Acceleration of renal disease in obese SHR by exacerbation of hypertension

1. Obese SHR have lower blood pressures than lean littermates on ad libitum diets of standard rat chow and develop spontaneous progressive kidney disease with marked proteinuria, whereas lean SHR have only mild proteinuria. 2. On a high-salt diet, obese SHR show dramatic elevations in blood pressure accompanied by accelerated renal disease and mortality. Lean SHR are also salt sensitive but to a lesser degree. 3. Weight cycling elevates blood pressure in obese SHR to levels comparable to lean SHR littermates. This elevation in blood pressure is accompanied by an exacerbation of kidney disease relative to age-matched controls. 4. Ganglionic blockade reversed the elevation in blood pressure in obese SHR elicited by either high-salt diet or weight cycling. Therefore, excess sympathetic nervous activity contributes to the impact of these hypertensive stimuli. 5. Exacerbation of hypertension accelerates renal disease in obese SHR.     

Potential impact of evidence-based medicine in acute coronary syndromes: insights from GUSTO-IIb. Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes trial

OBJECTIVES: The purpose of this study to determine whether use of cardiac medications reflects evidence-based recommendations for patients with non-ST elevation acute coronary syndromes. BACKGROUND: Agency for Health Care Policy and Research practice guidelines for unstable angina recommend the use of cardiac medications based on evidence from randomized trials. It is unknown whether practitioners in the U.S., Canada and Europe follow these recommendations in patients with non-ST elevation acute coronary syndromes. METHODS: We studied 7,743 patients with non-ST elevation acute coronary syndromes enrolled in the international Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes trial. The use of aspirin, beta-adrenergic blocking agents, angiotensin-converting enzyme inhibitors and calcium channel blocking agents was determined at discharge for all patients and "ideal" patients (those with indications and no contraindications). Using published estimates of relative mortality reductions with these drugs, we calculated the lives that could have been saved at 1 year if discharge medication use had better matched guideline recommendations. RESULTS: Overall, guideline adherence at discharge in "ideal" patients was 85.6% for aspirin, 59.1% for beta-blockers and 51.7% for angiotensin-converting enzyme inhibitors. Calcium channel blockers were given to 26.7% of patients with a contraindication to these drugs. These rates were similar across locations of enrollment. Women and older patients less often received aspirin when "ideal," and younger patients more often received calcium channel blockers when they were contraindicated. If medication use had been more evidence-based, 1-year mortality might have been reduced by a relative 22%. CONCLUSIONS: There is significant room for improvement in the use of recommended drugs in patients with non-ST elevation acute coronary syndromes. Medication use that more closely follows recommendations could reduce mortality in this population.     

Early and late post-ischaemic recovery of contractile function is affected to different degrees by isoflurane and halothane in the anaesthetized rabbit model

We took advantage of the partial protection exerted by suitable dosages of nicotinamide against the beta-cytotoxic effect of streptozotocin (STZ) to create a new experimental diabetic syndrome in adult rats that appears closer to NIDDM than other available animal models with regard to insulin responsiveness to glucose and sulfonylureas. Among the various dosages of nicotinamide tested in 3-month-old Wistar rats (100-350 mg/kg body wt), the dosage of 230 mg/kg, given intraperitoneally 15 min before STZ administration (65 mg/kg i.v.) yielded a maximum of animals with moderate and stable nonfasting hyperglycemia (155 +/- 3 vs. 121 +/- 3 mg/dl in controls; P < 0.05) and 40% preservation of pancreatic insulin stores. We also evaluated beta-cell function both in vitro and in vivo 4-9 weeks after inducing diabetes. In the isolated perfused pancreas, insulin response to glucose elevation (5-11 mmol/l) was clearly present, although significantly reduced with respect to controls (P < 0.01). Moreover, the insulin response to tolbutamide (0.19 mmol/l) was similar to that observed in normal pancreases. Perfused pancreases from diabetic animals also exhibited a striking hypersensitivity to arginine infusion (7 mmol/l). In rats administered STZ plus nicotinamide, intravenous glucose tolerance tests revealed clear abnormalities in glucose tolerance and insulin responsiveness, which were interestingly reversed by tolbutamide administration (40 mg/kg i.v.). In conclusion, this novel NIDDM syndrome with reduced pancreatic insulin stores, which is similar to human NIDDM in that it has a significant response to glucose (although abnormal in kinetics) and preserved sensitivity to tolbutamide, may provide a particularly advantageous tool for pharmacological investigations of new insulinotropic agents.     

Dietary behavior during obesity

Human alimentary behavior deals with a threefold need: energetic, hedonic and sociocultural. Among the clinical constellation offered by obese patients it could be worthwile to distinguish: 1. Some constitutional and organic obesities, pathogenesis of which does not imply an abnormality of alimentary behavior; 2. Conversely, in some other cases, psychological induced behavioral abnormalities are able to lead to an overstepping of the so called "normal" weight; 3. In other instances, the alimentary behavior reflects the elevation of the set point for weight. All these mechanisms are mutally reinforcing and could act simultaneously or successively accounting for the great variability of the individual situations. In any case environmental conditions are operating and play a pathogenic role more especially as the anatomic, physiologic and psychologic background is predisposed.     

Proteoglycans in the nucleus pulposus of canine intervertebral discs after chondroitinase ABC treatment

BACKGROUND: Obese patients operated with jejunoileal bypass (JIB) have reduced plasma concentrations of insulin and glucose. Gastric inhibitory peptide/glucose-dependent insulinotropic peptide (GIP) and glucagon-like peptide-1 (GLP-1) have been found to have a profound incretin effect in humans. The aim of the present study was to examine the long-term effect of JIB on glucose metabolism. METHODS: Four groups (lean, nonoperated obese, obese 9 months after JIB and obese 20 years after JIB) of six females each were given a mixed meal (280 kcal). Plasma samples were obtained every 10 min for 60 min postprandially and were analyzed for glucose, insulin, GIP and GLP-1. RESULTS: A reduction in body mass index (kg/m2) was seen for the two patient groups operated with JIB (12.1, at 9 months post-op; 13.1, at 20 years post-op). Surgery by JIB resulted in a reduction of glucose and insulin values. Concomitantly there was an elevation of postprandial GIP and GLP-1 plasma concentrations. In the obese subjects 20 years after JIB both fasting and postprandial GIP and GLP-1 values were markedly elevated compared with the other three groups; and plasma glucose and insulin concentrations were maintained at normal levels. CONCLUSIONS: The improvement in glucose metabolism seen after JIB may be due to reduced insulin resistance after weight loss and/or increased levels of the incretin hormones GIP and GLP-1. Progressively, elevated levels of GIP and GLP-1 seem to be necessary to maintain glucose homeostasis at long-term follow-up after this procedure.     

Effects of acute and chronic ingestion of tolbutamide in the chicken

The effects of acute and chronic ingestion of tolbutamide were studied in the growing chicken. After an oral load of 100 or 25 mg tolbutamide/kg b.w., plasma insulin levels increased in a dose-dependent manner but to relatively low levels for about 10 min, while 10-20 min following tolbutamide, plasma glucose levels were markedly decreased and remained so for 2--5 hr. After 100 mg tolbutamide/kg, the profound hypoglycaemia which developed, was generally accompanied by symptoms resembling an hypoglycaemic coma: panting, muscular flacidity and convulsion. Body temperature and plasma calcium levels were not changed during and after tolbutamide-induced insulin release. In the chicken, tolbutamide response is therefore characterized by a fugitive insulin release and a profound and prolonged hypoglycaemia which suggest that the action of insulin is potentiated by other factors. Chronic ingestion of tolbutamide in the diet transiently (for one week) increased the live body weight of a dose of 400 mg tolbutamide/kg of diet. Long term (5 weeks) fasting plasma glucose levels were unchanged and fasting plasma insulin levels were decreased in the chronic tolbutamide treated chickens.     

Tolbutamide causes open channel blockade of cystic fibrosis transmembrane conductance regulator Cl- channels

Cystic fibrosis transmembrane conductance regulator (CFTR) is an epithelial Cl- channel that is regulated by protein kinase A and cytosolic nucleotides. Previously, Sheppard and Welsh reported that the sulfonylureas glibenclamide and tolbutamide reduced CFTR whole cell currents. The aim of this study was to quantify the effects of tolbutamide on CFTR gating in excised membrane patches containing multiple channels. We chose tolbutamide because weak (i.e., fast-type) open channel blockers introduce brief events into multichannel recordings that can be readily quantified by current fluctuation analysis. Inspection of current records revealed that the addition of tolbutamide reduced the apparent single-channel current amplitude and increased the open-channel noise, as expected for a fast-type open channel blocker. The apparent decrease in unitary current amplitude provides a measure of open probability within a burst (P0 Burst), and the resulting concentration-response relationship was described by a simple Michaelis-Menten inhibition function. The concentration of tolbutamide causing a 50% reduction of Po Burst (540 +/- 20 microM) was similar to the concentration producing a 50% inhibition of short-circuit current across T84 colonic epithelial cell monolayers (400 +/- 20 microM). Changes in CFTR gating were then quantified by analyzing current fluctuations. Tolbutamide caused a high-frequency Lorentzian (corner frequency, fc > 300 Hz) to appear in the power density spectrum. The fc of this Lorentzian component increased as a linear function of tolbutamide concentration, as expected for a pseudo-first-order open-blocked mechanism and yielded estimates of the on rate (koff = 2.8 +/- 0.3 microM-1 s-1), the off rate (kon = 1210 +/- 225 s-1), and the dissociation constant (KD = 430 +/- 80 microM). Based on these observations, we propose that there is a bimolecular interaction between tolbutamide and CFTR, causing open channel blockade.     

Glucose and tolbutamide induce apoptosis in pancreatic beta-cells. A process dependent on intracellular Ca2+ concentration

High concentrations of glucose are considered to be toxic for the pancreatic beta-cell. However, the mechanisms underlying beta-cell dysfunction and resulting cell death are not fully characterized. In the present study we have demonstrated that incubation of pancreatic islets and beta-cells from ob/ob mice and Wistar rats with glucose induced a process of apoptotic beta-cell death, as shown by DNA laddering, TdT-mediated dUTP-biotin nick end-labeling (TUNEL) technique, and by using DNA-staining dye HOECHST 33342. The obtained results show that the percentage of apoptotic cells was dependent on glucose concentration, being minimal at 11 mM glucose. At a concentration of 100 microM, aurintricarboxylic acid, an inhibitor of endonuclease activity, almost completely inhibited apoptosis triggered by 17 mM glucose. We have also shown that long term incubation with 100 microM sulfonylurea, tolbutamide, triggered apoptosis in pancreatic beta-cells. The process of beta-cell death induced by high glucose concentration and tolbutamide were Ca2+-dependent, because introduction to the culture medium of 50 microM D-600 or 200 microM diazoxide, which blocked glucose- and tolbutamide-induced [Ca2+]i increase, inhibited apoptosis. Thus, this study shows for the first time that high glucose concentrations and tolbutamide induce apoptosis in pancreatic beta-cells, and that this process is Ca2+-dependent.     

Abnormal functional connectivity in Alzheimer''s disease: intrahemispheric EEG coherence during rest and photic stimulation

Tolbutamide is a sulfonylurea oral hypoglycaemic agent with suspected teratogenicity in humans and demonstrated teratogenicity in laboratory animals, but the underlying mechanism is unknown. This study examined maternal-to-conceptus tolbutamide transfer on gestational days 9.5 and 10.5 and drug concentration in embryonic head, heart, and trunk regions on gestational day 10.5 after maternal dosing in mouse. Embryos exposed to tolbutamide in vitro on gestational day 8.5 were assayed for glucose uptake, glycolysis, and protein content after 6, 12, and 24 hr. Dose-dependent tolbutamide transfer from maternal serum to extraembryonic fluid occurred on gestational day 9.5 and 10.5, with highest tolbutamide levels in embryonic heart on gestational day 10.5. In vitro tolbutamide exposure on gestational day 8.5 decreased glycolysis at 6 hr, increased glycolysis at 24 hr, and had no effect on glucose uptake at 6, 12, or 24 hr. Embryonic protein content reflected growth retardation after 24 hr tolbutamide exposure. Thus, mouse embryos are directly exposed to tolbutamide after maternal dosing on gestational day 9.5 and 10.5, with concentration of drug within embryonic heart. Tolbutamide-induced changes in glucose metabolism are less apparent in whole embryos than reported in adult tissues.     

Effects of heparin treatment on hemostatic abnormalities in obese non-insulin-dependent diabetic patients

This study was conducted to identify the mechanisms responsible for coagulative and fibrinolytic alterations and to study the effects of a short-term treatment with low-dose heparin on hemostatic abnormalities in obese non-insulin-dependent diabetes mellitus (NIDDM) patients. Four groups of age- and sex-matched patients were studied: (1) lean nondiabetic subjects (n = 30) with a body mass index (BMI) less than 25 kg/m2 (lean control subjects), (2) obese nondiabetic subjects (n = 30) with a BMI greater than 30 kg/m2 (obese control subjects), (3) lean NIDDM patients (n = 30), and (4) obese NIDDM patients (n = 30). All subjects were tested on the following parameters: fibrinogen, factor VII, prothrombin fragment 1 + 2 (F1 + 2), thrombin-antithrombin III complexes (TAT), tissue plasminogen activator (t-PA) antigen (Ag) before and after venous occlusion (VO), and plasminogen activator inhibitor type-1 (PAI-1) activity pre- and post-VO. In addition, all these parameters were evaluated in obese NIDDM patients after 10 days of treatment with a single dose of 12,500-U/d subcutaneous calcium heparin and after a 10-day washout period. At baseline, obese nondiabetic subjects, lean NIDDM patients, and especially obese NIDDM patients displayed significantly (P < .01) higher levels of fibrinogen, factor VII, F1 + 2, TAT, t-PA(Ag) pre-VO, and PAI-1 pre- and post-VO and significantly (P < .01) lower levels of t-PA(Ag) post-VO. In obese NIDDM patients treated with heparin fibrinogen, factor VII, F1 + 2, TAT, t-PA(Ag) pre-VO, and PAI-1 pre- and post-VO levels significantly (P < .01) decreased and t-PA(Ag) post-VO levels significantly (P < .01) increased at the end of treatment. Our findings demonstrate in obese nondiabetic subjects, lean NIDDM patients, and especially obese NIDDM patients the hemostatic abnormalities contributing to an enhanced risk of thrombotic complications. We conclude that in obese NIDDM patients, short-term treatment with heparin may reduce this thrombophilic state and have a potential benefit in the progression of diabetic microvascular and macrovascular disease and needs further investigation.     

Effects of tolbutamide on insulin binding to isolated fat cells of the rat

In isolated fat cells of the rat the in vitro and in vivo effects of tolbutamide on insulin binding and insulin response were studied. 450 mg tolbutamide/kg/day given for 7 days significantly increased the binding of insulin to isolated adipocytes. The binding curves reflected an increase in the number of receptor sites rater than in the affinity. The effect was associated with an enhanced response to insulin of the adipose tissue, since the fat cells obtained from animals treated with tolbutamide converted significantly more glucose to lipids in the presence of insulin than those obtained from the control group. However, the augmentation of insulin binding sites was observed only at a large tolbutamide dosage, which reduced the pancreatic insulin content, the secretory response of the isolated pancreas, and the serum insulin levels. Smaller doses, sufficient to produce metabolic effects via a stimulation of insulin secretion, did not provide additional insulin binding sites. When added in vitro to the binding assay or to adipose tissue incubated for 16 h, tolbutamide failed to increase insulin binding of the fat cells. It is suggested, therefore, that the effects produced by tolbutamide after in vivo treatment reflect an indirect rather than a direct action of the sulphonylurea.     

The effects of tolbutamide on the myocardium in experimental diabetes

The effects of chronic tolbutamide treatment were examined in a diabetic animal model in which abnormal myocardial function and composition have previously been demonstrated. Eight diabetic dogs were given tolbutamide 250 mg/day orally and compared with seven untreated diabetics, five healthy dogs receiving tolbutamide, and eight normal controls. After one year, resting hemodynamic studies in the intact anesthetized state showed that treated diabetic dogs had a significantly higher left ventricular end-diastolic pressure of 12.1+/-1.3 mm Hg associated with normal end-diastolic volume, compared to 6.1+/-0.8 mm Hg in untreated diabetics (P less than 0.01) and 6.3+/-0.5 in normals. Stroke work and ejection fraction were similar to normals. Acute volume expansion revealed a larger rise of left ventricular end-diastolic pressure in treated and untreated diabetics than normals, without a significant stroke volume response in treated diabetics. Enhanced stiffness of myocardium appeared to be related to interstitial accumulation of periodic acid-Schiff staining material, further intensified in treated diabetics by triglyceride accumulation observed on electron microscopy and by chemical analysis. Thus treatment of diabetes with tolbutamide, despite improved glucose tolerance, effected further reduction of left ventricular function and altered morphology of myocardium.     

High-pressure liquid chromatographic analysis of tolbutamide in serum

A high-pressure liquid chromatographic (HPLC) analysis of tolbutamide in serum is described. The assay requires only 1 ml of serum and is capable of measuring as little as 2 mug of tolbutamide. The metabolites of tolbutamide do not interfere in the assay. Human serum samples, taken after a 1-g oral dose of tolbutamide, were analyzed by the HPLC and an existing GLC procedure, and the results are compared.     

17beta-ol androgens and free index in hirsute and hirsute obese women

We have found the mean levels of combined serum testosterone and dihydrotestosterone (T+DHT) and the free index (FI) to be significantly higher and the mean dihydrotestosterone precipitation index (DHT-PI) to be significantly lower in hirsute women than in normal women. Although the mean T+DHT values of the different groups of hirsute patients were comparable, the FI value of the oligomenorrheic and/or obese patient was higher than that of the nonobese, normally menstruating group. In addition, the mean DHT-PI level of obese patients was significantly lower than that of nonobese patients. The lowest androgen binding was found in obese patients with oligomenorrhea. In our experience, hirsutism is associated with T+DHT values of 150 ng/dl or lower. Measurement of androgen binding and androgen levels in unchromatographed serum extracts provides valuable information in the treatment of hirsute women.     

Total knee arthroplasty in morbidly obese patients

We reviewed the clinical outcomes of fifty primary total knee arthroplasties that had been performed with cement in forty patients who were considered morbidly obese (a Quetelet index of more than forty). These results were compared with those of 1768 similar procedures, performed during the same time-period by the same surgeon, in 1539 patients who were not morbidly obese (controls). At a mean of approximately five years postoperatively, there was a significant difference between the morbidly obese patients and the control group with regard to the knee and functional scores (84 and 53 points compared with 92 and 67 points; p < 0.00005 for both scores). No significant difference was detected, with the numbers available, with regard to the range of motion or the radiographic score (p = 0.77). The rate of perioperative complications was significantly higher in the morbidly obese patients (p < 0.00005). Of the fifty knees in these patients, eleven (22 percent) had a wound complication, five (10 percent) had an infection, and four (8 percent) had an avulsion of the medial collateral ligament. The five infections developed within twenty weeks after the operation, and three were associated with a wound complication. In comparison, thirty-five (2 percent) of the 1768 knees in the control group had a wound complication, eleven (0.6 percent) had an infection, and none had an avulsion of the medial collateral ligament. We concluded that total knee arthroplasty in morbidly obese patients can be successful but is associated with an increased rate of perioperative complications, including problems with wound-healing, infection, and avulsion of the medial collateral ligament. Alterations in the operative technique for soft-tissue closure and protection of the medial collateral ligament have decreased the rates of complications related to wound-healing and the medial collateral ligament.     

Cooperative study on the radioimmunological thyrotropin determination (hTSH) in serum (author''s transl)

The increased incidence of drowsiness in hypoalbuminemic patients administered diazepam and more rapid clearance of tolbutamide in cirrhotics may be due to changes in plasma protein binding. The binding of diazepam and tolbutamide was studied by equilibrium dialysis at 37degreesC over a total drug concentration range of 1 to 10 mug/ml and 50 to 300 mug/ml, respectively, in plasma from 21 normal and 14 alcoholic subjects. At 1 mug/ml, diazepam plasma protein binding (+/- S.D.) was 98.5+/-0.4 per cent in normals and 97.8+/-1.2 per cent in alcoholics; at 100 mug/ml, tolbutamide binding was 97.8+/-0.3 per cent in normals and 95.1+/-4.2 per cent in alcoholics. For both agents at all concentrations, the binding to plasma from alcoholics was significantly decreased (P less than 0.01-less than 0.02). The extent of binding of both drugs was dependent on the albumin concentration. These findings suggest that important changes in pharmacologic effect, distribution, and clearance of diazepam and tolbutamide can be anticipated in alcoholics with hypoalbuminemia.     

Autonomic functions in restrictive cardiomyopathy and constrictive pericarditis: a comparison

1. The glucose-dependence of beta-cell electrical activity and the effects of tolbutamide and diazoxide were studied in anaesthetized mice. 2. In untreated animals there was a direct relationship between glycaemia and the burst pattern of electrical activity. Animals with high glucose concentration showed continuous electrical activity. The application of insulin led to a steady decrease in blood glucose concentration and a transition from continuous to oscillatory activity at 7.7+/-0.1 mM glucose (mean+/-s.d.) and a subsequent transition from oscillatory to silent at 4.7+/-0.6 mM glucose. 3. At physiological blood glucose concentrations the electrical activity was oscillatory. The injection of tolbutamide (1800 mg kg[-1]) transformed this oscillatory pattern into one of continuous electrical activity. The increased electrical activity was associated with a decrease in blood glucose concentration from 7.1+/-0.9 (control) to 5.5+/-1.0 mM (10 min after tolbutamide injection). The effects of tolbutamide are consistent with a direct blocking effect on the K(ATP) channel that leads to membrane depolarization. 4. The injection of diazoxide (6000 mg kg[-1]) hyperpolarized the cells and transformed the oscillatory pattern into a silent one. This is consistent with a direct stimulant effect by diazoxide on the K(ATP) channel. The use of tolbutamide or diazoxide correspondingly led to the lengthening or shortening of the active phase of electrical activity, respectively. This indicates that in vivo, such activity can be modulated by the relative degree of activation or inhibition of the K(ATP) channel. 5. These results indicate that under physiological conditions, tolbutamide and diazoxide have direct and opposite effects on the electrical activity of pancreatic beta-cells, most likely through their action on K(ATP) channels. This is consistent with previous work carried out on in vitro models and explains the drugs hypo- and hyperglycaemic effects.     

Revising and validating the random search model for competitive search

The aim of the present study is a comparison of family relations in families with an obese adolescent and families with a normal-weight adolescent. Particularly, we studied the parents' and children's perceptions of some crucial areas of their relationship, e.g., communication, support, and some factors of "psychosocial risk" for the adolescents. We compared 30 family triads each with an obese child and 30 family triads each with a normal-weight child. We used a questionnaire aimed to evaluate some crucial variables of family functioning such as communication, family climate, support and satisfaction. A multivariate analysis of variance yielded no difference between obese and nonobese adolescents concerning communication with their mothers and fathers and concerning support given and received from them. In particular, analysis indicated no difference between parents of obese adolescents and parents of normal-weight adolescents regarding openness and problems in communication. As a protective factor against psychosocial risk, in both the samples the relationship with the mother arises as relevant, but, for the nonobese adolescents, both support and communication with this parent were important, whereas for the obese adolescents only support seemed to be really important. The results are discussed with respect to this approach which considered the family as the unit of analysis both from a theoretical and a methodological point of view.     

Hemodynamic changes in acute respiratory insufficiency: the role of the right ventricle

Acute respiratory failure, particularly if associated with sepsis, results in diffuse changes in pulmonary vascular geometry and the afterload characteristics against which the right ventricle must perform. Therapy in these patients frequently requires replacement of intravascular volume which, if pulmonary vascular resistance is abnormally elevated, may cause a substantial enlargement in right ventricular (RV) end-diastolic volume. The low compliance characteristics of the RV invalidate the use of filling pressure (CVP) as a guide to RV size. We have examined RV volume in critically ill patients by means of the gated 99TAc scan and noted a substantial increase in RV volume despite filling pressure in the upper normal range. This enlargement appears to encroach upon LV function because the ejection fraction of the LV remained high despite elevation of pulmonary capillary wedge pressure (PCWP). Older patients with "silent" right coronary artery disease may become hemodynamically limited during therapy for acute respiratory failure and sepsis due to RV enlargement, increased wall tension and RV ischemia, a condition not readily diagnosed at the bedside with the usual monitoring techniques.     

Effect of acute pharmacological reduction of plasma free fatty acids on growth hormone (GH) releasing hormone-induced GH secretion in obese adults with and without hypopituitarism

In obesity, there is a markedly decreased GH secretion. The diagnosis of GH deficiency (GHD) in adults is based on peak GH responses to stimulation tests. In the severely obese, peak GH levels after pharmacological stimulation are often in the range that is observed in hypopituitary patients. To distinguish obese subjects from GHD patients, it will be necessary to demonstrate that reduced GH responsiveness to a given test is reversible in the former, but not in the latter, group. Recent studies have shown that reduction of plasma free fatty acids (FFA) with acipimox in obese patients restores their somatotrope responsiveness. There are no data evaluating GH responsiveness to acipimox plus GHRH in obese adults with hypopituitarism. The aim of the present study was to evaluate the effect of acute pharmacological reduction of plasma FFA on GHRH-mediated GH secretion in obese normal subjects and obese adults with hypopituitarism. Eight obese patients with a body mass index of 34.2+/-1.2; eight obese adults with hypopituitarism, with a body mass index of 35.5+/-1.9; and six control subjects were studied. All the patients showed an impaired response to an insulin-tolerance test (0.15 U/kg, i.v.), with a peak GH secretion of less than 3 microg/L. Two tests were carried out. On one day, they were given GHRH (100 microg, i.v., 0 min), preceded by placebo; and blood samples were taken every 15 min for 60 min. On the second day, they were given GHRH (100 microg, i.v., 0 min), preceded by acipimox (250 mg, orally, at -270 min and -60 min); and blood samples were taken every 15 min for 60 min. The administration of acipimox induced a FFA reduction during the entire test. Normal control subjects had a mean peak (microg/L) of 23.8+/-4.8 after GHRH-induced GH secretion; previous acipimox administration increased GHRH-induced GH secretion, with a mean peak of 54.7+/-14.5. In obese patients, GHRH-induced GH secretion was markedly reduced, with a mean peak (microg/L) of 3.9+/-1; previous administration of acipimox markedly increased GHRH-mediated GH secretion, with a mean peak of 16.0+/-3.2 (P < 0.05). In obese adults with hypopituitarism, GHRH-induced GH secretion was markedly reduced, with a mean peak (microg/L) of 2+/-0.7; previous acipimox administration did not significantly modify GHRH-mediated GH secretion, with a mean peak of 3.3+/-1.1 (P < 0.05). The GH response of obese patients and obese adults with hypopituitarism was similar after GHRH alone. In contrast, the GH response after GHRH plus acipimox, was markedly decreased in obese adults with hypopituitarism (mean peak, 3.3+/-1.1), compared with obese patients (mean peak, 16.0+/-3.2) (P < 0.05) and control subjects (mean peak, 54.7+/-14.5) (P < 0.01). In conclusion, GH secretion, after GHRH-plus-acipimox administration, is reduced in obese adults with hypopituitarism patients, when compared with obese normal patients. Testing with GHRH plus acipimox is safe and is free from side effects and could be used for the diagnosis of GHD in adults.