Pulsatile insulin
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Pulsatile intravenous insulin therapy, sometimes called metabolic activation therapy or cellular activation therapy, describes in a literal sense the intravenous injection of insulin in pulses versus continuous infusions. Injection of insulin in pulses mimics the physiological secretions of insulin by the
pancreas The pancreas is an organ of the digestive system and endocrine system of vertebrates. In humans, it is located in the abdomen behind the stomach and functions as a gland. The pancreas is a mixed or heterocrine gland, i.e. it has both an en ...
into the portal vein which then drains into the
liver The liver is a major organ only found in vertebrates which performs many essential biological functions such as detoxification of the organism, and the synthesis of proteins and biochemicals necessary for digestion and growth. In humans, it ...
. In healthy, non-diabetic individuals, pancreatic secretions of insulin correspond to the intake of food. The pancreas will secrete variable amounts of insulin based upon the amount of food consumed (basically speaking, the more food that is consumed, the more insulin the pancreas will secrete) among other factors. Continuous exposure to insulin and glucagon is known to decrease the hormones' metabolic effectiveness on
glucose Glucose is a simple sugar with the molecular formula . Glucose is overall the most abundant monosaccharide, a subcategory of carbohydrates. Glucose is mainly made by plants and most algae during photosynthesis from water and carbon dioxide, u ...
production in
humans Humans (''Homo sapiens'') are the most abundant and widespread species of primate, characterized by bipedalism and exceptional cognitive skills due to a large and complex brain. This has enabled the development of advanced tools, culture, ...
due to the body developing an increased tolerance to the hormones. Down-regulation at the
cellular Cellular may refer to: *Cellular automaton, a model in discrete mathematics * Cell biology, the evaluation of cells work and more * ''Cellular'' (film), a 2004 movie *Cellular frequencies, assigned to networks operating in cellular RF bands *Cell ...
level may partially explain the decreased action of steady-state levels of insulin, while pulsatile
hormone A hormone (from the Greek participle , "setting in motion") is a class of signaling molecules in multicellular organisms that are sent to distant organs by complex biological processes to regulate physiology and behavior. Hormones are require ...
secretion may allow recovery of
receptor Receptor may refer to: * Sensory receptor, in physiology, any structure which, on receiving environmental stimuli, produces an informative nerve impulse *Receptor (biochemistry), in biochemistry, a protein molecule that receives and responds to a ...
affinity and numbers for insulin. Intermittent intravenous insulin administration with peaks of insulin concentrations may enhance suppression of gluconeogenesis and reduce
hepatic The liver is a major organ only found in vertebrates which performs many essential biological functions such as detoxification of the organism, and the synthesis of proteins and biochemicals necessary for digestion and growth. In humans, it is ...
glucose production.


Background

Dr. Thomas Aoki, former Head of
Metabolism Metabolism (, from el, μεταβολή ''metabolē'', "change") is the set of life-sustaining chemical reactions in organisms. The three main functions of metabolism are: the conversion of the energy in food to energy available to run c ...
Research at the
Joslin Diabetes Center Joslin Diabetes Center is the world's largest diabetes research center, diabetes clinic, and provider of diabetes education. It is located in the Longwood Medical and Academic Area in Boston, Massachusetts, United States. Among the Harvard Medica ...
in
Boston Boston (), officially the City of Boston, is the state capital and most populous city of the Commonwealth of Massachusetts, as well as the cultural and financial center of the New England region of the United States. It is the 24th- mo ...
, Massachusetts, and a former Professor of Medicine at the
University of California, Davis The University of California, Davis (UC Davis, UCD, or Davis) is a public land-grant research university near Davis, California. Named a Public Ivy, it is the northernmost of the ten campuses of the University of California system. The inst ...
, led the field as a pioneer of using pulsatile insulin in the treatment of diabetes. Aoki's work focused on the role of liver dysfunction in diabetic metabolism. He theorized that end organ damage in diabetes is caused by abnormal hepatic glucose metabolism, inadequate insulin delivery, and insulin resistance. He called his approach Metabolic Activation Therapy (MAT), which consisted of an ever-increasing baseline of insulin using Respiratory Quotient to determine the efficiency of treatment (US Patent 4,826,810).


Pulsatile insulin and the liver

Normally, insulin is secreted from the pancreas in pulses into the portal vein which brings blood into the liver in variable amounts, closely related to
ingestion Ingestion is the consumption of a substance by an organism. In animals, it normally is accomplished by taking in a substance through the mouth into the gastrointestinal tract, such as through eating or drinking. In single-celled organisms in ...
of meals. For induction and maintenance of insulin-dependent enzymes essential for glucose metabolism in the liver (e.g. hepatic glucokinase,
phosphofructokinase Phosphofructokinase (PFK) is a kinase enzyme that phosphorylates fructose 6-phosphate in glycolysis. Function The enzyme-catalysed transfer of a phosphoryl group from ATP is an important reaction in a wide variety of biological processes. ...
, and
pyruvate kinase Pyruvate kinase is the enzyme involved in the last step of glycolysis. It catalyzes the transfer of a phosphate group from phosphoenolpyruvate (PEP) to adenosine diphosphate (ADP), yielding one molecule of pyruvate and one molecule of ATP. P ...
), the
hepatocytes A hepatocyte is a cell of the main parenchymal tissue of the liver. Hepatocytes make up 80% of the liver's mass. These cells are involved in: * Protein synthesis * Protein storage * Transformation of carbohydrates * Synthesis of cholesterol, ...
require a defined insulin level (200-500 µU/ml in the portal vein) concomitant with high glucose levels (which acts as a bimolecular signal). In non-diabetic subjects, portal insulin concentrations are twofold to threefold greater than those in the peripheral circulation. During the first pass through the liver, 50% of the insulin is removed, strongly insinuating that the liver is the principal metabolic target organ of the
gastrointestinal The gastrointestinal tract (GI tract, digestive tract, alimentary canal) is the tract or passageway of the digestive system that leads from the mouth to the anus. The GI tract contains all the major organs of the digestive system, in humans and ...
tract and the pancreas. The insulin retained by the hepatocytes may itself be essential for the long-term effects of insulin on hepatic glucose metabolism as well as growth and de novo enzyme synthesis. Following oral glucose intake, the liver accounts for an equal or greater portion of total net glucose uptake compared to the periphery. Insulin exerts pivotal control of glucose levels through its ability to regulate hepatic glucose production directly or indirectly. The traditional subcutaneous (S.C.) insulin administration regimens used by diabetic patients fails to capture the pulsatile nature of natural insulin secretion and does not reach high enough insulin concentrations at the hepatocyte level (e.g., 10 U regular insulin injected S.C. produce a peak systemic circulation concentration of 30–40 µU/ml and an even lower portal vein concentration of 15–20 µU/ml).


Reviews on efficacy

Several literature reviews by insurers conclude that there is insufficient evidence of efficacy. Studies have not shown a benefit with pulsatile insulin delivery.


Third party payment

Most insurers refuse to cover the treatment. In some hearings and cases where a judge has heard evidence, insurance companies have been ordered to pay for that patient. For example, a trial with
CalPERS The California Public Employees' Retirement System (CalPERS) is an agency in the California executive branch that "manages pension and health benefits for more than 1.5 million California public employees, retirees, and their families".CalPERSFa ...
resulted in a decision ordering Blue Cross and other insurance providers to pay for the therapy as to those parties. However, a subsequent assessment by CMS found no evidence that Pulsatile Insulin improves the condition of type 1 and 2 diabetics and has issued a National non-coverage decision which to date is still in effect. CMS has issued a specific code to use when billing this treatment to avoid erroneous payment by billing by the individual procedures that are used in the treatment. Until acceptable clinical trials are performed to show the benefit of pulsatile insulin or Artificial Pancreas Treatment as it is being currently marketed as, the Medicare NCD will continue to remain in effect.


Notes

{{Diabetes Insulin therapies