasodilator to accelerate the absorption of meal boluses of insulin, besides using it conventionally to treat hypoglycaemia.
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Affiliation(s)
- Ingrid Anna Teigen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- *Correspondence: Ingrid Anna Teigen,
| | - Misbah Riaz
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Endocrinology, St. Olav’s Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Marte Kierulf Åm
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Sverre Christian Christiansen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Endocrinology, St. Olav’s Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Sven Magnus Carlsen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Endocrinology, St. Olav’s Hospital, Trondheim University Hospital, Trondheim, Norway
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5
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The role of pancreas to improve hyperglycemia in STZ-induced diabetic rats by thiamine disulfide. Nutr Diabetes 2022; 12:32. [PMID: 35725834 PMCID: PMC9209469 DOI: 10.1038/s41387-022-00211-5] [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: 01/24/2022] [Revised: 05/04/2022] [Accepted: 06/06/2022] [Indexed: 12/04/2022] Open
Abstract
Background The present study investigated the effect of thiamine disulfide (TD) on the pancreas in terms of hyperglycemia improvement and insulin sensitivity increase in diabetic male rats. We also aimed to study the function of Pdx1 (pancreatic and duodenal homeobox 1) and Glut2 (glucose transporter 2) genes in pancreatic tissue. Methods Type 1 diabetes was induced through injection of 60 mg/kg streptozotocin (STZ). The diabetic rats were divided into four groups, namely diabetic control (DC), diabetic treated with thiamine disulfide (D-TD), diabetic treated with insulin (D-insulin), and diabetic treated with TD and insulin (D-insulin+TD). The non-diabetic (NDC) and diabetic groups received a normal diet (14 weeks). Blood glucose level and body weight were measured weekly; insulin tolerance test (ITT) and glucagon tolerance test (GTT) were performed in the last month of the study. The level of serum insulin and glucagon were measured monthly and a hyperglycemic clamp (Insulin Infusion rate (IIR)) was done for all the groups. Pancreas tissue was isolated so that Pdx1and Glut2 genes expression could be measured. Results We observed that TD therapy decreased blood glucose level, ITT, and serum glucagon levels in comparison with those of the DC group; it also increased serum insulin levels, IIR, and expression of Pdx1 and Glut2 genes in comparison with those of the DC group. Conclusion Administration of TD could improve hyperglycemia in type 1 diabetic animals through improved pancreas function. Therefore, not only does TD have a significant effect on controlling and reducing hyperglycemia in diabetes, but it also has the potential to decrease the dose of insulin administration.
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6
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The effect of glucagon on local subcutaneous blood flow in non-diabetic volunteers; a proof-of-concept study. Eur J Pharmacol 2022; 926:175045. [DOI: 10.1016/j.ejphar.2022.175045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 05/04/2022] [Accepted: 05/18/2022] [Indexed: 01/26/2023]
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7
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Abstract
Closed-loop insulin delivery systems are fast becoming the standard of care in the management of type 1 diabetes and have led to significant improvements in diabetes management. Nevertheless, there is still room for improvement for the closed-loop systems to optimize treatment and meet target glycemic control. Adjunct treatments have been introduced as an alternative method to insulin-only treatment methods to overcome diabetes treatment challenges and improve clinical and patient reported outcomes during closed-loop treatment. The adjunct treatment agents mostly consist of medications that are already approved for type 2 diabetes treatment and aim to complete the missing physiologic factors, such as the entero-endocrine system, that regulate glycemia in addition to insulin. This paper will review many of these adjunct therapies, including the basic mechanisms of action, potential benefits, side effects, and the evidence supporting their use during closed-loop treatment.
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Affiliation(s)
- Shylaja Srinivasan
- Division of Pediatric Endocrinology and
Diabetes, University of San Francisco, CA, USA
| | - Laya Ekhlaspour
- Division of Pediatric Endocrinology and
Diabetes, Stanford University, Palo Alto, CA, USA
| | - Eda Cengiz
- Division of Pediatric Endocrinology and
Diabetes, Yale University, New Haven, NJ, USA
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8
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Infante M, Baidal DA, Rickels MR, Fabbri A, Skyler JS, Alejandro R, Ricordi C. Dual-hormone artificial pancreas for management of type 1 diabetes: Recent progress and future directions. Artif Organs 2021; 45:968-986. [PMID: 34263961 DOI: 10.1111/aor.14023] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 06/09/2021] [Accepted: 06/14/2021] [Indexed: 02/06/2023]
Abstract
Over the last few years, technological advances have led to tremendous improvement in the management of type 1 diabetes (T1D). Artificial pancreas systems have been shown to improve glucose control compared with conventional insulin pump therapy. However, clinically significant hypoglycemic and hyperglycemic episodes still occur with the artificial pancreas. Postprandial glucose excursions and exercise-induced hypoglycemia represent major hurdles in improving glucose control and glucose variability in many patients with T1D. In this regard, dual-hormone artificial pancreas systems delivering other hormones in addition to insulin (glucagon or amylin) may better reproduce the physiology of the endocrine pancreas and have been suggested as an alternative tool to overcome these limitations in clinical practice. In addition, novel ultra-rapid-acting insulin analogs with a more physiological time-action profile are currently under investigation for use in artificial pancreas devices, aiming to address the unmet need for further improvements in postprandial glucose control. This review article aims to discuss the current progress and future outlook in the development of novel ultra-rapid insulin analogs and dual-hormone closed-loop systems, which offer the next steps to fully closing the loop in the artificial pancreas.
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Affiliation(s)
- Marco Infante
- Clinical Cell Transplant Program, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Division of Endocrinology, Metabolism and Diabetes, Department of Systems Medicine, CTO A. Alesini Hospital, Diabetes Research Institute Federation, University of Rome Tor Vergata, Rome, Italy.,UniCamillus, Saint Camillus International University of Health Sciences, Rome, Italy
| | - David A Baidal
- Clinical Cell Transplant Program, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Michael R Rickels
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Institute for Diabetes, Obesity and Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Andrea Fabbri
- Division of Endocrinology, Metabolism and Diabetes, Department of Systems Medicine, CTO A. Alesini Hospital, Diabetes Research Institute Federation, University of Rome Tor Vergata, Rome, Italy
| | - Jay S Skyler
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Rodolfo Alejandro
- Clinical Cell Transplant Program, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Camillo Ricordi
- Clinical Cell Transplant Program, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
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9
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Pharmacokinetics of Intraperitoneally Delivered Glucagon in Pigs: A Hypothesis of First Pass Metabolism. Eur J Drug Metab Pharmacokinet 2021; 46:505-511. [PMID: 34100220 PMCID: PMC8298214 DOI: 10.1007/s13318-021-00692-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2021] [Indexed: 01/23/2023]
Abstract
Background and Objective Artificial pancreases administering low-dose glucagon in addition to insulin have the scope to improve glucose control in patients with diabetes mellitus type 1. If such a device were to deliver both hormones intraperitoneally, it would mimic normal physiology, which may be beneficial. However, the pharmacokinetic properties of glucagon after intraperitoneal administration are not well known. Hence, the current study aims to evaluate the relationship between the amount of intraperitoneally delivered glucagon and pharmacokinetic variables in a pig model. Methods Pharmacokinetic data was retrieved from experiments on 19 anaesthetised pigs and analysed post hoc. The animals received a single intraperitoneal bolus of glucagon ranging from 0.30 to 4.46 µg/kg. Plasma glucagon was measured every 2–10 min for 50 min. Results Peak plasma concentration and area under the time–plasma concentration curve of glucagon correlated positively with the administered dose, and larger boluses provided a relatively greater increase. The mean (standard deviation) time to maximum glucagon concentration in plasma was 11 (5) min, and the mean elimination half-life of glucagon in plasma was 19 (7) min. Conclusions Maximum plasma concentration and area under the time–plasma concentration curve of glucagon increase nonlinearly in relation to the intraperitoneally administered glucagon dose. We hypothesise that the results are compatible with a satiable first-pass metabolism in the liver. Time to maximum glucagon concentration in plasma and the elimination half-life of glucagon in plasma seem independent of the drug dose.
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10
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Laugesen C, Schmidt S, Holst JJ, Nørgaard K, Ranjan AG. The effect of preceding glucose decline rate on low-dose glucagon efficacy in individuals with type 1 diabetes: A randomized crossover trial. Diabetes Obes Metab 2021; 23:1057-1062. [PMID: 33336888 DOI: 10.1111/dom.14301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/04/2020] [Accepted: 12/13/2020] [Indexed: 11/30/2022]
Abstract
Identifying determinants of low-dose glucagon efficacy is important to optimise its utilization for prevention and treatment of hypoglycaemia in individuals with type 1 diabetes. The study objective was to investigate whether the preceding glucose decline rate affects glucose response to low-dose glucagon administration. Ten adults with insulin pump-treated type 1 diabetes were included in this randomized, single-blind, two-way crossover study. Using a hyperinsulinaemic clamp technique, plasma glucose levels were reduced with either a rapid or slow decline rate while maintaining fixed insulin levels. When the plasma glucose level reached 3.9 mmoL/L, insulin and glucose infusions were discontinued and 150 μg subcutaneous glucagon was administered, followed by 120 minutes of plasma glucose monitoring. The positive incremental area under the glucose curve after administration of low-dose glucagon did not differ between the rapid-decline and slow-decline visits (mean ± SEM: 220 ± 49 vs. 174 ± 31 mmoL/L x min; P = 0.21). Similarly, no differences in total area under the glucose curve, peak plasma glucose, incremental peak plasma glucose, time-to-peak plasma glucose or end plasma glucose were observed. Thus, preceding glucose decline rate did not significantly affect the glucose response to low-dose glucagon.
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Affiliation(s)
| | - Signe Schmidt
- Clinical Research, Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | - Jens Juul Holst
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kirsten Nørgaard
- Clinical Research, Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | - Ajenthen G Ranjan
- Clinical Research, Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Danish Diabetes Academy, Odense, Denmark
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11
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Zhang Y, Zhou X, Liu P, Chen X, Zhang J, Zhang H, Li S, Chen Y, Song X, Wang J, Zeng H, Zhang X, Tang C, Yu C, Li Y, Xu C. GCSF deficiency attenuates nonalcoholic fatty liver disease through regulating GCSFR-SOCS3-JAK-STAT3 pathway and immune cells infiltration. Am J Physiol Gastrointest Liver Physiol 2021; 320:G531-G542. [PMID: 33470903 DOI: 10.1152/ajpgi.00342.2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/11/2021] [Indexed: 01/31/2023]
Abstract
Granulocyte colony stimulating factor (GCSF) is a cytokine with immunomodulation effects. However, little is known about its role in metabolic diseases. In the current study, we aimed to explore the role of GCSF in nonalcoholic fatty liver disease (NAFLD). Male GCSF-/- mice were used to investigate the function of GCSF in vivo after high-fat diet (HFD). Primary hepatocytes were used for evaluating the function of GCSF in vitro. Liver immune cells were isolated and analyzed by flow cytometry. Our results showed that GCSF administration significantly increased serum triglyceride (TG) levels in patients. Circulating GCSF was markedly elevated in HFD-fed mice. GCSF-/- mice exhibited alleviated HFD-induced obesity, insulin resistance, and hepatic steatosis. Extra administration of GCSF significantly aggravated palmitic acid (PA)-induced lipid accumulation in primary hepatocytes. Mechanically, GCSF could bind to granulocyte colony stimulating factor receptor (GCSFR) and regulate suppressors of cytokine signaling 3, Janus kinase, signal transducer and activator of transcription 3 (SOCS3-JAK-STAT3) pathway. GCSF also enhanced hepatic neutrophils and macrophages infiltration, thereby modulating NAFLD. These findings suggest that GCSF plays an important regulatory role in NAFLD and may be a potential therapeutic target for NAFLD.NEW & NOTEWORTHY We found GCSF was involved in lipid metabolism and NAFLD development. GCSF administration increased serum triglyceride levels in patients. GCSF deficiency alleviated HFD-induced insulin resistance and hepatic steatosis in mice. GCSF could directly act on hepatocytes through GCSFR-SOCS3-JAK-STAT3 pathway, and regulate the infiltration of immune cells into the liver to indirectly modulate NAFLD. Our finding indicates that GCSF may provide new strategies for the treatment of NAFLD.
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Affiliation(s)
- Yuwei Zhang
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xuefeng Zhou
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Peihao Liu
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xueyang Chen
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jie Zhang
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hong Zhang
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Sha Li
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yishu Chen
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xin Song
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jinghua Wang
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hang Zeng
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaofen Zhang
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chenxi Tang
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chaohui Yu
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Youming Li
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chengfu Xu
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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12
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Ranjan AG, Schmidt S, Nørgaard K. Glucagon for hypoglycaemia treatment in type 1 diabetes. Diabetes Metab Res Rev 2020; 37:e3409. [PMID: 33090668 DOI: 10.1002/dmrr.3409] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/14/2020] [Accepted: 09/14/2020] [Indexed: 12/22/2022]
Abstract
To achieve strict glycaemic control and avoid chronic diabetes complications, individuals with type 1 diabetes (T1D) are recommended to follow an intensive insulin regimen. However, the risk and fear of hypoglycaemia often prevent individuals from achieving the treatment goals. Apart from early insulin suspension in insulin pump users, carbohydrate ingestion is the only option for preventing and treating non-severe hypoglycaemic events. These rescue treatments may give extra calories and cause overweight. As an alternative, the use of low-dose glucagon to counter hypoglycaemia has been proposed as a tool to raise glucose concentrations without adding extra calories. Previously, the commercially available glucagon formulations required reconstitution from powder to a solution before being injected subcutaneously or intramuscularly-making it practical only for treating severe hypoglycaemia. Several companies have developed more stable formulations that do not require the time-consuming reconstitution process before use. As well as treating severe hypoglycaemia, non-severe and impending hypoglycaemia can also be treated with lower doses of glucagon. Once available, low-dose glucagon can be either delivered manually, as an injection, or automatically, by an infusion pump. This review focuses on the role and perspectives of using glucagon to treat and prevent hypoglycaemia in T1D.
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Affiliation(s)
- Ajenthen G Ranjan
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Danish Diabetes Academy, Odense, Denmark
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13
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Åm MK, Dirnena-Fusini I, Fougner AL, Carlsen SM, Christiansen SC. Intraperitoneal and subcutaneous glucagon delivery in anaesthetized pigs: effects on circulating glucagon and glucose levels. Sci Rep 2020; 10:13735. [PMID: 32792580 PMCID: PMC7426268 DOI: 10.1038/s41598-020-70813-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 07/07/2020] [Indexed: 12/18/2022] Open
Abstract
Glucagon is a pancreatic hormone and increases the blood glucose levels. It may be incorporated in a dual hormone artificial pancreas, a device to automatically and continuously control blood glucose levels of individuals with diabetes. Artificial pancreas systems have been developed for use in the subcutaneous tissue; however, the systems are not fully automated due to slow dynamics. The intraperitoneal space is therefore investigated as an alternative location for an artificial pancreas. Glucose dynamics after subcutaneous and intraperitoneal glucagon delivery in ten anaesthetized pigs were investigated. The pigs received intraperitoneal boluses of 0.3 µg/kg and 0.6 µg/kg and a subcutaneous bolus of 0.6 µg/kg in randomized order. They also received an intraperitoneal bolus of 1 mg given at the end of the experiments to test the remaining capacity of rapid glucose release. Six pigs were included in the statistical analysis. The intraperitoneal glucagon bolus of 0.6 µg/kg gave a significantly higher glucose response from 14 to 30 min compared with the subcutaneous bolus. The results indicate that glucagon induces a larger glucose response after intraperitoneal delivery compared with subcutaneous delivery and is encouraging for the incorporation of glucagon in an intraperitoneal artificial pancreas.
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Affiliation(s)
- Marte Kierulf Åm
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Postboks 8905, 7491, Trondheim, Norway. .,Department of Endocrinology, St Olav's Hospital, Trondheim, Norway.
| | - Ilze Dirnena-Fusini
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Postboks 8905, 7491, Trondheim, Norway.,Department of Endocrinology, St Olav's Hospital, Trondheim, Norway
| | - Anders Lyngvi Fougner
- Department of Engineering Cybernetics, Faculty of Information Technology and Electrical Engineering, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Sven Magnus Carlsen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Postboks 8905, 7491, Trondheim, Norway.,Department of Endocrinology, St Olav's Hospital, Trondheim, Norway
| | - Sverre Christian Christiansen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Postboks 8905, 7491, Trondheim, Norway.,Department of Endocrinology, St Olav's Hospital, Trondheim, Norway
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14
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Abstract
Treatment of type 1 diabetes with exogenous insulin often results in unpredictable daily glucose variability and hypoglycemia, which can be dangerous. Automated insulin delivery systems can improve glucose control while reducing burden for people with diabetes. One approach to improve treatment outcomes is to incorporate the counter-regulatory hormone glucagon into the automated delivery system to help prevent the hypoglycemia that can be induced by the slow pharmacodynamics of insulin action. This article explores the advantages and disadvantages of incorporating glucagon into dual-hormone automated hormone delivery systems.
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Affiliation(s)
- Leah M Wilson
- Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Harold Schnitzer Diabetes Health Center, 3181 Southwest Sam Jackson Park Road, L607, Portland, OR 97239-3098, USA.
| | - Peter G Jacobs
- Department of Biomedical Engineering, Oregon Health & Science University, Mail Code: CH13B, 3303 Southwest Bond Avenue, Portland, OR 97239, USA
| | - Jessica R Castle
- Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Harold Schnitzer Diabetes Health Center, 3181 Southwest Sam Jackson Park Road, L607, Portland, OR 97239-3098, USA
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15
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Moscardó V, Díez JL, Bondia J. Parallel Control of an Artificial Pancreas with Coordinated Insulin, Glucagon, and Rescue Carbohydrate Control Actions. J Diabetes Sci Technol 2019; 13:1026-1034. [PMID: 31631688 PMCID: PMC6835176 DOI: 10.1177/1932296819879093] [Citation(s) in RCA: 4] [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] [Indexed: 12/12/2022]
Abstract
BACKGROUND An artificial pancreas with insulin and glucagon delivery has the potential to reduce the risk of hypo- and hyperglycemia in people with type 1 diabetes. However, a maximum dose of glucagon of 1 mg/d is recommended, potentially still requiring rescue carbohydrates in some situations. This work presents a parallel control structure with intrinsic insulin, glucagon, and rescue carbohydrates coordination to overcome glucagon limitations when needed. METHODS The coordinated controller that combines insulin, glucagon, and rescue carbohydrate suggestions (DH-CC-CHO) was compared with the insulin and glucagon delivery coordinated controller (DH-CC). The impact of carbohydrate quantization for practical delivery was also assessed. An in silico study using the UVA-Padova simulator, extended to include exercise and various sources of variability, was performed. RESULTS DH-CC and DH-CC-CHO performed similarly with regard to mean glucose (126.25 [123.43; 130.73] vs 127.92 [123.99; 132.97] mg/dL, P = .088), time in range (93.04 [90.00; 95.92] vs 92.91 [90.05; 95.75]%, P = .508), time above 180 mg/dL (4.94 [2.72; 7.53] vs 4.99 [2.93; 7.24]%, P = .966), time below 70 mg/dL (0.61 [0.09; 1.75] vs 0.96 [0.23; 2.17]%, P = .1364), insulin delivery (43.50 [38.68; 51.75] vs 42.86 [38.58; 51.36] U/d, P = .383), and glucagon delivery (0.75 [0.40; 1.83] vs 0.76 [0.43; 0.99] mg/d, P = .407). Time below 54 mg/dL was different (0.00 [0.00; 0.05] vs 0.00 [0.00; 0.16]%, P = .036), although non-clinically significant. This was due to the carbs quantization effect in a specific patient, as no statistical difference was found when carbs were not quantized (0.00 [0.00; 0.05] vs 0.00 [0.00; 0.00]%, P = .265). CONCLUSIONS The new strategy of automatic rescue carbohydrates suggestion in coordination with insulin and glucagon delivery to overcome constraints on daily glucagon delivery was successfully evaluated in an in silico proof of concept.
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Affiliation(s)
- Vanessa Moscardó
- Instituto Universitario de Automática e Informática Industrial, Universitat Politècnica de València, Valencia, Spain
| | - José Luis Díez
- Instituto Universitario de Automática e Informática Industrial, Universitat Politècnica de València, Valencia, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Av. Monforte de Lemos, Madrid, Spain
| | - Jorge Bondia
- Instituto Universitario de Automática e Informática Industrial, Universitat Politècnica de València, Valencia, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Av. Monforte de Lemos, Madrid, Spain
- Jorge Bondia, Instituto Universitario de Automática e Informática Industrial, Universitat Politècnica de València, C/Camino de Vera, s/n, 46022 Valencia, Spain.
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16
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Moscardó V, Herrero P, Díez JL, Giménez M, Rossetti P, Georgiou P, Bondia J. Coordinated dual-hormone artificial pancreas with parallel control structure. Comput Chem Eng 2019. [DOI: 10.1016/j.compchemeng.2019.06.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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17
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Haidar A. Insulin-and-Glucagon Artificial Pancreas Versus Insulin-Alone Artificial Pancreas: A Short Review. Diabetes Spectr 2019; 32:215-221. [PMID: 31462876 PMCID: PMC6695257 DOI: 10.2337/ds18-0097] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IN BRIEF The advantage of the insulin-and-glucagon artificial pancreas is based on the rapid effect of subcutaneous glucagon delivery in preventing hypoglycemia compared to suspension of insulin delivery. In short-term studies, the dual-hormone artificial pancreas reduced daytime hypoglycemia, especially during exercise, compared to the insulin-alone artificial pancreas, but the insulin-alone system seemed sufficient in eliminating nocturnal hypoglycemia. The comparative benefits of the single- and dual-hormone systems for improving A1C and preventing severe hypoglycemia remain unknown.
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Affiliation(s)
- Ahmad Haidar
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
- Division of Endocrinology and Metabolism, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- The Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
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18
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Beato-Víbora PI, Arroyo-Díez FJ. New uses and formulations of glucagon for hypoglycaemia. Drugs Context 2019; 8:212599. [PMID: 31402931 PMCID: PMC6675539 DOI: 10.7573/dic.212599] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/23/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022] Open
Abstract
Hypoglycaemia is the more frequent complication of insulin therapy and the main barrier to tight glycaemic control. Injectable glucagon and oral intake of carbohydrates are the recommended treatments for severe and non-severe hypoglycaemia episodes, respectively. Nasal glucagon is currently being developed as a ready-to-use device, to simplify severe hypoglycaemia rescue. Stable forms of liquid glucagon could open the field for different approaches for mild to moderate hypoglycaemia treatment, such as mini-doses of glucagon or continuous subcutaneous glucagon infusion as a part of dual-hormone closed-loop systems. Pharmaceutical companies are developing stable forms of native glucagon or glucagon analogues for that purpose.
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Affiliation(s)
- Pilar I Beato-Víbora
- Department of Endocrinology and Nutrition, Department of Paediatrics, Badajoz University Hospital, Badajoz, Spain
| | - Francisco J Arroyo-Díez
- Department of Endocrinology and Nutrition, Department of Paediatrics, Badajoz University Hospital, Badajoz, Spain
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19
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Janah L, Kjeldsen S, Galsgaard KD, Winther-Sørensen M, Stojanovska E, Pedersen J, Knop FK, Holst JJ, Wewer Albrechtsen NJ. Glucagon Receptor Signaling and Glucagon Resistance. Int J Mol Sci 2019; 20:E3314. [PMID: 31284506 PMCID: PMC6651628 DOI: 10.3390/ijms20133314] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 06/28/2019] [Accepted: 07/03/2019] [Indexed: 02/08/2023] Open
Abstract
Hundred years after the discovery of glucagon, its biology remains enigmatic. Accurate measurement of glucagon has been essential for uncovering its pathological hypersecretion that underlies various metabolic diseases including not only diabetes and liver diseases but also cancers (glucagonomas). The suggested key role of glucagon in the development of diabetes has been termed the bihormonal hypothesis. However, studying tissue-specific knockout of the glucagon receptor has revealed that the physiological role of glucagon may extend beyond blood-glucose regulation. Decades ago, animal and human studies reported an important role of glucagon in amino acid metabolism through ureagenesis. Using modern technologies such as metabolomic profiling, knowledge about the effects of glucagon on amino acid metabolism has been expanded and the mechanisms involved further delineated. Glucagon receptor antagonists have indirectly put focus on glucagon's potential role in lipid metabolism, as individuals treated with these antagonists showed dyslipidemia and increased hepatic fat. One emerging field in glucagon biology now seems to include the concept of hepatic glucagon resistance. Here, we discuss the roles of glucagon in glucose homeostasis, amino acid metabolism, and lipid metabolism and present speculations on the molecular pathways causing and associating with postulated hepatic glucagon resistance.
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Affiliation(s)
- Lina Janah
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Sasha Kjeldsen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Katrine D Galsgaard
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Marie Winther-Sørensen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Elena Stojanovska
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Jens Pedersen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital Hillerød, University of Copenhagen, 3400 Hillerød, Denmark
| | - Filip K Knop
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, 2900 Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, 2820 Gentofte, Denmark
| | - Jens J Holst
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Nicolai J Wewer Albrechtsen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark.
- Department of Clinical Biochemistry, Rigshospitalet, 2100 Copenhagen, Denmark.
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2100 Copenhagen, Denmark.
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20
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Hövelmann U, Olsen MB, Mouritzen U, Lamers D, Kronshage B, Heise T. Low doses of dasiglucagon consistently increase plasma glucose levels from hypoglycaemia and euglycaemia in people with type 1 diabetes mellitus. Diabetes Obes Metab 2019; 21:601-610. [PMID: 30350477 PMCID: PMC6587565 DOI: 10.1111/dom.13562] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/07/2018] [Accepted: 10/16/2018] [Indexed: 02/06/2023]
Abstract
AIM To characterize the pharmacokinetic and pharmacodynamic properties of dasiglucagon, a novel, stable and liquid formulated glucagon analogue, during hypoglycaemic and euglycaemic conditions in adult patients with type 1 diabetes mellitus. RESEARCH DESIGN AND METHODS In this randomized double-blind trial, 17 patients received four single subcutaneous doses (0.03, 0.08, 0.2 and 0.6 mg) of dasiglucagon (4 mg/mL formulation) under euglycaemic (plasma glucose [PG] 5.6 mmol/L [100 mg/dL]) or hypoglycaemic (PG 3.1-3.7 mmol/L [56-66 mg/dL]) conditions. For comparison, three doses (0.03, 0.08 and 0.2 mg) of a commercial glucagon formulation (Eli Lilly) were investigated at euglycaemia. RESULTS Dasiglucagon led to a dose-dependent and rapid increase in PG levels across all doses tested (mean increases 30 minutes post-dosing of 2.2 to 4.4 mmol/L [39-80 mg/dL] from euglycaemia and 1.3 to 5.2 mmol/L [24-94 mg/dL] from hypoglycaemia), which was higher than the rises elicited by similar doses of commercial glucagon (1.7-3.9 mmol/L [30-71 mg/dL]). The median time (range) to an increase in PG of >1.1 mmol/L (20 mg/dL) was <20 (18-19.5) minutes with 0.03 mg dasiglucagon and, with higher doses, the median times ranged from 9 to 15 minutes (commercial glucagon 13-14 minutes). In hypoglycaemia, 0.03 and 0.08 mg dasiglucagon re-established normoglycaemia (PG ≥3.9 mmol/L [70 mg/dL]) within median times of 14 and 10 minutes, respectively. Nausea and vomiting occurred more frequently with dasiglucagon than with commercial glucagon at identical doses which might be attributable to dasiglucagon's higher potency. CONCLUSION Dasiglucagon rapidly increased PG at doses of 0.03 to 0.6 mg in a dose-dependent manner and, therefore, is a good candidate for use in dual-hormone artificial pancreas systems.
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21
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Castle JR. Is Mini-Dose Glucagon the Answer to Preventing Exercise-Related Dysglycemia? Diabetes Care 2018; 41:1842-1843. [PMID: 30135198 DOI: 10.2337/dci18-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Jessica R Castle
- Division of Endocrinology, Diabetes & Clinical Nutrition, Department of Medicine, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR
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22
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Peters TM, Haidar A. Dual-hormone artificial pancreas: benefits and limitations compared with single-hormone systems. Diabet Med 2018; 35:450-459. [PMID: 29337384 DOI: 10.1111/dme.13581] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2018] [Indexed: 12/17/2022]
Abstract
Technological advances have made the artificial pancreas a reality. This has the potential to improve the lives of individuals with Type 1 diabetes by reducing the risk of hypoglycaemia, achieving better overall glucose control, and enhancing quality of life. Both single-hormone (insulin-only) and dual-hormone (insulin and glucagon) systems have been developed; however, a focused review of the relative benefits of each artificial pancreas system is needed. We reviewed studies that directly compared single- and dual-hormone systems to evaluate the efficacy of each system for preventing hypoglycaemia and maintaining glycaemic control, as well as their utility in specific situations including during exercise, overnight and during the prandial period. We observed additional benefits with the dual-hormone artificial pancreas for reducing the risk of hypoglycaemic events overall and during exercise over the study duration. The single-hormone artificial pancreas was sufficient for maintenance of euglycaemia in the overnight period and for preventing late-onset post-exercise hypoglycaemia. Future comparative studies of longer duration are required to determine whether one system is superior for improving mean glucose control, eliminating severe hypoglycaemia, or improving quality of life.
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Affiliation(s)
- T M Peters
- Division of Endocrinology and Metabolism, Faculty of Medicine
| | - A Haidar
- Division of Endocrinology and Metabolism, Faculty of Medicine
- Department of Biomedical Engineering, McGill University
- The Research Institute of the McGill University Health Centre, Montreal, Canada
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23
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Ranjan A, Nørgaard K, Tetzschner R, Steineck IIK, Clausen TR, Holst JJ, Madsbad S, Schmidt S. Effects of Preceding Ethanol Intake on Glucose Response to Low-Dose Glucagon in Individuals With Type 1 Diabetes: A Randomized, Placebo-Controlled, Crossover Study. Diabetes Care 2018; 41:797-806. [PMID: 29358493 DOI: 10.2337/dc17-1458] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 12/20/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study investigated whether preceding ethanol intake impairs glucose response to low-dose glucagon in individuals with type 1 diabetes. RESEARCH DESIGN AND METHODS This was a randomized, crossover, placebo-controlled study in 12 insulin pump-treated individuals (median [interquartile range] age, 37 [31-51] years; HbA1c, 57 [51-59] mmol/mol or 7.3% [6.8-7.5]; and BMI, 23.9 [22-25] kg/m2). During two overnight study visits, a 6 p.m. dinner (1 g carbohydrates/kg) was served with diet drink (placebo) or diet drink and ethanol (0.8 g/kg). After 8-9 h, ethanol was estimated to be metabolized, and a subcutaneous (s.c.) insulin bolus was given to induce mild hypoglycemia. When plasma glucose (PG) was ≤3.9 mmol/L, 100 µg glucagon was given s.c., followed by another s.c. 100 µg glucagon 2 h later. Primary end point was incremental peak PG induced by the first glucagon bolus. RESULTS Ethanol was undetectable before insulin administration at both visits. The insulin doses (mean ± SEM: 2.5 ± 0.4 vs. 2.7 ± 0.4 IU) to induce hypoglycemia (3.7 ± 0.1 vs. 3.9 ± 0.1 mmol/L) did not differ and caused similar insulin levels (28.3 ± 4.6 vs. 26.1 ± 4.0 mU/L) before glucagon administration on ethanol and placebo visits (all, P > 0.05). The first glucagon bolus tended to cause lower incremental peak PG (2.0 ± 0.5 vs. 2.9 ± 0.3 mmol/L, P = 0.06), lower incremental area under the curve (87 ± 40 vs. 191 ± 37 mmol/L × min, P = 0.08), and lower 2-h PG level (3.6 ± 1.0 vs. 4.8 ± 0.4 mmol/L, P = 0.05) after ethanol compared with placebo. The second glucagon bolus had similar responses between visits, but PG remained 1.8 ± 0.7 mmol/L lower after ethanol compared with placebo. CONCLUSIONS The ability of low-dose glucagon to treat mild hypoglycemia persisted with preceding ethanol intake, although it tended to be attenuated.
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Affiliation(s)
- Ajenthen Ranjan
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark .,Danish Diabetes Academy, Odense, Denmark
| | - Kirsten Nørgaard
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Rikke Tetzschner
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Isabelle Isa Kristin Steineck
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark.,Danish Diabetes Academy, Odense, Denmark
| | | | - Jens Juul Holst
- Novo Nordisk Foundation Center for Basic Metabolic Research and Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark.,Novo Nordisk Foundation Center for Basic Metabolic Research and Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Signe Schmidt
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark.,Danish Diabetes Academy, Odense, Denmark
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24
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Hövelmann U, Bysted BV, Mouritzen U, Macchi F, Lamers D, Kronshage B, Møller DV, Heise T. Pharmacokinetic and Pharmacodynamic Characteristics of Dasiglucagon, a Novel Soluble and Stable Glucagon Analog. Diabetes Care 2018; 41:531-537. [PMID: 29273578 DOI: 10.2337/dc17-1402] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 11/22/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Treatment of severe hypoglycemia outside of the hospital setting is limited to glucagon formulations requiring reconstitution before use, which may lead to erroneous or delayed glucagon administration. We compared the pharmacokinetic (PK) and pharmacodynamic (PD) characteristics and safety and tolerability of different doses of dasiglucagon, a novel soluble glucagon analog, with approved pediatric and full doses of GlucaGen in insulin-induced hypoglycemia in patients with type 1 diabetes. RESEARCH DESIGN AND METHODS In this single-center, randomized, double-blind trial, 58 patients with type 1 diabetes received single subcutaneous injections of 0.1, 0.3, 0.6, or 1.0 mg dasiglucagon or 0.5 or 1.0 mg GlucaGen in a state of hypoglycemia (blood glucose target 55 mg/dL) induced by an intravenous insulin infusion. RESULTS Dasiglucagon demonstrated a dose-dependent and rapid increase in plasma concentrations, reaching a maximum at ∼35 min with a half-life of ∼0.5 h. Dasiglucagon rapidly increased plasma glucose (PG) by ≥20 mg/dL (9-14 min) to PG ≥70 mg/dL (within 6-10 min), similar to GlucaGen, but with a longer-lasting and greater effect on PG. All patients on both treatments reached these end points within 30 min (predefined success criteria). Both treatments were well tolerated. Nausea was the most frequent adverse event, occurring at a similar rate (44-56%). CONCLUSIONS Dasiglucagon was well tolerated and showed an early PD response similar to that of GlucaGen at corresponding doses, suggesting comparable clinical effects of the two glucagon formulations. Dasiglucagon has the potential to become an effective and reliable rescue treatment for severe hypoglycemia in a ready-to-use pen.
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25
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Wendt SL, Ranjan A, Møller JK, Schmidt S, Knudsen CB, Holst JJ, Madsbad S, Madsen H, Nørgaard K, Jørgensen JB. Cross-Validation of a Glucose-Insulin-Glucagon Pharmacodynamics Model for Simulation Using Data From Patients With Type 1 Diabetes. J Diabetes Sci Technol 2017; 11:1101-1111. [PMID: 28654314 PMCID: PMC5951032 DOI: 10.1177/1932296817693254] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Currently, no consensus exists on a model describing endogenous glucose production (EGP) as a function of glucagon concentrations. Reliable simulations to determine the glucagon dose preventing or treating hypoglycemia or to tune a dual-hormone artificial pancreas control algorithm need a validated glucoregulatory model including the effect of glucagon. METHODS Eight type 1 diabetes (T1D) patients each received a subcutaneous (SC) bolus of insulin on four study days to induce mild hypoglycemia followed by a SC bolus of saline or 100, 200, or 300 µg of glucagon. Blood samples were analyzed for concentrations of glucagon, insulin, and glucose. We fitted pharmacokinetic (PK) models to insulin and glucagon data using maximum likelihood and maximum a posteriori estimation methods. Similarly, we fitted a pharmacodynamic (PD) model to glucose data. The PD model included multiplicative effects of insulin and glucagon on EGP. Bias and precision of PD model test fits were assessed by mean predictive error (MPE) and mean absolute predictive error (MAPE). RESULTS Assuming constant variables in a subject across nonoutlier visits and using thresholds of ±15% MPE and 20% MAPE, we accepted at least one and at most three PD model test fits in each of the seven subjects. Thus, we successfully validated the PD model by leave-one-out cross-validation in seven out of eight T1D patients. CONCLUSIONS The PD model accurately simulates glucose excursions based on plasma insulin and glucagon concentrations. The reported PK/PD model including equations and fitted parameters allows for in silico experiments that may help improve diabetes treatment involving glucagon for prevention of hypoglycemia.
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Affiliation(s)
- Sabrina Lyngbye Wendt
- Zealand Pharma A/S, Glostrup, Denmark
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Ajenthen Ranjan
- Department of Endocrinology, Hvidovre University Hospital, Hvidovre, Denmark
- Danish Diabetes Academy, Odense, Denmark
| | - Jan Kloppenborg Møller
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Signe Schmidt
- Department of Endocrinology, Hvidovre University Hospital, Hvidovre, Denmark
- Danish Diabetes Academy, Odense, Denmark
| | | | - Jens Juul Holst
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Hvidovre University Hospital, Hvidovre, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Madsen
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Kirsten Nørgaard
- Department of Endocrinology, Hvidovre University Hospital, Hvidovre, Denmark
| | - John Bagterp Jørgensen
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Kgs. Lyngby, Denmark
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26
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Ranjan A, Wendt SL, Schmidt S, Madsbad S, Holst JJ, Madsen H, Knudsen CB, Jørgensen JB, Nørgaard K. Relationship between Optimum Mini-doses of Glucagon and Insulin Levels when Treating Mild Hypoglycaemia in Patients with Type 1 Diabetes - A Simulation Study. Basic Clin Pharmacol Toxicol 2017; 122:322-330. [DOI: 10.1111/bcpt.12907] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 09/06/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Ajenthen Ranjan
- Department of Endocrinology; Copenhagen University Hospital Hvidovre; Hvidovre Denmark
- Danish Diabetes Academy; Odense Denmark
| | - Sabrina L. Wendt
- Department of Bioanalysis and Pharmacokinetics; Zealand Pharma A/S; Glostrup Denmark
- Department of Applied Mathematics and Computer Science; Technical University of Denmark; Kgs. Lyngby Denmark
| | - Signe Schmidt
- Department of Endocrinology; Copenhagen University Hospital Hvidovre; Hvidovre Denmark
- Danish Diabetes Academy; Odense Denmark
| | - Sten Madsbad
- Department of Endocrinology; Copenhagen University Hospital Hvidovre; Hvidovre Denmark
- NFF Center for Basic Metabolic Research and Department of Biomedical Sciences; University of Copenhagen; Copenhagen Denmark
| | - Jens J. Holst
- NFF Center for Basic Metabolic Research and Department of Biomedical Sciences; University of Copenhagen; Copenhagen Denmark
| | - Henrik Madsen
- Department of Applied Mathematics and Computer Science; Technical University of Denmark; Kgs. Lyngby Denmark
| | - Carsten B. Knudsen
- Department of Bioanalysis and Pharmacokinetics; Zealand Pharma A/S; Glostrup Denmark
| | - John B. Jørgensen
- Department of Applied Mathematics and Computer Science; Technical University of Denmark; Kgs. Lyngby Denmark
| | - Kirsten Nørgaard
- Department of Endocrinology; Copenhagen University Hospital Hvidovre; Hvidovre Denmark
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27
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Ranjan A, Schmidt S, Damm-Frydenberg C, Steineck I, Clausen TR, Holst JJ, Madsbad S, Nørgaard K. Low-Carbohydrate Diet Impairs the Effect of Glucagon in the Treatment of Insulin-Induced Mild Hypoglycemia: A Randomized Crossover Study. Diabetes Care 2017; 40:132-135. [PMID: 27797928 DOI: 10.2337/dc16-1472] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 10/01/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study compared the ability of glucagon to restore plasma glucose (PG) after mild hypoglycemia in patients with type 1 diabetes on an isocaloric high-carbohydrate diet (HCD) versus a low-carbohydrate diet (LCD). RESEARCH DESIGN AND METHODS Ten patients with insulin pump-treated type 1 diabetes randomly completed 1 week of the HCD (≥250 g/day) and 1 week of the LCD (≤50 g/day). After each week, mild hypoglycemia was induced by a subcutaneous insulin bolus in the fasting state. When PG reached 3.9 mmol/L, 100 µg glucagon was given subcutaneously, followed by 500 µg glucagon 2 h later. RESULTS Compared with the HCD, the LCD resulted in lower incremental rises in PG after the first (mean ± SEM: 1.3 ± 0.3 vs. 2.7 ± 0.4 mmol/L, P = 0.002) and second glucagon bolus (4.1 ± 0.2 vs. 5.6 ± 0.5 mmol/L, P = 0.002). No differences were observed between the diets regarding concentrations of insulin, glucagon, and triglycerides. CONCLUSIONS The LCD reduces the treatment effect of glucagon on mild hypoglycemia. Carbohydrate intake should be considered when low-dose glucagon is used to correct hypoglycemia.
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Affiliation(s)
- Ajenthen Ranjan
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark .,Danish Diabetes Academy, Odense, Denmark
| | - Signe Schmidt
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Danish Diabetes Academy, Odense, Denmark
| | | | - Isabelle Steineck
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Danish Diabetes Academy, Odense, Denmark
| | | | - Jens Juul Holst
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kirsten Nørgaard
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
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28
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Taleb N, Haidar A, Messier V, Gingras V, Legault L, Rabasa-Lhoret R. Glucagon in artificial pancreas systems: Potential benefits and safety profile of future chronic use. Diabetes Obes Metab 2017; 19:13-23. [PMID: 27629286 DOI: 10.1111/dom.12789] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 09/09/2016] [Accepted: 09/11/2016] [Indexed: 12/17/2022]
Abstract
The role of glucagon in the pathophysiology of diabetes has long been recognized, although its approved clinical use has so far been limited to the emergency treatment of severe hypoglycaemia. A novel use of glucagon as intermittent mini-boluses is proposed in the dual-hormone version (insulin and glucagon) of the external artificial pancreas. Short-term studies suggest that the incorporation of glucagon into artificial pancreas systems has the potential to further decrease hypoglycaemic risk and improve overall glucose control; however, the potential long-term safety and benefits also need to be investigated given the recognized systemic effects of glucagon. In the present report, we review the available animal and human data on the physiological functions of glucagon, as well as its pharmacological use, according to dosing and duration (acute and chronic). Along with its main role in hepatic glucose metabolism, glucagon affects the cardiovascular, renal, pulmonary and gastrointestinal systems. It has a potential role in weight reduction through its central satiety function and its role in increasing energy expenditure. Most of the pharmacological studies investigating the effects of glucagon have used doses exceeding 1 mg, in contrast to the mini-boluses used in the artificial pancreas. The available data are reassuring but comprehensive human studies using small but chronic glucagon doses that are close to the physiological ranges are lacking. We propose a list of variables that could be monitored during long-term trials of the artificial pancreas. Such trials should address the questions about the risk-benefit ratio of chronic glucagon use.
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Affiliation(s)
- Nadine Taleb
- Metabolic diseases unit, Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
- Department of Biomedical Sciences, Faculty of Medicine, Édouard-Montpetit, Université de Montréal, Montréal, Québec, Canada
| | - Ahmad Haidar
- Department of Biomedical Engineering, Faculty of Medicine, McGill University, Montréal, Québec, Canada
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Virginie Messier
- Metabolic diseases unit, Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
| | - Véronique Gingras
- Metabolic diseases unit, Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
- Nutrition Department, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Laurent Legault
- Montreal Children's Hospital, Department of Pediatrics, McGill University Health Centre, Montréal, Québec, Canada
| | - Rémi Rabasa-Lhoret
- Metabolic diseases unit, Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
- Montreal Diabetes Research Center, Montréal, Québec, Canada
- Nutrition Department, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
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29
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Bally L, Thabit H, Hovorka R. Role of Dual-Hormone Closed-Loop Delivery System in the Future. Diabetes Technol Ther 2016; 18:452-4. [PMID: 27500812 DOI: 10.1089/dia.2016.0259] [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] [Indexed: 11/13/2022]
Affiliation(s)
- Lia Bally
- 1 Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge , Cambridge, United Kingdom
- 2 Department of Diabetes & Endocrinology, Cambridge University Hospitals NHS Foundation Trust , Cambridge, United Kingdom
- 3 Division of Diabetes, Endocrinology, Clinical Nutrition & Metabolism, Inselspital, Bern University Hospital, University of Bern , Bern, Switzerland
| | - Hood Thabit
- 1 Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge , Cambridge, United Kingdom
- 2 Department of Diabetes & Endocrinology, Cambridge University Hospitals NHS Foundation Trust , Cambridge, United Kingdom
| | - Roman Hovorka
- 1 Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge , Cambridge, United Kingdom
- 4 Department of Paediatrics, University of Cambridge , Cambridge, United Kingdom
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30
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Leclair E, Liggins RT, Peckett AJ, Teich T, Coy DH, Vranic M, Riddell MC. Glucagon responses to exercise-induced hypoglycaemia are improved by somatostatin receptor type 2 antagonism in a rat model of diabetes. Diabetologia 2016; 59:1724-31. [PMID: 27075449 DOI: 10.1007/s00125-016-3953-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 03/18/2016] [Indexed: 12/18/2022]
Abstract
AIMS/HYPOTHESIS Regular exercise is at the cornerstone of care in type 1 diabetes. However, relative hyperinsulinaemia and a blunted glucagon response to exercise promote hypoglycaemia. Recently, a selective antagonist of somatostatin receptor 2, PRL-2903, was shown to improve glucagon counterregulation to hypoglycaemia in resting streptozotocin-induced diabetic rats. The aim of this study was to test the efficacy of PRL-2903 in enhancing glucagon counterregulation during repeated hyperinsulinaemic exercise. METHODS Diabetic rats performed daily exercise for 1 week and were then exposed to saline (154 mmol/l NaCl) or PRL-2903, 10 mg/kg, before hyperinsulinaemic exercise on two separate occasions spaced 1 day apart. In the following week, animals crossed over to the alternate treatment for a third hyperinsulinaemic exercise protocol. RESULTS Liver glycogen content was lower in diabetic rats compared with control rats, despite daily insulin therapy (p < 0.05). Glucagon levels failed to increase during exercise with saline but increased three-to-six fold with PRL-2903 (all p < 0.05). Glucose concentrations tended to be higher during exercise and early recovery with PRL-2903 on both days of treatment; this difference did not achieve statistical significance (p > 0.05). CONCLUSIONS/INTERPRETATION PRL-2903 improves glucagon counterregulation during exercise. However, liver glycogen stores or other factors limit the prevention of exercise-induced hypoglycaemia in rats with streptozotocin-induced diabetes.
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Affiliation(s)
- Erwan Leclair
- School of Kinesiology and Health Science, York University, Toronto, ON, M3J 1P3, Canada
| | | | - Ashley J Peckett
- School of Kinesiology and Health Science, York University, Toronto, ON, M3J 1P3, Canada
| | - Trevor Teich
- School of Kinesiology and Health Science, York University, Toronto, ON, M3J 1P3, Canada
| | - David H Coy
- Department of Medicine, Peptide Research Labs, Tulane University Medical Center, New Orleans, LA, USA
| | - Mladen Vranic
- Departments of Physiology and Medicine, University of Toronto, Toronto, ON, Canada
| | - Michael C Riddell
- School of Kinesiology and Health Science, York University, Toronto, ON, M3J 1P3, Canada.
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31
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Emami A, Youssef JE, Rabasa-Lhoret R, Pineau J, Castle JR, Haidar A. Modeling Glucagon Action in Patients With Type 1 Diabetes. IEEE J Biomed Health Inform 2016; 21:1163-1171. [PMID: 27448377 DOI: 10.1109/jbhi.2016.2593630] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The dual-hormone artificial pancreas is an emerging technology to treat type 1 diabetes (T1D). It consists of a glucose sensor, infusion pumps, and a dosing algorithm that directs hormonal delivery. Preclinical optimization of dosing algorithms using computer simulations has the potential to accelerate the pace of development for this technology. However, current simulation environments consider glucose regulation models that either do not include glucagon action submodels or include submodels that were proposed without comparison to other candidate models. We consider here nine candidate models of glucagon action featuring a number of possible characteristics: insulin-independent glucagon action, insulin/glucagon ratio effect on hepatic glucose production, insulin-dependent suppression of glucagon action, and the effect of rate of change of glucagon. To assess the models, we use measurements of plasma insulin, plasma glucagon, and endogenous glucose production collected from experiments involving eight subjects with T1D who receive four subcutaneous glucagon boluses. We estimate each model's parameters using a Bayesian approach, and the models are contrasted based on the deviance information criterion. The model achieving the best fit features insulin-dependent suppression of glucagon action and incorporates effects of both glucagon levels and its rate of change.
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32
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Haidar A, Smaoui MR, Legault L, Rabasa-Lhoret R. The role of glucagon in the artificial pancreas. Lancet Diabetes Endocrinol 2016; 4:476-9. [PMID: 27138734 DOI: 10.1016/s2213-8587(16)30006-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 03/16/2016] [Accepted: 03/17/2016] [Indexed: 11/24/2022]
Affiliation(s)
- Ahmad Haidar
- Department of Biomedical Engineering, Division of Endocrinology, Faculty of Medicine, McGill University, Montréal, QC H3A 2B4, Canada.
| | - Mohamed Raef Smaoui
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, QC H3A 2B4, Canada; Institut de Recherches Cliniques de Montréal, Montréal, QC, Canada
| | - Laurent Legault
- Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - Rémi Rabasa-Lhoret
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, QC H3A 2B4, Canada; Institut de Recherches Cliniques de Montréal, Montréal, QC, Canada; Nutrition Department, Faculty of Medicine, University of Montréal, Montréal, QC, Canada; Montreal Diabetes Research Center, Montreal, QC, Canada
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33
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Ranjan A, Schmidt S, Madsbad S, Holst JJ, Nørgaard K. Effects of subcutaneous, low-dose glucagon on insulin-induced mild hypoglycaemia in patients with insulin pump treated type 1 diabetes. Diabetes Obes Metab 2016; 18:410-8. [PMID: 26743775 DOI: 10.1111/dom.12627] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 11/22/2015] [Accepted: 12/20/2015] [Indexed: 02/06/2023]
Abstract
AIM To investigate the dose-response relationship of subcutaneous (s.c.) glucagon administration on plasma glucose and on counter-regulatory hormone responses during s.c. insulin-induced mild hypoglycaemia in patients with type 1 diabetes treated with insulin pumps. METHODS Eight insulin pump-treated patients completed a blinded, randomized, placebo-controlled study. Hypoglycaemia was induced in the fasting state by an s.c. insulin bolus and, when plasma glucose reached 3.4 mmol/l [95% confidence interval (CI) 3.2-3.5], an s.c. bolus of either 100, 200, 300 µg glucagon or saline was administered. Plasma glucose, counter-regulatory hormones, haemodynamic variables and side effects were measured throughout each study day. Peak plasma glucose level was the primary endpoint. RESULTS Plasma glucose level increased significantly by a mean (95% CI) of 2.3 (1.7-3.0), 4.2 (3.5-4.8) and 5.0 (4.3-5.6) mmol/l to 6.1 (4.9-7.4), 7.9 (6.4-9.3) and 8.7 (7.8-9.5) vs 3.6 (3.4-3.9) mmol/l (p < 0.001) after the three different glucagon doses as compared with saline, and the increase was neither correlated with weight nor insulin levels. Area under the plasma glucose curve, peak plasma glucose, time to peak plasma glucose and duration of plasma glucose level above baseline were significantly enhanced with increasing glucagon doses; however, these were not significantly different between 200 and 300 µg glucagon. Free fatty acids and heart rates were significantly lower initially after glucagon than after saline injection. Other haemodynamic variables, counter-regulatory hormones and side effects did not differ between interventions. CONCLUSIONS An s.c. low-dose glucagon bolus effectively restores plasma glucose after insulin overdosing. Further research is needed to investigate whether low-dose glucagon may be an alternative treatment to oral carbohydrate intake for mild hypoglycaemia in patients with type 1 diabetes.
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Affiliation(s)
- A Ranjan
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Danish Diabetes Academy, Odense, Denmark
| | - S Schmidt
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Danish Diabetes Academy, Odense, Denmark
| | - S Madsbad
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Novo Nordisk Foundation Centre for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - J J Holst
- Novo Nordisk Foundation Centre for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - K Nørgaard
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
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34
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Blauw H, Wendl I, DeVries JH, Heise T, Jax T. Pharmacokinetics and pharmacodynamics of various glucagon dosages at different blood glucose levels. Diabetes Obes Metab 2016; 18:34-9. [PMID: 26343550 DOI: 10.1111/dom.12571] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 08/05/2015] [Accepted: 08/28/2015] [Indexed: 11/29/2022]
Abstract
AIMS To evaluate the pharmacokinetics and pharmacodynamics of different doses of glucagon administered subcutaneously (s.c.) at different blood glucose levels. METHODS This study was an open-label, randomized, three-period, cross-over experiment in 6 patients with type 1 diabetes. During each of the three periods, different blood glucose levels were established in four consecutive steps (8, 6, 4 and 2.8 mmol/l) and glucagon was given at each blood glucose level in doses from 0.11 to 0.44 mg and 0.33, 0.66 and 1 mg at the lowest glucose concentration. RESULTS Maximum glucagon concentration and area under the curve increased with increasing glucagon dose. Maximum glucagon concentration was reached after 10-20 min. Glucagon raised blood glucose in a dose-dependent manner at different baseline blood glucose levels. The median glucose excursion ranged from 2.6 to 6.2 mmol/l. Time to maximum glucose concentration was dose-dependent for the glucagon doses at 2.8 mmol/l, with median values from 40 to 80 min. CONCLUSIONS Glucagon administered s.c. produces a stable pharmacokinetic and pharmacodynamic response at lower doses than the usual rescue dose and across a range of hypo- to hyperglycaemic blood glucose levels. This supports the use of small glucagon doses in the artificial pancreas to correct and prevent hypoglycaemia.
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Affiliation(s)
- H Blauw
- Inreda Diabetic BV, Goor, The Netherlands
- Department of Endocrinology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - I Wendl
- Profil Institut für Stoffwechselforschung GmbH, Neuss, Germany
| | - J H DeVries
- Department of Endocrinology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - T Heise
- Profil Institut für Stoffwechselforschung GmbH, Neuss, Germany
| | - T Jax
- Profil Institut für Stoffwechselforschung GmbH, Neuss, Germany
- Herzzentrum Wuppertal, Universität Witten-Herdecke, Witten, Germany
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35
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Castle JR, El Youssef J, Bakhtiani PA, Cai Y, Stobbe JM, Branigan D, Ramsey K, Jacobs P, Reddy R, Woods M, Ward WK. Effect of Repeated Glucagon Doses on Hepatic Glycogen in Type 1 Diabetes: Implications for a Bihormonal Closed-Loop System. Diabetes Care 2015; 38:2115-9. [PMID: 26341131 PMCID: PMC4613914 DOI: 10.2337/dc15-0754] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 08/10/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate subjects with type 1 diabetes for hepatic glycogen depletion after repeated doses of glucagon, simulating delivery in a bihormonal closed-loop system. RESEARCH DESIGN AND METHODS Eleven adult subjects with type 1 diabetes participated. Subjects underwent estimation of hepatic glycogen using (13)C MRS. MRS was performed at the following four time points: fasting and after a meal at baseline, and fasting and after a meal after eight doses of subcutaneously administered glucagon at a dose of 2 µg/kg, for a total mean dose of 1,126 µg over 16 h. The primary and secondary end points were, respectively, estimated hepatic glycogen by MRS and incremental area under the glucose curve for a 90-min interval after glucagon administration. RESULTS In the eight subjects with complete data sets, estimated glycogen stores were similar at baseline and after repeated glucagon doses. In the fasting state, glycogen averaged 21 ± 3 g/L before glucagon administration and 25 ± 4 g/L after glucagon administration (mean ± SEM) (P = NS). In the fed state, glycogen averaged 40 ± 2 g/L before glucagon administration and 34 ± 4 g/L after glucagon administration (P = NS). With the use of an insulin action model, the rise in glucose after the last dose of glucagon was comparable to the rise after the first dose, as measured by the 90-min incremental area under the glucose curve. CONCLUSIONS In adult subjects with well-controlled type 1 diabetes (mean A1C 7.2%), glycogen stores and the hyperglycemic response to glucagon administration are maintained even after receiving multiple doses of glucagon. This finding supports the safety of repeated glucagon delivery in the setting of a bihormonal closed-loop system.
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Affiliation(s)
- Jessica R Castle
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon Health & Science University, Portland, OR
| | - Joseph El Youssef
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon Health & Science University, Portland, OR
| | - Parkash A Bakhtiani
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon Health & Science University, Portland, OR
| | - Yu Cai
- Advanced Imaging Research Center, Oregon Health & Science University, Portland, OR
| | - Jade M Stobbe
- Advanced Imaging Research Center, Oregon Health & Science University, Portland, OR
| | - Deborah Branigan
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon Health & Science University, Portland, OR
| | - Katrina Ramsey
- Oregon Clinical and Translational Research Institute Biostatistics & Design Program, Oregon Health & Science University, Portland, OR
| | - Peter Jacobs
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Ravi Reddy
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Mark Woods
- Advanced Imaging Research Center, Oregon Health & Science University, Portland, OR Portland State University, Portland, OR
| | - W Kenneth Ward
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon Health & Science University, Portland, OR
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36
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Jacobs PG, Resalat N, El Youssef J, Reddy R, Branigan D, Preiser N, Condon J, Castle J. Incorporating an Exercise Detection, Grading, and Hormone Dosing Algorithm Into the Artificial Pancreas Using Accelerometry and Heart Rate. J Diabetes Sci Technol 2015; 9:1175-84. [PMID: 26438720 PMCID: PMC4667295 DOI: 10.1177/1932296815609371] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In this article, we present several important contributions necessary for enabling an artificial endocrine pancreas (AP) system to better respond to exercise events. First, we show how exercise can be automatically detected using body-worn accelerometer and heart rate sensors. During a 22 hour overnight inpatient study, 13 subjects with type 1 diabetes wearing a Zephyr accelerometer and heart rate monitor underwent 45 minutes of mild aerobic treadmill exercise while controlling their glucose levels using sensor-augmented pump therapy. We used the accelerometer and heart rate as inputs into a validated regression model. Using this model, we were able to detect the exercise event with a sensitivity of 97.2% and a specificity of 99.5%. Second, from this same study, we show how patients' glucose declined during the exercise event and we present results from in silico modeling that demonstrate how including an exercise model in the glucoregulatory model improves the estimation of the drop in glucose during exercise. Last, we present an exercise dosing adjustment algorithm and describe parameter tuning and performance using an in silico glucoregulatory model during an exercise event.
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Affiliation(s)
- Peter G Jacobs
- Department of Biomedical Engineering, Oregon Health and Science University, Portland OR, USA
| | - Navid Resalat
- Department of Biomedical Engineering, Oregon Health and Science University, Portland OR, USA
| | - Joseph El Youssef
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland OR, USA
| | - Ravi Reddy
- Department of Biomedical Engineering, Oregon Health and Science University, Portland OR, USA
| | - Deborah Branigan
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland OR, USA
| | - Nicholas Preiser
- Department of Biomedical Engineering, Oregon Health and Science University, Portland OR, USA
| | - John Condon
- Department of Biomedical Engineering, Oregon Health and Science University, Portland OR, USA
| | - Jessica Castle
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland OR, USA
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37
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Hinshaw L, Mallad A, Dalla Man C, Basu R, Cobelli C, Carter RE, Kudva YC, Basu A. Glucagon sensitivity and clearance in type 1 diabetes: insights from in vivo and in silico experiments. Am J Physiol Endocrinol Metab 2015; 309:E474-86. [PMID: 26152766 PMCID: PMC4556882 DOI: 10.1152/ajpendo.00236.2015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 06/29/2015] [Indexed: 11/22/2022]
Abstract
Glucagon use in artificial pancreas for type 1 diabetes (T1D) is being explored for prevention and rescue from hypoglycemia. However, the relationship between glucagon stimulation of endogenous glucose production (EGP) viz., hepatic glucagon sensitivity, and prevailing glucose concentrations has not been examined. To test the hypothesis that glucagon sensitivity is increased at hypoglycemia vs. euglycemia, we studied 29 subjects with T1D randomized to a hypoglycemia or euglycemia clamp. Each subject was studied at three glucagon doses at euglycemia or hypoglycemia, with EGP measured by isotope dilution technique. The peak EGP increments and the integrated EGP response increased with increasing glucagon dose during euglycemia and hypoglycemia. However, the difference in dose response based on glycemia was not significant despite higher catecholamine concentrations in the hypoglycemia group. Knowledge of glucagon's effects on EGP was used to develop an in silico glucagon action model. The model-derived output fitted the obtained data at both euglycemia and hypoglycemia for all glucagon doses tested. Glucagon clearance did not differ between glucagon doses studied in both groups. Therefore, the glucagon controller of a dual hormone control system may not need to adjust glucagon sensitivity, and hence glucagon dosing, based on glucose concentrations during euglycemia and hypoglycemia.
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Affiliation(s)
- Ling Hinshaw
- Endocrine Research Unit, Division of Endocrinology, Mayo College of Medicine, Rochester, Minnesota
| | - Ashwini Mallad
- Endocrine Research Unit, Division of Endocrinology, Mayo College of Medicine, Rochester, Minnesota
| | - Chiara Dalla Man
- Department of Information Engineering, University of Padova, Padua, Italy
| | - Rita Basu
- Endocrine Research Unit, Division of Endocrinology, Mayo College of Medicine, Rochester, Minnesota;
| | - Claudio Cobelli
- Department of Information Engineering, University of Padova, Padua, Italy
| | - Rickey E Carter
- Department of Health Sciences Research, Mayo College of Medicine, Rochester, Minnesota; and
| | - Yogish C Kudva
- Endocrine Research Unit, Division of Endocrinology, Mayo College of Medicine, Rochester, Minnesota
| | - Ananda Basu
- Endocrine Research Unit, Division of Endocrinology, Mayo College of Medicine, Rochester, Minnesota
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Meek TH, Dorfman MD, Matsen ME, Fischer JD, Cubelo A, Kumar MR, Taborsky GJ, Morton GJ. Evidence That in Uncontrolled Diabetes, Hyperglucagonemia Is Required for Ketosis but Not for Increased Hepatic Glucose Production or Hyperglycemia. Diabetes 2015; 64:2376-87. [PMID: 25633417 PMCID: PMC4477352 DOI: 10.2337/db14-1562] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 01/24/2015] [Indexed: 12/16/2022]
Abstract
Several lines of evidence implicate excess glucagon secretion in the elevated rates of hepatic glucose production (HGP), hyperglycemia, and ketosis characteristic of uncontrolled insulin-deficient diabetes (uDM), but whether hyperglucagonemia is required for hyperglycemia in this setting is unknown. To address this question, adult male Wistar rats received either streptozotocin (STZ) to induce uDM (STZ-DM) or vehicle and remained nondiabetic. Four days later, animals received daily subcutaneous injections of either the synthetic GLP-1 receptor agonist liraglutide in a dose-escalating regimen to reverse hyperglucagonemia or its vehicle for 10 days. As expected, plasma glucagon levels were elevated in STZ-DM rats, and although liraglutide treatment lowered glucagon levels to those of nondiabetic controls, it failed to attenuate diabetic hyperglycemia, elevated rates of glucose appearance (Ra), or increased hepatic gluconeogenic gene expression. In contrast, it markedly reduced levels of both plasma ketone bodies and hepatic expression of the rate-limiting enzyme involved in ketone body production. To independently confirm this finding, in a separate study, treatment of STZ-DM rats with a glucagon-neutralizing antibody was sufficient to potently lower plasma ketone bodies but failed to normalize elevated levels of either blood glucose or Ra. These data suggest that in rats with uDM, hyperglucagonemia is required for ketosis but not for increased HGP or hyperglycemia.
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Affiliation(s)
- Thomas H Meek
- Diabetes and Obesity Center of Excellence, Department of Medicine, University of Washington, Seattle, WA
| | - Mauricio D Dorfman
- Diabetes and Obesity Center of Excellence, Department of Medicine, University of Washington, Seattle, WA
| | - Miles E Matsen
- Diabetes and Obesity Center of Excellence, Department of Medicine, University of Washington, Seattle, WA
| | - Jonathan D Fischer
- Diabetes and Obesity Center of Excellence, Department of Medicine, University of Washington, Seattle, WA
| | - Alexis Cubelo
- Diabetes and Obesity Center of Excellence, Department of Medicine, University of Washington, Seattle, WA
| | - Monica R Kumar
- University of South Alabama College of Medicine, Mobile, AL
| | - Gerald J Taborsky
- VA Puget Sound Health Care System, Department of Veterans Affairs Medical Center, Seattle, WA
| | - Gregory J Morton
- Diabetes and Obesity Center of Excellence, Department of Medicine, University of Washington, Seattle, WA
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Abstract
PURPOSE OF REVIEW Autoimmune destruction of the β cells is considered the key abnormality in type 1 diabetes mellitus and insulin replacement the primary therapeutic strategy. However, a lack of insulin is accompanied by disturbances in glucagon release, which is excessive postprandially, but insufficient during hypoglycaemia. In addition, replacing insulin alone appears insufficient for adequate glucose control. This review focuses on the growing body of evidence that glucagon abnormalities contribute significantly to the pathophysiology of diabetes and on recent efforts to target the glucagon axis as adjunctive therapy to insulin replacement. RECENT FINDINGS This review discusses recent (since 2013) advances in abnormalities of glucagon regulation and their link to the pathophysiology of diabetes; new mechanisms of glucagon action and regulation; manipulation of glucagon in diabetes treatment; and analytical and systems biology tools to study glucagon regulation. SUMMARY Recent efforts 'resurrected' glucagon as a key hormone in the pathophysiology of diabetes. New studies target its abnormal regulation and action that is key for improving diabetes treatment. The progress is promising, but major questions remain, including unravelling the mechanism of loss of glucagon counterregulation in type 1 diabetes mellitus and how best to manipulate glucagon to achieve more efficient and safer glycaemic control.
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Affiliation(s)
- Leon S Farhy
- Division of Endocrinology and Metabolism, Department of Medicine and Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
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40
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Boido A, Ceriani V, Pontiroli AE. Glucagon for hypoglycemic episodes in insulin-treated diabetic patients: a systematic review and meta-analysis with a comparison of glucagon with dextrose and of different glucagon formulations. Acta Diabetol 2015; 52:405-12. [PMID: 25323325 DOI: 10.1007/s00592-014-0665-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 10/06/2014] [Indexed: 10/24/2022]
Abstract
AIMS Glucagon is used as an emergency drug in hypoglycemia, mainly when the patient is unconscious. A few studies report on ineffectiveness of glucagon in relieving hypoglycemia. The present systematic review and meta-analysis evaluate the effectiveness of glucagon alone and in comparison with dextrose and the effectiveness of intranasal glucagon in comparison with injected glucagon. METHODS Studies were grouped into three groups: (1) reports on glucagon ineffectiveness; (2) comparison of glucagon and dextrose; (3) comparison of intranasal glucagon and injected glucagon. In groups 2 and 3, only controlled studies were included in the analysis, whether randomized or non-randomized studies. Appropriate methodology (PRISMA statement) was adhered to, and publication bias was formally assessed. Sixteen studies, published in any language as full papers, were analysed to identify predictors of ineffectiveness, and they were included in a meta-analysis (random effects model) to study the effect of different strategies. Intervention effect (number of failures) was expressed as odds ratio (OR), with 95 % confidence intervals. RESULTS Failure rate ranged from 0.0 to 2.31 %, to 7.6 %, to 14.4 %, and to 59 %. Comparing glucagon and dextrose, the OR was 0.53 (0.20-1.42); comparing intranasal and intramuscular glucagon, the OR was 1.40 (0.18-10.93). Heterogeneity was low and not statistically significant. Publication bias was absent. CONCLUSIONS These data indicate that ineffectiveness of glucagon is unfrequent, not different from dextrose; in addition, intranasal and injected glucagon are similarly effective. In the case of failure, a second dose can be administered.
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Affiliation(s)
- Augusto Boido
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milano, Italy
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