A Balancing Act Disrupted in Cushing’s Syndrome

January 9, 2024by Dr. S. F. Czar0

The GIP-Glucagon Axis:

Cushing’s syndrome, a rare disorder characterized by chronic exposure to elevated glucocorticoid levels, disrupts the delicate interplay between various hormonal systems in the body. One such crucial interaction is the GIP-glucagon axis, playing a pivotal role in glucose metabolism and postprandial insulin secretion. Understanding this axis’s dysregulation in Cushing’s syndrome sheds light on the metabolic complications associated with the disease and paves the way for potential therapeutic interventions.

Enter the GIP-Glucagon Duo:

Glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) are incretin hormones secreted by the small intestine in response to food intake. These gut hormones work in tandem, amplifying insulin secretion from the pancreas while simultaneously suppressing glucagon release, leading to balanced postprandial blood glucose levels.

GLP-1, the Star Player:

GLP-1 assumes the leading role in this duo. It directly stimulates insulin-producing beta cells in the pancreas, promoting insulin secretion. Additionally, GLP-1 inhibits alpha cells, responsible for glucagon production, thus preventing a rise in blood sugar after meals.

GIP, the Supportive Partner:

While less potent than GLP-1, GIP acts synergistically to potentiate insulin secretion and suppress glucagon release. GIP also exhibits other beneficial effects, like enhancing satiety and delaying gastric emptying, contributing to overall glycemic control.

Cushing’s Syndrome Throws a Wrench in the Works:

Chronic glucocorticoid excess in Cushing’s syndrome throws this well-coordinated ballet into disarray. High cortisol levels directly impact the enteroendocrine cells of the small intestine, leading to:

  • Decreased GIP and GLP-1 secretion: Glucocorticoids suppress the expression of genes responsible for incretin production, resulting in blunted gut hormone responses to meals.
  • Impaired insulin secretion: Cortisol antagonizes the insulinotropic effects of GLP-1 and GIP on beta cells, further compromising postprandial insulin release.
  • Enhanced glucagon secretion: Glucocorticoids stimulate alpha cells, leading to excessive glucagon release and contributing to hyperglycemia.

The Result: A Metabolic Mayhem:

These combined effects contribute to the characteristic metabolic disturbances observed in Cushing’s syndrome, including:

  • Impaired glucose tolerance and fasting hyperglycemia: The blunted incretin response and enhanced glucagon action lead to inadequate insulin secretion and elevated blood sugar levels.
  • Insulin resistance: Chronic exposure to cortisol impairs insulin’s ability to promote glucose uptake in peripheral tissues, further exacerbating hyperglycemia.
  • Central obesity: Glucocorticoids promote fat accumulation in the abdomen, contributing to the characteristic “buffalo hump” and central obesity often seen in Cushing’s patients.

Therapeutic Implications:

Understanding the disrupted GIP-glucagon axis in Cushing’s syndrome opens doors for potential therapeutic strategies:

  • GLP-1 receptor agonists: These medications mimic the effects of GLP-1, stimulating insulin secretion and suppressing glucagon release, offering promising glycemic control benefits.
  • DPP-4 inhibitors: These drugs prevent the degradation of GLP-1 and GIP, allowing their incretin effects to persist for a longer duration and potentially improve postprandial glucose control.
  • GIP agonists: While still under development, these novel agents could directly target the GIP pathway, further amplifying insulin secretion and contributing to glycemic management.

Beyond Blood Sugar:

The GIP-glucagon axis disruption in Cushing’s syndrome extends beyond glycemic control. Reduced GLP-1 levels may contribute to other complications, like:

  • Fatty liver disease: GLP-1’s anti-inflammatory and lipid-lowering properties are blunted, potentially contributing to fat accumulation in the liver.
  • Bone loss: GLP-1 promotes bone formation, and its deficiency in Cushing’s syndrome may contribute to osteoporosis.
  • Cardiovascular dysfunction: GLP-1’s protective effects on the heart and vasculature are compromised, potentially increasing the risk of cardiovascular complications.

Normal Duet:

  • GLP-1: Stimulates insulin, curbs glucagon, lowers blood sugar after meals.
  • GIP: Supports GLP-1, enhances satiety, slows stomach emptying.

Cushing’s Disrupts the Rhythm:

  • Reduced GIP & GLP-1: Glucocorticoids suppress gut hormone production.
  • Impaired Insulin Secretion: Cortisol counteracts incretin effects on beta cells.
  • Enhanced Glucagon Release: Glucocorticoids boost glucagon, raising blood sugar.

The Consequence:

  • Impaired Glucose Tolerance: Blunted incretins and high glucagon lead to hyperglycemia.
  • Insulin Resistance: Cortisol hinders insulin’s ability to utilize glucose.
  • Central Obesity: Glucocorticoids promote fat accumulation in the abdomen.

Potential Remedies:

  • GLP-1 receptor agonists: Mimic GLP-1, boosting insulin and suppressing glucagon.
  • DPP-4 inhibitors: Prolong GLP-1 and GIP activity for better glycemic control.
  • GIP agonists (future): Directly target the GIP pathway to amplify insulin secretion.

Beyond Blood Sugar:

  • Fatty Liver Disease: Reduced GLP-1 may contribute to fat buildup in the liver.
  • Bone Loss: GLP-1 deficiency potentially leads to osteoporosis.
  • Cardiovascular Dysfunction: Compromised GLP-1 protection may increase heart and vascular risks.


The GIP-glucagon axis plays a crucial role in maintaining postprandial glucose homeostasis, and its dysregulation in Cushing’s syndrome contributes significantly to the metabolic disturbances associated with the disease. Understanding these mechanisms paves the way for novel therapeutic strategies aimed at restoring glycemic control and potentially mitigating other long-term complications. By investigating the intricate dance between gut hormones and glucocorticoids, we can move closer to achieving better outcomes for patients with Cushing’s syndrome.

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