Abstract. Pancreatic beta cell dysfunction is pivotal to the development of diabetes, and restoration of insulin action is of primary importance. Here, we present a review of the mechanism of insulin secretion by pancreatic beta cells and discuss the mutual interaction of signaling pathways in stimulus-secretion coupling to better understand the scientific basis of pharmacological treatment for insulin secretion deficiency. Glucose stimulates insulin secretion via membrane depolarization by closure of ATP-sensitive K + channels (K ATP channels) and opening of L-type voltage-dependent Ca 2+ channels. The resultant elevation of cytosolic free Ca 2+ triggers insulin exocytosis. This is termed the "K ATP -dependent pathway" and is shared by sulfonylurea, which closes K ATP channels. Glucose also stimulates insulin release independent of its action on K ATP channels. This is referred to as the "K ATP -independent pathway," the molecular basis of which remains elusive. In the pancreatic beta cell, incretin hormones increase cAMP level, which enhances glucose-stimulated insulin release by protein kinase A-dependent and -independent mechanisms. Importantly, cAMP does not directly augment Ca
2+-stimulated insulin release per se. The stimulatory level of ambient glucose is an absolute requirement for incretin to enhance insulin release. Therefore, incretin/cAMP enhances K ATP -independent insulinotropic action of glucose. The robust glucoselowering effect of DPP4 inhibitor add-on in diabetic patients with sulfonylurea secondary failure is intriguing. With the clinical availability of DPP4 inhibitor and GLP-1 mimetics, the importance of the interactions between cAMP signaling and K ATP channel-independent actions of glucose is reappraised.Key words: Glucose, Insulin secretion, ATP-sensitive K + channel, Incretin, cAMPInsulIn is the only hormone that lowers plasma glucose concentration. Therefore, insufficient insulin activity leads to chronic elevation of plasma glucose and diabetes mellitus, and restoration of insulin activity is vital for normalization of metabolism in diabetes.Here, we present a review of the pathophysiology of insulin deficiency in type 2 diabetes (T2D), stimulussecretion coupling in the pancreatic beta cells, and the interaction of glucose and cAMP signal to provide a comprehensive view regarding the basis of pharmacological treatment of patients with T2D.