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Physiol Rev 87: 1409 –1439, 2007;

doi:10.1152/physrev.00034.2006.

The Physiology of Glucagon-like Peptide 1

JENS JUUL HOLST

Department of Medical Physiology, The Panum Institute, University of Copenhagen, Copenhagen, Denmark

I.Introduction and Historical Overview 1409

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II.Proglucagon Gene Expression, Posttranslational Processing, and Chemical Structures 1411
III.Proglucagon Distribution 1412
IV. Measurement, Release, and Metabolism 1413
V. Regulation of Secretion 1414
VI. Effects of Glucagon-like Peptide 1 1416
A. The GLP-1 receptor 1416
B. The incretin effect 1417
C. Effects on the beta-cells 1418
D. Effects on glucagon secretion 1420
E. Effects on the gastrointestinal tract 1421
F. Central targets for peripherally released GLP-1 1422
G. Effects on appetite and food intake 1423
H. Other effects 1424
I. Whole body effects, peripheral effects, and effects on insulin action 1426
VII. Glucagon-like Peptide 1 Pathophysiology 1427
A. Obesity 1427
B. Reactive hypoglycemia 1428
C. Diabetes 1428

Holst JJ. The Physiology of Glucagon-like Peptide 1. Physiol Rev 87: 1409 –1439, 2007; doi:10.1152/physrev.00034.2006.—
Glucagon-like peptide 1 (GLP-1) is a 30-amino acid peptide hormone produced in the intestinal epithelial endocrine
L-cells by differential processing of proglucagon, the gene which is expressed in these cells. The current knowledge
regarding regulation of proglucagon gene expression in the gut and in the brain and mechanisms responsible for the
posttranslational processing are reviewed. GLP-1 is released in response to meal intake, and the stimuli and
molecular mechanisms involved are discussed. GLP-1 is extremely rapidly metabolized and inactivated by the
enzyme dipeptidyl peptidase IV even before the hormone has left the gut, raising the possibility that the actions of
GLP-1 are transmitted via sensory neurons in the intestine and the liver expressing the GLP-1 receptor. Because of
this, it is important to distinguish between measurements of the intact hormone (responsible for endocrine actions)
or the sum of the intact hormone and its metabolites, reflecting the total L-cell secretion and therefore also the
possible neural actions. The main actions of GLP-1 are to stimulate insulin secretion (i.e., to act as an incretin
hormone) and to inhibit glucagon secretion, thereby contributing to limit postprandial glucose excursions. It also
inhibits gastrointestinal motility and secretion and thus acts as an enterogastrone and part of the “ileal brake”
mechanism. GLP-1 also appears to be a physiological regulator of appetite and food intake. Because of these actions,
GLP-1 or GLP-1 receptor agonists are currently being evaluated for the therapy of type 2 diabetes. Decreased
secretion of GLP-1 may contribute to the development of obesity, and exaggerated secretion may be responsible for
postprandial reactive hypoglycemia.

I. INTRODUCTION AND tracts of the gastrointestinal mucosa, and Sutherland and


HISTORICAL OVERVIEW DeDuve suggested in 1948 (276), based on bioassays, that
gastric extracts might contain glucagon, a finding that was
The glucoregulatory hormone glucagon was discov- confirmed in several subsequent studies. Furthermore,
ered in 1923 as a hyperglycemic substance present in endocrine cells that resemble the pancreatic A-cells were
pancreatic extracts (196). Subsequent research indicated reported to be present in the gastrointestinal mucosa
that hyperglycemic substances were also present in ex- (225). Upon the advent of the radioimmunoassay for glu-

www.prv.org 0031-9333/07 $18.00 Copyright © 2007 the American Physiological Society 1409
1410 JENS JUUL HOLST

cagon, one of the first radioimmunoassays to be devel- of the NH2-terminal extension peptide, which was named
oped (296), it was confirmed that the gastrointestinal tract glicentin-related pancreatic polypeptide (GRPP) (282).
contains substances with glucagon immunoreactivity, i.e., From studies of the biosynthesis of glucagon in the
reacting with the antibodies employed in the radioimmu- pancreatic islets, however, it was evident that a large
noassay (297). In addition, in immunohistochemical stud- molecule (mol wt ⬃10,000), subsequently designated “the
ies, some intestinal endocrine cells could be stained using major proglucagon fragment” (MPGF) that did not con-
glucagon antibodies (83), but it was also shown that these tain the glucagon sequence, was also formed in parallel
cells differed from the pancreatic A-cells with respect to with glucagon (236). As the structures of glucagon-encod-
granule morphology (83), and they were hence designated ing mRNA and of the glucagon gene were determined (14,
as “L-cells” (26). Furthermore, in 1968, it was established 15), it became evident that, in mammals, this major frag-
(298) that the glucagon-like immunoreactive material that ment of proglucagon contains two glucagon-like se-
was secreted in response to an oral glucose load differed quences, now designated glucagon-like peptides 1 and 2
from true glucagon both physicochemically and biologi-

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(GLP-1 and GLP-2, respectively). For a while it was
cally. Furthermore, it was demonstrated that this “gut thought that the GLP-2 moiety was an evolutionary late
glucagon-like immunoreactivity” was heterogeneous, con- addition to the gene, since fish and bird proglucagon
sisting of at least two distinct moieties differing in molec-
appeared to contain only a single glucagon-like peptide
ular size (301). Through contributions from independent
corresponding to GLP-1 (172). Subsequent research, how-
groups, it was eventually demonstrated that the two pre-
ever, established that the proglucagon genes in these
dominant molecular forms of gut glucagon-like immuno-
species (there are two glucagon encoding genes in fish)
reactivity both contain the entire 29-amino acid glucagon
also contain the GLP-2 encoding sequence, which, how-
sequence (13, 114, 116, 281) (see Fig. 1). One has a COOH-
ever, is sequestered by differential splicing upon pancre-
terminal octapeptide extension, and the other has the
same COOH-terminal extension plus an NH2-terminal ex- atic expression of the gene (142) but remains in sequence
tension of 30 amino acids. The former molecule was upon intestinal expression.
named oxyntomodulin because of its effects on the oxyn- In further studies of the processing and secretion of
tic mucosa in some species (13), and the latter was des- proglucagon products in humans and other mammals, it
ignated glicentin partly because of its glucagon-like im- was confirmed that, in the pancreas, the two glucagon-like
munoreactivity and partly because it was first thought to peptides are contained in a single large molecule, the
consist of 100 amino acids (274). Full sequence analysis, major proglucagon fragment, secreted in parallel with
however, revealed it to consist of 69 amino acids (281). glucagon (121, 189, 227, 229). In the intestinal mucosa,
The NH2-terminal extension of glucagon in glicentin was however, the two glucagon-like peptides are formed and
identified also in extracts from the pancreas, from which secreted separately, whereas the NH2-terminal part of the
it was shown to be secreted in parallel with glucagon precursor, i.e., the part that corresponds to glicentin,
(193, 282). Conceivably, therefore, glicentin was a proglu- remains uncleaved (189, 227) or partly cleaved into GRPP
cagon, a biosynthetic precursor for glucagon, which in the and oxyntomodulin (see Fig. 1). This review deals with
pancreas was cleaved to glucagon and equimolar amounts the physiology and pathophysiology of GLP-1.

FIG. 1. Differential posttranslational processing


of proglucagon in the pancreas and in the gut and
brain. The numbers indicate amino acid positions in
the 160-amino acid proglucagon sequence. The verti-
cal lines indicate positions of basic amino acid resi-
dues, typical cleavage sites. GRPP, glicentin-related
pancreatic polypeptide; IP-1, intervening peptide-1;
IP-2, intervening peptide-2.

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THE PHYSIOLOGY OF GLUCAGON-LIKE PEPTIDE 1 1411

II. PROGLUCAGON GENE EXPRESSION, tibility through modulation of intestinal proglucagon


POSTTRANSLATIONAL PROCESSING, gene expression and hence possibly plasma levels of
AND CHEMICAL STRUCTURES GLP-1 (81).
The differential posttranslational processing of pro-
The structure of proglucagon was deduced from the glucagon in the pancreas and gut results in the pancreas
sequence of the cDNA encoding hamster proglucagon in the formation of glucagon, the GRPP, a small fragment
(15) and the human proglucagon gene (14). Also the mu- corresponding to the proglucagon sequence (PG) 64 – 69
rine and bovine genes were cloned (105, 171). Apparently, and the major proglucagon fragment corresponding to PG
only a single gene encodes proglucagon in mammalian 72– 60 (121) (see Fig. 1), and all of these peptide products
species, and identical mRNAs are produced in the pan- are secreted in parallel upon stimulation (121). The pro-
creas and the intestines (189, 221). The differences in the cessing in the alpha cells is due to the coexpression of the
proglucagon products in these tissues are, therefore, due prohormone convertase PC2, which has been demon-
to tissue-specific, differential, posttranslational process- strated to be both necessary and sufficient for cleaving

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ing of proglucagon (189, 227). The proglucagon gene is proglucagon as outlined (256). In agreement with this,
also expressed in certain neurons in the nucleus of the animals in which the PC2 gene is disrupted cannot cleave
solitary tract in the brain stem (161). Recent studies proglucagon in the alpha cells (73) and, as a result, have
have shed some light on the mechanisms that result in the lower glucose levels than wild-type animals and improved
tissue specificity and the mechanisms that regulate the tolerance to glucose, and they develop alpha cell hyper-
expression of the proglucagon gene in the gut in vivo. plasia, features that also characterize mice with a deletion
Thus it has been established that the transcription factor of the glucagon receptor gene (77).
pax6 is expressed in intestinal endocrine cells and acti- The intestinal processing results in the formation of
vates proglucagon transcription (292). Mice with a domi- glicentin, corresponding to proglucagon residues 1– 69,
nant negative pax6 mutation exhibit a total absence of gut part of which may be cleaved further to oxyntomodulin,
endocrine cells expressing GLP-1 or GLP-2. Disruption of corresponding to PG 33– 69 (9, 227). The proglucagon
the pax6 gene disrupts both islet development and selec- sequence that corresponds to the major proglucagon frag-
tively eliminates the endocrine cell population of the ment contains pairs of basic amino residues, canonical
small and large bowel, including the proglucagon-produc- cleavage sites for the prohormone convertases, flanking
ing cells (111, 292). Yi et al. (338) recently demonstrated both of the glucagon-like peptide sequences in the human
that ␤-catenin, the major effector of the Wnt signaling cDNA, and it was therefore predicted that the prohor-
pathway, activates proglucagon expression in intestinal, mone might be cleaved at these sites (227) and that the
but not in islet cells. Furthermore, this effect was medi- sequences of GLP-1 and GLP-2 would therefore corre-
ated by the transcription factor TCF-4, which is highly spond to PG 72–108 and 126 –158, 126 –159, or 126 –160
expressed in intestinal endocrine cells, but not in islets. (the nucleotide codon encoding residue 160 is found in a
Both TCF-4 and ␤-catenin bind to the proglucagon gene separate exon and was therefore overlooked in the first
promoter, and a dominant negative TCF-4 repressed pro- cloning experiments). However, sequencing of the natu-
glucagon expression in an intestinal cell line that ex- rally occurring peptides extracted from human gut re-
presses proglucagon and produces GLP-1 (338). It is of vealed that the structure of native GLP-1 corresponds to
interest that ⬃1,250 nucleotides of the rat proglucagon PG 78 –107 (126). This turned out to be of utmost impor-
gene promoter direct the expression to pancreatic islets tance, since the truncated peptide was found to be a
and neurons of the brain, whereas additional upstream potent stimulator of glucose-induced insulin secretion,
sequences extending to ⫺2,250 are required for expres- whereas full-length GLP-1 was inactive (126, 191). The
sion of the gene in intestinal endocrine cells (166). How- truncation also had consequences for the nomenclature,
ever, the mechanisms regulating tissue specific progluca- since the naturally occurring peptide was henceforth des-
gon gene expression in humans appear to differ from ignated either truncated GLP-1 or GLP-1 7–36amide (or
those described for the rat gene (213, 214), and unfortu- GLP-1 7–37). In current literature, the unqualified desig-
nately, little is known about the regulation of the human nation GLP-1 covers only the truncated peptide. It was
gene. also found that the Gly corresponding to PG 108 serves as
The TCF-4-mediated regulation of proglucagon ex- substrate for amidation of the COOH-terminal Arg (226),
pression in the gut is of considerable interest in view of but the biological consequences of the amidation are
the recent demonstration in several unrelated populations unclear. The amidated and the Gly-extended forms have
of a genetic association of a specific single nucleotide similar bioactivities and overall metabolism (232), al-
polymorphism (SNP), the microsatellite DG10S478 in in- though the amidated form may exhibit slightly improved
tron 3 of the TCF4 gene (now designated TCF7L2), and stability towards plasma enzymes (326). In humans, al-
the development of type 2 diabetes. These findings raise most all of GLP-1 secreted from the gut is amidated (231),
the possibility that this SNP influences disease suscep- whereas in many animals (rodents, pigs), part of the

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1412 JENS JUUL HOLST

secreted peptide is GLP-1-(7–37) (97, 190). This poses with the base resting on the basal lamina and a long
special problems with respect to the measurement of cytoplasmic process reaching the gut lumen. This process
GLP-1 secretion in these species (see below). The se- is equipped with microvilli that protrude into the lumen. It
quence of naturally occurring GLP-2 was found to corre- may be via these microvilli that the L-cell can sense the
spond to PG 126 –158 (27, 103). A comparison of GLP presence of nutrients in the lumen and transform this
sequences among species shows that the GLP-1 sequence information into a stimulation of secretion. The peptide
is preserved 100% in all mammals, where this has been products of the A- and L-cells have been identified at the
studied, and the sequence homology is pronounced cellular level by immunocytochemistry. As expected, an-
across other classes of animals (149). GLP-2 shows more tisera directed against the midregion of glucagon (“side
variation with, e.g., four substitutions between human viewing”) stain the pancreatic A-cells as well as the intes-
and porcine GLP-2. The Ala in position 7 of human inter- tinal L-cells, whereas antibodies against the free COOH
vening peptide 2 is also variable with Thr or Asn in, e.g., terminus of glucagon (which is not exposed in the L-cells)
the porcine and bovine peptides.

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only stain the A-cells. Antisera against the NH2-terminal,
The processing of proglucagon in the intestinal non-glucagon part of glicentin stain both the A-cells and
L-cells results from the actions of coexpressed prohor- the L-cells because they react with GRPP in the pancreas
mone convertase (PC) 1/3, which is both necessary and and with glicentin in the gut (224). As expected from their
sufficient for the complete processing (295, 344). Interest- common origin, both GLP-1 and GLP-2 show complete
ingly, the NH2-terminal cleavage site of GLP-1 is not a coexistence with glucagon (side-viewing antisera) upon
classical pair of basic amino acids, but represents a single immunohistochemical examination (189, 227, 229). GLP-1
Arg residue; however, in vitro coexpression of PC 1/3 and and GLP-2 immunoreactivity have been colocalized with
proglucagon has demonstrated efficient cleavage at this glucagon in the electron-dense core of the A-cells, pre-
site (255). In agreement with this, mutations in PC 1/3 lead sumably due to their presence in the major proglucagon
to abnormalities in GLP-1 processing and secretion, asso- fragment (302).
ciated with multiple endocrinopathies (143) (undoubtedly
The density of L-cells shows a maximum in the ileum
because PC 1/3 is important for processing of many reg-
in most species (25, 62); no or very few cells are present
ulatory peptides/hormones), and mice with a targeted
proximal to the ligament of Treitz in humans and other
deletion of the PC-1/3 gene are unable to process proglu-
primates. A considerable number is present in the colon
cagon to GLP-2 and GLP-1 (295, 344). Interestingly, it was
(151), particularly the distal part. Surprisingly, the entirely
recently demonstrated that adenovirus-mediated expres-
unrelated peptide YY (PYY) has also been localized to the
sion of PC 1/3 in the pancreatic alpha cells increases islet
L-cells in all mammals studies so far (23) and was even
GLP-1 secretion, resulting in improved glucose-stimulated
found to be localized to the same granules as glicentin by
insulin secretion and enhanced survival in response to
cytokine treatment as well as enhanced performance af- immunocytochemistry at the electron microscopic level
ter transplantation to mouse models of type 1 diabetes, a (23). The distribution was reexamined in a recent study
finding of considerable clinical interest (see below) (331). involving combined in situ hybridization, peptide chemis-
try, and immunohistochemistry. In this study of endocrine
cells of the porcine, rat, and human small intestines (195),
III. PROGLUCAGON DISTRIBUTION GLP-1 nearly always (92%) colocalized with either the
incretin hormone GIP (glucose-dependent insulinotropic
It has been known since 1968 that endocrine cells polypeptide, formerly known as gastric inhibitory
resembling pancreatic A-cells occur in the intestinal mu- polypeptide) or the enterogastrone hormone PYY. GIP
cosa (225). Later research demonstrated cells that are and PYY were rarely colocalized. In the mid small intes-
indistinguishable at the electron microscopic level from tine, 55–75% of the cells staining for either GLP-1 or GIP
the pancreatic A-cells in the oxyntic mucosa of some also expressed the other incretin hormone. Concentra-
species (275). Particularly in dogs such cells are abundant tions of extractable GIP and PYY were highest in the
and appear to secrete apparently true glucagon in appre- midjejunum [154 (95–167) and 141 (67–158) pmol/g, me-
ciable amounts (167). Similar cells have not been found in dian and range, respectively], whereas GLP-1 concentra-
humans, however (120). The majority of the intestinal tions were highest in the ileum [92 (80 –207) pM], but,
proglucagon-derived peptides are secreted from the importantly, GLP-1, GIP, and PYY immunoreactive cells
L-cells, which differ clearly from the A-cells by their gran- were found throughout the (porcine) small intestine. This
ule morphology (224). A-cell granules show a distinct halo finding is of particular interest in view of the finding that
of less electron-dense material surrounding a core of GIP can stimulate GLP-1 secretion. GIP is only active in
dense material, whereas the granules of the L-cells are pharmacological concentrations (99), but might act lo-
homogeneous without halo formation. The L-cell is an cally in a paracrine or autocrine manner. This study (195)
open-type endocrine cell with a slender triangular form thus suggested that simultaneous, rather than sequential,

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THE PHYSIOLOGY OF GLUCAGON-LIKE PEPTIDE 1 1413

secretion of these hormones would occur by postprandial last of which may be released in small amounts from both
luminal stimulation. pancreas and gut. With such antisera, it may be possible
As mentioned, the proglucagon gene is also ex- to measure what might be designated “total glucagon”
pressed in the central nervous system. Thus cells immu- concentrations. But results obtained in these assays are
noreactive for GLP-1, glucagon, and glicentin have been not easy to interpret, because the peptides measured may
demonstrated in the nucleus of the solitary tract of the be derived from both the pancreas and the gut. Upon oral
brain stem of rats , monkeys, and humans (52, 144, 145). administration of carbohydrates, pancreatic A-cell secre-
These neurons project to many regions in the brain, in tion is suppressed and L-cell secretion stimulated, and in
particular the nuclei of the hypothalamus, including the this case, such assays may provide a reasonable estimate
arcuate and the paraventricular nuclei (161). The process- of L-cell secretion. The designation “enteroglucagon se-
ing of proglucagon has been examined both at the level of cretion” is sometimes coined for the results of such mea-
the cell bodies and at the levels of the fibers projecting to surements. More specific information may be obtained
the hypothalamus (161). The pattern was intestinal with a with antisera that react exclusively with the unmodified

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pronounced contribution of processed oxyntomodulin, and unextended COOH terminus of glucagon. Such anti-
and this is important, since such neurons would be ex- sera do not react with glicentin and oxyntomodulin and
pected upon stimulation to release simultaneously three therefore mainly measure pancreatic glucagon (117). By
hormonal products (oxyntomodulin, GLP-1, and GLP-2), subtracting the results obtained with COOH-terminal an-
which all have been demonstrated to inhibit food intake tisera from those obtained with side-viewing antisera, one
when administered intracerebroventricularly (see below). gets, at least in principle, the concentration of the gut
peptides glicentin and oxyntomodulin (104), and the com-
bined assays, therefore, represent another method for
IV. MEASUREMENT, RELEASE, quantification of enteroglucagon or gut glucagon-like im-
AND METABOLISM munoreactivity (117).
The specificity and accuracy problems that trouble
As will be apparent from the above, measurement in the glucagon assays apply to the assays of GLP-1 and
plasma of the products of proglucagon gene expression GLP-2 as well. Again, side-viewing antibodies will react
will require assays for at least eight different peptides, with both intestinal and pancreatic products. As men-
three from the pancreas (glucagon, GRPP, major proglu- tioned, in humans, almost all of intestinal GLP-1 is COOH-
cagon fragment) and five from the intestine (glicentin, terminally amidated, and assays directed against the ami-
oxyntomodulin, GLP-1, GLP-2, and intervening peptide 2). dated COOH terminus will therefore reliably measure
For estimation of the secretory state of the alpha or intestinal GLP-1 secretion [although a small contribution
L-cells, it might be proposed to measure just a single of GLP-1 1–36amide from the pancreas cannot be ex-
proglucagon product, because studies involving isolated cluded (121)]. Assays in species where both GLP-1 7–36
perfused preparations of the pancreas or the ileum have amide and GLP-1 7–37 are produced in the gut (rodents,
shown that the pancreatic and intestinal products, respec- pigs) pose a special problem. In principle, assays directed
tively, are secreted synchronously and in equimolar against the intact NH2 terminus might be useful here (90),
amounts. [This does not apply to glicentin and oxynto- as would sandwich assays where one antibody is NH2
modulin, since oxyntomodulin is a breakdown product of terminal and the other COOH terminal but capable of
glicentin. Therefore, it is the sum of the two moieties reacting with both the amidated and the Gly-extended
which equals the secreted amount of other proglucagon- forms. A few assays are based on this principle (317), and
like GLP-1 and -2 (193, 227)]. However, each of the pro- one is commercially available (Linco, St. Charles, MO;
glucagon products is being eliminated from the circula- www.lincoresearch.com). The greatest problem with this
tion at its own particular rate (see below). A reliable approach, however, is related to the rapid degradation of
estimate of the secretion and the plasma concentration of GLP-1. GLP-1 is extremely susceptible to the catalytic
any of the products will therefore require specific mea- activity of the enzyme dipeptidyl peptidase IV (DDP-IV),
surement. which cleaves off the two NH2-terminal amino acids (44).
Methods for determination of the glucagon-contain- The metabolite thus generated, GLP-1 9 –36 amide or
ing products date back to the first descriptions of bioas- GLP-1 (9 –37), is inactive and may even act as a compet-
says and radioimmunoassays for glucagon (104, 117). The itive antagonist at the GLP-1 receptor (44, 153), although
cross-reaction of certain antisera with material from the its formation does not seem to result in antagonism
gut caused considerable confusion in these early days. in vivo (339). In studies of GLP-1 secretion from isolated
Antisera directed against the midregion of glucagon, also perfused porcine ileum, it has been shown that a very
called “side-viewing antisera,” will react with any product large part of the GLP-1 that leaves the gut is already
that contains this sequence, i.e., glucagon, glicetin, oxyn- degraded to the inactive metabolite (96) (see Fig. 2). At
tomodulin, and proglucagon (or glicentin) 1– 61 (10), the first, the degradation was calculated to amount to about

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1414 JENS JUUL HOLST

kidneys, with a half-life of 4 –5 min (182, 309). It has been


established that GLP-1 is also a substrate for the enzyme,
neutral endopeptidase 24.11 (134), and recent studies
have shown that inhibition of this enzyme will enhance
survival of both endogenous and exogenous GLP-1 in vivo
(242). However, the enhanced survival will only be appar-
ent if the NH2-terminal degradation by DDP-IV has been
prevented. Because of the extensive degradation, the
plasma concentrations of the intact hormone are very low
and may not even rise significantly in response to small
meals (312). However, determination of the concentra-
tions of the metabolite, which will be much higher, may
reveal that a stimulation of the L-cells has nevertheless

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taken place. It follows that for estimation of L-cell secre-
tion it is best to measure the sum of the intact hormone
and the primary metabolite. In humans, this can be ac-
complished with assays for the amidated COOH terminus
of the molecule, which is common to the intact hormone
and the metabolite, because in humans, all of the GLP-1
released from the gut is amidated (231). Such assays are
frequently designated “total” GLP-1 assays. Clearly, for
estimation of the impact of circulating intact GLP-1 for
FIG. 2. The endocrine pathway for the actions of GLP-1. GLP-1 insulin secretion via the endocrine route, it is necessary to
secretion is stimulated by nutrients in the gut lumen (a magnified measure the concentration of the intact hormone, which
intestinal villus with an open-type L-cell is shown at the lower left).
GLP-1 diffuses across the basal lamina into the lamina propria and is may be accomplished with sandwich assays as mentioned
taken up by a capillary, only to be broken down by dipeptidyl peptidase (often designated “active GLP-1 assays”). However, as will
IV (DPP-IV), located on the luminal surface of the endothelial cells be evident below, this is unlikely to reflect to total influ-
(white cells lining the capillary) so that only 25% of the secreted amount
reaches the portal circulation. In the liver, a further 40 –50% is destroyed ence of L-cell secretion on insulin secretion.
so that only 10 –15% enters the systemic circulation and may reach the
pancreas and the brain via the endocrine pathway (perhaps even less
because of the continued proteolytic activity of soluble DPP-IV present V. REGULATION OF SECRETION
in plasma).

GLP-1 secretion is clearly meal related (233). In the


two-thirds of the total amount secreted, but subsequent fasting state, the plasma concentrations are very low.
studies revealed that also the porcine gut releases signif- They are not immeasurable though, and it has been dem-
icant amounts of nonamidated GLP-1 9 –37 (97), which onstrated that the fasting concentrations can be lowered
was not taken into account in the original study. There- with somatostatin in humans (287), suggesting that there
fore, ⬍25% of newly secreted GLP-1 leaves the gut in an is a certain basal rate of secretion. This also seems evi-
intact, active form. A similar degradation amounting to dent from studies involving DPP-IV inhibitors, which in-
⬃40 –50% takes place in the liver (46), and it can therefore crease the levels of intact endogenous GLP-1 (174) also in
be calculated that only ⬃10 –15% of newly secreted GLP-1 the intervals between meals and in the fasting state (174).
reaches the systemic circulation in the intact form (see This would not have been possible without a significant
Fig. 2). This is in contrast to the fact that virtually all of interdigestive and fasting secretion of GLP-1. Meal intake
GLP-1 stored in the granules of the L-cells is intact (96). It causes a rapid increase in L-cell secretion, most evident
has been shown that the degradation is due to the actions when measured with COOH-terminal assays (233) (see
of the enzyme DDP-IV, which is expressed not only in the Fig. 3), but often measurable also with assays for the
enterocyte brush border but also in the endothelial cells intact hormone (317). The response is noticeable after
lining the capillaries of the lamina propria (96). In agree- ⬃10 min, but occurs later than the “cephalic phase” stim-
ment with this, inhibitors of DPP-IV can completely pre- ulation of insulin secretion (3), suggesting that the neu-
vent this degradation (96). DPP-IV activity is also respon- ronal, possibly vagal, signals that cause insulin secretion
sible for the extremely rapid initial whole body metabo- do not influence GLP-1 (or GIP) secretion. There are
lism of GLP-1, which results in an apparent half-life for many reasons to believe that it is the actual presence of
intact GLP-1 in plasma of 1–2 min and a metabolic clear- nutrients in the gut lumen and possibly their interaction
ance rate exceeding cardiac output by a factor of 2–3 (46, with the microvilli of the L-cells (62) that are responsible
309). The metabolite is also cleared rapidly, mainly in the for the GLP-1 response. Thus a very rapid GLP-1 response

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THE PHYSIOLOGY OF GLUCAGON-LIKE PEPTIDE 1 1415

intestinal digestion and absorption of carbohydrates and


cause a transfer of nutrients to distal segments of the gut,
are consistent with this. Acarbose reduces GIP secretion,
but augments GLP-1 secretion (244) and may, partly be-
cause of this, improve glucose tolerance in patients with
diabetes. Other experiments, however, suggest that the
secretion of GIP is closely linked to that of GLP-1 and vice
versa. Thus, in the laboratory of the author, volunteers
were intubated with long (ileal) or short (duodenal) cath-
eters, and small amounts of glucose were instilled to
produce a selective response of either of the incretin
hormones. Surprisingly, the glucose instillation resulted
in almost equal GIP and GLP-1 responses whether intro-

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duced proximally or distally (118; unpublished studies).
This may be explained by the fact that both GLP-1- and
GIP-producing cells are found throughout the small intes-
tine and by the above-mentioned finding that a significant
number of gut endocrine cells in several mammals, in-
cluding humans, produce both GIP and GLP-1 (195). In
agreement with this, a mixed meal will normally cause a
release of both peptides, but whereas the GIP concentra-
tions may increase to several hundred picomolar, GLP-1
concentrations (intact ⫹ metabolite) rarely exceed 50 pM
(233) (see Fig. 3). In subjects with accelerated gastric
emptying, for instance after gastrectomy or gastric bypass
operations for obesity, the secretion of GLP-1 may be
greatly exaggerated (6, 187, 235) and may in such patients
be the cause of reactive hypoglycemia, because of a
FIG. 3. Plasma concentrations of insulin, GLP-1 (total), and gastric resulting inappropriate hyperinsulinemia (76, 286) (see
inhibitory peptide (GIP; total) during the day time in healthy subjects. below).
Note the rather low concentrations of GLP-1 compared with the high It has often been said that indirect mechanisms for
concentrations of GIP. Arrows indicate large meals. Values are means ⫾
SE (n ⫽ 8 subjects). [From Orskov et al. (233).] release were required to explain the rapid onset of the
meal response, taking the distal location of the L-cells into
consideration. However, although the density of L-cells is
is seen in humans after ileal instillations of lipids or higher in the ileum, there are numerous L-cells in the
carbohydrate in amounts corresponding to “the physio- proximal jejunum as already pointed out, and these may
logical malabsorption” of these nutrients (164). The os- very well be responsible for the early response. The de-
molarity of the solutions appears not to be of importance, pendency of the response on the magnitude of the meal
since hyperosmolar salt solutions have no effect (240). may reflect that a larger area of the gut and thereby an
The meal response depends on the size of the meal (317) increasing number of L-cells is being exposed with larger
and is strongly correlated to the gastric emptying rate meals.
(187). The response is uninfluenced by minor intestinal Little is known about the mechanisms whereby nu-
resections (which interrupt intramural reflex pathways) trients stimulate GLP-1 secretion. In canine ileum, block-
(212). It has been suggested that the purpose of having ade of the luminal sodium/glucose cotransporter, SGLT-1,
two incretin hormones is related to their location with with phlorizin inhibited GLP-1 secretion (273), suggesting
one, GIP, being predominantly secreted from the upper that absorption of glucose is essential, but unfortunately
small intestine, and the other mainly secreted from the the experiment could not distinguish between effects of
lower small intestine where the density of the L-cells is the blocker on the L-cells or on neighboring cells. Gribble
higher. Conceivably, therefore, smaller loads of rapidly et al. (82) recently found that SGLT-1 was important for
absorbable nutrients would preferentially activate the up- glucose-induced GLP-1 secretion in a proglucagon-ex-
per incretin hormone, i.e., GIP, whereas ingestion of pressing cell line called GLUTag (82). The GLUTag cell
larger meals containing more complex nutrients requiring line is derived from a colonic neuroendocrine tumor gen-
more extensive digestive processing would also activate erated in a transgenic mouse expressing the simian virus
the distal incretin, i.e., GLP-1. Experiments with ␣-glyco- 40 (SV40) T-antigen under the control of the proglucagon
sidase inhibitors such as acarbose, which delay upper promoter (53). Unfortunately, this cell line does not ex-

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1416 JENS JUUL HOLST

hibit the polarity of the L-cell, and it is therefore difficult the importance of the neural regulation (100). It was
to extrapolate results obtained with these cells to natural confirmed that the sympathetic innervation to the gut is
L-cells. GLP-1 secretion from the GLUTag cells may also inhibitory to GLP-1 secretion (with norepinephrine as the
be stimulated by metabolizable sugars by a mechanism responsible transmitter), whereas the extrinsic vagal in-
that involves closure of ATP-sensitive K⫹ channels (8). nervation had no effect. Intrinsic, cholinergic activity may
This seems to be consistent with the recent demonstra- play a minor role, however.
tion of stimulation of GLP-1 secretion from isolated seg- One of the most powerful mechanisms for regulation
ments of porcine ileum by glucose administered both of GLP-1 secretion appears to be a local paracrine control
luminally and via the perfusate (98). Fructose stimulates exerted by neighboring somatostatin producing D-cells
secretion both in vivo and in the GLUTag cells (107), (97). Elimination of somatostatin’s restraint (by immuno-
suggesting that GLUT5 transporters may also be involved. neutralization) may increase GLP-1 secretion up to eight-
Involvement of neurohormonal mechanisms to ex- fold, much more than observed with any other stimulus. It
plain the rapid postprandial onset of secretion has been deserves mentioning that the neuropeptide gastrin releas-

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considered by several authors. In rats, glucose-dependent ing polypeptide (GRP), as well as its COOH-terminal de-
insulinotropic peptide (GIP) has been shown to stimulate capeptide neuromedin C, and the related 14-amino acid
GLP-1 secretion via activation of a neural pathway involv- frog-skin peptide bombesin (which exhibits strong
ing the vagus nerve (254). Administration of muscarinic COOH-terminal homology to GRP) are powerful stimu-
cholinergic agonists to isolated perfused rat ileum and lants of GLP-1 secretion (96, 227). A release of GRP can be
colon resulted in stimulation of GLP-1 secretion (54, 109), measured from vagally innervated organs during vagal
and studies in anesthetized rats and in fetal rat intestinal stimulation, but as mentioned, vagal stimulation does not
cells suggested that both M1 and M2 muscarinic receptors result in a release of GLP-1 (154). Lipids provide a rather
could be involved in control of GLP-1 release (7). Cat- strong stimulus for GLP-1 secretion (63), and in this con-
echolamines could also be part of a neural stimulatory nection it is of interest that L-cells were recently reported
pathway in rats, as infusion of a ␤-adrenergic agonist to express a deorphanized G protein-coupled receptor for
stimulated GLP-1 secretion in isolated perfused rat ileum long-chain saturated fatty acids, GPR120 (112). Further-
and colon (54, 241). more, activation of this receptor with fatty acids stimu-
In humans and pigs, none of the known duodenal lated secretion of GLP-1 both in vitro and in vivo. In
peptides (including GIP), in normal physiological post- recent studies involving the GLUTag cell line, which as
prandial concentrations, is capable of stimulating GLP-1 mentioned is a model for the L-cells and expresses the
secretion (68, 99, 206). Indeed, in the author’s laboratory, GPR120 receptor, the atypical protein kinase C (PKC-␨),
a systematic search of fractionated (gel and high-perfor- known to be involved in fatty acid signaling in many cells,
mance liquid chromatography) extracts of the duodenal was found to be required for oleic acid-induced GLP-1
mucosa was carried out using GLP-1 secretion from iso- secretion (136). In other recent studies involving GLUTag
lated perfused ileum as bioassay, but no unknown GLP-1 cells, the neurotransmitters glycine and GABA were re-
stimulating agents could be identified (95, 99). Infusion of ported to provide a strong stimulus for secretion (74).
atropine in humans delays the increase of both plasma
glucose and GLP-1 after an oral glucose load and reduces
VI. EFFECTS OF GLUCAGON-LIKE PEPTIDE 1
the GLP-1 response (12), but these effects likely reflect
the effects of atropine on gastrointestinal motility. Studies
using the human NCI-H716 cell line have shown that A. The GLP-1 Receptor
cholinergic agonists stimulated GLP-1 release and sug-
gested, as mentioned above, that M1 and M2 muscarinic The GLP-1 receptor is a class 2, G protein-coupled
receptors are involved (7, 251). In isolated perfused por- receptor (176) and was first cloned by expression cloning
cine ileum, GLP-1 secretion could be increased by infu- from a rat pancreatic islet library by Bernard Thorens in
sion of acetylcholine during coinfusion of phentolamine 1992. Thorens subsequently also cloned the highly homol-
(an ␣-adrenergic blocker, which will eliminate the sym- ogous human receptor (283, 284) and also confirmed that
pathetic inhibition of GLP-1 secretion) (97). All this sug- the 53% homologous lizard peptide exendin 4 is a full
gests that acetylcholine could be a transmitter in a neural agonist and the truncated peptide exendin 9 –39 is a po-
stimulatory pathway for GLP-1 secretion. However, an- tent antagonist of the receptor (78) (see also sect. VII). The
other study in conscious pigs indicated that the vagus GLP-1 receptor belongs to the same family as the GIP and
nerve is not involved in control of GLP-1 release (18). the glucagon receptors (176). The receptor typically cou-
Finally, in recent extensive studies employing both iso- ples via a stimulatory G protein to adenylate cyclase (285,
lated perfused porcine ileum and intact pigs, a variety of 330). The signaling in beta cells is discussed below. The
neurally active agents as well as electrical stimulation of receptor is widely distributed in pancreatic islets, brain,
the abdominal vagal trunks were employed to investigate heart, kidney, and the gastrointestinal tract (5, 28, 33, 322,

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THE PHYSIOLOGY OF GLUCAGON-LIKE PEPTIDE 1 1417

323) including the stomach, where the receptor is ex- the incretin effect ensures that postprandial glucose ex-
pressed on the parietal cells (262). Its function is not cursions are limited and similar regardless of the carbo-
known for all these locations (see below). For instance, in hydrate load. The increase in insulin secretion is mainly
the parietal cells, activation of the receptor increases due to the actions of insulinotropic gut hormones (177,
aminopyrine accumulation, which is an indirect indicator 178). The same gut hormones are also released by mixed
of acid secretion (258), whereas in vivo, GLP-1 strongly meals, and given that their postprandial concentrations in
inhibits acid secretion (see below). Numerous attempts plasma are similar and that the elevations in glucose
have been made to identify alternative GLP-1 receptors or concentrations are also similar, it is generally assumed
subtypes (see below), but at present only a single GLP-1 that the incretin hormones are playing a similarly impor-
receptor has been identified, whether expressed in the tant role for the meal-induced insulin secretion. Part of
brain, the stomach, or the pancreas (322). However, the increase in the peripheral insulin concentrations may
since the pulmonary receptor was found to differ from be due to a decreased hepatic uptake of insulin during
the islet receptor with respect to electrophoretic mobility, oral glucose ingestion, resulting in more insulin being

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whereas the primary sequence was identical, it was con- passed on to the peripheral circulation rather than repre-
cluded that glycosylation patterns might differ (158). Bi- senting an increased secretion. This could be mistaken for
ological consequences of such differences are unknown. an incretin effect. However, if the analysis is based on
As mentioned, exendin 9 –39 acts as a potent and specific measurements of insulin’s C-peptide instead of insulin, it
antagonist at the GLP-1 receptor (284), and all effects of is possible to eliminate the influence of the varying he-
GLP-1 transmitted via this receptor would be expected to patic extraction of insulin since C-peptide is not taken up
be blocked by the antagonist. However, in certain exper- by the liver. Several studies have shown that during iso-
iments involving effects of afferent vagus signaling or glycemic glucose challenges in healthy subjects, plasma
enterogastrone effects of GLP-1 (see below), this has not C-peptide concentrations show very similar changes as do
been the case (71, 219), raising speculations about the insulin concentrations with much higher response to the
existence of another receptor. Currently, its nature re- oral versus the intravenous challenge. This proves that
mains elusive. There is considerable controversy with the larger response to oral versus intravenous glucose is
respect to possible effects of GLP-1 on adipose tissue, due to increased secretion of insulin. Calculation of the
muscle tissue, and the liver, and coupled to this is of incretin effect can also be based on measurements of
course the question whether the GLP-1 receptor is ex- actual prehepatic insulin secretion rates. These can be
pressed in these tissues. Some studies have been negative calculated from measurements of C-peptide levels by ap-
(28), and others less clear (33). In addition, there may be plication of C-peptide elimination kinetics and deconvo-
differences between species, with dogs possibly express- lution. The actual prehepatic insulin secretion rates also
ing the receptor in muscle and adipose tissue (257) and exhibit much larger increases after oral compared with
mice expressing it in liver (33). See below for a further isoglycemic intravenous glucose stimulation (175).
discussion of extrapancreatic effects of GLP-1. Many hormones have been suspected to be respon-
sible for the incretin effect (125), but today there is ample
evidence to suggest that the two most important incretins
B. The Incretin Effect are GIP and GLP-1 (310). Both have been established as
important incretin hormones in mimicry experiments in
One of the most important functions of GLP-1 is to humans, where the hormones were infused together with
act as an incretin hormone (124, 310). intravenous glucose to concentrations approximately cor-
“The incretin effect” designates the amplification of responding to those observed during oral glucose toler-
insulin secretion elicited by hormones secreted from the ance tests. Both hormones powerfully enhanced insulin
gastrointestinal tract. In the most strict sense, it is quan- secretion, each of them actually to an extent that can fully
tified by comparing insulin responses to oral and intrave- explain the insulin response (157, 202). Likewise, admin-
nous glucose administration, where the intravenous infu- istration of GLP-1 and GIP receptor antagonists to rodents
sion is adjusted so as to result in the same (isoglycemic) or immunoneutralization have clearly indicated that both
peripheral (preferably arterialized) plasma glucose con- hormones play an important role for the incretin effect
centrations (177, 237). In healthy subjects, oral adminis- (75, 155). However, there has been some uncertainty
tration causes a two- to threefold larger insulin response about the relative roles of the two hormones. GIP is
compared with the intravenous route. It is, however, im- circulating in 10-fold higher concentrations than GLP-1
portant to realize that the effect varies with the size of the [and this is true also with respect to the concentrations of
glucose challenge, being small with, e.g., 25 g and very the intact hormones (312)], whereas GLP-1 appears more
large with 100 g of glucose (208). In these dose-response potent than GIP (206). Furthermore, it is often empha-
experiments, the plasma glucose excursions were identi- sized that both hormones require elevated plasma glucose
cal despite the increasing glucose loads. In other words, concentrations for stimulation of insulin secretion, for

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1418 JENS JUUL HOLST

GIP may be as much as 8 mM. The insulinotropic potential


of GLP-1 and GIP was, therefore, reinvestigated in recent
human experiments involving clamping of blood glucose
at fasting and postprandial levels and exact copying of the
meal-induced concentrations of both GLP-1 and GIP by
intravenous infusions (See Figs. 4 and 5). The results
showed that both hormones are active with respect to
enhancing insulin secretion from the beginning of a meal
(even at fasting glucose levels) and that they contribute
almost equally, but with the effect of GLP-1 predominat-

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FIG. 5. Insulin and glucagon responses in healthy volunteers to
intravenous infusions of GLP-1 and GIP at normal postprandial physio-
logical concentrations (see Fig. 3) carried out during clamping of plasma
glucose at fasting levels and at 1 and 2 mM above that (see Fig. 4). The
responses to the glucose alone are also shown. Note that both GIP and
GLP-1 stimulate insulin secretion even at fasting glucose levels. Also
note that whereas GIP has litte effect on glucagon secretion, GLP-1
causes an additional inhibition. [Modified from Vilsboll et al. (315).]

ing at higher glucose levels (315). The effects of the two


hormones with respect to insulin secretion have been
shown to be additive in humans (204). It should be noted
that only GLP-1, not GIP, causes an inhibition of glucagon
secretion exceeding that elicited by glucose clamping.
From studies in mice with targeted lesions of the both
GLP-1 and GIP receptors, it was concluded that both
hormones are essential for a normal glucose tolerance
and that the effect of deletion of one receptor was “addi-
tive” to the effect of deleting the other (102, 243). Thus
there is little doubt that the incretin effect plays an im-
portant role in postprandial insulin secretion and, there-
fore, glucose tolerance in humans and animals.

FIG. 4. Incretin effect of GLP-1 and GIP in humans. Postprandial


concentrations of GIP and GLP-1 (see Fig. 3) were copied by intravenous C. Effects on the Beta-Cells
infusion in healthy volunteers, while plasma glucose levels were
clamped at fasting levels, and at 1 and 2 mM above that. The insulin and
glucagon responses to these infusions are shown in Fig. 5. [Modified GLP-1’s insulinotropic activity, which is strictly glu-
from Vilsboll et al. (315).] cose dependent, is, at least partly (see below), exerted via

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THE PHYSIOLOGY OF GLUCAGON-LIKE PEPTIDE 1 1419

interaction with the GLP-1 receptor located on the cell the intracellular ATP levels and, thereby, to glucose me-
membrane of the beta cells (124). Binding of GLP-1 to the tabolism of the beta cells, but may also be affected
receptor causes activation, via a stimulatory G protein, of (closed, resulting in subsequent depolarization of the
adenylate cyclase resulting in the formation of cAMP. plasma membrane and opening of voltage-sensitive cal-
Most of the actions of GLP-1 are secondary to the forma- cium channels) by protein kinase A (PKA) activated by
tion of cAMP (see Fig. 6). Subsequent activation of pro- GLP-1 (85, 132, 170). Apparently, PKA-mediated phos-
tein kinase A and the cAMP-regulated guanine nucleotide phorylation of S1448 in the SUR1 subunit leads to KATP
exchange factor II (cAMP-GEFII, also known as Epac2) channel closure via an ADP-dependent mechanism. In
leads to a plethora of events including altered ion channel animals with a targeted deletion of the SUR1 subunit of
activity, elevation of intracellular calcium concentrations, the channels, the incretins can still elevate cAMP levels,
and enhanced exocytosis of insulin-containing granules but no longer stimulate glucose-induced insulin secretion
(130). GLP-1 also stimulates coordinated oscillations in (199). However, this impairment was thought to be due to
both intracellular calcium and cAMP, and these are po- a restriction in the beta cells to sense cAMP correctly,

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tentiated by glucose (56). Furthermore, sustained eleva- since inhibitors of PKA did not inhibit the insulin re-
tions of cAMP concentrations induce nuclear translo- sponse to GLP-1 (199). There is also evidence that GLP-1
cation of the catalytic subunit of the cAMP-dependent acts as a glucose sensitizer. Thus GLP-1 has been found to
protein kinase, presumably leading to CREB activation facilitate glucose-dependent mitochondrial ATP produc-
and likely cell proliferation and survival. The effects of tion (293). At any rate, it is of potential clinical impor-
glucose and GLP-1 may converge at the level of the KATP tance that sulfonylurea drugs, which bind to and close the
channels of the beta cells. These channels are sensitive to KATP channels and thereby cause membrane depolariza-

FIG. 6. Summary of the cellular actions of GLP-1 that lead to stimulation of insulin secretion. Binding of GLP-1 to its receptors couple to
activation of adenylate cyclase; intracellular cAMP levels are elevated leading to activation of protein kinase A (PKA) and cAMP-regulated guanine
nucleotide exchange factor II (cAMP-GEFII, also known as Epac2). These two proteins are likely to mediate the plethora of molecular mechanisms
(summarized below in points 1– 6). 1) GLP-1 acts synergistically with glucose to close ATP-sensitive K⫹ (KATP) channels and thus facilitates
membrane depolarization and the induction of electrical activity. 2) Once electrical activity is initiated, the slower time course of inactivation of the
Ca2⫹ channels results in prolonged bursts of action potentials. In addition, each action potential will be associated with a slightly greater Ca2⫹ influx
because the amplitude of the Ca2⫹ current is moderately increased (86). 3) Antagonism by GLP-1 of the delayed rectifying K⫹ (Kv) channels will
increase excitability and results in prolongation of the duration of action potentials. 4) In the presence of stimulatory levels of glucose and GLP-1,
Ca2⫹ influx through the Ca2⫹ channels feeds forward into mobilization of Ca2⫹ from intracellular stores by Ca2⫹-induced Ca2⫹ release through PKA-
and cAMP-GEFII-dependent mechanisms. 5) Ca2⫹ mobilization from intracellular stores will stimulate mitochondrial ATP synthesis, which will
promote further membrane depolarization via closure of KATP channels. ATP is also required for stimulation of exocytosis of the insulin-containing
granules. 6) The elevation in the cytoplasmic free Ca2⫹ concentration ([Ca2⫹]i) triggers the exocytotic response that is further potentiated by
increased cAMP levels. This effect is principally attributable to the ability of cAMP to accelerate granule mobilization resulting in an increased size
of the pools of granules that are immediately available for release. These effects depend both on cAMP binding to PKA and cAMP-GEFII.
Quantitatively the last mechanism is by far the most important one and may account for 70% or more of the total insulinotropic activity of GLP-1
and GIP (86). [Modified from Holst and Gromada (124).]

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1420 JENS JUUL HOLST

tion and calcium influx, may uncouple the glucose depen- bility that GLP-1 could be useful as a therapeutic agent in
dency of GLP-1 (40). Thus GLP-1 administration to iso- conditions with increased beta-cell apoptosis, which
lated perfused rat pancreases at low perfusate glucose would include type 1 as well type 2 diabetes in humans
concentrations normally does not affect insulin secretion, (32). Thus treatment of mice with the GLP-1 agonist ex-
but resulted in dramatic stimulation of insulin secretion endin 4 reduced beta-cell apoptosis induced by strepto-
after pretreatment with sulfonylurea drugs (40, 89). In- zotocin (while GLP-1 receptor knockout mice were ab-
deed, 30 – 40% of patients treated with both sulfonyl urea normally susceptible to streptozotocin-induced beta-cell
compounds and a GLP-1 agonist (exendin 4, see below) apoptosis) (169). Also, cytokine-induced apoptosis may
experience, usually mild, hypoglycemia. be inhibited, and GLP-1 agonism increased cell survival
cAMP generated by activation of the GLP-1 receptor and reduced caspase activation in BHK fibroblasts ex-
may also influence the exocytotic process directly, and pressing a transfected GLP-1 receptor (169). In this con-
this process has been estimated to account for up to 70% nection, it is of considerable interest that exendin treat-
of the entire secretory response (124). Also, ATP may ment (in combination with lisophylline) prior to the de-

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directly influence the exocytotic process and may, there- velopment of diabetes markedly improved glucose
fore, represent another site of convergence for the glu- control in NOD mice, a model of type 1 diabetes, and
cose- and GLP-1-mediated signals (86). Other changes preserved the number of intact islets and reduced the
that occur in the beta cells appear to be PKA independent. extent of inflammation in the remaining islets (337), again
Thus the actions of GLP-1 on the insulin gene promoter suggesting that GLP-1 treatment might be able to reduce
appear to be mediated by both PKA-dependent and -inde- the beta-cell destruction in human autoimmune diabetes.
pendent mechanisms, the latter possibly involving the GLP-1 treatment was demonstrated to delay the onset of
mitogen-activated protein kinase pathway (146). The ef- diabetes when given to 8-wk-old db/db mice, which de-
fect of GLP-1 on the insulin promoter appears to be velop diabetes secondary to an inactivating mutation of
mediated by two distinct cis-acting sequences, both in a the hypothalamic leptin receptor causing massive obesity
PKA-dependent and PKA-independent manner (268). (320). Impressively, GLP-1 or exendin 4 administration for
There is also evidence that glucose and GLP-1, by increas- 5 days in the neonatal Goto-Kakisaki (GK) rat, a polyge-
ing intracellular calcium, may potentiate insulin gene netic and hypoinsulinemic model of type 2 diabetes, re-
transcription in a calcineurin- and nuclear factor of acti- sulted in persistent improvement in glucose homeostasis
vated T-cells (NFAT)-dependent manner (162). The tran- and maintenance of beta-cell mass adult age (290). It is
scription factor PDX-1, a key regulator of islet growth and important to note that the trophic effects of GLP-1 ago-
insulin gene transcription, appears to be essential for nists in rodents, like their insulinotropic properties, are
most of the glucoregulatory, proliferative, and cytoprotec- coupled to the presence of hyperglycemia, and also to
tive actions of GLP-1 (168). In addition, GLP-1 upregulates note that as GLP-1 alleviates hyperglycemia, which is in
the genes for the cellular machinery involved in insulin itself a very strong stimulus to beta-cell growth in rodents;
secretion, such as the glucokinase and GLUT2 genes (31). this growth stimulus is reduced (272). Thus, in nondia-
Much attention was aroused by the finding that GLP-1 betic rats, the increase in beta-cell mass was transient and
appeared to be essential for conveying “glucose compe- disappeared upon prolonged administration (6 wk) of a
tence” to the beta cells, i.e., without GLP-1 signaling, beta stable long-acting GLP-1 analog (20).
cells would not be responsive to glucose (86, 133). How- A most striking demonstration of the beta-cell pro-
ever, the beta cells of mice with disruption of the GLP-1 tective/proliferative effects of GLP-1 receptor activation
receptor gene show preserved glucose competence (69). was provided by Stoffers et al. (270), who studied the
It is possible, however, that glucagon from neighboring diabetes developing in rats subjected to intrauterine
alpha cells may substitute, since glucagon may also pro- growth retardation. Treatment with exendin 4 in the neo-
vide glucose competence to beta cells (69). natal period completely prevented development of diabe-
As already alluded to, GLP-1 also has trophic effects tes and restored beta-cell mass, which otherwise is
on beta cells (59). Not only does it stimulate beta-cell strongly reduced in these animals.
proliferation (57, 66, 271, 333), it also enhances the dif- The complicated and incompletely elucidated mech-
ferentiation of new beta cells from progenitor cells in the anisms that could be involved in the GLP-1-induced tro-
pancreatic duct epithelium (343). Thus GLP-1 has been phic effects on the beta cells were reviewed recently (24,
demonstrated to be capable of differentiating the pancre- 51, 267).
atic duct cell line AR42J into endocrine insulin-secreting
cells (168, 343). Most recently, GLP-1 has been shown to
be capable of inhibiting apoptosis of beta cells including D. Effects on Glucagon Secretion
human beta cells (30, 65). Since the normal number of
beta cells is maintained in a balance between apoptosis GLP-1 strongly inhibits glucagon secretion (228).
and proliferation (21), this observation raises the possi- Since in patients with type 2 diabetes there is fasting

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THE PHYSIOLOGY OF GLUCAGON-LIKE PEPTIDE 1 1421

hyperglucagonemia as well as exaggerated glucagon re- inhibit pancreatic secretion in response to intraduodenal
sponses to meal ingestion (288), and since it is likely that stimulation (84). The inhibitory effect of GLP-1 on acid
the hyperglucagonemia contributes to the hyperglycemia secretion could be elicited by physiological elevations of
of the patients (265), this effect may be as important the GLP-1 concentrations in plasma and was, remarkably,
clinically as the insulinotropic effects (see below). In- additive to the inhibitory effects of PYY, which is released
deed, in patients with type 1 diabetes and complete lack from the L-cell in parallel with GLP-1 (324). Together the
of beta-cell activity (C-peptide negative), GLP-1 is still two peptides almost abolished gastrin-stimulated secre-
capable of lowering fasting plasma glucose concentra- tion, indicating that these two peptides are the likely
tions, presumably as a consequence of a powerful lower- mediators of the “ileal brake effect,” i.e., the endocrine
ing of the plasma glucagon concentrations (35). The inhibition of upper gastrointestinal functions elicited by
mechanism of GLP-1-induced inhibition of glucagon se- the presence of unabsorbed nutrients in the ileum (113,
cretion is not completely elucidated. Insulin is generally 163, 249). These effects of GLP-1, also designated enter-
thought to inhibit glucagon secretion, and local elevations gastrone effects, are likely to be physiological, since stim-

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of insulin levels around the alpha cells might inhibit their ulation of endogenous GLP-1 secretion by intraileal instil-
secretion in a paracrine manner, but the preserved and lation of nutrients corresponding to the “physiological
pronounced inhibitory effect of GLP-1 in type 1 diabetic malabsorption,” resulted in concomitant inhibition of gas-
patients without residual beta-cell function (35) would tric and pancreatic secretions (164) (See Fig. 7). Further
suggest that other mechanisms must also be involved. studies documented that GLP-1 could completely abolish
Similarly, GLP-1 strongly inhibits glucagon secretion in acid secretion resulting from pure vagal stimulation in
isolated rat pancreas perfused with low perfusate glucose humans (as elicited by modified sham feeding: the “chew-
concentration and immeasurable insulin secretion (41). and-spit technique”) (325) and that the inhibitory effect
GLP-1 stimulates pancreatic somatostatin secretion (228), was lost in people that had had a truncal vagotomy for
which in turn might inhibit glucagon secretion by para- duodenal ulcer disease (329). This would indicate that all
crine interaction (67), as evidenced by the ability of so- of the actions of GLP-1 on gastric functions are mediated
matostatin antibodies as well as a somatostatin receptor 2 via vagal pathways (see below). In recent studies Schirra
antagonist to abolish the inhibitory effect of GLP-1 (41). et al. (260) were able to demonstrate the importance of
Interestingly, in isolated alpha cells, ⬃20% of which may endogenous GLP-1 for regulation of antroduodenal motil-
express the GLP-1 receptor (106) (although this is con- ity (and pancreatic endocrine secretion) by administra-
troversial, Ref. 188), GLP-1 appears to stimulate GLP-1 tion of the GLP-1 receptor antagonist exendin 9 –39 (see
secretion (50). Fig. 8). The physiological relevance of the ileal-brake
The inhibitory effect of GLP-1 on glucagon secre- effects of GLP-1 in humans thus seems established.
tion in vivo is only observed at glucose levels at or
above fasting levels (see Fig. 5). In studies involving
graded hypoglycemic clamping in humans, the inhibi-
tory effect of GLP-1 was lost at glucose levels just
below normal fasting levels, and the normal stimulation
of glucagon secretion at hypoglycemic levels was un-
impeded by GLP-1 (205). This is important because it
implies that treatment with GLP-1 (see below) does not
weaken the counterregulatory responses to hypoglyce-
mia and, therefore, does not lead to an increased risk of
hypoglycemia.

E. Effects on the Gastrointestinal Tract

Further important effects of GLP-1 include inhibition


of gastrointestinal secretion and motility (211, 327). It was
first noted that GLP-1 inhibits gastrin-induced acid secre-
tion in humans (261), and subsequently demonstrated that
GLP-1 also inhibits meal-induced secretion as well as FIG. 7. Relationship between (total) plasma GLP-1 responses and
gastric emptying and pancreatic secretion (327). The ef- inhibition of gastric acid secretion in healthy volunteers undergoing ileal
fect on pancreatic exocrine secretion was first suspected instillations of solutions of NaCl, protein, lipid, and carbohydrates
(CHO) corresponding to the amounts normally present in this section of
to be secondary to the inhibition of gastric emptying, but the gut after mixed meal ingestion. [From Layer et al. (164), with kind
in subsequent studies, GLP-1 was demonstrated to also permission of Springer Science and Business Media.]

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1422 JENS JUUL HOLST

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FIG. 8. Antroduodenal motility (pressure waves) in response to intraduodenal glucose infusions in healthy volunteers with or without infusion
of a GLP-1 receptor antagonist (exendin 9 –39). The antagonist clearly enhanced to motor responses, indicating removal of a GLP-1-mediated
inhibition. [From Schirra et al. (260), with permission from BMJ Publishing Group Ltd.]

F. Central Targets for Peripherally pretation was that physiological amounts of GLP-1 de-
Released GLP-1 pended on reflex pathways for stimulation of insulin se-
cretion, whereas higher doses leading to higher plasma
As alluded to above, very little GLP-1 reaches the concentrations might activate islet receptors directly and
systemic circulation in the intact form. One may ask why therefore equally in control and denervated mice. Thus,
particularly GLP-1 is degraded so extensively that a rise in regarding the mechanism of GLP-1-stimulated insulin se-
the concentration of the intact peptide frequently may not cretion under physiological circumstances, the neural
be noticeable after intake of smaller meals. The observa- pathway may be more important than the endocrine
tion has led to the hypothesis that GLP-1 must act locally route. However, the concentration of intact GLP-1 does
in the lamina propria before being degraded (96, 123; see rise after meal intake and rises more the larger the meal
Fig. 9). Once released from the L-cells, GLP-1 diffuses is (317). Thus it seems probable that the endocrine route
across the basal lamina and enters the lamina propria. becomes more prominent after extensive L-cell stimula-
Here it is taken up by capillaries, the endothelial mem- tion.
branes of which will then degrade the hormone, because The pathways whereby GLP-1 exerts its “ileal brake”
they express DPP-IV (96). However, on its way to the effects (119) also seem to depend on signaling via afferent
capillary, GLP-1 may interact with afferent sensory nerve sensory neurons relaying in the brain stem or the hypo-
fibers arising from the nodose ganglion, sending impulses thalamus and regulating efferent parasympathetic outflow
to the nucleus of the solitary tract and onwards to the (139, 328). Thus GLP-1 has no effect on vagally stimulated
hypothalamus (See Fig. 9) (123). Recent observations that antral motility in isolated perfused preparations of the pig
the GLP-1 receptor is expressed in nodose ganglion cells stomach (328) and no effect on vagally stimulated exo-
support this view (198). In addition, it has been demon- crine secretion from isolated perfused porcine pancreas
strated that intraportal administration of GLP-1 causes (127). Furthermore, as mentioned, the acid inhibitory ac-
increased impulse activity in the vagal trunks (220). These tivity in humans exclusively depends on vagal mecha-
impulses may be reflexly transmitted to the pancreas nisms (325, 329). Finally, the inhibitory effect on gastric
(197). Studies in rats employing ganglionic blockers have emptying in rats is lost after vagal deafferentation (139).
shown that the insulin response to intraportal administra- Studies in rats have suggested that a hepatoportal
tion of GLP-1 and glucose may be reduced to that glucose sensor may reflexly influence peripheral glucose
elicited by glucose alone after ganglionic blockade (11) metabolism and that this sensor is somehow linked to a
(see Fig. 10). Similarly, in mice rendered sensory dener- GLP-1 receptor expression, since its effects on peripheral
vated by neonatal administration of the neurotoxin cap- glucose disposal are abrogated by exendin 9 –39 and can-
saicin, low doses of GLP-1 that augmented glucose-in- not be demonstrated in GLP-1 receptor knockout mice
duced insulin secretion in control animals had little effect (29). In dogs, pharmacological amounts of intraportal
in the denervated mice, whereas high doses had the same GLP-1 were required to elicit changes in peripheral glu-
effects in control and denervated animals (1). The inter- cose metabolism (218), and in further dog studies, insulin-

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THE PHYSIOLOGY OF GLUCAGON-LIKE PEPTIDE 1 1423

FIG. 9. The neural pathway for the actions of


GLP-1. GLP-1 secretion is stimulated by nutrients in the
gut lumen (a magnified intestinal villus with an open-
type L-cell is shown at the lower left), and newly re-
leased GLP-1 diffuses across the basal lamina into the
lamina propria. On its way to the capillary, however, it

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may bind to and activate sensory afferent neurons (f)
originating in the nodose ganglion (c), which may in turn
activate neurons of the solitary tract nucleus (a). The
same neuronal pathway may be activated by sensory
neurons in the hepatoportal region (29) (e) or in the liver
tissue (39) (d). Ascending fibers from the solitary tract
neurons may generate reflexes in the hypothalamus, and
descending impulses (from neurons in the paraventricu-
lar nucleus?) may activate vagal motor neurons (b), that
send stimulatory (h) or inhibitory (g) impulses to the
pancreas and the gastrointestinal tract. Interactions be-
tween ascending sensory nerve fibers and vagal motor-
neurons may also take place at the level of the brain
stem.

independent effects of GLP-1 on glucose disposal in the actions of the peptide. Early studies indicated an effect on
liver required long-term (up to 5 h) infusions and were appetite and food intake (259), and subsequent more
independent of route of administration (portal vs. periph- detailed studies confirmed these effects after intracere-
eral) (39). Similar to the findings in mice, intraportal broventricular administration of low doses of the peptide
GLP-1 and glucose infusions in other dog studies were (278, 294). The proglucagon-producing neurons of the brain
found to decrease peripheral glucose levels indepen- stem may represent a link in a system whereby entero-
dently of hyperinsulinemia (140). However, it should be ceptive stress, but possibly also food ingestion, transmits
noted that peripheral administration of GLP-1 to dogs at a satiety signals to the brain (160, 253). Thus the cells are
similar rate is claimed not to enhance glucose-induced activated (show c-fos expression) upon distension of the
insulin secretion in this species (141). This is again in stomach (319). GLP-1 receptors are expressed in many
sharp contrast to very consistent findings in humans (135, regions of the brain and in particular in the arcuate nu-
157) and therefore suggests that dogs (and possibly mice) cleus and other hypothalamic regions involved in the
differ radically from humans in this respect. regulation of food intake (79). Destruction of the arcuate
nucleus with perinatal monosodium glutamate abolishes
G. Effects on Appetite and Food Intake the inhibitory effect of intracerebroventricularly adminis-
tered GLP-1 on food intake and appetite (280), indicating
There have been reports on the presence of glucagon that this nucleus is essential for the response. As men-
in the brain for many years (277), and it has been specu- tioned earlier, processing of proglucagon in the brain
lated that the peptide might play a role in regulation of stem neurons leads to the formation of GLP-1 as well as
food intake. When GLP-1 was also discovered in the brain GLP-2 and oxyntomodulin, all of which have been re-
(144), it was relevant to investigate the possible central ported to inhibit food intake after intracerebroventricular

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1424 JENS JUUL HOLST

perhaps via diffusion from the median eminence (160).


Recent studies have demonstrated that infusions of the
orexigenic peptide ghrelin may dampen the effects of
GLP-1 on gastric emptying and food intake, and the
authors suggested that the stimulating effect of ghrelin
on food intake might derive at least in part from its
ability to attenuate the effects of GLP-1 (and PYY 3–36)
on gastric emptying and food intake (34).
It should be noted that GLP-1 receptor knockout
mice do not become obese (263), but this may reflect the
redundancy of the appetite regulating mechanisms rather
than ineffectiveness of the signal. In fact, the efficacy of
the appetite-reducing effect was convincingly demon-

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strated not only in the clinical studies referred to above
but also in recent studies involving life-long administra-
tion of exendin 4 to rats. The treated animals survived
longer than controls, an effect that was thought to result
FIG. 10. Insulin responses to intraportal infusions of glucose and
from decreased food intake and hence a significantly
GLP-1 in rats with or without intravenous infusion of a ganglionic
blocker (chlorisondamine). Note that the ganglionic blocker completely lower body weight (110).
eliminated the GLP-1-induced enhancement of glucose-stimulated insu- Central administration of GLP-1 may also affect
lin secretion. [From Balkan and Li (11).] drinking behavior. Thus intracerebroventricular GLP-1
profoundly inhibited angiotensin II-induced drinking be-
administration (37, 279). Thus it is possible that the im- havior in rats, and water intake was suppressed by exog-
pact on food intake of activation of these neurons is enous GLP-1 in rats habituated to a water restriction
underestimated when only a single transmitter is studied. schedule. In contrast to the effects of GLP-1 on food
Nutrients in the ileum are thought to have a sati- intake, these effects were reproduced by intraperitoneal
ating effect, curtailing food intake (249), and GLP-1 is administration of GLP-1. Furthermore, intracerebroven-
released simultaneously (164). Does peripheral GLP-1 tricular GLP-1 stimulated urinary excretion of water and
play a physiological role as a satiating agent? Several sodium (278). Subsequent studies confirmed that intrave-
studies have shown that infusions of GLP-1 significantly nous infusion of pharmacological doses of GLP-1 may
and dose dependently enhance satiety and reduce food modulate drinking behavior and increase renal sodium
intake in normal subjects (70, 305). The effect on food excretion in healthy volunteers as well as in patients with
intake and satiety is preserved in obese subjects (200) type 2 diabetes (92, 94). However, long-term treatment of
as well as in obese subjects with type 2 diabetes (91, patients with type 2 diabetes with GLP-1 analogs does not
340). This raises the possibility that GLP-1 is not only a seem to be associated with disturbances of fluid or elec-
physiological regulator of food intake but also has a trolyte balance.
therapeutic potential. Recent clinical studies have
shown that subcutaneous injections of a stable GLP-1
H. Other Effects
receptor agonist (exendin 4) given twice daily for sev-
eral years to people with type 2 diabetes are associated
1. Cardiovascular
with a gradual and linear weight loss with no signs of
impaired efficacy with time (19, 108). It is well established that there are glucagon recep-
The mechanism whereby peripherally adminis- tors in the heart and that glucagon has inotropic and
tered GLP-1 inhibits food intake is not clear. It is un- chronotropic actions on the heart. Now it turns out that
likely to be related to the effect on gastric motility and there are also GLP-1 receptors in the heart (28, 33, 283).
emptying, since appetite reduction can be elicited also GLP-1 was also demonstrated to increase cAMP levels in
in fasting subjects (93). It is more likely that interaction adult rat cardiac myocytes (307), but in that study GLP-1
with sensory neurons in the gastrointestinal tract or the decreased contraction amplitude as opposed to isoproter-
hepatoportal bed is involved as discussed above. An- enol, which augmented amplitude and, again unlike iso-
other possibility is that peripherally administered proterenol, GLP-1 did not bring about any intracellular
GLP-1 can access the brain via leaks in the blood-brain calcium transients, but did cause a modest intracellular
barrier such as the subfornical organ and the area acidification. Further evidence for a role for GLP-1 in
postrema, as demonstrated to occur in rats (230). It has cardiac function was derived from studies in mice lacking
also been claimed that regulatory peptides from the the GLP-1 receptor (87). At the age of 2 mo, these animals
periphery can somehow access the arcuate nucleus had reduced resting heart rate and elevated left ventricu-

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THE PHYSIOLOGY OF GLUCAGON-LIKE PEPTIDE 1 1425

lar (LV) end-diastolic pressure, compared with wild-type myocardial oxygen uptake, 6-min walking distance, and
controls. At the age of 5 mo, echocardiography and his- quality of life, and the treatment was well tolerated (269).
tology demonstrated increased LV thickness. In addition, In other studies (216), again involving pacing-induced
there was impaired LV contractility and diastolic function dilated cardiomyopathy in conscious dogs as a model, the
after insulin administration. LV contractility was also re- effects of 48-h infusions of either GLP-1 or its primary
duced after exogenous epinephrine. These data suggest metabolite after DPP-IV degradation [which occurs with a
that GLP-1 exerts physiologically important effects on half-life of 1–2 min in the circulation of pigs and humans
cardiac function. (46, 309)], GLP-1 9 –36 amide, were investigated. The dogs
In a more recent study, Bose et al. (22) demonstrated were studied under basal as well as insulin-stimulated
that GLP-1 significantly reduced infarction size in both conditions (hyperinsulinemic euglycemic clamps). The dogs
in vitro (isolated perfused rat heart) and in vivo models of with dilated cardiomyopathy demonstrated insulin resis-
ischemia-reperfusion damage. The protective effect
tance. Surprisingly, both GLP-1 and GLP-1 9 –36 amide
in vitro was abolished by the GLP-1 receptor antagonist

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significantly and equally reduced LV end diastolic pres-
exendin 9 –39, cAMP inhibitors, as well as phosphatidyl-
sure and increased LV performance and cardiac output.
inositol 3-kinase and mitogen-activated protein kinase in-
Both peptides increased myocardial glucose uptake inde-
hibitors, suggesting involvement of these pathways in the
pendently of insulin. Since during the infusion of GLP-1
protective response. Zhao et al. (342) were also able to
demonstrate direct effects of GLP-1 on myocardial con- 7–36 amide ⬃80% of the peptide is metabolized to GLP-1
tractility and glucose uptake in normal and postischemic 9 –36 amide, these results would suggest that GLP-1 9 –36
isolated rat hearts. They measured LV function, myocar- is the active peptide. In recent animal and human studies
dial glucose uptake, and lactate production under basal (45, 181), the metabolite GLP-1 9 –36 amide was demon-
conditions and after low-flow ischemia with or without strated to lower blood glucose slightly and independently
GLP-1 or buffer or insulin. GLP-1 increased myocardial of insulin and glucagon secretion, which remained unaf-
glucose uptake almost threefold via increased nitric oxide fected by the metabolite. The mechanism of action could
production and GLUT1 translocation, but decreased LV not be revealed, but may be related to the cardiac effects.
pressure. Furthermore, GLP-1 treatment significantly im- The cardiac effect of the metabolite/GLP-1 has potential
proved postischemia LV end-diastolic pressure and LV clinical implication because it would suggest that it would
developed pressure. Thus, in the normal resting heart, not be observed after administration of analogs of GLP-1
GLP-1 reduces contractility. However, it increases glu- that are stabilized against the actions of DPP-IV and there-
cose uptake by mechanisms distinct from insulin, but fore do not lead to the formation of the metabolite (see
improves recovery after ischemia in a fashion similar to below).
that of insulin. In summary, GLP-1 is likely to have physiological
The cardiac effects of GLP-1 were studied in con- effects on the heart. In the basal state, GLP-1 may inhibit
scious dogs with pacing-induced dilated cardiomyopathy, contractility, but after cardiac injury GLP-1 has constantly
which was induced by 28 days of rapid pacing (215). increased myocardial performance both in experimental
The dogs received a 48-h infusion of GLP-1 (1.5 animals and in patients. GLP-1 enhances insulin secretion
pmol䡠kg⫺1 䡠min⫺1, a dose that efficaciously lowers plasma and may enhance myocardial performance via the com-
glucose in diabetic patients but does not cause significant bined effects of enhanced insulin secretion and action
side effects). The GLP-1 infusion was associated with
[insulin therapy has been demonstrated to have beneficial
large improvements in LV performance, stroke volume,
effects of its own on the course of myocardial infarction
and cardiac output as well as significant decreases in LV
in patients with type 2 diabetes (341) ], but also appears to
end-diastolic pressure, heart rate, and, interestingly, sys-
have direct effects that are independent of insulin action.
temic vascular resistance. GLP-1 also increased myocar-
dial insulin sensitivity and glucose uptake. The same The potentially important observation that it may be the
group also reported (217) effects of a 72-h infusion of metabolite of GLP-1 that is the active agent in cardiac
GLP-1 (same dose) added to background therapy in 10 protection requires independent confirmation and raises
patients with acute myocardial infarction (AMI) and LV the question of the nature of the receptor involved, but
ejection fraction ⬍40% after successful primary angio- may be consistent with the finding that GLP-1 9 –36 amide
plasty compared with placebo. Both groups had severe LV appears to lower blood glucose in humans and pigs inde-
dysfunction [LV ejection fraction (LVEF) ⫽ 29 ⫾ 2%]. pendent of insulin and glucagon secretion.
GLP-1 significantly improved LVEF (to 39 ⫾ 2%) and also As discussed above, the GLP-1 receptor is expressed
improved global and local wall motion indices. Most re- in the lungs (158), but the functions of GLP-1 in the lungs
cently, the same group studied the effects of a 5-wk are unclear, although it has been reported to increase the
infusion of GLP-1 added to standard therapy in 12 patients secretion of macromolecules from the neuroendocrine
with heart failure. GLP-1 significantly improved LVEF, cells (252).

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1426 JENS JUUL HOLST

2. Neurotropic and other neural effects the chosen approach has been questioned because insulin
secretion was markedly stimulated in the GLP-1 experi-
GLP-1 may also possess neurotropic effects. Thus
ment, but not in the control experiment. A valid control
intracerebroventricular GLP-1 administration was associ-
experiment might involve infusion of insulin to achieve
ated with improved learning in rats and also displayed
similar levels as those achieved during GLP-1 infusion
neuroprotective effects (55, 238), and GLP-1 has been
(ideally identical intraportal concentrations). In further
proposed as a new therapeutic agent for neurodegenera-
studies, Toft-Nielsen et al. (287) administered GLP-1 to
tive diseases, including Alzheimer’s disease (239). It has
healthy subjects with or without concomitant infusion of
been reported that cerebral GLP-1 receptor stimulation
500 ␮g/h somatostatin. Glucose assimilation was then
increases blood pressure and heart rate and activates
studied by an intravenous glucose tolerance test. It turned
autonomic regulatory neurons in rats, leading to down-
out that even with this (high) dose of somatostatin, insu-
stream activation of cardiovascular responses (335). Fur-
lin (and C-peptide) secretion was still slightly stimulated
thermore, it has been suggested that catecholaminergic
by GLP-1. In agreement with this, the glucose elimination

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neurons in the area postrema expressing the GLP-1 recep-
rate (Kg) was increased by GLP-1. Fortuitously, these
tor may link peripheral GLP-1 and central autonomic
results documented the exquisite sensitivity of the ap-
control sites that mediate the diverse neuroendocrine and
proach. The somatostatin infusion rate was then in-
autonomic actions of peripheral GLP-1 (334). However,
creased to 1,000 ␮g/h, and now insulin secretion remained
peripheral administration of GLP-1 in humans is not as-
constant. In this case, there was no change of Kg during
sociated with changes in blood pressure or heart rate
GLP-1 administration, and it was concluded that GLP-1
(340).
had no direct effect on glucose uptake by the peripheral
tissues (or at least that any effect must be very small).
I. Whole Body Effects, Peripheral Effects, Subsequently, the effects of physiological elevations of
and Effects on Insulin Action GLP-1 or saline infusions on insulin-stimulated glucose
uptake were studied in human volunteers by the euglyce-
After the incretin functions of GLP-1 were estab- mic hyperinsulinemic clamp technique (234). In addition,
lished in humans (157) and the hormone was demon- somatostatin was administered to clamp insulin secretion
strated to be capable of normalizing the elevated plasma at a low level, whereas basal glucagon and growth hor-
glucose levels in patients with type 2 diabetes (210), mone levels were maintained by intravenous infusion.
several studies were carried out to elucidate in more Furthermore, glucose turnover rates were evaluated by a
detail its mechanisms of action. Hvidberg et al. (135) tracer technique. However, there were no differences be-
studied glucose turnover in fasting healthy subjects in tween GLP-1 and saline infusions with respect to any
response to physiological and supraphysiological infu- parameter studied, including glucose infusion rates re-
sions of GLP-1 and found that insulin secretion was en- quired to maintain euglycemia, glucose appearance and
hanced and glucagon secretion inhibited by both. Con- disappearance rates, as well as forearm arteriovenous
comitantly, hepatic glucose production was inhibited, and glucose differences. Vella et al. (304) studied the effects of
therefore, the plasma glucose concentration fell by ⬃1 pharmacological doses of both the GLP-1 receptor agonist
mM. Glucose clearance was also increased, but this was exendin 4 and the native peptide in healthy subjects in
interpreted to be a consequence of the increased insulin three-step hyperinsulinemic clamp experiments. Both
concentrations. The role of the suppression of glucagon peptides increased cortisol secretion, but neither influ-
was studied further in subjects with type 1 diabetes and enced insulin action (304). In further studies, GLP-1 was
no residual beta-cell function (35). In these subjects an infused in supraphysiological amounts to patients with
infusion of GLP-1 significantly lowered fasting glucose type 2 diabetes, and insulin sensitivity was estimated
levels, concurrently with a marked lowering of plasma using clamp techniques (4). However, in these experi-
glucagon concentrations. It was concluded that the glu- ments, there was no effect of GLP-1 on insulin sensitivity
cose-lowering action in this case was due to a decreased either. In further studies, Vella et al. (303) infused phar-
hepatic glucose production resulting from decreased glu- macological (treatment relevant) doses of GLP-1 or saline
cagon secretion. D’Alessio et al. (36) found in a study to subjects with type 2 diabetes while at the same time
involving the minimal model approach (a computerized infusing glucose to mimic postprandial glucose concen-
calculation of insulin sensitivity and insulin-independent, trations and clamping insulin and glucagon levels at basal
glucose-mediated glucose uptake, based on frequent de- or postprandial levels. Under these conditions, GLP-1 had
terminations of insulin and glucose concentrations after no influence on glucose disappearance or suppression of
an intravenous glucose infusion) that GLP-1 was capable endogenous glucose production. On the basis of all these
of increasing glucose-mediated glucose uptake (glucose studies, it seems justified to conclude that GLP-1 has very
effectiveness) in healthy subjects by a mechanism inde- little acute effect on insulin-dependent and -independent
pendent of insulin secretion. However, the relevance of glucose turnover when its effects on the endocrine pan-

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THE PHYSIOLOGY OF GLUCAGON-LIKE PEPTIDE 1 1427

creas are prevented. Zander et al. (340) infused GLP-1 or evidence that the effects were transmitted via receptors
saline continuously for 6 wk to patients with type 2 dia- distinct from the classical GLP-1 receptor (336). Most
betes and determined insulin sensitivity by hyperinsuline- recently, GLP-1 was again reported to enhance glucose
mic euglycemic clamps before and after the treatment. uptake in human myocytes, and evidence for the involved
Insulin sensitivity was unchanged in the saline-treated signaling pathways was provided (80). It should be men-
group, but was almost doubled in the GLP-1-treated tioned that other studies failed to identify actions of
group. The study was not designed to elucidate the un- GLP-1 on glucose metabolism in muscle tissue (72). Some
derlying mechanisms, but it should be noted that GLP-1 of the cited studies suggested that GLP-1 may activate
was administered during the clamp (and actually resulted more than one receptor. As discussed above, a study of
in a slightly higher insulin level) and that the GLP-1- the enterogastrone effects of GLP-1 and PYY in dogs,
treated subjects experienced markedly improved glyce- where the GLP-1 receptor antagonist exendin 9 –39 was
mic control as well as lower free fatty acid levels and also incapable of blocking the inhibitory actions of GLP-1 (71),
lost ⬃2 kg of body weight. The weight loss as well as suggested that another receptor was involved. In other

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reduced gluco- and lipotoxicity induced by GLP-1 were studies, the local paracrine actions of GLP-1 in the canine
considered likely explanations for the improved insulin ileum could not be blocked by exendin 9 –39 (38). The
sensitivity. Similar findings were made in a study involv- effects of intraportal GLP-1 on impulse traffic in vagal
ing 3 mo of continuous subcutaneous infusion of GLP-1 to afferent sensory nerve fibers were also resistant to ex-
diabetic subjects (183). However, the same group re- endin 9 –39 (219). The liver has repeatedly been reported
ported acute augmentation by GLP-1 of insulin-mediated to be a target for GLP-1, although initial careful studies
glucose uptake in elderly patients with diabetes (185) and indicated that hepatocytes did not express GLP-1 recep-
also reported insulin-mimetic effects of GLP-1 in obese tor (17). Thus GLP-1 has been reported to bind to rat
subjects compared with nonobese matched controls (60). hepatic membranes but without influencing adenylate cy-
Nevertheless, the group was unable to identify effects of clase activity, as expected from the classical GLP-1 recep-
GLP-1 on insulin-mediated glucose uptake in patients tor (308). Rather, inositol phosphoglycans were thought
with type 1 diabetes (184). D’Alessio et al. (36), who were to act as mediators (291). The same group also described
the first to suggest extrapancreatic metabolic effects of activation of phosphatidylinositol 3-kinase/protein kinase
GLP-1 in humans, later studied eight healthy subjects B, protein kinase C, and protein phosphatase-1 pathways
using somatostatin clamp and tracer techniques similar to to transmit the actions on glycogen synthase in rat hepa-
those employed by Orskov et al. (234) and reported a 17% tocytes (250). Ikezawa et al. (138) reported inhibition of
decrease in rate of glucose appearance resulting in a glucagon-induced glycogenolysis in isolated perivenous
lower blood glucose and concluded that GLP-1 had ex- rat hepatocytes. Along the same lines, some studies have
trapancreatic metabolic effects, possibly mediated via in- reported effects of exendin 4 that are not shared by
traportal GLP-1 receptors (see below). As already dis- GLP-1. Thus exendin 4, but not GLP-1, was reported to
cussed, it may be difficult to control GLP-1-stimulated enhance insulin sensitivity in 3T3 adipocytes (137). The
insulin secretion with somatostatin, and the significance two peptides were also reported to activate different sig-
of these findings cannot be settled presently. naling pathways in human myotubes (80). Again, it should
However, in contrast to the human studies, several, be noted that these in vitro studies are in sharp contrast
mainly in vitro, studies support that GLP-1 may have to the in vivo studies, particularly in humans, as discussed
effects on peripheral tissues and/or the liver that are above.
independent of its effects on the islet hormones. Thus it
has been reported that membranes from human adipose
VII. GLUCAGON-LIKE PEPTIDE 1
tissue express GLP-1 receptors (186), and similar findings
PATHOPHYSIOLOGY
have been reported for rats (300). GLP-1 was also re-
ported to enhance fatty acid synthesis in explants of rat
Abnormal function of GLP-1 has been implicated in
adipose tissue (223) and was reported to enhance insulin-
three pathological conditions: obesity, postprandial reac-
stimulated glucose uptake in 3T3-L1 adipocytes (61, 321).
tive hypoglycemia, and type 2 diabetes.
Evidence was provided, however, that the responsible
receptor differed from the GLP-1 receptor (192). Never-
theless, in studies involving direct determination of lipol- A. Obesity
ysis rates in human subcutaneous tissue, Bertin et al. (16)
were unable to find any effects of GLP-1. GLP-1 receptors A role for GLP-1 in the development of obesity was
have also been claimed to be present in rat skeletal mus- suggested partly because of the apparently physiological
cle (49), and GLP-1 was reported to stimulate glucose effects of the hormones on appetite and food intake (305),
metabolism in human myocytes (173). Similar observa- and partly because of the reports that GLP-1 secretion
tions were made in studies of L6 myotubes, and there was may be reduced in obesity. Thus, in 1983, it was demon-

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1428 JENS JUUL HOLST

strated that the diurnal L-cell secretion (measured as L-cells is highest, as the likely explanation for exagger-
enteroglucagon secretion) was dramatically decreased in ated GLP-1 responses after bariatric surgery, GLP-1 secre-
morbid obesity (128), and in a subsequent study, again tion is also strongly dependent on gastric emptying rates
in morbidly obese subjects, there was no measurable and hence the rate of exposure of the small intestinal
increase in postprandial GLP-1 secretion (201). However, mucosa to nutrients (187). Therefore, conditions with
after a jejuno-ileal bypass operation, meal responses were accelerated gastric emptying are also associated with ex-
restored to normal values. This should not be interpreted aggerated GLP-1 responses (187). It was, therefore, pro-
to suggest that the weight loss restored L-cell sensitivity posed that exaggerated GLP-1 secretion might be respon-
to meal stimulation, since it is known that abnormal sible for the postprandial reactive hypoglycemia that may
exposure of the distal gut to unabsorbed nutrients as be observed after gastric surgery (gastrectomy) (187) as
occurs after jejuno-ileal bypass as well as gastric bypass well as after gastric bypass operations (264). Indeed, if the
operations results in exaggerated L-cell secretion (129, postprandial glucose and GLP-1 responses observed in
235). However, obese subjects showing decreased post- such patients were reproduced in healthy subjects by

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prandial GLP-1 responses compared with lean controls intravenous infusion, it was possible to create a dramatic
did exhibit improved secretion after weight loss (306). hypoglycemic response, partly due to enhanced insulin
The mechanism whereby obesity lowers GLP-1 secretion secretion and partly due to suppressed glucagon secre-
is not known, but may be related to the insulin resistance tion (286). In gastrectomized subjects with reactive hypo-
that accompanies weight gain (248). It has been suggested glycemia, postprandial glucagon concentrations may be
that particularly the L-cell responsiveness to carbohy- elevated compared with nonoperated controls (6), but
drates is affected (247) and that circulating fatty acids this is probably a consequence of the generalized sympa-
could be responsible (246). However, in a large study in thetic discharge that accompanies the “dumping syn-
both diabetic and nondiabetic subjects, in which body drome” of which the reactive hypoglycemia is part (76). It
mass index again emerged as a significant negative factor has been proposed that the gastric bypass operations in
for meal-induced GLP-1 secretion, free fatty acid levels some cases might result in the development of hyperin-
did not appear to influence the responses upon multiple sulinemic pancreatic nesidioblastosis as a result of the
regression analysis (288). trophic effects of GLP-1 on the beta cells (235, 264).
Together, the data would suggest that the decreased However, in a subsequent reanalysis of the pancreatic
GLP-1 secretion in obesity, which is not a consistent sections on which this hypothesis was based, the exis-
finding (317), develops secondarily to weight gain. How- tence of nesidioblastosis could not be confirmed (179),
ever, in view of the likely role of GLP-1 as a regulator of and the most likely explanation for the hypoglycemic
appetite and food intake, it remains possible that the attacks is probably exaggerated GLP-1-stimulated insulin
decreased secretion results in inadequate postprandial secretion in combination with alleviation of insulin resis-
satiation and therefore contributes to the positive energy tance after weight loss and lack of downregulation of
balance of developing obesity. Further support for an functional beta cell mass [which may have been increased
important role of GLP-1 (and PYY) in the regulation of because of obesity (32)] after weight loss.
appetite and food intake comes from studies of GLP-1 The effects of GLP-1 on appetite and food intake
secretion after bariatric surgery. As a rule, the weight loss show up very strongly in clinical studies involving native
after surgery does not involve malabsorption, and al- GLP-1, GLP-1 analogs, or GLP-1 receptor activators like
though the reduced gastric capacity undoubtedly contrib- exendin. Although nearly all studies so far have been
utes, the secretion of GLP-1 (and PYY) is greatly elevated, aimed at treating type 2 diabetes, an important and con-
particularly after bypass operations, and is believed to stant finding has been a continued and sustained weight
result in reduced appetite and food intake and hence loss both in short-term and chronic studies (19, 108, 148,
weight loss (165, 194, 235). It is of interest that the oper- 340). This obviously has important clinical implications.
ations also cause a dramatic improvement in glucose
tolerance that occurs very early postoperatively, before a
major weight loss has been achieved (88). Again, it is C. Diabetes
thought that the exaggerated GLP-1 secretion may be
responsible, via its effects on insulin and glucagon secre- The main clinical interest in GLP-1 focuses on its role
tion. in the development and treatment of type 2 diabetes. Type
2 diabetes is characterized by a severely reduced or ab-
sent incretin effect (203), and this undoubtedly contrib-
B. Reactive Hypoglycemia utes to the inappropriate insulin secretion that character-
izes the disease. It is now clear that the incretin defect is
In agreement with increased exposure to nutrients of due to an almost complete loss of the insulinotropic effect
the distal small intestinal mucosa, where the density of of GIP (206, 314), whereas the secretion of GIP is normal

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THE PHYSIOLOGY OF GLUCAGON-LIKE PEPTIDE 1 1429

or near normal (288). Regarding GLP-1, a significant and believed that several of the many actions of GLP-1 are
sometimes substantial reduction in meal-induced GLP-1 involved in its antidiabetic effects (115). One important
secretion is found whether this is measured as the con- mechanism is of course the restoration of glucose-induced
centrations of the intact hormone or the metabolite GLP-1 insulin secretion. Generally, peripheral insulin levels do not
9 –36 amide (see above) (288, 312). In contrast to GIP, the increase during chronic GLP-1 treatment, but these levels
insulinotropic effect of GLP-1 is retained in patients with are maintained in spite of the concomitant reductions of
type 2 diabetes (206), and it is possible with infusions of plasma glucose by up to 5– 6 mM (340). Upon intravenous
GLP-1 to completely normalize glucose-induced insulin infusion of GLP-1 to fasting type 2 diabetic subjects, insulin
secretion in the patients as analyzed in hyperglycemic secretion first rises, but then, as plasma glucose concentra-
clamp experiments (150, 314). However, from dose-re- tions are lowered, decreases again to baseline levels (210).
sponse studies it appears that the potency of GLP-1 with The numerous molecular actions of GLP-1 on the beta cell
respect to enhancing glucose-induced insulin secretion is have been discussed above. Another important factor is the
greatly reduced (to ⬃20%) in the patients compared with inhibition of glucagon secretion. Again, during intravenous

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healthy controls (150). Thus both defects in the secretion infusion of GLP-1 to fasting type 2 diabetic subjects, gluca-
and actions of the incretin hormones are responsible for gon secretion is suppressed as long as plasma glucose is still
the reduced incretin effect and hence the inadequate in- elevated, but as glucose concentrations approach normal
sulin secretion seen in the patients. The question then values, glucagon secretion again rises to baseline levels
arises whether these defects are primary or secondary in (210). In chronic studies, mean glucagon levels may be
relation to diabetes, but the evidence to date suggests that significantly lowered or remain at baseline levels, but this
the abnormalities are secondary to the development of again occurs in the face of much lower plasma glucose
diabetes and/or insulin resistance. Thus the secretion of concentrations which, all others being equal, would have
both GIP and GLP-1 is normal in glucose-tolerant first-de- resulted in higher levels of glucagon (340). As already al-
gree relatives of individuals with type 2 diabetes (222). Sim- luded to, the importance of the inhibition of glucagon secre-
ilarly, incretin secretion was normal in women with previous tion for the antidiabetic actions of GLP-1 showed up clearly
gestational diabetes who are at particularly high risk for in a study in patients with type 1 diabetes and no residual
developing type 2 diabetes (180). In a study in identical beta-cell function. In these patients GLP-1 infusion still low-
twins, discordant for type 2 diabetes (at the time of investi- ered plasma glucose in parallel with a rather strong reduc-
gation), only the diabetic twin had decreased GLP-1 secre- tion in glucagon levels (35).
tion (299). And finally, in patients with diabetes secondary to The inhibition of gastric emptying also plays an im-
chronic pancreatitis, a similar incretin deficiency develops portant role as this greatly reduces postprandial glucose
early in the development of diabetes, and reduced effects of excursions (332). This effect, which in healthy subjects
the incretin hormones are also similar to those observed in shows rapid tachyphylaxis (181a), is retained also in
the classical obese type 2 diabetic patients (311). In a de- chronic studies involving short-acting GLP-1 receptor
tailed study of 55 patients with type 2 diabetes as well as in agonists (exendin 4) (147).
individuals with impaired or normal glucose tolerance, meal- The clinical results with GLP-1 receptor activators,
induced GLP-1 secretion was negatively associated with now often designated incretin mimetics, are promising
body mass index as discussed above, but also with the and suggest that one can expect lasting improvement of
presence or absence of diabetes (lower responses in dia- glycemic control as evidenced by much improved levels
betic subjects), whereas factors such as the presence or of glycated hemoglobin (HbA1c) (19). Synthetic exendin 4
absence of neuropathy and concentrations of free fatty acids (exenatide) was approved for diabetes treatment in 2005
in plasma did not seem to play a role (288). As already and is commercially available under the trade name
mentioned, it is possible that insulin sensitivity is of impor- Byetta (www.byetta.com). Exendin 4 was isolated from
tance (248). The molecular mechanisms underlying the re- the venom of the lizard, Heloderma suspectum, in a sys-
duced beta-cell sensitivity to GLP-1 and the nearly lost sen- tematic search for biologically active peptides (64) and is,
sitivity to GIP are currently unknown. However, the fact that as discussed above, a full agonist for the GLP-1 receptor
insulin secretion can be restored to normal levels by admin- which is equipotent with GLP-1 (284). Unlike GLP-1, it is
istration of GLP-1 (in other words, that the beta-cell respon- not degraded by DPP-IV and is cleared in the kidneys only
siveness to glucose is normalized) is clearly of considerable by glomerular filtration (266), whereby the molecule ob-
clinical interest and provides part of the background for the tains a half-life of ⬃30 min (58). After subcutaneous in-
clinical use of GLP-1 receptor agonists in diabetes treatment. jection of the maximally tolerated dose, a significant ele-
Intravenous administration of slightly supraphysiological vation of its plasma concentration may be observed for
amounts of GLP-1 can completely normalize fasting glucose 5 h (156). Because of its stability relative to GLP-1, ex-
concentrations in type 2 diabetic patients regardless of the endin 4 has been very useful as a tool for elucidating the
severity and duration of disease (207, 289) and may nearly actions of GLP-1 particularly in rodents, where the sur-
normalize also postprandial glucose responses (245). It is vival of GLP-1 is so brief that it is difficult to detect any

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1430 JENS JUUL HOLST

effects of the peptide at all. GLP-1 analogs still under Univ. of Copenhagen, DK-2200 Copenhagen, Denmark (e-mail:
clinical development include Liraglutide, which consists holst@mfi.ku.dk).
of the GLP-1 molecule to which is attached a C-16 acyl
chain (via a glutamic acid linker) to Lys-26 (while Lys-33
REFERENCES
is substituted by Arg to prevent acylation here) (152).
Thereby, the molecule binds to albumin and acquires 1. Ahren B. Sensory nerves contribute to insulin secretion by gluca-
some of the pharmacokinetics of this molecule. The renal gon-like peptide-1 in mice. Am J Physiol Regul Integr Comp
Physiol 286: R269 –R272, 2004.
elimination is prevented for the bound molecule, and its 2. Ahren B, Gomis R, Standl E, Mills D, Schweizer A. Twelve- and
half-life after subcutaneous injections is ⬃12 h. Clinically, 52-week efficacy of the dipeptidyl peptidase IV inhibitor LAF237 in
the molecule has similar actions as continuously infused metformin-treated patients with type 2 diabetes. Diabetes Care 27:
2874 –2880, 2004.
GLP-1 (48) and appears to have a similar clinical potential 3. Ahren B, Holst JJ. The cephalic insulin response to meal inges-
as exendin 4 (318). tion in humans is dependent on both cholinergic and noncholin-
The antidiabetic effects of GLP-1 can also be ex- ergic mechanisms and is important for postprandial glycemia.

Downloaded from http://physrev.physiology.org/ by 10.220.33.4 on November 24, 2017


Diabetes 50: 1030 –1038, 2001.
ploited by protecting endogenous GLP-1 from degrada- 4. Ahren B, Larsson H, Holst JJ. Effects of glucagon-like peptide-1
tion by the enzyme DPP-IV (122). Administration of inhib- on islet function and insulin sensitivity in noninsulin-dependent
itors of this enzyme increases the circulating levels of diabetes mellitus. J Clin Endocrinol Metab 82: 473– 478, 1997.
5. Alvarez E, Martinez MD, Roncero I, Chowen JA, Garcia-
both active GLP-1 and GIP, and this is associated with the Cuartero B, Gispert JD, Sanz C, Vazquez P, Maldonado A, de
expected antidiabetic effects (43). The inhibitors are CJ, Desco M, Pozo MA, Blazquez E. The expression of GLP-1
small molecules that are active upon oral administration, receptor mRNA and protein allows the effect of GLP-1 on glucose
metabolism in the human hypothalamus and brainstem. J Neuro-
and they appear to have chronic antidiabetic effects that chem 92: 798 – 806, 2005.
are very similar to those obtained with the incretin mi- 6. Andreasen JJ, Orskov C, Holst JJ. Secretion of glucagon-like
peptide-1 and reactive hypoglycemia after partial gastrectomy.
metics, which all require parenteral administration (2). Digestion 55: 221–228, 1994.
However, the inhibitors have little effects on body weight, 7. Anini Y, Brubaker PL. Muscarinic receptors control glucagon-like
presumably because the plasma concentrations of active peptide 1 secretion by human endocrine L cells. Endocrinology
144: 3244 –3250, 2003.
GLP-1 are not elevated sufficiently to exert this effect 8. Baggio L, Kieffer TJ, Drucker DJ. Glucagon-like peptide-1, but
(42). One explanation for this appears to be a negative- not glucose-dependent insulinotropic peptide, regulates fasting gly-
feedback inhibition of L-cell secretion by the elevated cemia and nonenteral glucose clearance in mice. Endocrinology
141: 3703–3709, 2000.
levels of active GLP-1 brought about by DPP-IV inhibition 9. Baldissera FG, Holst JJ. Glucagon-related peptides in the human
(47), an effect which may be mediated by a paracrine gastrointestinal mucosa. Diabetologia 26: 223–228, 1984.
action of somatostatin secreted from neighboring D-cells 10. Baldissera FG, Holst JJ. Glicentin 1– 61 probably represents a
major fraction of glucagon-related peptides in plasma of anaesthe-
in the gut (97, 98). Because of the negative-feedback tized uraemic pigs. Diabetologia 29: 462– 467, 1986.
inhibition, the concentrations of active GLP-1 only rise by 11. Balkan B, Li X. Portal GLP-1 administration in rats augments the
a factor of two to three, where one would have expected insulin response to glucose via neuronal mechanisms. Am J
Physiol Regul Integr Comp Physiol 279: R1449 –R1454, 2000.
an up to fivefold increase if L-cell secretion had been 12. Balks HJ, Holst JJ, von zur M, Brabant G. Rapid oscillations in
unaltered (122). Elegant experiments in mice with dele- plasma glucagon-like peptide-1 (GLP-1) in humans: cholinergic
tions of the genes for the two incretin hormone receptors control of GLP-1 secretion via muscarinic receptors. J Clin Endo-
crinol Metab 82: 786 –790, 1997.
have shown that whereas DPP-IV inhibitors effectively 13. Bataille D, Tatemoto K, Gespach C, Jornvall H, Rosselin G,
lowered blood glucose and stimulated insulin secretion in Mutt V. Isolation of glucagon-37 (bioactive enteroglucagon/oxyn-
animals with a single deletion, they had no effect in mice tomodulin) from porcine jejuno-ileum. Characterization of the pep-
tide. FEBS Lett 146: 79 – 86, 1982.
in which both receptor genes were deleted (102). Thus 14. Bell GI, Sanchez-Pescador R, Laybourn PJ, Najarian RC. Exon
their effect in nondiabetic mice can be ascribed to en- duplication and divergence in the human preproglucagon gene.
Nature 304: 368 –371, 1983.
hancement of the actions of both incretin hormones, 15. Bell GI, Santerre RF, Mullenbach GT. Hamster preproglucagon
while mechanisms beyond protection of these hormones contains the sequence of glucagon and two related peptides.
do not appear to play a role. Several specific inhibitors are Nature 302: 716 –718, 1983.
16. Bertin E, Arner P, Bolinder J, Hagstrom-Toft E. Action of
currently undergoing clinical development, and for two glucagon and glucagon-like peptide-1- (7–36) amide on lipolysis in
inhibitors [Januvia (www.Merck.com) and Galvus human subcutaneous adipose tissue and skeletal muscle in vivo.
(www.novartis.com)], applications for registration as new J Clin Endocrinol Metab 86: 1229 –1234, 2001.
17. Blackmore PF, Mojsov S, Exton JH, Habener JF. Absence of
drugs were filed with the American Food and Drug Ad- insulinotropic glucagon-like peptide-I (7–37) receptors on isolated
ministration in 2006, and Januvia was approved in Mexico rat liver hepatocytes. FEBS Lett 283: 7–10, 1991.
and the United States in the fall of 2006. 18. Blat S, Guerin S, Chauvin A, Seve B, Morgan L, Cuber JC,
Malbert CH. The vagus is inhibitory of the late postprandial
insulin secretion in conscious pigs. Auton Neurosci 101: 68 –77,
ACKNOWLEDGMENTS 2002.
19. Blonde L, Klein EJ, Han J, Zhang B, Mac SM, Poon TH, Taylor
Address for reprint requests and other correspondence: KL, Trautmann ME, Kim DD, Kendall DM. Interim analysis of
J. J. Holst, Dept. of Medical Physiology, The Panum Institute, the effects of exenatide treatment on A1C, weight and cardiovas-

Physiol Rev • VOL 87 • OCTOBER 2007 • www.prv.org


THE PHYSIOLOGY OF GLUCAGON-LIKE PEPTIDE 1 1431

cular risk factors over 82 weeks in 314 overweight patients with 41. De Heer J, Hoy M, Holst JJ. GLP-1, but not GIP, inhibits gluca-
type 2 diabetes. Diabetes Obes Metab 8: 436 – 447, 2006. gon secretion via somatostatin in the perfused rat pancreas (Ab-
20. Bock T, Pakkenberg B, Buschard K. The endocrine pancreas in stract). Diabetologia 48 Suppl 1: A64, 2005.
non-diabetic rats after short-term and long-term treatment with the 42. Deacon CF. MK431 (Merck). Curr Opin Invest Drugs 6: 419 – 426,
long-acting GLP-1 derivative NN2211. APMIS 111: 1117–1124, 2003. 2005.
21. Bonner-Weir S. Beta-cell turnover: its assessment and implica- 43. Deacon CF, Holst JJ. Dipeptidyl peptidase IV inhibitors: a prom-
tions. Diabetes 50 Suppl 1: S20 –S24, 2001. ising new therapeutic approach for the management of type 2
22. Bose AK, Mocanu MM, Carr RD, Brand CL, Yellon DM. Gluca- diabetes. Int J Biochem Cell Biol 38: 831– 844, 2006.
gon-like peptide 1 can directly protect the heart against ischemia/ 44. Deacon CF, Johnsen AH, Holst JJ. Degradation of glucagon-like
reperfusion injury. Diabetes 54: 146 –151, 2005. peptide-1 by human plasma in vitro yields an N-terminally trun-
23. Bottcher G, Alumets J, Hakanson R, Sundler F. Co-existence of cated peptide that is a major endogenous metabolite in vivo. J Clin
glicentin and peptide YY in colorectal L-cells in cat and man. An Endocrinol Metab 80: 952–957, 1995.
electron microscopic study. Regul Pept 13: 283–291, 1986. 45. Deacon CF, Plamboeck A, Moller S, Holst JJ. GLP-1- (9 –36)
24. Brubaker PL, Drucker DJ. Minireview: glucagon-like peptides amide reduces blood glucose in anesthetized pigs by a mechanism
regulate cell proliferation and apoptosis in the pancreas, gut, cen- that does not involve insulin secretion. Am J Physiol Endocrinol
tral nervous system. Endocrinology 145: 2653–2659, 2004. Metab 282: E873–E879, 2002.
25. Bryant MG, Bloom SR, Polak JM, Hobbs S, Domschke W, 46. Deacon CF, Pridal L, Klarskov L, Olesen M, Holst JJ. Gluca-

Downloaded from http://physrev.physiology.org/ by 10.220.33.4 on November 24, 2017


Domschke S, Mitznegg P, Ruppin H, Demling L. Measurement gon-like peptide 1 undergoes differential tissue-specific metabo-
of gut hormonal peptides in biopsies from human stomach and lism in the anesthetized pig. Am J Physiol Endocrinol Metab 271:
proximal small intestine. Gut 24: 114 –119, 1983. E458 –E464, 1996.
26. Buffa R, Capella C, Fontana P, Usellini L, Solcia E. Types of 47. Deacon CF, Wamberg S, Bie P, Hughes TE, Holst JJ. Preser-
endocrine cells in the human colon and rectum. Cell Tissue Res vation of active incretin hormones by inhibition of dipeptidyl pep-
192: 227–240, 1978. tidase IV suppresses meal-induced incretin secretion in dogs. J
27. Buhl T, Thim L, Kofod H, Orskov C, Harling H, Holst JJ. Endocrinol 172: 355–362, 2002.
Naturally occurring products of proglucagon 111–160 in the por- 48. Degn KB, Juhl CB, Sturis J, Jakobsen G, Brock B, Chan-
cine and human small intestine. J Biol Chem 263: 8621– 8624, 1988. dramouli V, Rungby J, Landau BR, Schmitz O. One week’s
28. Bullock BP, Heller RS, Habener JF. Tissue distribution of mes- treatment with the long-acting glucagon-like peptide 1 derivative
senger ribonucleic acid encoding the rat glucagon-like peptide-1 liraglutide (NN2211) markedly improves 24-h glycemia and alpha-
receptor. Endocrinology 137: 2968 –2978, 1996. and beta-cell function and reduces endogenous glucose release in
29. Burcelin R, Da Costa A, Drucker D, Thorens B. Glucose com- patients with type 2 diabetes. Diabetes 53: 1187–1194, 2004.
petence of the hepatoportal vein sensor requires the presence of an 49. Delgado E, Luque MA, Alcantara A, Trapote MA, Clemente F,
activated glucagon-like peptide-1 receptor. Diabetes 50: 1720 –1728, Galera C, Valverde I, Villanueva Penacarrillo ML. Glucagon-
2001.
like peptide-1 binding to rat skeletal muscle. Peptides 16: 225–229,
30. Buteau J, El-Assaad W, Rhodes CJ, Rosenberg L, Joly E,
1995.
Prentki M. Glucagon-like peptide-1 prevents beta cell glucolipo-
50. Ding WG, Renstrom E, Rorsman P, Buschard K, Gromada J.
toxicity. Diabetologia 47: 806 – 815, 2004.
Glucagon-like peptide I and glucose-dependent insulinotropic
31. Buteau J, Roduit R, Susini S, Prentki M. Glucagon-like pep-
polypeptide stimulate Ca2⫹-induced secretion in rat alpha-cells by
tide-1 promotes DNA synthesis, activates phosphatidylinositol 3-ki-
a protein kinase A-mediated mechanism. Diabetes 46: 792– 800,
nase and increases transcription factor pancreatic and duodenal
1997.
homeobox gene 1 (PDX-1) DNA binding activity in beta (INS-1)-
51. Drucker DJ. The biology of incretin hormones. Cell Metab 3:
cells. Diabetologia 42: 856 – 864, 1999.
32. Butler AE, Janson J, Bonner-Weir S, Ritzel R, Rizza RA, 153–165, 2006.
Butler PC. Beta-cell deficit and increased beta-cell apoptosis in 52. Drucker DJ, Asa S. Glucagon gene expression in vertebrate brain.
humans with type 2 diabetes. Diabetes 52: 102–110, 2003. J Biol Chem 263: 13475–13478, 1988.
33. Campos RV, Lee YC, Drucker DJ. Divergent tissue-specific and 53. Drucker DJ, Jin T, Asa SL, Young TA, Brubaker PL. Activation
developmental expression of receptors for glucagon and glucagon- of proglucagon gene transcription by protein kinase-A in a novel
like peptide-1 in the mouse. Endocrinology 134: 2156 –2164, 1994. mouse enteroendocrine cell line. Mol Endocrinol 8: 1646 –1655,
34. Chelikani PK, Haver AC, Reidelberger RD. Ghrelin attenuates 1994.
the inhibitory effects of glucagon-like peptide-1 and peptide YY 54. Dumoulin V, Dakka T, Plaisancie P, Chayvialle JA, Cuber JC.
(3–36) on food intake and gastric emptying in rats. Diabetes 55: Regulation of glucagon-like peptide-1- (7–36) amide, peptide YY,
3038 –3046, 2006. neurotensin secretion by neurotransmitters and gut hormones in
35. Creutzfeldt WO, Kleine N, Willms B, Orskov C, Holst JJ, the isolated vascularly perfused rat ileum. Endocrinology 136:
Nauck MA. Glucagonostatic actions and reduction of fasting hy- 5182–5188, 1995.
perglycemia by exogenous glucagon-like peptide I (7–36) amide in 55. During MJ, Cao L, Zuzga DS, Francis JS, Fitzsimons HL, Jiao
type I diabetic patients. Diabetes Care 19: 580 –586, 1996. X, Bland RJ, Klugmann M, Banks WA, Drucker DJ, Haile CN.
36. D’Alessio DA, Kahn SE, Leusner CR, Ensinck JW. Glucagon- Glucagon-like peptide-1 receptor is involved in learning and neu-
like peptide 1 enhances glucose tolerance both by stimulation of roprotection. Nat Med 9: 1173–1179, 2003.
insulin release and by increasing insulin-independent glucose dis- 56. Dyachok O, Isakov Y, Sagetorp J, Tengholm A. Oscillations of
posal. J Clin Invest 93: 2263–2266, 1994. cyclic AMP in hormone-stimulated insulin-secreting beta-cells.
37. Dakin CL, Gunn I, Small CJ, Edwards CM, Hay DL, Smith DM, Nature 439: 349–352, 2006.
Ghatei MA, Bloom SR. Oxyntomodulin inhibits food intake in the 57. Edvell A, Lindstrom P. Initiation of increased pancreatic islet
rat. Endocrinology 142: 4244 – 4250, 2001. growth in young normoglycemic mice (Umea ⫹/?). Endocrinology
38. Daniel EE, Anvari M, Fox-Threlkeld JE, McDonald TJ. Local, 140: 778 –783, 1999.
exendin- (9 –39)-insensitive, site of action of GLP-1 in canine ileum. 58. Edwards CM, Stanley SA, Davis R, Brynes AE, Frost GS, Seal
Am J Physiol Gastrointest Liver Physiol 283: G595–G602, 2002. LJ, Ghatei MA, Bloom SR. Exendin-4 reduces fasting and post-
39. Dardevet D, Moore MC, Neal D, DiCostanzo CA, Snead W, prandial glucose and decreases energy intake in healthy volunteers.
Cherrington AD. Insulin-independent effects of GLP-1 on canine Am J Physiol Endocrinol Metab 281: E155–E161, 2001.
liver glucose metabolism: duration of infusion and involvement of 59. Egan JM, Bulotta A, Hui H, Perfetti R. GLP-1 receptor agonists
hepatoportal region. Am J Physiol Endocrinol Metab 287: E75– are growth and differentiation factors for pancreatic islet beta
E81, 2004. cells. Diabetes Metab Res Rev 19: 115–123, 2003.
40. De Heer J, Holst JJ. Sulfonylurea compounds uncouple the glu- 60. Egan JM, Meneilly GS, Habener JF, Elahi D. Glucagon-like
cose dependence of the insulinotropic effect of glucagon-like pep- peptide-1 augments insulin-mediated glucose uptake in the obese
tide 1. Diabetes. In press. state. J Clin Endocrinol Metab 87: 3768 –3773, 2002.

Physiol Rev • VOL 87 • OCTOBER 2007 • www.prv.org


1432 JENS JUUL HOLST

61. Egan JM, Montrose Rafizadeh C, Wang Y, Bernier M, Roth J. 78. Goke R, Fehmann HC, Linn T, Schmidt H, Krause M, Eng J,
Glucagon-like peptide-1 (7–36) amide (GLP-1) enhances insulin- Goke B. Exendin-4 is a high potency agonist and truncated ex-
stimulated glucose metabolism in 3T3-L1 adipocytes: one of several endin- (9 –39)-amide an antagonist at the glucagon-like peptide
potential extrapancreatic sites of GLP-1 action. Endocrinology 135: 1- (7–36)-amide receptor of insulin-secreting beta-cells. J Biol
2070 –2075, 1994. Chem 268: 19650 –19655, 1993.
62. Eissele R, Goke R, Willemer S, Harthus HP, Vermeer H, 79. Goke R, Larsen PJ, Mikkelsen JD, Sheikh SP. Distribution of
Arnold R, Goke B. Glucagon-like peptide-1 cells in the gastroin- GLP-1 binding sites in the rat brain: evidence that exendin-4 is a
testinal tract and pancreas of rat, pig and man. Eur J Clin Invest ligand of brain GLP-1 binding sites. Eur J Neurosci 7: 2294 –2300,
22: 283–291, 1992. 1995.
63. Elliott RM, Morgan LM, Tredger JA, Deacon S, Wright J, 80. Gonzalez N, Acitores A, Sancho V, Valverde I, Villanueva-
Marks V. Glucagon-like peptide-1 (7–36) amide and glucose-depen- Penacarrillo ML. Effect of GLP-1 on glucose transport and its cell
dent insulinotropic polypeptide secretion in response to nutrient signalling in human myocytes. Regul Pept 126: 203–211, 2005.
ingestion in man: acute post-prandial and 24-h secretion patterns. J 81. Grant SF, Thorleifsson G, Reynisdottir I, Benediktsson R,
Endocrinol 138: 159 –166, 1993. Manolescu A, Sainz J, Helgason A, Stefansson H, Emilsson V,
64. Eng J, Kleinman WA, Singh L, Singh G, Raufman JP. Isolation Helgadottir A, Styrkarsdottir U, Magnusson KP, Walters GB,
and characterization of exendin-4, an exendin-3 analogue, from Palsdottir E, Jonsdottir T, Gudmundsdottir T, Gylfason A,
Heloderma suspectum venom. Further evidence for an exendin Saemundsdottir J, Wilensky RL, Reilly MP, Rader DJ, Bagger

Downloaded from http://physrev.physiology.org/ by 10.220.33.4 on November 24, 2017


receptor on dispersed acini from guinea pig pancreas. J Biol Chem Y, Christiansen C, Gudnason V, Sigurdsson G, Thorsteinsdot-
267: 7402–7405, 1992. tir U, Gulcher JR, Kong A, Stefansson K. Variant of transcrip-
65. Farilla L, Bulotta A, Hirshberg B, Li CS, Khoury N, Noush- tion factor 7-like 2 (TCF7L2) gene confers risk of type 2 diabetes.
mehr H, Bertolotto C, Di MU, Harlan DM, Perfetti R. Gluca- Nat Genet 38: 320 –323, 2006.
gon-like peptide 1 inhibits cell apoptosis and improves glucose 82. Gribble FM, Williams L, Simpson AK, Reimann F. A novel
responsiveness of freshly isolated human islets. Endocrinology glucose-sensing mechanism contributing to glucagon-like peptide-1
144: 5149 –5158, 2003. secretion from the GLUTag cell line. Diabetes 52: 1147–1154, 2003.
66. Farilla L, Hui H, Bertolotto C, Kang E, Bulotta A, Di MU, 83. Grimelius L, Capella C, Buffa R, Polak JM, Pearse AG, Solcia
Perfetti R. Glucagon-like peptide-1 promotes islet cell growth and E. Cytochemical and ultrastructural differentiation of enterogluca-
inhibits apoptosis in Zucker diabetic rats. Endocrinology 143: gon and pancreatic-type glucagon cells of the gastrointestinal tract.
4397– 4408, 2002. Virchows Arch B Cell Pathol 20: 217–228, 1976.
67. Fehmann HC, Goke R, Goke B. Cell and molecular biology of the 84. Groger G, Unger A, Holst JJ, Goebell H, Layer P. Ileal carbo-
incretin hormones glucagon-like peptide-I and glucose-dependent hydrates inhibit cholinergically stimulated exocrine pancreatic se-
insulin releasing polypeptide. Endocr Rev 16: 390 – 410, 1995. cretion in humans. Int J Pancreatol 22: 23–29, 1997.
68. Fieseler P, Bridenbaugh S, Nustede R, Martell J, Orskov C, 85. Gromada J, Bokvist K, Ding WG, Holst JJ, Nielsen JH, Rors-
man P. Glucagon-like peptide 1 (7–36) amide stimulates exocytosis
Holst JJ, Nauck MA. Physiological augmentation of amino acid-
in human pancreatic beta-cells by both proximal and distal regula-
induced insulin secretion by GIP and GLP-I but not by CCK-8. Am J
tory steps in stimulus-secretion coupling. Diabetes 47: 57– 65, 1998.
Physiol Endocrinol Metab 268: E949 –E955, 1995.
86. Gromada J, Holst JJ, Rorsman P. Cellular regulation of islet
69. Flamez D, Van Breusegem A, Scrocchi LA, Quartier E, Pipe-
hormone secretion by the incretin hormone glucagon-like peptide
leers D, Drucker DJ, Schuit F. Mouse pancreatic beta-cells ex-
1. Pflügers Arch 435: 583–594, 1998.
hibit preserved glucose competence after disruption of the gluca-
87. Gros R, You X, Baggio LL, Kabir MG, Sadi AM, Mungrue IN,
gon-like peptide-1 receptor gene. Diabetes 47: 646 – 652, 1998.
Parker TG, Huang Q, Drucker DJ, Husain M. Cardiac function
70. Flint A, Raben A, Astrup A, Holst JJ. Glucagon-like peptide 1
in mice lacking the glucagon-like peptide-1 receptor. Endocrinology
promotes satiety and suppresses energy intake in humans. J Clin
144: 2242–2252, 2003.
Invest 101: 515–520, 1998. 88. Guidone C, Manco M, Valera-Mora E, Iaconelli A, Gniuli D,
71. Fung LC, Chisholm C, Greenberg GR. Glucagon-like peptide-1- Mari A, Nanni G, Castagneto M, Calvani M, Mingrone G.
(7–36) amide and peptide YY mediate intraduodenal fat-induced Mechanisms of recovery from type 2 diabetes after malabsorptive
inhibition of acid secretion in dogs. Endocrinology 139: 189 –194, bariatric surgery. Diabetes 55: 2025–2031, 2006.
1998. 89. Gutniak MK, Juntti-Berggren L, Hellstrom PM, Guenifi A,
72. Furnsinn C, Ebner K, Waldhausl W. Failure of GLP-1 (7–36) Holst JJ, Efendic S. Glucagon-like peptide I enhances the insuli-
amide to affect glycogenesis in rat skeletal muscle. Diabetologia notropic effect of glibenclamide in NIDDM patients and in the
38: 864 – 867, 1995. perfused rat pancreas. Diabetes Care 19: 857– 863, 1996.
73. Furuta M, Yano H, Zhou A, Rouille Y, Holst JJ, Carroll R, 90. Gutniak MK, Larsson H, Sanders SW, Juneskans O, Holst JJ,
Ravazzola M, Orci L, Furuta H, Steiner DF. Defective prohor- Ahren B. GLP-1 tablet in type 2 diabetes in fasting and postpran-
mone processing and altered pancreatic islet morphology in mice dial conditions. Diabetes Care 20: 1874 –1879, 1997.
lacking active SPC2. Proc Natl Acad Sci USA 94: 6646 – 6651, 1997. 91. Gutzwiller JP, Drewe J, Goke B, Schmidt H, Rohrer B,
74. Gameiro A, Reimann F, Habib AM, O’Malley D, Williams L, Lareida J, Beglinger C. Glucagon-like peptide-1 promotes satiety
Simpson AK, Gribble FM. The neurotransmitters glycine and and reduces food intake in patients with diabetes mellitus type 2.
GABA stimulate glucagon-like peptide-1 release from the GLUTag Am J Physiol Regul Integr Comp Physiol 276: R1541–R1544, 1999.
cell line. J Physiol 569: 761–772, 2005. 92. Gutzwiller JP, Hruz P, Huber AR, Hamel C, Zehnder C, Drewe
75. Gault VA, O’Harte FP, Harriott P, Mooney MH, Green BD, J, Gutmann H, Stanga Z, Vogel D, Beglinger C. Glucagon-like
Flatt PR. Effects of the novel (Pro3)GIP antagonist and exendin peptide-1 is involved in sodium and water homeostasis in humans.
(9 –39) amide on GIP- and GLP-1-induced cyclic AMP generation, Digestion 73: 142–150, 2006.
insulin secretion and postprandial insulin release in obese diabetic 93. Gutzwiller JP, Goke B, Drewe J, Hildebrand P, Ketterer S,
(ob/ob) mice: evidence that GIP is the major physiological incretin. Handschin D, Winterhalder R, Conen D, Beglinger C. Gluca-
Diabetologia 46: 222–230, 2003. gon-like peptide-1: a potent regulator of food intake in humans. Gut
76. Gebhard B, Holst JJ, Biegelmayer C, Miholic J. Postprandial 44: 81– 86, 1999.
GLP-1, norepinephrine, reactive hypoglycemia in dumping syn- 94. Gutzwiller JP, Tschopp S, Bock A, Zehnder CE, Huber AR,
drome. Dig Dis Sci 46: 1915–1923, 2001. Kreyenbuehl M, Gutmann H, Drewe J, Henzen C, Goeke B,
77. Gelling RW, Du XQ, Dichmann DS, Romer J, Huang H, Cui L, Beglinger C. Glucagon-like peptide 1 induces natriuresis in
Obici S, Tang B, Holst JJ, Fledelius C, Johansen PB, Rossetti healthy subjects and in insulin-resistant obese men. J Clin Endo-
L, Jelicks LA, Serup P, Nishimura E, Charron MJ. Lower blood crinol Metab 89: 3055–3061, 2004.
glucose, hyperglucagonemia, pancreatic alpha cell hyperplasia in 95. Hansen L. Proksimal styring af den distale tarms hormonsekre-
glucagon receptor knockout mice. Proc Natl Acad Sci USA 100: tion: en duodenoileal loop (Dissertation). Copenhagen: Univ. of
1438 –1443, 2003. Copenhagen, 1999.

Physiol Rev • VOL 87 • OCTOBER 2007 • www.prv.org


THE PHYSIOLOGY OF GLUCAGON-LIKE PEPTIDE 1 1433

96. Hansen L, Deacon CF, Orskov C, Holst JJ. Glucagon-like pep- 120. Holst JJ, Aggestrup S, Loud FB, Olesen M. Content and gel
tide-1- (7–36)amide is transformed to glucagon-like peptide-1- (9 – filtration profiles of glucagon-like and somatostatin-like immuno-
36)amide by dipeptidyl peptidase IV in the capillaries supplying the reactivity in human fundic mucosa. J Clin Endocrinol Metab 56:
L cells of the porcine intestine. Endocrinology 140: 5356 –5363, 729 –732, 1983.
1999. 121. Holst JJ, Bersani M, Johnsen AH, Kofod H, Hartmann B,
97. Hansen L, Hartmann B, Bisgaard T, Mineo H, Jørgensen PN, Orskov C. Proglucagon processing in porcine and human pan-
Holst JJ. Somatostatin restrains the secretion of glucagon-like creas. J Biol Chem 269: 18827–18833, 1994.
peptide-1 and 2 from isolated perfused porcine ileum. Am J Physiol 122. Holst JJ, Deacon CF. Inhibition of the activity of dipeptidyl-
Endocrinol Metab 278: E1010 –E1018, 2000. peptidase IV as a treatment for type 2 diabetes. Diabetes 47: 1663–
98. Hansen L, Hartmann B, Mineo H, Holst JJ. Glucagon-like pep- 1670, 1998.
tide-1 secretion is influenced by perfusate glucose concentration 123. Holst JJ, Deacon CF. Glucagon-like peptide-1 mediates the ther-
and by a feedback mechanism involving somatostatin in isolated apeutic actions of DPP-IV inhibitors. Diabetologia 48: 612– 615,
perfused porcine ileum. Regul Pept 118: 11–18, 2004. 2005.
99. Hansen L, Holst JJ. The effects of duodenal peptides on gluca- 124. Holst JJ, Gromada J. Role of incretin hormones in the regulation
gon-like peptide-1 secretion from the ileum. A duodeno–ileal loop? of insulin secretion in diabetic and nondiabetic humans. Am J
Regul Pept 110: 39 – 45, 2002. Physiol Endocrinol Metab 287: E199 –E206, 2004.
100. Hansen L, Lampert S, Mineo H, Holst JJ. Neural regulation of 125. Holst JJ, Orskov C. Incretin hormones–an update. Scand J Clin

Downloaded from http://physrev.physiology.org/ by 10.220.33.4 on November 24, 2017


glucagon-like peptide-1 secretion in pigs. Am J Physiol Endocrinol Lab Invest Suppl 75– 85, 2001.
Metab 287: E939 –E947, 2004. 126. Holst JJ, Orskov C, Nielsen OV, Schwartz TW. Truncated glu-
102. Hansotia T, Baggio LL, Delmeire D, Hinke SA, Yamada Y, cagon-like peptide I, an insulin-releasing hormone from the distal
Tsukiyama K, Seino Y, Holst JJ, Schuit F, Drucker DJ. Double gut. FEBS Lett 211: 169 –174, 1987.
incretin receptor knockout (DIRKO) mice reveal an essential role 127. Holst JJ, Rasmussen TN, Harling H, Schmidt P. Effect of
for the enteroinsular axis in transducing the glucoregulatory ac- intestinal inhibitory peptides on vagally induced secretion from
tions of DPP-IV inhibitors. Diabetes 53: 1326 –1335, 2004. isolated perfused porcine pancreas. Pancreas 8: 80 – 87, 1993.
103. Hartmann B, Johnsen AH, Orskov C, Adelhorst K, Thim L, 128. Holst JJ, Schwartz TW, Lovgreen NA, Pedersen O, Beck-
Holst JJ. Structure, measurement, secretion of human glucagon- Nielsen H. Diurnal profile of pancreatic polypeptide, pancreatic
like peptide-2. Peptides 21: 73– 80, 2000. glucagon, gut glucagon and insulin in human morbid obesity. Int J
104. Heding LG. Radioimmunological determination of pancreatic and Obesity 7: 529 –538, 1983.
gut glucagon in plasma. Diabetologia 7: 10 –19, 1971. 129. Holst JJ, Sorensen TI, Andersen AN, Stadil F, Andersen B,
105. Heinrich G, Gros P, Habener JF. Glucagon gene sequence. Four Lauritsen KB, Klein HC. Plasma enteroglucagon after jejunoileal
of six exons encode separate functional domains of rat pre-proglu- bypass with 3:1 or 1:3 jejunoileal ratio. Scand J Gastroenterol 14:
cagon. J Biol Chem 259: 14082–14087, 1984. 205–207, 1979.
106. Heller RS, Kieffer TJ, Habener JF. Insulinotropic glucagon-like
130. Holz GG. Epac: a new cAMP-binding protein in support of gluca-
peptide I receptor expression in glucagon-producing alpha-cells of
gon-like peptide-1 receptor-mediated signal transduction in the
the rat endocrine pancreas. Diabetes 46: 785–791, 1997.
pancreatic beta-cell. Diabetes 53: 5–13, 2004.
107. Henriksen DB, Alexandersen P, Bjarnason NH, Vilsboll T,
132. Holz GG, Kuhtreiber WM, Habener JF. Pancreatic beta-cells are
Hartmann B, Henriksen EEG, Byrjalsen I, Holst JJ, Chris-
rendered glucose-competent by the insulinotropic hormone gluca-
tiansen C.Role of gastrointestinal hormones in postprandial re-
gon-like peptide-1 (7–37). Nature 361: 362–365, 1993.
duction of bone resorption. J Bone Miner Res 18: 2180 –2189, 2003.
133. Holz GH, Kuhtreiber WM, Habener JF. Induction of glucose
108. Henry RR, Ratner RE, Stonehouse AH, Guan X, Poon T,
competence in pancreatic beta cells by glucagon- like peptide-1
Malone JK, Kim D, Kendall DM. Exenatide maintained glycemic
(7–37). Trans Assoc Am Physicians 105: 260 –267, 1992.
control with associated weight loss reduction over 2 years in
patients with type 2 diabetes (Abstract). Diabetes 55: A116, 2006. 134. Hupe-Sodmann K, Goke R, Goke B, Thole HH, Zimmermann
109. Herrmann-Rinke C, Voge A, Hess M, Goke B. Regulation of B, Voigt K, McGregor GP. Endoproteolysis of glucagon-like pep-
glucagon-like peptide-1 secretion from rat ileum by neurotransmit- tide (GLP)-1 (7–36) amide by ectopeptidases in RINm5F cells.
ters and peptides. J Endocrinol 147: 25–31, 1995. Peptides 18: 625– 632, 1997.
110. Hiles R, Carpenter T, Serota D, Schafer K, Ross P, Nelsen D, 135. Hvidberg A, Nielsen MT, Hilsted J, Orskov C, Holst JJ. Effect
Rebelatto M. Exenatide does not cause pancreatic tumours or of glucagon-like peptide-1 (proglucagon 78 –107amide) on hepatic
malignancies in rats and mice following a 2-year period of exposure glucose production in healthy man. Metabolism 43: 104 –108, 1994.
(Abstract). Diabetes 53 Suppl 2: A380, 2004. 136. Iakoubov R, Izzo A, Yeung A, Whiteside CI, Brubaker PL.
111. Hill ME, Asa SL, Drucker DJ. Essential requirement for Pax6 in Protein kinase C␨ is required for oleic acid-induced secretion of
control of enteroendocrine proglucagon gene transcription. Mol glucagon-like peptide-1 by intestinal endocrine L cells. Endocrinol-
Endocrinol 13: 1474 –1486, 1999. ogy 148: 1089 –1098, 2006.
112. Hirasawa A, Tsumaya K, Awaji T, Katsuma S, Adachi T, 137. Idris I, Patiag D, Gray S, Donnelly R. Exendin-4 increases
Yamada M, Sugimoto Y, Miyazaki S, Tsujimoto G. Free fatty insulin sensitivity via a PI-3-kinase-dependent mechanism: con-
acids regulate gut incretin glucagon-like peptide-1 secretion trasting effects of GLP-1. Biochem Pharmacol 63: 993–996, 2002.
through GPR120. Nat Med 11: 90 –94, 2005. 138. Ikezawa Y, Yamatani K, Ohnuma H, Daimon M, Manaka H,
113. Holst JJ. Enteroglucagon. Annu Rev Physiol 59: 257–271, 1997. Sasaki H. Glucagon-like peptide-1 inhibits glucagon-induced gly-
114. Holst JJ. Evidence that glicentin contains the entire sequence of cogenolysis in perivenous hepatocytes specifically. Regul Pept 111:
glucagon. Biochem J 187: 337–343, 1980. 207–210, 2003.
115. Holst JJ. Glucagon-like peptide-1: from extract to agent. The 139. Imeryuz N, Yegen BC, Bozkurt A, Coskun T, Villanueva-
Claude Bernard Lecture, 2005. Diabetologia 49: 253–260, 2006. Penacarrillo ML, Ulusoy NB. Glucagon-like peptide-1 inhibits
116. Holst JJ. Evidence that enteroglucagon (II) is identical with the gastric emptying via vagal afferent-mediated central mechanisms.
C-terminal sequence (residues 33– 69) of glicentin. Biochem J 207: Am J Physiol Gastrointest Liver Physiol 273: G920 –G927, 1997.
381–388, 1982. 140. Ionut V, Hucking K, Liberty IF, Bergman RN. Synergistic effect
117. Holst JJ. Gut glucagon, enteroglucagon, gut glucagonlike immu- of portal glucose and glucagon-like peptide-1 to lower systemic
noreactivity, glicentin— current status. Gastroenterology 84: 1602– glucose and stimulate counter-regulatory hormones. Diabetologia
1613, 1983. 48: 967–975, 2005.
118. Holst JJ. On the physiology of GIP and GLP-1. Horm Metab Res 36: 141. Ionut V, Liberty IF, Hucking K, Lottati M, Stefanovski D,
747–754, 2004. Zheng D, Bergman RN. Exogenously imposed postprandial-like
119. Holst JJ. Glucagon-like peptide 1 (GLP-1): an intestinal hormone rises in systemic glucose and GLP-1 do not produce an incretin
signalling nutritional abundance, with an unusual therapeutic po- effect, suggesting an indirect mechanism of GLP-1 action. Am J
tential. Trends Endocrinol Metab 10: 229 –234, 1999. Physiol Endocrinol Metab 291: E779 –E785, 2006.

Physiol Rev • VOL 87 • OCTOBER 2007 • www.prv.org


1434 JENS JUUL HOLST

142. Irwin DM, Wong J. Trout and chicken proglucagon: alternative 163. Layer P. Intestinale Regulation der Pankreasenzymsekretion:
splicing generates mRNA transcripts encoding glucagon-like pep- Stimulatorische und inhibitorische Mechanismen. Z Gastroenterol
tide 2. Mol Endocrinol 9: 267–277, 1995. 30: 495– 497, 1992.
143. Jackson RS, Creemers JW, Farooqi IS, Raffin-Sanson ML, 164. Layer P, Holst JJ, Grandt D, Goebell H. Ileal release of gluca-
Varro A, Dockray GJ, Holst JJ, Brubaker PL, Corvol P, Po- gon-like peptide-1 (GLP-1). Association with inhibition of gastric
lonsky KS, Ostrega D, Becker KL, Bertagna X, Hutton JC, acid secretion in humans. Dig Dis Sci 40: 1074 –1082, 1995.
White A, Dattani MT, Hussain K, Middleton SJ, Nicole TM, 165. Le Roux CW, Aylwin SJ, Batterham RL, Borg CM, Coyle F,
Milla PJ, Lindley KJ, O’Rahilly S. Small-intestinal dysfunction Prasad V, Shurey S, Ghatei MA, Patel AG, Bloom SR. Gut
accompanies the complex endocrinopathy of human proprotein hormone profiles following bariatric surgery favor an anorectic
convertase 1 deficiency. J Clin Invest 112: 1550 –1560, 2003. state, facilitate weight loss, improve metabolic parameters. Ann
144. Jin SL, Han VK, Simmons JG, Towle AC, Lauder JM, Lund PK. Surg 243: 108 –114, 2006.
Distribution of glucagonlike peptide I (GLP-I), glucagon, glicentin 166. Lee YC, Asa SL, Drucker DJ. Glucagon gene 5⬘-flanking se-
in the rat brain: an immunocytochemical study. J Comp Neurol 271: quences direct expression of simian virus 40 large T antigen to the
519 –532, 1988. intestine, producing carcinoma of the large bowel in transgenic
145. Kauth T, Metz J. Immunohistochemical localization of glucagon- mice. J Biol Chem 267: 10705–10708, 1992.
like peptide 1. Use of poly- and monoclonal antibodies. Histochem- 167. Lefebvre PJ, Luyckx AS. Neurotransmitters and glucagon release
istry 86: 509 –515, 1987. from the isolated, perfused canine stomach. Diabetes 29: 697–701,

Downloaded from http://physrev.physiology.org/ by 10.220.33.4 on November 24, 2017


146. Kemp DM, Habener JF. Insulinotropic hormone glucagon-like 1980.
peptide 1 (GLP-1) activation of insulin gene promoter inhibited by 168. Li Y, Cao X, Li LX, Brubaker PL, Edlund H, Drucker DJ. ␤-Cell
p38 mitogen-activated protein kinase. Endocrinology 142: 1179 – Pdx1 expression is essential for the glucoregulatory, proliferative,
1187, 2001. cytoprotective actions of glucagon-like peptide-1. Diabetes 54: 482–
147. Kendall DM, Kim D, Maggs D. Incretin mimetics and dipeptidyl 491, 2005.
peptidase-IV inhibitors: a review of emerging therapies for type 2 169. Li Y, Hansotia T, Yusta B, Ris F, Halban PA, Drucker DJ.
diabetes. Diabetes Technol Ther 8: 385–396, 2006. Glucagon-like peptide-1 receptor signaling modulates beta cell
148. Kendall DM, Riddle MC, Rosenstock J, Zhuang D, Kim DD, apoptosis. J Biol Chem 278: 471– 478, 2003.
Fineman MS, Baron AD. Effects of exenatide (exendin-4) on 170. Light PE, Manning Fox JE, Riedel MJ, Wheeler MB. Glucagon-
glycemic control over 30 weeks in patients with type 2 diabetes like peptide-1 inhibits pancreatic ATP-sensitive potassium chan-
treated with metformin and a sulfonylurea. Diabetes Care 28: 1083– nels via a protein kinase A- and ADP-dependent mechanism. Mol
1091, 2005. Endocrinol 16: 2135–2144, 2002.
149. Kieffer TJ, Habener JF. The glucagon-like peptides. Endocr Rev 171. Lopez LC, Frazier ML, Su CJ, Kumar A, Saunders GF. Mam-
20: 876 –913, 1999. malian pancreatic preproglucagon contains three glucagon-related
150. Kjems LL, Holst JJ, Volund A, Madsbad S. The influence of peptides. Proc Natl Acad Sci USA 80: 5485–5489, 1983.
GLP-1 on glucose-stimulated insulin secretion: effects on beta-cell 172. Lund PK, Goodman RH, Dee PC, Habener JF. Pancreatic pre-
sensitivity in type 2 and nondiabetic subjects. Diabetes 52: 380 –386, proglucagon cDNA contains two glucagon-related coding se-
2003. quences arranged in tandem. Proc Natl Acad Sci USA 79: 345–349,
151. Knudsen JB, Holst JJ, Asnaes S, Johansen A. Identification of 1982.
cells with pancreatic-type and gut-type glucagon immunoreactivity 173. Luque MA, Gonzalez N, Marquez L, Acitores A, Redondo A,
in the human colon. Acta Pathol Microbiol Scand 83: 741–743, 1975. Morales M, Valverde I, Villanueva-Penacarrillo ML. Glucagon-
152. Knudsen LB, Nielsen PF, Huusfeldt PO, Johansen NL, Mad- like peptide-1 (GLP-1) and glucose metabolism in human myocytes.
sen K, Pedersen FZ, Thogersen H, Wilken M, Agerso H. Potent J Endocrinol 173: 465– 473, 2002.
derivatives of glucagon-like peptide-1 with pharmacokinetic prop- 174. Mari A, Sallas WM, He YL, Watson C, Ligueros-Saylan M,
erties suitable for once daily administration. J Med Chem 43: Dunning BE, Deacon CF, Holst JJ, Foley JE. Vildagliptin, a
1664 –1669, 2000. dipeptidyl peptidase-IV inhibitor, improves model-assessed ␤-cell
153. Knudsen LB, Pridal L. Glucagon-like peptide-1- (9 –36) amide is a function in patients with type 2 diabetes. J Clin Endocrinol Metab
major metabolite of glucagon-like peptide-1- (7–36) amide after in 90: 4888 – 4894, 2005.
vivo administration to dogs, it acts as an antagonist on the pancre- 175. Mari A, Schmitz O, Gastaldelli A, Oestergaard T, Nyholm B,
atic receptor. Eur J Pharmacol 318: 429 – 435, 1996. Ferrannini E. Meal and oral glucose tests for assessment of
154. Knuhtsen S, Holst JJ, Knigge U, Olesen M, Nielsen OV. Ra- beta-cell function: modeling analysis in normal subjects. Am J
dioimmunoassay, pharmacokinetics, neuronal release of gastrin- Physiol Endocrinol Metab 283: E1159 –E1166, 2002.
releasing peptide in anesthetized pigs. Gastroenterology 87: 372– 176. Mayo KE, Miller LJ, Bataille D, Dalle S, Goke B, Thorens B,
378, 1984. Drucker DJ. International Union of Pharmacology. XXXV. The
155. Kolligs F, Fehmann HC, Goke R, Goke B. Reduction of the Glucagon Receptor Family. Pharmacol Rev 55: 167–194, 2003.
incretin effect in rats by the glucagon-like peptide 1 receptor 177. McIntyre N, Holdsworth CD, Turner DS.New interpretation of
antagonist exendin (9 –39) amide. Diabetes 44: 16 –19, 1995. oral glucose tolerance. Lancet II: 20 –21, 1964.
156. Kolterman OG, Kim DD, Shen L, Ruggles JA, Nielsen LL, 178. McIntyre N, Holdsworth CD, Turner DS. Intestinal factors in
Fineman MS, Baron AD. Pharmacokinetics, pharmacodynamics, the control of insulin secretion. J Clin Endocrinol Metab 25: 1317–
safety of exenatide in patients with type 2 diabetes mellitus. Am J 1324, 1965.
Health Syst Pharm 62: 173–181, 2005. 179. Meier JJ, Butler AE, Galasso R, Butler PC. Hyperinsulinemic
157. Kreymann B, Williams G, Ghatei MA, Bloom SR. Glucagon-like hypoglycemia after gastric bypass surgery is not accompanied by
peptide-1 7–36: a physiological incretin in man. Lancet 2: 1300 – islet hyperplasia or increased beta-cell turnover. Diabetes Care 29:
1304, 1987. 1554 –1559, 2006.
158. Lankat-Buttgereit B, Goke R, Fehmann HC, Richter G, Goke 180. Meier JJ, Gallwitz B, Askenas M, Vollmer K, Deacon CF,
B. Molecular cloning of a cDNA encoding for the GLP-1 receptor Holst JJ, Schmidt WE, Nauck MA. Secretion of incretin hor-
expressed in rat lung. Exp Clin Endocrinol 102: 341–347, 1994. mones and the insulinotropic effect of gastric inhibitory polypep-
160. Larsen PJ, Holst JJ. Glucagon-related peptide 1 (GLP-1): hor- tide in women with a history of gestational diabetes. Diabetologia
mone and neurotransmitter. Regul Pept 128: 97–107, 2005. 48: 1872–1881, 2005.
161. Larsen PJ, Tang-Christensen M, Holst JJ, Orskov C. Distribu- 181. Meier JJ, Gethmann A, Nauck MA, Goetze O, Schmitz F,
tion of glucagon-like peptide-1 and other preproglucagon-derived Deacon CF, Gallwitz B, Schmidt WE, Holst JJ. The glucagon-
peptides in the rat hypothalamus and brainstem. Neuroscience 77: like peptide 1 metabolite GLP-1 (9 –36)amide reduces postprandial
257–270, 1997. glycemia independently of gastric emptying and insulin secretion in
162. Lawrence MC, Bhatt HS, Easom RA. NFAT regulates insulin humans. Am J Physiol Endocrinol Metab 290: E1118 –E1123, 2006.
gene promoter activity in response to synergistic pathways induced 181a.Meier JJ, Kemmeries G, Holst JJ, Nauck MA. Erythromycin
by glucose and glucagon-like peptide-1. Diabetes 51: 691– 698, 2002. antagonizes the deceleration of gastric emptying by glucagon-like

Physiol Rev • VOL 87 • OCTOBER 2007 • www.prv.org


THE PHYSIOLOGY OF GLUCAGON-LIKE PEPTIDE 1 1435

peptide 1 and unmasks its insulinotropic effect in healthy subjects. 200. Naslund E, Barkeling B, King N, Gutniak M, Blundell JE,
Diabetes 54: 2212–2218, 2005. Holst JJ, Rossner S, Hellstrom PM. Energy intake and appetite
182. Meier JJ, Nauck MA, Kranz D, Holst JJ, Deacon CF, Gaeckler are suppressed by glucagon-like peptide-1 (GLP-1) in obese men.
D, Schmidt WE, Gallwitz B. Secretion, degradation, elimination Int J Obes Relat Metab Disord 23: 304 –311, 1999.
of glucagon-like peptide 1 and gastric inhibitory polypeptide in 201. Naslund E, Gryback P, Backman L, Jacobsson H, Holst JJ,
patients with chronic renal insufficiency and healthy control sub- Theodorsson E, Hellstrom PM. Distal small bowel hormones:
jects. Diabetes 53: 654 – 662, 2004. correlation with fasting antroduodenal motility and gastric empty-
183. Meneilly GS, Greig N, Tildesley H, Habener JF, Egan JM, ing. Dig Dis Sci 43: 945–952, 1998.
Elahi D. Effects of 3 months of continuous subcutaneous admin- 202. Nauck M, Schmidt WE, Ebert R, Strietzel J, Cantor P, Hoff-
istration of glucagon-like peptide 1 in elderly patients with type 2 mann G, Creutzfeldt W. Insulinotropic properties of synthetic
diabetes. Diabetes Care 26: 2835–2841, 2003. human gastric inhibitory polypeptide in man: interactions with
184. Meneilly GS, McIntosh CH, Pederson RA, Habener JF, Ehlers glucose, phenylalanine, cholecystokinin-8. J Clin Endocrinol
MR, Egan JM, Elahi D. Effect of glucagon-like peptide 1 (7–36 Metab 69: 654 – 662, 1989.
amide) on insulin-mediated glucose uptake in patients with type 1 203. Nauck M, Stockmann F, Ebert R, Creutzfeldt W. Reduced
diabetes. Diabetes Care 26: 837– 842, 2003. incretin effect in type 2 (non-insulin-dependent) diabetes. Diabe-
185. Meneilly GS, McIntosh CH, Pederson RA, Habener JF, Gin- tologia 29: 46 –52, 1986.
gerich R, Egan JM, Finegood DT, Elahi D. Effect of glucagon- 204. Nauck MA, Bartels E, Orskov C, Ebert R, Creutzfeldt W.

Downloaded from http://physrev.physiology.org/ by 10.220.33.4 on November 24, 2017


like peptide 1 on non-insulin-mediated glucose uptake in the Additive insulinotropic effects of exogenous synthetic human gas-
elderly patient with diabetes. Diabetes Care 24: 1951–1956, 2001. tric inhibitory polypeptide and glucagon-like peptide-1- (7–36)
186. Merida E, Delgado E, Molina LM, Villanueva Penacarrillo ML, amide infused at near-physiological insulinotropic hormone and
Valverde I. Presence of glucagon and glucagon-like peptide-1- glucose concentrations. J Clin Endocrinol Metab 76: 912–917,
(7–36)amide receptors in solubilized membranes of human adipose 1993.
tissue. J Clin Endocrinol Metab 77: 1654 –1657, 1993. 205. Nauck MA, Heimesaat MM, Behle K, Holst JJ, Nauck MS,
187. Miholic J, Orskov C, Holst JJ, Kotzerke J, Meyer HJ. Empty- Ritzel R, Hufner M, Schmiegel WH. Effects of glucagon-like
ing of the gastric substitute, glucagon-like peptide-1 (GLP-1), reac- peptide 1 on counterregulatory hormone responses, cognitive func-
tive hypoglycemia after total gastrectomy. Dig Dis Sci 36: 1361– tions, insulin secretion during hyperinsulinemic, stepped hypogly-
1370, 1991. cemic clamp experiments in healthy volunteers. J Clin Endocrinol
188. Moens K, Heimberg H, Flamez D, Huypens P, Quartier E, Ling Metab 87: 1239 –1246, 2002.
Z, Pipeleers D, Gremlich S, Thorens B, Schuit F. Expression 206. Nauck MA, Heimesaat MM, Orskov C, Holst JJ, Ebert R,
and functional activity of glucagon, glucagon-like peptide I, glu- Creutzfeldt W. Preserved incretin activity of glucagon-like pep-
cose-dependent insulinotropic peptide receptors in rat pancreatic tide 1 [7–36 amide] but not of synthetic human gastric inhibitory
islet cells. Diabetes 45: 257–261, 1996. polypeptide in patients with type-2 diabetes mellitus. J Clin Invest
189. Mojsov S, Heinrich G, Wilson IB, Ravazzola M, Orci L,
91: 301–307, 1993.
Habener JF. Preproglucagon gene expression in pancreas and
207. Nauck MA, Holst JJ, Willms B. Glucagon-like peptide 1 and its
intestine diversifies at the level of post-translational processing.
potential in the treatment of non-insulin-dependent diabetes melli-
J Biol Chem 261: 11880 –11889, 1986.
tus. Horm Metab Res 29: 411– 416, 1997.
190. Mojsov S, Kopczynski MG, Habener JF. Both amidated and
208. Nauck MA, Homberger E, Siegel Allen RC, Eaton RP, Ebert R,
nonamidated forms of glucagon-like peptide I are synthesized in
Creutzfeldt W. Incretin effects of increasing glucose loads in man
the rat intestine and the pancreas. J Biol Chem 265: 8001– 8008,
calculated from venous insulin and C-peptide responses. J Clin
1990.
Endocrinol Metab 63: 492– 498, 1986.
191. Mojsov S, Weir GC, Habener JF. Insulinotropin: glucagon-like
210. Nauck MA, Kleine N, Orskov C, Holst JJ, Willms B,
peptide I (7–37) co-encoded in the glucagon gene is a potent
stimulator of insulin release in the perfused rat pancreas. J Clin Creutzfeldt W. Normalization of fasting hyperglycaemia by exog-
Invest 79: 616 – 619, 1987. enous glucagon-like peptide 1 (7–36 amide) in type 2 (non-insulin-
192. Montrose-Rafizadeh C, Yang H, Wang Y, Roth J, Montrose dependent) diabetic patients. Diabetologia 36: 741–744, 1993.
MH, Adams LG. Novel signal transduction and peptide specificity 211. Nauck MA, Niedereichholz U, Ettler R, Holst JJ, Orskov C,
of glucagon-like peptide receptor in 3T3–L1 adipocytes. J Cell Ritzel R, Schmiegel WH. Glucagon-like peptide 1 inhibition of
Physiol 172: 275–283, 1997. gastric emptying outweighs its insulinotropic effects in healthy
193. Moody AJ, Holst JJ, Thim L, Jensen SL. Relationship of glicen- humans. Am J Physiol Endocrinol Metab 273: E981–E988, 1997.
tin to proglucagon and glucagon in the porcine pancreas. Nature 212. Nauck MA, Siemsgluss J, Orskov C, Holst JJ. Release of
289: 514 –516, 1981. glucagon-like peptide 1 (GLP-1 [7–36 amide]), gastric inhibitory
194. Morinigo R, Moize V, Musri M, Lacy AM, Navarro S, Marin JL, polypeptide (GIP) and insulin in response to oral glucose after
Delgado S, Casamitjana R, Vidal J. Glucagon-like peptide-1, upper and lower intestinal resections. Z Gastroenterol 34: 159 –166,
peptide YY, hunger, satiety after gastric bypass surgery in morbidly 1996.
obese subjects. J Clin Endocrinol Metab 91: 1735–1740, 2006. 213. Nian M, Drucker DJ, Irwin D. Divergent regulation of human and
195. Mortensen K, christensen LL, Holst JJ, Orskov C. GLP-1 and rat proglucagon gene promoters in vivo. Am J Physiol Gastrointest
GIP are colocalized in a subset of endocrine cells in the small Liver Physiol 277: G829 –G837, 1999.
intestine. Regul Pept 114: 189 –196, 2003. 214. Nian M, Gu J, Irwin DM, Drucker DJ. Human glucagon gene
196. Murlin JR, Clough HD, Gibbs CBF, Stokes AM. J Biol Chem 56: promoter sequences regulating tissue-specific versus nutrient-reg-
253–296, 1923. ulated gene expression. Am J Physiol Regul Integr Comp Physiol
197. Nakabayashi H, Nishizawa M, Nakagawa A, Takeda R, Niijima 282: R173–R183, 2002.
A. Vagal hepatopancreatic reflex effect evoked by intraportal ap- 215. Nikolaidis LA, Elahi D, Hentosz T, Doverspike A, Huerbin R,
pearance of tGLP-1. Am J Physiol Endocrinol Metab 271: E808 – Zourelias L, Stolarski C, Shen YT, Shannon RP. Recombinant
E813, 1996. glucagon-like peptide-1 increases myocardial glucose uptake and
198. Nakagawa A, Satake H, Nakabayashi H, Nishizawa M, Furuya improves left ventricular performance in conscious dogs with pac-
K, Nakano S, Kigoshi T, Nakayama K, Uchida K. Receptor gene ing-induced dilated cardiomyopathy. Circulation 110: 955–961,
expression of glucagon-like peptide-1, but not glucose-dependent 2004.
insulinotropic polypeptide, in rat nodose ganglion cells. Auton 216. Nikolaidis LA, Elahi D, Shen YT, Shannon RP. Active metabo-
Neurosci 110: 36 – 43, 2004. lite of GLP-1 mediates myocardial glucose uptake and improves left
199. Nakazaki M, Crane A, Hu M, Seghers V, Ullrich S, Aguilar- ventricular performance in conscious dogs with dilated cardiomy-
Bryan L, Bryan J. cAMP-activated protein kinase-independent opathy. Am J Physiol Heart Circ Physiol 289: H2401–H2408, 2005.
potentiation of insulin secretion by cAMP is impaired in SUR1 null 217. Nikolaidis LA, Mankad S, Sokos GG, Miske G, Shah A, Elahi
islets. Diabetes 51: 3440 –3449, 2002. D, Shannon RP. Effects of glucagon-like peptide-1 in patients with

Physiol Rev • VOL 87 • OCTOBER 2007 • www.prv.org


1436 JENS JUUL HOLST

acute myocardial infarction and left ventricular dysfunction after 236. Patzelt C, Schug G. The major proglucagon fragment: an abun-
successful reperfusion. Circulation 109: 962–965, 2004. dant islet protein and secretory product. FEBS Lett 129: 127–130,
218. Nishizawa M, Moore MC, Shiota M, Gustavson SM, Snead WL, 1981.
Neal DW, Cherrington AD. Effect of intraportal glucagon-like 237. Perley M, Kipnis DM. Plasma insulin responses to oral and intra-
peptide-1 on glucose metabolism in conscious dogs. Am J Physiol venous glucose: studies in normal and diabetic subjects. J Clin
Endocrinol Metab 284: E1027–E1036, 2003. Invest 46: 1954 –1962, 1967.
219. Nishizawa M, Nakabayashi H, Kawai K, Ito T, Kawakami S, 238. Perry T, Haughey NJ, Mattson MP, Egan JM, Greig NH. Pro-
Nakagawa A, Niijima A, Uchida K. The hepatic vagal reception of tection and reversal of excitotoxic neuronal damage by glucagon-
intraportal GLP-1 is via receptor different from the pancreatic like peptide-1 and exendin-4. J Pharmacol Exp Ther 302: 881– 888,
GLP-1 receptor. J Auton Nerv Syst 80: 14 –21, 2000. 2002.
220. Nishizawa M, Nakabayashi H, Uchida K, Nakagawa A, Niijima 239. Perry TA, Greig NH. A new Alzheimer’s disease interventive
A. The hepatic vagal nerve is receptive to incretin hormone gluca- strategy: GLP-1. Curr Drug Targets 5: 565–571, 2004.
gon-like peptide-1, but not to glucose-dependent insulinotropic 240. Petersen B, Christiansen J, Holst JJ. A glucose-dependent
polypeptide, in the portal vein. J Auton Nerv Syst 61: 149 –154, mechanism in jejunum inhibits gastric acid secretion: a response
1996. mediated through enteroglucagon? Scand J Gastroenterol 20: 193–
221. Novak U, Wilks A, Buell G, McEwen S. Identical mRNA for 197, 1985.
preproglucagon in pancreas and gut. Eur J Biochem 164: 553–558,

Downloaded from http://physrev.physiology.org/ by 10.220.33.4 on November 24, 2017


241. Plaisancie P, Bernard C, Chayvialle JA, Cuber JC. Regulation
1987.
of glucagon-like peptide-1- (7–36) amide secretion by intestinal
222. Nyholm B, Walker M, Grauholt CH, Alberti KGMM, Holst JJ,
neurotransmitters and hormones in the isolated vascularly per-
Schmitz O. Twenty-four hour profiles of insulin, substrates and gut
fused rat colon. Endocrinology 135: 2398 –2403, 1994.
incretin hormones: early defects in glucose tolerant offspring of
type II (non-insulin dependent) diabetic patients. Diabetologia 42: 242. Plamboeck A, Holst JJ, Carr RD, Deacon CF. Neutral endopep-
1314 –1323, 1999. tidase 24.11 and dipeptidyl peptidase IV are both mediators of the
223. Oben J, Morgan L, Fletcher J, Marks V. Effect of the entero- degradation of glucagon-like peptide 1 in the anaesthetised pig.
pancreatic hormones, gastric inhibitory polypeptide and glucagon- Diabetologia 48: 1882–1890, 2005.
like polypeptide-1 (7–36) amide, on fatty acid synthesis in explants 243. Preitner F, Ibberson M, Franklin I, Binnert C, Pende M,
of rat adipose tissue. J Endocrinol 130: 267–272, 1991. Gjinovci A, Hansotia T, Drucker DJ, Wollheim C, Burcelin R,
224. Orci L, Bordi C, Unger RH, Perrelet A. Glucagon- and glicentin- Thorens B. Gluco-incretins control insulin secretion at multiple
producing cells. In: Glucagon, edited by Lefebvre PJ. Berlin: Springer- levels as revealed in mice lacking GLP-1 and GIP receptors. J Clin
Verlag, 1983, p. 57–79. Invest 113: 635– 645, 2004.
225. Orci L, Pictet R, Forssmann WG, Renold AE, Rouiller C. 244. Qualmann C, Nauck MA, Holst JJ, Orskov C, Creutzfeldt W.
Structural evidence for glucagon producing cells in the intestinal Glucagon-like peptide 1 (7–36 amide) secretion in response to
mucosa of the rat. Diabetologia 4: 56 – 67, 1968. luminal sucrose from the upper and lower gut. A study using
226. Orskov C, Bersani M, Johnsen AH, Hojrup P, Holst JJ. Com- alpha-glucosidase inhibition (acarbose). Scand J Gastroenterol 30:
plete sequences of glucagon-like peptide-1 from human and pig 892– 896, 1995.
small intestine. J Biol Chem 264: 12826 –12829, 1989. 245. Rachman J, Barrow BA, Levy JC, Turner RC. Near-normalisa-
227. Orskov C, Holst JJ, Knuhtsen S, Baldissera FG, Poulsen SS, tion of diurnal glucose concentrations by continuous administra-
Nielsen OV. Glucagon-like peptides GLP-1 and GLP-2, predicted tion of glucagon-like peptide-1 (GLP-1) in subjects with NIDDM.
products of the glucagon gene, are secreted separately from pig Diabetologia 40: 205–211, 1997.
small intestine but not pancreas. Endocrinology 119: 1467–1475, 246. Ranganath L, Norris F, Morgan L, Wright J, Marks V. Inhibition
1986. of carbohydrate-mediated glucagon-like peptide-1 (7–36)amide se-
228. Orskov C, Holst JJ, Nielsen OV. Effect of truncated glucagon- cretion by circulating non-esterified fatty acids. Clin Sci 96: 335–
like peptide-1 [proglucagon- (78 –107) amide] on endocrine secre- 342, 1999.
tion from pig pancreas, antrum, and nonantral stomach. Endocri- 247. Ranganath LR, Beety JM, Morgan LM, Wright JW, Howland R,
nology 123: 2009 –2013, 1988. Marks V. Attenuated GLP-1 secretion in obesity: cause or conse-
229. Orskov C, Holst JJ, Poulsen SS, Kirkegaard P. Pancreatic and quence? Gut 38: 916 –919, 1996.
intestinal processing of proglucagon in man. Diabetologia 30: 874 – 248. Rask E, Olsson T, Soderberg S, Johnson O, Seckl J, Holst JJ,
881, 1987. Ahren B. Impaired incretin response after a mixed meal is asso-
230. Orskov C, Poulsen SS, Moller M, Holst JJ. Glucagon-like pep- ciated with insulin resistance in nondiabetic men. Diabetes Care
tide I receptors in the subfornical organ and the area postrema are 24: 1640 –1645, 2001.
accessible to circulating glucagon-like peptide I. Diabetes 45: 832– 249. Read N, French S, Cunningham K. The role of the gut in regu-
835, 1996. lation food intake in man. Nutr Rev 52: 1–10, 1994.
231. Orskov C, Rabenhoj L, Wettergren A, Kofod H, Holst JJ.
250. Redondo A, Trigo MV, Acitores A, Valverde I, Villanueva-
Tissue and plasma concentrations of amidated and glycine-ex-
Penacarrillo ML. Cell signalling of the GLP-1 action in rat liver.
tended glucagon-like peptide I in humans. Diabetes 43: 535–539,
Mol Cell Endocrinol 204: 43–50, 2003.
1994.
251. Reimer RA, Darimont C, Gremlich S, Nicolas-Metral V, Ruegg
232. Orskov C, Wettergren A, Holst JJ. Biological effects and meta-
bolic rates of glucagonlike peptide-1 7–36 amide and glucagonlike UT, Mace K. A human cellular model for studying the regulation of
peptide-1 7–37 in healthy subjects are indistinguishable. Diabetes glucagon-like peptide-1 secretion. Endocrinology 142: 4522– 4528,
42: 658 – 661, 1993. 2001.
233. Orskov C, Wettergren A, Holst JJ. Secretion of the incretin 252. Richter G, Feddersen O, Wagner U, Barth P, Goke R, Goke B.
hormones glucagon-like peptide-1 and gastric inhibitory polypep- GLP-1 stimulates secretion of macromolecules from airways and
tide correlates with insulin secretion in normal man throughout the relaxes pulmonary artery. Am J Physiol Lung Cell Mol Physiol 265:
day. Scand J Gastroenterol 31: 665– 670, 1996. L374 –L381, 1993.
234. Orskov L, Holst JJ, Moller J, Orskov C, Moller N, Alberti KG, 253. Rinaman L. Interoceptive stress activates glucagon-like peptide-1
Schmitz O. GLP-1 does not acutely affect insulin sensitivity in neurons that project to the hypothalamus. Am J Physiol Regul
healthy man. Diabetologia 39: 1227–1232, 1996. Integr Comp Physiol 277: R582–R590, 1999.
235. Patti ME, McMahon G, Mun EC, Bitton A, Holst JJ, Gold- 254. Rocca AS, Brubaker PL. Role of the vagus nerve in mediating
smith J, Hanto DW, Callery M, Arky R, Nose V, Bonner-Weir proximal nutrient-induced glucagon-like peptide-1 secretion. Endo-
S, Goldfine AB. Severe hypoglycaemia post-gastric bypass requir- crinology 140: 1687–1694, 1999.
ing partial pancreatectomy: evidence for inappropriate insulin se- 255. Rouille Y, Kantengwa S, Irminger JC, Halban PA. Role of the
cretion and pancreatic islet hyperplasia. Diabetologia 48: 2236 – prohormone convertase PC3 in the processing of proglucagon to
2240, 2005. glucagon-like peptide 1. J Biol Chem 272: 32810 –32816, 1997.

Physiol Rev • VOL 87 • OCTOBER 2007 • www.prv.org


THE PHYSIOLOGY OF GLUCAGON-LIKE PEPTIDE 1 1437

256. Rouille Y, Westermark G, Martin SK, Steiner DF. Proglucagon from the isolated perfused canine ileum by glucose absorption.
is processed to glucagon by prohormone convertase PC2 in alpha Digestion 55: 24 –28, 1994.
TC1– 6 cells. Proc Natl Acad Sci USA 91: 3242–3246, 1994. 274. Sundby F, Jacobsen H, Moody AJ. Purification and character-
257. Sandhu H, Wiesenthal SR, MacDonald PE, McCall RH, ization of a protein from porcine gut with glucagon-like immuno-
Tchipashvili V, Rashid S, Satkunarajah M, Irwin DM, Shi ZQ, reactivity. Horm Metab Res 8: 366 –371, 1976.
Brubaker PL, Wheeler MB, Vranic M, Efendic S, Giacca A. 275. Sundler F, Alumets J, Holst J, Larsson LI, Hakanson R.
Glucagon-like peptide 1 increases insulin sensitivity in depancre- Ultrastructural identification of cells storing pancreatic-type gluca-
atized dogs. Diabetes 48: 1045–1053, 1999. gon in dog stomach. Histochemistry 50: 33–37, 1976.
258. Schepp W, Schmidtler J, Riedel T, Dehne K, Schusdziarra V, 276. Sutherland EW, De Duve C. Origin and distribution of the hyper-
Holst JJ, Eng J, Raufman JP, Classen M. Exendin-4 and ex- glycemic-glycogenolytic factor of the pancreas. J Biol Chem 175:
endin- (9 –39)NH2: agonist and antagonist, respectively, at the rat 663– 674, 1948.
parietal cell receptor for glucagon-like peptide-1- (7–36)NH2. Eur 277. Tager H, Hohenboken M, Markese J, Dinerstein RJ. Identifi-
J Pharmacol 269: 183–191, 1994. cation and localization of glucagon-related peptides in rat brain.
259. Schick RR, vorm Walde T, Zimmermann JP, Schusdziarra V, Proc Natl Acad Sci USA 77: 6229 – 6233, 1980.
Classen M. Glucagon-like peptide 1: a novel brain peptide involved 278. Tang-Christensen M, Larsen PJ, Goke R, Fink-Jensen A, Jes-
in feeding regulation. In: Obesity in Europe 1993, edited by Dit- sop DS, Moller M, Sheikh SP. Central administration of GLP-1-
schuneit H, Gries FA, Hauner H, Schusdziarra V, Wechsler JG. (7–36) amide inhibits food and water intake in rats. Am J Physiol

Downloaded from http://physrev.physiology.org/ by 10.220.33.4 on November 24, 2017


Libbey, 1994, p. 363–367. Regul Integr Comp Physiol 271: R848 –R856, 1996.
260. Schirra J, Nicolaus M, Roggel R, Katschinski M, Storr M, 279. Tang-Christensen M, Larsen PJ, Thulesen J, Romer J, Vrang
Woerle HJ, Goke B. Endogenous glucagon-like peptide 1 controls N. The proglucagon-derived peptide, glucagon-like peptide-2, is a
endocrine pancreatic secretion and antro-pyloro-duodenal motility neurotransmitter involved in the regulation of food intake. Nat Med
in humans. Gut 55: 243–251, 2006. 6: 802– 807, 2000.
261. Schjoldager BT, Mortensen PE, Christiansen J, Orskov C, 280. Tang-Christensen M, Vrang N, Larsen PJ. Glucagon-like pep-
Holst JJ. GLP-1 (glucagon-like peptide 1) and truncated GLP-1, tide 1 (7–36) amide’s central inhibition of feeding and peripheral
fragments of human proglucagon, inhibit gastric acid secretion in inhibition of drinking are abolished by neonatal monosodium glu-
humans. Dig Dis Sci 34: 703–708, 1989. tamate treatment. Diabetes 47: 530 –537, 1998.
262. Schmidtler J, Dehne K, Allescher HD, Schusdziarra V, Clas- 281. Thim L, Moody AJ. The amino acid sequence of porcine glicentin.
sen M, Holst JJ, Polack A, Schepp W. Rat parietal cell receptors Peptides 2 Suppl 2: 37–39, 1981.
for GLP-1- (7–36) amide: northern blot, cross-linking, radioligand 282. Thim L, Moody AJ. Purification and chemical characterization of
binding. Am J Physiol Gastrointest Liver Physiol 267: G423–G432, a glicentin-related pancreatic peptide (proglucagon fragment) from
1994. porcine pancreas. Biochim Biophys Acta 703: 134 –141, 1982.
263. Scrocchi LA, Brown TJ, MaClusky N, Brubaker PL, Auerbach 283. Thorens B. Expression cloning of the pancreatic beta cell receptor
AB, Joyner AL, Drucker DJ. Glucose intolerance but normal for the gluco-incretin hormone glucagon-like peptide 1. Proc Natl
satiety in mice with a null mutation in the glucagon-like peptide 1 Acad Sci USA 89: 8641– 8645, 1992.
receptor gene. Nat Med 2: 1254 –1258, 1996. 284. Thorens B, Porret A, Buhler L, Deng SP, Morel P, Widmann C.
264. Service GJ, Thompson GB, Service FJ, Andrews JC, Collazo- Cloning and functional expression of the human islet GLP-1 recep-
Clavell ML, Lloyd RV. Hyperinsulinemic hypoglycemia with ne- tor. Demonstration that exendin-4 is an agonist and exendin- (9 –
sidioblastosis after gastric-bypass surgery. N Engl J Med 353: 249 – 39) an antagonist of the receptor. Diabetes 42: 1678 –1682, 1993.
254, 2005. 285. Thorens B, Widmann C. Signal transduction and desensitization
265. Shah P, Vella A, Basu A, Basu R, Schwenk WF, Rizza RA. Lack of the glucagon-like peptide-1 receptor. Acta Physiol Scand 157:
of suppression of glucagon contributes to postprandial hypergly- 317–319, 1996.
cemia in subjects with type 2 diabetes mellitus. J Clin Endocrinol 286. Toft-Nielsen M, Madsbad S, Holst JJ. Exaggerated secretion of
Metab 85: 4053– 4059, 2000. glucagon-like peptide-1 (GLP-1) could cause reactive hypoglycae-
266. Simonsen L, Holst JJ, Deacon CF. Exendin-4, but not glucagon- mia. Diabetologia 41: 1180 –1186, 1998.
like peptide-1, is cleared exclusively by glomerular filtration in 287. Toft-Nielsen M, Madsbad S, Holst JJ. The effect of glucagon-
anaesthetised pigs. Diabetologia 1–7, 2006. like peptide I (GLP-I) on glucose elimination in healthy subjects
267. Sinclair EM,Drucker DJ. Proglucagon-derived peptides: mecha- depends on the pancreatic glucoregulatory hormones. Diabetes 45:
nisms of action and therapeutic potential. Physiology 20: 357–365, 552–556, 1996.
2005. 288. Toft-Nielsen MB, Damholt MB, Madsbad S, Hilsted LM,
268. Skoglund G, Hussain MA, Holz GG. Glucagon-like peptide 1 Hughes TE, Michelsen BK, Holst JJ. Determinants of the im-
stimulates insulin gene promoter activity by protein kinase A-inde- paired secretion of glucagon-like peptide-1 in type 2 diabetic pa-
pendent activation of the rat insulin I gene cAMP response element. tients. J Clin Endocrinol Metab 86: 3717–3723, 2001.
Diabetes 49: 1156 –1164, 2000. 289. Toft-Nielsen MB, Madsbad S, Holst JJ. Determinants of the
269. Sokos GG, Nikolaidis LA, Mankad S, Elahi D, Shannon RP. effectiveness of glucagon-like peptide-1 in type 2 diabetes. J Clin
Glucagon-like peptide-1 infusion improves left ventricular ejection Endocrinol Metab 86: 3853–3860, 2001.
fraction and functional status in patients with chronic heart failure. 290. Tourrel C, Bailbe D, Lacorne M, Meile MJ, Kergoat M, Portha
J Card Fail 12: 694 – 699, 2006. B. Persistent improvement of type 2 diabetes in the Goto-Kakizaki
270. Stoffers DA, Desai BM, DeLeon DD, Simmons RA. Neonatal rat model by expansion of the beta-cell mass during the prediabetic
exendin-4 prevents the development of diabetes in the intrauterine period with glucagon-like peptide-1 or exendin-4. Diabetes 51:
growth retarded rat. Diabetes 52: 734 –740, 2003. 1443–1452, 2002.
271. Stoffers DA, Kieffer TJ, Hussain MA, Drucker DJ, Bonner- 291. Trapote MA, Clemente F, Galera C, Morales M, Alcantara AI,
Weir S, Habener JF, Egan JM. Insulinotropic glucagon-like pep- Lopez Delgado MI, Villanueva Penacarrillo ML, Valverde I.
tide 1 agonists stimulate expression of homeodomain protein IDX-1 Inositolphosphoglycans are possible mediators of the glucagon-like
and increase islet size in mouse pancreas. Diabetes 49: 741–748, peptide 1 (7–36)amide action in the liver. J Endocrinol Invest 19:
2000. 114 –118, 1996.
272. Sturis J, Gotfredsen CF, Romer J, Rolin B, Ribel U, Brand CL, 292. Trinh DK, Zhang K, Hossain M, Brubaker PL, Drucker DJ.
Wilken M, Wassermann K, Deacon CF, Carr RD, Knudsen LB. Pax-6 activates endogenous proglucagon gene expression in the
GLP-1 derivative liraglutide in rats with beta-cell deficiencies: in- rodent gastrointestinal epithelium. Diabetes 52: 425– 433, 2003.
fluence of metabolic state on beta-cell mass dynamics. Br J Phar- 293. Tsuboi T, da Silva X, Holz GG, Jouaville LS, Thomas AP,
macol 140: 123–132, 2003. Rutter GA. Glucagon-like peptide-1 mobilizes intracellular Ca2⫹
273. Sugiyama K, Manaka H, Kato T, Yamatani K, Tominaga M, and stimulates mitochondrial ATP synthesis in pancreatic MIN6
Sasaki H. Stimulation of truncated glucagon-like peptide-1 release beta-cells. Biochem J 369: 287–299, 2003.

Physiol Rev • VOL 87 • OCTOBER 2007 • www.prv.org


1438 JENS JUUL HOLST

294. Turton MD, O’Shea D, Gunn I, Beak SA, Edwards CM, Meeran cagon-like peptide 1 in type 2 diabetic patients. Diabetes 50: 609 –
K, Choi SJ, Taylor GM, Heath MM, Lambert PD, Wilding JP, 613, 2001.
Smith DM, Ghatei MA, Herbert J, Bloom SR. A role for gluca- 314. Vilsboll T, Krarup T, Madsbad S, Holst JJ. Defective amplifica-
gon-like peptide-1 in the central regulation of feeding. Nature 379: tion of the late phase insulin response to glucose by GIP in obese
69 –72, 1996. Type II diabetic patients. Diabetologia 45: 1111–1119, 2002.
295. Ugleholdt R, Zhu X, Deacon CF, Orskov C, Steiner DF, Holst 315. Vilsboll T, Krarup T, Madsbad S, Holst JJ. Both GLP-1 and GIP
JJ. Impaired intestinal proglucagon processing in mice lacking are insulinotropic at basal and postprandial glucose levels and
prohormone convertase 1. Endocrinology 145: 1349 –1355, 2004. contribute nearly equally to the incretin effect of a meal in healthy
296. Unger RH, Eisentraut AM, McCall RH, Madison LL. Glucagon subjects. Regul Pept 114: 115–121, 2003.
antibodies and an immunoassay for glucagon. J Clin Invest 40: 317. Vilsboll T, Krarup T, Sonne J, Madsbad S, Volund A, Juul AG,
1280 –1289, 1961. Holst JJ. Incretin secretion in relation to meal size and body
297. Unger RH, Ketterer H, Eisentraut AM. Distribution of immuno- weight in healthy subjects and people with type 1 and type 2
assayable glucagon in gastrointestinal tissues. Metabolism 15: 865– diabetes mellitus. J Clin Endocrinol Metab 88: 2706 –2713, 2003.
867, 1966. 318. Vilsboll T, Zdravkovic M, Le-Thi T, Krarup T, Schmitz O,
298. Unger RH, Ohneda A, Valverde I, Eisentraut AM, Exton J. Courreges J, Verhoven Buganova IR, Madsbad S. Liraglutide
Characterization of the responses of circulating glucagon-like im- significantly improves glycemic control, lowers body weight with-
munoreactivity to intraduodenal and intravenous administration of out risk of either major or minor hypoglycemic episodes in subjects

Downloaded from http://physrev.physiology.org/ by 10.220.33.4 on November 24, 2017


glucose. J Clin Invest 47: 48 – 65, 1968. with type 2 diabetes (Abstract). Diabetes 55: A27–A28, 2006.
299. Vaag AA, Holst JJ, Volund A, Beck-Nielsen HB. Gut incretin 319. Vrang N, Phifer CB, Corkern MM, Berthoud HR. Gastric dis-
hormones in identical twins discordant for non-insulin-dependent tension induces c-Fos in medullary GLP-1/2-containing neurons.
diabetes mellitus (NIDDM)– evidence for decreased glucagon-like Am J Physiol Regul Integr Comp Physiol 285: R470 –R478, 2003.
peptide 1 secretion during oral glucose ingestion in NIDDM twins. 320. Wang Q, Brubaker PL. Glucagon-like peptide-1 treatment delays
Eur J Endocrinol 135: 425– 432, 1996. the onset of diabetes in 8-week-old db/db mice. Diabetologia 45:
300. Valverde I, Merida E, Delgado E, Trapote MA, Villanueva 1263–1273, 2002.
Penacarrillo ML. Presence and characterization of glucagon-like 321. Wang Y, Kole HK, Montrose-Rafizadeh C, Perfetti R, Bernier
peptide-1 (7–36) amide receptors in solubilized membranes of rat M, Egan JM. Regulation of glucose transporters and hexose up-
adipose tissue. Endocrinology 132: 75–79, 1993. take in 3T3-L1 adipocytes: glucagon-like peptide-1 and insulin
301. Valverde I, Rigopoulou D, Exton J, Ohneda A, Eisentraut A, interactions. J Mol Endocrinol 19: 241–248, 1997.
Unger RH. Demonstration and characterization of a second frac- 322. Wei Y, Mojsov S. Tissue-specific expression of the human recep-
tion of glucagon-like immunoreactivity in jejunal extracts. Am J tor for glucagon-like peptide-I: brain, heart and pancreatic forms
Med Sci 255: 415– 420, 1968. have the same deduced amino acid sequences. FEBS Lett 358:
302. Varndell IM, Bishop AE, Sikri KL, Uttenthal LO, Bloom SR, 219 –224, 1995.
Polak JM. Localization of glucagon-like peptide (GLP) immunore- 323. Wei Y, Mojsov S. Distribution of GLP-1 and PACAP receptors in
actants in human gut and pancreas using light and electron micro- human tissues. Acta Physiol Scand 157: 355–357, 1996.
scopic immunocytochemistry. J Histochem Cytochem 33: 1080 – 324. Wettergren A, Maina P, Boesby S, Holst JJ. Glucagon-like
1086, 1985. peptide-1 7–36 amide and peptide YY have additive inhibitory effect
303. Vella A, Shah P, Basu R, Basu A, Holst JJ, Rizza RA. Effect of on gastric acid secretion in man. Scand J Gastroenterol 32: 552–
glucagon-like peptide 1 (7–36) amide on glucose effectiveness and 555, 1997.
insulin action in people with type 2 diabetes. Diabetes 49: 611– 617, 325. Wettergren A, Petersen H, Orskov C, Christiansen J, Sheikh
2000. SP, Holst JJ. Glucagon-like peptide-1 7–36 amide and peptide YY
304. Vella A, Shah P, Reed AS, Adkins AS, Basu R, Rizza RA. Lack from the L-cell of the ileal mucosa are potent inhibitors of vagally
of effect of exendin-4 and glucagon-like peptide-1- (7, 36)-amide on induced gastric acid secretion in man. Scand J Gastroenterol 29:
insulin action in non-diabetic humans. Diabetologia 45: 1410 –1415, 501–505, 1994.
2002. 326. Wettergren A, Pridal L, Wojdemann M, Holst JJ. Amidated and
305. Verdich C, Flint A, Gutzwiller JP, Naslund E, Beglinger C, non-amidated glucagon-like peptide-1 (GLP-1): non-pancreatic ef-
Hellstrom PM, Long SJ, Morgan LM, Holst JJ, Astrup A. A fects (cephalic phase acid secretion) and stability in plasma in
meta-analysis of the effect of glucagon-like peptide-1 (7–36) amide humans. Regul Pept 77: 83– 87, 1998.
on ad libitum energy intake in humans. J Clin Endocrinol Metab 86: 327. Wettergren A, Schjoldager B, Mortensen PE, Myhre J, Chris-
4382– 4389, 2001. tiansen J, Holst JJ. Truncated GLP-1 (proglucagon 78 –107-
306. Verdich C, Toubro S, Buemann B, Lysgard MJ, Juul HJ, amide) inhibits gastric and pancreatic functions in man. Dig Dis
Astrup A. The role of postprandial releases of insulin and incretin Sci 38: 665– 673, 1993.
hormones in meal-induced satiety-effect of obesity and weight 328. Wettergren A, Wojdemann M, Holst JJ. Glucagon-like peptide-1
reduction. Int J Obes Relat Metab Disord 25: 1206 –1214, 2001. inhibits gastropancreatic function by inhibiting central parasympa-
307. Vila Petroff MG, Egan JM, Wang X, Sollott SJ. Glucagon-like thetic outflow. Am J Physiol Gastrointest Liver Physiol 275:
peptide-1 increases cAMP but fails to augment contraction in adult G984 –G992, 1998.
rat cardiac myocytes. Circ Res 89: 445– 452, 2001. 329. Wettergren A, Wojdemann M, Meisner S, Stadil F, Holst JJ.
308. Villanueva-Penacarrillo ML, Delgado E, Trapote MA, Alcan- The inhibitory effect of glucagon-like peptide-1 (GLP-1) 7–36 amide
tara A, Clemente F, Luque MA, Perea A, Valverde I. Glucagon- on gastric acid secretion in humans depends on an intact vagal
like peptide-1 binding to rat hepatic membranes. J Endocrinol 146: innervation. Gut 40: 597– 601, 1997.
183–189, 1995. 330. Wheeler MB, Gelling RW, McIntosh CH, Georgiou J, Brown
309. Vilsboll T, Agerso H, Krarup T, Holst JJ. Similar elimination JC, Pederson RA. Functional expression of the rat pancreatic islet
rates of glucagon-like peptide-1 in obese type 2 diabetic patients glucose-dependent insulinotropic polypeptide receptor: ligand
and healthy subjects. J Clin Endocrinol Metab 88: 220 –224, 2003. binding and intracellular signaling properties. Endocrinology 136:
310. Vilsboll T, Holst JJ. Incretins, insulin secretion and Type 2 dia- 4629 – 4639, 1995.
betes mellitus. Diabetologia 47: 357–366, 2004. 331. Wideman RD, Yu IL, Webber TD, Verchere CB, Johnson JD,
311. Vilsboll T, Knop FK, Krarup T, Johansen A, Madsbad S, Cheung AT, Kieffer TJ. Improving function and survival of pan-
Larsen S, Hansen T, Pedersen O, Holst JJ. The pathophysiology creatic islets by endogenous production of glucagon-like peptide 1
of diabetes involves a defective amplification of the late-phase (GLP-1). Proc Natl Acad Sci USA 103: 13468 –13473, 2006.
insulin response to glucose by glucose-dependent insulinotropic 332. Willms B, Werner J, Holst JJ, Orskov C, Creutzfeldt W,
polypeptide-regardless of etiology and phenotype. J Clin Endocri- Nauck MA. Gastric emptying, glucose responses, and insulin se-
nol Metab 88: 4897– 4903, 2003. cretion after a liquid test meal: effects of exogenous glucagon-like
312. Vilsboll T, Krarup T, Deacon CF, Madsbad S, Holst JJ. Re- peptide-1 (GLP-1)- (7–36) amide in type 2 (noninsulin-dependent)
duced postprandial concentrations of intact biologically active glu- diabetic patients. J Clin Endocrinol Metab 81: 327–332, 1996.

Physiol Rev • VOL 87 • OCTOBER 2007 • www.prv.org


THE PHYSIOLOGY OF GLUCAGON-LIKE PEPTIDE 1 1439

333. Xu G, Stoffers DA, Habener JF, Bonner-Weir S. Exendin-4 339. Zander M, Madsbad S, Deacon CF, Holst JJ. The metabolite
stimulates both beta-cell replication and neogenesis, resulting in generated by dipeptidyl-peptidase 4 metabolism of glucagon-like
increased beta-cell mass and improved glucose tolerance in dia- peptide-1 has no influence on plasma glucose levels in patients with
betic rats. Diabetes 48: 2270 –2276, 1999. type 2 diabetes. Diabetologia 49: 369 –374, 2006.
334. Yamamoto H, Kishi T, Lee CE, Choi BJ, Fang H, Hollenberg 340. Zander M, Madsbad S, Madsen JL, Holst JJ. Effect of 6-week
AN, Drucker DJ, Elmquist JK. Glucagon-like peptide-1-respon- course of glucagon-like peptide 1 on glycaemic control, insulin
sive catecholamine neurons in the area postrema link peripheral sensitivity, and beta-cell function in type 2 diabetes: a parallel-
glucagon-like peptide-1 with central autonomic control sites. group study. Lancet 359: 824 – 830, 2002.
J Neurosci 23: 2939 –2946, 2003. 341. Zarich SW. The role of intensive glycemic control in the manage-
335. Yamamoto H, Lee CE, Marcus JN, Williams TD, Overton JM, ment of patients who have acute myocardial infarction. Cardiol
Lopez ME, Hollenberg AN, Baggio L, Saper CB, Drucker DJ, Clin 23: 109 –117, 2005.
Elmquist JK. Glucagon-like peptide-1 receptor stimulation in-
342. Zhao T, Parikh P, Bhashyam S, Bolukoglu H, Poornima I, Shen
creases blood pressure and heart rate and activates autonomic
YT, Shannon RP. Direct effects of glucagon-like peptide-1 on
regulatory neurons. J Clin Invest 110: 43–52, 2002.
336. Yang H, Egan JM, Wang Y, Moyes CD, Roth J, Montrose MH, myocardial contractility and glucose uptake in normal and post-
Montrose-Rafizadeh C. GLP-1 action in L6 myotubes is via a ischemic isolated rat hearts. J Pharmacol Exp Ther 317: 1106 –
receptor different from the pancreatic GLP-1 receptor. Am J 1113, 2006.

Downloaded from http://physrev.physiology.org/ by 10.220.33.4 on November 24, 2017


Physiol Cell Physiol 275: C675–C683, 1998. 343. Zhou J, Wang X, Pineyro MA, Egan JM. Glucagon-like peptide 1
337. Yang Z, Chen M, Carter JD, Nunemaker CS, Garmey JC, and exendin-4 convert pancreatic AR42J cells into glucagon- and
Kimble SD, Nadler JL. Combined treatment with lisofylline and insulin-producing cells. Diabetes 48: 2358 –2366, 1999.
exendin-4 reverses autoimmune diabetes. Biochem Biophys Res 344. Zhu X, Zhou A, Dey A, Norrbom C, Carroll R, Zhang C, Lau-
Commun 344: 1017–1022, 2006. rent V, Lindberg I, Ugleholdt R, Holst JJ, Steiner DF. Disrup-
338. Yi F, Brubaker PL, Jin T. TCF-4 mediates cell type-specific tion of PC1/3 expression in mice causes dwarfism and multiple
regulation of proglucagon gene expression by beta-catenin and neuroendocrine peptide processing defects. Proc Natl Acad Sci
glycogen synthase kinase-3␤. J Biol Chem 280: 1457–1464, 2005. USA 99: 10293–10298, 2002.

Physiol Rev • VOL 87 • OCTOBER 2007 • www.prv.org