Is daytime insulin more physiologic and less atherogenic than bedtime insulin?

The question is whether bedtime insulin, one of the standard therapy regimens of type 2 diabetes, can be more atherogenic than daytime insulin. There is no study to answer this question. However, pharmacokinetics of drugs and physiopathology of type 2 diabetes are considered, we can assume that daytime OAD plus bedtime insulin therapy might be more atherogenic than daytime insulin plus bedtime OAD therapy. The rationale for combination therapy is based on the assumption that, if evening insulin lowers the fasting glucose concentration to normal, then daytime oral agents will be more effective in controlling postprandial hyperglycemia. However, exogenous insulin administration is not a convenient way to inhibit hepatic glucose production which determines fasting plasma glucose because in post absorptive period, hepatic glucose production is determined by high glucagon and low insulin levels. In postprandial period, beta cell-originated insulin inhibits glucagon synthesis by paracrine effect and also inhibits hepatic glucose production by using half of its concentration that administered to portal system. Since half of insulin that found in portal system is exposed to hepatic clearance to inhibit hepatic glucose production, portal insulin concentration is 2-4-folds higher than peripheral insulin concentration. But, exogenous insulin neither inhibits glucagon synthesis via paracrine effect, nor reaches desired portal concentrations because it has a short half-life and in opposition to physiologic states it is not administered to the portal system. On the contrary, its peripheral concentration is higher than portal one. Thus, exogenous insulin that is used to inhibit hepatic glucose production requires higher concentrations than physiologic values. Eventually, peripheral hyperinsulinemic state which is a risk factor of CVD is created iatrogenically. Bearing in mind that PI3K pathway, working synchronously with the diurnal rhythm of other metabolic hormones, is more active during daytime especially in postprandial period when aminoacids and glucose exist in the environment, and that decreased insulin response in PI3K pathway in diabetics, we may propose iatrogenically created hyperinsulinemia can cause more atherogenic effects via MAPK pathway. For that reason, using OAD instead of bedtime insulin may be a more convenient way to inhibit hepatic glucose production. Thus, glucagon synthesis inhibition can be achieved via paracrine effect of OAD-induced insulin secretion, as well as required portal insulin concentration can be reached by the direct secretion of insulin to the portal system. Moreover, lower peripheral hyperinsulinemia state can be provided.     

Is insulin the new intermittent hypoxia?

The sympathoexcitatory effects of insulin are well-established, although the exact mechanisms by which insulin stimulates the sympathetic nervous system are not completely understood. The majority of research supports a primary role for the central nervous system in the gradual and sustained rise in muscle sympathetic nerve activity (MSNA) in response to hyperinsulinemia; in addition, recent studies in animals suggests carotid body chemoreceptors respond to increases in systemic insulin levels. Intermittent activation of the carotid chemoreceptors, similar to that seen in patients with sleep apnea, can result in sensory long term facilitation and may contribute to the observed rise in baseline MSNA in this population. Consistent with this idea, insulin exposure results in sustained increases in MSNA that persist even when plasma insulin levels return to baseline. We propose the carotid chemoreceptors contribute to insulin-mediated sympathoexcitation and the persistent rise in MSNA in patients with sustained hyperinsulinemia. If the carotid chemoreceptors sense and respond to changes in systemic insulin levels, these organs may provide a viable target for the treatment of disorders known to exhibit sustained hyperinsulinemia and sympathoexcitation including, but not limited to, obesity, hypertension, sleep apnea, metabolic syndrome, cardiovascular disease, and diabetes.     

Coordinated control of both insulin secretion and insulin action through calpain-10-mediated regulation of exocytosis?

Calpain-10 was first identified through a genome scan seeking to identify diabetes predisposition genes. Both genetic and functional data has since indicated that calpain-10 has an important role in insulin resistance and intermediate phenotypes, including those associated with adipocytes and skeletal muscle. Evidence presented in this issue by Brown, Yeaman, and Walker utilizes siRNA technology to specifically knock down calpain-10 expression, and suggests that calpain-10 facilitates GLUT4 translocation through effects on the distal secretory pathway. Calpain-10 is also an important molecule in the pancreatic β-cell, where it has been shown to regulate exocytosis through partial proteolysis of a member of the secretory granule fusion machinery. In addition, calpain-10 has also been implicated in reorganization of the actin cytoskeleton that accompanies both GLUT4 vesicle translocation and insulin secretion. Taken together, these findings provide fresh hope for the development of novel diabetic treatments, utilizing either pharmacological activators that specifically target calpain-10, or through targeted calpain-10 gene therapy. Therapeutic intervention in this way could simultaneously enhance both insulin secretion and insulin action.     

Is myopia another clinical manifestation of insulin resistance?

Myopia is a multifactorial visual refraction disease, in which the light rays from distant objects are focused in front of retina, causing blurry vision. Myopic eyes are characterized by an increased corneal curvature and/or ocular axial length. The prevalence of myopia has increased in recent decades, a trend that cannot be attributed exclusively to genetic factors. Low and middle income countries have a higher burden of refractive error, which we propose could be a consequence of a shorter exposure time to a westernized lifestyle, a phenomenon that may also explain the rapid increase in cardiometabolic diseases, such as diabetes, among those populations. We suggest that interactions between genetic, epigenetic and a rapidly changing environment are also involved in myopia onset and progression. Furthermore, we discuss several possible mechanisms by which insulin resistance may promote abnormal ocular growth and myopia to support the hypothesis that insulin resistance and hyperinsulinemia are involved in its pathogenesis, providing a link between trends in myopia and those of cardiometabolic diseases. There is evidence that insulin have direct ocular growth promoting effects as well an indirect effect via the induction of insulin-like growth factors leading to decreases insulin-like growth factor-binding protein, also implicated in ocular growth.     

Polyelectrolyte multilayer films: A sponge for insulin?

Considering restrictive diabetes treatments, new insulin administration strategies constitute a huge medical challenge. This study aimed at developing a new support for insulin reservoirs, using polyelectrolyte multilayer films (PEM films), and thus studying this hormone release in a progressive manner. At first, insulin was loaded in (PDADMAC-PAA)n films, by immerging them for various periods of time (2, 14 and 24 h) in a solution containing this protein. Confocal laser scanning microscopy (CLSM) revealed that insulin-FITC could diffuse inside the film with a bigger concentration in the upper part of the film (after 2 and 14 h in contact with the polypeptide solution), and then in the whole film (after 24 h) from a solution at pH=4.3 (below insulin's isolelectric point). Environmental scanning electron microscopy (ESEM) and CLSM showed that the film swells upon insulin loading. We finally investigated the insulin release by ATR-FTIR spectroscopy. It revealed that a loaded (PDADMAC-PAA)15 film, immerged in distilled water, showed no measurable insulin release. In contrast, a slow unloading was observed in the presence of a NaCl 0.15 M solution (salinity close to physiological serum). This study could open the route for a new way of insulin delivery.     

Does insulin resistance cause atherosclerosis in the post-prandial period?

Insulin resistance would appear to be a causal factor for the development of early occlusive atherosclerosis. This paper proposes that post-prandial insulin resistance, in association with raised levels of cortisol and catecholamines, plays the major role, and may even be the primary causative factor. Therefore, factors that lead to insulin resistance in the post-prandial period, specifically stress, will accelerate the development of CHD. This may explain the low rate of CHD in France, as their eating habits (in common with many other Mediterranean countries) are more relaxed than those in Northern Europe.     

Novel iron–polysaccharide multilayered microcapsules for controlled insulin release

Iron–polysaccharide complexes have been extensively used for the treatment of iron-deficiency anemia without side-effects. In this study, insulin-loaded microcapsules were prepared via layer-by-layer deposition of oppositely charged Fe³⁺ and dextran sulfate (DS) onto the surface of insulin microparticles. Fe³⁺ was combined with DS via both electrostatic interaction and chemical complexation process, leading to the formation of a stable complex of Fe³⁺/DS. Subsequently, protamine was used as the outermost layer of the insulin-loaded microcapsules to facilitate nuclear delivery. The sufficient charge reversal with successive deposition cycles and successful fabrication of hollow microcapsules provided strong evidence for the growth of (Fe³⁺/DS)_n multilayer on the surface of microparticles. The experiments showed that the microcapsules successfully entrapped insulin with encapsulation efficiency of 70.56 ± 0.97% and drug loading content of 46.15 ± 0.97%. It was found that the release time and hypoglycemic effect increased as the number of deposited bilayers increased. The insulin-loaded microcapsules significantly improved glucose tolerance from 2 h (free insulin) to even 12 h (insulin-loaded microcapsules with 10 bilayers). Moreover, the microcapsules with protamine as the outermost layer displayed a prolonged and stable glucose-lowering profile over a period of over 6 h compared with Fe³⁺ as the outermost layer. These findings indicate that such microcapsules can be a promising approach for the construction of an effective controlled release delivery system of insulin as well as other proteins with short half-life time.     

Orexin and adiponectin in high fat diet–induced insulin resistance

Orexin A (OXA) is a hypothalamic neuropeptide with both central and peripheral activities on insulin signaling and energy balance. Adiponectin is an adipocytokine which regulates metabolisms of lipid and glucose via its receptors AdipoR1 and AdipoR2. This study investigated immunohistochemical changes in expressions of OXA, its receptor OX1R in pancreas and AdipoR1 in skeletal muscle with a high fat diet (HFD)-induced insulin resistance (IR). Standard 45% fat and 60% fat diets were administered to Wistar rats for 3 and 8 w. OXA expression increased with both 3- and 8-w 45% fat diets. OX1R expression also increased with a 3-w 45% fat diet, but decreased with the 3-w 60% fat diet. OXA, OX1R, and AdipoR1 expressions decreased with a 8-w 60% fat diet. An early adaptation in context of OXA was observed in pancreas β-cell to HFD-induced IR. OXA, OX1R, and AdipoR1 expressions decreased with either the higher amount or longer duration of HFD consumption.     

REG3α gene promotes insulin secretion by pancreatic endothelial cells

目的 探讨小鼠胰岛再生衍生因子3α( REG3α)对胰岛β细胞功能代偿作用.方法 建立小鼠部分(90％)胰腺切除模型,分别于术前、术后12和24h检测血糖,术后48 h收集小鼠剩余胰腺组织,经全基因组芯片分析、q-PCR验证REG3α表达;然后构建REG3α过表达质粒,转染MS1细胞系,48 h后ELISA检测细胞上清培养液胰岛素分泌量的变化,并通过q-PCR检测转染后MS1中PDX1、INSULIN2 mRNA表达水平.结果 小鼠部分胰腺切除后REG3α发生高表达.转染REG3α过表达质粒组胰岛素分泌量显著高于未转染组(转染REG3α组879±2 ng/L,未转染组686±5 ng/L,P＜0.01);转染REG3α过表达质粒组胰岛素分泌量显著高于转染空载体pcDNA3.1组(转染REG3α组879±2 ng/L,转染空载体组671±5 ng/L,P＜0.01).转染REG3α过表达质粒后MS1中的PDX1、INSULIN2mRNA表达水平明显高于未转染组及转染空载体pcDNA3.1组(P＜0.01).结论 REG3α促进内皮细胞表达和分泌胰岛素可能具有对胰岛β细胞功能代偿作用.     

Symptoms of hypoglycemia — A comparison between porcine and human insulin

Summary For more than 2 years now it has been controversially debated whether awareness of hypoglycemia is reduced when type I diabetic patients are switched from porcine to human insulin. In order to address this question, we studied nine C-peptide negative diabetics (age 27.6 years, Broca index 106%, duration of diabetes 5.7 years, HbA₁, 8.8%) in comparison with eight healthy volunteers (age 22.4 years, Broca index 104%). Following euglycemic monitoring overnight, a controlled hypoglycemia was induced by altering the algorithms of the Biostator. This was done in a double-blind, cross-over fashion using porcine or human insulin on 2 nonconsecutive days. There were no differences between the results obtained with respect to the time course of the study, blood glucose, amount of insulin infused, and concentration of venous free insulin achieved. Of the nine diabetics, eight were aware of hypoglycemia at a higher blood glucose level under porcine insulin. The first symptom of hypoglycemia was percieved at a mean blood glucose level of 61.1±5.4 mg/dl under porcine insulin and of 44.4 ± 5.3 mg/dl under human insulin (P0.05). Thirty symptoms were noted under porcine insulin exclusively or preferentially as opposed to only eight which were observed exclusively or preferentially under human insulin. The healthy volunteers evidenced fewer symptoms at lower blood glucose concentrations than the diabetics. The clear difference between human and porcine insulin could not unequivocally be reproduced in this group. We conclude that type I diabetic patients, who are maintained on a treatment regimen with human insulin, perceive symptoms of hypoglycemia at higher blood glucose concentrations when hypoglycemia is induced by porcine insulin as compared with human insulin. As every single patient and healthy volunteer was aware of at least one symptom of hypoglycemia under both insulins, it is possible to react appropriately to counteract this situation. Nevertheless, diabetic patients should be informed about this phenomenon.Abbreviations P porcine insulin - H human insulin - IU international units Supported by Nordisk Deutschland     

Is fasting insulin associated with blood pressure in obese children?

PRIMARY OBJECTIVE: We tested whether fasting insulin levels are associated with blood pressure in a large sample of obese children. SUBJECTS AND METHODS: Three hundred and fifty obese children (F:M ratio = 1.03) of 10.1 +/- 2.7 y of age (mean +/- SD) were consecutively enrolled at an Outpatient Paediatric Clinic. Obesity was diagnosed on the basis of a relative weight for age > 120% and hypertension on the basis of a systolic (SBP) or diastolic (DBP) blood pressure > 95th percentile for age after adjustment for height (Ht). MAIN OUTCOME AND RESULTS: Insulin was significantly higher in hypertensive (n = 202, 58%) than normotensive (n = 148, 42%) children (16 vs 14 microU mL(-1), geometric mean, p < 0.01, ANOVA) but the difference was not clinically relevant. Moreover, (log-transformed) insulin explained only 7 and 4% of SBP and DBP variance, respectively (p < 0.0001 for both) and this contribution disappeared after the confounding effects of age, weight or other anthropometric dimensions were taken into account (p = ns, ANCOVA). CONCLUSIONS: This study does not support the hypothesis of a clinically relevant association between fasting insulin and blood pressure in obese children.     

Can the glyoxylate pathway contribute to fat-induced hepatic insulin resistance?

Recent studies have shown that increased hepatic gluconeogenesis is the predominant contributor to fasting hyperglycemia - the hallmark of type 2 diabetes. Although it has been known for a long time that over-supply of fat is able to stimulate gluconeogenesis both in-vitro and in-vivo, neither the leading substrate nor the mechanism responsible for this phenomenon have been fully identified. Recent observations that the glyoxylate pathway may exist in animals has shed light on this question. The glyoxylate pathway is able to convert fatty acid into glucose but has been thought to be absent in animals. Although further evidence is needed, current available data does suggest a possible mechanism which, by integrating both glucose and lipid metabolism together rather than interpreting them separately, may explain the role of fatty acids in hepatic insulin resistance. This hypothesis is based on current understanding of insulin resistance and supported by many laboratory observations.     

Lipid-mediated muscle insulin resistance: different fat,different pathways?

Increased dietary fat intake and lipolysis result in excessive lipid availability, which relates to impaired insulin sensitivity. Over the last years, several mechanisms possibly underlying lipid-mediated insulin resistance evolved. Lipid intermediates such as diacylglycerols (DAG) associate with changes in insulin sensitivity in many models. DAG activate novel protein kinase C (PKC) isoforms followed by inhibitory serine phosphorylation of insulin receptor substrate 1 (IRS1). Activation of Toll-like receptor 4 (TLR4) raises another lipid class, ceramides (CER), which induce pro-inflammatory pathways and lead to inhibition of Akt phosphorylation. Inhibition of glucosylceramide and ganglioside synthesis results in improved insulin sensitivity and increased activatory tyrosine phosphorylation of IRS1 in the muscle. Incomplete fat oxidation can increase acylcarnitines (ACC), which in turn stimulate pro-inflammatory pathways. This review analyzed the effects of lipid metabolites on insulin action in skeletal muscle of humans and rodents. Despite the evidence for the association of both DAG and CER with insulin resistance, its causal relevance may differ depending on the subcellular localization and the tested cohorts, e.g., athletes. Nevertheless, recent data indicate that individual lipid species and their degree of fatty acid saturation, particularly membrane and cytosolic C18:2 DAG, specifically activate PKCθ and induce both acute lipid-induced and chronic insulin resistance in humans.     

Obstructive sleep apnea and insulin resistance: a role for microcirculation?

Obstructive sleep apnea is an increasingly recognized medical problem. The recent attention to its frequency in the general population and its important role in metabolic, vascular, and behavioral aspects have sharply increased the number and nature of investigations, thereby revealing new aspects that open new approaches in research. Whereas obstructive sleep apnea is a well-known phenomenon accompanying obesity and diabetes, new findings strongly suggest that this close relationship may also operate in the opposite direction. Indeed obstructive sleep apnea may be a primary feature inducing or aggravating a series of vascular and metabolic disturbances closely resembling the metabolic syndrome. This review will discuss established and potential mechanisms responsible for these changes. Obstructive sleep apnea indeed appears to gather all the elements necessary to induce insulin resistance, hypertension, and possibly heart failure. After careful analysis of these modifications and considering how they are intertwined, we propose that microcirculation could represent the common denominator mediating the progression of this pathology, as it is eventually the case in the metabolic syndrome and diabetes domain. This plausible hypothesis is discussed in detail and should be verified by appropriate preclinical and clinical protocols, which are now achievable by using noninvasive techniques in humans.     

Does the mechanism responsible for TNF-mediated insulin resistance involve the proteasome?

Recent studies have demonstrated that in many pathological states there is an overproduction of tumour necrosis factor-alpha (TNF). Interestingly, TNF also seems to be responsible for the insulin resistance associated with these pathological states, since decreases the tyrosine kinase activity of the insulin receptor. Our group has demonstrated that TNF is able to activate the proteasome-mediated ubiquitin-dependent proteolysis. Since this proteolytic system is involved in the control of receptor-associated tyrosine kinase activity (i.e. insulin receptor), it is postulated here that the mechanism of TNF-induced insulin resistance is mediated by the activation of the proteasomic, ubiquitin-dependent proteolysis.     

Interaction effect between common polymorphisms in PPARγ2 (Pro12Ala) and insulin receptor substrate 1 (Gly972Arg) on insulin sensitivity

The Pro12Ala polymorphism in the peroxisome proliferator-activated receptor (PPAR) gamma2 gene is associated with a reduced risk of type 2 diabetes. A beneficial effect on insulin sensitivity is reported in some but not all populations. It is possible that this genetic variant produces a characteristic phenotype only against a certain genetic background. We therefore tested the hypothesis that carriers of the Ala allele of PPARgamma2 exhibit a different phenotype against the background of the Gly972Arg polymorphism in the insulin receptor substrate (IRS) 1. We determined insulin sensitivity in the four combinations defined by the absence or presence of the polymorphic allele (healthy, glucose tolerant subjects), by the oral glucose tolerance test (OGTT; using a validated index, n=318) and hyperinsulinemic clamp ( n=201). Insulin sensitivity was not or was only marginally different between Pro/Pro and X/Ala in the overall population. Interestingly, using the OGTT index, insulin sensitivity was significantly greater in X/Ala (PPARgamma2) + X/Arg (IRS-1) than in Pro/Pro (PPARgamma2) + X/Arg (IRS-1). On the other hand, insulin sensitivity was similar in the X/Ala (PPARgamma2) + Gly/Gly (IRS-1 972) and the Pro/Pro (PPARgamma2) + Gly/Gly (IRS-1). The results were practically identical using insulin sensitivity from the clamp. In conclusion, the Arg972 (IRS-1) background produced a marked difference in insulin sensitivity between X/Ala and Pro/Pro (PPARgamma) which was not present in the whole population or against the Gly972 (IRS-1) background. This suggests that the Ala allele of PPARgamma2 becomes particularly advantageous against the background of an additional, possibly disadvantageous genetic polymorphism. Allowing for gene-gene interaction effects may reveal novel information regarding metabolic effects of genetic variants.     

Nestin、CK19及insulin等在胚胎胰腺发育中的表达

目的:研究Nestin、CK19、胰岛素、胰高血糖素及生长抑素在胚胎胰腺发育中的表达,探讨胰岛细胞分化发育的机制。方法:采用免疫组化SABC法及免疫组化双染法(LAB SA),对30例6～14wk人胚胎胰腺中,Nestin、CK19、胰岛素,胰高血糖素及生长抑素阳性的细胞进行定位。结果:(1)胚胎胰腺发育中Nestin阳性细胞存在于胰腺的间质,数量极少;CK19在胰腺导管上皮分化中持续表达,呈强阳性;(2)7wk胰腺导管上皮开始分化出胰岛细胞,胰岛素、胰高血糖素及生长抑素表达阳性,三者的表达并无时段差异性;随着胎龄的增加,阳性细胞数增加,14wk时胰岛逐渐形成,表达达到高峰。结论:胚胎胰腺的发育中,胰腺间质存在胰腺干细胞;胚胎早期胰腺导管上皮细胞开始分化并分泌胰岛素,其自分泌的激素可能参与调节胰岛细胞的迁移和胰岛的形成。     

Pulsatile intravenous insulin therapy: The best practice to reverse diabetes complications?

In the basal state and after oral ingestion of carbohydrate, the normal pancreas secretes insulin into the portal vein in a pulsatile manner. The end organ of the portal vein is the liver, where 80% of pancreatic insulin is extracted during first pass. In Type 1 diabetes, pancreatic insulin secretion is nearly or completely absent whilst in Type 2 diabetes the normal pattern is absent, abnormal, or blunted. Exogenous subcutaneous insulin treatment results in plasma insulin concentrations that are not pulsatile and a fraction of normal portal vein levels. Oral hypoglycemic agents also do not result in normal pulsatile response to a glucose load. Due to hypoglycemia risk, intensive treatment is not recommended after serious complications develop. Consequently, no conventional therapy has proved effective in treating advanced diabetes complications. Beta-cell replacement using whole pancreas or islet transplantation has been utilized to treat certain problems in Type 1 diabetic patients, but still unavailable for all diabetics. Pulsatile intravenous insulin therapy (PIVIT) is an insulin therapy, which mimics the periodicity and amplitude of normal pancreatic function. Numerous studies show PIVIT effective in preventing, reversing, and reducing the severity and progression of diabetes complications, however, the mechanisms involved with the improvement are not clearly understood. Here, we review the cellular basis of normal and abnormal insulin secretion, current treatments available to treat diabetes, the physiologic basis of PIVIT and possible mechanisms of action.