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Fabricius TW, Verhulst CEM, Kristensen PL, Tack CJ, McCrimmon RJ, Heller S, Evans ML, Amiel SA, Pieber TR, de Galan BE, Pedersen-Bjergaard U. Hyperinsulinaemic-hypoglycaemic glucose clamps in human research: a systematic review of the literature. Diabetologia 2021; 64:727-736. [PMID: 33566134 PMCID: PMC7940281 DOI: 10.1007/s00125-020-05361-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/09/2020] [Indexed: 11/26/2022]
Abstract
AIMS/HYPOTHESIS The hyperinsulinaemic-hypoglycaemic glucose clamp technique has been developed and applied to assess effects of and responses to hypoglycaemia under standardised conditions. However, the degree to which the methodology of clamp studies is standardised is unclear. This systematic review examines how hyperinsulinaemic-hypoglycaemic clamps have been performed and elucidates potential important differences. METHODS A literature search in PubMed and EMBASE was conducted. Articles in English published between 1980 and 2018, involving adults with or without diabetes, were included. RESULTS A total of 383 articles were included. There was considerable variation in essential methodology of the hypoglycaemic clamp procedures, including the insulin dose used (49-fold difference between the lowest and the highest rate), the number of hypoglycaemic steps (range 1-6), the hypoglycaemic nadirs (range 2.0-4.3 mmol/l) and the duration (ranging from 5 to 660 min). Twenty-seven per cent of the articles reported whole blood glucose levels, most venous levels. In 70.8% of the studies, a dorsal hand vein was used for blood sampling, with some form of hand warming to arterialise venous blood in 78.8% of these. Key information was missing in 61.9% of the articles. CONCLUSIONS/INTERPRETATION Although the hyperinsulinaemic-hypoglycaemic clamp procedure is considered the gold standard to study experimental hypoglycaemia, a uniform standard with key elements on how to perform these experiments is lacking. Methodological differences should be considered when comparing results between hypoglycaemic clamp studies. PROSPERO REGISTRATION This systematic review is registered in PROSPERO (CRD42019120083).
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Affiliation(s)
- Therese W Fabricius
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Denmark.
| | - Clementine E M Verhulst
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands.
| | - Peter L Kristensen
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Denmark
| | - Cees J Tack
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Rory J McCrimmon
- Department of Internal Medicine, University of Dundee, Dundee, UK
| | - Simon Heller
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Mark L Evans
- Wellcome Trust/MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Stephanie A Amiel
- Department of Diabetes, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Thomas R Pieber
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Bastiaan E de Galan
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Mather KJ, Tjaden AH, Hoehn A, Nadeau KJ, Buchanan TA, Kahn SE, Arslanian SA, Caprio S, Atkinson KM, Cree-Green M, Utzschneider KM, Edelstein SL. Precision and accuracy of hyperglycemic clamps in a multicenter study. Am J Physiol Endocrinol Metab 2021; 320:E797-E807. [PMID: 33645253 PMCID: PMC8238133 DOI: 10.1152/ajpendo.00598.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Application of glucose clamp methodologies in multicenter studies brings challenges for standardization. The Restoring Insulin Secretion (RISE) Consortium implemented a hyperglycemic clamp protocol across seven centers using a combination of technical and management approaches to achieve standardization. Two-stage hyperglycemic clamps with glucose targets of 200 mg/dL and >450 mg/dL were performed utilizing a centralized spreadsheet-based algorithm that guided dextrose infusion rates using bedside plasma glucose measurements. Clamp operators received initial and repeated training with ongoing feedback based on surveillance of clamp performance. The precision and accuracy of the achieved stage-specific glucose targets were evaluated, including differences by study center. We also evaluated robustness of the method to baseline physiologic differences and on-study treatment effects. The RISE approach produced high overall precision (3%-9% variance in achieved plasma glucose from target at various times across the procedure) and accuracy (SD < 10% overall). Statistically significant but numerically small differences in achieved target glucose concentrations were observed across study centers, within the magnitude of the observed technical variability. Variation of the achieved target glucose over time in placebo-treated individuals was low (<3% variation), and the method was robust to differences in baseline physiology (youth vs. adult, IGT vs. diabetes status) and differences in physiology induced by study treatments. The RISE approach to standardization of the hyperglycemic clamp methodology across multiple study centers produced technically excellent standardization of achieved glucose concentrations. This approach provides a reliable method for implementing glucose clamp methodology across multiple study centers.NEW & NOTEWORTHY The Restoring Insulin Secretion (RISE) study centers undertook hyperglycemic clamps using a simplified methodology and a decision guidance algorithm implemented in an easy-to-use spreadsheet. This approach, combined with active management including ongoing central data surveillance and routine feedback to study centers, produced technically excellent standardization of achieved glucose concentrations on repeat studies within and across study centers.
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Affiliation(s)
- Kieren J Mather
- Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Ashley H Tjaden
- The Biostatistics Center, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Adam Hoehn
- College of Osteopathic Medicine, Marian University, Indianapolis, Indiana
| | - Kristen J Nadeau
- Department of Pediatrics, School of Medicine, University of Colorado Denver, Colorado
| | - Thomas A Buchanan
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Steven E Kahn
- Department of Medicine, VA Puget Sound Health Care System, University of Washington, Seattle, Washington
| | - Silva A Arslanian
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pennsylvania
| | - Sonia Caprio
- Department of Pediatrics, School of Medicine, Yale University, New Haven, Connecticut
| | - Karen M Atkinson
- Department of Medicine, VA Puget Sound Health Care System, University of Washington, Seattle, Washington
| | - Melanie Cree-Green
- Department of Pediatrics, School of Medicine, University of Colorado Denver, Colorado
| | - Kristina M Utzschneider
- Department of Medicine, VA Puget Sound Health Care System, University of Washington, Seattle, Washington
| | - Sharon L Edelstein
- The Biostatistics Center, Milken Institute School of Public Health, George Washington University, Washington, DC
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Abstract
BACKGROUND There is no consensus in the field regarding the optimal method for the expression of metabolic flux data, such as glucose disposal rates during hyperinsulinemic-euglycemic clamp experiments. Several normalization methods are in use today, but their impact on study outcomes is rarely discussed. METHODS We illustrate this issue using clamp data from 92 lean and 66 obese subjects. Glucose kinetics and insulin sensitivity were determined during hyperinsulinemic-euglycemic clamp studies using [6,6-2H2]glucose. From this single dataset, we calculated 21 expression methods for the glucose disposal rate during hyperinsulinemic conditions. RESULTS AND DISCUSSION With most normalization methods, the obese subjects demonstrated reduced insulin-stimulated glucose disposal as compared to the lean subjects. However, depending on the normalization method, glucose disposal rates in obese subjects ranged from 26 ± 1% to 207 ± 10% of glucose disposal rates in lean subjects. We conclude that data normalization methods greatly impacted metabolic flux outcomes in our dataset of lean and obese subjects. There is no compelling evidence to select one method over the other, but we encourage authors in the metabolic arena to think about, and provide a rationale for, the best normalization method for their specific research questions.
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Affiliation(s)
- Kasper W Ter Horst
- Department of Endocrinology and Metabolism, Amsterdam University Medical Center, location AMC, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
| | - Mireille J Serlie
- Department of Endocrinology and Metabolism, Amsterdam University Medical Center, location AMC, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
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Glicksman M, Grewal S, Sortur S, Abel BS, Auh S, Gaillard TR, Osei K, Muniyappa R. Assessing the predictive accuracy of oral glucose effectiveness index using a calibration model. Endocrine 2019; 63:391-397. [PMID: 30402674 PMCID: PMC6448593 DOI: 10.1007/s12020-018-1804-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 10/25/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE Current reference methods for measuring glucose effectiveness (GE) are the somatostatin pancreatic glucose clamp and minimal model analysis of frequently sampled intravenous glucose tolerance test (FSIVGTT), both of which are laborious and not feasible in large epidemiological studies. Consequently, surrogate indices derived from an oral glucose tolerance test (OGTT) to measure GE (oGE) have been proposed and used in many studies. However, the predictive accuracy of these surrogates has not been formally validated. In this study, we used a calibration model analysis to evaluate the accuracy of surrogate indices to predict GE from the reference FSIVGTT (SgMM). METHODS Subjects (n = 123, mean age 48 ± 11 years; BMI 35.9 ± 7.3 kg/m2) with varying glucose tolerance (NGT, n = 37; IFG/IGT, n = 78; and T2DM, n = 8) underwent FSIVGTT and OGTT on two separate days. Predictive accuracy was assessed by both root mean squared error (RMSE) of prediction and leave-one-out cross-validation-type RMSE of prediction (CVPE). RESULTS As expected, insulin sensitivity, SgMM, and oGE were reduced in subjects with T2DM and IFG/IGT when compared with NGT. Simple linear regression analyses revealed a modest but significant relationship between oGE and SgMM (r = 0.25, p < 0.001). However, using calibration model, measured SgMM and predicted SgMM derived from oGE were modestly correlated (r = 0.21, p < 0.05) with the best fit line suggesting poor predictive accuracy. There were no significant differences in CVPE and RMSE among the surrogates, suggesting similar predictive ability. CONCLUSIONS Although OGTT-derived surrogate indices of GE are convenient and feasible, they have limited ability to robustly predict GE.
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Affiliation(s)
- Michael Glicksman
- Diabetes, Endocrinology, and Obesity Branch, NIDDK, Bethesda, MD, USA
| | - Shivraj Grewal
- Diabetes, Endocrinology, and Obesity Branch, NIDDK, Bethesda, MD, USA
| | - Shrayus Sortur
- Diabetes, Endocrinology, and Obesity Branch, NIDDK, Bethesda, MD, USA
| | - Brent S Abel
- Diabetes, Endocrinology, and Obesity Branch, NIDDK, Bethesda, MD, USA
| | - Sungyoung Auh
- Diabetes, Endocrinology, and Obesity Branch, NIDDK, Bethesda, MD, USA
| | - Trudy R Gaillard
- Nicole Wertheim College of Nursing and Health Sciences, Florida International University, Miami, FL, USA
| | - Kwame Osei
- Division of Endocrinology, Diabetes and Metabolism, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
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Heise T, Zijlstra E, Nosek L, Heckermann S, Plum-Mörschel L, Forst T. Euglycaemic glucose clamp: what it can and cannot do, and how to do it. Diabetes Obes Metab 2016; 18:962-72. [PMID: 27324560 DOI: 10.1111/dom.12703] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 06/05/2016] [Accepted: 06/06/2016] [Indexed: 01/20/2023]
Abstract
The hyperinsulinaemic-euglycaemic glucose clamp has always been regarded as the "gold standard" for the assessment of pharmacodynamic (PD) properties of insulin preparations; however, there has been controversy over a variety of methodogical details, such as study population, dosing time and the initial stabilization of blood glucose (BG) concentrations at the clamp target level, among clamp groups. As the impact of these details on PD results is unclear, the present review provides an overview of different methodological approaches for both the manual and the automated hyperinsulinaemic-euglycaemic glucose clamp. The advantages and limitations of several methodological details are discussed as well as the relevance of clamp results for the prediction of clinical outcomes. Overall, the best method strongly depends on the exact objective of the trial. If, for instance, duration of action is the primary objective, studies should be carried out in patients with type 1 diabetes to avoid any interference of endogenous insulin. This is less important for variables such as onset of action or early metabolic activity. The hyperinsulinaemic-euglycaemic glucose clamp has a high sensitivity to detect even minor differences between different insulin preparations. The practical relevance of potential differences, however, needs to be investigated in clinical studies. A major prerequisite for obtaining reliable glucose clamp results is the attainment of high clamp quality (i.e. keeping BG concentrations close to the clamp target throughout the experiments). Unfortunately, measures of clamp quality are often under-reported, as is the variability in PD profiles, although these might explain some unconfirmed extreme results obtained in a few clamp studies.
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Winner D, Norton L, Kanat M, Arya R, Fourcaudot M, Hansis-Diarte A, Tripathy D, DeFronzo RA, Jenkinson CP, Abdul-Ghani M. Strong association between insulin-mediated glucose uptake and the 2-hour, not the fasting plasma glucose concentration, in the normal glucose tolerance range. J Clin Endocrinol Metab 2014; 99:3444-9. [PMID: 24796924 PMCID: PMC4154101 DOI: 10.1210/jc.2013-2886] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
AIM The aim of this study was to examine the relationship between whole-body insulin-mediated glucose disposal and the fasting plasma glucose concentration in nondiabetic individuals. RESEARCH DESIGN AND METHODS Two hundred fifty-three nondiabetic subjects with normal glucose tolerance (NGT), impaired fasting glucose (IFG), impaired glucose tolerance, and combined glucose intolerance received a 75-g oral glucose tolerance test and euglycemic hyperinsulinemic clamp. Total glucose disposal (TGD) during the insulin clamp was compared in IFG and NGT individuals and was related to fasting and 2-hour plasma glucose concentrations in each group. RESULTS TGD varied considerably between NGT and IFG individuals and displayed a strong inverse relationship with the 2-hour plasma glucose (PG; r = 0.40, P < .0001) but not with the fasting PG. When IFG and NGT individuals were stratified based on their 2-hour PG concentration, the increase in 2-hour PG was associated with a progressive decrease in TGD in both groups, and the TGD was comparable among NGT and IFG individuals. CONCLUSION The present results indicate the following: 1) as in NGT, insulin-stimulated TGD varies considerably in IFG individuals; 2) the large variability in TGD in IFG and NGT individuals is related to the 2-hour PG concentration; and 3) after adjustment for the 2-hour proglucagon concentration, IFG subjects have comparable TGD with NGT individuals.
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Affiliation(s)
- Diedre Winner
- Diabetes Division (D.W., L.N., R.A., M.F., A.H.-D., D.T., R.A.D., C.P.J., M.A.-G.), University of Texas Health Science Center at San Antonio, Texas 78229; and Division of Diabetes (M.K.), Istanbul Medipol University, 34810 Istanbul, Turkey
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7
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Dalla Man C, Piccinini F, Basu R, Basu A, Rizza RA, Cobelli C. Modeling hepatic insulin sensitivity during a meal: validation against the euglycemic hyperinsulinemic clamp. Am J Physiol Endocrinol Metab 2013; 304:E819-25. [PMID: 23443923 PMCID: PMC3625785 DOI: 10.1152/ajpendo.00482.2012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Recently, we proposed a model describing the suppression of endogenous glucose production (EGP) during a meal. It assumes that EGP suppression depends on glucose concentration and its rate of change and on delayed insulin action. Hepatic insulin sensitivity (S(I)(Lmeal)) can be derived from EGP model parameters. This model was shown to adequately describe EGP profiles measured with multiple tracer techniques; however, S(I)(Lmeal) has never been compared directly with its euglycemic hyperinsulinemic clamp counterpart (S(I)(Lclamp)). To do so, 62 subjects with different degrees of glucose tolerance underwent a triple-tracer mixed meal. Fifty-seven subjects also underwent a labeled ([3-(3)H]glucose) euglycemic hyperinsulinemic clamp. From the triple-tracer meal data, virtually model-independent estimates of EGP were obtained using the tracer-to-tracee clamp technique, and the EGP model was identified in each subject. Model fit was satisfactory, and S(I)(Lmeal) was estimated with good precision. Correlation between S(I)(Lclamp) and S(I)(Lmeal) was good (r = 0.72, P < 0.001); however, S(I)(Lmeal) was lower than S(I)(Lclamp) (4.60 ± 0.64 vs. 8.73 ± 1.07 10(-4) dl·kg(-1)·min(-1) per μU/ml, P < 0.01). This difference may be due to different ranges of insulin explored during the two tests (ΔI(clamp) = 15.60 ± 1.61 vs. ΔI(meal)= 83.37 ± 10.71 μU/ml) as well as steady- vs. non-steady-state glucose and insulin profiles. In conclusion, the new EGP model provides an estimate of hepatic insulin sensitivity during a meal that is in good agreement with that derived in the same individuals with a hyperinsulinemic clamp. When used in conjunction with the minimal model, the approach potentially enables estimation of hepatic insulin sensitivity from a single-tracer labeled meal or oral glucose tolerance test.
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Affiliation(s)
- Chiara Dalla Man
- Department of Information Engineering, University of Padua, Padua, Italy
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Abstract
The two basal insulin analogs, insulin glargine and insulin detemir, were developed to ameliorate the well-known limitations of NPH insulin. In contrast to rapid-acting analogs, which differ exclusively in terms of primary structure while sharing similar pharmacokinetics (PK) and pharmacodynamics (PD), the two long-acting insulin analogs are different chemical and structural entities, exhibiting distinct modes of protracting the insulin effect. So far, PK and PD studies of long-acting analogs have often shown conflicting results, pointing out different conclusions, thereby leading to animated controversies. The methods used in the evaluation of basal insulins might have been partially responsible as, although the euglycemic clamp technique has been broadly acknowledged to be the "gold standard" reference to assess the glucose-lowering effect of an insulin preparation, its execution and interpretation might have been substantially different across studies, in various methodological and analytical aspects, ultimately providing an explanation for some of these controversies. This review will present and describe the basic methods used in the evaluation of basal insulins and will critically summarize the points that might have been responsible for the different outcomes. The findings of glucose clamp studies demonstrate that the two long-acting insulin analogs are different, to some extent, in both their PK and PD profiles. These differences should be taken into consideration when the individual analogs are introduced to provide basal insulin supplementation to optimize blood glucose control in patients with type 1 and type 2 diabetes as well.
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Affiliation(s)
- David H Wasserman
- Department of Molecular Physiology and Biophysics, Vanderbilt Mouse Metabolic Phenotyping Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
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Le DSNT, Brookshire T, Krakoff J, Bunt JC. Repeatability and reproducibility of the hyperinsulinemic-euglycemic clamp and the tracer dilution technique in a controlled inpatient setting. Metabolism 2009; 58:304-10. [PMID: 19217443 PMCID: PMC2692526 DOI: 10.1016/j.metabol.2008.09.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Accepted: 09/09/2008] [Indexed: 11/18/2022]
Abstract
The objective of the study was to evaluate the reproducibility and repeatability of the combined use of the hyperinsulinemic-euglycemic (H-E) clamp and tracer dilution techniques. Ten nondiabetic men underwent a low-dose (40 mU/[m(2) min]) H-E clamp that was repeated within 3 to 4 days using porcine or human insulin in a double-blinded, randomized, crossover design. Coefficients of variation (CVs) for intraindividual differences and repeatability coefficient were calculated to evaluate reproducibility and repeatability. The Bland and Altman method was used to quantify repeatability. The CVs for intraindividual differences were 5.7% +/- 3.5% for steady-state (SS) insulin; 6.7% +/- 6.2% and 54.2 +/- 38.3% for basal and SS endogenous glucose product (EGP), respectively; and 10.3% +/- 8.5% for total insulin-stimulated glucose disposal (M) values. Basal EGP, SS EGP, and SS glucose and insulin concentrations were similar for the 2 clamps; but glucose infusion rate (P = .02) and M (borderline significant, P = .06) were higher in the first clamp than the second clamp. No significant correlations between mean of differences and average of basal and SS EGP, SS insulin concentration, and M between the 2 clamps were observed. We also found that the different values were less than the repeatability coefficients of these parameters and that the 95% limits of agreement and the interval of repeatability coefficient of these parameters were similar. There were no differences in metabolic responses between clamps when compared by the type of insulin (porcine vs human) infused. Our findings indicate that, although SS EGP has a high CV, the clamp, which measures insulin action (ie, SS insulin, M), and the tracer dilution technique for assessing basal EGP are repeatable and reproducible. Decreased glucose infusion rate and M over a short period in the second clamp may reflect an accumulative effect of continued physical inactivity.
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Affiliation(s)
- Duc Son N T Le
- Obesity and Diabetes Clinical Research Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ 85016, USA.
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Sesti G, Andreozzi F, Bonadonna RC, De Mattia G, Leonetti F, Luzi L, Marini MA, Natali A, Vettor R, Bonora E. Impact of lowering the criterion for impaired fasting glucose on identification of individuals with insulin resistance. The GISIR database. Diabetes Metab Res Rev 2008; 24:130-6. [PMID: 17922529 DOI: 10.1002/dmrr.775] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We assessed the accuracy of the American Diabetes Association (ADA)2003 definition of impaired fasting glucose (IFG) in identifying subjects with low insulin sensitivity, and determined cardiovascular risk factors in ADA2003 IFG subjects. RESEARCH DESIGN AND METHODS This study included 930 non-diabetic Italian Caucasians from the GISIR database in which subjects underwent a hyperinsulinaemic-euglycaemic clamp performed with a standard technique. Low insulin sensitivity was defined as being in the lower quartile of glucose metabolized during the last hour of the clamp (M). Subjects were stratified in the following groups: normal fasting glucose (NFG) (<100 mg/dL), IFG100 (100-109 mg/dL), ADA1997 IFG110 (110-125 mg/dL), and ADA2003 IFG (100-125 mg/dL). RESULTS The sensitivity of identifying subjects with low insulin sensitivity increased adopting the ADA2003 criterion. After Bonferroni correction for multiple comparisons, both IFG100 and ADA1997 IFG110 showed significantly higher body mass index (BMI), waist, systolic blood pressure (SBP) and diastolic blood pressure (DBP), triglyceride, fasting plasma insulin (FPI) and fasting plasma glucose (FPG), and lower insulin sensitivity as compared with NFG. As compared with IFG100, ADA1997 IFG110 showed significantly higher BMI, waist, SBP, FPI, FPG, and lower insulin sensitivity. ADA2003 IFG group showed significantly higher BMI, waist, SBP and DBP, triglyceride, cholesterol, FPI, and FPG, but lower HDL levels and insulin sensitivity compared with NFG subjects. CONCLUSIONS Although neither the ADA2003 nor the ADA1997 definition of IFG appears to be particularly efficacious for the identification of subjects' low insulin sensitivity, lowering the criterion to the ADA2003 glucose threshold increased the sensitivity without affecting the specificity. ADA2003 IFG showed a worse cardiovascular risk profile compared with NFG.
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Affiliation(s)
- Giorgio Sesti
- Department of Experimental and Clinical Medicine, University of Catanzaro, Italy.
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12
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Diamanti-Kandarakis E, Kouli C, Alexandraki K, Spina G. Failure of mathematical indices to accurately assess insulin resistance in lean, overweight, or obese women with polycystic ovary syndrome. J Clin Endocrinol Metab 2004; 89:1273-6. [PMID: 15001622 DOI: 10.1210/jc.2003-031205] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Insulin resistance is a common metabolic feature of polycystic ovary syndrome (PCOS). In this study, we examined the validity of the mathematical indices [the quantitative insulin sensitivity check index (QUICKI) and the homeostasis model of assessment (HOMA)] that calculate insulin sensitivity and their correlation to glucose utilization with the insulin infusion rate in 40 mU/m(2).min by the euglycemic clamp (M) in women with PCOS. We studied 59 women with PCOS (20 lean, 16 overweight, and 23 obese subjects). Euglycemic clamp testing was performed, and QUICKI, HOMA, total testosterone, fasting insulin, fasting glucose, and glucose-to-insulin ratio were estimated. No difference was found in testosterone and glucose levels among the three groups. Lean or overweight women compared with obese women differed in insulin levels, glucose-to-insulin ratio, QUICKI, and HOMA (P < 0.01). No statistical difference was found between lean and overweight women in the above parameters. M differed when lean women were compared with overweight (P < 0.002) or obese women (P < 0.0001); however, no statistical difference was observed between overweight and obese women. No significant correlation was found between M and QUICKI or HOMA. We conclude that mathematical indices should be applied with caution in different insulin-resistant populations and should not be considered a priori equivalent to the euglycemic clamp technique.
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Affiliation(s)
- Evanthia Diamanti-Kandarakis
- Endocrine Section of the First Department of Internal Medicine, Athens University School of Medicine, Laiko General Hospital, Athens 115 27, Greece.
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Yeckel CW, Weiss R, Dziura J, Taksali SE, Dufour S, Burgert TS, Tamborlane WV, Caprio S. Validation of insulin sensitivity indices from oral glucose tolerance test parameters in obese children and adolescents. J Clin Endocrinol Metab 2004; 89:1096-101. [PMID: 15001593 DOI: 10.1210/jc.2003-031503] [Citation(s) in RCA: 268] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Given the extreme increase in prediabetes, type 2 diabetes, and the potential for metabolic syndrome in obese youth, identifying simplified indexes for assessing stimulated insulin sensitivity is critical. The purpose of this study was validation of two surrogate indexes of insulin sensitivity determined from the oral glucose tolerance test (OGTT): the composite whole body insulin sensitivity index (WBISI) and the insulin sensitivity index (ISI). An obese population (aged 8-18 yr) of normal and impaired glucose tolerance individuals was studied. One group (n = 38) performed both the euglycemic-hyperinsulinemic clamp and OGTT for comparison of insulin sensitivity measurements as well as (1)H-magnetic resonance spectroscopy estimates of intramyocellular lipid content. Another larger (n = 368) cohort participated only in an OGTT. Both the WBISI and ISI represented good estimates (r = 0.78 and 0.74; P < 0.0005) for clamp-derived insulin sensitivity (glucose disposed, M-value), respectively. In the large cohort, the surrogate indexes demonstrated the shift toward poorer function and increased risk profile as a function of insulin resistance. Additionally, the WBISI and ISI correlated with intramyocellular lipid content (r = -0.74 and -0.71; P < 0.0001), a tissue marker for insulin resistance. Insulin sensitivity can be estimated using plasma glucose and insulin responses derived from the OGTT in obese youth with normal and impaired glucose tolerance.
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Affiliation(s)
- Catherine W Yeckel
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut 06520, USA
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Radikova Z. Assessment of insulin sensitivity/resistance in epidemiological studies. Endocr Regul 2003; 37:189-94. [PMID: 14986725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
Hyperinsulinemic euglycemic clamp is known to be the "gold standard" in measurement insulin sensitivity. However, its time and financially consuming realization led to a simplified approach in quantification of insulin sensitivity. Various indices of insulin sensitivity/resistance using the data from an oral glucose tolerance test were proposed in last 20 years. The aim of this review is to evaluate critically the use of some of the proposed indices in insulin sensitivity estimation. There are two groups of insulin sensitivity indices: 1. indices calculated by using fasting plasma concentrations of insulin, glucose and triglycerides, 2. indices calculated by using plasma concentrations of insulin and glucose obtained during 120 min of a standard (75 g glucose) oral glucose tolerance test. Some authors used demographic parameters (BMI, age, weight) in their formulas to achieve the best correlation with euglycemic clamp data. These indices are conveniently used in epidemiological and clinical studies to predict diabetes development in a non-diabetic population. Their use in clinical practice is limited because of the absence of reference values for normal and impaired insulin sensitivity.
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Affiliation(s)
- Zofia Radikova
- Institute of Experimental Endocrinology, Slovak Academy of Sciences, 833 06 Bratislava, Slovakia.
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Abstract
AIMS To evaluate the relationship between surrogate measures of insulin sensitivity and results from euglycaemic insulin clamp in Chinese diabetic patients and their offspring. METHODS The study included 59 volunteers from 20 diabetic families. Each participant completed a 75-g oral glucose tolerance test (OGTT) and a euglycaemic insulin clamp. We tested the correlation of surrogate measures of insulin sensitivity with M-values and M/I ratios (the amount of glucose infused during 90-120 min of the clamp was defined as M, and the mean values of plasma insulin during 90-120 min as I) from the euglycaemic insulin clamp. These measures included fasting insulin (FPI), insulin at 120 min of OGTT, insulin area under the curve of OGTT, fasting glucose-to-insulin ratio, homeostasis model assessment for insulin sensitivity (HOMA-IR and HOMA %S) and the Matsuda-DeFronzo index from OGTT. RESULTS The Matsuda-DeFronzo index closely correlated to M-value and M/I in 21 diabetic, 38 non-diabetic individuals and the 59 participants overall (with M-value, r = 0.68, 0.84 and 0.84; with M/I, r = 0.71, 0.72 and 0.75, respectively, all P < 0.001). Without OGTT, HOMA %S was a good surrogate index for diabetic (correlated to M-value and M/I, r = 0.71 and 0.68, P = 0.001) and for non-diabetic subjects (to M-value, r = 0.73; to M/I, r = 0.55, both P < 0.001). FPI was as good as HOMA %S and Matsuda-DeFronzo index. CONCLUSIONS The Matsuda-DeFronzo index, HOMA %S and FPI are good surrogate estimates of insulin sensitivity in Chinese diabetic subjects and their offspring.
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Affiliation(s)
- C S Kuo
- Section of Endocrinology and Metabolism, Department of Medicine, Tapei Veterans Hospital, Tapei, Taiwan
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Godsland IF, Walton C. Maximizing the success rate of minimal model insulin sensitivity measurement in humans: the importance of basal glucose levels. Clin Sci (Lond) 2001; 101:1-9. [PMID: 11410108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
Minimal model analysis of glucose and insulin concentrations in the intravenous glucose tolerance test (IVGTT) has been widely used to obtain a measure of insulin sensitivity in humans. Issues of model validity and IVGTT protocol have been explored extensively. Less attention has been paid, however, to the computer programming protocol for estimating the model parameters (programming implementation). Minimal model analysis of data from an IVGTT protocol involving a high glucose dose (0.5 g/kg) and a reduced sample schedule, employed in healthy pre- or post-menopausal women, healthy men or men with coronary heart disease or chronic heart failure (20 in each group), was undertaken according to 12 different programming implementations using a commercially available model-equation-solving program. The ability of the program to arrive at an acceptable solution to the model equations gave a success rate of between 39% and 96%, depending on the implementation. Variation in basal glucose assignment significantly affected the magnitude of estimates of insulin sensitivity. The maximum modelling success rate was achieved by introduction of an imputed glucose measurement at 360 min from the glucose injection, taking the basal glucose level as the fasting glucose concentration, and overweighting the initial glucose measurement after a delay for mixing. Use of this implementation to analyse data from a study comparing insulin sensitivities obtained using the minimal model and a euglycaemic clamp reference gave a correlation of 0.80 (P<0.001) between the two methods. Straightforward variations in programming implementation, involving appropriate assignment of the basal glucose concentration and use of an imputed glucose measurement signifying re-establishment of basal glucose levels following the IVGTT, can considerably improve modelling success rate.
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Affiliation(s)
- I F Godsland
- The Wynn Department of Metabolic Medicine, Division of Medicine, Imperial College School of Medicine (St Mary's Campus), Norfolk Place, London W2 1PG, U.K.
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Fritsche A, Stefan N, Hardt E, Schützenauer S, Häring H, Stumvoll M. A novel hyperglycaemic clamp for characterization of islet function in humans: assessment of three different secretagogues, maximal insulin response and reproducibility. Eur J Clin Invest 2000; 30:411-8. [PMID: 10809901 DOI: 10.1046/j.1365-2362.2000.00649.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Characterization of beta-cell function in humans is essential for identifying genetic defects involved in abnormal insulin secretion and the pathogenesis of type 2 diabetes. MATERIALS AND METHODS We designed a novel test assessing plasma insulin and C-peptide in response to 3 different secretagogues. Seven lean, healthy volunteers twice underwent a 200 min hyperglycaemic clamp (10 mmol L-1) with administration of GLP-1 (1.5 pmol. kg-1. min-1) starting at 120 min and an arginine bolus at 180 min. We determined glucose-induced first and second-phase insulin secretion, GLP-1-stimulated insulin secretion, arginine-stimulated insulin response (increase above prestimulus, DeltaIarg) and the maximal, i. e. highest absolute, insulin concentration (Imax). Insulin sensitivity was assessed during second-phase hyperglycaemia. On a third occasion 6 subjects additionally received an arginine bolus at > 25 mM blood glucose, a test hitherto claimed to provoke maximal insulin secretion. RESULTS Insulin levels increased from 46 +/- 11 pM to 566 +/- 202 pM at 120 min, to 5104 +/- 1179 pM at 180 min and to maximally 8361 +/- 1368 pM after arginine (all P < 0.001). The within subject coefficients of variation of the different secretion parameters ranged from 10 +/- 3% to 16 +/- 6%. Except for second-phase which failed to correlate significantly with DeltaIarg (r = 0.52, P = 0.23) and Imax (r = 0.75, P = 0.053) all phases of insulin secretion correlated with one another. The insulin concentration after the arginine bolus at > 25 mM glucose (n = 6) was 2773 +/- 855 pM vs. 7562 +/- 1168 pM for Imax (P = 0.003). CONCLUSION This novel insulin secretion test elicits a distinct pattern of plasma insulin concentrations in response to the secretagogues glucose, GLP-1 and arginine and is highly reproducible and can be used for differential characterization of islet function.
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Affiliation(s)
- A Fritsche
- Eberhard-Karls-Universität, Tübingen, Germany
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Bokemark L, Frödén A, Attvall S, Wikstrand J, Fagerberg B. The euglycemic hyperinsulinemic clamp examination: variability and reproducibility. Scand J Clin Lab Invest 2000; 60:27-36. [PMID: 10757451 DOI: 10.1080/00365510050185010] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
The aim was to examine the reproducibility of the euglycemic hyperinsulinemic clamp method. From a random population sample of 60-year-old clinically healthy men, 32 subjects with varying degrees of insulin sensitivity were recruited. Conventional 2-h clamp examinations were carried out at an interval of 2 weeks. Insulin was infused intravenously (priming for 10 min and thereafter 1.0 mU/kg body wt/min). Glucose was infused concomitantly aiming at a whole blood glucose of 5 mmol/L. The glucose infusion rate (GIR) was adjusted for body weight or fat free mass (FFM), the latter measured with dual-energy X-ray absorptiometry. During the final hour of each examination (60-120 min) the mean whole blood glucose concentrations were 5.06+/-0.15 and 5.09+/-0.17 mmol/L, respectively. Of the different time intervals studied, the glucose infusion rate during the final hour (GIR60-120) showed the highest correlation and lowest coefficient of variation (GIR60-120 adjusted by FFM: r=0.70, coefficient of variation=14.7%). Adjustment of GIR for weight instead of FFM underestimated insulin sensitivity in obese men. GIR60-120 adjusted for FFM tended to increase during the second examination. The measurement error was constant across all GIR. In summary, the euglycemic hyperinsulinemic clamp method has a coefficient of variation around 15%. The glucose infusion rate should be adjusted for fat free mass.
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Affiliation(s)
- L Bokemark
- Department of Medicine, Sahlgrenska University Hospital, Göteborg, Sweden
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Abstract
The Biostator makes it possible to perform glucose clamp experiments almost automatically. Thus, blood glucose concentrations can be maintained at (or close to) a target level with substantially less effort than with the manual clamp technique. The automatisation also avoids a potential bias on the part of the investigator. However, as with the non-automated manual clamp technique, blood glucose concentrations do not remain exactly at the target value, as they show a considerable scatter around the target value. This scatter is generated by the time constants of the Biostator, i.e. the whole closed-loop system, and the autoregressive properties of the glucose clamp algorithm used. In order to describe the quality of glucose clamps over time more precisely, "cumulative sums" as an alternative to the usual coefficient of variation can be used. Practical work with the Biostator is burdened with technical difficulties and considerable costs in comparison to the manual clamp technique. Deficits concerning data storage and presentation capability of the Biostator have been overcome by an appropriate programme for an external computer. The use of the Biostator for the glucose clamp technique is not mandatory, but, the use of this machine makes it possible to perform glucose clamp studies under standardised and reproducible conditions.
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Affiliation(s)
- L Heinemann
- Klinik für Stoffwechselkrankheiten und Ernährung (WHO Collaborating Center for Diabetes), Heinrich-Heine-Universität Düsseldorf, Germany
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