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Sanchez-Rangel E, Deajon-Jackson J, Hwang JJ. Pathophysiology and management of hypoglycemia in diabetes. Ann N Y Acad Sci 2022; 1518:25-46. [PMID: 36202764 DOI: 10.1111/nyas.14904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In the century since the discovery of insulin, diabetes has changed from an early death sentence to a manageable chronic disease. This change in longevity and duration of diabetes coupled with significant advances in therapeutic options for patients has fundamentally changed the landscape of diabetes management, particularly in patients with type 1 diabetes mellitus. However, hypoglycemia remains a major barrier to achieving optimal glycemic control. Current understanding of the mechanisms of hypoglycemia has expanded to include not only counter-regulatory hormonal responses but also direct changes in brain glucose, fuel sensing, and utilization, as well as changes in neural networks that modulate behavior, mood, and cognition. Different strategies to prevent and treat hypoglycemia have been developed, including educational strategies, new insulin formulations, delivery devices, novel technologies, and pharmacologic targets. This review article will discuss current literature contributing to our understanding of the myriad of factors that lead to the development of clinically meaningful hypoglycemia and review established and novel therapies for the prevention and treatment of hypoglycemia.
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Affiliation(s)
- Elizabeth Sanchez-Rangel
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jelani Deajon-Jackson
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Janice Jin Hwang
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA.,Division of Endocrinology, Department of Internal Medicine, University of North Carolina - Chapel Hill, Chapel Hill, North Carolina, USA
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Farrell CM, McCrimmon RJ. Clinical approaches to treat impaired awareness of hypoglycaemia. Ther Adv Endocrinol Metab 2021; 12:20420188211000248. [PMID: 33796253 PMCID: PMC7968015 DOI: 10.1177/20420188211000248] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 02/12/2021] [Indexed: 01/25/2023] Open
Abstract
Impaired awareness of hypoglycaemia (IAH) affects between 25% and 30% of all people with type 1 diabetes (T1D) and markedly increases risk of severe hypoglycaemia. This greatly feared complication of T1D impairs quality of life and has a recognised morbidity. People with T1D have an increased propensity to hypoglycaemia as a result of fundamental physiological defects in their ability to respond appropriately to a fall in blood glucose levels. With repeated exposure to low glucose, many then develop a condition referred to as IAH, where there is a reduced ability to perceive the onset of hypoglycaemia and take appropriate corrective action. The management of individuals with IAH relies initially on its identification in the clinic through a detailed exploration of the frequency of hypoglycaemia and an assessment of the individual's ability to recognise these episodes. In this review article, we will address the clinical strategies that may help in the management of the patient with IAH once identified, who may or may not also suffer from problematic hypoglycaemia. The initial focus is on how to identify such patients and then on the variety of approaches involving educational programmes and technological approaches that may be taken to minimise hypoglycaemia risk. No single approach can be advocated for all patients, and it is the role of the health care professional to identify the clinical strategy that best enables their patient to achieve this goal.
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Affiliation(s)
- Catriona M. Farrell
- Division of Systems Medicine, School of Medicine, University of Dundee, Dundee, UK
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Kalinovich A, Dehvari N, Åslund A, van Beek S, Halleskog C, Olsen J, Forsberg E, Zacharewicz E, Schaart G, Rinde M, Sandström A, Berlin R, Östenson CG, Hoeks J, Bengtsson T. Treatment with a β-2-adrenoceptor agonist stimulates glucose uptake in skeletal muscle and improves glucose homeostasis, insulin resistance and hepatic steatosis in mice with diet-induced obesity. Diabetologia 2020; 63:1603-1615. [PMID: 32472192 PMCID: PMC7351816 DOI: 10.1007/s00125-020-05171-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/27/2020] [Indexed: 12/19/2022]
Abstract
AIMS/HYPOTHESIS Chronic stimulation of β2-adrenoceptors, opposite to acute treatment, was reported to reduce blood glucose levels, as well as to improve glucose and insulin tolerance in rodent models of diabetes by essentially unknown mechanisms. We recently described a novel pathway that mediates glucose uptake in skeletal muscle cells via stimulation of β2-adrenoceptors. In the current study we further explored the potential therapeutic relevance of β2-adrenoceptor stimulation to improve glucose homeostasis and the mechanisms responsible for the effect. METHODS C57Bl/6N mice with diet-induced obesity were treated both acutely and for up to 42 days with a wide range of clenbuterol dosages and treatment durations. Glucose homeostasis was assessed by glucose tolerance test. We also measured in vivo glucose uptake in skeletal muscle, insulin sensitivity by insulin tolerance test, plasma insulin levels, hepatic lipids and glycogen. RESULTS Consistent with previous findings, acute clenbuterol administration increased blood glucose and insulin levels. However, already after 4 days of treatment, beneficial effects of clenbuterol were manifested in glucose homeostasis (32% improvement of glucose tolerance after 4 days of treatment, p < 0.01) and these effects persisted up to 42 days of treatment. These favourable metabolic effects could be achieved with doses as low as 0.025 mg kg-1 day-1 (40 times lower than previously studied). Mechanistically, these effects were not due to increased insulin levels, but clenbuterol enhanced glucose uptake in skeletal muscle in vivo both acutely in lean mice (by 64%, p < 0.001) as well as during chronic treatment in diet-induced obese mice (by 74%, p < 0.001). Notably, prolonged treatment with low-dose clenbuterol improved whole-body insulin sensitivity (glucose disposal rate after insulin injection increased up to 1.38 ± 0.31%/min in comparison with 0.15 ± 0.36%/min in control mice, p < 0.05) and drastically reduced hepatic steatosis (by 40%, p < 0.01) and glycogen (by 23%, p < 0.05). CONCLUSIONS/INTERPRETATION Clenbuterol improved glucose tolerance after 4 days of treatment and these effects were maintained for up to 42 days. Effects were achieved with doses in a clinically relevant microgram range. Mechanistically, prolonged treatment with a low dose of clenbuterol improved glucose homeostasis in insulin resistant mice, most likely by stimulating glucose uptake in skeletal muscle and improving whole-body insulin sensitivity as well as by reducing hepatic lipids and glycogen. We conclude that selective β2-adrenergic agonists might be an attractive potential treatment for type 2 diabetes. This remains to be confirmed in humans. Graphical abstract.
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Affiliation(s)
- Anastasia Kalinovich
- Department of Molecular Biosciences, the Wenner-Gren Institute, Stockholm University, Svante Arrhenius väg 20B, Arrhenius laboratories F3, 10691, Stockholm, Sweden
- Atrogi AB, Stockholm, Sweden
| | - Nodi Dehvari
- Department of Molecular Biosciences, the Wenner-Gren Institute, Stockholm University, Svante Arrhenius väg 20B, Arrhenius laboratories F3, 10691, Stockholm, Sweden
- Atrogi AB, Stockholm, Sweden
| | - Alice Åslund
- Department of Molecular Biosciences, the Wenner-Gren Institute, Stockholm University, Svante Arrhenius väg 20B, Arrhenius laboratories F3, 10691, Stockholm, Sweden
| | - Sten van Beek
- Department of Nutrition and Movement Sciences, Maastricht University, Maastricht, the Netherlands
| | - Carina Halleskog
- Department of Molecular Biosciences, the Wenner-Gren Institute, Stockholm University, Svante Arrhenius väg 20B, Arrhenius laboratories F3, 10691, Stockholm, Sweden
- Atrogi AB, Stockholm, Sweden
| | - Jessica Olsen
- Department of Molecular Biosciences, the Wenner-Gren Institute, Stockholm University, Svante Arrhenius väg 20B, Arrhenius laboratories F3, 10691, Stockholm, Sweden
- Atrogi AB, Stockholm, Sweden
| | | | - Evelyn Zacharewicz
- Department of Nutrition and Movement Sciences, Maastricht University, Maastricht, the Netherlands
| | - Gert Schaart
- Department of Nutrition and Movement Sciences, Maastricht University, Maastricht, the Netherlands
| | - Mia Rinde
- Department of Molecular Biosciences, the Wenner-Gren Institute, Stockholm University, Svante Arrhenius väg 20B, Arrhenius laboratories F3, 10691, Stockholm, Sweden
| | - Anna Sandström
- Department of Molecular Biosciences, the Wenner-Gren Institute, Stockholm University, Svante Arrhenius väg 20B, Arrhenius laboratories F3, 10691, Stockholm, Sweden
- Atrogi AB, Stockholm, Sweden
| | | | - Claes-Göran Östenson
- Department of Molecular Medicine and Surgery, Endocrine and Diabetes Unit, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Joris Hoeks
- Department of Nutrition and Movement Sciences, Maastricht University, Maastricht, the Netherlands
| | - Tore Bengtsson
- Department of Molecular Biosciences, the Wenner-Gren Institute, Stockholm University, Svante Arrhenius väg 20B, Arrhenius laboratories F3, 10691, Stockholm, Sweden.
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Hostrup M, Jacobson GA, Jessen S, Lemminger AK. Anabolic and lipolytic actions of beta
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‐agonists in humans and antidoping challenges. Drug Test Anal 2020; 12:597-609. [DOI: 10.1002/dta.2728] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/29/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Morten Hostrup
- Department of Nutrition, Exercise and Sports, Section of Integrative PhysiologyUniversity of Copenhagen Copenhagen Denmark
| | - Glenn A. Jacobson
- School of Pharmacy and Pharmacology, College of Health and MedicineUniversity of Tasmania Hobart Australia
| | - Søren Jessen
- Department of Nutrition, Exercise and Sports, Section of Integrative PhysiologyUniversity of Copenhagen Copenhagen Denmark
| | - Anders Krogh Lemminger
- Department of Nutrition, Exercise and Sports, Section of Integrative PhysiologyUniversity of Copenhagen Copenhagen Denmark
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McNeilly AD, McCrimmon RJ. Impaired hypoglycaemia awareness in type 1 diabetes: lessons from the lab. Diabetologia 2018; 61:743-750. [PMID: 29417183 PMCID: PMC6448989 DOI: 10.1007/s00125-018-4548-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 10/20/2017] [Indexed: 01/28/2023]
Abstract
Hypoglycaemia remains the most common metabolic adverse effect of insulin and sulfonylurea therapy in diabetes. Repeated exposure to hypoglycaemia leads to a change in the symptom complex that characterises hypoglycaemia, culminating in a clinical phenomenon referred to as impaired awareness of hypoglycaemia (IAH). IAH effects approximately 20-25% of people with type 1 diabetes and increases the risk of severe hypoglycaemia. This review focuses on the mechanisms that are responsible for the much higher frequency of hypoglycaemia in people with diabetes compared with those without, and subsequently how repeated exposure to hypoglycaemia leads to the development of IAH. The mechanisms that result in IAH development are incompletely understood and likely to reflect changes in multiple aspects of the counterregulatory response to hypoglycaemia, from adaptations within glucose and non-glucose-sensing cells to changes in the integrative networks that govern glucose homeostasis. Finally, we propose that the general process that incorporates many of these changes and results in IAH following recurrent hypoglycaemia is a form of adaptive memory called 'habituation'.
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Affiliation(s)
- Alison D McNeilly
- Division of Molecular and Clinical Medicine, Mailbox 12, Level 5, Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, UK
| | - Rory J McCrimmon
- Division of Molecular and Clinical Medicine, Mailbox 12, Level 5, Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, UK.
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Naik S, Belfort-DeAguiar R, Sejling AS, Szepietowska B, Sherwin RS. Evaluation of the counter-regulatory responses to hypoglycaemia in patients with type 1 diabetes during opiate receptor blockade with naltrexone. Diabetes Obes Metab 2017; 19:615-621. [PMID: 27987236 PMCID: PMC6015737 DOI: 10.1111/dom.12855] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 11/30/2016] [Accepted: 12/12/2016] [Indexed: 12/16/2022]
Abstract
AIMS Hypoglycaemia is the major limiting factor in achieving optimal glycaemic control in people with type 1 diabetes (T1DM), especially intensively treated patients with impaired glucose counter-regulation during hypoglycaemia. Naloxone, an opiate receptor blocker, has been reported to enhance the acute counter-regulatory response to hypoglycaemia when administered intravenously in humans. The current study was undertaken to investigate the oral formulation of the long-acting opiate antagonist, naltrexone, and determine if it could have a similar effect, and thus might be useful therapeutically in treatment of T1DM patients with a high risk of hypoglycaemia. MATERIALS AND METHODS We performed a randomized, placebo-controlled, double-blinded, cross-over study in which 9 intensively treated subjects with T1DM underwent a 2-step euglycaemic-hypoglycaemic-hyperinsulinaemic clamp on 2 separate occasions. At 12 hours and at 1 hour before the clamp study, participants received 100 mg of naltrexone or placebo orally. Counter-regulatory hormonal responses were assessed at baseline and during each step of the hyperinsulinaemic-clamp. RESULTS Glucose and insulin levels did not differ significantly between the naltrexone and placebo visits; nor did the glucose infusion rates required to keep glucose levels at target. During hypoglycaemia, naltrexone, in comparison with the placebo group, induced an increase in epinephrine levels ( P = .05). However, no statistically significant differences in glucagon, cortisol and growth hormone responses were observed. CONCLUSION In contrast to the intravenous opiate receptor blocker naloxone, overnight administration of the oral long-acting opiate receptor blocker, naltrexone, at a clinically used dose, had a limited effect on the counter-regulatory response to hypoglycaemia in intensively treated subjects with T1DM.
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MESH Headings
- Adult
- Blood Glucose/analysis
- Connecticut/epidemiology
- Cross-Over Studies
- Delayed-Action Preparations/adverse effects
- Delayed-Action Preparations/therapeutic use
- Diabetes Mellitus, Type 1/blood
- Diabetes Mellitus, Type 1/drug therapy
- Double-Blind Method
- Drug Monitoring
- Epinephrine/blood
- Epinephrine/metabolism
- Female
- Glucose Clamp Technique
- Glycated Hemoglobin/analysis
- Humans
- Hypoglycemia/chemically induced
- Hypoglycemia/epidemiology
- Hypoglycemia/prevention & control
- Hypoglycemic Agents/adverse effects
- Hypoglycemic Agents/blood
- Hypoglycemic Agents/pharmacokinetics
- Hypoglycemic Agents/therapeutic use
- Insulin, Regular, Human/adverse effects
- Insulin, Regular, Human/blood
- Insulin, Regular, Human/pharmacokinetics
- Insulin, Regular, Human/therapeutic use
- Male
- Naltrexone/adverse effects
- Naltrexone/therapeutic use
- Nausea/chemically induced
- Risk
- Sensory System Agents/adverse effects
- Sensory System Agents/therapeutic use
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Affiliation(s)
- Sarita Naik
- Department of Internal Medicine and Endocrinology, Yale University School of Medicine, New Haven, Connecticut
- Department of Diabetes and Endocrinology, University College Hospital, London, UK
| | - Renata Belfort-DeAguiar
- Department of Internal Medicine and Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | - Anne-Sophie Sejling
- Department of Internal Medicine and Endocrinology, Yale University School of Medicine, New Haven, Connecticut
- Department of Cardiology, Nephrology and Endocrinology, Nordsjaellands Hospital, Hillerød, Denmark
| | - Barbara Szepietowska
- Department of Internal Medicine and Endocrinology, Yale University School of Medicine, New Haven, Connecticut
- Heart Research Follow-Up Program, University of Rochester Medical Center, Rochester, New York
| | - Robert S Sherwin
- Department of Internal Medicine and Endocrinology, Yale University School of Medicine, New Haven, Connecticut
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