Hypoglycemia Associated Autonomic Failure in Type 1 Diabetes Mellitus

Summary

Principal Investigator: Stephen N Davis
Affiliation: Vanderbilt University
Country: USA
Abstract: Intensive glycemic control reduces the onset and slows the progression of microvascular complications in patients with type 1 diabetes (T1DM). Unfortunately, the major obstacle preventing the goal of euglycemia in T1DM is the associated three-fold increase in severe hypoglycemia. Many studies have identified acquired failure of neuroendocrine and in particular autonomic nervous system (ANS), counterregulatory responses as a cause of the increased prevalence of hypoglycemia occurring in intensively treated T1DM. Central to the development of the acquired ANS failure are prior episodes of hypoglycemia. The mechanisms responsible for prior hypoglycemia resulting in acquired ANS and neuroendocrine failure during subsequent hypoglycemia need to be determined. During the last several years, there has been a growing interest in the role played by cerebral mechanisms in regulating ANS and neuroendocrine responses during hypoglycemia. Brain corticosteroid and gamma-aminobutyric acid (A) (GABA (A)) receptors are known to exert inhibitory influences on ANS and neuroendocrine function. We hypothesize that activation of brain corticosteroid (type 1 MR and/or type 2 GR) and/or GABA (A) receptors by prior hypoglycemia may be important mechanisms responsible for the blunted ANS and neuroendocrine counterregulatory responses occurring in intensively treated T1DM patients. Currently, there are no readily available adjunct treatments that protect the ANS from the deleterious effects of repeated hypoglycemia. In this proposal, we will conduct experiments to determine whether the adrenal hormone dihydroepiandrostenedione-sulfate (DHEAS) which has recognized anticorticosteroid and anti GABA (A) receptor activity may preserve ANS function during prior episodes of hypoglycemia in T1DM. Both antecedent episodes of hypoglycemia and exercise can blunt epinephrine responses during subsequent episodes of hypoglycemia. However, it is unknown whether episodes of hypoglycemia and/or exercise will also reduce the physiologic actions of this key hormone in intensively treated T1DM patients. This information is needed as treatment strategies, aimed at increasing epinephrine responses during hypoglycemia in T1DM, will have limited effectiveness if target organs are unresponsive. The studies outlined in this proposal are therefore focused at determining the in-vivo mechanisms regulating ANS counterregulatory failure during hypoglycemia in T1DM humans. Experiments will use the glucose clamp technique. ANS responses to hypoglycemia will be assessed by measuring circulating catecholamines, pancreatic polypeptide, muscle sympathetic nerve activity, symptom scores, and heart rate variability. Neuroendocrine responses will be determined by measuring growth hormone, cortisol and ACTH. Metabolic counterregulatory mechanisms will be determined by measuring glucose and glycerol turnover, skeletal muscle metabolism with muscle biopsies, substrate levels, and substrate oxidation via indirect calorimetry. The specific aims of this proposal are to determine: 1) the roles played by gamma aminobutyric acid (GABA (A)) and corticosteroid receptors in the development of hypoglycemia associated autonomic failure in type 1 diabetes, 2) if dihydroepiandrostenedione-sulfate can prevent hypoglycemia associated autonomic failure in type 1 diabetic man, 3) if prior hypoglycemia and/or exercise blunts subsequent metabolic/cardiovascular responses to epinephrine in type 1 diabetic man, and 4) if selective serotonin reuptake inhibitors blunt counterregulatory responses to hypoglycemia in type 1 DM man.
Funding Period: 2004-09-30 - 2009-06-30
more information: NIH RePORT

Top Publications

  1. ncbi Type 1 diabetes: exercise and hypoglycemia
    Vanessa Jones Briscoe
    Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, 715 Preston Research Building, Nashville, TN 37232 6303, USA
    Appl Physiol Nutr Metab 32:576-82. 2007
  2. ncbi Antecedent short-term central nervous system administration of estrogen and progesterone alters counterregulatory responses to hypoglycemia in conscious male rats
    Darleen A Sandoval
    Univ of Cincinnati, 2170 E Galbraith Rd, Bldg E, Rm 317, Cincinnati, OH 45237, USA
    Am J Physiol Endocrinol Metab 293:E1511-6. 2007
  3. ncbi Stimulation of both type I and type II corticosteroid receptors blunts counterregulatory responses to subsequent hypoglycemia in healthy man
    Stephanie M Gustavson
    Department of Medicine, Div of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center 7465 MRB IV, Nashville, TN 37232 0475, USA
    Am J Physiol Endocrinol Metab 294:E506-12. 2008
  4. ncbi Role of the endocannabinoid system in management of patients with type 2 diabetes mellitus and cardiovascular risk factors
    Stephen N Davis
    Division of Diabetes, Endocrinology and Metabolism, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, USA
    Endocr Pract 13:790-804. 2007
  5. ncbi Effects of a selective serotonin reuptake inhibitor, fluoxetine, on counterregulatory responses to hypoglycemia in healthy individuals
    Vanessa J Briscoe
    Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
    Diabetes 57:2453-60. 2008
  6. ncbi Effects of oral carbohydrate on autonomic nervous system counterregulatory responses during hyperinsulinemic hypoglycemia and euglycemia
    Andrew C Ertl
    Division of Diabetes, Endocrinology and Metabolism, Dept of Medicine, 7465 MRB IV, Nashville, TN 37232 0475, USA
    Am J Physiol Endocrinol Metab 295:E618-25. 2008
  7. ncbi Effects of the selective serotonin reuptake inhibitor fluoxetine on counterregulatory responses to hypoglycemia in individuals with type 1 diabetes
    Vanessa J Briscoe
    Department of Medicine, Vanderbilt University, Nashville, TN, USA
    Diabetes 57:3315-22. 2008
  8. ncbi Effects of intensive therapy and antecedent hypoglycemia on counterregulatory responses to hypoglycemia in type 2 diabetes
    Stephen N Davis
    Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
    Diabetes 58:701-9. 2009
  9. ncbi Effects of differing antecedent increases of plasma cortisol on counterregulatory responses during subsequent exercise in type 1 diabetes
    Shichun Bao
    Department of Medicine, Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, Tennessee, USA
    Diabetes 58:2100-8. 2009

Scientific Experts

  • Stephen N Davis
  • Darleen A Sandoval
  • Vanessa J Briscoe
  • Andrew C Ertl
  • Donna B Tate
  • Shichun Bao
  • Stephanie M Gustavson
  • Vanessa Jones Briscoe
  • Sheila Dawling
  • Stephnie Mann
  • Hannah B Blair
  • Antoinette Richardson
  • Satish R Raj
  • Donna Bowman Tate

Detail Information

Publications9

  1. ncbi Type 1 diabetes: exercise and hypoglycemia
    Vanessa Jones Briscoe
    Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, 715 Preston Research Building, Nashville, TN 37232 6303, USA
    Appl Physiol Nutr Metab 32:576-82. 2007
    ..Similarly, antecedent episodes of exercise can blunt counterregulatory responses during subsequent hypoglycemia, thereby creating reciprocal feed-forward vicious cycles that increase the risk of hypoglycemia during either stress...
  2. ncbi Antecedent short-term central nervous system administration of estrogen and progesterone alters counterregulatory responses to hypoglycemia in conscious male rats
    Darleen A Sandoval
    Univ of Cincinnati, 2170 E Galbraith Rd, Bldg E, Rm 317, Cincinnati, OH 45237, USA
    Am J Physiol Endocrinol Metab 293:E1511-6. 2007
    ....
  3. ncbi Stimulation of both type I and type II corticosteroid receptors blunts counterregulatory responses to subsequent hypoglycemia in healthy man
    Stephanie M Gustavson
    Department of Medicine, Div of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center 7465 MRB IV, Nashville, TN 37232 0475, USA
    Am J Physiol Endocrinol Metab 294:E506-12. 2008
    ..Both type I and type II corticosteroid receptors may be involved in the multiple mechanisms controlling counterregulatory responses to hypoglycemia in healthy man...
  4. ncbi Role of the endocannabinoid system in management of patients with type 2 diabetes mellitus and cardiovascular risk factors
    Stephen N Davis
    Division of Diabetes, Endocrinology and Metabolism, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, USA
    Endocr Pract 13:790-804. 2007
    ....
  5. ncbi Effects of a selective serotonin reuptake inhibitor, fluoxetine, on counterregulatory responses to hypoglycemia in healthy individuals
    Vanessa J Briscoe
    Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
    Diabetes 57:2453-60. 2008
    ....
  6. ncbi Effects of oral carbohydrate on autonomic nervous system counterregulatory responses during hyperinsulinemic hypoglycemia and euglycemia
    Andrew C Ertl
    Division of Diabetes, Endocrinology and Metabolism, Dept of Medicine, 7465 MRB IV, Nashville, TN 37232 0475, USA
    Am J Physiol Endocrinol Metab 295:E618-25. 2008
    ....
  7. ncbi Effects of the selective serotonin reuptake inhibitor fluoxetine on counterregulatory responses to hypoglycemia in individuals with type 1 diabetes
    Vanessa J Briscoe
    Department of Medicine, Vanderbilt University, Nashville, TN, USA
    Diabetes 57:3315-22. 2008
    ..Therefore, the specific aim of this study was to test the hypothesis that 6-week use of the SSRI fluoxetine would amplify autonomic nervous system (ANS) counterregulatory responses to hypoglycemia in individuals with type 1 diabetes...
  8. ncbi Effects of intensive therapy and antecedent hypoglycemia on counterregulatory responses to hypoglycemia in type 2 diabetes
    Stephen N Davis
    Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
    Diabetes 58:701-9. 2009
    ..0% would blunt autonomic nervous system (ANS) responses to hypoglycemia, and 2) antecedent hypoglycemia will result in counterregulatory failure during subsequent hypoglycemia in patients with suboptimal and good glycemic control...
  9. ncbi Effects of differing antecedent increases of plasma cortisol on counterregulatory responses during subsequent exercise in type 1 diabetes
    Shichun Bao
    Department of Medicine, Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, Tennessee, USA
    Diabetes 58:2100-8. 2009
    ..The aim of this study was to determine whether antecedent increase of plasma cortisol is a mechanism responsible for this finding...