HYPOTHYROIDISM PREVALENCE IN THE UNITED STATES: A RETROSPECTIVE STUDY COMBINING NHANES AND CLAIMS DATA, 2009—2019

Previous estimates determined prevalence of hypothyroidism (HT) to be 4.6% of the United States (US) population. This study aimed to update estimates of HT prevalence in the US by retrospective analysis of two datasets. Data on HT type (overt or subclinical HT) and treatment were collected from the 2009–2010 and 2011–2012 National Health and Nutrition Examination Survey (NHANES) cycles. From the Optum administrative claims database, medical and pharmacy claims were collected between 01/01/2012 and 12/31/2019. Patients were defined as having HT if, per given year, they had >1 prescription for HT treatment,  > 1 claim indicating an HT diagnosis, or TSH levels >4.0 mIU/L (NHANES arm). For both studies, treatment was defined as any evidence of synthetic or natural thyroid hormone replacement, identified by pharmacy claims or patient surveys. Data are reported as percentage of patients with HT and treatments received. Between 2009 and 2012, HT prevalence remained around 9.6% of the US population. The administrative claims dataset showed that HT prevalence grew from 9.5% in 2012 to 11.7% in 2019 and that >78% of patients received thyroxine (T4) monotherapy. Similarly, the NHANES dataset showed that T4 replacement therapy was the most common treatment for HT. From 2012–2019, patients with untreated HT grew from 11.8% to 14.4%. The prevalence of HT in the US has steadily increased since 2009. Likewise, the percentage of hypothyroid-diagnosed patients not receiving treatment also increased, suggesting that the increased prevalence may be due to increased cases of subclinical HT.

Interferon gamma mediates the reduction of adipose tissue regulatory T cells in human obesity

Decreased adipose tissue regulatory T cells contribute to insulin resistance in obese mice, however, little is known about the mechanisms regulating adipose tissue regulatory T cells numbers in humans. Here we obtain adipose tissue from obese and lean volunteers. Regulatory T cell abundance is lower in obese vs. lean visceral and subcutaneous adipose tissue and associates with reduced insulin sensitivity and altered adipocyte metabolic gene expression. Regulatory T cells numbers decline following high-fat diet induction in lean volunteers. We see alteration in major histocompatibility complex II pathway in adipocytes from obese patients and after high fat ingestion, which increases T helper 1 cell numbers and decreases regulatory T cell differentiation. We also observe increased expression of inhibitory co-receptors including programmed cell death protein 1 and OX40 in visceral adipose tissue regulatory T cells from patients with obesity. In human obesity, these global effects of interferon gamma to reduce regulatory T cells and diminish their function appear to instigate adipose inflammation and suppress adipocyte metabolism, leading to insulin resistance.

Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Management of Dyslipidemia and Prevention of Cardiovascular Disease Algorithm - 2020 Executive Summary

The treatment of lipid disorders begins with lifestyle therapy to improve nutrition, physical activity, weight, and other factors that affect lipids. Secondary causes of lipid disorders should be addressed, and pharmacologic therapy initiated based on a patient's risk for atherosclerotic cardiovascular disease (ASCVD). Patients at extreme ASCVD risk should be treated with high-intensity statin therapy to achieve a goal low-density lipoprotein cholesterol (LDL-C) of <55 mg/dL, and those at very high ASCVD risk should be treated to achieve LDL-C <70 mg/dL. Treatment for moderate and high ASCVD risk patients may begin with a moderate-intensity statin to achieve an LDL-C <100 mg/dL, while the LDL-C goal is <130 mg/dL for those at low risk. In all cases, treatment should be intensified, including the addition of other LDL-C-lowering agents (i.e., proprotein convertase subtilisin/kexin type 9 inhibitors, ezetimibe, colesevelam, or bempedoic acid) as needed to achieve treatment goals. When targeting triglyceride levels, the desirable goal is <150 mg/dL. Statin therapy should be combined with a fibrate, prescription-grade omega-3 fatty acid, and/or niacin to reduce triglycerides in all patients with triglycerides ≥500 mg/dL, and icosapent ethyl should be added to a statin in any patient with established ASCVD or diabetes with ≥2 ASCVD risk factors and triglycerides between 135 and 499 mg/dL to prevent ASCVD events. Management of additional risk factors such as elevated lipoprotein(a) and statin intolerance is also described.

Insulin Pump Malfunction During Hospitalization: Two Case Reports

BACKGROUND

Insulin pump malfunctions and failures continue to occur; however, more severe malfunctions such as the "runaway pump" phenomenon are rarely reported. This article describes two cases of pump malfunction in which pump users appear to have received an unsolicited bolus of insulin resulting in severe episodes of hypoglycemia during hospitalization.

MATERIALS AND METHODS

Both cases of insulin pump malfunction occurred in the inpatient setting at a large academic medical center in the United States. An analysis of the corresponding insulin pump downloads was performed. The Food and Drug Administration's (FDA's) Manufacturer and User Facility Device Experience (MAUDE) database was searched for similar cases involving Medtronic (Northridge, CA) insulin pumps using the terms "pump," "infusion," "insulin AND malfunction AND Medtronic."

RESULTS

The two cases described show remarkable similarities, each demonstrating a severe hypoglycemic event preceded by an infusion site change followed by an alarm. In both cases a rapid spraying of insulin was reported. The insulin pump downloads validated much of the patients' and medical staff's descriptions of events. The FDA's MAUDE database search revealed 425 cases meeting our search term criteria. All cases were reviewed. Seven cases were identified involving independent movement of the reservoir piston.

CONCLUSIONS

The cases detailed are the first to describe an insulin pump malfunction of this nature in the hospital setting involving unsolicited insulin boluses leading to severe hypoglycemia. The cases are particularly compelling in that they were witnessed by medical personnel. Providers and patients should receive instruction education on the recognition and management of insulin pump malfunction.

The many faces of pheochromocytoma

OBJECTIVE

To recognize and manage pheochromocytomas in unusual settings.

METHODS

Three case reports are presented with clinical, biochemical, imaging, and operative findings. The pitfalls in diagnosis of pheochromocytomas and management are addressed.

RESULTS

We begin with a 27-yr-old gravida 2, para 1 Caucasian woman with unexplained tachycardia and hypertension during a routine pre-natal visit at 30 weeks estimated gestational age. Urinary studies revealed elevated catecholamines. Magnetic resonance imaging localized a 6.6-cm right adrenal mass with features consistent with a pheochromocytoma. She was medically managed with phenoxybenzamine and propranolol until 35 weeks, after which she underwent a combined Cesarean section, and open right adrenalectomy. Another patient, a 36-yr-old African-American woman presented to a hospital in cardiac arrest, with elevated serum troponins, and underwent cardiac catheterization, which revealed normal coronary arteries. A computed tomography (CT) scan revealed a left adrenal mass and CT-guided biopsy was consistent with a pheochromocytoma, although prior studies were negative. Finally, we present a 49-yr-old Caucasian woman who had a right adrenalectomy 10 yr prior and presented to the clinic with fluctuating blood pressures, headaches, and palpitations. Further testing revealed she had a recurrent metastatic pheochromocytoma. The challenges behind treating these patients are further explored.

CONCLUSION

Antenatal diagnosis of pheochromocytoma, though challenging, is associated with lower maternal and fetal morbidity and mortality. The differential diagnosis for cardiac arrest in the presence of normal coronary arteries should include a pheochromocytoma. Finally, treatment with iodinated metaiodobenzylguanidine may be a therapeutic option for those patients with metastatic pheochromocytomas.

Management of type 2 diabetes mellitus: is it time for a paradigm shift?

Type 2 diabetes mellitus is a multi-organ disease that results from the combination of insulin resistance and a beta-cell secretory defect. The worldwide prevalence of type 2 diabetes has increased substantially during the past decade, and patients with this disease continue to experience a high incidence of morbidity and mortality. Because the complications associated with this disease affect multiple organ systems and have a dramatic impact on daily life, the importance of lowering glycosylated hemoglobin (HbA(1c)) levels to within the normal range cannot be overemphasized. The introduction in the past decade of several new classes of pharmacological agents to treat patients with type 2 diabetes now provides the opportunity to focus therapy on treating the underlying disease process instead of just reacting to the blood glucose levels. The thiazolidinediones are unique in their ability to modulate free fatty acid metabolism and to improve insulin sensitivity. These agents also exert numerous nonglycemic effects on the vasculature and lipid metabolism and may improve many of the risk factors associated with metabolic syndrome. Data from the United Kingdom Prospective Diabetes Study (UKPDS) group showed that conventional methods of managing type 2 diabetes, including the use of sulfonylureas or biguanides, do not provide long-term glycemic control. Consequently, new treatment paradigms stressing the earlier use of thiazolidinediones, either alone or in combination with metformin, may lead to more durable glycemic control, thus facilitating the reduction of complications in patients with type 2 diabetes.

Thiazolidinediones and risk for atherosclerosis: pleiotropic effects of PPar gamma agonism

Despite advances in the development of anti-hyperglycaemic drugs and a greater focus on cardiovascular risk modification for patients with diabetes, cardiovascular disease remains the most common complication of type 2 diabetes. Since their initial availability in 1997, the thiazolidinediones have become one of the most commonly prescribed classes of medications for type 2 diabetes. In addition to glucose control, the thiazolidinediones have a number of pleiotropic effects on myriad traditional and non-traditional risk factors for cardiovascular disease, and hold promise with regard to modification of cardiovascular risk. In a recently reported large-scale clinical trial, pioglitazone was associated with improved cardiovascular outcomes in patients with type 2 diabetes and prevalent atherosclerotic disease. In this review, we summarise the experimental, preclinical and clinical data regarding the effects of the thiazolidinediones on cardiovascular risk factors and clinical outcomes.

The metabolic syndrome: evolving evidence that thiazolidinediones provide rational therapy

The metabolic syndrome, also known as the dysmetabolic syndrome, syndrome X or the insulin resistance syndrome, refers to the clustering of cardiovascular disease risk factors that are present in many individuals who are at increased risk for both cardiovascular events and type 2 diabetes. Prediabetic subjects typically exhibit an atherogenic pattern of cardiovascular risks that is associated with hyperinsulinaemia. Thus, identification of components of the metabolic syndrome is important if patients are to be treated early enough to prevent cardiovascular events and other complications related to diabetes. Therapies targeted to specific components of the metabolic syndrome such as improving glycaemic control, managing dyslipidaemia and reducing the prothrombotic state should help to minimize cardiovascular risk, particularly if initiated early. Traditional pharmacologic agents used to manage the individual components of the metabolic syndrome do not typically impact the other components. The thiazolidinediones, a new class of agents that improve insulin resistance, have the ability, in addition to their glucose-lowering effects, to exert several powerful anti-atherogenic properties, including anti-inflammatory effects in the vascular endothelium, redistribution of visceral fat and reduction of insulin resistance, hyperinsulinaemia and hyperproinsulinaemia. This makes the thiazolidinediones ideal candidates for the early treatment of many components associated with the metabolic syndrome.

Metabolic syndrome: Demographic features, etiology, and clinical management

The metabolic syndrome, also known as the dysmetabolic syndrome, syndrome X, or the insulin resistance syndrome, refers to the clustering of cardiovascular disease risk factors that are present in many individuals who are at increased risk for cardiovascular events and/or type 2 diabetes. The criteria for metabolic syndrome include a combination of categorical and borderline risk factors that can be readily measured in clinical practice. Although the Adult Treatment Panel III of the National Cholesterol Education Program set the criteria to identify cardiovascular risk, the syndrome had already been well recognized in the endocrine community as identifying people at risk for diabetes. Recently, the International Diabetes Federation proposed a worldwide definition with ethnic-specific criteria for waist circumference. Therapies targeted to specific components of the metabolic syndrome, such as improving glycemic control, managing dyslipidemia, and reducing the prothrombotic state, should help to minimize cardiovascular risk, particularly if initiated early.

The role of thyroid hormone therapy in acutely ill cardiac patients

The presence of a 'low T₃ syndrome' in the setting of nonthyroidal illness has long been recognized as the 'euthyroid sick syndrome', with the recommendation to observe and not treat with thyroid hormone replacement therapy. That approach has recently been challenged in the setting of critical cardiac illness. Research demonstrating that thyroid hormone therapy may improve hemodynamic parameters has rekindled interest in the use of thyroid hormone therapy in critical illness. Continued improvements in survival after critical cardiac illness provokes the question of whether thyroid hormone therapy would provide further incremental benefit.

Thiazolidinediones, peripheral oedema and congestive heart failure: what is the evidence?

Cardiovascular disease is the most common complication of type 2 diabetes mellitus (type 2 DM), accounting for approximately 80% of deaths. While atherosclerotic vascular disease accounts for much of the cardiovascular morbidity and mortality among diabetic patients, congestive heart failure (CHF) is another key complication associated with diabetes, with an incidence three to five times greater in diabetic patients than in those without diabetes. One of the most promising developments in the treatment of type 2 DM has been the introduction of the thiazolidinedione (TZD) class of drugs, which appear to have pleiotropic effects beyond glycaemic control. Enthusiasm has been tempered, however, by concerns for safety in patients with CHF, given reports of worsening heart failure symptoms and peripheral oedema. With the growing epidemic of type 2 DM and the increasing use of TZDs, such concern has important therapeutic implications for a population of patients with a high prevalence of often subclinical systolic and diastolic dysfunction. This review provides an overview of the currently available data regarding the effects of TZDs on fluid retention and cardiac function. Particular emphasis is placed on the mechanisms of development of peripheral oedema and its significance in patients with impaired left ventricular function. TZDs are well known to cause an expansion in plasma volume; there has also been concern that TZDs may have direct toxic effects on the myocardium, leading to impaired cardiac function. Studies to date do not support this hypothesis and in fact there is growing evidence from animal models and human trials that treatment with TZDs actually improves cardiac function. There are also preclinical data to suggest TZDs may protect the myocardium in the setting of ischaemic insult or the toxic effects of myocardial lipid deposition. Ongoing clinical trials examining the use of these agents in patients at risk for heart failure will probably provide further insight into the aggregate cardiovascular effects of this promising class of medications.

Free fatty acids and type 2 diabetes mellitus

Acute elevation of plasma free fatty acids (FFAs) is necessary for insulin secretion. Sustained elevation, however, leads to apoptosis of pancreatic beta-cells and is a major risk factor for cardiovascular disease and sudden death in patients with insulin resistance or a family history of diabetes mellitus, as well as in individuals with normal glucose tolerance. Data suggest that reduction of FFA plasma levels may reduce the incidence of cardiovascular disease in these at-risk patients. Thiazolidinediones have been shown not only to improve insulin sensitivity but also to reduce FFA plasma levels. Consequently, endothelial function is maintained, vascular smooth muscle cell proliferation and migration are minimized, elevated blood pressure and microalbuminuria are reduced, and high-density lipoprotein and low-density lipoprotein cholesterol particle sizes are improved.

Constructing an algorithm for managing type 2 diabetes. Focus on role of the thiazolidinediones

With the understanding of type 2 diabetes mellitus constantly evolving, and with the introduction of many new agents during the past few years, it is often difficult to keep up to date with the management of type 2 diabetes. This article reviews the pathophysiology of type 2 diabetes, oral pharmacologic treatment, and proposed diabetes treatment algorithms, which aim to guide clinicians in the use of thiazolidinediones (TZDs) earlier in the course of diabetes. This is important because studies indicate that sulfonylureas, biguanides, and insulin do not protect the beta cell and cannot provide sustainable glycemic control. The basis for TZD use earlier in diabetes is 2-fold: to preserve beta-cell function while maintaining appropriate glycemic control for a longer duration than is usually attained through monotherapy with a secretagogue or biguanide, and to prevent or reverse the insulin resistance phenomenon of reduced insulin utilization that appears even prior to the clinical diagnosis of diabetes. Notably, decreasing insulin resistance also may reduce the incidence of adverse atherosclerotic consequences.

The need for reappraisal of type 2 diabetes mellitus management

Type 2 diabetes is a multiorgan disease that results from the combination of insulin resistance and a beta-cell secretory defect. Because the complications associated with this disease are so significant, the importance of lowering glycosylated hemoglobin levels to within the normal range cannot be overemphasized. Thiazolidinediones (TZDs) modulate lipid metabolism, improve insulin sensitivity, exert numerous nonglycemic effects on the vasculature and lipid metabolism, and may improve many risk factors associated with the metabolic syndrome. Data from the UK Prospective Diabetes Study showed that conventional methods of managing type 2 diabetes, including sulfonylureas and biguanides, do not provide long-term glycemic control. Consequently, new treatment paradigms stressing earlier use of TZDs may lead to more durable glycemic control, facilitating the reduction of complications in patients with type 2 diabetes.

Scavenger receptor, class B, type I-dependent stimulation of cholesterol esterification by high density lipoproteins, low density lipoproteins, and nonlipoprotein cholesterol

Scavenger receptor, class B, type I (SR-BI) is a cell surface glycoprotein that mediates selective uptake and efflux of sterols from high density lipoproteins (HDL) to cells. A Chinese hamster ovary cell line that is deficient in functional LDL receptors, but has high expression levels of recombinant SR-BI (ldlA7-SR-BI), was used to examine the effect of SR-BI on the trafficking of sterols between lipoproteins and cells. To monitor the fate of sterols transported by SR-BI into cells, we measured the incorporation of [14C]oleate into cholesterol esters by acyl-CoA:cholesteryl acyltransferase in the endoplasmic reticulum. We show that incubation of ldlA7-SRBI cells with either LDL or HDL resulted in an equally dramatic increase in the formation of [14C]oleate-labeled cholesterol esters. The lipoprotein-stimulated, SR-BI-dependent increase in cholesterol esterification was inhibited by chloroquine. The uptake of sterols and their incorporation into cholesterol esters by SR-BI from LDL was largely a selective process. The addition of free cholesterol to ldlA7-SRBI cells also stimulated cholesterol ester formation in a chloroquine-sensitive fashion. We also show that SR-BI mediates the efflux of endogenously synthesized sterols from the cell membrane. From these studies we conclude that, in the absence of the LDL receptor, overexpression of SR-BI can mediate significant transport of sterols between lipoproteins and the endoplasmic reticulum of cells.

Transport of maternal LDL and HDL to the fetal membranes and placenta of the Golden Syrian hamster is mediated by receptor-dependent and receptor-independent processes

Maternal lipoproteins provide nutrients to the fetus via the placenta, yolk sac, and uterine membrane plus decidua. To determine the transport processes that are responsible for the removal of lipoproteins from the maternal circulation, we measured the clearance rates of maternal LDL and HDL in vivo, as well as the tissue distribution of expression of the LDL receptor, glycoprotein 330 (gp330) and the newly described HDL receptor, SR-BI, in the placenta, yolk sac, and uterine membrane plus decidua at mid- and late-gestation of the hamster. In mid-gestation (day 10.5), LDL clearance rates of the placenta and yolk sac were similar to those in the liver (approximately 100 microl/h per g) and higher than those in the decidua (18 +/- 3 microl/h per g). Clearance rates for HDL-apoA-I and HDL-cholesteryl ether were similar to those of LDL in the placenta and decidua whereas rates in the yolk sac were dramatically higher (>1700 microl/h per g). Additionally, albumin was cleared in the placenta and decidua at approximately 16 microl/h per g whereas the yolk sac cleared the protein at much higher rates (196 +/- 22 microl/h per g). Low levels of LDL receptor were detected by immunoblot analysis in the placenta with trace amounts in the yolk sac. Gp330 and SR-BI were both barely detectable in the placenta but were expressed at high levels in the yolk sac. As gestation progressed to day 14.5, LDL and HDL clearance rates decreased in all three tissues; immunodetectable LDL receptor decreased in the placenta whereas the expression of gp330 and SR-BI in the placenta and yolk sac remained relatively constant. These data suggest that the clearance of maternal lipoproteins by the placenta, yolk sac, and decidua are mediated by receptor-mediated as well as receptor-independent processes.

Structure and localization of the human gene encoding SR-BI/CLA-1. Evidence for transcriptional control by steroidogenic factor 1

The scavenger receptor, class B, type 1 receptor (SR-BI) mediates the selective transport of lipids from high density lipoprotein to cells. We describe the structure and subchromosomal location of human SR-BI and provide evidence that it is regulated by the transcription factor, steroidogenic factor 1 (SF-1). SR-BI resides on chromosome 12q24.2-qter, spans approximately 75 kilobase pairs, and contains 13 exons. RNA blot analysis of human tissues reveals an expression pattern similar to that described previously for rodents with the highest levels of mRNA in the adrenal gland, ovary, and liver. Unlike rodents, human SR-BI was expressed at high levels in the placenta. The transcription start site for SR-BI was mapped, and DNA sequence analysis revealed a binding site for SF-1 in the proximal 5'-flanking sequence. SF-1, an orphan member of the nuclear hormone receptor gene family, plays a key role in the regulation of steroidogenesis and is expressed at high levels in steroidogenic tissues. SF-1 binds to the SR-BI promoter in a sequence-specific manner, and efficient transcription from this promoter in adrenocortical Y1 cells is dependent on an intact SF-1 site. These data extend our understanding of SF-1 function within steroidogenic tissues and suggest that SR-BI, which serves to supply selected tissues with lipoprotein-derived lipids, is part of the repertoire of SF-1-responsive genes involved in steroidogenesis.

Expression of the VLDL receptor in endothelial cells

In this article we describe the cellular distribution of the very low density lipoprotein receptor (VLDLR), a transmembrane protein that is expressed at high concentrations in skeletal muscle, heart, adipose tissue, and brain but in only trace amounts in the liver. Indirect immunofluorescence localization studies were performed in murine and bovine tissues using a rabbit polyclonal anti-human VLDLR antibody. Immunoreactive VLDLR protein was detected in the endothelium of capillaries and small arterioles but not in veins or venules of bovine skeletal muscle, heart, ovary, and brain. In the liver, there was intense staining of the capillaries and arterioles that supply the capsule and hepatic vessels but no staining of the sinusoidal surfaces. We failed to detect any signal from nonendothelial cells in the liver or peripheral organs. The VLDLR was also expressed at high levels on the endothelial surface of bovine coronary arteries; in contrast, little or no staining was seen in aortic endothelium. Antibody staining of cultured bovine coronary artery endothelial cells demonstrated punctate cell-surface staining, as well as staining of large and small cytoplasmic vesicles. This tissue and cell pattern of expression suggests that the VLDLR plays a role in the transport of VLDL or another plasma constituent from the vascular compartment to adjacent tissues.

Regulation of the very low density lipoprotein receptor by thyroid hormone in rat skeletal muscle

A new member of the low density lipoprotein receptor gene family that binds and internalizes very low density lipoprotein (VLDL) particles was previously cloned and characterized from the rabbit and human. The physiological role of this putative VLDL receptor is not known, but its tissue distribution and ligand specificity suggest a possible role in the delivery of triglycerides to peripheral tissue. To learn more about the potential function of this receptor, we measured the changes in VLDL receptor mRNA and protein in various tissues following dietary or hormonal manipulation of rats. No significant changes in the VLDL receptor mRNA or protein were seen after a 48-h fast and subsequent to refeeding. A striking change in receptor mRNA and protein was observed in skeletal muscle of hypothyroid and hyperthyroid rats. In hypothyroid rats, the amount of immunodetectable VLDL receptor was reduced by 80%, while in the hyperthyroid animals it was increased by 300%. These maneuvers did not affect VLDL receptor mRNA or protein levels in adipose tissue or heart. The changes in VLDL receptor mRNA in muscle were opposite to those observed with lipoprotein lipase. These studies suggest that the VLDL receptor plays a role in a metabolic process in muscle that is regulated by thyroid hormone.

Rat granulosa cell apolipoprotein E secretion. Regulation by cell cholesterol

We have demonstrated previously that cultured rat ovarian granulosa cells synthesize and secrete apoE, and this production of apoE is increased by agents that stimulate protein kinase A (cyclic AMP-dependent enzyme) (for example, cholera toxin) and protein kinase C (Ca2+/phospholipid-dependent enzyme) (for example, 12-O-tetradecanoylphorbol-13-acetate, a phorbol ester). In the studies presented in this report, we have examined the effect of changes in cell cholesterol synthesis on the production of apoE by rat ovarian granulosa cells. Mevinolin, an inhibitor of hydroxymethylglutaryl (HMG)-CoA reductase (the rate-limiting enzyme in cholesterol synthesis), and 4,4,10 beta-trimethyl-trans-decal-3 beta-ol, an inhibitor of squalene cyclization, both attenuate the cholera toxin or 12-O-tetradecanoylphorbol-13-acetate stimulation of granulosa cell apoE secretion and apoE mRNA content in a dose-responsive manner. The inhibitory effect of mevinolin is reversed by the concomitant administration of mevalolactone, which provides the cells with the product of the reaction catalyzed by HMG-CoA reductase. Steroidogenesis per se has no effect on apoE production. Aminoglutethimide, which blocks the rate-limiting step in steroidogenesis, has no effect on apoE or apoE mRNA. The data indicate that products of HMG-CoA reductase (isoprenes, cholesterol and/or cholesterol metabolites) are required along with stimulators of protein kinases A and C, to regulate ovarian granulosa cell apoE production.

Regulation of apolipoprotein E biosynthesis by cAMP and phorbol ester in rat ovarian granulosa cells

Apolipoprotein E (apoE) is synthesized by the liver and many peripheral cells. Rat ovarian granulosa cells synthesize and secrete apoE, and this apoE production is increased by agents that increase cellular cAMP. In these studies of granulosa cell apoE synthesis we have examined the effect of agents that stimulate various cell kinases, including protein kinases A, G, and C. The cell content of apoE mRNA was measured simultaneously. Cholera toxin (1.25 micrograms/ml), dibutyryl-cAMP (5 mg/ml), and forskolin (10(-4) M), all of which increase cellular cAMP, stimulate apoE accumulation in the medium 7-10-fold. On the other hand, dibutyryl-cGMP (20 mg/ml) has no effect on apoE synthesis or secretion. The phorbol ester 12-O-tetradecanoylphorbol 13-acetate (100 ng/ml), a protein kinase C stimulator, increases apoE accumulation in the medium 8-10-fold, while 4 alpha-phorbol 12,13-didecanoate, the inactive phorbol congener, has no such effect. The cAMP effect on apoE synthesis by granulosa cells is maximal at 48 h, while the phorbol ester effect is maximal at 72-96 h in culture. The data indicate that agents whose effects are mediated by activation of protein kinases A and C, but not G, stimulate granulosa cell apoE production. These effects on the amount of secreted apoE are temporally preceded by increases in the granulosa cell content of apoE messenger RNA. Together, these data suggest that the regulation of apoE production in the rat ovarian granulosa cell could involve transcriptional and post-transcriptional mechanisms.