Evaluating the role of alpha cell dysregulation in the progression to type 2 diabetes using mathematical simulations.

AIMS/HYPOTHESIS Alpha cell dysregulation is an integral part of type 2 diabetes pathophysiology, increasing fasting as well as postprandial glucose concentrations. Alpha cell dysregulation occurs in tandem with the development of insulin resistance and changes in beta cell function. Our aim was to investigate, using mathematical modelling, the role of alpha cell dysregulation in beta cell compensatory insulin secretion and subsequent failure in the progression from normoglycaemia to type 2 diabetes defined by ADA criteria. METHODS We developed a physiological model of glucose homeostasis, whereby the fast dynamics of glucose, insulin and glucagon are coupled to the dynamics of beta cell functional mass (a product of individual beta cell functional capacity and mass). Beta cell functional mass exhibits an initial compensatory increase in response to hyperglycaemia, followed by an eventual decline due to glucotoxicity. Alpha cell dysregulation, defined as increased glucagon secretion and lowered glucagon suppression resulting in hyperglycaemia, was introduced to varying extents, and simulations were carried out to assess the effects on beta cell functional mass over a 20 year period. RESULTS The simulations were carried out under conditions of moderate, mild or no alpha cell dysregulation. The parameters representing insulin resistance, glucagon secretion and suppression for an individual with normoglycaemia obtained from previously published work were evolved over a period of 20 years to the mean values observed in type 2 diabetes. The model was validated by visually matching the beta cell functional mass obtained from the simulations of the disease progression model to previously published parameters. Those parameters were obtained from fits of a model of OGTTs to data from a cross-sectional cohort that spanned the spectrum from normoglycaemia to type 2 diabetes. We found that mild alpha cell dysregulation elicited robust beta cell compensation, resulting in controlled postprandial glucose excursions despite the development of insulin resistance. Moderate alpha cell dysregulation initially enhanced compensation but eventually accelerated the progression to type 2 diabetes. Alpha cell dysregulation impacted the time course of the standard markers of diabetes (fasting glucose, 2 h plasma glucose and HbA1c) during disease progression. CONCLUSIONS/INTERPRETATION The early stages of alpha cell dysregulation led to robust beta cell functional mass compensation driven by elevated fasting glucose. When the dysregulation progressed further, glucose levels rose to levels of glucotoxicity, exacerbating beta cell functional mass loss and accelerating the onset of type 2 diabetes. The various markers of diabetes (fasting glucose, 2 h plasma glucose and HbA1c) differed in terms of the prediction of timing of onset of disease, depending on the extent of alpha cell dysregulation.