Chapter 150
Glucagon
Nori Geary
ABSTRACT
Glucagon is a peptide hormone synthesized and secreted by the
pancreatic α-cells. The glucagon receptor is a G-protein-coupled,
seven-transmembrane domain receptor and is expressed in the
liver, pancreatic islets, heart, adipose tissue, and, less abundantly,
in other tissues. Glucagon is secreted when blood glucose concen-
trations decrease, and it rapidly increases hepatic glucose produc-
tion, through glycogenolysis for the first approximately 3 h and
both glycogenolysis and gluconeogenesis thereafter. Glucagon has
several effects on lipid metabolism, notably stimulation of hepatic
fatty acid oxidation and ketone synthesis. Glucagon is also secreted
during stress, such as during exercise, and contributes to the main-
tenance of metabolic fuel homeostasis in these situations. Glucagon
is secreted during most meals, and prandial glucagon secretion
contributes to meal-ending satiation. Plasma glucagon concentra-
tions are chronically elevated in diabetes and contribute to its patho-
physiological consequences. The therapeutic potential of glucagon
in several of the areas mentioned is the focus of current research.
INTRODUCTION
Glucagon research has a long history.19 In their initial
description of the discovery of insulin in 1921, Banting and
Best3 noted that their pancreatic extracts had hyperglycemic
and hypoglycemic properties. Only 2 years later, Murlin
et al.22 isolated pancreatic extracts that had only hypergly-
cemic activity and named the putative active molecule glu-
cagon. Glucagon was isolated to the pancreatic α-cells by
Sutherland and de Duve in 1948,28 the amino acid sequence
of glucagon was established by Bromer et  al. in 1956,4
and a radioimmunoassay was developed by Unger et al. in
1959.29 Consistent with its long history and potent biologi-
cal effects, glucagon physiology and pathophysiology have
been studied extensively in mice, rats, dogs, pigs, nonhuman
primates, and, of course, humans. The good correspondence
of most results in these diverse animal models with those
in humans indicates the high translational utility of animal
research on glucagon. Progress in glucagon physiology and
pathophysiology through the mid-1990s was reviewed in
detail in three volumes of the Handbook of Experimental
Pharmacology.16–18
Handbook of Biologically Active Peptides. http://dx.doi.org/10.1016/B978-0-12-385095-9.00150-0
1118
GLUCAGON AND THE GLUCAGON
RECEPTOR
Posttranslational processing of the glucagon gene product
proglucagon, a 160-amino-acid polypeptide, produces a
variety of bioactive peptide hormones. This processing is
tissue-specific because of the differential expression of the
prohormone convertase PC2 (or neuroendocrine convertase
2, NEC2) in the pancreatic α-cells and PC1/3 elsewhere,
respectively (see the Peptide Biosynthesis/Processing sec-
tion of the book). Glucagon, human proglucagon 33–61, is
synthesized and released mainly from the pancreatic α-cells
and acts almost exclusively on the glucagon receptor, which
recognizes glucagon’s C-terminal. The exception is that
glucagon has pharmacological and perhaps physiological
actions on gastrointestinal smooth muscles that are medi-
ated by an unknown receptor that recognizes glucagon’s
N-terminal. The major residues of glucagon synthesis, that
is, proglucagon 1–30 (GRPP, glicentin-related polypeptide),
proglucagon 64–69 (intervening peptide-1), and progluca-
gon 72–158 (MPGF, major proglucagon fragment), seem
to be inactive. The glucagon gene and its posttranslational
products are highly conserved in the vertebrate lineage. Rat,
mouse, and human glucagons are identical.
Intestinal L cells produce glicentin (proglucagon 1–69),
which seems to be inactive, as well as glucagon-like pep-
tide-1 (GLP-1; proglucagon 78–107amide), GLP-2 (proglu-
cagon 126–158), and oxytomodulin (proglucagon 33–69),
all of which are active. Small amounts of GLP-1 may also
result form cleavage of MPGF in the α-cells. As the pro-
glucagon amino acid sequences of these peptides suggest,
only oxyntomodulin has structural homology to glucagon
and mimics glucagon’s bioactivity. Oxyntomodulin, how-
ever, stimulates hepatic glucose production about an order
of magnitude less potently than does glucagon, presumably
because its C-terminal extension interferes with receptor
binding. The actions of GLP-1 and GLP-2 are independent
of those of glucagon. L cells also produce glucagon in physi-
ologically relevant amounts if the pancreatic α-cells do not,
for example, after pancreotomy. Finally, a circumscribed set
of neurons in the nucleus tractus solitarius produces GLP-1,
Copyright © 2013 Elsevier Inc. All rights reserved.
SECTION | XII    Handbook of Biologically Active Peptides: Ingestive Peptides
but whether glucagon is produced or acts in the CNS remains
controversial.
The human glucagon receptor is a 485-amino-acid
protein with a 143-amino-acid extracellular N-terminal.
Amino acids 80–142 seem crucial for specific recognition
of glucagon, and other sites in the N terminal as well as
other extracellular domains seem to determine the recep-
tor conformation that permits binding. The structure of
the glucagon receptor, like that of glucagon, is highly con-
served. The N-terminal sequence of the glucagon receptor
is 97% identical in rats and humans. Glucagon receptors are
expressed densely in the liver and also in physiologically
relevant numbers in the pancreatic islets, kidney, heart,
adipose tissue, gastrointestinal tract, and, possibly, brain.
The glucagon receptor is a member of a distinct family of
G-protein-coupled seven transmembrane domain receptors,
whose activation leads to activation of membrane-bound
adenyl cyclase, which increases intracellular cyclic adenos-
ine monophosphate (cAMP) and via cAMP increases inosi-
tol 1,4,5-triphsophate (InsP3) or Ca2+. Work on glucagon’s
intracellular signaling pathway led to Nobel Prizes to Earl
Sutherland in 1971, for cAMP signaling, and to Martin
Rodbell in 1994, for G-protein-coupled receptor signaling.
This remains the canonical glucagon-signaling pathway,
although additional mechanisms may contribute in some
tissues. For example, some results indicate that some eleva-
tion of intracellular InsP3 and Ca2+ may occur independent
of cAMP in the liver.
Glucagon itself is a prohormone in some target tissues,
including liver and heart, where glucagon 19–29, or mini-
glucagon, is produced by endopeptidases that attack the
arginine doublet at positions 17 and 18 of glucagon. Mini-
glucagon inhibits the hepatic Ca2+ pump 2–3 orders of mag-
nitude more potently than glucagon and also is a component
of the positive inotropic effect of glucagon in the heart.
GLUCAGON SECRETION
Glucagon is secreted tonically as plasma glucose concentra-
tions decrease during fasting or in hypoglycemia and pha-
sically during sudden-onset hypoglycemia, during meals
(except pure carbohydrate meals), and during certain physi-
ological stresses, including exercise. The increase in gluca-
gon secretion produced by decreasing plasma glucose levels
is in large part an indirect effect caused by release from a
number of inhibitory signals that are tonically active during
euglycemia, with some contribution of a direct inhibitory
action of glucose.11,20 The most important of the inhibi-
tory signals that tonically inhibit glucagon secretion are
related to local, intra-islet secretions. Falling plasma glu-
cose decreases the secretion of insulin, zinc, and GABA by
the pancreatic β-cells. Insulin and zinc act on ATP-sensitive
K+ channels to hyperpolarize the α-cell membrane. GABA,
1119
acting via cognate receptors on the α-cell membrane, also
produces α-cell hyperpolarization. Decreases in plasma
glucose concentratons are also sensed in the ventromedial
hypothalamus and other brain sites, leading to increases
in sympathetic and parasympathetic neural activity, both
of which can stimulate glucagon secretion. Increased epi-
nephrine secretion by the adrenal medulla also participates.
The autonomic nervous system is also the main mediator of
stress-related and prandial glucagon secretion. Further con-
trols include somatostatin and GLP-1, both of which act on
receptors on the α-cell membrane to inhibit glucagon secre-
tion, and various plasma amino acids, which stimulate glu-
cagon secretion (and presumably participate in the increase
in glucagon secretion afater ingestion of high-protein
meals). Although glucagon secretion is pulsatile, pulsatility
has not been shown to affect glucagon’s potency in vivo.
PHYSIOLOGICAL EFFECTS
Glucagon has a panoply of physiological effects,13,16–18 a
few of which are briefly reviewed here.
Hepatic Glucose Production
Glucagon phasically and tonically stimulates hepatic glu-
cose output.6,7,11,23,25 The phasic effect results entirely from
the stimulation of glycogenolysisis. Over its physiological
range of approximately 0–200 ng/L plasma, glucagon has a
relatively linear effect on hepatic glucose production, which
can vary approximately 10-fold, between 2.5 and 25 µmol/
kg/min.25 The increase in glycogenolysis is mediated by
glucagon-stimulated increases in cAMP in the hepatocytes,
which activate glycogen phosphorylase and inhibit glyco-
gen synthase. Maximal hepatic glycogenolysis is sustained
only for approximately 15 min, however, after which the
rate of glycogenolysis decreases to approximately one-third
maximal over approximately 3 h. Hepatic gluconeogenesis
increases beginning around 3 h after the initial increase in
glucagon. This is mediated by slowly developing increases
in the activity of pyruvate carboxylase and other gluco-
neogenic enzymes and by upregulation of several genes.
Glycogenolysis and gluconeogenesis seem to contribute
quantitatively similar amounts to the tonic stimulation of
hepatic glucose production that follows an overnight fast.
Lipid Metabolism
Glucagon and insulin cooperate in the regulation of hepatic
ketogenesis. Insulin inhibits adipose tissue lipolysis, thus
increasing the supply of nonesterified fatty acids (NEFA)
to the liver, which is necessary for ketogenesis. An increase
in the liver’s capacity for fatty acid oxidation and concomi-
tant decrease in hepatic lipogenesis is also required, which
is produced by an increase in the glucagon:insulin ratio.
1120
Ketogenesis results from β-oxidation of fatty acids in the
hepatic mitochondria, which is regulated by the activity of
carnitine palmitytol transferase I, which catalyzes uptake
of fatty acid acyl-CoA into the mitochondria. In turn, mal-
onyl-CoA, the first committed intermediate in the conver-
sion of glucose into fat, acts to negatively regulate carnitine
palmitytol transferase I, such that the fall in malonyl-CoA
that accompanies the increase in the glucagon:insulin ratio
occurring during the transition from the fed to the fasted
state directs the flow of fatty acids into ketogenesis.21
Ketones provide an alternate source of metabolic fuel for
otherwise glucose-dependent tissues.
Numerous in vitro studies indicate that glucagon acts
on glucagon receptors on adipocytes to reduce lipolysis
and decrease nonesterified fatty acid release.13 Attempts to
document these phenomena in vivo, however, have met with
mixed success,10 probably partly because of the complex
interactions between the effects of insulin and glucagon on
lipid metabolism.
Glucagon causes the movement of plasma cholesterol
and triglycerides into the platelet fraction of the blood. Glu-
cagon also reduces the synthesis of triglycerides and apoli-
poprotein E in the liver and increases the binding capacity
of low-density lipoprotein receptors. In this case as well,
the normal physiological relevance of these effects remains
unresolved.
Bile Acid Metabolism
A study by Song and Chiang27 indicates that glucagon down
regulates hepatic expression of cholesterol 7-alpha-mono-
oxygenase, the rate-limiting enzyme in bile acid synthesis.
This suggests a role for glucagon in the regulation of bile
acid metabolism and provides another potential mechanism
for its control of plasma cholesterol.
Cardiac Effects
Glucagon stimulates the release of cAMP in the myocar-
dium, thus leading to positive inotropic and chronotropic
effects.30 Because this action does not require a beta-1 adre-
noceptor stimulation, glucagon is used to treat overdoes of
beta-blockers and other drugs. It may also be used for this
purpose in shock, but does not function as effectively as
catecholamine treatment in this situation.
Satiation
As mentioned above, glucagon secretion increases during
meals, except during very high-carbohydrate meals. The
demonstration that antagonizing circulating glucagon dur-
ing meals increased meal size implicates prandial glucagon
secretion in normal meal-ending satiation.14 This, inciden-
tally, was the first use of an antagonist strategy to identify
Chapter | 150  Glucagon
a normal endocrine control of eating. A subsequent study
showed that intravenous infusion of a physiological gluca-
gon dose was sufficient to hasten satiation in normal weight
men.9 The satiating effect of glucagon occurs in the liver or
portal vein and is relayed to the brain via vagal afferents.
PATHOPHYSIOLOGY
Diabetes Mellitus
Glucagon has been implicated in the pathophysiologies
of both type 1 and type 2 diabetes mellitus (T1DM and
T2DM, respectively).1,2,6,7,12,26 The normal or near-normal
fasting plasma glucagon concentrations found in patients
with T2DM represent marked hyperglucagonemia rela-
tive to the elevated concentrations of plasma glucose and
insulin, both of which normally inhibit glucagon secretion,
and lead to increased hepatic glucose production. Similarly,
carbohydrate ingestion fails to inhibit glucagon secretion
after meals, leading to exaggerated prandial glucagonemia
and continued hepatic glucose production. The glucagon
response to protein ingestion is also exaggerated. Thus,
disturbances in glucose-controlled and prandial glucagon
secretion are an important component of the pathophysiol-
ogy of T2DM, and their control may represent a therapeu-
tic option. The mechanisms underlying these disturbances,
unfortunately, remain obscure.
Relative hyperglucagonemia has also been implicated in
the pathophysiology of T1DM. Lee et al.15 indicate that this
contribution is not merely related to unrestrained glucose
production, as described above. These investigators found,
as others had reported, that streptozotocin, which is toxic
to the pancreatic β-cells and produces a model of T1DM,
fails to elicit hyperglycemia in transgenic mice lacking the
glucagon receptor. In addition, and very surprisingly, they
found that these mice display normal glucose tolerance,
suggesting that the lack of glucagon signaling somehow
increases the ability of liver and muscle to take up glucose
in the absence of insulin. In so far as muscle normally fails
to express glucagon receptors, the mechanism must be at
least in part indirect. One possibility is that the markedly
increased plasma GLP-1 levels in the diabetic, glucagon-
receptor knockout mice contribute.
Glucagonoma
Glucagonomas are rare, slow-growing, malignant, glucagon-
secreting tumors of the pancreatic islets. Fasting plasma
glucagon concentrations are elevated 2- to 200-fold. The
commonest presenting sign is necrolytic migratory erythema-
totic rash. Mild T2DM, weight loss, and anorexia are typical.
Metastases occur in the liver, bone, lymph glands, and other
tissues. Because glucagonomas are rarely detected early,
management is challenging. A combination of dermatologic
SECTION | XII    Handbook of Biologically Active Peptides: Ingestive Peptides
treatments, tumor-reducing surgery, hepatic artery emboliza-
tion, and antagonism of the effects of glucagon with soma-
tostatin analogs usually effectively reverses the signs and
symptoms of glucagonoma.8
THERAPEUTIC USE
Hypoglycemia
The longest-standing therapeutic application of glucagon is
in the treatment of acute hypoglycemic episodes that are
too severe to permit the patient to ingest glucose orally and
if intravenous glucose infusion therapy is not available. It
is physiologically benign, with glucagon hypersensitiv-
ity very rarely observed. Thus, glucagon can be used even
when diagnosis of hypoglycemia is uncertain, as in ana-
phylaxis, or when its cause is unknown. Because glucagon
leads to catecholamine release, pheochromocytoma is a
contraindication.
Gastrointestinal Radiology and Esophageal
Foreign Body Impaction (EFBI)
Because glucagon relaxes gastrointestinal smooth muscle,
especially esophageal smooth muscle, a second standard
use of glucagon is to relax the gastrointestinal tract before
radiologic examination. Again, the main contraindication
for this use of glucagon is pheochromocytoma.
Glucagon’s effect to relax the esophagus has led to
its use in emergency medicine to treat EFBI. A recent
review,2 however, indicates that glucagon is not an
effective therapy for EFBI and, because it can elicit vom-
iting, increases the risks of aspiration and esophageal
perforation.
Diabetes
The emerging role of relative hyperglucagonemia in diabe-
tes mellitus described above has led to speculation as to the
usefulness of glucagon antagonism in diabetes treatment,
and promising results have been reported in animal models
of both T1DM and T2DM.1,6,7,12,15,25,26
Obesity
Two studies5,24 suggest that formulations with both gluca-
gon and GLP-1 receptor-agonist properties reduce body
weight in rodent models. Changes in both eating and
energy expenditure contribute to the effects. Future work
will have to address the conundrum that GLP-1 agonism
plus glucagon antagonism appear beneficial in T2DM,
which is most frequently caused by obesity, whereas
GLP-1 agonism plus glucagon antagonism seem benefi-
cial in obesity.
1121
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