Download Glucose - The Stephens Lab

Hormones of the Pancreas
bulk of the pancreas is an exocrine gland secreting
Endocrine pancreas
Scattered through the pancreas are several hundred thousand
clusters of cells called
islets of Langerhans.
The islets are endocrine tissue containing 4 types of cells.
In order of abundance, they are the:
b cells-secrete insulin and amylin;
a cells- secrete glucagon;
d cells-secrete somatostatin
 cells-secrete a polypeptide of unknown function.
(36 aa and plays a role in food intake)
The endocrine portion of the
pancreas takes the form of
many small clusters of cells
called islets of Langerhans or,
more simply, islets.
Humans have roughly
one million islets.
In standard histological sections
of the pancreas, islets are seen
as relatively pale-staining
groups of cells embedded in a
sea of darker-staining
exocrine tissue. The image to
the right shows 3 islets in a
horse pancreas.
Interestingly, the different cell types within
an islet are not randomly distributed –
beta cells occupy the central portion of the
islet and are surrounded by a "rind" of a
and d cells.
Aside from the insulin, glucagon and
somatostatin, a number of other "minor"
hormones have been identified as products
of pancreatic islets cells.
Islets are richly vascularized, allowing their
secreted hormones ready access to the
circulation.
Although islets comprise only 1-2% of the
mass of the pancreas, they receive about 10
to 15% of the pancreatic blood flow.
Additionally, they are innervated by
parasympathetic and sympathetic neurons,
and nervous signals clearly modulate
secretion of insulin and glucagon.
Insulin Synthesis and Secretion
Structure of Insulin
Insulin is a rather small protein, with a molecular weight of about
6000 Daltons.
composed of 2 chains held together by disulfide bonds.
The figure shows a molecular model of bovine insulin, with the A
chain colored blue and the larger B chain green.
The amino acid sequence is highly
conserved among vertebrates, and
insulin from one mammal almost
certainly is biologically active in
another. For years diabetic patients
were treated with insulin extracted
from pig or cow pancreases.
Biosynthesis of Insulin
Insulin is synthesized in significant quantities only in b cells in the
pancreas.
The insulin mRNA is translated as a single chain precursor called
preproinsulin, and removal of its signal peptide during insertion
into the endoplasmic reticulum generates proinsulin.
Proinsulin consists of three domains: an amino-terminal B chain, a
carboxy-terminal A chain and a connecting peptide in the middle
known as the C peptide.
Within the endoplasmic reticulum, proinsulin is exposed to several
specific endopeptidases which excise the C peptide, thereby
generating the mature form of insulin.
Insulin and free C peptide are packaged in the Golgi into secretory
granules which accumulate in the cytoplasm.
Since insulin was
discovered in 1921,
it has become one
of the most
thoroughly
studied molecules in
scientific history.
Control of Insulin Secretion
Insulin is secreted in primarily in response to elevated blood
concentrations of glucose.
This makes sense because insulin is "in charge" of facilitating
glucose entry into cells.
Some neural stimuli (e.g. site and taste of food) and increased blood
concentrations of other fuel molecules, including amino acids and
fatty acids, also WEAKLY promote insulin secretion.
Our understanding of the mechanisms behind insulin secretion
remain somewhat fragmentary.
Nonetheless, certain features of this process have been clearly and
repeatedly demonstrated, yielding the following model:
Control of Insulin Secretion
Glucose is transported into the b cell by facilitated
diffusion through a glucose transporter; elevated
concentrations of glucose in extracellular fluid
lead to elevated concentrations of glucose within
the b cell.
Elevated concentrations of glucose within the b
cell ultimately leads to membrane depolarization
and an influx of extracellular calcium. The
resulting increase in intracellular calcium is
thought to be one of the primary triggers for
exocytosis of insulin-containing secretory
granules.
Control of Insulin Secretion
The mechanisms by which elevated glucose levels within
the b cell cause depolarization is not clearly established,
but seems to result from metabolism of glucose and
other fuel molecules within the cell, perhaps sensed as
an alteration of ATP:ADP ratio and transduced into
alterations in membrane conductance.
Increased levels of glucose within b cells also appears to
activate calcium-independent pathways that participate
in insulin secretion.
Control of Insulin Secretion
Stimulation of insulin release is readily
observed in whole animals or people. The
normal fasting blood glucose concentration
in humans and most mammals is 80-90 mg
per 100 ml, associated with very low levels
of insulin secretion.
Control of Insulin Secretion
The figure depicts the effects on insulin
secretion when enough glucose is
infused to maintain blood levels 2-3
times the fasting level for an hour.
Almost immediately after the infusion
begins, plasma insulin levels increase
dramatically. This initial increase is
due to secretion of preformed insulin,
which is soon significantly depleted.
The secondary rise in insulin reflects
the considerable amount of newly
synthesized insulin that is released
immediately. Clearly, elevated glucose
not only simulates insulin secretion, but
also transcription of the insulin gene
and translation of its mRNA.
Physiologic Effects of Insulin
Stand on a streetcorner and ask people if they know what
insulin is, and many will reply, "Doesn't it have
something to do with blood sugar?"
Indeed, that is correct, but such a response is a bit like saying
"Mozart? Wasn't he some kind of a musician?"
Insulin is a key player in the control of intermediary
metabolism. It has profound effects on both
carbohydrate and lipid metabolism, and significant
influences on protein and mineral metabolism.
Consequently, derangements in insulin signalling have
widespread and devastating effects on many organs and
tissues.
Physiologic Effects of Insulin
The Insulin Receptor (IR) and Mechanism of
Action
Like the receptors for other protein hormones, the
receptor for insulin is embedded in the PM
The IR is composed of 2 alpha subunits and 2 beta
subunits linked by S-S bonds. The alpha chains
are entirely extracellular and house insulin
binding domains, while the linked beta chains
penetrate through the PM.
The IR is a tyrosine kinase.
it functions as an enzyme that
transfers phosphate groups
from ATP to tyrosine residues
on target proteins. Binding of
insulin to the alpha subunits
causes the beta subunits to
phosphorylate themselves
(autophosphorylation), thus
activating the catalytic activity
of the receptor. The activated
receptor then phosphorylates a
number of intracellular
proteins, which in turn alters
their activity, thereby
generating a biological response.
Physiologic Effects of Insulin
Several intracellular proteins have been identified
as phosphorylation substrates for the insulin
receptor, the best-studied of which is
Insulin receptor substrate 1 or IRS-1.
When IRS-1 is activated by phosphorylation, a lot
of things happen. Among other things, IRS-1
serves as a type of docking center for
recruitment and activation of other enzymes that
ultimately mediate insulin's effects.
Physiologic Effects of Insulin
Insulin and Carbohydrate Metabolism
Glucose is liberated from dietary carbohydrate such as
starch or sucrose by hydrolysis within the SI, and is
then absorbed into the blood.
Elevated concentrations of glucose in blood stimulate
release of insulin, and insulin acts on cells thoughout
the body to stimulate uptake, utilization and storage of
glucose.
Physiologic Effects of Insulin
Two important effects are:
Insulin facilitates entry of glucose into muscle, adipose and several
other tissues.
The only mechanism by which cells can take up glucose is by
facilitated diffusion through a family of glucose transporters.
LARGELY FAT and SKELETAL MUSCLE
Physiologic Effects of Insulin
Two important effects are:
In many tissues - muscle being a prime example - the major
transporter used for uptake of glucose (called GLUT4) is made
available in the plasma membrane through the action of insulin.
In the absense of insulin, GLUT4 glucose transporters are
present in cytoplasmic vesicles, where they are useless for
transporting glucose. Binding of insulin to IR on such cells leads
rapidly to fusion of those vesicles with the plasma membrane and
insertion of the glucose transporters, thereby giving the cell an
ability to efficiently take up glucose.
When blood levels of insulin decrease and insulin receptors are no
longer occupied, the glucose transporters are recycled back into
the cytoplasm.
Family of Glucose transport proteins
Uniporters-transfer one molecule at a time
Facillitated diffusion
Energy indepednent
GLUT1- found on PM every single cell in your body for
glucose uptake
GLUT2-liver transporter, also found in b cells
GLUT3- fetal transporter
GLUT4- insulin sensitive glucose transporter
GLUT5GLUT7
NOT to be confused with Na+glucose transporter in lumen
of SI which is a symporter, couple the movement of
glucose (against) with Na+ (with gradient)
GLUT1-glucose
transporter on the
plasma membrane
of every cell in your
body
Glucose
Glucose
= GLUT1
Glucose
Glucose
Cytoplasm
Nucleus
Glucose
GLUT4-a tissue specific insulin
sensitive glucose transporter
Glucose
= GLUT1
Glucose
= GLUT4
Glucose
Glucose
Glucose
Glucose
Glucose
Fat and Skeletal Muscle Cells have
GLUT4
Nucleus
Glucose
INSULIN
= GLUT1
= GLUT4
Glucose
Insulin binds its cell
surface receptor
Glucose
GLUT4 vesicles
travel
to PM
Nucleus
INSULIN
Glucose
= GLUT1
= GLUT4
Glucose
Glucose
Glucose
Glucose
Glucose
Lots of
glucose
inside cell
Nucleus
What tissue uses
the most
glucose??
Very important that
glucose is in cells
and not in blood
Hyperglycemiahigh blood glucose
What tissue uses
the most
glucose??
In the absense of insulin, GLUT4 glucose
transporters are present in cytoplasmic vesicles,
where they are useless for transporting glucose.
Binding of insulin to receptors on such cells
leads rapidly to fusion of those vesicles with the
plasma membrane and insertion of the glucose
transporters, thereby giving the cell an ability to
efficiently take up glucose. When blood levels of
insulin decrease and insulin receptors are no
longer occupied, the glucose transporters are
recycled back into the cytoplasm.
I- IR-IRS1-PI3K-AKT(PKB)-glut 4
INSULIN TALK TO LIVER TO SUPPRESS HGO
Hepatic glucose output
GLUT2 is the liver transporter
Insulin stimulates the liver to store glucose in the
form of glycogen. Some glucose absorbed from
the SI is immediately taken up by hepatocytes,
which convert it into the storage polymer
glycogen.
Insulin has several effects in liver which stimulate glycogen
synthesis.
First, it activates the enzyme hexokinase, which
phosphorylates glucose, trapping it within the cell.
Coincidently, insulin acts to inhibit the activity of glucose6-phosphatase.
Insulin also activates several of the enzymes that are
directly involved in glycogen synthesis, including
phosphofructokinase and glycogen synthase.
The net effect is clear: when the supply of glucose is
abundant, insulin "tells" the liver to bank as much of it
as possible for use later.
well-known effect of insulin is to decrease the concentration of
glucose in blood
Another important consideration is that, as blood glucose
concentrations fall, insulin secretion ceases.
In the absense of insulin, a bulk of the cells in the body become
unable to take up glucose, and begin a switch to using
alternative fuels like fatty acids for energy. Neurons, however,
require a constant supply of glucose, which in the short term, is
provided from glycogen reserves.
In the absense of insulin, glycogen synthesis in the liver ceases and
enzymes responsible for breakdown of glycogen become active.
Glycogen breakdown is stimulated not only by the absense of
insulin but by the presence of glucagon which is secreted when
blood glucose levels fall below the normal range.
Insulin and Lipid Metabolism
The metabolic pathways for utilization of fats
and carbohydrates are deeply and
intricately intertwined.
Considering insulin's profound effects on
carbohydrate metabolism, it stands to
reason that insulin also has important
effects on lipid metabolism.
Insulin and Lipid Metabolism
Notable effects of insulin on lipid metabolism include the following:
Insulin promotes synthesis of fatty acids in the liver. As discussed
above, insulin is stimulatory to synthesis of glycogen in the liver.
However, as glycogen accumulates to high levels (roughly 5% of
liver mass), further synthesis is strongly suppressed.
When the liver is saturated with glycogen, any additional glucose
taken up by hepatocytes is shunted into pathways leading to
synthesis of fatty acids, which are exported from the liver as
lipoproteins. The lipoproteins are ripped apart in the circulation,
providing free fatty acids for use in other tissues, including
adipocytes, which use them to synthesize triglyceride.
Insulin and Lipid Metabolism
Insulin promotes synthesis of
fatty acids in the liver.
When the liver is saturated
with glycogen, any additional
glucose taken up by
hepatocytes is shunted into
pathways leading to synthesis
of fatty acids, which are
exported from the liver as
lipoproteins. The lipoproteins
are ripped apart in the
circulation, providing free
fatty acids for use in other
tissues, including adipocytes,
which use them to synthesize
triglyceride.
Insulin and Lipid Metabolism
Insulin inhibits breakdown of fat in
adipose tissue by inhibiting the
intracellular lipase that
hydrolyzes triglycerides to release
fatty acids.
Insulin facilitates entry of glucose
into adipocytes, and within those
cells, glucose can be used to
synthesize glycerol. This glycerol,
along with the fatty acids
delivered from the liver, are used
to synthesize triglyceride within
the adipocyte. By these
mechanisms, insulin is involved in
further accumulation of
triglyceride in fat cells.
INSULIN IN AN ANABOLIC HORMONE
From a whole body perspective, insulin has a fatsparing effect. Not only does it drive most cells to
preferentially oxidize carbohydrates instead of
fatty acids for energy, insulin indirectly
stimulates accumulation of fat is adipose tissue.
Other Notable Effects of Insulin (I)
In addition to insulin's effect on entry of glucose into
cells, it also stimulates the uptake of amino acids,
again contributing to its overall anabolic effect.
When I levels are low, as in the fasting state, the
balance is pushed toward intracellular protein
degradation.
Insulin also increases the permiability of many cells
to K+, magnesium and phosphate ions.
The effect on K+ is clinically important. Insulin
activates Na+ K+ ATPases in many cells, causing
a flux of K+ into cells. Under some circumstances,
injection of insulin can kill patients because of its
ability to acutely suppress plasma [K+]
Review
Insulin made in the beta cells
Has actions on fat and skeletal muscle to increase glucose
uptake and actions on liver
to inhibit HGO.
MAINTAIN GLUCOSE HOMEOSTASIS
Action of other Endocrine Hormones
Besides Insulin
Insulin-shuts down HGO
When liver is saturated with glyogen, used for
fatty acid synthesis in form of lipoproteins
which are secreted.
Lipid from these lipoproteins get stored in
fat.
Insulin also acts directly on fat to increase
glucose uptake and inhibit FA breakdown
Glucagon
Glucagon has a major role in maintaining normal
concentrations of glucose in blood, and is often
described as having the opposite effect of insulin. So, it
increases blood glucose levels.
Glucagon is a linear peptide of 29 aa.
Its primary sequence is almost perfectly conserved among
vertebrates, and it is structurally related to the secretin
family of peptide hormones.
Glucagon
Glucagon is synthesized as proglucagon and proteolytically
processed to yield glucagon within alpha cells of the
pancreatic islets.
Proglucagon is also expressed within the intestinal tract,
where it is processed not into glucagon, but to a family
of glucagon-like peptides (enteroglucagon).
Physiologic Effects of Glucagon
The major effect of glucagon is to stimulate an
increase in blood concentration of glucose.
The brain in particular has an absolute dependence
on glucose as a fuel, because neurons cannot
utilize alternative energy sources like fatty acids
to any significant extent.
When blood levels of glucose begin to fall below the
normal range, it is imperative to find and pump
additional glucose into blood. Glucagon exerts
control over two pivotal metabolic pathways
within the liver, leading that organ to dispense
glucose to the rest of the body:
Glucagon stimulates breakdown of glycogen
stored in the liver.
When blood glucose levels are high, glucose is
taken up by the liver. Under the influence
of insulin, much of this glucose is stored in
the form of glycogen. Later, when blood
glucose levels begin to fall, glucagon is
secreted and acts on hepatocytes to activate
the enzymes that depolymerize glycogen
and release glucose.
Glucagon activates hepatic gluconeogenesis.
Gluconeogenesis is the pathway by which nonhexose substrates such as amino acids are
converted to glucose.
As such, it provides another source of glucose for
blood.
HGO
This is especially important in animals like cats and sheep
that don't absorb much if any glucose from the intestine
- in these species, activation of gluconeogenic enzymes is
the chief mechanism by which glucagon does its job.
Breakdown glycogen
Increase gluconeogenesis
Glucagon also appears to have a minor effect of
enhancing lipolysis of triglyceride in adipose
tissue, which could be viewed as an addition
means of conserving blood glucose by providing
fatty acid fuel to most cells.
Control of Glucagon Secretion
So glucagon's major effect is to increase
blood glucose levels-it makes sense that
glucagon is secreted in response to
hypoglycemia or low blood
concentrations of glucose.
Disease States
Diseases associated with excessively high or low secretion
of glucagon are rare.
Cancers of alpha cells (glucagonomas) are one situation known to
cause excessive glucagon secretion. These tumors typically lead to
a wasting syndrome and, interestingly, rash and other skin
lesions.
Although insulin deficiency is clearly the major defect in type 1
diabetes mellitus, there is considerable evidence that aberrant
secretion of glucagon contributes to the metabolic derangements
seen in this important disease.
For example, many diabetic patients with hyperglycemia also have
elevated blood concentrations of glucagon, but glucagon
secretion is normally suppressed by elevated levels of blood
glucose.
Control of Glucagon Secretion
Two other conditions are known to trigger glucagon secretion:
Elevated blood levels of amino acids, as would be seen after consumption
of a protein-rich meal: In this situation, glucagon would foster
conversion of excess aa to glucose by enhancing gluconeogenesis.
Since high blood levels of amino acids also stimulate insulin release,
this would be a situation in which both insulin and glucagon are
active.
Exercise: In this case, it is not clear whether the actual stimulus is exercise
per se, or the accompanying exercise-induced depletion of glucose.
In terms of negative control, glucagon secretion is inhibited by high
levels of blood glucose. It is not clear whether this reflects a direct
effect of glucose on the alpha cell, or perhaps an effect of insulin,
which is known to dampen glucagon release.
Another hormone well known to inhibit glucagon secretion is
somatostatin.
Compare Insulin knockout mice
to glucagon knock out mice
Somatostatin
Somatostatin was first discovered in hypothalamic extracts and
identified as a hormone that inhibited secretion of GH.
Subsequently, SS was found to be secreted by a broad range of
tissues, including pancreas, intestinal tract and regions of the
central nervous system outside the hypothalamus.
Structure and Synthesis
Two forms of somatostatin are synthesized.
They are referred to as SS-14 and SS-28, reflecting their aa length.
Both forms of SS are generated by proteolytic cleavage of
prosomatostatin, which itself is derived from preprosomatostatin.
Two cysteine residues in SS-14 allow the peptide to form an internal
disulfide bond.
Somatostatin
The relative amounts of SS-14 vs. SS-28 secreted
depends upon the tissue.
SS-14 is the predominant form produced in the
nervous system and the sole form secreted from
pancreas, whereas the intestine secretes mostly
SS-28.
In addition to tissue-specific differences in secretion
of SS-14 and SS-28, the two forms of this
hormone can have different biological potencies.
SS-28 is roughly 10X more potent in inhibition of
GH secretion, but less potent that SS-14 in
inhibiting glucagon release.
Somatostatin
Receptors and Mechanism of Action
Five somatostatin receptors have been identified and
characterized, all of which are members of the G
protein-coupled receptor superfamily.
Each of the receptors activates distinct signalling
mechanisms within cells, although all inhibit adenylyl
cyclase.
Four of the five receptors do not differentiate
SS-14 from SS-28.
Somatostatin
Physiologic Effects
SS acts by both endocrine and paracrine pathways to
affect its target cells.
A majority of the circulating SS appears to come from the
pancreas and GI tract.
If one had to summarize the effects of somatostatin in one
phrase, it would be: "somatostatin inhibits the secretion
of many other hormones".
Somatostatin Physiologic Effects
Effects on the Pituitary Gland
Somatostatin was named for its effect of inhibiting
secretion of GH Experimentally, all known
stimuli for GH secretion are suppressed by SS
administration. Additionally, animals treated
with antisera to SS show elevated blood
concentrations of GH, as do animals that are
genetically engineered to disrupt their SS gene.
Ultimately, GH secretion is controlled by the
interaction of SS and GHRH
Somatostatin Physiologic Effects
Effects on the Pancreas
Cells within islets secrete SS.
SS appears to act primarily in a paracrine manner
to inhibit the secretion of both I and glucagon.
It also has the effect in suppressing pancreatic
exocrine secretions, by inhibiting CCK stimulated enzyme secretion and Secretin
stimulated bicarbonate secretion.
Somatostatin Physiologic Effects
Effects on the Gastrointestinal Tract
SS is secreted by scattered cells in the GI epithelium, and by neurons
in the enteric nervous system. It has been shown to inhibit
secretion of many of the other GI hormones, including gastrin,
CCK, Secreting and VIP.
In addition to the direct effects of inhibiting secretion of other GI
hormones, SS has a variety of other inhibitory effects on the GI
tract, which may reflect its effects on other hormones, plus some
additional direct effects.
SS suppresses secretion of gastric acid and pepsin, lowers the rate of
gastric emptying, and reduces smooth muscle contractions and
blood flow within the intestine. Collectively, these activities seem
to have the overall effect of decreasing the rate of nutrient
absorption.
Somatostatin Physiologic Effects
Effects on the Nervous System
SS is often referred to as having neuromodulatory
activity within the central nervous sytem, and
appears to have a variety of complex effects on
neural transmission.
Injection of SS into the brain of rodents leads to
such things as increased arousal and decreased
sleep, and impairment of some motor responses.
Somatostatin
Pharmacologic Uses
SS and its synthetic analogs are used clinically to treat a
variety of neoplasms.
It is also sometimes in to treat gigantism and acromegaly,
due to its ability to inhibit GH secretion.
Why is this a bad idea?
Amylin
Amylin is a peptide of 37 aa which is also
secreted by the beta cells of the pancreas.
Some of its actions:
inhibits the secretion of glucagon;
slows the emptying of the stomach;
sends a satiety signal to the brain.
All of its actions tend to supplement those of
insulin, reducing the level of glucose in the
blood.
Diabetes: 'dia' = through - 'betes' = to go
1500 B.C. Ancient Egyptians had a number of
remedies for combating the passing of too much urine
(polyuria).
Hindus in the Ayur Veda recorded that insects and
flies were attracted to the urine of some people, that
the urine tasted sweet, and that this was associated
with certain diseases.
1000 B.C. The father of medicine in India, Susruta
of the Hindus, diagnosed Diabetes Mellitus (DM).
Early Greeks had no treatment for DM, latter Greeks
like Aretaeus, Celsus and Galen described DM. Celsus
described the pathologic condition "diabetes"
Diabetes: 'dia' = through - 'betes' = to go
1798 A.D. John Rollo certifies excess sugar
in the blood.
1889 A.D. Mehring and Minkowski produce
DM in dogs by removing the pancreas.
1921 A.D. Banting and Best find insulin is
secreted from the islet cells of the
pancreas.
Diabetes is a
disease that is the
th
5 leading cause of
death in the USA
20.8 Million
Americans have
Diabetes (7% pop)
More have pre-diabetes
There are two (or 3)
different types of
diabetes and the
diseases are very
different
There are three categories of diabetes
mellitus:
Insulin-Dependent Diabetes Mellitus (IDDM)
[also called "Type 1" diabetes]
and
Non Insulin-Dependent Diabetes Mellitus
(NIDDM)
["Type 2"]
Inherited Forms of Diabetes Mellitus
(MODY)
There are three categories of diabetes mellitus:
IDDM (also called Type 1 diabetes)
is characterized by little (hypo) or no circulating insulin;
most commonly appears in childhood.
It results from destruction of the beta cells of the islets.
The destruction results from a cell-mediated
AUTOIMMUNE ATTACK of the beta cells.
What triggers this attack is still a mystery
IDDM is controlled by carefully-regulated injections of
insulin.
(Insulin cannot be taken by mouth)
Inhalable insulin was introduced in mid-2006
The first such product to be marketed was Exubera, a powdered form of
recombinant human insulin, delivered through an inhaler into the lungs
where it is absorbed. Once it has been absorbed, it begins working within
the body over the next few hours. Diabetics still need to take a longer
acting basal insulin by injection.
It has been concluded that inhaled insulin "appears to be as effective, but
no better than injected short-acting insulin.
The additional cost is so much more that it is unlikely to be costeffective."[\
In October 2007, Pfizer announced that it would be discontinuing the
production and sale of Exubera due to poor sales.
Several other companies are developing inhaled forms of the drug to
reduce the need for daily injections among diabetics.
PFIZER LOSS = 2.8 billion
For many years, insulin extracted from the glands
of cows and pigs was used. However, pig insulin
differs from human insulin by one amino acid;
beef insulin by three. Although both work in
humans to lower blood sugar, they are seen by
the immune system as "foreign" and induce an
antibody response in the patient that blunts their
effect and requires higher doses.
Two approaches were taken to solve this problem:
There are three categories of diabetes mellitus:
Two approaches have been taken to solve this problem:
Convert pig insulin into human insulin by removing the one amino
acid that distinguishes them and replacing it with the human
version.
This approach is expensive, so now the favored approach is to
Insert the human gene for insulin into E.coli and grow recombinant
human insulin in culture tanks.
Insulin is not a GLYCOPROTEIN so E. coli is able to manufacture a
fully-functional molecule (trade name = Humulin).
Yeast is also used (trade name = Novolin).
Recombinant DNA technology has also made it possible to
manufacture slightly-modified forms of human insulin that work
faster (Humalog® and NovoLog®) or slower (Lantus®) than
regular human insulin.
Each cell has
thousands of
proteins.
In many cases a
missing or defective
protein has no effect
Inherited Forms of Diabetes Mellitus
Some cases of diabetes result from mutant genes inherited from one
or both parents.
Examples:
mutant genes for one or another of the transcription factors needed
for transcription of the insulin gene .
mutations in one or both copies of the gene encoding the insulin
receptor.
These patients usually have extra-high levels of circulating insulin
but defective receptors.
The mutant receptors
may fail to be expressed properly at the cell surface or
may fail to transmit an effective signal to the interior of the cell.
Diagnostic Diabetes:
diagnosing maturity-onset
diabetes of the young
(MODY)
Diagnosing MODY
• What is MODY?
• Different types of MODY
- Glucokinase MODY
- Transcription factor MODY
• Separate from Type 1, Type 2 and
genetic syndromes
MODY (inherited)
MODY is caused by a change in a single gene.
6 genes have been identified that account for 87% of
MODY:
HNF1-a
Glucokinase
HNF1-b
HNF4-a
IPF1
Neuro D1
MOST ARE TF’s that modulate insulin transcription
Important to diagnose MODY
Diabetes in Young Adults (15-30 years)
Type 2
Type 1
MODY
MIDD
5
10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90
Age of diagnosis
Diagnostic criteria for MODY
•Early-onset diabetes
•Not insulin-dependent
diabetes
•Autosomal dominant
Diagnosis of diabetes before 25
years in at least 1 & ideally 2
family members
Off insulin treatment or
measurable C-peptide at least 3
(ideally 5) years after diagnosis
inheritance
•Caused by a single gene
defect altering beta-cell
function, obesity unusual
Tattersall (QJM 1974)
Must be diabetes in one parent
(2 generations) and ideally a
grandparent or child ( 3
generations)
The Genetic Causes of MODY
MODY
75%
11%
14%
Transcription factors
MODY x
Glucokinase
(MODY2) 69%
3%
3% <1% <1%
HNF1a HNF4a HNF1b IPF1 NeuroD1
(MODY3)
Frayling, et al Diabetes 2001
Two subtypes of MODY
Glucokinase and Transcription factor
Transcription
factor
(HNF-1a)
20
16
Glucose
(mmol/l)
12
Glucokinase
8
.
Normal
4
0
0
20
40
60
80
100
Age (yr..)
Pearson, et al Diabetes 2001
Glucokinase and Transcription factor diabetes
MODY
Glucokinase
mutations
Transcription factor
mutations
(HNF-1a, HNF-1b, HNF-4a)
Onset at birth
Stable hyperglycemia
Diet treatment
Complications rare
Adolescence/young adult onset
Progressive hyperglycemia
1/3 diet, 1/3 other, 1/3 Insulin
Complications frequent
MODY
Non insulin dependent
Parents affected
Yes
1
Type 2
Type1
Yes
No
1-2
0-1
Age of onset < 25yr
Yes
unusual
Yes
Obesity
+/-
+++
+/-
Acanthosis
Nigricans
-
++
-
Racial groups
(Type 2 prevalence)
low
high
low
MODY
Diagnostic Genetic Testing: why do
it?
• Makes diagnosis : defines monogenic and
defines subtype
• Differentiates from type 1
• Helps define prognosis
• Helps family counselling
• Helps treatment decisions
Inherited Forms of Diabetes Mellitus
a mutant version of the gene encoding glucokinase, the enzyme that
phosphorylates glucose in the first step of glycolysis.
Mutant version of insulin gene TFs
mutations in the gene encoding part of K+channel in the plasma
membrane of the b cell. The channels fail to close properly
causing the cell to become hyperpolarized and blocking insulin
secretion.
mutations in several mitochondrial genes which reduce insulin
secretion by b cells. These diseases are inherited from the mother
as only her mitochondria survive in the fertilized egg.
While symptoms usually appear in childhood or adolescence,
patients with inherited diabetes differ from most children with
NIDDM in having a history of diabetes in the family and not
being obese.
Inherited Forms of Diabetes Mellitus
MODY GENES
like Mutant glucokinase
insulin gene TFs
K+channel of the b cell.
IR
some mitochondria genes
Of 20+ million
Americans with
Diabetes, only 10%
have type I
diabetes
Most diabetics
Have Type II
diabetes
T2DM or NIDDM
90% of diabetics in
industrialized
nations have Type
II diabetes
Type II diabetes
Defined by insulin
resistance
insulin resistanceinability to respond
to insulin
Hyperglycemia
causes retinopathy,
neuropathy, and
nephropathy
Type II diabetespatients are insulin
resistance so can’t
get glucose into
cells
How do you get high blood glucose?
Glucose comes from the food you eat and is also made in
your liver and muscles.
Your blood carries the glucose to all the cells in your body.
Insulin controls glucose disposal into fat and skeletal
muscle
The pancreas releases insulin into the blood.
Insulin helps the glucose from food get into your cells.
If your body doesn't make enough insulin or if the insulin
doesn't work the way it should, glucose can't get into
your cells. It stays in your blood instead. Your blood
glucose level then gets too high, causing pre-diabetes or
diabetes.
Type II diabetes
research related to
adipocytes
Adipocytes
accumulate
lipid
accumulate
lipid
insulin
insulinsensitive
sensitive
Endocrine
Endocrine
functions
function
Most patients with
Type II diabetes
are obese
> 85%
Strong link
between NIDDM
and Obesity
Many diseases due
to loss or defect of
one protein
Sickle Cell Anemia
Huntington’s Disease
Type I Diabetes
MODY
Many diseases due
to loss or defects in
many proteins
Heart Disease
Cancer
Type II Diabetes
Very hard to cure
diseases that have
multiple proteins
defective
What is pre-diabetes?
Pre-diabetes is a condition in which blood glucose
levels are higher than normal but are not high
enough for a diagnosis of diabetes.
People with pre-diabetes are at increased risk for
developing type 2 diabetes and for heart disease
and stroke.
The good news is if you have pre-diabetes, you can
reduce your risk of getting diabetes. With
modest weight loss and moderate physical
activity, you can delay or prevent type 2 diabetes
and even return to normal glucose levels.
How does Exercise work
Exercise results in an increase in
GLUT4 vesicles moving to the PM
The effect is independent of insulin
The effects of insulin and exercise are additive.
Exercise, even in the absense of WEIGHT LOSS
can reduce blood glucose levels and increase insulin
sensitivity
What are the signs of diabetes?
being very thirsty
urinating often
feeling very hungry or tired
losing weight without trying
having sores that heal slowly
having dry, itchy skin
losing the feeling in your feet or having tingling in
your feet
having blurry eyesight
may have had one or more of these signs before you found
out you have diabetes. Or may have had no signs at all.
A blood test to check your glucose levels will show if you
have pre-diabetes or diabetes.
A1C, also known as glycated hemoglobin or
glycosylated hemoglobin, indicates a patient's blood
sugar control over the last 2-3 months.
A1C is formed when glucose in the blood binds
irreversibly to hemoglobin to form a stable glycated
hemoglobin complex.
Since the normal life span of red blood cells is 90-120
days, the A1C will only be eliminated when the red
cells are replaced; A1C values are directly
proportional to the concentration of glucose in the
blood over the full life span of the red blood cells.
A1C values are not subject to the fluctuations that are seen
with daily blood glucose monitoring.
The A1C value is an index of mean blood glucose over the
past 2-3 months but is weighted to the most recent
glucose values.
Values show the past 30 days as ~50% of the A1C, the
preceding 60 days giving ~25% of the value and the
preceding 90 days giving ~25% of the value. This bias is
due to the body's natural destruction and replacement of
RBC. Because RBCs are constantly being destroyed and
replaced, it does not take 120 days to detect a clinically
meaningful change in A1C following a significant change
in mean blood glucose.
WHY IS IT SO HARD
TO TREAT NIDDM
Medications for NIDDM
Many types of diabetes pills can help people with T2DM
lower their blood glucose.
Each type of pill helps lower blood glucose in a different
way.
Sulfonylureas- stimulate your pancreas to make
more insulin.
Biguanides decrease the amount of glucose made
by your liver.
a glucosidase inhibitors slow the absorption of
the starches you eat.
Medications for NIDDM
Thiazolidinediones TZDs-make you more sensitive
to insulin.
Meglitinides -stimulate your pancreas to make
more insulin.
D-phenylalanine derivatives -help your pancreas
make more insulin quickly.
Combination oral medicines put together
different kinds of pills.
Gila monsters are one of only
two venomous lizards in the
world, the other being the
closely related beaded lizards
A fairly new diabetes treatment from Eli Lilly and
Amylin that is extracted from the saliva of the
Gila monster received approval from the Food
and Drug Administration in April 2005
Byetta, which was co-developed by both companies,
improves blood sugar control in patients with type
2 diabetes. The drug, developed from a compound
in the toxic saliva of a rare lizard found only in the
Southwest U.S. and Mexico.
Came on Market in June of 2005
Used in patients who aren't getting enough insulin
through oral medication
DRAWBACK:
Has to be injected twice a day
Some History
• 1980s an endocrinologist named Dr. John Eng
worked of the VA Medical Center in the Bronx
His mentor - Dr. Rosalyn S. Yalow, won the
1977 Nobel Prize in Physiology or Medicine for
the development of RIAs of peptide hormones.
• Dr. Eng wanted to discover new hormones.
RIA are insensitive and not a good way to
discover new hormones. But chemical assays
are sensitive. So he developed a new type of
chemical assay and looked for hormones that no
one had discovered.
Some History
• Dr. Eng first discovered a new hormone in the
venom of the Mexican beaded lizard, which in
1990 he named exendin-3. But this hormone was
vasoactive, which means that it contracts or
dilates blood vessels.
• Prompted Dr. Eng to look at the venom of the
Gila monster, which is not vasoactive. There he
discovered a hormone, which he named
exendin-4, that was similar in structure to
glucagon-like peptide 1 (GLP-1).
Some History
• GLP-1 regulates blood glucose and satiety, as a
potential drug it has a short half-life requiring
multiple daily injections. He published his key
paper on exendin-4 in a 1992 issue of The Journal
of Biological Chemistry.
• But exendin-4 works for 12 or more hours.
"That's how it is better," Dr. Eng says. So,
Amylin Pharmaceuticals invested millions of
dollars to develop it.
Some History
• When Dr. Eng began to realize exendin-4's
potential to control diabetes, he told the
Department of Veterans Affairs that the agency
should patent it. " VA declined, because at that
time inventions must be veteran specific," he
recalls. The VA did retain a royalty-free license.
• "That put me in a difficult position," he says,
"because it meant I had to essentially make a bet.
Patenting it came out of my pocket with no
guarantee that anything would come of it. I
ended up with this patent, and I couldn't develop
it. So I went around to drug companies."
Some History
• Finally, in 1996, Dr. Eng licensed the patent to
Amylin, which calls it AC2993. The company
completed the Phase 1 study in 1998 and filed an
investigational new drug application with the
FDA in 1999. Phase 2 studies, announced at the
ADA's 2001 Annual Meeting, showed an
approximate 1% reduction in A1c after 28 days.
Since A1c measures average blood glucose of the
past 2-3 months, this is a lot.
• Amylin had success in Phase 3 trials.
Some History
• Used by 2 injections a day. "The initial target
population is for people with NIDDM who have
not progressed to taking insulin," "It stimulates
insulin production when it is needed and is only
active when glucose is high." It also reduces
appetite, causing some weight loss.
• Amylin is also working on alternatives to shots
and a long-acting formulation of one shot a
month, AC2993 LAR.
Some History
• Who would have imagined that a Gila monster
could be so valuable to people with diabetes? But
Dr. Eng did. Ironically, the venom he worked
with came from a lab in Utah, and he says he has
never seen a Gila monster.
Not as many proteins as we thought.
Not surprising we have some "super-genes“like one
that encodes glucagon (increases glucose).
As it turns out, the gene for glucagon also codes
for at least 2 other hormones, called glucagonlike peptides 1 and 2 (GLP-1, GLP-2). Not only
do the GLPs come from the same gene as
glucagon, but have a very similar aa sequence as
well.
Despite these parallels, the GLPs have very
different functions than glucagon, and there is a
lot of excitement about using these hormones to
treat problems ranging from diabetes and obesity
to chemotherapy-induced intestinal damage.
From a diabetes perspective, the interesting GLP is
GLP-1.
GLP-1 is secreted from cells in the gut in response to a
meal, and helps to integrate many of the normal
physiological responses that occur after eating.
For one, GLP-1 induces insulin secretion from the
pancreas, and simultaneously reduces glucagon
release. This release of insulin actually seems to
occur only when the ambient glucose concentration
is high, thus reducing the chance that hypoglycemia
will develop (an especially attractive feature in a
diabetes therapy).
Over a longer period, GLP-1 actually
increases the number of insulinproducing b cells.
GLP-1 also acts directly on the GI tract,
reducing the rate at which food spills
out of the stomach and into the SI,
making the absorption and storage of
energy more efficient.
Finally, and perhaps most intriguingly, GLP-1
acts on the CNS to signal a sense of fullness so
that we don't overeat.
So isn’t GLP-1 prescribed to everyone with
T2DM? Well, there are a few problems, The
most daunting has been that our bodies destroy
GLP-1 within a few minutes. This means that
it needs to be continuously infused (Because it
is a protein, GLP-1 cannot be given orally),
which is clearly not going to work for most
people. The enzyme that destroys GLP-1 is
called dipeptidyl-peptidase IV (DPP IV), and
intense focus has been placed on figuring out
ways to disable the enzyme so that GLP-1 can
do it's thing for longer periods of time.
One way to get around the problem of DPP IV is to administer
a form of GLP-1 that is resistant to destruction. Such forms
of GLP-1 have already been found, and the source is
delightfully unexpected--the poisonous saliva of the Gila
monster lizard. GLP-1 (called exendin-4) from these reptiles
has a few key differences from the form found in humans,
one consequence of which is immunity to DPP IV.
pharmaceutical companies made synthetic forms of exendin-4
(one imagines that it's easier to make the chemical from
scratch than it is to harvest toxic lizard spit).
Phase 2 clinical trials of exendin-4 in patients with T2DM
showed improvements in hemoglobin A1c levels
comparable to those seen with currently available ant
diabetic drugs. Other studies show reductions of caloric
intake after exendin-4 administration.
Another strategy that is being pursued is the use of drugs that will
inhibit DPP IV directly.
Studies have shown that 24 hours after taking such a drug, patients with
mild T2DM have reduced fasting, post-meal, and average blood sugar
levels.
The primary advantage of this approach (vs. exendin-4) is that DPP
IV inhibitors can be given orally. On the other hand, DPP IV affects
other hormones besides GLP-1, and there is concern that blocking the
enzyme could cause other problems.
One reassuring piece of data is that mice that are genetically engineered
to lack DPP IV are viable and appear to do well, and this provides
some reassurance that the strategy is sound. Still, longer term studies
with both DPP IV inhibitors need to be performed to assess possible
toxicity. It is also unclear if the beneficial effects of GLP-1 will be
sustained over time, and this too will have to be tested. Nonetheless, a
drug that that causes weight loss as well as improved insulin secretion
in type 2 diabetes is a potential blockbuster.
GLP-1
extendin-4
DDP1V
Diabetes Myths
Myth #1 You can catch diabetes from someone else.
Myth #2 People with diabetes can't eat sweets or chocolate.
Myth #3 Eating too much sugar causes diabetes.
Myth #4 People with diabetes should eat special diabetic foods.
Myth #5 If you have diabetes, you should only eat small amounts of
starchy foods, such as bread, potatoes and pasta.
Myth #6 People with diabetes are more likely to get colds and other
illnesses.
.
Myth #7 Insulin causes atherosclerosis (hardening of the arteries)
and high blood pressure.
Diabetes Myths
Myth #8 Insulin causes weight gain, and because obesity is bad for
you, insulin should not be taken.
Myth #9 Fruit is a healthy food. Therefore, it is ok to eat as
much of it as you wish.
Myth #10 You don’t need to change your diabetes regimen
unless your A1C is greater than 8 %