Pharmacology – IIIPHL-418

Pancreatic Hormones & Antidiabetic Drugs

Dr. Hassan Madkhali

Assistant ProfessorDepartment of Pharmacology

E mail: h.madkhali@psau.edu.sa

Content Layout with List

• OVERVIEW: PANCREASE and PANCREATIC HORMONES

• INSULIN AND GLUCAGON• ACTIONS OF INSULIN• DIABETES MELLITUS• DRUGS FOR THE TREATMENT OF DIABETES MELLITUS• INSULIN• ORAL ANTI-DIABETIC DRUGS

Pancreas• Digestive functions• Secretes two important hormones

Insulin GlucagonSecretes other hormones, such as amylin, somatostatin, and pancreatic polypeptide

Physiologic Anatomy of the PancreasTwo major types of tissues1) The acini,which secrete digestive juices into duodenum2) The islets of Langerhans, which secrete insulin and glucagon into

blood.

The islets contain three major types of cells alpha, beta, delta cellThe beta cells 60 % of all the cells of the islets, lie mainly in the middle

of each islet and secrete insulin and amylin,The alpha cells, 25 % of the total, secrete glucagonThe delta cells, about 10 %, secrete somatostatin.

Hormones

Insulin is a polypeptide containing two amino acid chains (21 and 30 amino acids, respectively) connected by disulfide bridges.

Glucagon is a straight-chain polypeptide of 29 amino acid residues.

Both insulin and glucagon circulate unbound to carrier proteins and have short half-lives of 6 minutes.

Approximately 50% of the insulin and glucagon in blood is metabolized in the liver; most of the remaining hormone is metabolized by the kidneys.

Insulin Is a Hormone Associated with Energy Abundance

• When there is great abundance of energy-giving foods in the diet, especially excess amounts of carbohydrates, insulin is secreted in great quantity.

• Insulin plays an important role in storing the excess energy.• In the case of excess carbohydrates, it causes them to be stored as

glycogen mainly in the liver and muscles.• Excess carbohydrates is also converted under the stimulus of insulin

into fats and stored in the adipose tissue.• Insulin has a direct effect in promoting amino acid uptake by cells and

conversion of these amino acids into protein.• In addition, it inhibits the breakdown of the proteins that are already in

the cells.

Actions of Insulin• To initiate its effects on target cells, insulin first binds with and activates

a membrane receptor protein• The insulin receptor is a tetramer made up of two α-subunits that lie

outside the cell membrane and two β-subunits that penetrate the cell membrane and protrude into the cytoplasm

• When insulin binds with the alpha subunits on the outside of the cell, portions of the beta subunits protruding into the cell become autophosphorylated.

• Thus, the insulin receptor is an example of an enzyme-linked receptor• Autophosphorylation of the beta subunits of the receptor activates a

local tyrosine kinase, which in turn causes phosphorylation of multiple other intracellular enzymes including a group called insulin-receptor substrates (IRS).

• The net effect is to activate some of these enzymes while inactivating others.

• In this way, insulin directs the intracellular metabolic machinery to produce the desired effects on carbohydrate, fat, and protein metabolism.

Effect on Carbohydrate Metabolism

• Immediately after a high-carbohydrate meal, glucose that is absorbed into the blood causes rapid secretion of insulin

• Insulin causes rapid uptake, storage, and use of glucose by almost all tissues of the body, but especially by the muscles, adipose tissue, and liver.

In Muscle, Insulin Promotes the Uptake and Metabolism of Glucose

Mostly muscle tissue depends not on glucose for its energy but on fatty acids, because normal resting muscle membrane is only slightly permeable to glucose, except when the muscle fiber is stimulated by insulin.

Under two conditions the muscles do use large amounts of glucose.

1. During moderate or heavy exercise: because exercising muscle fibers become more permeable to glucose even in the absence of insulin

2. During few hours after a meal: At this time the blood glucose concentration is high and the pancreas is secreting large quantities of insulin. The extra insulin causes rapid transport of glucose into the muscle cells.

Abundant glucose transported into the muscle cells is stored in the form of muscle glycogen

In the Liver, Insulin Promotes Glucose Uptake and Storage, and Use

Insulin causes most of the glucose absorbed after a meal to be stored almost immediately in the liver in the form of glycogen.

The mechanism of glucose uptake and storage in the liver :

1. Insulin inactivates liver phosphorylase, which normally causes liver glycogen to split into glucose.

2. Insulin causes enhanced uptake of glucose from blood by liver by increasing the activity of the enzyme glucokinase, causes the initial phosphorylation of glucose after it diffuses into liver

3. Insulin also increases the activities of the enzymes that promote glycogen synthesis, glycogen synthase

Glucose Is Released from the Liver Between Meals

When the blood glucose level begins to fall to a low level between meals, several events cause the liver to release glucose back into the circulating blood:

1. The decreasing blood glucose causes the pancreas to decrease its insulin secretion.

2. The lack of insulin then reverses all the effects for glycogen storage

3. The lack of insulin activates the enzyme phosphorylase, causes the splitting of glycogen into glucose phosphate.

4. The enzyme glucose phosphatase, now becomes activated by the insulin lack and causes the phosphate radical to split away from the glucose

Thus, the liver removes glucose from the blood when it is present in excess after a meal and returns it to the blood when the blood glucose concentration falls between meals

Insulin Promotes Conversion of Excess Glucose into Fatty Acids and Inhibits Gluconeogenesis in Liver.

• When the quantity of glucose entering the liver cells is more, insulin promotes the conversion of all this excess glucose into fatty acids.

• These packaged as triglycerides in VLDL and transported by blood to the adipose tissue and deposited as fat.

• Insulin also inhibits gluconeogenesis.

Lack of Effect of Insulin on Glucose Uptake and Usage by the Brain

• Insulin has little effect on uptake or use of glucose in brain• Instead, the brain cells are permeable to glucose • The brain cells are also quite different from most other

cells of the body in that they normally use only glucose for energy and can use other energy substrates, such as fats, only with difficulty.

• It is essential that the blood glucose level always be maintained above a critical level

• When the blood glucose falls too low, symptoms of hypoglycemic shock develop, characterized by progressive nervous irritability that leads to fainting, seizures, and even coma.

Effect of Insulin on Carbohydrate Metabolism in Other Cells

• Insulin increases glucose transport into and glucose usage by most other cells of the body

• The transport of glucose into adipose cells mainly provides substrate for the glycerol portion of the fat molecule.

• Therefore, in this indirect way, insulin promotes deposition of fat in these cells.

Effect of Insulin on Fat Metabolism

Insulin Promotes Fat Synthesis and Storage• Insulin has several effects that lead to fat storage in

adipose tissue.• Insulin increases the utilization of glucose by body• Insulin promotes fatty acid synthesis, in liver cells• Fatty acids are then transported from the liver by way

of the blood lipoproteins to the adipose cells to be stored

Role of Insulin in Storage of Fat in the Adipose Cells

• Insulin has two other essential effects that are required for fat storage in adipose cells:

1. Insulin inhibits the action of hormone-sensitive lipase. This is the enzyme that causes hydrolysis of the triglycerides already stored in the fat cells.

2. Insulin promotes glucose transport through the cell membrane into the fat cells. Some of this glucose is then used to synthesize minute amounts of fatty acids, but forms large quantities of a-glycerol phosphate. This substance supplies the glycerol that combines with fatty acids to form the triglycerides that are the storage form of fat

Insulin Deficiency Increases Use of Fat for Energy

• All aspects of fat breakdown and use for providing energy are greatly enhanced in the absence of insulin.

• This occurs even normally between meals when secretion of insulin is minimal, but it becomes extreme in diabetes mellitus .

• Insulin Deficiency Causes Lipolysis of Storage Fat and Release of Free Fatty Acids.

• Consequently, the plasma concentration of free fatty acids begins to rise within minutes.

• This free fatty acid then becomes the main energy substrate used by essentially all tissues of the body besides the brain.

Insulin Deficiency Increases Plasma Cholesterol and Phospholipid Concentrations

• The excess of fatty acids in the plasma associated with insulin deficiency also promotes liver conversion of some of the fatty acids into phospholipids and cholesterol, two of the major products of fat metabolism.

• These two substances, along with excess triglycerides formed at the same time in the liver, are then discharged into the blood in the lipoproteins, so the plasma lipoproteins increase

• This high lipid concentration—especially the high concentration of cholesterol—promotes the development of atherosclerosis in people with serious diabetes.

Excess Usage of Fats During Insulin Lack Causes Ketosis and Acidosis

• Insulin lack also causes excessive amounts of acetoacetic acid to be formed in the liver cells.

• At the same time, the absence of insulin also depresses the utilization of acetoacetic acid in the peripheral tissues.

• Thus, so much acetoacetic acid is released from the liver • Some of the acetoacetic acid is also converted into b-

hydroxybutyric acid and acetone. • These two substances, along with the acetoacetic acid,

are called ketone bodies, and their presence in large quantities in the body fluids is called ketosis.

• In severe diabetes the acetoacetic acid and the b-hydroxybutyric acid can cause severe acidosis and coma, which often leads to death.

Effect of Insulin on Protein Metabolism and on Growth

Insulin Promotes Protein Synthesis and Storage• During the few hours after a meal proteins are also stored in

the tissues by insulin

1. Insulin stimulates transport of many of amino acids into the cells, eg valine, leucine, isoleucine, tyrosine, and phenylalanine.

2. Insulin increases the translation of mRNA, thus forming new proteins

3. Over a longer period of time, insulin also increases the rate of transcription of selected DNA, forming increased quantities of RNA and still more protein synthesis

4. Insulin inhibits the catabolism of proteins

5. In the liver, insulin depresses the rate of gluconeogenesis, this suppression of gluconeogenesis conserves the amino acids in the protein stores of the body.

The major effects of insulin on muscle and adipose tissue are: • (1) Carbohydrate metabolism:

• (2) Lipid metabolism:

• (3) Protein metabolism:

(a) it increases the rate of glucose transport across the cell membrane.(b) it increases the rate of glycolysis by increasing hexokinase (glucokinase) and 6-phosphofructokinase activity. (c) it stimulates the rate of glycogen synthesis and decreases the rate of glycogen breakdown.

(a) it decreases the rate of lipolysis in adipose tissue and hence lowers the plasma fatty acid level. (b) it stimulates fatty acid and triacylglycerol synthesis in tissues. (c) it increases the uptake of triglycerides from the blood into adipose tissue and muscle. (d) it decreases the rate of fatty acid oxidation in muscle and liver.

(a) it increases the rate of transport of some amino acids into tissues. (b) it increases the rate of protein synthesis in muscle, adipose tissue, liver, and other tissues.(c) it decreases the rate of protein degradation in muscle (and perhaps other tissues).

Summary

Insulin and Growth Hormone Interact Synergistically to Promote Growth

• Because insulin is required for the synthesis of proteins, it is as essential for growth of an animal as growth hormone is.

• A combination of these hormones causes dramatic growth.

• Thus, it appears that the two hormones function synergistically to promote growth.

Mechanisms of Insulin Secretion

Beta-cell

Gly

coly

sis

Insulin vesicles or granules

GLUCAGON

-Glucagon is also called the hyperglycemic hormone

-The binding of glucagon to hepatic receptors results in activation of adenylyl cyclase and generation of the second messenger cyclic AMP, which in turn activates protein kinase, leading to phosphorylation that results in the activation or deactivation of a number of enzymes.

Effects on Glucose Metabolism

• Glucagon Promotes Hyperglycemia• Greatly enhance the availability of glucose to the organs of the

body

Glucagon stimulates glycogenolysis:• Glucagon has immediate and pronounced effects on the liver to

increase glycogenolysis and the release of glucose into the blood.• This effect is achieved through activation of liver phosphorylase and

simultaneous inhibition of glycogen synthase.

Glucagon stimulates gluconeogenesis:

• Glucagon increases the hepatic extraction of amino acids from the plasma and increases the activities of key gluconeogenic enzymes.

Other Effects of Glucagon

• Occurs only when its concentration rises well above the maximum normally found in the blood.

• Activates adipose cell lipase, making increased quantities of fatty acids available to the energy systems of the body.

• Glucagon also inhibits the storage of triglycerides in the liver, which prevents the liver from removing fatty acids from the blood.

• Enhances the strength of the heart• Increases blood flow in some tissues, especially the

kidneys• Enhances bile secretion • Inhibits gastric acid secretion.

Regulation of Glucagon Secretion

• Increased Blood Glucose Inhibits Glucagon Secretion

• Increased Blood Amino Acids Stimulate Glucagon Secretion

• Exercise Stimulates Glucagon Secretion• Somatostatin Inhibits Glucagon and Insulin

Secretion

SomatostatinSomatostatin is a peptide hormone secreted by δ cells of thepancreatic islets (also produced in the hypothalamus) in response to: - blood glucose - plasma amino acids - fatty acidsSomatostatin decreases gastrointestinal functions by: - motility - secretion - absorption

Somatostatin splanchnic blood flow

Somatostatin release of:- insulin- glucagon

Diabetes Mellitus (DM)

• Diabetes mellitus is a syndrome of impaired carbohydrate, fat, and protein metabolism caused by either lack of insulin secretion or decreased sensitivity of the tissues to insulin.

Two major forms of diabetes mellitus• Type I diabetes mellitus, also called insulin-

dependent diabetes mellitus (IDDM), is caused by impaired secretion of insulin.

• Type II diabetes mellitus, also called non–insulin-dependent diabetes mellitus (NIDDM), is caused by resistance to the metabolic effects of insulin in target tissues.

Other forms include:

-Gestational DM, GDM (triggered by pregnancy)

-DM can also result rarely from diseases of the pancreas, and medications (Drug-induced diabetes: thiazide diuretics, beta-blockers and statins).

DM in KSA

The yearly total number of registered cases of diabetes according to gender (G) and type (T) of diabetes from the start of registry in 2000 to 2012.Ref: Khalid Al-Rubeaan et al. A Web-Based Interactive Diabetes Registry for Health Care Management and Planning in Saudi Arabia. J Med Internet Res 2013;15(9):e202.

DM in KSA

Source: International Diabetes Federation Middle East & North Africa (MENA)

Anti-diabetic drugs:

• Insulin• Incretin mimetics• Oral Anti-diabetics

TREATMENT OF DM

Insulin

• Insulin is a 51 AA peptide• Not active orally.• Insulin is inactivated by insulinase found mainly in

liver and kidney.• Dose reduced in renal insufficiency• Sources of Insulin :

– Bovine pancreas / Porcine pancreas – Human insulin: Recombinant DNA origin

Insulin preparations :

• Rapid acting insulin : Lispro, Aspart and Glulisine• Short acting insulin: Regular (crystalline)• Intermediate acting insulin: NPH (isophane) and

Lente (insulin zinc) • Long acting insulin: Ultralente, Detimir and Glargine

Insulin Duration Route Features

Lispro 3 – 5 hrs I.V or S.C Onset within 15 minutes

Regular (crystalline)

7 – 10 hrs I.V or S.C common

NPH (Neutral protamine hagedorn)

16 – 20 hrs S.C NPH can mix with regular

Ultralente 24 – 30 hrs S.C Basal level

https://en.wikipedia.org/wiki/Insulin_(medication)

Oral Anti-diabetic drugs

A. Sulfonylureas:

B. Meglitinides (Glinides): Repaglinide (Prandin), Nateglinide (Starlix)

C. Biguanines: Metformin (Glucophage)

D. Thiozolidonediones (glitazones): Pioglitazone (Actos), rosiglitazone (Avandia)

E. α-Glucosidase inhibitors: Acarbose (Precose), Miglitol (Glycet)

F. Dipeptidyl peptidase IV inhibitors (DPP-4 inhibitors): Sitagliptin (Januvia)

G. Sodium-glucose cotransporter 2 (SGLT2) inhibitors: Canagliflozin (Invokana)

1st generation 2nd generation

Acetohexamide (Dymelor)Chlorpropamide (Diabinese)

Tolazamide (Tolinase)Tolbutamide (Orinase)

Glyburide (Micronase)Glipizide (Glucotrol)Glimepiride (Amaryl)

Ref: BEATRIZ LUNA and MARK N. FEINGLOS. Oral Agents in the Management of Type 2 Diabetes Mellitus. AMERICAN FAMILY PHYSICIAN. MAY 1, 2001 / VOLUME 63, NUMBER 9

Note:Metformin is considered to be one of the most effective therapeutics for treating type 2 diabetes, why? because it specifically reduces hepatic gluconeogenesis without increasing insulin secretion, inducing weight gain or posing a risk of hypoglycaemia.(This is explain why it is included in the most of combination therapies)

Combinations:

• Pioglitazone & metformin (Actoplus Met)• Glyburide & metformin (Glucovance) • Glipizide & metformin (Metaglip)• Sitagliptin & metformin (Janumet)• Saxagliptin & metformin (kombiglyze)• Repaglinide & metformin (Prandimet)• Pioglitazone & glimepiride (Duetact)

Metformin MOA

MOA

PPARs: peroxisomeproliferator-activated receptors

SulfonylureasMeglitinides, inhibit the efflux of K+

Sulfonylureas & Meglitinides MOA

α-Glucosidase inhibitors MOA

Dipeptidyl peptidase IV inhibitors and Incretin mimetics MOA

GLP-1: glucagon-like peptide-1

Incretin mimitics bind to GLP-1 receptors

SGLT2 inhibitors MOA

Pharmacist roles and responsibilities in diabetes care and management

• Inform the diabetic patients that health education could make a significant difference and it is needed to give the diabetic patients a certain understanding of the disease

 • Inform them about the importance of compliance with medication, diet and exercise,

weight control and the use of herbal preparations.

• Encourage them to do self blood glucose monitoring regularly.

 • Monitor and promote patient adherence to recommended treatment regimens

 • Identify and resolving drug-related problems

 • Provide education

 • Remind them about the importance of doing regular exams

 • Inform and convince them that unhealthy diet and physical inactivity are the most

important risk factors of DM. Encourage them to participate actively in managing and monitoring their condition.

Thank you ?