Insulin detemir (2)

Morphine is a rather odd opioid analgesic. It has a complex multi-ring structure with two rather prominent hydroxyl groups which render it rather more hydrophilic and significantly less lipid soluble than many of its relatives. If you bolus a patient with IV morphine there is a delay in its passage across the blood-brain barrier due to this relatively poor lipid solubility. Time to peak effect is significantly delayed to somewhere around 15 minutes because the brain concentration lags way behind the rapidly changing plasma concentration. The brain never "sees" the peak plasma concentration due to this delay.

Now, if you boil some morphine up with acetic acid you can form ester linkages joining acetate on to those two hydroxyl radicals to give you di-acetyl morphine, better known as diamorphine or heroin. Masking the hydroxyl radicals markedly increases the lipid solubility of the drug and so the brain concentration rapidly follows the plasma concentration. In general lipid soluble agents cross the blood brain barrier rather faster than more water soluble agents. Peak plasma concentration will give a rapid onset peak brain concentration, which appears to be associated with effects rarely seen with morphine itself. Giving the enhanced recreational potential. This is all basic anaesthesia pharmacology with excerpts from Trainspotting thrown in.

Insulin detemir was developed to give an insulin with a very flat glycaemia controlling effect for use as a basal or background insulin. The clever people at Novo Nordisk deleted the terminal threonine from the B chain and attached a medium chain fatty acid to the now terminal lysine at position B29. The rather nice 14 carbon saturated fat, myristic acid, sticks out from the insulin molecule and neatly binds to the fatty acid binding site of albumin. It does this very rapidly and keeps the insulin bound and ineffective. Over the hours which follow there is a slow dissociation of the insulin from albumin which allows a very shallow dose response rate for glucose control. Ideal for a basal insulin.

There is a suggestion that this tagging of insulin might facilitate its transport in to the brain, a sort of heroin-insulin tweak. The idea is that myristic acid might facilitate the transport of insulin in to the brain and lead to a massive suppression of eating and subsequent weight loss. Assuming you are a true believer in the central anorectic effect of insulin. Which, sadly, I'm not.

Years ago, when insulin determir was first paraded as the living proof of the central anorectic effect of insulin, I looked up its structure and thought, as you do, that FFAs in general have very limited access to the brain. Insulin is not morphine and the myristic acid is not acetic acid. That big, long side chain of detemir is directly related to the sorts of free fatty acids which are specifically excluded from the brain. My own prediction would be that insulin detemir would have a significantly REDUCED effect within the brain.

It turns out that, at least in some labs, that my idea was slightly correct. But my idea was limited compared to the actual effect. Insulin detemir not only fails to cross the blood brain barrier itself but it also blocks the ability of ordinary human insulin to pass from plasma in to the brain. There is probably a specific insulin transporter which is nicely blockaded by an insulin molecule with the fatty acid tail of detemir sticking out. This paper says it all:

Insulin Detemir is Not Transported Across the Blood-Brain Barrier

Not a lot of mincing of words there.

If we go to labs with an outlook on life which I find comprehensible we can clearly see that physiological doses of insulin, within the brain, augment lipid uptake in to adipocytes, enhance adipocyte sensitivity to insulin, increase lipogenesis and augment fat gain. Largely through the sympathetic nervous system. I can't see how anyone would be surprised by this. Quite why anyone would expect central insulin to do the opposite of what peripheral insulin does at a comparable concentration is beyond me. I enjoyed this paper:

Central insulin action regulates peripheral glucose and fat metabolism in mice

"Moreover, chronic intracerebroventricular insulin treatment of control mice increased fat mass, fat cell size, and adipose tissue lipoprotein lipase expression, indicating that CNS insulin action promotes lipogenesis. These studies demonstrate that central insulin action plays an important role in regulating WAT mass and glucose metabolism via hepatic Stat3 activation".

How clearly does it need to be spelled out? This one is fun too:

Brain insulin controls adipose tissue lipolysis and lipogenesis.

"Here, we show that insulin infused into the mediobasal hypothalamus (MBH) of Sprague-Dawley rats increases WAT lipogenic protein expression, inactivates hormone-sensitive lipase (Hsl), and suppresses lipolysis. Conversely, mice that lack the neuronal insulin receptor exhibit unrestrained lipolysis and decreased de novo lipogenesis in WAT".


If you go looking you can find papers from Oz and Cincinatti which show that insulin detemir DOES cross the blood brain barrier and DOES suppress food intake, far better than neutral insulin does. In their own labs of course.

But I cannot forget that if you transport a researcher out of a Cincinatti psychiatry department and put her in to an industrial insulin lab she cannot get any effect of centrally infused insulin detemir or neutral insulin for that matter. Novo Nordisk cannot demonstrate this marvellous effect of insulin, even their own special insulin, in their own lab. We all know that much of the mindset of obesity research is not particularly effective at producing results which work. How they get the results derived from their ideas in their labs is what fascinates me! You couldn't make stuff up this counter intuitive. Maybe in another post.

Back in the real world we have this:

Insulin detemir results in less weight gain than NPH insulin when used in basal-bolus therapy for type 2 diabetes mellitus, and this advantage increases with baseline body mass index

Insulin detemir causes a small weight loss in morbidly obese patients, those with BMI >35kg/m2. Why? Because it blocks the brain entry of the chronically (and markedly) elevated levels of insulin so common in the morbidly obese. It has limited or zero effect within the brain in its own right. The brain simply loses awareness of the systemic pathologically elevated insulin. If plasma insulin is high enough this sudden loss of insulin's access to the brain can result in a decrease in brain driven, neurologically mediated, forced lipid storage in adipocytes, i.e. a little weight loss.

In the absence of marked hyperinsulinamia, i.e. in less obese type 2 diabetics, insulin detemir causes weight gain because there is less tonically elevated plasma insulin for the central uptake blockade to neutralise. There is no weight loss effect, although gain is undoubtedly blunted.

Insulin detemir is the best indicator I have seen that the central role of physiological concentrations of insulin within the brain is to augment fat storage. This makes sense to me.

I wouldn't ask a psychiatrist to develop an anaesthetic protocol. Or a weight loss protocol!

Peter