George Grunberger

Hypoglycemia Associated with Antibodies to the Insulin Receptor

Antibodies to the insulin receptor are insulinomimetic in vitro, although they generally induce insulin resistance in vivo. We report the novel case of a patient who presented with fasting hypoglycemia as the sole manifestation of autoantibodies to the insulin receptor. Prednisone therapy (120 mg per day) produced a rise in fasting glucose to more than 100 mg per deciliter (6 mmol per liter) within 48 hours, although there was no detectable change in the titer of antireceptor antibodies. After 10 weeks of therapy, the titer of antireceptor antibodies had fallen approximately 100-fold, and prednisone could be discontinued without recurrence of hypoglycemia. This case demonstrates that antireceptor antibodies must be considered in the differential diagnosis of hypoglycemia, especially in patients with other manifestations of autoimmunity.

Insulin-like growth factor-I (IGF-I) stimulates tyrosine kinase activity in purified receptors from a rat liver cell line

Solubilized, lectin-purified receptor preparations from BRL 3A2 rat liver cells are rich in Type I and Type II IGF receptors, but possess few insulin receptors. High concentrations of IGF-I or insulin stimulate phosphorylation of a Mr congruent to 98K membrane protein in these preparations. Phosphorylation of a synthetic polymer of tyrosine and glutamic acid was stimulated by IGF-I greater than IGF-II congruent to insulin. These relative potencies, together with the results of immunodepletion experiments using an autoantibody to the insulin receptor, suggest that the effects of each of these hormones is mediated by the Type I IGF receptor. Our results are consistent with the Type I IGF receptor having intrinsic tyrosine kinase activity capable of phosphorylating the receptor itself and other substrates.

Factitious Hypoglycemia Due to Surreptitious Administration of Insulin: Diagnosis, Treatment, and Long-Term Follow-Up

Ten patients had factitious hypoglycemia due to surreptitious insulin injections diagnosed and were followed for up to 15 years (median, 5 years; range, 2 months to 15 years). When available, demonstration of anti-insulin antibodies was the most helpful diagnostic test. Decreased plasma C-peptide levels corroborated the diagnosis. Young women (nine of ten) with knowledge of the medical profession or relatives with diabetes mellitus predominated in the sample. Five of the patients had a history of insulin-requiring diabetes mellitus. Two patients eventually committed suicide despite the best efforts at therapy. Only three of ten patients made a successful transition into productive life after the diagnosis of factitious hypoglycemia was established. Factitious hypoglycemia remains a difficult diagnosis to make, and the long-term outcome after the diagnosis is established is unpredictable. All efforts have to be made to confirm the diagnosis before the patients are approached. The confrontation is to be made by an experienced team of health care professionals who have gained the patients confidence through an understanding but firm manner. Long-term therapy must be planned and initiated before the patients discharge.

11 Insulin receptors in normal and disease states

Summary The binding of insulin to its receptor has been studied under various physiological and pathological conditions. Quantitative studies have involved human circulating cells such as monocytes and erythrocytes, adipocytes, placental cells, and cultured cells such as fibroblasts and transformed lymphocytes. In animals, other target tissues such as liver and muscle have been studied and correlated with the human studies. Various physiological conditions such as diurnal rhythm, diet, age, exercise and the menstrual cycle affect insulin binding; in addition, many drugs perturb the receptor interaction. Disease affecting the insulin receptor can be divided into five general categories: (1) Receptor regulation — this involves diseases characterized by hyper- or hypoinsulinaemia. Hyperinsulinaemia in the basal state usually leads to receptor ‘down’ regulation as seen in obesity, type II diabetes, acromegaly and islet cell tumours. Hypoinsulinaemia such as seen in anorexia nervosa or type I diabetes may lead to elevated binding. (2) Anti-receptor antibodies — these immunoglobulins bind to the receptor and competitively inhibit insulin binding. They may act as agonists, antagonists or partial agonists. (3) Genetic diseases which produce fixed alterations in both freshly isolated and cultured cells. (4) Diseases of receptor specificity where insulin may bind with different affinity to its own receptor or related receptors such as receptors for insulin-like growth factors. (5) Disease of affinity modulation where physical factors such as pH, temperature, ions, etc. may modify binding. In this review, we have considered primarily abnormality in insulin receptor binding. There are numerous other functions of the receptor such as coupling and transmission of the biological signal. These mechanisms are frequently referred to as postreceptor events, but more properly should be referred to as postbinding events since the receptor subserves other functions in addition to recognition and binding of insulin.

CONTINUOUS GLUCOSE MONITORING: A CONSENSUS CONFERENCE OF THE AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY

OBJECTIVE/METHODSnBarriers to continuous glucose monitoring (CGM) use continue to hamper adoption of this valuable technology for the management of diabetes. The American Association of Clinical Endocrinologists and the American College of Endocrinology convened a public consensus conference February 20, 2016, to review available CGM data and propose strategies for expanding CGM access.nnnRESULTSnConference participants agreed that evidence supports the benefits of CGM in type 1 diabetes and that these benefits are likely to apply whenever intensive insulin therapy is used, regardless of diabetes type. CGM is likely to reduce healthcare resource utilization for acute and chronic complications, although real-world analyses are needed to confirm potential cost savings and quality of life improvements. Ongoing technological advances have improved CGM accuracy and usability, but more innovations in human factors, data delivery, reporting, and interpretation are needed to foster expanded use. The development of a standardized data report using similar metrics across all devices would facilitate clinician and patient understanding and utilization of CGM. Expanded CGM coverage by government and private payers is an urgent need.nnnCONCLUSIONnCGM improves glycemic control, reduces hypoglycemia, and may reduce overall costs of diabetes management. Expanding CGM coverage and utilization is likely to improve the health outcomes of people with diabetes.nnnABBREVIATIONSnA1C = glycated hemoglobin AACE = American Association of Clinical Endocrinologists ACE = American College of Endocrinology ASPIRE = Automation to Simulate Pancreatic Insulin Response CGM = continuous glucose monitoring HRQOL = health-related quality of life ICER = incremental cost-effectiveness ratio JDRF = Juvenile Diabetes Research Foundation MARD = mean absolute relative difference MDI = multiple daily injections QALY = quality-adjusted life years RCT = randomized, controlled trial SAP = sensor-augmented pump SMBG = self-monitoring of blood glucose STAR = Sensor-Augmented Pump Therapy for A1C Reduction T1D = type 1 diabetes T2D = type 2 diabetes.

Sulfonylureas Do Not Affect Insulin Binding or Glycemic Control in Insulin-dependent Diabetics

Sulfonylureas alone are ineffective in the therapy of insulin-independent diabetes mellitus (IDDM). These agents, however, might serve as an adjunct to insulin treatment if they directly affect insulin binding to its receptor. We studied 11 patients with IDDM to determine whether chlorpropamide acts directly on the insulin receptor and whether it could augment the effect of insulin on glycemic control. Mean tracer insulin binding to both peripheral monocytes and erythrocytes in 11 poorly controlled patients was normal. Optimization of glucose control by continuous subcutaneous insulin infusion for 7–10 days did not alter insulin binding to either cell type. Addition of chlorpropamide, 250–500 mg/day for another 7–10 days did not affect any aspect of insulin binding (tracer binding, number of receptor sites, insulin sensitivity, or affinity) in either cell type. Insulin binding was not changed in one patient after 3 days of 250 mg/day of the drug and in another after 500 mg/day over 3 mo. The sulfonylurea, in addition, provides no additive effect with insulin on blood glucose levels or insulin doses required to maintain euglycemia. We conclude that short-term use of chlorpropamide in addition to insulin in IDDM does not alter insulin binding to circulating monocytes or erythrocytes. In addition, we were unable to show that this agent is a clinically useful adjunct to insulin in IDDM.

Insulin stimulates phosphorylation of serine residues in soluble insulin receptors

Using lectin affinity-purified receptor preparations from human hepatoma cells, insulin (10(-7)M) specifically stimulated phosphorylation of the 95,000 dalton (beta) subunit of its own receptor. Phospho-amino acid analysis of the receptor subunit revealed that insulin increased at least 2.5-fold the content of phosphoserine and of phosphotyrosine. In intact cells, the major effect of insulin is to increase the phosphoserine content of its receptor. These findings are the first demonstration of an insulin-stimulated serine kinase in a cell-free system.

Protein kinase activity of the insulin receptor in human circulating and cultured mononuclear cells

In lectin-purified receptor preparations from human monocyte-like cell (U-937), insulin (10(-7)M) stimulated phosphorylation of the 95,000 dalton subunit of its own receptor. In addition, insulin stimulated phosphorylation of exogenously added substrates like casein, (T,G)-A--L, and histones. Phosphorylation of the synthetic peptide (T,G)-A--L indicates the presence of at least one insulin-dependent tyrosine kinase in these cell extracts. Insulin receptor preparations from freshly isolated human mononuclear blood cells were also shown to possess insulin-dependent casein and (T,G)-A--L kinase activity. Phosphorylations in these systems are specific for insulin and dependent on insulin concentration. A simple and rapid method is described that is relevant for clinical investigations of early postbinding events.

Insulin Analogs—Are They Worth It? Yes!

The availability of insulin analogs has offered insulin replacement strategies that are proposed to more closely mimic normal human physiology. Specifically, there are a considerable number of reports demonstrating that prandial insulin analogs (lispro, aspart, glulisine) have pharmacokinetic and pharmacodynamic profiles closer to normal, with resulting faster onset and offset of insulin effect when compared with regular human insulin. In addition, basal insulin analogs (glargine, detemir) have been reported to offer longer duration of action, less variability, more predictability, less hypoglycemia (especially nocturnal), and a favorable effect on weight. However, an argument against use of analog insulins as compared with use of regular or NPH insulin is one that states that the effectiveness and risk of hypoglycemia are the only two valid clinical outcomes that should be used to compare the analog and human insulins. Thus, there remains a debate in some circles that analog insulins are no more effective than human insulins, yet at a much higher financial cost. To provide an in-depth understanding of both sides of the argument, we provide a discussion of this topic as part of this two-part point-counterpoint narrative. In the counterpoint narrative, Dr. Davidson provides his argument and defends his opinion that outside of a few exceptions, analog insulins provide no clinical benefit compared with human insulins but cost much more. In the point narrative presented here, Dr. Grunberger provides a defense of analog insulins and their value in clinical management and suggests that when evaluating the “cost” of therapy, a much more global assessment is needed. —William T. Cefalu Editor in Chief, Diabetes Care

An Alteration in Apparent Molecular Weight of the Insulin Receptor from the Human Monocyte Cell Line U-937

We have studied the structure of the insulin receptor from a human cultured monocyte cell line, U-937. The receptor is composed of alpha and beta subunits as seen in other insulin receptors, but these subunits are of greater apparent molecular weight (alpha 150,000 and beta 102,000) than in typical insulin receptors. Despite this, the U-937 insulin receptor appears to function normally. The alpha subunit binds insulin and the beta subunit is phosphorylated in response to insulin stimulation. Both subunits are expressed in the plasma membrane. Insulin binding isotherms are similar to those seen in IM-9 lymphocytes. Thus, the insulin receptor from U-937 monocytes appears functionally normal despite alterations in molecular weight of the subunits.