Intraislet Hyperinsulinemia Prevents the Glucagon Response to Hypoglycemia Despite an Intact Autonomic Response

Because absence of the glucagon response to falling plasma glucose concentrations plays a key role in the pathogenesis of iatrogenic hypoglycemia in patients with insulin-deficient diabetes and the mechanism of this defect is unknown, and given evidence in experimental animals that a decrease in intraislet insulin is a signal to increased glucagon secretion, we examined the role of endogenous insulin in the physiological glucagon response to hypoglycemia. We tested the hypothesis that intraislet hyperinsulinemia prevents the glucagon response to hypoglycemia despite an intact autonomic—adrenomedullary, sympathetic neural, and parasympathetic neural—response and a low α-cell glucose concentration. Twelve healthy young adults were studied on three separate occasions. Insulin was infused in hourly steps in relatively low doses (1.5, 3.0, 4.5, and 6.0 pmol · kg−1 · min−1) from 60 through 300 min on all three occasions. Plasma glucose levels were clamped at euglycemia (∼5.0 mmol/l, ∼90 mg/dl) on one occasion and at hourly steps of ∼4.7, 4.2, 3.6, and 3.0 mmol/l (∼85, 75, 65, and 55 mg/dl) from 60 through 300 min on the other two occasions. On one of the latter occasions, the β-cell secretagogue tolbutamide was infused in a dose of 1.0 g/h from 60 through 300 min. Hypoglycemia with tolbutamide infusion, compared with similar hypoglycemia alone, was associated with higher ( P < 0.0001) C-peptide levels (final values of 1.0 ± 0.2 vs. 0.1 ± 0.0 nmol/l), higher ( P < 0.0001) rates of insulin secretion (final values of 198 ± 60 vs. 15 ± 4 pmol/min), and higher ( P < 0.0001) insulin levels (final values of 325 ± 30 vs. 245 ± 20 pmol/l) as expected. The glucagon response to hypoglycemia was prevented during tolbutamide infusion ( P < 0.0001). Glucagon levels were 17 ± 1 pmol/l at baseline on both occasions, 14 ± 1 vs. 15 ± 1 pmol/l, respectively, during the initial hyperinsulinemic euglycemia, and 15 ± 1 vs. 22 ± 2 pmol/l, respectively, during hypoglycemia with and without tolbutamide infusion. Autonomic—adrenomedullary (plasma epinephrine), sympathetic neural (plasma norepinephrine), and parasympathetic neural (plasma pancreatic polypeptide)—responses to hypoglycemia were not reduced during tolbutamide infusion. We conclude that intraislet hyperinsulinemia prevents the glucagon response to hypoglycemia despite an intact autonomic response and a low α-cell glucose concentration.