This is an uncopyedited electronic version of an article accepted for publication in Diabetes Care. The American Diabetes Association, publisher of Diabetes Care, is not responsible for any errors or omissions in this version of the manuscript or any version derived from it by third parties. The definitive publisherauthenticated version will be available in a future issue of Diabetes Care in print and online at http://care.diabetesjournals.org. Diabetes Care Publish Ahead of Print, published online March 16, 2009

WSTEP. Celem pracy by³a ocena skuteczno¶ci i bezpieczenstwa liraglutydu (agonisty receptora glukagonopodobnego peptydu 1) do³±czonego do metforminy i rozyglitazonu w leczeniu chorych na cukrzyce typu 2. MATERIA£ I METODY. Trwaj±ce 26 tygodni badanie, przeprowadzone metod± podwojnie ¶lepej proby w uk³adzie rownoleg³ym z grup± kontroln± przyjmuj±c± placebo, obje³o 533 pacjentow przydzielonych losowo do trzech grup (1:1:1): osoby przyjmuj±ce liraglutyd (1,2 lub 1,8 mg) raz dziennie lub placebo liraglutydu w po³±czeniu z metformin± (1 g 2 × d.) i rozyglitazonem (4 mg 2 × d.). Badanie obejmowa³o chorych na cukrzyce typu 2, z warto¶ciami HbA1c 7-11% (osoby stosuj±ce wcze¶niej doustne leki przeciwcukrzycowe w monoterapii przez ≥ 3 miesiecy) i 7-10% (osoby stosuj±ce wcze¶niej terapie skojarzon± lekami przeciwcukrzycowymi przez ≥ 3 miesiecy) oraz BMI ≥ 45 kg/m2. WYNIKI. U osob stosuj±cych liraglutyd ¶rednie warto¶ci HbA1c uleg³y znaczniejszemu zmniejszeniu w porownaniu z osobami przyjmuj±cymi placebo [¶rednia ± odchylenie standardowe (SE) -1,5 ± 0,1% dla obu dawek liraglutydu 1,2 mg i 1,8 mg v. -0,5 ± 0,1% dla placebo]. Ste?enie glukozy na czczo zmniejszy³o sie o odpowiednio o 40, 44 i 8 mg/dl w grupach przyjmuj±cych liraglutyd w dawce 1,2 mg, 1,8 mg i placebo; ste?enie glukozy 90 minut po posi³ku zmala³o odpowiednio o 47, 49 i 14 mg/dl (p < 0,001 dla obu grup przyjmuj±cych liraglutyd w porownaniu z grup± stosuj±c± placebo). Utrate masy cia³a zale?n± od dawki obserwowano w grupach przyjmuj±cych liraglutyd w dawce 1,2 mg i 1,8 mg (odpowiednio: 1,0 ± 0,3 i 2,0 ± 0,3 kg) (p < 0,0001) w porownaniu ze zwiekszeniem masy cia³a w grupie przyjmuj±cej placebo (0,6 ± 0,3 kg). Skurczowe ci¶nienie tetnicze zmniejszy³o sie o odpowiednio 6,7, 5,6 i 1,1 mm Hg w grupach przyjmuj±cych liraglutyd w dawce 1,2 mg i 1,8 mg oraz w grupie stosuj±cej placebo. W grupach leczonych liraglutydem, w porownaniu z grup± przyjmuj±c± placebo, obserwowano istotne zwiekszenie ste?enia peptydu C i poprawe czynno¶ci komorek b ocenian± w modelu homeostazy oraz istotne zmniejszenie stosunku ste?en proinsuliny do insuliny. Umiarkowana hipoglikemia wystepowa³a cze¶ciej w grupach przyjmuj±cych liraglutyd, nie obserwowano jednak incydentow cie?kiej hipoglikemii. Objawy uboczne ze strony przewodu pokarmowego obserwowano cze¶ciej w¶rod pacjentow stosuj±cych liraglutyd, jednak wiekszo¶ae z nich wystepowa³a na wczesnym etapie leczenia i mia³a charakter przej¶ciowy. WNIOSKI. Terapia liraglutydem w po³±czeniu z metformin± i tiazolidynodionami jest dobrze tolerowana przez chorych na cukrzyce typu 2 oraz zapewnia istotn± poprawe kontroli glikemii.

OBJECTIVE:Regulation of postprandial (pp) plasma glucose excursions is complex. Insulin and glucagon are thought to play the predominant role. Nevertheless, only 50% of the variation in pp plasma glucose excursions is explained by variations by the latter. Theoretically, gastric emptying (GE) should be another important factor. However, its impact on pp glucose homeostasis is unknown.RESEARCH DESIGN AND METHODS:We examined the consequences of pramlintide-induced delay in GE on pp glycemia and glucose fluxes, determined isotopically. GE was recorded by scintigraphy. Fourteen healthy subjects (8 men, 6 women; age 40 +/- 3 yr, body mass index 27.8 +/- 1.1 kg/m2) ate a mixed meal, and 30 microg of pramlintide (PRAM) or placebo (PBO) were injected subcutaneously.RESULTS:At 60 min, greater proportions of the initial gastric contents remained in the stomach (PBO vs. PRAM). Thereafter, GE slopes paralleled until 240 min. Fifty percent retention times were lower when PBO was given (P < 0.001). GE was greater from 240 min to the end of the PRAM experiments, so that only slightly greater proportions of the meal remained in the stomach at 330 min. Reductions of GE lowered pp glucose (7.5 +/- 0.3 vs. 6.0 +/- 0.2 mmol/l, P < 0.001), even though plasma insulin was lower with PRAM (164 +/- 13 vs. 138 +/- 13 pmol/ml, both P < 0.01). Reduction in total glucose appearance (P < 0.001) was due to reduced meal-derived glucose appearance (10.2 +/- 0.5 vs. 7.0 +/- 0.4 micromol.kg(-1).min(-1), P < 0.001). Endogenous glucose appearance was greater with PRAM (P < 0.001). Splanchnic glucose uptake was greater with PRAM (26.5 +/- 1.6 vs. 32.5 +/- 2.1%, P = 0.014).CONCLUSIONS:These data support the concept that GE is an important physiological regulator of pp glucose homeostasis in humans.

OBJECTIVE:Animal and in vitro studies indicate that a decrease in beta-cell insulin secretion, and thus a decrease in tonic alpha-cell inhibition by intraislet insulin, may be an important factor for the increase in glucagon secretion during hypoglycemia. However, in humans this role of decreased intraislet insulin is still unclear. RESEARCH DESIGN AND METHODS:We studied glucagon responses to hypoglycemia in 14 nondiabetic subjects on two separate occasions. On both occasions, insulin was infused from 0 to 120 min to induce hypoglycemia. On one occasion, somatostatin was infused from -60 to 60 min to suppress insulin secretion, so that the decrement in intraislet insulin during the final 60 min of hypoglycemia would be reduced. On the other occasion, subjects received an infusion of normal saline instead of the somatostatin. RESULTS:During the 2nd h of the insulin infusion, when somatostatin or saline was no longer being infused, plasma glucose ( approximately 2.6 mmol/l) and insulin levels ( approximately 570 pmol/l) were comparable in both sets of experiments (both P > 0.4). In the saline experiments, insulin secretion remained unchanged from baseline (-90 to -60 min) before insulin infusion and decreased from 1.20 +/- 0.12 to 0.16 +/- 0.04 pmol . kg(-1) . min(-1) during insulin infusion (P < 0.001). However, in the somatostatin experiments, insulin secretion decreased from 1.18 +/- 0.12 pmol . kg(-1) . min(-1) at baseline to 0.25 +/- 0.09 pmol . kg(-1) . min(-1) before insulin infusion so that it did not decrease further during insulin infusion (-0.12 +/- 0.10 pmol . kg(-1) . min(-1), P = 0.26) indicating the complete lack of a decrement in intraislet insulin during hypoglycemia. This was associated with approximately 30% lower plasma glucagon concentrations (109 +/- 7 vs. 136 +/- 9 pg/ml, P < 0.006) and increments in plasma glucagon above baseline (41 +/- 8 vs. 67 +/- 11 pg/ml, P < 0.008) during the last 15 min of the hypoglycemic clamp. In contrast, increases in plasma growth hormone were approximately 70% greater during hypoglycemia after somatostatin infusion (P < 0.007), suggesting that to some extent the increases in plasma glucagon might have reflected a rebound in glucagon secretion. CONCLUSIONS:These results provide direct support for the intraislet insulin hypothesis in humans. However, the exact extent to which a decrement in intraislet insulin accounts for the glucagon responses to hypoglycemia remains to be established.

CONTEXT During hypoglycemia, systemic glucose uptake (SGU) decreases and endogenous glucose release (EGR) increases. Skeletal muscle appears to be primarily responsible for the reduced SGU and may be important for the increased EGR by providing lactate for gluconeogenesis (GN). OBJECTIVE The objective of the study was to test the hypothesis that reduced muscle glucose uptake and increased muscle lactate release both make major contributions to glucose counterregulation using systemic isotopic techniques in combination with forearm net balance measurements. SETTING The study was conducted at the University of Giessen Clinical Research Center. PARTICIPANTS Nine healthy volunteers participated in the study. INTERVENTION A 2-h hyperinsulinemic euglycemic clamp (blood glucose approximately 4.4 mm) was followed by a 90-min hypoglycemic clamp (blood glucose approximately 2.6 mm). RESULTS Compared with the euglycemic clamp, SGU decreased (21.0 +/- 2.0 vs. 29.6 +/- 1.8 micromol.kg body weight(-1).min(-1); P < 0.001), whereas EGR (11.2 +/- 1.7 vs. 4.9 +/- 1.3 micromol.kg body weight(-1) .min(-1); P < 0.003), arterial lactate concentrations (1051 +/- 162 vs. 907 +/- 115 microm; P < 0.02), systemic lactate release (23.5 +/- 0.9 vs. 17.1 +/- 0.9 micromol.kg body weight(-1).min(-1); P < 0.001), and lactate GN (4.50 +/- 0.60 vs. 2.74 +/- 0.30 micromol.kg body weight(-1).min(-1); P < 0.02) increased during hypoglycemia; the proportion of lactate used for GN remained unchanged (38 +/- 4 vs. 32 +/- 3%; P = 0.27). Whole-body muscle glucose uptake decreased approximately 50% during hypoglycemia (6.4 +/- 1.9 vs. 13.6 +/- 2.9 micromol.kg body weight(-1).min(-1); P < 0.001), which accounted for approximately 85% of the reduction of SGU. Whole-body muscle lactate release increased 6.6 +/- 1.6 micromol.kg body weight(-1). min(-1) (P < 0.01), which could have accounted for all the increase in systemic lactate release and, considering the proportion of lactate used for GN, contributed 1.4 +/- 0.4 micromol.kg body weight(-1).min(-1) (approximately 25%) to the increase in EGR. CONCLUSIONS Reduced muscle glucose uptake and increased muscle lactate release both make major contributions to glucose counterregulation in humans.

Insulin suppresses and counterregulatory hormones increase proteolysis. Therefore, if proteolysis were a major factor determining amino acid fluxes in plasma, one would expect release of glutamine into plasma to be suppressed by insulin under euglycemic conditions and to be stimulated under hypoglycemic conditions. However, release of glutamine into plasma remains unaltered or increases during euglycemic hyperinsulinemia and decreases during insulin-induced hypoglycemia. To investigate the mechanisms for these paradoxical observations and the role of skeletal muscle, we infused overnight fasted volunteers with [U-14C] glutamine and measured release of glutamine into plasma, its removal from plasma, and forearm glutamine net balance, fractional extraction, uptake and release during 4-hour euglycemic (∼5.0 mmol/L, n = 7) and hypoglycemic (∼3.1 mmol/L, n = 8) hyperinsulinemic (∼230 pmol/L) clamp experiments. During the euglycemic clamps, plasma glutamine uptake and release (both P < .05) and forearm muscle glutamine fractional extraction (P < .05), uptake (P < .02) and release (P < .01) all increased, whereas forearm glutamine net balance remained unchanged. The increase in muscle glutamine release (from 1.85 ± 0.26 to 2.18 ± 0.30 μmol · kg−1 · min−1) accounted for approximately 60% of the increase in total glutamine release into plasma (from 5.54 ± 0.47 to 6.10 ± 0.64 μmol · kg−1 · min−1) and correlated positively with the increase in muscle glucose uptake (r = 0.80, P < .03). During the hypoglycemic clamps, plasma glutamine uptake and release and forearm glutamine release remained unaltered, but forearm glutamine fractional extraction and uptake decreased approximately 25% (both P < .01) so that forearm glutamine net release increased from 0.37 ± 0.06 to 0.61 ± 0.09 μmol · kg−1 · min−1 (P < .03). We conclude that skeletal muscle is largely responsible for the increased release of glutamine into plasma during euglycemic hyperinsulinemia in humans, and that this may be due to increased conversion of glucose to glutamine as part of the glucose-glutamine cycle; during hypoglycemic hyperinsulinemia decreased glutamine uptake by skeletal muscle may be important for providing substrate for increased glutamine gluconeogenesis.

Splanchnic and renal net balance measurements indicate that lactate and glycerol may be important precursors for epinephrine-stimulated gluconeogenesis (GNG) in liver and kidney, but the effects of epinephrine on their renal and hepatic conversion to glucose in humans have not yet been reported. We therefore used a combination of renal balance and isotopic techniques in nine postabsorptive volunteers to measure systemic and renal GNG from these precursors before and during a 3-h infusion of epinephrine (270 pmol. kg-1. min-1) and calculated hepatic GNG as the difference between systemic and renal rates. During infusion of epinephrine, renal and hepatic GNG from lactate increased 4- to 6-fold and accounted for approximately 85 and 70% of renal and hepatic glucose release, respectively, at the end of study; renal and hepatic GNG from glycerol increased approximately 1.5- to 2-fold and accounted for approximately 7-9% of renal and hepatic glucose release at the end of study. The increased renal GNG from lactate and glycerol was due not only to their increased renal uptake (approximately 3.3- and 1.4-fold, respectively) but also increased renal gluconeogenic efficiency (approximately 1.8- and 1.5-fold). The increased renal uptake of lactate and glycerol was wholly due to their increased arterial concentrations, since their renal fractional extraction remained unchanged and renal blood flow decreased. We conclude that 1) lactate is the predominant precursor for epinephrine-stimulated GNG in both liver and kidney, 2) hepatic and renal GNG from lactate and glycerol are similarly sensitive to stimulation by epinephrine, and 3) epinephrine increases renal GNG from lactate and glycerol by increasing substrate availability and the gluconeogenic efficiency of the kidney.

In type 2 diabetes renal and hepatic glucose release are increased and free fatty acids (FFA) clearance is reduced. Restoration of normoglycemia by exogenous insulin replacement normalizes overall glucose release and plasma FFA concentrations. However, it is unclear to what extent normalization of overall glucose release is due to suppression of hepatic (HGR) and renal glucose release (RGR) and whether the abnormal FFA clearance is improved. We therefore determined overall, renal, and hepatic glucose release, as well as systemic FFA release and clearance by tracer techniques in type 2 diabetic subjects with (DM(+)) and without (DM(-)) physiologic overnight insulin infusion and in nondiabetic volunteers (NV). Insulin infusion normalized plasma glucose (5.3 +/- 0.1 v 5.2 +/- 0.1 mmol/L in NV) and overall glucose release (10.1 +/- 0.7 v 10.6 +/- 0.4 micromol x kg(-1) x min(-1) in NV), (both P >.9). Values in DM(-) were 9.1 +/- 0.6 mmol/L and 14.6 +/- 0.8 micromol x kg(-1) x min(-1), respectively (both P <.001 v DM(+) and NV). The correction of overall glucose release in DM(+) was due to suppression of HGR to rates below normal (6.11 +/- 0.53 v 8.67 +/- 0.44 micromol x kg(-1) x min(-1) in NV, P <.03). RGR remained increased (3.91 +/- 0.38 v 1.90 +/- 0.28 micromol x kg(-1) x min(-1) in NV, P <.002) and was similar to DM(-) (3.97 +/- 0.33 micromol x kg(-1) x min(-1), P >.9). Insulin infusion also normalized plasma FFA levels (450 +/- 45 v 476 +/- 42 in NV, P >.9 and v613 +/- 33 micromol/L in DM(-), P <.04). This was due to suppression of FFA release to below normal (4.04 +/- 0.45 v 5.25 +/- 0.25 micromol x kg(-1) x min(-1) in NV, P <.04). Plasma FFA clearance remained reduced (7.2 +/- 1.0 v 11.4 +/- 1.2 mL x kg(-1) x min(-1) in NV, P <.04) and was similar to DM(-) (7.3 +/- 0.5 mL x kg(-1) x min(-1), P >.9). We conclude that in contrast to the excessive HGR, excessive RGR and impaired FFA clearance are not corrected by acute exogenous insulin replacement.

Release of glucose by the kidney in postabsorptive normal humans is generally regarded as being wholly due to gluconeogenesis. Although lactate is the most important systemic gluconeogenic precursor and there is appreciable net renal lactate uptake, renal lactate gluconeogenesis has not yet been investigated. The present studies were therefore undertaken to quantitate the contribution of lactate to renal gluconeogenesis and the role of the kidney in lactate metabolism. We determined systemic and renal lactate conversion to glucose as well as renal lactate net balance, fractional extraction, uptake, and release in 24 postabsorptive humans by use of a combination of isotopic and renal balance techniques. For comparative purposes, accumulated similar data for glutamine, alanine, and glycerol are also reported. Systemic lactate gluconeogenesis (1.97 +/- 0.12 micromol x kg(-1) x min(-1)) was about threefold greater than that from glycerol, glutamine, and alanine. The sum of gluconeogenesis from these precursors, uncorrected for tricarboxylic acid (TCA) cycle carbon exchange, explained 34% of systemic glucose release. Renal lactate uptake (3.33 +/- 0.28 micromol x kg(-1) x min(-1)) accounted for nearly 30% of its systemic turnover. Renal gluconeogenesis from lactate (0.78 +/- 0.10 micromol x kg(-1) x min(-1)) was 3.5, 2.5, and 9.6-fold greater than that from glycerol, glutamine, and alanine. The sum of renal gluconeogenesis from these precursors equaled approximately 40% of the sum of their systemic gluconeogenesis. When the isotopically determined rates of systemic and renal gluconeogenesis were corrected for TCA cycle carbon exchange, gluconeogenesis from these precursors accounted for 43% of systemic glucose release and 89% of renal glucose release. We conclude that 1) in postabsorptive normal humans, lactate is the dominant precursor for both renal and systemic gluconeogenesis; 2) the kidney is an important organ for lactate disposal; 3) under these conditions, renal glucose release is predominantly, if not exclusively, due to gluconeogenesis; and 4) liver and kidney are similarly important for systemic gluconeogenesis.