PowerPoint Presentation Rezulin

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Diabetes A Global Problem
Amos AF, McCarty DJ, Zimmet P. Diabetic Med
199714(Suppl 5)S7.
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Pathogenesis of Hyperglycemia in Type 2 Diabetes
Insulin resistance
Muscle
Liver
Glucose
Increased glucose production
Pancreas
Impairedinsulinsecretion
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13C NMR Spectra of Muscle Glycogen
C1 Glycogen
120 min
90 min
60 min
30 min
0 min
110
105
100
95
90
PPM
Shulman GI et al. N Engl J Med. 1990322223228.
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Incremental Change in Muscle Glycogen
20
Control
15
Increment(mmol glucosyl units/kg muscle)
10
5
Type 2 diabetes
0
20
40
60
80
100
120
Minutes
Shulman GI et al. N Engl J Med. 1990322223228.
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Potential Rate-Controlling Steps inMuscle
Glucose Metabolism
Glycogen
Glycogensynthase
UDP-glucose
Hexokinase
Plasmaglucose
GLUT 4
Glucose
Glucose-6-phosphate
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31P NMR Spectra of Muscle
Baseline
ATP
40-80 min
PCr
Pi
G6P
Difference
x16
10.0
5.0
0.0
-5.0
-10.0
-15.0
PPG
Rothman DL et al. J Clin Invest.
1992891069-1075.
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Glucose-6-Phosphate Time Course
0.3
Hyperglycemic-hyperinsulinemic clamp
Controls
Glucose-6-phosphate (mM)
0.2
Type 2 diabetes
0.1
Rothman DL et al. J Clin Invest.
1992891069-1075.
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Glucose Transport/Phosphorylation Is Decreased in
Type 2 Diabetes
Glycogen
Glycogensynthase
UDP-glucose
Hexokinase
GLUT 4
Glucose
Glucose-6-phosphate
Plasma glucose
Rothman DL et al. J Clin Invest.
1992891069-1075.
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Offspring of Patients With Type 2 Diabetes

• 40 lifetime risk of developing type 2 diabetes
• Insulin resistance is the best predictor

Warram JH et al. Ann Intern Med. 1990113909-915.
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Glucose-6-Phosphate Time Course
Rothman DL et al. Proc Natl Acad Sci USA.
199592983-987.
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Glucose Transport/Phosphorylation Is Decreased in
Type 2 Diabetes and Prediabetic Offspring
Glycogen
Glycogensynthase
UDP-glucose
Hexokinase
GLUT 4
Glucose
Glucose-6-phosphate
Plasma glucose
Rothman DL et al. J Clin Invest.
1992891069-1075.
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13C NMR Spectra of Muscle and Plasma
Mannitol
b-C1 Glucose
Creatine
a-C1 Glucose
Muscle
Plasma
Cline et al, N Engl J Med. 1999341240-246
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Intra- and Extracellular Glucose Concentrations

Extra- cellular
Extra- cellular
(mM)

Intra- cellular 0.24.11
Intra- cellular 0.11.17
Control Type 2
Cline et al, N Engl J Med. 1999341240-246
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Glucose Transport Activity Is Decreased in Type 2
Diabetes
Glycogen
Glycogensynthase
UDP-glucose
Hexokinase
GLUT 4
Glucose
Glucose-6-phosphate
Plasma glucose
Cline et al N Engl J Med. 1999341240-246
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High Plasma FFA Predicts Insulin Resistance
1200
r 0.48
1000
800
600
400
200
1
2
3
4
5
6
7
8
9
10
Glucose infusion rate(mg/kg/min)
Perseghin et al. Diabetes 1997461001-1009
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1H spectrum of the soleus muscle of a lean
subject
IMCL
EMCL
2.5
2.0
1.5
1.0
0.5
ppm
Diabetologia 199942113-116
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Randle Mechanism of Fat Induced Insulin
Resistance
Citrate
PDH
PFK
Acetyl CoA CoA
Glucose G-6-P Pyruvate
GLUT 4
Plasma glucose
Plasma FFA
Lancet i785-789, 1963
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Plasma Glucose, Insulin, and FFA
Roden et al. J Clin Invest. 199697642-648
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Effect of FFA on Glucose Metabolism
Roden et al. J Clin Invest. 199697642-648
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FFA Inhibits Glucose Transport/Phosphorylation
HK
PDH
PFK
Glucose G-6-P Pyruvate Acetyl CoA
GLUT 4
Plasma FFA
Plasma glucose
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Effect of FFA on Intra- and Extracellular Glucose
Glycerol Lipid
6
5
4
Glucose (mM)
3
2
1
0
Dresner et al. J Clin Invest. 1999103253-259
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FFA Inhibits Glucose Transport Activity
HK
PDH
PFK
Glucose G-6-P Pyruvate Acetyl CoA
GLUT 4
Plasma FFA
Plasma glucose
Dresner et al. J Clin Invest. 1999103253-259
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Potential Mechanisms by which Fatty Acids
Inhibit Glucose Transport Activity
Insulin
IRS-1
Glucose
GLUT 4
PI 3-kinase
Fatty Acid
Plasma glucose
Shulman J Clin Invest. 2000106171
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Effect of FFA on PI 3-Kinase Activity
p600
500
400
PI3-kinase activity ( of basal)
300
200
100
0
Basal Glycerol Lipid
Dresner et al. J Clin Invest. 1999103253-259
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Insulin

IRS-1/IRS-2 serine/threonine phosphorylation IRS-
1/IRS-2 tyrosine phosphorylation
(serine kinase cascade)
IKKB/JNK1
PI 3 kinase
glucose
PKCq
UCP
fatty acyl CoA diacylglycerol
HEAT
GLUT 4
TNFa ? Adiponectin ? Leptin ? Resistin ?
LPL
FATP1
plasma glucose
plasma fatty acid
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Insulin Resistance in the Elderly
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Prevalence of Diabetes and Glucose Intolerance
of Population
Harris. Diabetes Care 199316642-652.
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Subject Characteristics
Petersen et al, Science 3001140, 2003
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Oral Glucose Tolerance Test - Glucose
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Oral Glucose Tolerance Test - Insulin
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Rates of Insulin Stimulated Whole Body Glucose
Uptake
40
30
µmol / kg LBM-min
20
10
0
Young
Elderly
Petersen et al, Science 3001140, 2003
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Intramyocellular and Hepatic Triglyceride Content
Intramyocellular Triglyceride ()
Hepatic Triglyceride ()
2.0
1.6
1.5
1.2
1.0
0.8
0.5
0.4
0.0
0.0
Young
Elderly
Young
Elderly
Petersen et al, Science 3001140, 2003
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Increased Fatty Acid Delivery and/or Decreased
Fatty Acid Oxidation?
CO2
H
H
ATP
ADP
TCA
?
?
H
Petersen et al, Science 3001140, 2003
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Microdialysis Technique
Fat Cells
Catheter
Saline
Glycerol
Dialysate
Membrane
Collection Vial
Petersen et al, Science 3001140, 2003
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Microdialysis Glycerol Release from Adipocytes
80
PNS
60
Insulin Suppression ()
40
20
0
Young
Elderly
Petersen et al, Science 3001140, 2003
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Rates of Whole Body Glycerol Turnover
Basal
Clamp
(µmol/kg fat mass-min)
(µmol/kg fat mass-min)
0
Young
Elderly
Young
Elderly
Petersen et al, Science 3001140, 2003
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13C NMR measurement of TCA cycle

• Infusion of 2-13C acetate
• ?Monitor 13C incorporation into Glutamate
  Carbon 4 and Carbon 2 by NMR
• Mathematical model of TCA cycle
• ? inputs
• - muscle Glutamate C4 and C2
• plasma acetate 13C enrichment and conc.
• ? output TCA Cycle Flux (VTCA)

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13C NMR spectra during 13C acetate infusion
Petersen et al, Science 3001140, 2003
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NMR Time Course of 13C incorporation from
Acetate into Glutamate
Glutamate C2
Glutamate C4
300
Peak Area
200
100
0
0
30
60
90
Time (min)
41
31P NMR measurement of ATP synthase flux
?ATP
Pi
?ATP saturation
Pi
ppm
Petersen et al, Science 3001140, 2003
42
Mitochondrial Oxidative-Phosphorylation Activity
ATP Synthesis Rates
TCA Flux Rates
(nmol/g/min)
(?mol/g/min)
P
120
9.00
P
8.00
100
7.00
80
6.00
5.00
60
4.00
40
3.00
2.00
20
1.00
0
0.00
Young
Elderly
Young
Elderly
Petersen et al, Science 3001140, 2003
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Mitochondrial Oxidative-Phosphorylation Activity
is Reduced in the Elderly
CO2
Acyl CoAs
Acyl CoAs
mitochondrial oxidative- phosphorylation activity
Petersen et al, Science 3001140, 2003
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The Road to Insulin Resistance
CO2
H
H
ATP
ADP
TCA
H
Defects in Adipocyte Fatty Acid Metabolism
Acquired (aging) or Inherited (IR
Offspring) Defects in Mitochondrial Metabolism
Caloric Intake
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Collaborators
Irene Moore Susanne Neschen Gianluca
Perseghin Michael Roden Anthony Romanelli Varman
Samuel

• Douglas Befroy
• Yan Chen
• Alan Dresner
• Sylvie Dufour
• Jonathon Fillmore
• Ripu Hundal
• Silvio Inzucchi
• Beat Jucker
• Yanna Kosover
• Martin Krssak
• Didier Laurent
• Rebecca Lepine
• Vincent Lebon
• Zhen-xiang Liu
• Melissa Marcucci
• Katsutaro Morino

Rockefeller Jan Breslow Jeff Friedman
Columbia Ira Goldberg
Garvan Institute Kim Bell Ted Kraegen
Univ of Penn Morrie Birnbaum Mitch Lazar
Joslin Diabetes Center Laurie Goodyear C. Ronald
Kahn Steve Shoelson Morris White
Yale-NIH Mouse Metabolic Phenotyping
Center Kevin Behar (NMR Core) Gary Cline (Stable
Isotope Core) Jason Kim (In Vivo
Core) Yale-Magnetic Resonance Research
Center Douglas Rothman Robin de Graf Graeme
Mason Scott McIntyre Terry Nixon
NIH Elif Arioglu Oral Oksana Gavrilova Philip
Gorden Marc Reitman Simeon Taylor
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Liver
Glycogenolysis
Glucose
Gluconeogenesis
47
13C NMR Spectra of C1 Glycogen During a Fast
C1 Glycogen
t 64
t 52
t 40
t 28
t 16
t 8
110
105
100
95
90
Chemical shift (ppm)
Rothman DL et al. Science. 1991254573-576.
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Hepatic Glycogen Time Course
500
400
300
Glycogen (mmol/L-liver)
200
100
0
10
0
20
30
40
50
60
70
Hours of fasting
Rothman DL et al. Science. 1991254573-576.
49
Rates of Glucose Production, Net Hepatic
Glycogenolysis, and Gluconeogenesis
15
Glycogenolysis Gluconeogenesis
10
Glucose productionµmol/kg/min
5
55 6
64 5
82 5
96 1
0
612h
2246h
4664h
1222h
Petersen KF et al. Am J Physiol.
1996270E186E191. Rothman DL et
al. Science. 1991254573576.
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Endogenous Glucose ProductionCorrelates With
Fasting Glucose
120
r 0.57
90
Endogenousglucose production (µmol/m2/min)
60
30
0
100
200
300
400
Fasting glucose (mg/dL)
Maggs D et al. Ann Intern Med. 1998128176-185.
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Hepatic Glycogen Time Course
400
300
Control
Glycogen (mmol/L-liver)
200
Type 2 diabetes
100
0
0
3
6
9
12
15
18
21
24
Hours of fasting
J Clin Invest. 1992901323-1327.
52
Rates of Glucose Production, Net Hepatic
Glycogenolysis and Gluconeogenesis
15
25
10
Glucoseproduction (µmol/kg/min)
60
5
0
Difference from control (endogenous glucose
production) Difference from control
(gluconeogenesis) PJ Clin Invest. 1992901323-1327.
53
Metformin Effects on Glucose Production
1.0
0.75
P 0.0009
P 0.01
(mmol/m2.min)
0.5
84
0.25
70
0
Pre-Met
Post-Met
Hundal et al, Diabetes 2001