Italian Society for the Study of Diabetes (SID)/Italian Endocrinological Society (SIE) guidelines on the treatment of hyperglycemia in Cushing's syndrome and acromegaly.

BACKGROUND: Hyperglycemia is a common feature associated with states of increased growth hormone secretion and glucocorticoid levels. AIMS: The purpose of these guidelines is to assist clinicians and other health care providers to take evidence-based therapeutic decisions for the treatment of hyperglycemia in patients with growth hormone and corticosteroid excess. METHODOLOGY: Both the SID and SIE appointed members to represent each society and to collaborate in Guidelines writing. Members were chosen for their specific knowledge in the field. Each member agreed to produce--and regularly update--conflicts of interest. The Authors of these guidelines prepared their contributions following the recommendations for the development of Guidelines, using the standard classes of recommendation shown below. All members of the writing committee provided editing and systematic review of each part of the manuscript, and discussed the grading of evidence. Consensus was guided by a systematic review of all available trials and by interactive discussions.

Italian Society for the Study of Diabetes (SID)/Italian Endocrinological Society (SIE) guidelines on the treatment of hyperglycemia in Cushing's syndrome and acromegaly.

Hyperglycemia is a common feature associated with states of increased growth hormone secretion and glucocorticoid levels. The purpose of these guidelines is to assist clinicians and other health care providers to take evidence-based therapeutic decisions for the treatment of hyperglycemia in patients with growth hormone and corticosteroid excess. Both the SID and SIE appointed members to represent each society and to collaborate in Guidelines writing. Members were chosen for their specific knowledge in the field. Each member agreed to produce-and regularly update-conflicts of interest. The authors of these guidelines prepared their contributions following the recommendations for the development of Guidelines, using the standard classes of recommendation shown below. All members of the writing committee provided editing and systematic review of each part of the manuscript, and discussed the grading of evidence. Consensus was guided by a systematic review of all available trials and by interactive discussions.

The tall cell variant of papillary thyroid carcinoma: clinical and pathological features and outcomes.

BACKGROUND: The tall cell variant (TCV) is a relatively rare variant of papillary thyroid cancer. Since a controversy exists whether or not the TCV has a worse outcome, the aim of our study was to retrospectively compare the clinicopathological features and outcomes in a group of TCV patients and a larger group of patients with classical papillary thyroid carcinoma (cPTC). SUBJECTS AND METHODS: Data from 30 TCV and 293 cPTC patients were analyzed. Among the 293 cPTC, we also selected a "high-risk" cPTC group (no.=103) that was treated with the same protocol used for the TCV patients. All data were managed by Cox analysis. RESULTS: Compared to all cPTC patients, TCV subjects displayed only a significantly higher rate of extrathyroid extension. At multivariate analysis, TCV was not an independent variable for the prediction of a high risk of persistent/recurrent disease. At the last follow-up observation, there was no difference in the disease status between the TCV and all cPTC patients. Moreover, "high-risk" cPTC patients had a significant increase in persistent/recurrent disease. CONCLUSIONS: In our study, although the TCV histotype is associated with a higher prevalence of extrathyroid extension, it is characterized by an outcome that is not significantly different from that of all cPTC patients and is more favorable than that of "high-risk" cPTC patients. Only those TCV patients classified as "high risk" based on specific pathological and clinical features, according to current guidelines, should be treated aggressively, such as with a total thyroidectomy, neck lymph node dissection or ablative radioiodine treatment.

Effects of prophylaxis with iodised salt in an area of endemic goitre in north-eastern Sicily.

In developed countries, the use of iodised salt represents the best prophylaxis of endemic goitre in areas exposed to iodine deficiency. In the present study we re-evaluated goitre prevalence and iodine intake 10 years after the introduction of iodised salt in an area of goitre endemia in north-eastern Sicily (Italy), and we compared these results with those obtained in previous surveys. Three centres with known moderate goitre endemia (Bronte, Nicosia, and Gagliano) and three other smaller ones with severe goitre endemia (Sperlinga, Villadoro, and Maniace) were studied. We surveyed 697 schoolchildren. Goitre prevalence was assessed by thyroid palpation and by a thyroid ultrasound scan. Iodine urinary excretion was also measured. Iodised salt consumption was 44% of total salt consumption. Goitre prevalence assessed by thyroid palpation was significantly decreased in all towns studied compared to previous surveys. However, the persistence of a mild goitre endemia was observed in some small rural centres (5.8% in Sperlinga/Villadoro, and 11.4% in Maniace). Goitre prevalence evaluated by thyroid ultrasound scan was greater than 5% in all centres of the endemic area and was always greater than that assessed by thyroid palpation. Iodine urinary excretion was above 100 microg/l in all localities studied. In conclusion, our studies indicate a progressive reduction in goitre prevalence over a period of about 30 years in schoolchildren in a well-characterised endemic area in northeastern Sicily. The decrease in goitre prevalence was associated with a significant increase in urinary iodine excretion. However, it may be speculated that iodine deficiency is the pre-eminent, but not the exclusive cause of goitre endemia in this area.

Radiometabolic treatment of hyperthyroidism with a calculated dose of 131-iodine: results of one-year follow-up.

Oral administration of radioactive iodine (131I) is a well-known and effective procedure for the treatment of hyperthyroidism. However, the optimal dose is still a matter of debate, as is the frequency of recurrence and hypothyroidism. The aim of our study was to evaluate the 1-yr outcome of a calculated dose of 131I activity in the treatment of hyperthyroidism, following the guidelines published jointly by the Italian Society of Endocrinology and the Italian Society of Nuclear Medicine.We studied 84 patients affected with hyperthyroidism (55 with Graves' disease and 29 with toxic adenoma), who were treated with a dose of 131I activity obtained by using the formula from the guidelines. In all patients serum free T4, free T3, and TSH were measured before, and 2, 6, and 12 months after radiometabolic therapy. A thyroid scan and thyroid uptake with 131I were also performed before treatment, and a thyroid ultrasound scan was obtained before and 1 yr after treatment. One year after treatment, 22 out of 55 patients with Graves' diseases (40.0%) had persistence/ recurrence of hyperthyroidism, whereas only 1 patient of the 29 with toxic adenoma (3.4%) was still in a hyperthyroid state. The frequency of hypothyroidism in patients responsive to therapy was higher in subjects with Graves' disease (45.5%), than in those with toxic adenoma (17.3%, p=0.02). Overall size reduction of the target lesion was 56.2+/-23.1%. In conclusion, the dose calculation suggested by the guidelines represents an effective method for treating thyroid toxic adenoma. In subjects with Graves' disease, we propose using a pre-determined 131I activity, which is higher than that derived from the guidelines. Such an approach would reduce the incidence of recurrent/persistent hyperthyroidism. On the other hand, an increase in post-131I hypothyroidism should not be regarded as a negative effect in these patients, since hypothyroidism is easily corrected, and the risk of worsening ophthalmopathy is reduced.

Therapeutic options for elderly diabetic subjects: open label, randomized clinical trial of insulin glargine added to oral antidiabetic drugs versus increased dosage of oral antidiabetic drugs.

Glycemic control in elderly persons with type 2 diabetes mellitus (T2DM) is challenging because they are more likely to have other age-associated medical conditions and to experience hypoglycemia during intensive therapy. A best therapeutic strategy for these patients has not yet been defined. We investigated the efficacy and safety of adding once-daily insulin glargine to patients' current oral antidiabetic drugs (OAD) regimen, compared to increasing the OAD doses. The study enrolled patients aged 65 years or more, with poor glycemic control. Patients were randomized to two groups and entered a 3-week titration period in which their actual therapy was adjusted to meet the study's glycemic goals, by either adding insulin glargine to current therapy (group A, 27 patients) or increasing current OAD dosages (group B, 28 patients). Thereafter, therapies were continued unchanged for a 24-week observation period. The mean therapeutic dosage of insulin glargine in group A was 14.9 IU/day (SD = 5.0 IU/day). During the observation period, mean levels of glycosylated hemoglobin (HbA1c) reduced by 1.5% in group A and 0.6% in group B (P = 0.381). An HbA1c level <7.0% was achieved by five patients in each group. Mean fasting blood glucose levels reduced by 29 and 15% in groups A and B, respectively (P = 0.029). Group A had fewer total hypoglycemic events (23 vs. 79, P = 0.030) and fewer patients experiencing any such event (9 vs. 17, P = 0.045). Neither a serious hypoglycemic event nor other adverse event occurred. These results suggest that, compared to increasing OAD dosage, the addition of insulin glargine to current OAD therapy is as effective but safer in terms of the risk for hypoglycemia in elderly patients with T2DM.

Elevated insulin receptor content in human breast cancer.

The growth of breast cancer cells is under the regulation of hormones, growth factors, and their receptors. In the present study, we have employed a new, sensitive, and specific radioimmunoassay for the direct measurement of insulin receptors in surgical specimens of breast cancers. In 159 specimens the insulin receptor content was 6.15 +/- 3.69 ng/0.1 mg protein. This value was more than sixfold higher than the mean value found in both 27 normal breast tissues obtained at total mastectomy (0.95 + 0.68, P less than 0.001) and in six normal specimens obtained from reduction mammoplasty (0.84 +/- 0.78, P less than 0.001). The insulin receptor content in breast cancer tissues was also higher than in any normal tissue investigated including liver (Pezzino, V., V. Papa, V. Trischitta, A. Brunetti, P.A. Goodman, M.K. Treutelaar, J.A. Williams, B.A. Maddux, R. Vigneri, and I.D. Goldfine, 1989. Am. J. Physiol. 257:E451-457). The insulin receptor in breast cancer retained its ability to both bind insulin and undergo insulin-induced tyrosine kinase activation. Immunostaining of the specimens revealed that the insulin receptor was present in malignant epithelial cells, but was not detected in stromal and inflammatory cells. Univariant analysis revealed that the insulin receptor content of the tumors correlated positively with tumor size (P = 0.014), histological grading (P = 0.030), and the estrogen receptor content (P = 0.035). There were no significant correlations between insulin receptor content and the age, body weight, menopausal status, and nodal involvement of the patients. These studies indicate, therefore, that the insulin receptor content is increased in breast cancers and raise the possibility that the insulin receptor may have a role in the biology of these tumors.

Insulin and glucagon receptors in Morris hepatomas of varying growth rates.

The binding of both insulin and glucagon to receptors in plasma membranes from five hepatomas of varying growth rates was diminished when compared to plasma membranes from normal liver. Scatchard analyses of the binding data suggested that the decrease in glucagon binding was due to a decrease in binding capacity, whereas the decrease in insulin binding was due either to a decrease in binding affinity or to site-site interactions. The decreased binding of insulin, but not of glucagon, showed a significant correlation with increasing growth rate of the tumors. These data suggest, therefore, that decreased binding of insulin to receptors could be a feature of increasing growth rate in hepatomas.

Insulin-like growth factor-I receptors are overexpressed and predict a low risk in human breast cancer.

IGF-I receptor (IGFR) content and its prognostic significance were evaluated in human breast cancer specimens using a sensitive and specific radioimmunoassay (V. Pezzino et al., Metabolism, 40: 861, 1991). The prognostic significance of IGFR expression was investigated by two different approaches: (a) detectable IGFR content was measured in 82% of specimens in a consecutive series of 184 human breast cancers and in 32% of 19 normal breast tissues. The average IGFR content in breast cancer was nearly 10-fold higher than the value observed in normal breast tissue (7.6 +/- 0.8 versus 0.8 +/- 0.1 ng/0.1 mg protein, mean +/- SEM; P < 0.001). IGFR content was positively correlated with estrogen (ER) and insulin receptor content (r = 0.269 and 0.515, respectively, Pearson correlation) but not with progesterone receptors (PR). No significant correlation was observed between IGFR content and a variety of tumor parameters (tumor size, lymph node involvement, grade) and host characteristics (age, body mass index, menopausal status); (b) IGFR content was measured in a noncontinuous series of 265 primary breast cancer specimens subdivided into 136 high-risk and 129 low-risk specimens on the basis of being either negative (ER-/PR-/aneuploid/high S-phase) or positive (ER+/PR+/diploid/low S-phase) for four well-established prognostic factors. IGFR levels were significantly higher in the low-risk group (6.4 +/- 0.4 ng/0.1 mg protein, mean +/- SEM) than in the high-risk group (3.6 +/- 0.5; P < 0.0001, Wilcoxon sum rank test). In summary, our data indicate that there is an elevated IGFR content in most human breast cancers compared with normal breast tissue and that an elevated IGFR content is a favorable prognostic indicator.

Growth hormone levels in diabetes. Correlation with the clinical control of the disease.

We carried out contemporaneous daytime blood sugar and growth hormone (HGH) determinations in eight juvenile and six middle-aged diabetics under both poor and good metabolic control. A continuous blood sampling technic was used. The following results were obtained: 1. HGH values in poorly controlled diabetics were higher and more fluctuating than in normals of a corresponding age. 2. After good control was reached, a significant HGH decrease was observed in all patients but one. In this condition HGH levels were normalized in middle-aged diabetics but not in juvenile ones. In the latter group HGH values, even if decreased, were persistently higher than in controls of the same age. 3. No difference was observed between newly diagnosed diabetics and patients known to have had diabetes for some years. Our data support the suggestion that HGH abnormalities in diabetes are a consequence of the metabolic disturbance.

Phenformin increases insulin binding to human cultured breast cancer cells.

The effect of the hypoglycemic biguanide, phenformin, on the binding of insulin to MCF-7 cells, an in vitro line derived from a human breast cancer, has been investigated. Cells incubated for 24 h in the presence of 1.0 micrograms/ml of phenformin bound 62.2 +/- 8.1% (mean +/- SE) more 125I-insulin than did controls. The phenformin effect was dose-dependent over the concentration range of 0.1 micrograms/ml to 10.0 micrograms/ml. The increased binding was due to an increase in receptor number without a change in binding affinity. This demonstration of increased receptor number in response to phenformin exposure provides support for the hypothesis that one action of phenformin is to enhance tissue sensitivity to insulin.

Metformin and insulin receptors.

We evaluated the effect of metformin (N,N-dimethylbiguanide), a biguanide known to be less toxic than phenformin, on insulin binding to its receptors, both in vitro and in vivo. Specific 125I-insulin binding to cultured IM-9 human lymphocytes and MCF-7 human breast cancer cells was determined after preincubation with metformin. Specific 125I-insulin binding to circulating monocytes was also evaluated in six controls, eight obese subjects, and six obese type II diabetic patients before and after a short-term treatment with metformin (850 mg orally, b.i.d., for 4 days). Plasma insulin levels and blood glucose were also measured on both occasions. Metformin significantly increased insulin binding in vitro to both IM-9 lymphocytes and MCF-7 cells; the maximum increment was 47.1% and 38.0%, respectively. Metformin treatment significantly increased insulin binding in vivo to monocytes of obese subjects (+ 31%, P less than 0.05) and diabetic patients (+ 63%, P less than 0.01). Scatchard analysis indicated that the increased binding was mainly due to an increase in receptor capacity. Insulin binding to monocytes of normal controls was unchanged after metformin as were insulin levels in all groups; blood glucose was significantly reduced after metformin only in diabetic patients. These data indicate that metformin increases insulin binding to its receptors in vitro and in vivo. The effect in vivo is observed in obese subjects and in obese type II diabetic patients, paralleling the clinical effectiveness of this antidiabetic agent, and is not due to receptor regulation by circulating insulin, since no variation in insulin levels was recorded. By this mechanism, therefore, metformin may contribute to restoring insulin effectiveness in subjects with impaired insulin responsiveness.

Effects of biguanides and sulfonylureas on insulin receptors in cultured cells.

The effects of the two groups of oral agents on insulin receptors were studied in several types of cells in tissue culture: MCF-7 human breast cancer cells, IM-9 human lymphocytes, human fibroblasts, and H-35 rat hepatoma cells. In none of these cells did the four sulfonylureas tested, tolbutamide, glibenclamide (glyburide), gliclazide, and glisolamide, have any significant effects on insulin binding to its receptor. In contrast the two biguanides tested, phenformin and metformin, increased insulin binding in all cell types by 44 to 101%. These studies raise the possibility, therefore, that biguanides may have a direct effect on insulin receptors and this effect may account for the known effects of biguanides to lower elevated blood sugar levels in diabetic patients.

Regenerating rat liver: insulin and glucagon serum levels and receptor binding.

Serum insulin and glucagon levels and liver plasma membrane receptor binding were studied in rats after partial hepatectomy. To clarify whether the surgical stress and decreased food intake that accompanies partial hepatectomy influenced these parameters, sham-operated rats were also studied. When sham-operated rats were compared to nonoperated controls, there was a 30% fall in insulin levels and a significant rise in the number of insulin receptors. In contrast, glucagon levels and glucagon receptor binding were unchanged. When partially hepatectomized rats were compared to sham-operated rats, there was no significant change in either insulin levels or the number of plasma membrane insulin receptors. Insulin degradative activity, however, was decreased in liver plasma membranes from partially hepatectomized animals, causing an apparent increase in [125I]iodoinsulin binding to this organelle. Bacitracin, an inhibitor of insulin degradation, abolished this difference in insulin binding. Glucagon levels rose by 65% after partial hepatectomy, whereas the number of glucagon receptors decreased significantly. The studies demonstrate, therefore, that after partial hepatectomy, serum insulin levels and insulin receptor binding in liver are altered, and these alterations are due to surgical stress and decreased food intake. Glucagon levels and glucagon receptor binding are also altered after partial hepatectomy, but these alterations are due to liver regeneration per se.

An intact and functional soluble form of the insulin receptor is secreted by cultured cells.

We have recently reported that the insulin receptor (IR), a tetrameric transmembrane protein located on the surface of target cells, is present as a soluble form in human plasma. In the present study we investigated whether human cells in culture release an intact and functional form of the IR. We found that IRs are secreted into the incubation medium by four cell lines (IM-9 human lymphoblasts, MCF-7 human breast cancer cells, HepG2 human hepatoma cells, and 3T3 mouse fibroblasts transfected with human IRs). IR secretion was further characterized in IM-9 cells. IR release was time, temperature, and energy dependent, and enhanced by incubation with insulin. The dilution slope of secreted IRs in a specific IR RIA was parallel to that produced by highly purified human placenta IRs. Ligand binding studies revealed that secreted receptors bound insulin with high affinity, and the Scatchard analysis revealed two orders of binding sites (the high affinity site had a dissociation constant of 0.32 +/- 0.08 nM). Analysis of secreted receptors by sodium dodecyl sulfate-polyacrylamide gel electrophoresis demonstrated a molecular size of 135 kilodaltons for the alpha-subunit and 95 kilodaltons for the beta-subunit. Other experiments indicated that the beta-subunit tyrosine kinase activity of the secreted receptor was stimulated by insulin. These studies indicate, therefore, that a soluble, intact, and functional IR is secreted by cultured cells, and that this soluble protein could be involved in certain insulin-mediated functions, such as receptor down-regulation.

Metformin normalizes insulin binding to monocytes from obese nondiabetic subjects and obese type II diabetic patients.

In order to evaluate the in vivo effects of biguanides on the insulin receptor, we have studied insulin binding to circulating monocytes of six normal controls, eight obese nondiabetic subjects, and six obese type II diabetic patients, both before and after 4 days of treatment with the biguanide metformin (850 mg twice daily orally). Before drug administration, 125I-insulin binding to monocytes was decreased in obese subjects and diabetic patients. After metformin administration, an increase in insulin binding to peripheral monocytes was observed in seven of eight obese nondiabetic subjects (3.57 +/- 0.43 to 4.69 +/- 0.59% bound at 10(7) monocytes, mean +/- SEM, P less than 0.01) and in all diabetic patients (3.21 +/- 0.21 to 5.22 +/- 0.34, P less than 0.01). Scatchard plots indicated that the increased binding was due to an increase in the receptor number. In contrast, no significant change in insulin binding was found in normal controls after metformin administration (5.31 +/- 0.14 and 4.70 +/- 0.12). These studies indicate that metformin normalizes the binding of insulin to its receptor in obese subjects and diabetic patients. It is suggested, therefore, that the action of metformin on the insulin receptor may be one of the mechanisms of the antidiabetic effect of this drug.

The effect of short-term triiodothyronine administration on thyroxine response to exogenous TSH in man.

In order to examine whether thyroid hormone concentration interfere with the thyroid gland responsivity to TSH, paired studies on the effect of short-term T3 treatment on T4 response to exogenous TSH ( 5 I.U. i.m.) were carried out in 10 euthyroid volunteers. During T3 administration ( 120 mcg/day for 4 days starting 48 hr before TSH injection) a significant decrease in T4 concentrations was observed both prior to and after TSH, with an inhibition of the T4 response ranging from 36-77% as calculated from the area under the response curve. The present data are in agreement with the existence of a "short-loop" thyroid-thyroid regulatory mechanism in man. In fact, the decreased percent rise of T4 after TSH suggests an inhibitory effect of T4 release following TSH, even though a modification of T4 kinetic parameters during T3 administration may account for a portion of the lowering of T4 blood concentrations.

Comparison of the in vitro effect of biguanides and sulfonylureas on insulin binding of its receptors in target cells.

The in vitro effects of two biguanides (phenformin and metformin) and four sulfonylureas (tolbutamide, glyburide, gliclazide, and glisolamide) on insulin binding to its receptors were studied in four cultured cell lines: human skin fibroblasts, IM-9 lymphoblasts, MCF-7 human mammary carcinoma, and H35 rat hepatoma. After a 24-h preincubation with maximal stimulatory concentrations of phenformin, specific [125I] insulin binding to its receptors in the four different cell lines were increased over control by 67.2 +/ 17.0%, 101.3 +/- 11.5%, 65.1 +/- 8.0%, and 44.0 +/- 12.1%, respectively (mean +/- SE). Phenformin was effective in IM-9 cells that were down-regulated by unlabeled insulin, and the effect of phenformin on insulin binding was not affected by inhibition of protein synthesis with cycloheximide. In concert with this observation. Scatchard plots indicated that phenformin increased the insulin receptor's affinity rather than the number of insulin-binding sites on IM-9 cells. Metformin was also effective in significantly enhancing insulin binding in both IM-9 and MCF-7 cells. In contrast to the effects of biguanides, none of the four sulfonylureas tested had any significant influence on insulin binding to any of the four cell lines. These agents were also ineffective in IM-9 cells that were down-regulated by insulin. Therefore, these studies suggest that: 1) in vitro, biguanides enhance insulin binding to its receptors in a variety of cell types; 2) this effect of biguanides doesn't depend on new receptor synthesis; it is a result of changes in the affinity of the insulin receptor; and 3) in contrast to the biguanides, the sulfonylureas do not have a major direct effect on insulin binding to its receptors in most cell types.