eric niederhoffer siu-som a 59-year-old man with a history of diabetes and alcohol abuse is brought...
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![Page 1: Eric Niederhoffer SIU-SOM A 59-year-old man with a history of diabetes and alcohol abuse is brought to the emergency room in a semiconscious and minimally](https://reader037.vdocuments.us/reader037/viewer/2022103123/56649d9f5503460f94a89be6/html5/thumbnails/1.jpg)
Eric Niederhoffer
SIU-SOM
A 59-year-old man with a history of diabetes and alcohol abuse is
brought to the emergency room in a semiconscious and minimally
responsive state
How are glucose, triacylglycerols, and amino acids normally metabolized and what happens in diabetes?
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Regulation of Metabolism and Diabetes
• Clinical focus of glucose metabolism
• Pathways overview
• Tissues overview
• Glucose homeostasis
• Regulation of carbohydrate metabolism
Glycogenesis, glycogenolysis, glycolysis, fructose
metabolism gluconeogenesis
• Regulation of fats metabolism
Lipogenesis, lypolysis
• Impact of diabetes on metabolism
• Pathway pearls
• Drug classes
• Review questions
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Clinical Focus of Glucose Metabolism
• Glucose intolerance
Type 1 diabetes mellitus
Type 2 diabetes mellitus
Gestational diabetes
Maturity onset diabetes of the young (MODY)
Incretin hormone/dipeptidyl peptidase IV defects
Insulin resistance
(ketoacidosis, nephropathy, neuropathy, retinopathy)
• Hypoglycemia
• Glycogen storage diseases
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Acetyl-CoALactate
Production of ATP
G6P
Glucose
Glycolysis
Pyruvate
Krebscycle
ElectronTransport
Chain
Glycogen
Glycogenolysis
Fatty acids(TAG)
β-Oxidation
Ketone bodies
Pathways Overview
Glycogenesis
Gluconeogenesis
Lipogenesis
Amino acids
(Protein)
Lipolysis
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GlycogenesisGlycogenolysis
GlycolysisLipogenesis
Lipolysisβ-Oxidation
GlycogenesisGlycogenolysis
GlycolysisGluconeogenesi
sLipogenesis
Lipolysisβ-OxidationKetogenesis
GlycogenesisGlycogenolysis
Glycolysisβ-Oxidation
GlycogenesisGlycogenolysis
Glycolysisβ-Oxidation
Tissues Overview
Blood GlucoseSerum Triglycerides
GlycogenesisGlycogenolysis
GlycolysisGluconeogenesi
sβ-Oxidation
LiverAdiposeTissue
Kidney
HeartSkeletalMuscle
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Glucose Homeostasis
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Glycogenesis and Glycogenolysis
Insulin (ML)
IR
Ep (ML)
βARcAMP
Glucagon (L)
GS GSPn
GSK-3
AKT PDK-1
AKTP
PKA PKA
PPK PPKP
GSK-3P
PPaP
PPb PPaP
PKA PPKP
PrPase1P
PrPase1
Glycogenesis
Glc
Glycogen
G6P
G1P
UDP-GlcGlycogenolysis
Glycolysis
TCAETC
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Glycogenesis and Glycogenolysis
Insulin (ML)
IR
GS GSPn
GSK-3
AKT PDK-1
AKTP
GSK-3P
PrPase1P
PrPase1
Glycogenesis
Glc
Glycogen
G6P
G1P
UDP-Glc
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Glycogenesis and Glycogenolysis
Ep (ML)
βARcAMP
Glucagon (L)
GS GSPn
GSK-3
PKA PKA
PPK PPKP
PPaP
PPb PPaP
PKA PPKP
Glycogenesis
Glc
Glycogen
G6P
G1P
UDP-GlcGlycogenolysis
Glycolysis
TCAETC
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Glycogenesis and Glycogenolysis
Insulin (ML)
IR
Ep (ML)
βARcAMP
Glucagon (L)
GS GSPn
GSK-3
AKT PDK-1
AKTP
PKA PKA
PPK PPKP
GSK-3P
PPaP
PPb PPaP
PKA PPKP
PrPase1P
PrPase1
Glycogenesis
Glc
Glycogen
G6P
G1P
UDP-GlcGlycogenolysis
Glycolysis
TCAETC
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PK
PFK-1
Glc
Acetyl-CoA
Pyr
F6P
F16BP
PEP
G6P
PDH
F26BPasePFK-2
Glycolysis: Regulatory Steps
HK
Insulin
Glucagon
Ep
Adipose
HeartLiver
GK
Liver
Liver
Liver
Heart
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PK
PFK-1
Glc
Acetyl-CoA
Pyr
F6P
F16BP
PEP
G6P
PDH
Glycolysis (Liver)
Alanine
PDHPase
PDHK
PDHP
PKAPKP
F26BP
F26BPase-PFK-2
F26BPase-PFK-2P
Insulin
PrPase2A
GlucagonEp
PKA
also represses PFK synthesis
GK
ATPNADH
ATPCit
PrPase
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PK
PFK-1
Glc
Acetyl-CoA
Pyr
F6P
F16BP
PEP
G6P
PDH
Glycolysis (Liver)
PDHPase
PDHK
PDHP
F26BP
F26BPase-PFK-2
F26BPase-PFK-2P
Insulin
PrPase2A
GK
ATPCit
PrPase
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PK
PFK-1
Glc
Acetyl-CoA
Pyr
F6P
F16BP
PEP
G6P
PDH
Glycolysis (Liver)
Alanine
PDHK
PDHP
PKAPKP
F26BP
F26BPase-PFK-2
F26BPase-PFK-2P
GlucagonEp
PKA
also represses PFK synthesis
GK
ATPCit
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PK
PFK-1
Glc
Acetyl-CoA
Pyr
F6P
F16BP
PEP
G6P
PDH
Glycolysis (Liver)
Alanine
PDHPase
PDHK
PDHP
PKAPKP
F26BP
F26BPase-PFK-2
F26BPase-PFK-2P
Insulin
PrPase2A
GlucagonEp
PKA
also represses PFK synthesis
GK
ATPNADH
ATPCit
PrPase
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PK
PFK-1
Glc
Acetyl-CoA
Pyr
F6P
F16BP
PEP
G6P
PDH
Glycolysis (Skeletal Muscle)
PDHPase
PDHK
PDHP
F26BP
HK
ATPNADH
ATPCit
F26BPase-PFK-2
F26BPase-PFK-2
F6P↑F6P↓
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PK
PFK-1
Glc
Acetyl-CoA
Pyr
F6P
F16BP
PEP
G6P
PDH
PDHPase
PDHK
PDHP
F26BP
HK
ATPNADH
ATPCit
F26BPaseP-PFK-2
F26BPase-PFK-2PKA
Ep
Insulin
AKT/WISK???
Glycolysis (Heart)
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F26BPase-PFK-2 Regulation Comparison
F26BPase-PFK-2
F26BPase-PFK-2P
Insulin
PrPase2A
GlucagonEp
PKALiver
F26BPase-PFK-2
F26BPase-PFK-2
F6P↑F6P↓Skeletal Muscle
F26BPaseP-PFK-2
F26BPase-PFK-2
???PKA
Ep
Insulin
AKT/WISKHeart
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PK
PFK-1
Glc
Acetyl-CoA
Pyr
F6P
F16BP
PEP
G6P
PDH
Fructose Metabolism (Liver)
PDHPase
PDHK
PDHP
F26BPF26BPase-PFK-2
F26BPase-PFK-2P
Insulin
PrPase2A
GlucagonEp
PKA
GK
ATPNADH
ATPCit
GAP DHAP
Fructose
F1P
Glyceraldehyde
FK (KHK)
Aldolase B
Triose kinase
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Gluconeogenesis (Liver)
Glucagon
PKAPKP
F26BPase-PFK-2
F26BPase-PFK-2P
PKA
PK
PFK-1
GKG6Pase
F16BPase
PDHP
PDHKPDHPPDH
ATPNADH
Glc
Pyr
F6P
F16BP
PEP
G6P
Protein
MDH
PEPCK
Mal
OAA
PC
MDHMal
OAA
Mit
Cyt
PrPase2A
Insulin
Ala
KB
F26BP
Cortisol
CREBGR
Acetyl-CoA
TAG
Lipolysisβ-Oxidation
FA
HSLEp, Glucagon, CortisolInsulin
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Gluconeogenesis (Liver)
Glucagon
PKAPKP
F26BPase-PFK-2
F26BPase-PFK-2P
PKA
PK
PFK-1
GKG6Pase
F16BPase
PDHKPDHPPDH
ATPNADH
Glc
Pyr
F6P
F16BP
PEP
G6P
Protein
MDH
PEPCK
Mal
OAA
PC
MDHMal
OAA
Mit
Cyt
Ala
KB
F26BP
Cortisol
CREBGR
Acetyl-CoA
TAG
Lipolysisβ-Oxidation
FA
HSLEp, Glucagon, Cortisol
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Gluconeogenesis (Liver)
F26BPase-PFK-2
F26BPase-PFK-2P
PK
PFK-1
GKG6Pase
F16BPase
PDHPPDHPPDH
Glc
Pyr
F6P
F16BP
PEP
G6P
PEPCKOAA
Mit
Cyt
PrPase2A
Insulin
F26BP
Acetyl-CoA
TAGHSLInsulin
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Gluconeogenesis (Liver)
Glucagon
PKAPKP
F26BPase-PFK-2
F26BPase-PFK-2P
PKA
PK
PFK-1
GKG6Pase
F16BPase
PDHP
PDHKPDHPPDH
ATPNADH
Glc
Pyr
F6P
F16BP
PEP
G6P
Protein
MDH
PEPCK
Mal
OAA
PC
MDHMal
OAA
Mit
Cyt
PrPase2A
Insulin
Ala
KB
F26BP
Cortisol
CREBGR
Acetyl-CoA
TAG
Lipolysisβ-Oxidation
FA
HSLEp, Glucagon, CortisolInsulin
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Lipogenesis and Lipolysis (Adipose)
Acetyl-CoA
Pyr
PK
PFK-1
PDH
PKAPKP
F26BPase-PFK-2
F26BPase-PFK-2P
PKA
PDHK
ATPNADH
PrPase2A
InsulinGlc
G6P
GKPPP
(NADPH)
ACC
MCoA
FA
Glycerol
Acetyl-CoA
KBCit
Acetyl-CoA
PA
TAG
G3P
Esterification
HSLHSLP
PrPase2A
PDHP
PDHP
Insulin
ACCP
PrPase2A
PKAAMPK
GlucagonCortisol
Ep
PKA
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Lipogenesis and Lipolysis (Adipose)
PK
PFK-1
PDH
PKAPKP
F26BPase-PFK-2
F26BPase-PFK-2P
PKA
Acetyl-CoA
Pyr
Glc
G6P
GKPPP
(NADPH)
FA
Glycerol
Acetyl-CoA
KB
ACC
MCoA
Acetyl-CoA
TAGHSLHSLP
PDHK
ATPNADH
PDHP
ACCP
PKAAMPK
GlucagonCortisol
Ep
PKA
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Lipogenesis and Lipolysis (Adipose)
Acetyl-CoA
Pyr
PK
PFK-1
PDH
F26BPase-PFK-2
F26BPase-PFK-2P
PrPase2A
InsulinGlc
G6P
GKPPP
(NADPH)
ACC
MCoA
Glycerol
Cit
Acetyl-CoA
PA
TAG
G3P
Esterification
HSLHSLP
PrPase2A
PDHP
PDHP
Insulin
ACCP
PrPase2A
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Lipogenesis and Lipolysis (Adipose)
Acetyl-CoA
Pyr
PK
PFK-1
PDH
PKAPKP
F26BPase-PFK-2
F26BPase-PFK-2P
PKA
PDHK
ATPNADH
PrPase2A
InsulinGlc
G6P
GKPPP
(NADPH)
ACC
MCoA
FA
Glycerol
Acetyl-CoA
KBCit
Acetyl-CoA
PA
TAG
G3P
Esterification
HSLHSLP
PrPase2A
PDHP
PDHP
Insulin
ACCP
PrPase2A
PKAAMPK
GlucagonCortisol
Ep
PKA
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Impact of Diabetes on Metabolism
Acetyl-CoALactate
Production of ATP
G6P
Glucose
Glycolysis
Pyruvate
Krebscycle
ElectronTransport
Chain
Glycogen
Glycogenolysis
Fatty acids(TAG)
β-Oxidation
Ketone bodies
Glycogenesis
Gluconeogenesis
Lipogenesis
Amino acids
(Protein)
Lipolysis
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Impact of Diabetes on Glycogen
Glycogenolysis
PPaP
Glycogenesis
Insulin (ML)
IR
Ep (ML)
βARcAMP
Glucagon (L)
GS GSPn
GSK-3
AKT PDK-1
AKTP
PKA PKA
PPK PPKP
GSK-3PPPb PPaP
PKA PPKP
PrPase1P
PrPase1
Glc
Glycogen
G6P
G1P
UDP-Glc
Glycolysis
TCAETC
Glycogen breakdown
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Impact of Diabetes on Glycolysis (L)
PK
PFK-1
Glc
Acetyl-CoA
Pyr
F6P
F16BP
PEP
G6P
PDH
Alanine
PDHPase
PDHK
PDHP
PKAPKP
F26BP
F26BPase-PFK-2
F26BPase-PFK-2P
Insulin
PrPase2A
Glucagon
PKA
also represses PFK synthesis
GK
ATPNADH
ATPCit
Glycolysis inhibition
PrPase
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Impact of Diabetes on Glycolysis (M)
PK
PFK-1
Glc
Acetyl-CoA
Pyr
F6P
F16BP
PEP
G6P
PDH
PDHPase
PDHK
PDHP
F26BP
HK
ATPNADH
ATPCit
F26BPase-PFK-2
F26BPase-PFK-2
F6P↑F6P↓
Only impact is on GLUT4
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Impact of Diabetes on Glycolysis (H)
PK
PFK-1
Glc
Acetyl-CoA
Pyr
F6P
F16BP
PEP
G6P
PDH
PDHPase
PDHK
PDHP
F26BP
HK
ATPNADH
ATPCit
F26BPaseP-PFK-2
F26BPase-PFK-2
???PKA
Ep
Insulin
AKT/WISK
Heart uses more fatty acids
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Impact of Diabetes on Gluconeogenesis (L)
Glucagon
PKAPKP
F26BPase-PFK-2
F26BPase-PFK-2P
PKA
PK
PFK-1
GKG6Pase
F16BPase
PDHP
PDHKPDHPPDH
ATPNADH
Glc
Pyr
F6P
F16BP
PEP
G6P
Protein
MDH
PEPCK
Mal
OAA
PC
MDHMal
OAA
Mit
Cyt
PrPase2A
Insulin
Ala
KB
F26BP
Cortisol
CREBGR
Acetyl-CoA
TAG
Lipolysisβ-Oxidation
FA
HSLEp, Glucagon, CortisolInsulin
More glucose, fatty acids, ketone bodies
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Impact of Diabetes on Lipogenesis/Lypolysis (A)
Acetyl-CoA
Pyr
PK
PFK-1
PDH
PKAPKP
F26BPase-PFK-2
F26BPase-PFK-2P
PKA
PDHK
ATPNADH
PrPase2A
InsulinGlc
G6P
GKPPP
(NADPH)
ACC
MCoA
FA
Glycerol
Acetyl-CoA
KBCit
Acetyl-CoA
PA
TAG
G3P
Esterification
HSLHSLP
PrPase2A
PDHP
PDHP
Insulin
ACCP
PrPase2A
PKAAMPK
GlucagonCortisol
Ep
PKA
Increased fatty acids, ketone bodies, cholesterol
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LiverWell-fed
• Glucose to glycogen and triacylglycerols
Starvation
• Glucose from glycogen and gluconeogenesis
• Ketone bodies from amino acids and fatty acids
Diabetes
• Glucose from gluconeogenesis (muscle wasting)
• Ketone bodies from amino acids and fatty acids (DKA)
MuscleWell-fed
• Glucose to glycogen and triacylglycerols
Starvation
• Glucose from glycogen
• Alanine from protein
Diabetes
• Alanine from protein (muscle wasting)
AdipocytesWell-fed
• Glucose to glycogen and triacylglycerols
Starvation
• Fatty acids and glycerol from triacyglycerols
Diabetes
• Fatty acids and glycerol from triacylglycerols
Pathway Pearls
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Type 1
•Insulins
•Amylinomimetics - postprandial glucagon release
(Pramlintide acetate)
•Hypoglycemic antidotes – glycogenolysis and
gluconeogenesis (Glucagon)
Type 2
•Biguanides - gluconeogenesis (Metformin) AMPK/AC
•Sulfonylureas - insulin secretion (Glyburide,
Glipizide, Glimepiride)
•Meglitinides - insulin secretion (Repaglinide,
Nateglinide)
•α-Glucosidase inhibitors - glucose absorption
(Acarbose, Miglitol)
•Thiazolidinediones (glitazones) - fat cell
differentiation/fatty acid metabolism (Rosiglitazone,
Pioglitazone) PPAR
Drug Classes
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Type 2
•Glucagonlike peptide-1 agonists - insulin release
(Exenatide, Liraglutide, Albiglutide, Dulaglutide)
•Dipeptidyl peptidase IV inhibitors - insulin release
(Sitagliptin, Saxagliptin, Linagliptin, Alogliptin)
•Amylinomimetics - postprandial glucagon release
(Pramlintide acetate)
•Insulins
•Selective sodium-glucose transporter-2 inhibitors –
renal glucose threshold (Canagliflozin, Dapagliflozin,
Empagliflozin)
•Bile acid sequestrants – unknown glycemic
mechanism (Colesevelam)
•Dopamine agonists – reset abnormally increased
hypothalamic drive (Bromocriptine)
Drug Classes
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Review Questions• Which steps in carbohydrate
metabolism are regulated by glucagon, insulin, epinephrine, and cortisol?
• What are the roles of protein kinase A and protein phosphatase in regulating carbohydrate metabolism?
• Which steps in lipid metabolism are regulated by glucagon, insulin, epinephrine, and cortisol?
• What are the roles of AMPK, protein kinase A, and protein phosphatase in regulating lipid metabolism?
• What are the tissue differences in the regulation of metabolism?
• What are some key features associated with defects in glucose homeostasis?