Recombinant human (rh) insulin-like growth factor-I (IGF-I) is a potential therapy for individuals with severe insulin resistance, but its efficacy, mechanism of action, or duration of effect for these patients have not been explored fully. Two subjects with the type A phenotype of severe insulin resistance without insulin receptor mutations were investigated to assess insulin secretion, insulin action, and carbohydrate tolerance before and after 3-4 weeks of rhIGF-I treatment (100 micrograms/kg, sc, twice daily). Tests included 24-h glucose and insulin profile (modal day), standardized liquid meal with Sustacal, insulin tolerance test, insulin suppression test, and iv glucose tolerance test. In subject 1, the 24-h mean blood glucose level was 8.1 +/- 2.7 mmol/L before rhIGF-I treatment and fell to 4.2 +/- 0.9 mmol/L during rhIGF-I treatment. The pretreatment 24-h mean serum insulin level was 10,251 +/- 8,849 pmol/L and fell to 1533 +/- 1198 pmol/L. Fasting blood glucose fell from 4.4 to 3.4 mmol/L, and 2-h blood glucose after Sustacal administration fell from 10.3 to 5.3 mmol/L. Fasting serum insulin declined from 808 to 246 pmol/L, and the 2-h serum insulin level fell from 5,491 to 3,443 pmol/L. After bolus iv insulin injection (0.15 U/kg), glucose fell by 20% before rhIGF-I treatment and by 67% during rhIGF-I treatment. The steady state plasma glucose level was 18.2 +/- 0.7 before rhIGF-I and 10.8 +/- 0.1 mmol/L during rhIGF-I. In subject 2, fasting blood glucose fell from 12.0 to 7.4 mmol/L and 24-h mean blood glucose fell from 12.7 +/- 1.9 to 6.6 +/- 1.3 mmol/L. Twenty-four-hour mean serum insulin fell from 892 +/- 635 to 521 +/- 293 pmol/L, and first phase insulin secretion was restored during the iv glucose tolerance test. We conclude that sc rhIGF-I can reduce blood glucose effectively in selected patients with the type A phenotype of severe insulin resistance who have diabetes mellitus. rhIGF-I also can enhance insulin sensitivity, as assessed by a decrease in endogenous insulin levels, normalization of response to iv insulin, and a reduced steady state plasma glucose. The cellular mechanisms for these effects remain undefined.