Secondary sulphonylurea failure: what pathogenesis is responsible? 
Sulphonylurea (SU) stimulates insulin secretion by pancreatic beta-cells and is generally used as a first-line treatment for type 2 diabetes.  However, after long-term SU treatment (six months or over), some patients begin to show an increase in blood glucose once again (secondary SU failure).  Two theories have been put forward to explain this failure--dysfunction of the proinsulin conversion machinery or insulin resistance.  However, the primary pathogenesis behind secondary SU failure still needs to be investigated.  Using a reliable technique that specifically identifies intact proinsulin (IPI), total proinsulin (TPI) and specific insulin (SI), this study aims to discover if a defect in the proinsulin converting mechanism plays a role in SU failure.  Three groups were recruited for this study: healthy controls (n=8), SU responders (n=38) and secondary SU failures (n= 46).  Serum concentrations of insulin-related molecules released in response to a standard glucose challenge test were compared between the groups.  It was found that total SI was lower in the patient groups (P<0.05 compared to the control group), while TPI and IPI showed no distinct difference between the three groups (P>0.05).  TPI:SI ratio and IPI:SI ratio showed marked increases in the patient groups (P<0.05 compared to control group), with no obvious quantitative difference between SU responders and secondary SU failures (P>0.05).  Similar results for the Homa Insulin Resistant Index were found between the two patient groups.  Interestingly, blood glucose at 180 mins after glucose challenge was significantly higher in the secondary SU failure group (P<0.05), with no correlation to SI, while the SU responder group showed good correlation between the parameters (P<0.05).  We conclude that type 2 diabetes is associated with obvious dysfunction in the proinsulin-converting process and shows severe SI deficiency in responding to glucose challenge.  Dysfunction of the proinsulin conversion mechanism was not an extra cause responsible for SU failure.