Early postprandial glucagon concentrations are higher in type 1 diabetes (T1D) than in individuals with no diabetes (ND). To determine the cause, we infused stable [13C9, 15N1]glucagon before, during, and after a mixed meal in 16 ND and 16 T1D individuals to measure glucagon turnover. In a subcohort of 9 ND and 12 T1D individuals, we estimated [13C9, 15N1]glucagon kinetics during steady state. A linear, single-compartment model described [13C9, 15N1]glucagon kinetics and allowed precise estimation of the volume of distribution (VD) and clearance rate (CL). Model parameters were similar between groups, with the VD of [13C9, 15N1]glucagon at 42.1 ± 3.3 mL/kg, implying that [13C9, 15N1]glucagon distributes in a single compartment and with VD approximating the plasma volume and CL at 10.6 ± 0.9 mL/kg/min. Higher early (0–120 min after meal ingestion) postprandial glucagon concentrations (1,907.9 ± 373.4 vs. −93.6 ± 240.5 pg/mL · 120 min P < 0.001) observed in T1D was due to higher rates of glucagon appearance (3.39 ± 2.8 vs. −3.95 ± 2.0 ng/kg · 120 min, P < 0.04) and disappearance (2.13 ± 2.6 vs. −5.28 ± 2.1 ng/kg · 120 min, P < 0.04) compared with ND. We have determined postprandial glucagon turnover in humans and have demonstrated that changes in postprandial glucagon concentrations in T1D are due to increased rates of glucagon turnover during the early postprandial period. ARTICLE HIGHLIGHTS:This study was conducted to determine postprandial glucagon metabolism in people with and without type 1 diabetes. We wanted to determine the cause for higher early postprandial glucagon concentrations in type 1 diabetes. We found that higher early postprandial glucagon turnover is the cause of higher early postprandial glucagon concentrations in type 1 diabetes Strategies that decrease early post prandial glucagon fluxes could improve postprandial glucose concentrations in type 1 diabetes.

Current Type 2 diabetes therapies inadequately address multi-organ complications. We evaluated bivalent nanoparticles encapsulating curcumin, combined with insulin, against diabetic complications. Our data indicate shared pathophysiological mechanisms driving the association between retinal and cardiac injury, specifically systemic inflammation and mitochondrial dysregulation across both organs. Retinal stress (HIF1α, REDD1, VEGF) preceded cardiac remodeling, characterized by lymphangiogenesis (LYVE1, VEGFR3) and impaired PPARα/ PGC1α signaling. Furthermore, we identified a strong pathological correlation between intraocular and systemic blood pressures as an in-vivo physiological readout of widespread vascular dysregulation. While males exhibited an earlier onset, females progressed more rapidly to complications. The combination therapy proved highly effective in both sexes. While females exhibited a more pronounced reduction in systemic inflammation and pathological pressure correlation, males demonstrated robust metabolic and structural preservation. These findings highlight ocular hemodynamics as an early physiological indicator of cardiac complications, supporting this sex-specific nanotherapeutic strategy, combined with insulin, to mitigate diabetic complications.

Introduction and Objective: Postbariatric hypoglycemia (PBH) is responsive to glucagon, but therapeutic doses may trigger recurrent hyper- and hypoglycemia and side effects. In this study, we quantified the dose response of glucose to microdoses of glucagon in individuals with PBH. Methods: Individuals with PBH were enrolled (0 M, 12 F, age 51.0 ± 11.1, BMI 31.24 ± 4.59 kg/m2). After an overnight fast, serial microdoses of glucagon were administered in either ascending or descending doses on 2 study days (randomized order, range 75 to 450 mcg, every 30 minutes) to determine glucagon-stimulated incremental glucose and EGP. Glucose turnover was measured with [6,6-2H2] glucose infusion. Arterialized venous blood was collected to measure glucose, [6,6-2H2] glucose and hormone concentrations. Results: Initial doses of glucagon induced the greatest increment in glucose (p<0.05) and EGP (p<0.05), with greater responses to larger initial doses. Subsequent doses induced smaller changes in glucose, irrespective of order of dosing, potentially due to reduced hepatic glycogen. Incremental glucose and EGP were correlated (escalation: R=0.54, p=0.02, de-escalation: R=0.68, p=0.002). Conclusion: The data demonstrates that in fasted individuals with PBH, the initial microdose of glucagon results in predictable increment of glucose due to an increase in EGP, while subsequent doses may not. This data will inform dose optimization for closed-loop glucagon delivery to prevent and treat severe hypoglycemia in PBH. Disclosure S. Brown: None. F. Bril: Consultant; Current; Novo Nordisk. Advisory Panel; Current; Novo Nordisk. Consultant; Current; Madrigal Pharmaceuticals, Inc. Advisory Panel; Current; Madrigal Pharmaceuticals, Inc. Consultant; Current; Boehringer Ingelheim International GmbH. Advisory Panel; Current; Boehringer Ingelheim International GmbH. E. Arevalo-Rios: None. L. Pei: None. G. Londono: None. R. Basu: None. A. Basu: Research Support; Current; Dexcom, Inc. M.E. Patti: Other - My institution receives research funding for clinical trial.; Current; Recordati S.p.A, Amylyx. Other - Data Safety Monitoring Board; Current; Fractyl Health, Inc. Funding DK 137518DK 036836T32 DK 007260DK 029953DK 085516

Introduction and Objective: We have previously shown that the diurnal pattern of glucose tolerance following simple carbohydrate meals differ in people with or without type 2 diabetes (T2D). This study aimed to further characterize the inter-individual variability of insulin sensitivity (SI), beta cell responsivity (Φ) and disposition index (DI) in people with T2D. Methods: Nineteen subjects with T2D (Age=61±10 y; BMI=32±5 kg/m2; 7F) were studied with identical mixed meals (8 kcal/kg/meal;75 g carbohydrate) at breakfast, lunch, and dinner on 3 consecutive days in a randomized latin square design. Glucose and C-peptide minimal models were used to estimate SI, Φ and DI. We identified the maximum SI, Φ and DI in each individual and used Z-test to classify the remaining as high as the maximum (H) or significantly lower (L). Based on these classifications, each individual exhibited one of the following seven patterns across breakfast, lunch, and dinner: HHH, HHL, HLH, HLL, LHH, LHL, or LLH. Results: The most frequently observed patterns for SI, Φ and DI were LHL (7/19, 37%), HLL (7/19, 37%) and HHL (6/19, 32%), respectively (Fig.1). Conclusion: We described the heterogeneity of SI, Φ and DI daily patterns in T2D. Results show that, in most individuals with T2D, DI declines during the day. Perhaps changing meal type to complex carbohydrate or adjusting the exercise regimen could help sustaining glucose tolerance though the day. Disclosure J. Bonet: None. C. Dalla Man: Other - Webinar provider; Ended; Sanofi. Other - Joint research project; Current; Sanofi-Aventis Deutschland GmbH. B. Gran: None. A. Basu: Research Support; Current; Dexcom, Inc. M. Schiavon: Research Support; Current; Sanofi. R. Basu: None. Funding MUR PRIN 2022 PNRR (P2022XSFA7), NIH (R01 DK 029953)

Introduction and Objective: The relative contribution of circulating glucose and insulin concentrations to glucagon secretion in healthy individuals is unknown. We therefore assessed glucagon secretion using [13C9,15N1]-glucagon tracer at varying insulin and glucose concentrations in healthy individuals. Methods: After overnight fast, twelve healthy individuals underwent three separate clamp visits (hypo-, eu-, hyper-glycemia) in random order at two insulin infusion rates. Five (3F; mean±SE: age=27.6±4.1 y; BMI=24.1±1.8 kg/m²) received insulin infusion at 0.25 and 0.75 mU/kg/min for 90 min each; the remaining (3F; age=27.6±1.8 y; BMI=26.4±1.0 kg/m²) at 0.5 and 1 mU/kg/min over the same intervals. Simultaneously, [13C9,15N1]-glucagon tracer was infused. Arterialized venous blood was collected for plasma glucose, insulin, glucagon and glucagon tracer measurements. Systemic rate of glucagon appearance (Ra) was calculated as recently described. Results: At hyperglycemia, glucagon Ra was suppressed and did not differ from 0 at any insulin concentration. At euglycemia, a negative trend in glucagon Ra was observed with rising insulin levels. During hypoglycemia, glucagon Ra was significantly higher than eu- and hyper-glycemia (p<0.001), with no apparent effects of increasing insulin concentrations. Conclusion: Glucagon secretion appears to be primarily regulated by circulating glucose and not by insulin concentrations in healthy adults. Disclosure E. Zagallo: None. M. Schiavon: Research Support; Current; Sanofi. F. Ruchi: None. C. Dalla Man: Other - Webinar provider; Ended; Sanofi. Other - Joint research project; Current; Sanofi-Aventis Deutschland GmbH. R. Basu: None. A. Basu: Research Support; Current; Dexcom, Inc. Funding National Institutes of Health (DK085516), National Institutes of Health (DK029953)

CONTEXT:Higher gluconeogenesis (GNG) contributes to higher nocturnal endogenous glucose production (EGP) in type 2 diabetes (T2D). Studies using 13C magnetic resonance spectroscopy (MRS) have confirmed lower hepatic glycogen content in subjects with T2D than in subjects with no diabetes (ND). OBJECTIVE:We determined the role of glycogen loading (GL) vs nonglycogen loading (NGL) on the contribution of GNG to nocturnal EGP in T2D. METHODS:In total, 14 subjects with T2D and 15 matched subjects with ND were studied on 2 occasions, with GL (60% carbohydrate) vs NGL (40% carbohydrate) isocaloric meals for 3 days, in random order in the overnight state. [6,6-2H2] glucose was infused to measure EGP, deuterium labelled water was used to measure GNG, and 13C MRS scans were performed in fed and fasted states to measure hepatic glycogen content. RESULTS:Hepatic glycogen content and nocturnal EGP were higher (P < .05) in GL vs NGL in both cohorts. The % GNG to EGP averaged ∼50% in subjects with ND throughout the night after both meals. In contrast, % GNG to nocturnal EGP in T2D was lower with GL vs NGL and matched the pattern observed in subjects with ND with GL lowering overnight rates of GNG in subjects with T2D. CONCLUSION:Selective targeting of GNG at night with appropriate medications could reduce nocturnal and early morning fasting hyperglycemia and hepatic insulin resistance in people with T2D.

Circulating glucagon concentrations differ between nondiabetic (ND) and type 1 diabetes (T1D) individuals. We combined isotope dilution technique using stable tracers [6,22 13C9, 15N1]-Glucagon and [6,14,19,22 13C9, 15N1]-Glucagon with splanchnic and leg catheterization in ND (n=8; age 23.1±2.9 yrs, BMI 26.6±3.5 kg/m2, HbA1c 5.0±0.2% (31±2 mmol/mol) and T1D (n=6; 29.0±8.8 yrs, BMI 26.3±5.0 kg/m2, HbA1c 7.9±0.8% (63±8 mmol/mol) participants in the overnight fasted state. After baseline period, exogenous glucagon was infused at rates designed to achieve plasma glucagon concentrations spanning the physiological ranges, to determine the effects of rising glucagon concentrations on splanchnic and leg glucagon balance. At baseline, splanchnic glucagon extraction (SGE) was similar (30.7±2.7 vs. 29.1±2.9%), but leg glucagon extraction (LGE) lower (27.0±4.2 vs. 40.6±3.1%), in T1D than ND participants. However, with increasing plasma glucagon concentrations, while SGE remained unchanged within and between groups, LGE fell in ND (41 vs. 31 vs. 24%) but did not change in T1D participants. Despite a numerically lower net splanchnic glucagon production in T1D than ND participants, no changes were observed with increasing glucagon concentrations within the physiological range in both groups. This is the first human study, applying novel glucagon isotopes, that describes regional glucagon metabolism in ND and T1D participants. Our observations provide translational relevance for dual hormone closed loop systems as well as provide tools for probing the effects of GLP-1, dual and triple receptor agonists on pancreatic a-cell functions.

Circulating glucagon concentrations differ between individuals with no diabetes (ND) and those with type 1 diabetes (T1D). We combined an isotope dilution technique using stable tracers [6,22-13C9,15N1]glucagon and [6,14,19,22-13C9,15N1]glucagon with splanchnic and leg catheterization in participants with ND (n = 8; age 23.1 ± 2.9 years, BMI 26.6 ± 3.5 kg/m2, HbA1c 5.0 ± 0.2% [31 ± 2 mmol/mol]) and T1D (n = 6; 29.0 ± 8.8 years, BMI 26.3 ± 5.0 kg/m2, HbA1c 7.9 ± 0.8% [63 ± 8 mmol/mol]) in the overnight fasted state. After baseline period, exogenous glucagon was infused at rates designed to achieve plasma glucagon concentrations spanning the physiological ranges, to determine the effects of rising glucagon concentrations on splanchnic and leg glucagon balance. At baseline, splanchnic glucagon extraction (SGE) was similar (30.7 ± 2.7 vs. 29.1 ± 2.9%) but leg glucagon extraction (LGE) was lower (27.0 ± 4.2 vs. 40.6 ± 3.1%) in participants with T1D versus those with ND. However, with increasing plasma glucagon concentrations, while SGE remained unchanged within and between groups, LGE fell in participants with ND (41 vs. 31 vs. 24%) but did not change in those with T1D. Despite a numerically lower net splanchnic glucagon production in participants with T1D than in those with ND, no changes were observed with increasing glucagon concentrations within the physiological range in both groups. This is the first human study applying novel glucagon isotopes that describes regional glucagon metabolism in participants with ND and T1D. Our observations provide translational relevance for dual hormone closed-loop systems and provide tools for probing the effects of GLP-1, dual, and triple receptor agonists on pancreatic α-cell functions. ARTICLE HIGHLIGHTS:This study was conducted to assess splanchnic and leg glucagon metabolism in humans using stable glucagon isotopes. We wanted to evaluate whether splanchnic and leg glucagon metabolism differed between participants with no diabetes (ND) and those with type 1 diabetes (T1D) at glucagon concentrations spanning the physiological range. Whereas splanchnic glucagon extraction did not differ between participants with ND and those with T1D, leg glucagon extraction fell in those with ND but did not change in those with T1D as glucagon concentrations increased. Net splanchnic glucagon production did not change with exogenous glucagon infusion. Our study has implications for dual hormone closed-loop control in T1D where glucagon is infused for prevention of hypoglycemia and for investigating the effects of emerging GLP-1, glucose-dependent insulinotropic polypeptide, and glucagon receptor agonists on endogenous glucagon secretion and clearance.

Introduction and Objective: A novel tracer method using natural [13C]-enrichment of polysaccharides in commercially available grains was developed previously to measure postprandial insulin sensitivity and β-cell function, using Minimal Model analysis. This study was conducted to determine whether complex carbohydrate-based meals can improve insulin resistance in Type 2 diabetes (T2D). Methods: Seven T2D were studied twice following isocaloric mixed meals with identical macronutrient compositions (50% carb, 20% protein, 30% fat). The carbohydrate was either glucose (simple carb, SC) or sorghum (complex carb, CC). Oral antidiabetes medications were withheld prior to meal study. We estimated Si, a marker of whole-body insulin sensitivity, and beta cell responsiveness (Phitotal) in response to meal stimuli. Disposition index (DI; beta cell responsivity appropriate to the degree of insulin resistance) was computed as well. Results: Results are shown in Figure 1. Post meal glucose concentrations were lower with CC than SC meal. Si and DI were significantly higher (p<0.05) with CC vs SC meal while Phitotal increased but was not statistically different (p=0.21). Conclusion: Results suggest that CC meals significantly improve insulin resistance in people with T2D. We provide mechanistic insights as to why glucose tolerance improves with CC meals and should be preferred over SC meals in T2D. S. Perazzolo: Consultant; Abbott Diagnostics. U.S. Unni: None. C. Lane: None. B. Gran: None. A. Basu: None. R. Basu: Advisory Panel; Novo Nordisk, Boehringer-Ingelheim. National Institute of Health (R01 DK029953, R01 DK085516, DK059637 (MMPC)) and (DK020593 (DRTC))

Introduction and Objective: We have previously shown impaired direct pathway of hepatic UDP glucose flux implying a defect in hepatic glucokinase activity (GKA) in type 2 diabetes (T2D). Dorzagliatin is a new Glucokinase activator not yet approved in the US. This study was done under an FDA IND-159103 to provide mechanistic insight into whether Dorzagliatin enhances GKA in T2D. Methods: Six T2D subjects (age ~69 yrs, BMI ~31.0 kg/m2, FPG ~8.3 mmol/L, HbA1c ~7.4%, 17 years average diabetes duration) were studied before and after 6-week monotherapy with 75 mg twice daily oral Dorzagliatin. All other antidiabetes medications were discontinued prior to study. Subjects underwent a 3-hour hyperglycemic (~9.3 mM) hyperinsulinemic (0.25 mU/Kg/min) clamp at baseline and post treatment. Endogenous glucose production (EGP) and UDP-Glucose flux were estimated using [3-3H] Glucose and [1-14C] Galactose infusions as previously established. 50% dextrose containing [3-3H] Glucose was infused during the clamp to keep specific activity of tracer constant permitting steady state equations for calculation of fluxes. Results: The trial is ongoing. Plasma glucose, insulin and glucagon concentrations were similar during clamp baseline and post treatment. EGP was similar during clamp at baseline and post treatment (8.3±3.6 vs. 9.3±3.0 µmol/KgFFM/min). Total UDP glucose flux was ~30% higher (4.7±1.1 vs. 5.7±2.2 µmol/KgFFM/min) post treatment and was entirely due to increase in the direct pathway (2.4±0.5 vs. 3.1±1.1 µmol/KgFFM/min). No SAEs such as hypoglycemia occurred, and safety labs (LFT, uric acid and TG) remained within normal limits at the end of the trial. Conclusion: The initial data suggest that dorzagliatin increases total UDP-glucose flux through the direct pathway of glycogen synthesis, implying an increase in hepatic GKA in people with T2D. Future larger clinical trials are required to test long term glucose control with this new drug for T2D. U.S. Unni: None. A. Hodhod: None. D. Truong: None. B. Gran: None. A. Basu: None. R. Basu: Advisory Panel; Novo Nordisk, Boehringer-Ingelheim. National Institute of Health (R01 DK029953, R01 DK085516, DK059637 (MMPC) and DK020593 (DRTC).

To date, few studies have quantified glucagon kinetics in humans with and without diabetes, with results often varying due to differences in experimental designs and glucagon assay methodologies. This has limited the ability to study glucagon secretion in vivo using methods such as deconvolution. To overcome these limitations, a novel stable glucagon tracer, [13C15N]-glucagon, along with high-resolution mass spectrometry, has been used to study glucagon kinetics and turnover in humans.In this work, we present a nonlinear mixed effects modeling approach to describe glucagon kinetics in healthy subjects and individuals with type 1 diabetes (T1D). To do so, data from a novel stable isotope-labeled glucagon tracer ([13C15N]-glucagon), collected in 9 healthy controls (HC) and 12 individuals with T1D following an intravenous bolus injection under basal steady-state, post-absorptive conditions, were used. Models of increasing complexity were developed and tested against the data, with model selection guided by standard criteria such as the ability of the model to describe the data, precision and physiological plausibility of parameter estimates and parsimony.A one-compartment model effectively describes typical population kinetics (TPK) of glucagon, along with the between-subject variability (BSV) and inter-occasion variability (IOV), linking individual differences to easily accessible subject characteristics. In particular, model-predicted outcome highlights that variability in glucagon kinetics is predominantly explained by individual-specific factors, like age and body weight, rather than by group-specific factors, like HC vs. T1D.Future work will focus on integrating this model into simulation platforms to enable the evaluation of advanced artificial pancreas systems, further enhancing diabetes care.Clinical Relevance— This model is crucial for assessing glucagon turnover in the post-absorptive state and represents a significant step toward the quantification of glucagon secretion in humans.

Introduction and Objective: In Type 2 Diabetes (T2D) higher nocturnal glucose production (EGP) results from higher glycogenolysis (GGL) and gluconeogenesis (GNG). Appropriate medications are needed to restore nocturnal EGP. We hypothesized that Dorzagliatin (DG) IND-159103-Glucokinase activator), insulin glargine (IG) (inhibitor of GGL) and metformin (M) (inhibitor of GNG) may lower GGL and GNG thereby lowering EGP in T2D. Methods: Twenty-three T2D subjects (age ~62 yrs, BMI ~32.0Kg/m2, FPG ~7.0mmol/L, HbA1C ~7.0%, ~9 years average diabetes duration) insulin or long acting GLP-1 agonist naive received 6-week monotherapy with either DG=7 (75mg bid), IG=9 (once daily) or M=7 (1.5-2gm daily). All other antidiabetes medications were washed out. Studies were conducted overnight at baseline (BL) and post treatment (PT). EGP, GNG and GGL were estimated at 1,4,7 AM using infusion of [6,6-2H2] glucose (10 PM-7 AM) following ingestion of deuterium labeled water (2H2O) as previously established. Results: The trial is ongoing. EGP was lower with DG (BL vs PT:18.7±9.8vs.15.6±12.5 at 1am;15.4±4.9 vs 14.6±7.0 µmol/KgFFM/min at 7am) primarily due to lower GGL (BL vs PT:10.3±4.2 vs 9.1±7.5 at 1am; 10.4±3.4 vs 7.9±3.5 µmol/kgFFM/min at 7am with similar values at 4am). Similarly, EGP was lower with IG (BL vs PT:19.1±8.0 vs 18.5±10.4 at 1am, 17.9±5.6 vs 16.4±7.3 at 4am and 18.9±5.5 vs 17.1±8.1 µmol/kgFFM/min at 7am). Decrease in EGP was due to lower GGL overnight as hypothesized (9.8±4.2 vs 8.6±3.7 at 4am and 10.2±4.4 vs 9.3± 4.4 µmol/kgFFM/min at 7am). On the contrary, M therapy with the prescribed standard dose was insufficient to lower EGP overnight (BL vs PT: 14.3±8.8 vs 17.5±4.1 at 1am;18.0±5.0 vs 18.2±6.0 at 4am;12.2±4.6 vs 15.6±5.5 µmol/kgFFM/min at 7am). Conclusion: Both DG and IG lowered nocturnal EGP by reducing rates of GGL overnight with a smaller contribution of GNG. M used as monotherapy did not provide adequate lowering of nocturnal EGP. These drugs used in combination may target GGL and GNG overnight thereby reducing nighttime EGP. A. Hodhod: None. U.S. Unni: None. B. Gran: None. A. Basu: None. R. Basu: Advisory Panel; Novo Nordisk, Boehringer-Ingelheim. National Institutes of Health (R01 DK029953, R01 DK085516DK059637 (MMPC), and DK020593 (DRTC))

CONTEXT:Circulating lactate concentration is an important determinant of exercise tolerance. OBJECTIVE:This work aimed to determine the role of hyperglycemia on lactate metabolism during exercise in individuals with type 1 diabetes (T1D). METHODS:The protocol at the University of Virginia compared 7 T1D participants and 7 participants without diabetes (ND) at euglycemia (5.5 mM) or hyperglycemia (9.2 mM) in random order in T1D and at euglycemia in ND. Intervention included [1-13C] lactate infusion, exercise at 65% maximal oxygen uptake (VO2max), euglycemia, and hyperglycemia visits. The main outcome measure was lactate turnover before, during, and after 60 minutes of exercise at 65% VO2max. RESULTS:A 2-compartment model with loss only from the peripheral compartment described lactate kinetics. Volume of distribution of the accessible compartment was similar between T1D and ND individuals (P = .76) and concordant with plasma volume (∼40 mL/kg). Circulating lactate concentrations were higher (P < .001) in T1D participants during exercise at hyperglycemia than euglycemia. Exercise-induced lactate appearance did not differ (P = .13) between hyperglycemia and euglycemia. However, lactate clearance (CL) was lower (P = .03) during hyperglycemia than euglycemia in T1D participants. There were no differences in any of the aforementioned parameters between T1D and ND participants during euglycemia. CONCLUSION:Hyperglycemia modulates lactate metabolism during exercise by lowering CL, leading to higher circulating lactate concentrations in T1D individuals. This novel observation implies that exercise during hyperglycemia can lead to higher circulating lactate concentrations thus increasing the likelihood of reaching the lactate threshold sooner in T1D, and has high translational relevance both for providers and recreationally active people with T1D.

Receptor-mediated polyester drug delivery systems have tremendous potential for improving the clinical performance of existing pharmaceutical drugs. Despite significant progress made in this area, it remains unclear how and to what extent the polyester nanoparticle surface topography would affect the in vitro, ex vivo and in vivo performance of a drug, and if there exists a correlation between in vitro and in vivo, as well as healthy versus pathophysiological states. Herein, we report a systematic investigation of the interactions between ligands and receptors as a function of the linker length, two-carbon (2C) versus four-carbon (4C). The in vitro, ex vivo and in vivo in healthy models validate the hypothesis that 4C has better reach and binding to the receptors. The results indicate that 4C offered better performance over 2C in vivo in improving the oral bioavailability of insulin (INS) by 1.1-fold (3.5-fold compared to unfunctionalized nanoparticles) in a healthy rat model. Similar observations were made in pathophysiological models; however, the effects were less prominent compared to those in healthy models. Throughout, ligand decorated nanoparticles outperformed unfunctionalized nanoparticles. Finally, a semimechanistic pharmacokinetic and pharmacodynamic (PKPD) model was developed using the experimental data sets to quantitatively evaluate the effect of P2Ns-GA on oral bioavailability and efficacy of insulin. The study presents a sophisticated oral delivery system for INS or hydrophilic therapeutic cargo, highlighting the significant impact on bioavailability that minor adjustments to the surface chemistry can have.