Structural basis of insulin receptor antagonism by bivalent site 1-site 2 ligands

Congenital hyperinsulinism (HI) is a rare genetic disease characterized by overproduction of Insulin. One class of potential HI treatments is Insulin Receptor (IR) antagonists like S961 and Ins-AC-S2, peptides composed of binding segments for each of the IR sites capable of binding insulin: site 1 and site 2. Notably, S597 - containing the same IR binding segments as S961 but in the opposite order (site 2-site 1) - is an IR agonist rather than an antagonist. Using cryo-EM, we show how both S961 and Ins-AC-S2 bind an inactive conformation of IR, thereby explaining their antagonism. Furthermore, our structures reveal how agonist vs. antagonist activity is dictated by the order of site 1- and site 2-binding modules in bivalent ligands. Additionally, we uncover subtle differences between the binding mechanisms of S961 and Ins-AC-S2 to IR, which include displacement or engagement of αCT, respectively, and a novel binding interface between the Ins-AC-S2 Insulin and the receptor. These structural insights may inform development of next generation IR antagonists for treatment of HI.