【作者】 程时武；

【导师】 陆菊明； 潘长玉；

【作者基本信息】 中国人民解放军军医进修学院 ， 内分泌与代谢病， 2008， 博士

【摘要】 目的①建立精确测定胰岛素敏感性的高胰岛素-正常葡萄糖钳夹技术。②应用正常葡萄糖钳夹技术研究长效胰岛素类似物-重组甘精胰岛素注射液的人体药代动力学和药效学特性,并评价重组甘精胰岛素注射液国产制剂长秀霖和进口制剂来得时的生物等效性。③对库欣综合征患者进行高胰岛素-正常葡萄糖钳夹试验测定胰岛素敏感性,分析库欣综合征患者治疗前后代谢紊乱、胰岛素抵抗及心血管疾病危险因素。方法①应用高胰岛素-正常葡萄糖钳夹技术对10例正常体重、正常糖耐量的健康志愿者进行方法学研究。②采用随机、单盲法、单中心、三阶段交叉设计方法对16例健康男性志愿者进行皮下注射长秀霖和来得时的正常葡萄糖钳夹试验,其中6例还接受皮下注射诺和灵N试验。根椐试验中不同时间点血糖、葡萄糖输注率、血清胰岛素及血清C肽浓度进行相关药代动力学及药效学参数分析。③对11例库欣综合征进行高胰岛素-正常葡萄糖钳夹试验测定胰岛素敏感性,分析胰岛素敏感性指数与心血管疾病危险因素的相关性。对173例库欣综合征患者的临床资料进行回顾性分析,代谢综合征及代谢紊乱的诊断按照中华医学会糖尿病学分会2004年标准。结果①钳夹试验开始后,血浆胰岛素浓度迅速上升并维持在91.57±13.86mU/L,空腹血糖维持在正常水平4.99±0.15mmol/L。钳夹试验过程中内源性胰岛素和肝糖原输出得到完全抑制,血液升糖激素水平与基础状态时相比均明显下降。钳夹稳态期葡萄糖输注率为11.56±1.74mg/kg/min,不同性别受试者之间葡萄糖输注率差异无统计学意义（男性10.53±1.57mg/kg/min,女性12.25±1.59mg/kg/min,P＞0.05）。②与皮下注射诺和灵N相比,皮下注射长秀霖或来得时后试验中葡萄糖输注率及血清胰岛素浓度在2～4小时内迅速上升达到平台期,至注射后24小时仍保持较平稳,无明显峰值。长秀霖和来得时组试验中葡萄糖输注率最大值（P＜0.01）和血清胰岛素浓度最大值（P＜0.05）均明显低于诺和灵N组。多因素方差分析表明,皮下注射长秀霖和来得时组间主要药代动力学参数INS-AUC_0-24h、INS-Cmax差异均无统计学意义（P＞0.05）。Tmax经非参数检验法的秩和检验差异无统计学意义（P＞0.05）。经双单侧t检验及90%置信区间计算,Ln(AUC_0-24h)的90%置信区间（82.0%～105.2%）在80%～125%范围内,Ln（Cmax）的90%置信区间（78.9%～107.7%）在70%～143%范围内。③173例库欣综合征患者中169例（97.7%）合并代谢紊乱,其中符合代谢综合征88例（50.9%）。100例（57.8%）合并超重/月巴胖,143例（82.7%）合并高血压,108例（62.4%）合并糖代谢异常,81例（46.8%）合并血脂紊乱。35例患者手术前后资料分析显示,皮质醇水平恢复正常者代谢紊乱及心血管危险因素与库欣综合征活动期相比均有减轻,但仍有多项代谢指标异常。11例库欣综合征患者高胰岛素-正常葡萄糖钳夹试验中M值（4.54±1.77mg/kg/min）明显低于正常人（11.56±1.77mg/kg/min,P＜0.01）。相关分析结果显示M值与空腹血糖（r=0.71,P＜0.05）、空腹胰岛素水平（r=0.71,P＜0.05）及HOMA-IR指数（r=0.70,P＜0.05）均存在相关性,而与早8:00血皮质醇水平及24小时尿游离皮质醇水平（UFC）无显著相关性（P＞0.05）。结论①建立了高胰岛素-正常葡萄糖钳夹技术。②药代动力学和药效学参数结果表明长秀霖与来得时具有生物等效性,长秀霖或来得时均比诺和灵N有更平稳的血清胰岛素浓度和降糖效应。③库欣综合征患者大多合并多种代谢紊乱及心血管疾病危险因素。库欣综合征治愈、皮质醇水平恢复正常后仍存在与活动期类似的代谢紊乱和心血管疾病危险因素,其原因与中心性肥胖和/或胰岛素抵抗持续存在有关。更多还原

【Abstract】 Objective①To establish a hyperinsulinemic-euglycemic clamp technique,a method for the precise measurement of insulin sensitivity.②To study the pharmacokinetic and pharmacodynamic properties of the subcutaneously injected long-acting insulin analog-recombinant insulin glargine injections in healthy volunteers using an euglycemic glucose clamp technique, and to evaluate the bioequivalence of domestic recombinant insulin glargine injection preparation(Basalin^TM)and imported recombinant insulin glargine injection preparation（Lantus（R））.③To analyze the metabolic disorders,insulin resistance and cardiovascular risk factors in patients with Cushing’s syndrome before and after therapy.Methods①A hyperinsulinemic-euglycemic clamp technique was applied to the study of methodology in 10 healthy volunteers with normal body weight and glucose tolerance.②This single-center,randomized,single-blind,three-period,crossover design study was carried out by an euglycemic glucose clamp technique.After a baseline period of 2 hours,volunteers received single subcutaneous injection of 0.4 U/kg body weight of Basalin^TM,Lantus（R）,or Novolin（R）N on each study day.Basalin^TM and Lantus（R）were administrated in all 16 healthy male volunteers,and Novolin（R） N was administrated to only 6 of them.The pharmacokinetic and pharmacodynamic parameters were calculated according to GIR,insulin concentrations,C-peptide concentrations and blood glucose concentrations during the euglycemic glucose clamp test.③Totally 173 patients were retrospectively analyzed in this study.Metabolic syndrome and metabolic disorders were diagnosed according to the definition by Chinese Diabetes Society of Chinese Medical Association in 2004.A hyperinsulinemic-euglycemic clamp technique was applied to measure the insulin sensitivity in 11 patients.The correlation study between insulin sensitivity and cardiovascular risk factors were performed using simple linear regression analysis.Results①The serum insulin concentrations were acutely raised and maintained at 91.57±13.86 mU/L.During maintaining fasting euglycemia（4.99±0.15 mmol/L）,the secretion of endogenous insulin and hepatic glucose production were completely inhibited.In comparison with basal concentrations,the secretion of counter-regulatory hormones（including cortisol and growth hormone）were not significantly stimulated.Under these steady-state conditions of hyperinsulinemic-euglycemic,the glucose infusion rate was 11.56±1.74 mg/kg/min.There were no statistical difference in glucose infusion rate between male and female subjects（male 10.53±1.57 vs.female 12.25±1.59 mg/kg/min, P＞0.05）.②The injections of insulin glargine did not induce the pronounced peak in metabolic activity（P＜0.01）and serum insulin concentrations（P＜0.05） observed with the injection of NPH insulin,after an initial rise of 2～4 hours, metabolic activity was quite constant over the 24-hour study period.The statistic data were calculated by analysis of variance,two one-sided t tests and 90% confidence interval.There were no significant difference in INS-AUC_0-24h, INS-Cmax and INS-Tmax between the two preparations（P＞0.05）.The 90% confidence interval of Basalin^TM-Ln(AUC_0-24h)was 82.0%～105.2%which in the range of 80%～125%,the 90%confidence interval of Basalin^TM-Ln（Cmax） was 78.9%～107.7%which in the range of 70%～143%according to those of Lantus（R）.The relative bioavailability of the domestic recombinant insulin glargine injection preparation(Basalin^TM)were（99.2±20.7）%.③Of 173 patients with Cushing’s syndrome,metabolic disorders were presented in 169 patients（97.7%）,metabolic syndrome in 88 patients（50.9%）, overweight or obesity in 100 patients（57.8%）,arterial hypertension in 143 patients（82.7%）,impairment of glucose tolerance in 108 patients（62.4%）, and dyslipidemia in 81 patients（46.8%）.In 35 patients with clinical data before and after operation,the prevalence of these metabolic disorders and cardiovascular risk factors in the patients with normal circulating cortisol levels were still higher than normal,although these disorders were not as severe as those patients during their active phase of the disease.In 11 patients which accepted hyperinsulinemic-euglycemic clamp test,the M value of patients with Cushing’s syndrome were significantly lower than healthy volunteers（4.54±1.77 vs.11.56±1.77 mg/kg/min,P＜0.01）.A significant correlation was found between M value and fasting blood glucose（r=0.71,P＜0.05）,and fasting serum insulin levels（r=0.71,P＜0.05）,and HOMA-IR index（r=0.70,P＜0.05）.A significant correlation was not found between M value and serum cortisol levels at 8:00am and 24-hour urinary free cortisol levels（UFC）（P＞0.05）.Conclusions①The hyperinsulinemic-euglycemic clamp technique was successfully established.②The results of pharmacokinetic and pharmacodynamic properties demonstrated that the domestic insulin glargine injection preparation(Basalin^TM) and imported insulin glargine injection preparation（Lantus（R））were bioequivalent.The subcutaneously injected long-acting insulin analogrecombinant insulin glargine injections(Basalin^TMor Lantus（R）)induced more stable serum insulin concentrations and a smoother metabolic effect than the NPH insulin injection（Novolin（R）N）.③Patients with Cushing’s syndrome had a high prevalence of metabolic disorders and cardiovascular risk factors.Disease remission or normalization of circulating cortisol levels was not always followed by completely disappearance of metabolic disorders and cardiovascular risk factors which had existed in the active phase of the disease,probably due to a residual abdominal obesity and/or insulin resistance.更多还原