Pathophysiology of T2DM: is there a fundamental incretin defect? Jens Juul Holst Department of Medical Physiology Panum Institute University of Copenhagen Denmark Codhy Congress, Berlin, October 26
The incretin effect 7% of post-glucose insulin secretion is due to the effects of incretin The incretin effect is due to gut hormones the incretin hormones Glucose (mmol/l) 1 5 1 Glucose i.v. pr. OS Insulin (pmol/l) 5 Incretin
The Incretin Hormones Are Members of the Superfamily of Glucagon-Related GLUCAGON Peptides 5 1 15 2 25 3 35 4 45 H S Q G T F T S D Y S K Y L D S R R A Q D F F Q W L M N T GLP-1(7-37) G R G H A E G T F T S D V S S Y L E G Q A A K E F I A W L V K GLP-1(7-36)NH2 H A E G T F T S D V S S Y L E G Q A A K E F I A W L V K G R NH2 GIP Y A E G T F I S D Y S I A M D K I H Q Q D F V N W L L A Q K G K K N D W K H N I T Q EXENDIN-3 H S D G T F T S D L S K Q M E E E A V R L F I E W L K N G G P S S G A P P P S NH2 EXENDIN-4 H G E G T F T S D L S K Q M E E E A V R L F I E W L K N G G P S S G A P P P S NH2 SECRETIN H S D G T F T S E L S R L R E G A R L Q R L L Q G L V NH2 PHM H A D G V F T S D F S K L L G Q L S A K K Y L E S L M NH2 GLP-2 H A D G S F S D E M N T I L D N L A A R D F I N W L I Q T K I T D HELOSPECTIN-1 H S D A T F T A E Y S K L L A K L A L Q K Y L E S I L G S S T S P R P P S S HELOSPECTIN-2 H S D A T F T A E Y S K L L A K L A L Q K Y L E S I L G S S T S P R P P S HELODERMIN H S D A I F T E E Y S K L L A K L A L Q K Y L A S I L G S R T S P P P NH2 PACAP-38 H S D G I F T D S Y S R Y R K Q M A V K K Y L A A V L G K R Y K Q R V K N K NH2 PACAP-27 H S D G I F T D S Y S R Y R K Q M A V K K Y L A A V L NH2 PRP D V A H G I L N E A Y R K V L D Q L S A G K H L Q S L V A GRF Y A D A I F T N S Y R K V L G Q L S A R K L L Q D I M S R Q Q G E S N Q E R G A R A R L NH2 VIP H S D A V F T D N Y T R L R K Q M A V K K Y L N S I L N NH2
Plasma Levels of GLP-1, GIP and Insulin in Normal Subjects GLP-1 and GIP are secreted in response to meals (arrows) in normal subjects and correlate to insulin secretion. Can the insulinotropic effects of GLP-1 and GIP Reprinted from Ørskov C et al. Scand J Gastroenterol. 1996;31:665 67. pmol/l 4 2 4 2 3 Insulin GLP-1 GIP 9 13 19 22 9 Hours
Effect of GLP-1 and GIP During a Stepwise Glucose Clamp 8 Plasma glucose (mmol/l) 6 4 2 5 1 15 2 Glucose GIP GLP-1 Meal N=8 healthy males. Adapted from Vilsbøll T et al. Regul Pep. 23;114:115 121.
Insulin Responses to GIP and GLP- 1 During Glucose Clamps in Healthy Insulin (pmol/l) 35 3 25 2 15 1 Subjects Glucose GIP GLP-1 Meal 5 2 3 8 13 18 23 N=8 healthy males. Adapted from Vilsbøll T et al. Regul Pep. 23;114:115 121.
Why Is the Incretin Effect Reduced in Type 2 Diabetes? Is something wrong with the secretion of the incretin hormones? Is something wrong with the action of the incretin hormones?
P-glucagon (pmol/l) P-PP (pmol/l) P-GIP (pmol/l) Glucagon, PP and GIP 3 2 1 3 2 1 12 9 6 3 Meal NIDDM NGT 6 12 18 24 AUC AUC AUC 4 3 2 1 4 3 2 1 2 15 1 5 n = 55 * DM NGT DM NGT * DM NGT Toft-Nielsen et al. 21
Decreased GLP-1 concentrations in type 2 diabetes during a 24-minute meal test GLP-1 (pmol/l) 2 15 1 5 * * * * * * NGT subjects IGT subjects Type 2 diabetes patients 6 12 18 24 *p <.5 between the type 2 diabetes and NGT group The meal was started at time zero and finished in the 1- to 15-minute period Toft-Nielsen et al. J Clin Endocrinol Metab 21;86:3717 23
Summary of the Study Toft-Nielsen et al 21 The meal-induced secretion of GLP-1: 1. Is significantly decreased in type 2 diabetes 2. Is unaltered by diabetic neuropathy 3. Is not influenced by candidate L-cell regulators such as FFA or GIP 4. By multiple regression, the diabetic state (DM < NGT) gender (M < F), insulin sensitivity (+), and BMI ( ) emerge as significant factors FFA=free fatty acids. Toft-Nielsen M-B et al. J Clin Endocrinol Metab. 21; 86:3717 3723.
Plasma GLP-1 (pmol/l) 2 15 1 5 Meal-Stimulated Incretin Hormone Concentrations are Positively Correlated with Insulin Sensitivity in Non-Diabetic Men meal * GLP-1 3 6 9 12 18 Plasma GIP (pmol/l) 8 6 4 2 #* 3 6 9 12 18 meal GIP Rask et al. Diabetes Care (21) Lowest insulin sensitivity tertile (n=11) Middle insulin sensitivity tertile (n=11) Highest insulin senstivity tertile (n=11)
GLP-1 Secretion in Morbid Obesity Effect of Jejunoileal Bypass * (JIB) 25 2 M E A L * ** * ** * *** * *** *** * *** ** P ḠLP 1 ( pmol 15 1 5 * p<.5 for before and after JIB. ** p<.5 for obese after JIB vs control subjects. *** p<.5 for obese before JIB vs control subjects. Reprinted from Näslund E et al. Obes Surg. 1998;8:253 26. -1 1 2 3 4 5 6 Obese before JIB Obese after JIB Control subjects 12
GLP-1 Response Following a 2.5 MJ* Test Meal 3 Plasma GLP 1 ( pmol 2 1 Lean (n=12) Obese (n=19) Reduced obese (n=19) 2 4 6 8 1 12 14 16 18 *Unit of energy, megajoules. Reprinted from Verdich C et al. Int J Obes. 21;25:126 1214.
GIP: Obese, Healthy vs Lean, 7 6 5 4 Healthy Subjects Obese, healthy Lean, healthy Intact GIP 3 2 1-2 3 8 13 18 Adapted from Vilsbøll T et al. J Clin Endocrinol Metab. 23;88:276 2713. 14
Native GLP-1 is Rapidly Degraded by DPP IV DPP-IV His Ala Glu Gly Thr PheThr Ser Asp 7 9 Val Ser Glu Lys Ala Ala Gln Gly Glu Leu Tyr Ser Phe 36 Ile Ala Trp Leu Val Lys Gly Ala-NH 2 Plasma T ½ =1-2 minutes (i.v.) MCR = 5-1 l/min MCR=metabolic clearance rate. Vilsbøll T et al. J Clin Endocrinol Metab. 23;88:22 224. DPP IV (red) and GLP-1 (green) in human small intestine DPP IV=dipeptidyl peptidase IV Hansen et al, Endocrinology 1999; 14:5356-5363
Survival of sc GLP-1 in Type 2 Diabetes 1.5 nmol/kg sc GLP-1 (pmol/l) 4 3 2 1 ** Only ~1% GLP-1 survives intact after sc injection Intact GLP-1 + metabolite Intact GLP-1 ** ** ** ** ** * Deacon et al, Diabetes 1995; 44:1126-1131 3 6 9 12 15 18 21 24
Plasma Concentrations of Active GLP-1 Are Decreased in Type 2 3 Diabetes * GLP-1 (pmol/l) 2 1 * * Total GLP-1, type 2 diabetic patients Total GLP-1, control group Intact GLP-1, type 2 diabetic patients Intact GLP-1, control group 5 1 15 *p<.5 Adapted from Vilsbøll T et al. Diabetes. 21;5:69 613.
The Impaired Secretion of GLP-1 in Type 2 Diabetes Does Not Precede Diabetes Vaag et al, 1996: In identical twins discordant for type 2 diabetes, GLP-1 was decreased in the diabetic twin only Nyholm et al, 1999: 24-hour plasma profiles of GLP-1 were normal in healthy offspring of parents with type 2 diabetes Meier et al, 25: Incretin hormone
Why Is the Incretin Effect Reduced in Type 2 Diabetes? Is it the secretion of the incretin hormones? Is it the action of the incretin hormones?
Effect of GLP-1 on Beta-Cell Glucose Responsiveness in Type 2 Diabetes ISR (pmol/kg/min) 15 1 5 2 15 1 5 3 2 1 3 2 1 Relationship between average glucose concentrations and ISR in Control subjects Patients with Type 2 diabetes 4 1 16 4 8 12 4 8 12 4 8 12 Glucose (mmol/l) ISR (pmol/kg/min) 6 4 2 12 8 4 12 8 4 16 8 4 9 15 2 4 9 15 2 4 9 15 2 4 9 15 2 Glucose (mmol/l) Saline infusion GLP-1 (.5 pmol/kg/min) GLP-1 (1. pmol/kg/min) GLP-1 (2. pmol/kg/min) ISR=insulin secretion rate. Reprinted from Kjems LL et al. Diabetes. 23;52:38 386.
Effect of GLP-1 on Beta-Cell Responsiveness to Glucose 6 4 2 Type 2 diabetic: Saline infusion ISR (pmol/kg/min) 12 8 4 4 9 15 2 4 9 15 2 Type 2 diabetic: GLP-1 (.5 pmol/kg/min) 12 8 4 Type 2 diabetic: GLP-1 (.5 pmol/kg/min) + Controls: Saline infusion 4 9 15 2 Glucose (mmol/l) Adapted from Kjems LL et al. Diabetes. 23;52:38 386.
Beta-Cell Responsiveness to ISR vs glucose (pmol kg -1 min -1 /mmol/l) 8 6 4 2 Glucose Patients with type 2 diabetes Control subjects.5 1 1.5 2 GLP-1 (pmol kg -1 min -1 ) ISR=insulin secretion rate. Beta-cell responsiveness to glucose expressed as the slope of the linear relation between ISR and glucose concentration. Reprinted from Kjems LL et al. Diabetes. 23;52:38 386.
Effects of GLP-1 on insulin secretion in patients with 2DM: Glucose-induced insulin secretion may be restored to normal values The potency of GLP-1 with respect to enhancing the beta cell responsiveness to glucose is decreased This decreased potency can be improved by improved metabolic control
Hyperglycemic Clamp + GLP- 1/GIP in Patients With Type 2 Diabetes and Control Obese Diabetic Patients Healthy Subjects Glucose Low GIP (4 pmol/kg/min) Glucose Low GIP (4 pmol/kg/min) Plasma glucose (mmol/l) 2 15 1 5 High GIP (16 pmol/kg/min) GLP-1 (1 pmol/kg/min) -2 2 4 6 8 1 12 14 16 18 2 22 24 Reprinted from Vilsbøll T et al. Diabetologia. 22;45:1111 1119.
Second-Phase Insulin Responses to Hyperglycaemic Clamp During IV GIP and GLP-1 Obese Diabetic Patients Obese Control Subjects 5 Glucose Low GIP High GIP Glucose Low GIP Insulin (pmol/l) 4 3 2 1 GLP-1-2 8 18 All subjects were obese (BMI 29 kg/m 2 ); patients with type 2 diabetes (n=8); control subjects (n=6). IV=intravenous. Adapted from Vilsbøll Tl et al. Diabetologia. 22;45:1111 1119.
Insulin Responses (cont) Insulin (pmol/l) 6 4 2 High GIP, Patients Low GIP, Patients Glucose, Patients -2 2 4 6 8 1 12 14 16 18 2 22 24 All patients were obese with type 2 diabetes (n=8). This graph shows the insulin responses to the glucose clamp alone and with a low and high dose of GIP. Vilsbøll T et al. Diabetologia. 22;45:1111 1119.
Inhibition of Glucagon Secretion by Glucose + GIP or GLP-1 in Patients With Type 2 Diabetes and Matched Control Subjects Obese Patients Healthy Subjects Glucose Low GIP (4 pmol/kg/min) Glucose Low GIP (4 pmol/kg/min) Glucagon (pmol/l) 15 1 5 High GIP (16 pmol/kg/min) GLP-1 (1 pmol/kg/min) -2 5 12 19 Patients were obese with type 2 diabetes (n=8); healthy subjects (n=6). Reprinted from Vilsbøll T et al. Diabetologia. 22;45:1111 1119.
GLP-1 in Diabetes of Different Etiology Chronic pancreatitis Lean, Type 2 DM LADA Type 1 DM Plasma glucose (mmol/l) 2 15 1 5 GLP-1 (1 pmol/kg/min) GIP (4 pmol/kg/min) Glucose 7 Chronic pancreatitis Lean, Type 2 DM LADA Type 1 DM Plasma insulin (pmol/l) 6 5 4 3 2 1-2 -5 1 25 4 55 7 85 1 115-2 -5 1 25 4 55 7 85 1 115-2 -5 1 25 4 55 7 85 1 115-2 -5 1 25 4 55 7 85 1 115 n=6 in each group. Modified from from Vilsbøll T et al. J Clin Endocrinol Metab. 23;88:4897 493.
Loss of incretin function in type 2 diabetes mellitus Secretion of GLP-1 impaired Beta-cell sensitivity to GLP-1 decreased Secretion of GIP normal (or slightly impaired) effect of GIP abolished or grossly impaired Inhibition of glucagon impaired The defect is secondary to diabetes
If the impaired incretin response contributes significantly to the defective insulin secretion in type 2 diabetes, will restoration of incretin action improve metabolism?
Proof of hypothesis: Glucose tolerance can be restored by iv GLP-1 in T2DM 16 14 12 Diabetic - saline Diabetic - GLP-1 (1.2 pmol/kg/min) Non-diabetic Glucose (mmol/l) 1 8 6 4 2 Rachman et al., Diabetologia 1997;4:25-211 Breakfast Lunch Snack : 4: 8: 12: 16: Time of day
Summary Incretin hormone secretion and actions are impaired in type 2 diabetes. The defect is secondary to diabetes. Althoughβ-cell responsiveness to GLP-1 is reduced, exogenous GLP-1 can still restoreβcell sensitivity to glucose and improve glucoseinduced insulin secretion. A GLP-1 based therapy of type 2 diabetes may therefore be expected to