Diabetologia (2023) 66:1378–1394

https://doi.org/10.1007/s00125-023-05947-y

REVIEW

100 years of glucagon and 100 more

Nicolai J. Wewer Albrechtsen1,2 · Jens J. Holst3,4 · Alan D. Cherrington5 · Brian Finan6 · Lise Lotte Gluud7,8 ·
E. Danielle Dean5,9 · Jonathan E. Campbell10,11,12 · Stephen R. Bloom13 · Tricia M.‑M. Tan13 · Filip K. Knop7,14,15 ·
Timo D. Müller16,17

Received: 17 February 2023 / Accepted: 18 April 2023 / Published online: 27 June 2023
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2023

Abstract
The peptide hormone glucagon, discovered in late 1922, is secreted from pancreatic alpha cells and is an essential regulator
of metabolic homeostasis. This review summarises experiences since the discovery of glucagon regarding basic and clinical
aspects of this hormone and speculations on the future directions for glucagon biology and glucagon-based therapies. The
review was based on the international glucagon conference, entitled ‘A hundred years with glucagon and a hundred more’,
held in Copenhagen, Denmark, in November 2022. The scientific and therapeutic focus of glucagon biology has mainly
been related to its role in diabetes. In type 1 diabetes, the glucose-raising properties of glucagon have been leveraged to
therapeutically restore hypoglycaemia. The hyperglucagonaemia evident in type 2 diabetes has been proposed to contribute
to hyperglycaemia, raising questions regarding underlying mechanism and the importance of this in the pathogenesis of
diabetes. Mimicry experiments of glucagon signalling have fuelled the development of several pharmacological compounds
including glucagon receptor (GCGR) antagonists, GCGR agonists and, more recently, dual and triple receptor agonists
combining glucagon and incretin hormone receptor agonism. From these studies and from earlier observations in extreme
cases of either glucagon deficiency or excess secretion, the physiological role of glucagon has expanded to also involve
hepatic protein and lipid metabolism. The interplay between the pancreas and the liver, known as the liver–alpha cell axis,
reflects the importance of glucagon for glucose, amino acid and lipid metabolism. In individuals with diabetes and fatty liver
diseases, glucagon’s hepatic actions may be partly impaired resulting in elevated levels of glucagonotropic amino acids,
dyslipidaemia and hyperglucagonaemia, reflecting a new, so far largely unexplored pathophysiological phenomenon termed
‘glucagon resistance’. Importantly, the hyperglucagonaemia as part of glucagon resistance may result in increased hepatic
glucose production and hyperglycaemia. Emerging glucagon-based therapies show a beneficial impact on weight loss and
fatty liver diseases and this has sparked a renewed interest in glucagon biology to enable further pharmacological pursuits.

Keywords Amino acids · Co-agonists · Diabetes · GCGR​· Glucagon · Glucagon receptor · Gluconeogenesis · NAFLD ·
Review
Abbreviations NAFLD Non-alcoholic fatty liver disease
AMPK AMP-activated protein kinase PKA Protein kinase A
CNS Central nervous system STZ Streptozotocin
DIO Diet-induced obesity
FGF21 Fibroblast growth factor 21
GCGR​ Glucagon receptor The discovery of glucagon
GIP Glucose-dependent insulinotropic
polypeptide The discovery of insulin in 1921 by Banting et al [1] was
GLP-1 Glucagon-like peptide 1 paralleled by the observation that pancreatic extracts [2]
KATP channel ATP-sensitive potassium channel and crude insulin preparations [3] induce a brief hyper-
MBH Mediobasal hypothalamus glycaemic episode before glucose levels decrease below
baseline. Trying to optimise insulin purification, Charles
* Nicolai J. Wewer Albrechtsen Kimball and John Murlin, in 1922, isolated a pancreatic
[email protected] factor that elevates blood glucose in rabbits and dogs [4].
Extended author information is available on the last page of the article Consistent with its ability to oppose the hypoglycaemic

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Fig. 1  Key historical discoveries of glucagon biology over the last research. Glucagon, blue triangles; glucose, orange circles. Created
100 years. Pancreatic alpha cells (shown in the schematic) are the with BioRender.com. This figure is available as part of a download-
source of glucagon and the major focus in glucagon biology and able slideset

effect of insulin, the factor was called the ‘glucose agonist’ next section, therefore, we introduce and discuss the most
or, for short, ‘glucagon’ [4]. common aspects of alpha cell glucagon secretion.
During the following three decades, the hormonal sta-
tus of glucagon was not generally accepted, but several
groups had explored the possible mechanisms underly- Regulation of glucagon secretion
ing the hyperglycaemia induced by glucagon (at that
time it was also termed the ‘hyperglycaemic-glycogen- Introduction to the area
olytic factor’ due to its effect on glycogenolysis) [5]. In
1953, glucagon was purified and crystallised [6] and, in Major contributions to our understanding of the regulation
1957, the 29-long amino acid sequence was determined of glucagon secretion were made in the Unger laboratory.
by scientists from the Lilly Research Laboratories [7]. Using a variety of experimental models, glucose sensing
Meanwhile, Christian de Duve’s group and Earl Suther- and amino acid signalling in pancreatic islets were shown
land et al localised the secretory origin of glucagon to to play a fundamental role in glucagon secretion [12]. Unger
the pancreatic alpha cells and also identified the gastric and co-workers mapped secretory responses to meal inges-
mucosa as a source of glucagon [8, 9]. Finally, with the tion and also discovered the absolute or relative hyperglu-
introduction of the first glucagon radioimmunoassay cagonaemia in people with type 2 diabetes [13]. However,
by Roger Unger and colleagues in 1959 [10], it became it soon became clear that glucagon-like substances from
possible to measure plasma concentrations of glucagon the gut, as identified by Sutherland and de Duve [14], could
allowing physiological studies of glucagon and its role interfere with the measurement of glucagon. Furthermore,
in pathophysiological processes. Subsequently, it was from emerging evidence that gastrointestinal ‘glucagon’
discovered that individuals with diabetes had increased was functionally different from pancreatic glucagon and
plasma glucagon concentrations [11]. A brief historical secreted in response to different physiological stimuli,
overview of glucagon biology is shown in Fig. 1. it was realised that measuring glucagon was not simple.
A key focus of glucagon research has been to understand Moreover, low concentrations and the inherent instability of
the regulatory mechanism(s) controlling its secretion. In the glucagon further complicated the interpretation of data. It

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Fig. 2  Accurate measurement of glucagon. The precursor of with glucagon, complicating the process of measuring gluca-
glucagon, termed ‘proglucagon’ (160 amino acids) is expressed in gon using antibody-based approaches. For example, N-terminal
alpha cells and l-cells in the pancreas and intestine, respectively. glucagon antibodies also detect oxyntomodulin, while antibod-
Expression of proglucagon is also reported in brain tissue and its ies that target the mid portion of glucagon (‘side-viewing anti-
processing pattern in the brain seems to be similar to that within bodies’) also detect glicentin, oxyntomodulin and glucagon 1-61.
the intestine. Proglucagon is broken down into several peptides, C-terminal glucagon antibodies would also detect glucagon 1-61.
including glicentin-related polypeptide (GRPP), the major pro- Consequently, sandwich ELISAs are pertinent to accurate meas-
glucagon fragment and glucagon. In the pancreas, glucagon is urements of glucagon. GLP-1 and GLP-2 are not shown but these
formed and also detectable amounts of glucagon 1-61. In intesti- molecules also have sequence similarities with glucagon. Created
nal l-cells, proglucagon is processed to form glicentin and oxyn- with BioRender.com. This figure is available as part of a down-
tomodulin. All of these molecules share amino acid sequences loadable slideset

is, therefore, necessary to highlight the methodological and assays, but this circulates in low concentrations and is
technological advances that have enabled reliable and accu- secreted in parallel with pancreatic glucagon [18]). C-ter-
rate measurements of glucagon concentrations in plasma. minal (so-called ‘specific’) antisera have been used by
several laboratories [19]. Antibodies directed against the
Glucagon assays mid portion of glucagon (‘cross-reacting’ antisera) not
only react with glucagon but also with other proglucagon
A consideration of the biosynthesis of the glucagon mol- by-products, glicentin, glucagon 1-61 and oxyntomodu-
ecule illustrates the complexity of glucagon measurements. lin, and thus are of limited use. N-terminal antisera are
At least five glucagon-like molecules (and perhaps more as also of limited value due to glucagon and oxyntomodulin
a consequence of incomplete or additional protein cleav- cross-reactivity (see Fig. 2). Apart from the specificity-
age) are circulating in the body (Fig. 2) and this puts great related problems, glucagon assays must be able to detect
demands on the selectivity of glucagon assays [15]. subtle changes in glucagon levels (as little as 1 pmol/l)
The famous antibody 30K, used since 1975 in Unger’s to identify glucose-mediated suppression of secretion.
and many other laboratories [16, 17], is directed against Sandwich ELISA technology, when strictly based on N-
the C-terminus of glucagon and, therefore, does not show and C-terminal-binding antibodies, can solve these prob-
major cross-reactivity with the gut-derived products of lems [20]. Although such assays are now available, their
the glucagon gene (only the glucagon 1-61 peptide from specificity clearly depends on the exact binding epitopes;
the pancreas can interfere with C-terminal-targeting even the slightest aberration from terminal reactivity of

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the antibodies will negatively affect the accuracy of the in this phenomenon are unclear, including glucose sens-
assay. Moreover, physiological context can sometimes ing by the alpha cell. Conventional knowledge suggests
challenge assay performance. For example, after Roux- that alpha cells take up glucose via the glucose trans-
en-Y gastric bypass, the extreme mass of glicentin and porter GLUT1, and perhaps also via sodium-dependent
other proglucagon-derived peptides secreted after eating glucose cotransporters (sodium−glucose cotransporter
can cause interference even when using well-character- [SGLT] 1 and 2); however, expression levels of SGLTs
ised sandwich ELISAs [21]. Detailed guidelines for the are low in alpha cells and inhibitors of these transport-
measurement of glucagon are discussed elsewhere [15]. ers may not influence glucagon secretion [31]. It may
We now move on to describe and discuss the further com- be questioned whether the alpha cells depend on glucose
plexities underlying glucagon secretion. for energy supply at all. Any glucose that does enter the
alpha cell is assumed to be metabolised (via glucokinase,
Alpha cell secretion glycolysis and the Krebs cycle) to produce ATP, which
interacts with ATP-sensitive potassium channels ­( K ATP
The regulation of glucagon secretion by paracrine, hormonal channels), leading to cell depolarisation and generation
and nutrient stimuli is complex (Fig. 3) and still debated of action potentials [32, 33]. However, despite evidence
[22]. Several factors, such as the experimental setup used that glucose promotes alpha cell depolarisation, counter-
(e.g., in vitro vs in vivo), the technique of glucagon meas- intuitively, low glucose stimulates glucagon secretion
urements (see above) and dosing of the stimuli given (i.e. and high glucose inhibits it [34]. There is currently no
physiological vs pharmacological levels) may influence satisfactory explanation for this, and the lack of effects
results from studies in this area. An important impetus to the of sodium channel blockers (which prevent action poten-
study of alpha cell secretion of glucagon is the notion that tials) on glucagon secretion also contradicts this. Instead,
hyperglucagonaemia and the apparently abnormal regulation paracrine interactions of alpha cells with neighbouring
of glucagon by glucose in individuals with type 2 diabetes somatostatin-secreting delta cells may partly explain
is due to alpha cell dysfunction [23]. Furthermore, the up glucose-mediated regulation of glucagon secretion, as
to eightfold increase in glucagon secretion that is normally discussed in more detail below [35].
seen in response to hypoglycaemia [24] is often impaired in Fatty acids or amino acids may be more important than
individuals with type 1 diabetes. It has also been suggested glucose for regulating glucagon secretion. The stimulatory
that the intrinsic control of glucagon secretion in response to effect of certain amino acids may even override the influ-
high glucose is impaired during the development of diabe- ence of prevailing glucose concentrations [36]. Thus, the
tes [25]. On the other hand, most observations suggest that alpha cell may depend on amino acids for basal metabo-
alpha cells in individuals with obesity and type 2 diabetes lism and secretion. Many amino acids stimulate glucagon
do exactly what they are supposed to do: glucose inhibits secretion [37] and provide the fuels for ATP production.
glucagon secretion (although this may be delayed [26] and/ Fatty acids may have a similar function, although deep
or depend on the route of glucose administration [27]), while understanding is lacking [38]. Amino acids play a domi-
proteins/amino acids stimulate secretion [28]. Instead, it has nating role in alpha cell secretion, although their trans-
been suggested that the basal and postprandial hypersecre- duction mechanisms are poorly understood [39]. Arginine
tion of glucagon in type 2 diabetes could be owing to ele- has been known to provide a strong stimulus to glucagon
vated plasma amino acid levels and gastrointestinal factors secretion for many years and is often used as a test for
[29]. One of the reasons for the disparity in findings is the alpha cell function [12]. Alanine also provides a potent
lack of high-quality alpha cell models. Alpha cells are dif- stimulus to alpha cells [40]. In a systematic search for
ficult to isolate and respond poorly in isolation, and reliable glucagonotropic amino acids from isolated perfused pan-
cell lines do not exist. creas preparations, these two amino acids, as well as gly-
In in vivo studies, in the fasting state active secretion cine and proline, stood out as being the most important
of glucagon is evident and leads to peripheral plasma stimulatory amino acids [41]. The steatotic liver is resist-
concentrations of around 10 pmol/l (2–3-fold higher in ant to the effects of glucagon on amino acid metabolism
the portal vein), depending on the glucagon assay. Nor- and, because of this, steatosis is associated with elevated
mal alpha cell function results in suppression of gluca- levels of most amino acids, which in turn cause hyperse-
gon concentrations to very low levels (~1 pmol/l) during cretion of glucagon [42]. Importantly, steatosis does not
bouts of elevated plasma glucose (e.g. during i.v. glucose seem to cause a parallel resistance to the hyperglycae-
infusion) or, conversely, stimulation of glucagon secretion mic effects of glucagon (with glycogenolysis taking place
with low glucose levels, as is the case in insulin-induced mainly in the central part of the liver acinus and amino
hypoglycaemia [30]. Thus, glucose plays a fundamental acid metabolism taking part in the portal end), so hyper-
role for glucagon secretion, yet the mechanisms involved glucagonaemia still contributes to diabetes-associated

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GCGR GLP-1R GLUT1/SGLTs

Amino acids GCGR GLP-1R
FFARs
transporter

Alpha cell

PLC
SSTRs Delta cell
cAMP
cAMP
SSTRs
Beta cell

INSR

GLP-1
GIP
Oxyntomodulin Blood flow
Glucagon
secretion

Neural factors

Amino acids Fatty acids

Glucose

Glucose Insulin
Somatostatin Glucagon

Fig. 3  Regulation of glucagon secretion. Glucagon secretion is con- glucose cotransporter (SGLT) inhibitors and neprilysin inhibitors
trolled by numerous mechanisms, with only a few selected mecha- may also modulate alpha cell function by direct and indirect mecha-
nisms being shown in the figure. Intra-islet communication by delta nisms (not shown). GLP-1-based agents are glucagonostatic, exert-
and beta cells may suppress glucagon release in response to secreted ing their effects by stimulating somatostatin release. SGLT inhibi-
factors. The role of insulin in suppressing glucagon secretion is tors potentially have both direct (via the SGLT1 transporter in alpha
debated. In contrast, somatostatin exerts a well-characterised inhibi- cells) and indirect (by lowering blood glucose through blocking renal
tory effect on glucagon secretion by alpha cells through somatostatin reabsorption of glucose) effects. Neprilysin inhibitors may elevate
subtype receptors (SSTRs). Nutrients, such as glucose, fatty acids and plasma glucagon levels by directly protecting endogenous glucagon
amino acids play a major role in the regulation of glucagon secre- from degradation. Inhibitors of glucagon secretion shown in red text;
tion. Additionally, both neural and extrapancreatic factors, such as stimulators of glucagon secretion shown in blue text. FFAR, free fatty
peptides secreted from the gastrointestinal tract (e.g. GLP-1, GIP and acid receptor; GLP1-R, GLP-1 receptor; INSR, insulin receptor; PLC,
oxyntomodulin), may couple nutrient absorption to the regulation of phospholipase C. This figure is available as part of a downloadable
glucagon release. Several drugs, such as GLP-1 analogues, sodium− slideset

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hyperglycaemia [42, 43]. Unfortunately, there are huge secondary neurons innervating the islets. These secondary
gaps in our knowledge regarding the effects of individual neurons may also be cholinergic, but non-cholinergic non-
amino acids on glucagon secretion. Randomised crossover adrenergic signalling may also be involved. In particular,
studies in healthy individuals using infusion of labelled vasoactive intestinal polypeptide and pituitary adenylate
individual amino acids combined with isotope tracing and cyclase-activating polypeptide may be engaged as transmit-
accurate measurements of glucagon are required. ters [54]. Again, the final outcome is likely to be modulated
by paracrine influences (e.g. involving delta cells). The sym-
Intra‑islet regulation of glucagon secretion pathetic nervous system also plays an important role, with
direct stimulation of sympathetic fibres increasing glucagon
Glucagon secretion is important for insulin secretion and secretion and simultaneous release of adrenaline (epineph-
vice versa. Stimulation of beta cells via glucagon binding rine) from the adrenal medulla also potentially contributing.
to the glucagon receptor (GCGR) as well as the glucagon- Inhibitory activity may also be elicited upon alpha-1 adren-
like peptide 1 (GLP-1) receptors is essential for amino acid- ergic activity; however, during diffuse sympathetic activity
induced insulin secretion. Similarly, alpha cells are depend- (and also during cold exposure), stimulation of glucagon
ent on beta cells and somatostatin-producing delta cells for secretion is to be expected and, because of this, glucagon
appropriate functioning [44, 45]. Alpha cells are exquisitely may be considered a ‘stress hormone’ [55]. This may be
sensitive to inhibition by somatostatin, which is capable of particularly important during acute bouts of strenuous exer-
halting glucagon secretion [35]. Conversely, blockade of cise, whereas exercise at intermediate intensity appears to
somatostatin receptors (a combination of inhibitors of soma- stimulate glucagon secretion mainly via slight reductions
tostatin receptors 2 and 3 may be required for this) substan- in plasma glucose levels [56]. There is a general belief that
tially increases glucagon secretion, seemingly independent stimulated glucagon secretion only occurs below a certain
of glucose levels [46]. This suggests that somatostatin may (low) threshold of plasma glucose, but this only applies to
be involved in glucose-induced inhibition of glucagon secre- insulin-induced hypoglycaemia. During exercise (where
tion, particularly since somatostatin is secreted in response insulin is suppressed) and in other situations where glucose
to high glucose levels (>7 mmol/l) [47]. Nonetheless, the falls in an insulin-independent manner, glucagon secretion
role of the beta cells in glucagon secretion is controversial increases at the slightest lowering of plasma glucose [57].
and the mechanisms involved are unclear [48]. In many stud- Hypoglycaemia will lead to increases in both vagal and sym-
ies of isolated pancreases, inhibition of glucagon secretion pathetic activity and, evidently, both may participate in the
cannot be elicited with perfusate insulin concentrations as glucagon response to hypoglycaemia in humans. Remark-
high as 1 mmol/l and the potent insulin receptor antagonist ably, however, it is still not understood why the glucagon
S961 also has no effect on glucagon secretion at 1 mmol/l response is deficient or even absent in individuals with type
[49]. One may also ask how activation of the insulin recep- 1 diabetes (and long-standing type 2 diabetes [58]), where
tor, a tyrosine kinase, would bring about acute suppression this deficient response appears to be independent of the pres-
of glucagon secretion. This is unfortunately unexplored. ence or absence of autonomic neuropathy [59]. In people
The immediate conclusion is that beta cells do not influ- with insulin-induced hypoglycaemia, part of the glucagon
ence glucagon secretion via insulin [50]; however, beta cells response appears to be dependent on the modulation of neu-
release more than insulin, including peptides such as uro- ral input via the brain [60]. The response to meals and amino
cortin 3 and amylin, with urocortin 3 stimulating somato- acids is unimpaired in such individuals.
statin secretion from delta cells, and it may be through such
peptides that the beta cells mediate their glucagonostatic
effects [51]. Extrapancreatic hormones

Influence of extra‑islet factors Obviously, any hormone with an effect on plasma glucose
may potentially affect glucagon secretion. Direct effects may
Neural and endocrine factors also influence glucagon secre- be exerted by glucose-dependent insulinotropic polypeptide
tion. The alpha cells express receptors for a plethora of neu- (GIP) and GLP-1 from the gastrointestinal tract, which stim-
rotransmitters and modulators [52]. In pigs, when both the ulate and inhibit glucagon secretion, respectively [61]. GLP-
splanchnic and vagal nerves to the pancreas were directly 1-induced inhibition of glucagon secretion has been calcu-
stimulated, both divisions of the autonomic nervous system lated to be responsible for about half of the glucose-lowering
strongly stimulated glucagon secretion depending on the effects of exogenous GLP-1 in individuals with type 2 dia-
prevailing plasma glucose concentrations [53]. Regarding betes [62]. The impaired GLP-1 response observed in obe-
the vagal influence, signalling is interrupted in the intrapan- sity and type 2 diabetes has, therefore, been implicated in
creatic ganglia and transmitted, via nicotinic receptors, to the pathogenesis of hyperglucagonaemia [63]. Remarkably,

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however, GLP-1 does not inhibit glucagon secretion during gluconeogenesis. The effects on hepatic glucose produc-
insulin-induced hypoglycaemia, whether in individuals with tion are short-lasting, at least partly because of concomitant
type 2 or type 1 diabetes or control participants [64]; this is, glucagon-induced insulin secretion. Also neural or hormonal
of course, important since it demonstrates that GLP-1-based signals may contribute to the evanescence of glucose pro-
therapy does not impair this important counter-regulatory duction [73]. The hyperglycaemic effect of glucagon may
mechanism. Indeed, in isolated alpha cells, GLP-1 has been depend both on glycogenolysis in a dose-dependent man-
reported to stimulate glucagon secretion, consistent with ner, mediated through cAMP and on transcription-depend-
the expression of a small number of GLP-1 receptors on ent changes in rate-limiting gluconeogenic enzymes, such
these cells [65]. One theory is that the inhibition by GLP-1 as PEPCK. Given the absence of GCGRs on muscle cells
is normally exerted indirectly via paracrine somatostatin or adipocytes in humans, the effect of glucagon on gluco-
secretion, which markedly diminishes during hypoglycaemia neogenesis is likely to depend on substrate delivery, medi-
[66]. During hyperglycaemia, the inhibitory mechanism pre- ated by lipolysis and/or proteolysis. The stabilising effect of
dominates, so the weak stimulatory effect of GIP is mainly glucagon on blood glucose levels during prolonged fasting
visible at lower glucose levels [30]. The actions of GLP-1 may depend on neural activity and cortisol, which boost
on alpha cells may, therefore, primarily be dependent on lipolysis and proteolysis. It is likely that the physiological
indirect mechanism involving somatostatin and its receptor actions of glucagon differ between the fasting and postpran-
located on alpha cells [67]. dial state and, for the latter, the macronutrient composition
Moving forward from how glucagon secretion is controlled, of the meal. A high carbohydrate meal would be expected to
we now introduce key aspects of its actions and the inherent inhibit glucagon secretion, whereas a mixed meal containing
experimental challenges in differentiating between the physi- proteins increases glucagon secretion, thus counterbalanc-
ological and pharmacological actions of glucagon. ing amino acid-induced secretion of insulin, which would
otherwise potentially result in hypoglycaemia.
It has been speculated that glucagon also enhances glu-
Actions of glucagon coneogenesis in the gut and kidney as both organs possess
GCGRs [74] and are believed to generate glucose through
Introduction to the many actions of glucagon processes similar to those in the liver. However, direct evi-
dence for this is lacking.
The physiological actions of glucagon are difficult to define
due to differences between species (such as the lipolytic Hepatic actions of glucagon on amino acid catabo-
effects observed in rats but not in humans [68]), the rapid lism Metabolism of amino acids may generate ammo-
clearance of glucagon, dose-dependent interaction with the nia, which, in the liver, is converted to water-soluble urea
GLP-1 receptor [45], and direct vs indirect actions mediated through a series of enzymatic reactions, collectively termed
by activation of the sympathetic nervous system or through ‘ureagenesis’. Glucagon has both transcriptional and non-
secretion of hepatokines, such as fibroblast growth factor transcriptional effects on ureagenesis and also increases
21 (FGF21 [69]). Glucagon possesses effects on multiple amino acid uptake through transcriptional upregulation of
organs including the liver, pancreas, kidney, heart and brain amino acid transporters [75, 76]. The increase in plasma
(see Fig. 4) [22, 70]. For some of these organs, in particu- glucagon levels during a protein-rich meal thereby promotes
lar the brain and heart, its actions are not well established, catabolic utilisation of amino acids in the liver [77]. The
whereas for the liver, its role in glucose production has been exact mode of action of glucagon on ureagenesis is still
extensively studied. For glucagon to have a direct effect, the largely unknown and is discussed elsewhere, in detail [42].
GCGR must be expressed but, as mentioned previously, indi- Collectively, these hepatic actions of glucagon contribute to
rect actions may also occur via the GLP-1 receptor [71], pro- protein metabolism through the liver–alpha cell axis.
motion of the secretion of hormones (i.e. insulin and FGF21)
[45] or activation of the sympathetic nervous system [72]. The liver–alpha cell axis The first notions on the liver–
Such actions, which are important from a pharmacological alpha cell axis were based on the observation that selective
perspective, are less relevant when discussing the role of impairment of hepatic glucagon signalling causes dramatic
endogenous glucagon. increases in glucagon secretion (hyperglucagonaemia) and
In the following, we discuss selected physiological fea- also, in animal models, alpha cell hyperplasia [39]. Sub-
tures of glucagon. sequently, the link was identified as hyperaminoacidaemia
[78]. A series of animal and human data from different
Hepatic actions of glucagon on glucose production Gluca- groups support that glucagon acutely and chronically regu-
gon increases blood glucose by enhancing two cen- lates hepatic amino acid catabolism, while amino acids con-
tral hepatic biochemical processes, glycogenolysis and trol glucagon secretion in a relatively glucose-independent

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Fig. 4  Glucagon action and signalling. Glucagon acts via the depicts GCGR signalling through G-protein-coupled activation of
GCGR, and also via the GLP-1 receptor when administered at ­Gαsubunit and G ­ q, resulting in cAMP production and C­ a2+ signal-
pharmacological doses (not shown). The glucagon/GCGR sig- ling, respectively. The non-transcriptional mechanism(s) induced
nalling pathway in hepatocytes is shown, as well as the pro- by glucagon are largely unexplored but may include phospho-
cesses affected by glucagon in selected organs. The exact locali- rylation and acetylation of proteins, such as those involved in the
sation of the GCGR in the kidney, the intestine and the brain is urea cycle or glycogenolysis. The transcriptional effects of gluca-
controversial, while, in the heart, it is debated whether GCGR gon on the urea cycle are used an example of a glucagon-induced
is expressed at all. Glucagon may directly or indirectly increase transcriptional mechanism in the schematic. Glucagon signalling
heart rate [123], renal excretion of electrolytes [124] and gastric results in an increase in plasma glucose and decreased plasma lev-
emptying [125]/peristalsis [126]. In contrast, the actions of gluca- els of amino acids and lipids. Created with BioRender.com. This
gon on the liver and the pancreas are well established. The image figure is available as part of a downloadable slideset

manner [36]. The liver–alpha cell axis also involves glucose hyperlipidaemic by partial pancreatectomy, followed by a
(as already discussed) and possibly also lipids. series of studies showing that glucagon decreases circu-
lating levels of cholesterol in humans, rodents and dogs
Effects of glucagon on lipid metabolism Glucagon stimu- [79]. The clearance of cholesterol from the circulation is,
lates hepatic lipolysis and enhances clearance of choles- at least in part, attributed to glucagon’s ability to increase
terol from the circulation [79]. The first indications that activity of the LDL receptor and, hence, to promote uptake
glucagon affects cholesterol metabolism date back to the and clearance of cholesterol via the liver [81]. Glucagon
work of Raymond Caren and Lucille Carbo, who in 1956 further controls lipid metabolism through inhibition of de
showed that degranulation of alpha cells by i.v. infusion of novo lipogenesis and acceleration of lipolysis in the liver
cobalt chloride increases circulating levels of cholesterol and the adipose tissue [79]. The lipolytic effect of glucagon
in rabbits [80]. Supplementation of glucagon was subse- is attributed to its ability to enhance activity of hormone-
quently shown to decrease plasma lipid levels in dogs made sensitive lipase, the rate-limiting enzyme responsible for

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breakdown of triglycerides (also termed ‘triacylglycerol’ Glucagon may cross the blood–brain barrier [89] (through
for intracellularly stored lipids) [82], and to stimulate circumventricular organs) and, when injected into the third
the secretion of lipolytic hormones, such as growth hor- ventricle, inhibits food intake in rodents [90] and birds
mone, cortisol and adrenaline. Signs of glucagon resist- [91], potentially via mechanisms that include inhibition of
ance towards hepatic lipid metabolism have been reported protein kinase A (PKA)/Ca2+-calmodulin-dependent pro-
in individuals with non-alcoholic fatty liver disease tein kinase β (CaMKKβ), AMP-activated protein kinase
(NAFLD) [83]. Glucagon-mediated elevation of NEFAs (AMPK) and agouti-related protein [92]. In line with these
increases ketogenesis, and suppression of glucagon secre- observations, glucagon-induced inhibition of food intake is
tion using somatostatin may prevent/delay the development blunted upon inhibition of hypothalamic PKA and AMPK
of ketoacidosis in individuals with type 1 diabetes [84]. signalling [92]. Beyond the ability of glucagon to decrease
Hence, under conditions of fasting, glucagon contributes food intake via central mechanisms, its administration into
to energy homeostasis by elevating circulating levels of the third ventricle increases blood glucose in rodents, birds
glucose and promoting ketogenesis. However, there are and dogs, and this is paralleled by a decrease in liver gly-
important differences between species in this area. First, cogen [93]. Interestingly, the ability of centrally applied
high doses of glucagon also activate the sympathetic nerv- glucagon to increase hepatic glycogenolysis persists after
ous system [85]. Since most studies have investigated the vagotomy, but is blocked by pancreatectomy or spinal cord
impact of glucagon at doses of 1 mg in humans, resulting in transection [94]. Hence, these data suggest that centrally
hugely supraphysiological plasma concentrations, many of administered glucagon stimulates pancreatic glucagon
the published effects of glucagon in humans may be owing secretion to increase glucose levels via the action of pan-
to sympathetic nervous system activation [72] and this may creatic glucagon on hepatic glucose production and gly-
also include brown adipose tissue activation. Second, it cogenolysis [94]. The wiring is not established but may
appears that the GCGR is not expressed in human adipose involve the sympathetic nervous system. In rats, admin-
tissue at all or in the white adipose tissue of mice, while rat istration of glucagon into the mediobasal hypothalamus
adipose tissues seems to have expression this receptor [74]. (MBH) improves glucose tolerance by silencing de novo
Rodent studies, therefore, have limited translational value glucose production in the liver [95]. The glucose-lowering
regarding the impact of glucagon on lipolysis. effect of MBH-administered glucagon was mediated via
GCGR–PKA signalling, depended on functional ­K ATP
Central effects of glucagon The first evidence pointing to channels in the MBH and vanished upon hepatic vagotomy
a role of the brain in glucose metabolism dates back to the [95]. Therefore, it is well established that glucagon has
work of Claude Bernard, who in 1854 showed that punctur- effects on metabolism when administered directly into the
ing the floor of the fourth ventricle increases blood glucose CNS, but the physiological relevance of these mechanisms
in rodents [86]. Just over 100 years later, it was observed is yet to be established.
in rabbits that stimulation of the medial hypothalamic area
increases blood glucose, while stimulation of the lateral
hypothalamus has the opposite effect [87]. More recently, Glucagon in disease
glucose-sensing neurons have been identified in various
brain regions, including the hypothalamus, the nucleus Hyperglucagonaemia contributes to a variety
tractus solitarius and the area postrema, and are impli- of diseases
cated in the regulation of systemic energy metabolism.
The molecular events leading to activation or silencing of Hyperglucagonaemia has been reported in various diseases/
glucose-sensitive neurons are surprisingly similar to those conditions including type 2 diabetes, type 1 diabetes, obe-
of the endocrine pancreas and include neuronal uptake of sity, fatty liver diseases and kidney diseases [22]. The last
glucose via GLUT2, conversion to pyruvate (and finally 100 years of research have led to numerous hypotheses and
ATP) via glucokinase, and modulation of neuronal firing speculations on glucagon’s potential role in these diseases.
mediated by changes in ­KATP channel activity, cell depo- Increased glucagon may be explained by the following: (1)
larisation and ­Ca2+ influx. While glucose-activated neurons increased secretion; (2) decreased degradation/extraction/
increase their firing rate at high ATP levels via ­KATP chan- clearance; and (3) inaccurate measurements due to assay
nel-induced membrane depolarisation and increased ­Ca2+ cross-reactivity with other glucagon-like molecules (see
influx, glucose-inhibited neurons are silent under high ATP Fig. 5). Another important factor is in what setting the
levels and are activated when glucose levels (and hence hyperglucagonaemia is observed, for example under fasting
ATP levels) are low [88]. Several studies support the notion conditions, or postprandially after an OGTT or mixed meal.
that glucagon itself may also influence glucose metabolism Here we summarise specific aspects regarding the role of
via central nervous system (CNS)-associated mechanisms. glucagon in specific pathophysiological states.

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Diabetologia (2023) 66:1378–1394 1387

Fig. 5  Hyperglucagonaemia: causes and consequences. Increased speculated that, for example, chronic renal failure might contribute
glucagon may be explained by: (1) increased secretion; (2) decreased to hyperglucagonaemia. Within the islets, alpha cells may react para-
degradation/extraction/clearance; and (3) inaccurate measurements doxically to increased glucose levels; following the transport of glu-
due to assay cross-reactivity with other glucagon-like molecules (not cose molecules (depicted as blue circles) across the cell membrane
shown). The image depicts some potential causes for diabetogenic of pancreatic alpha cells, glucagon secretion may be increased rather
hyperglucagonaemia (glucagon depicted as orange hexagons). In than suppressed (whether this holds true in humans has not yet been
the liver, glucagon sensitivity may be impaired in individuals with determined). The discrepancies in findings on whether glucose stim-
fatty liver disease (disruption of the liver–alpha cell axis). Glucagon ulates or inhibits glucagon secretion may be owing to differences in
resistance may involve downregulation of amino acid transporters experimental settings (e.g. in vitro vs in vivo) and species (e.g. rats
and impairment of glucagon-induced non-transcriptional activation vs humans) [127]. Finally, obesity and diabetes have been associated
of ureagenesis in hepatocytes. The resulting phenotype is increased with reduced GLP-1 secretion and, given that part of the glucose-low-
plasma levels of amino acids and, perhaps also, lipids, which together ering effect of this hormone is mediated through its glucagonostatic
drives hypersecretion of glucagon and the ensuing increase in hepatic effects, impaired GLP-1 secretion may contribute to hyperglucago-
glucose production. Extraction of glucagon may be carried out by naemia. PLC, phospholipase C. Created with BioRender.com. This
several organs including the kidney, brain and liver, and it may be figure is available as part of a downloadable slideset

Glucagon in diabetes Raskin and Unger reported hyper- However, postprandial hyperglucagonaemia in type 2 dia-
glucagonaemia in individuals with diabetes more than betes (in response to OGTT) is not consistently observed. In a
four decades ago [11] and this has been replicated in cross-sectional trial in which plasma glucagon was measured
numerous studies [13, 20, 27]. Hyperglucagonaemia is during an OGTT in >1400 individuals, increased glucagon
generally found both during fasting and feeding condi- was observed at fasting and 30 min after the OGTT in indi-
tions in individuals with type 2 diabetes [96]. It has also viduals with type 2 diabetes compared with those without,
been demonstrated that GCGR antagonists lower glucose but levels at a later time point were similar between the two
and ­HbA1c levels in both rodent models of type 2 diabe- groups [26]. In agreement with other observations, these
tes and individuals with type 2 diabetes, suggesting that data suggest that lack of glucagon suppression may not be
hyperglucagonaemia directly contributes to hyperglycae- a central feature of diabetes [99]. Instead, fasting hyperglu-
mia in type 2 diabetes [97, 98]. cagonaemia appears to be associated with hepatic insulin

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1388 Diabetologia (2023) 66:1378–1394

resistance or, as shown in other studies, hepatic steatosis [83, with NAFLD, implying that elevated amino acid levels (and
100]. Thus, it has been suggested that the hyperglucagonae- potentially fatty acids) as opposed to dysfunctional glucose
mia observed with type 2 diabetes may be owing to con- sensing by the alpha cells are responsible for hyperglucago-
current liver disease, specifically hepatic steatosis, causing naemia [42].
impairment of the liver–alpha cell axis (owing to desensitised
hepatic GCGR signalling), resulting in hyperaminoacidaemia Glucagon in other diseases As mentioned above, individuals
and, thereby, increased plasma glucagon both in the fasting with chronic kidney disease have hyperglucagonaemia but
and postprandial state [99]. It should be noted that, in the studies have indicated that this is mainly due to the accumu-
authors’ opinion, a mixed meal as a test stimulus may better lation of N-terminally extended glucagon 1-61. Glucagon
reflect the dynamic changes in plasma glucagon that occur 1-61 a proglucagon product that may have some biological
in a real-world setting; following a mixed meal, glucagon impact through the GCGR [18]. In general, altered clear-
secretion may increase due to the protein and, potentially, ance of glucagon in various diseases does not appear to be
lipid content of the meal. OGTT-induced changes in gluca- responsible for increased glucagon levels [106]; however,
gon secretion, therefore, may not reflect daily living. the recently demonstrated importance of activity of the pro-
Hyperglucagonaemia has also been reported in newly tease neprilysin may have been underestimated [108]. Levels
diagnosed individuals with type 1 diabetes and in animal of neprilysin may vary with concurrent metabolic disease;
models of type 1 diabetes. In individuals with well-con- notably, inhibitors of neprilysin are used in heart failure and,
trolled type 1 diabetes, hyperglucagonaemia may not be in this context, metabolic benefits have been reported.
evident and may only result from inadequate insulin therapy
and/or increased neural activity (reflecting a catabolic stress
condition). Following on from this, a recent study in indi- Glucagon agonism, antagonism
viduals with type 1 diabetes treated with a GCGR antagonist or co‑agonism
demonstrated unimpressive effects of the therapy on blood
glucose levels [101]. The importance of hyperglucagonaemia for the pathogenesis
of type 2 diabetes has already been emphasised, and consistent
Glucagon in liver diseases Individuals with cirrhosis have with this, hepatic glucose production of glucagon is increased
been shown to have hyperglucagonaemia in some studies, in individuals with type 2 diabetes compared with individuals
although in others this was not evident [102, 103]. Cirrhosis without diabetes of a similar age and with a similar BMI. In
is somewhat extreme (compared with simple steatosis) since, addition, somatostatin-induced inhibition of glucagon lowers
besides the liver disease, which disrupts the liver–alpha cell blood glucose in insulin-deficient dogs and humans with type 1
axis, individuals with cirrhosis are at high risk of kidney diabetes [109]. Mice deficient for the GCGR may be protected
disease, which is often associated with hyperglucagonaemia from diet-induced obesity (DIO) and show improved glucose
[104]. Whether there are differences in hepatic extraction of tolerance and enhanced insulin sensitivity [110]. Interestingly,
glucagon (e.g. between individuals with and without diabe- GCGR-deficient mice are resistant to streptozotocin (STZ)-
tes) is controversial [105, 106] and the disparity of findings induced beta cell destruction and hyperglycaemia [111], which
in this area may be related to the choice of glucagon assay led to the suggestion that the presence of glucagon might be
[15]. In addition, for individuals with cirrhosis, variation in more important for the hyperglycaemia associated with type 1
shunting between the splanchnic and the systemic circula- diabetes than the lack of insulin [13]. However, these findings
tion may also contribute to hepatic glucagon extraction. A are in contrast to the demonstration that diabetes is an imme-
third element to if and how glucagon is extracted by the diate consequence of partial or total pancreatectomy in dogs,
liver may involve GCGR-mediated endocytosis (i.e. hepatic rabbits, rodents and humans [112]. Furthermore, deletion of
clearance), although this is controversial [107]. Findings of the GCGR in genetically induced insulin-deficient mice cannot
hyperglucagonaemia are more consistently reported in indi- rescue hyperglycaemia [113]. Blocking monoclonal antibodies
viduals with NAFLD independent of type 2 diabetes [99]. A against GCGR also had very limited effect on glucose control
major confounder is the close association between NAFLD in humans with type 1 diabetes [101]. Nevertheless, inhibition
and obesity and, hence, a key question is whether obesity of glucagon signalling has consistently been demonstrated to
or NAFLD drives hyperglucagonaemia. BMI-matched indi- improve glucose control in mice with DIO, ob/ob mice, db/db
viduals with and without NAFLD may be studied to answer mice, STZ-induced rat models of diabetes, Zucker rats, rabbits,
this question. Preliminary data from the authors’ laboratories dogs, monkeys and humans, which supports the therapeutic
suggest that both obesity and NAFLD may contribute to value of GCGR inhibition for the treatment of type 2 diabetes
hyperglucagonaemia, although via different mechanism(s) [13].
(unpublished results, N. J. Wewer Albrechtsen). A dis- In light of glucagon’s ability to increase glucose produc-
rupted liver–alpha cell axis has been observed in humans tion, and the documented beneficial effects of glucagon signal

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Diabetologia (2023) 66:1378–1394 1389

inhibition for the treatment of type 2 diabetes, at first glance

it seems counter-intuitive that glucagon could be used in Key notes on glucagon
unimolecular combinations with GLP-1 to treat obesity and
type 2 diabetes [114]. The rationale for the first engineered
• Charles Kimball and John Murlin in 1922 isolated a
GLP-1/GCGR co-agonist [114] originated from the obser- pancreatic factor that elevates blood glucose; the
vation that chronic administration of a water-soluble form factor was called the ‘glucose agonist’, for short
of glucagon not only decreased body weight in mice with ‘glucagon’
DIO, but also improved glucose tolerance with an efficacy • Regulation of glucagon is extremely complex and
similar to that obtained with exendin-4 [70]. Consistent with controversies may reside in the different experi-
the non-glycaemic effects of glucagon to inhibit food intake, mental approaches for glucagon measurement and
enhance lipid metabolism and accelerate energy expenditure variation between species
[70], a single-molecule GLP-1/GCGR co-agonist improved • Analytical and pre-analytical considerations must
body weight and glucose control in mice with DIO beyond be made when estimating glucagon levels due to
that observed with GLP-1 receptor agonism alone [114, 115]. inherent challenges with assay sensitivity and
specificity
That GLP-1/GCGR co-agonism can improve glucose, lipid
and energy metabolism has subsequently also been demon- • Increased plasma glucagon (hyperglucagonaemia)
strated in human studies [116, 117], and a series of co-ago- is observed in individuals with diabetes, liver
nists have advanced to clinical development for the treatment diseases and kidney failure
of type 2 diabetes, non-alcoholic steatohepatitis and obesity • Hyperglucagonaemia contributes to hyperglycae-
(as reviewed previously [117]). Building upon these findings, mia in individuals with diabetes
the addition of glucagon action has also been demonstrated
to enhance the metabolic effects of GLP-1/GIP receptor co-
• The liver–alpha cell axis encompasses glucagon’s
effects on glucose, lipid and amino acid
agonism [118]. Similar to the dual GLP-1/GCGR agonists, a metabolism, and the regulation of alpha cell
series of GLP-1/GIP/GCGR tri-agonists have made it to clini- function by these substances
cal development [117] and have shown favourable efficacy
• Glucagon agonism (in combination with GLP-1)
and safety in clinical studies [119, 120]. rather than antagonism shows promise as a future
therapeutic approach to combat diabetes and
related metabolic disorders
Future perspective of glucagon

Although glucagon has been studied for more than 100 Supplementary Information The online version contains a slide-
set of the figures for download available at https://​doi.​org/​10.​1007/​
years, its main physiological actions are still widely dis-
s00125-​023-​05947-y.
cussed and currently under investigation. While glucagon’s
role in hepatic glucose metabolism, and the regulation of Acknowledgements We acknowledge the many contributors to the
alpha cell glucagon secretion by glucose have been intensely glucagon field, including members from our own groups, without
whom this review would not have been made possible. This review was
investigated, numerous other aspects of glucagon biology
based on the international glucagon conference, entitled ‘A hundred
have received less attention. Key areas including the role years with glucagon and a hundred more’, held in Copenhagen, Den-
of glucagon in the kidney, the effect of glucagon on the mark, in November 2022. Figures were created with BioRender.com.
heart, and the question of the importance of GCGR signal-
Funding The review is supported by an unrestricted grant from the
ling for brain-associated metabolism and function includ-
Novo Nordic Foundation (NNF21OC0072718) to NJWA in relation
ing appetite and food intake, remain unresolved. Also, the to hosting the international glucagon conference in Copenhagen, 1–2
recent introduction of the concept of glucagon sensitivity November 2022, in the celebration of glucagon’s 100 year birthday. Fur-
[121] will probably result in studies on its importance. Of thermore, work in the authors’ laboratories is supported by several fund-
ing agencies: NJWA is supported by a grant from European Foundation
special clinical interest is the development of therapeutics
for the Study of Diabetes Future Leader Award (NNF21SA0072746)
based on glucagon’s metabolic actions, perhaps in particular and a grant from Independent Research Fund Denmark, Sapere Aude
in combination with GLP-1 receptor agonists, which may (1052–00003B); EDD is supported by the National Institute of Health
have superior actions, especially in those with the metabolic (R01DK132669 and R01DK117147); and TDM received funding from
the German Research Foundation (DFG TRR296, TRR152, SFB1123
liver diseases that often accompany obesity and/or type 2
and GRK 2816/1), the German Center for Diabetes Research (DZD e.V.)
diabetes. In this context, knowledge about the cardiovascular and the European Research Council ERC-CoG Trusted no. 101044445.
consequences of glucagon agonism is essential [122]. The
future use of GCGR agonism will, therefore, probably not Authors’ relationships and activities NJWA has received funding from,
and served on scientific advisory panels and/or speakers’ bureaus for
be limited to the prevention of hypoglycaemia.
Boehringer Ingelheim, MSD/MERCK, Novo Nordisk and Mercodia.

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1390 Diabetologia (2023) 66:1378–1394

JJH has served on scientific advisory panels and received speaker fees 11. Raskin P, Unger RH (1978) Hyperglucagonemia and its sup-
for Novo Nordisk. ADC’s external relationships include consulting, pression. N Engl J Med 299(9):433–436. https://d​ oi.o​ rg/1​ 0.1​ 056/​
research advisory boards and research contract: Abvance; Adipo- NEJM1​97808​31299​0901
Pharma; Cellular Longevity, Inc. dba Loyal; Diakard/Diabetica; Fractyl 12. Unger RH, Aguilar-Parada E, Muller WA, Eisentraut AM (1970)
Laboratories, Inc; Novo Nordisk, Inc; Sekki Bio; Senda Biosciences, Studies of pancreatic alpha cell function in normal and diabetic
Inc; Sensulin Labs, LLC; Thetis Pharmaceuticals, LLC; vTv Therapeu- subjects. J Clin Invest 49(4):837–848. https://​doi.​org/​10.​1172/​
tics. BF is employed at Novo Nordisk. LLG has received funding, con- JCI10​6297
sultant fees from and/or served on scientific advisory panels for Novo 13. Unger RH, Cherrington AD (2012) Glucagonocentric restructur-
Nordisk, Gilead, Becton Dickinson, Sobi, Pfizer and AstraZeneca. JEC ing of diabetes: a pathophysiologic and therapeutic makeover. J
receives research funding from Novo Nordisk and Eli Lilly. SRB and Clin Invest 122(1):4–12. https://​doi.​org/​10.​1172/​JCI60​016
TM-MT are shareholders in Zihipp, Ltd. FKK has served on scientific 14. Sutherland EW, de Duve C (1948) Origin and distribution of
advisory panels and/or been part of speaker’s bureaus for, served as the hyperglycemic-glycogenolytic factor of the pancreas. J Biol
a consultant to and/or received research support from Amgen, Astra- Chem 175:663–674. https://​doi.​org/​10.​1016/​S0021-​9258(18)​
Zeneca, Bayer, Boehringer Ingelheim, Carmot Therapeutics, Eli Lilly, 57183-0
Gubra, Lupin, MedImmune, MSD/Merck, Mundipharma, Norgine, 15. Holst JJ, WewerAlbrechtsen NJ (2019) Methods and guide-
Novo Nordisk, Pharmacosmos, Sanofi, ShouTi, Zealand Pharma and lines for measurement of glucagon in plasma. Int J Mol Sci
Zucara; and is a minority shareholder in Antag Therapeutics and co- 20(21):5416. https://​doi.​org/​10.​3390/​ijms2​02154​16
owner of the weight loss clinic Medicinsk Vægttabsbehandling ApS. 16. Unger RH (1973) Radioimmunoassay of glucagon. Metab Clin
TDM has received funding from Novo Nordisk. The remaining author Exp 22(8):979–985. https://​doi.​org/​10.​1016/​0026-​0495(73)​
(DD) declares that there are no relationships or activities that might 90215-1
bias, or be perceived to bias, their work. 17. Mashiter K, Harding PE, Chou M et al (1975) Persistent pancre-
atic glucagon but not insulin response to arginine in pancreatec-
tomized dogs. Endocrinology 96(3):678–693. https://​doi.​org/​10.​
Contribution statement NJWA, JJH and TDM drafted the first 1210/​endo-​96-3-​678
version of the review. ADC, BF, LLG, EDD, JEC, SRB, TM-MT and 18. Wewer Albrechtsen NJ, Kuhre RE, Hornburg D et al (2017)
FKK revised the review for important intellectual content. NJWA Circulating glucagon 1–61 regulates blood glucose by increas-
drafted figures. All authors approved the version to be published. ing insulin secretion and hepatic glucose production. Cell Rep
21(6):1452–1460. https://​doi.​org/​10.​1016/j.​celrep.​2017.​10.​034
19. Heding LG (1971) Radioimmunological determination of pan-
creatic and gut glucagon in plasma. Diabetologia 7(1):10–19.
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10.​1016/j.​molmet.​2016.​05.​014

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1394 Diabetologia (2023) 66:1378–1394

Authors and Affiliations

Nicolai J. Wewer Albrechtsen1,2 · Jens J. Holst3,4 · Alan D. Cherrington5 · Brian Finan6 · Lise Lotte Gluud7,8 ·
E. Danielle Dean5,9 · Jonathan E. Campbell10,11,12 · Stephen R. Bloom13 · Tricia M.‑M. Tan13 · Filip K. Knop7,14,15 ·
Timo D. Müller16,17

1 9
Department of Clinical Biochemistry, Copenhagen Division of Diabetes, Endocrinology, and Metabolism,
University Hospital - Bispebjerg and Frederiksberg Hospital, Department of Medicine, Vanderbilt University Medical
Copenhagen, Denmark Center, Nashville, TN, USA
2 10
Novo Nordisk Foundation Center for Protein Research, Duke Molecular Physiology Institute, Duke University
Faculty of Health and Medical Sciences, University Medical Center, Durham, NC, USA
of Copenhagen, Copenhagen, Denmark 11
Department of Medicine, Endocrinology Division, Duke
3
Department of Biomedical Sciences, Faculty of Health University Medical Center, Durham, NC, USA
and Medical Sciences, University of Copenhagen, 12
Department of Pharmacology and Cancer Biology, Duke
Copenhagen, Denmark
University Medical Center, Durham, NC, USA
4
Novo Nordisk Foundation Center for Basic Metabolic 13
Department of Metabolism, Digestion and Reproduction,
Research, Faculty of Health and Medical Sciences,
Imperial College London, London, UK
University of Copenhagen, Copenhagen, Denmark
14
5 Center for Clinical Metabolic Research, Gentofte Hospital,
Department of Molecular Physiology and Biophysics,
University of Copenhagen, Hellerup, Denmark
Vanderbilt University School of Medicine, Nashville, TN,
15
USA Steno Diabetes Center Copenhagen, Herlev, Denmark
6 16
Novo Nordisk Research Center Indianapolis, Indianapolis, Institute for Diabetes and Obesity, Helmholtz Diabetes
IN, USA Center, Helmholtz Center Munich, Neuherberg, Germany
7 17
Department of Clinical Medicine, Faculty of Health German Center for Diabetes Research (DZD),
and Medical Sciences, University of Copenhagen, München Neuherberg, Germany
Copenhagen, Denmark
8
Gastro Unit, Copenhagen University Hospital Hvidovre,
Hvidovre, Denmark

13