In individuals with type 1 diabetes, hypoglycemia is a common consequence of overinsulinization. Under conditions of insulin-induced hypoglycemia, glucagon is the most important stimulus for hepatic glucose production. In contrast, during euglycemia, insulin potently inhibits glucagon's effect on the liver. The first aim of the present study was to determine whether low blood sugar augments glucagon's ability to increase glucose production. Using a conscious catheterized dog model, we found that hypoglycemia increased glucagon's ability to overcome the inhibitory effect of insulin on hepatic glucose production by almost 3-fold, an effect exclusively attributable to marked enhancement of the effect of glucagon on net glycogen breakdown. To investigate the molecular mechanism by which this effect comes about, we analyzed hepatic biopsies from the same animals, and found that hypoglycemia resulted in a decrease in insulin signaling. Furthermore, hypoglycemia and glucagon had an additive effect on the activation of AMPK, which was associated with altered activity of the enzymes of glycogen metabolism.
IntroductionIn individuals with type 1 diabetes, hypoglycemia is a common consequence of overinsulinization. The incidence of hypoglycemia is less frequent in individuals with type 2 diabetes, but as the disease progresses and patients begin to use insulin, it once again becomes a limiting factor in glycemic control (1). The counterregulatory response to hypoglycemia in the normal individual involves the release of glucagon, epinephrine, norepinephrine, cortisol, and growth hormone, which together increase glucose production and limit glucose utilization (2). Glucagon has been shown to provide the primary stimulus for the counterregulatory increase in glucose production in response to insulin-induced hypoglycemia in the normal individual (2). Furthermore, abnormalities in the response of the α cell to hypoglycemia make individuals with diabetes more prone to low blood sugar (1, 2).We have previously examined the interaction between insulin and glucagon in controlling glucose production in the conscious dog (3). Intraportal replacement of basal amounts of insulin and glucagon in the presence of somatostatin infusion was associated with sustained basal glucose production. A selective 4-fold rise in glucagon resulted in an increment in glucose production of approximately 4.5 mg/kg/min at 30 minutes. In contrast, a selective 4-fold rise in insulin resulted in a decrement in glucose production of approximately 1.3 mg/kg/min at 30 minutes. When both hormones were simultaneously increased 4-fold, the decrement in glucose production at 30 minutes was only approximately 0.6 mg/kg/min. Therefore, glucagon's effect was 4.5 mg/kg/min in the presence of basal insulin -despite the accompanying hyperglycemia - and only 0.7 mg/kg/min in the presence of high insulin and euglycemia, a reduction of almost 85%. These data indicate that, in the absence of hypoglycemia, insulin dominates glucagon's action on the liver even when equimolar in...