Metabolic Signalling in Muscle- and Adipose-tissue Following Insulin Withdrawal and Growth Hormone Injection.

February 23, 2016 updated by: Thomas Schmidt Voss, University of Aarhus

Metabolic Signalling in Muscle- and Adipose Tissue Following Insulin Withdrawal and Growth Hormone Injection in Type I Diabetes Mellitus, a Clinical Experimental Study.

Diabetes mellitus type I (DM I) is characterized by lack of endogenous insulin and these patients are 100% dependent on insulin substitution to survive.

Insulin is a potent anabolic hormone with its primary targets in the liver, the skeletal muscle-tissue and - adipose-tissue.

Severe lack of insulin leads to elevated blood glucose levels, dehydration, electrolyte derangement, ketosis and thus eventually ketoacidosis.

Insulin signalling pathways are well-known.

Growth hormone (GH) is also a potent anabolic hormone, responsible for human growth and preservation of protein during fasting. GH (in concert with lack of insulin) induces lipolysis during fasting. It is not known how GH exerts its lipolytic actions.

The aim is to define insulin and growth hormone (GH) signalling pathways in 3 different states in patients with DM I.

And to test whether ATGL-related lipolysis in adipose tissue contributes to the development of ketosis.

  1. Good glycemic control
  2. Lack of insulin (ketosis/ketoacidosis)
  3. Good glycemic control and GH injection

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

Diabetes mellitus type I (DMI ) is characterized by lack of endogenous insulin and these patients are 100% dependent on insulin substitution to survive.

Insulin is a potent anabolic hormone with its primary targets in- the liver, -the skeletal muscle-tissue and - fat-tissue.

In the liver it enhances glycogenesis and inhibits glycogenolysis and gluconeogenesis.

In skeletal muscle-tissue, it enhances glucose transport into the cell, glycogenesis, glycolysis, glucose oxidation and protein synthesis.

In fat-tissue, it inhibits lipolysis and enhances lipogenesis.

This indicates that a fall in serum insulin levels lead to increased blood glucose and increased levels of FFA's (free fatty acids) in the blood - eventually leading to ketone production.

If this condition is not corrected, it will lead to ketoacidosis, which is a potentially life-threatening condition, that is to be corrected under hospital admission with fluid-therapy, electrolyte- and insulin-substitution.

Insulin has been studied thoroughly and signalling pathways are well known.

An interesting pathway is suppression of lipolysis. The most important and rate-limiting lipase in triglyceride hydrolysis is adipose triglyceride lipase (ATGL)(1-5). A connection between ATGL and G0/G1 switch gene (G0S2) has been shown (6,7). During lipolysis ATGL is up-regulated and G0S2 is down-regulated and the promoter region for G0S2 has binding-sites for glucose, insulin dependent transcription factors and peroxisome proliferator-activated receptors y (PPAR-y)(8).

One former study has shown that fasting reduces G0S2 and increases ATGL in humane adipose-tissue(7).

The anti-lipolytic effects of insulin, could be thought, to be mediated through increased transcription of G0S2 which then in turn inhibits ATGL. Conversely, increased lipolysis during lack of insulin.

Growth hormone and growth hormone dependent synthesis og IGF-1 (Insulin-like growth factor - 1) is crucial for human growth before and during adolescence. As an adult GH and IGF-1 are still potent growth factors and also they exert essential regulatory properties on human metabolism(9,10)

GH- signalling pathways go through the GH-receptor, which phosphorylates and thus activates the receptor associated Janus Kinase 2 (JAK2). The signals from this point have been examined in numerous studies.

In rodents, the signal has been shown to run three ways (9,10) Studies on human fibroblast cells have been able to support two of these pathways (MAPK - mitogen-activated protein kinase and STAT - signal transducer and activator of transcription), but not through the insulin receptor substrate (IRS) and phosphatidylinositol 3-kinase (PI3-K) pathway.

In human (in vivo) studies, GH stimulation and phosphorylation of STAT5 has been evident, however an association between GH stimulation and activation of MAPK and PI3-K has not been shown (11).

The latter is interesting and remarkable, considering the insulin-agonistic and antagonistic effects of GH.

GH stimulates lipolysis, but exactly how the lipolytic properties of GH are mediated is not fully understood. However, it is shown that GH has an effect on hormone-sensitive lipase (12) (HSL).

Other options could be, as found in rodents, interaction via PI3-K signaling pathway or via G0S2/ATGL interaction, either directly or perhaps mediated through IGF-1.

Humane intracellular signaling-pathways during development of ketosis/ketoacidosis are not well-known. The investigators believe that understanding these pathways and the exact mechanisms behind the development of ketoacidosis, is of great importance.

Study Type

Interventional

Enrollment (Actual)

9

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Denmark
    • Aarhus C
      • Aarhus, Aarhus C, Denmark, 8000
        • Institute of clinical medicine

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years to 65 years (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

Male

Description

Inclusion Criteria:

Diagnosis of Diabetes Mellitus Type I, C-peptide negative, 19 < BMI < 26, Written consent -

Exclusion Criteria:

Ischemic heart disease, Cardiac arrythmia, Epilepsy, Other medical illness

-

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Basic Science
  • Allocation: Randomized
  • Interventional Model: Factorial Assignment
  • Masking: Single

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
No Intervention: Insulin

good glycemic control: 50 % of the subject's basal insulin dosage will be given as a continuous IV administration of insuman rapid overnight (hospitalized and fasting from 10 p.m.) and on the study-day. Basal period from 7.00 am to 12.00pm. The subject will undergo a hyperinsulinemic euglycemic clamp from 12.00 pm to 2.30 pm.

Three muscle- and three fat-biopsies will be obtained. A palmitic-acid tracer, a glucose tracer, urea tracer, tyrosine- and phenylalanine- tracers will be given.
Experimental: Insulin withdrawal

10 % of the individual subject's regular insulin dosage will be given as a continuous IV administration of insuman rapid overnight (hospitalized and fasting from 10 p.m.) Basal period from 7.00 am to 12.00 pm (without insulin). The subject will undergo a hyperinsulinemic euglycemic clamp from 12.00 pm to 2.30 pm.

Three muscle- and three fat-biopsies will be obtained. A palmitic-acid tracer, a glucose tracer, urea tracer, tyrosine- and phenylalanine- tracers will be given.
Drug: Insulin withdrawal
Withdrawal of usual (evening) insulin, replaced by Insuman Rapid (10% of the amount of usual evening insulin) as a continuous IV- administration overnight until 8 o'clock on the study day.
Other Names:
  • Insuman Rapid
Experimental: Norditropin (Growth Hormone)

Same amount of insulin administered on the control day (good glycemic control) overnight and on the study day (hospitalized and fasting from 10 p.m.). On the study day, a bolus injection of 0,4 mg of growth hormone (Norditropin) will be administered at 7.05 am. Basal period from 7.00 am to 12.00 pm (good glycemic control).The subject will undergo a hyperinsulinemic euglycemic clamp from 12.00 pm to 2.30 pm.

Three muscle- and three fat-biopsies will be obtained. A palmitic-acid tracer, a glucose tracer, urea tracer, tyrosine- and phenylalanine- tracers will be given.
Drug: Norditropin
0,4 mg of GH administered at 7.05 A.M. on the study day.
Other Names:
  • Growth Hormone

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Insulin and growth hormone signalling, expressed as CHANGE in phosphorylation of intracellular target proteins and CHANGE in mRNA expression of target genes in muscle- and fat-tissue.
Time Frame: Muscle and fat biopsies obtained on each study day (arm): t1= 7.00 (0 min) am t2=11.30 (270min) am t3= 13.00 pm (360min)
Change in phosphorylation of target proteins and mRNA (messenger RNA) expression of target genes assessed with western blotting technique.
Muscle and fat biopsies obtained on each study day (arm): t1= 7.00 (0 min) am t2=11.30 (270min) am t3= 13.00 pm (360min)

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Change in Intracellular markers of lipid metabolism in muscle- and fat tissue biopsies.
Time Frame: Muscle and fat biopsies obtained on each study day (arm): t1= 7.00 (0 min) am t2=11.30 (270min) am t3= 13.00 pm (360min)
Assessed by Western blotting.
Muscle and fat biopsies obtained on each study day (arm): t1= 7.00 (0 min) am t2=11.30 (270min) am t3= 13.00 pm (360min)
Metabolism
Time Frame: Change in glucose, fat and protein metabolism between study days.

Change in glucose, fat and protein metabolism assessed by tracer kinetics on every study day (specific times below) and by indirect calorimetry.

[3H 3]Glucose tracer from t=80min - 260min. [9,10-3H]Palmitic acid tracer from t=200min - 260min. [13C] Urea tracer from 20min - 260min.

15N-phenylalanine tracer and 2H4-tyrosine tracer from 80 min - 260 min.
Change in glucose, fat and protein metabolism between study days.
Ghrelin
Time Frame: Plasma samples obtained at t=0, t=15, t=30, t=45, t=60, t=75, t=90, t=105, t=120, t=150, t=180, t=210, t=240, t=270, t=300
Change in circulating plasma acyl- and desacyl ghrelin levels between study days.
Plasma samples obtained at t=0, t=15, t=30, t=45, t=60, t=75, t=90, t=105, t=120, t=150, t=180, t=210, t=240, t=270, t=300

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

University of Aarhus

Investigators

  • Study Chair: Niels Møller, MD, Aarhus University / Aarhus University Hospital
  • Principal Investigator: Thomas Voss, MD, Aarhus University / Aarhus University Hospital

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start

May 1, 2014

Primary Completion (Actual)

September 1, 2015

Study Completion (Actual)

September 1, 2015

Study Registration Dates

First Submitted

February 20, 2014

First Submitted That Met QC Criteria

February 28, 2014

First Posted (Estimate)

March 4, 2014

Study Record Updates

Last Update Posted (Estimate)

February 24, 2016

Last Update Submitted That Met QC Criteria

February 23, 2016

Last Verified

February 1, 2016

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 1-10-72-247-13 (Other Identifier: Danish Ethics Committee)

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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