Is there a need to reconsider the use of metformin in COVID-19 patients with type 2 diabetes mellitus?

Treatment of type 2 diabetes mellitus with stem cells and antidiabetic drugs: a dualistic and future-focused approach

Type 2 Diabetes Mellitus (T2DM) accounts for more than 90% of total diabetes mellitus cases all over the world. Obesity and lack of balance between energy intake and energy expenditure are closely linked to T2DM. Initial pharmaceutical treatment and lifestyle interventions can at times lead to remission but usually help alleviate it to a certain extent and the condition remains, thus, recurrent with the patient being permanently pharmaco-dependent. Mesenchymal stromal cells (MSCs) are multipotent, self-renewing cells with the ability to secrete a variety of biological factors that can help restore and repair injured tissues. MSC-derived exosomes possess these properties of the original stem cells and are potentially able to confer superior effects due to advanced cell-to-cell signaling and the presence of stem cell-specific miRNAs. On the other hand, the repository of antidiabetic agents is constantly updated with novel T2DM disease-modifying drugs, with higher efficacy and increasingly convenient delivery protocols. Delving deeply, this review details the latest progress and ongoing studies related to the amalgamation of stem cells and antidiabetic drugs, establishing how this harmonized approach can exert superior effects in the management and potential reversal of T2DM.

Targeting T cell (oxidative) metabolism to improve immunity to viral infection in the context of obesity

Disorders of systemic metabolism can influence immunity. Individuals with obesity are known to have increased inflammation, increased risk to select autoimmune diseases, impaired response to several infections, and impaired vaccine response. For example, over the last decade, it has become clear that individuals with obesity have increased risk of morbidity and mortality from influenza infection. Unsurprisingly, this finding is also observed in the current COVID-19 pandemic: individuals with obesity, particularly severe obesity, have increased risk of poor outcomes from SARS-CoV-2 infection, including increased rates of hospitalization, ICU admission, mechanical ventilation, and death. Several studies have now demonstrated a critical role for T cells in the context of obesity-associated immune dysfunction in response to viral infection, and one mechanism for this may be altered T cell metabolism. Indeed, recent studies have shown that activated T cells from obese mice have an altered metabolic profile characterized by increased glucose oxidation, both in vitro and in vivo following viral infection. For that reason, treatments that target abnormal immune cell metabolism in obesity may improve outcomes to viral infection. To that end, several recent studies have shown that use of the metabolic drug, metformin, can reverse abnormal T cell metabolism and restore T cell immunity, as well as survival, in response to viral infection. These findings will be discussed in detail here.

Metformin-associated lactic acidosis and acute kidney injury in the era of COVID-19

COVID-19, provoked by SARS-CoV-2, constitutes a global health issue with high rates of mortality. The presence of diabetes mellitus is associated with severe coronavirus COVID-19 as it is related to increased death rates in patients admitted to the intensive care unit. Acute kidney injury is a frequent complication among patients hospitalized for COVID-19 and is met with high morbidity and mortality. Here, we present a case of a diabetic patient with acute kidney injury, metformin-associated lactic acidosis, and COVID-19. Lactic acidosis is a relatively rare but noteworthy complication of metformin use. However, the combination of those life-threatening situations could prove fatal for the patients despite optimal medical care.

Factors influencing on development of COVID-19 pneumonia and association with oral anti-diabetic drugs in hospitalized patients with diabetes mellitus

BACKGROUND

Diabetes mellitus (DM) increases mortality and morbidity in patients with coronavirus disease (COVID-19). In this study, it was aimed to assess factors influencing on COVID-19 pneumonia in hospitalized patients with diabetes and association with oral anti-diabetic drugs.

MATERIALS AND METHODS

This cross-sectional study included 432 patients with type 2 diabetes mellitus diagnosed with COVID-19. Data regarding clinical characteristics, demographic characteristics, intensive care unit (ICU) rate in patients admitted to ICU, laboratory results on day 1 and 7, thoracic computed tomography (CT) findings and oral anti-diabetic drugs used were extracted from medical records. In all patients, 75-days mortality was recorded. Data were assessed independently.

RESULTS

There was pneumonia in 386 (89.4%) of 432 patients with diabetes. The risk for pneumonia was markedly higher in patients on DPP-4 inhibitors; however, there was no significant among other oral anti-diabetic groups and subgroups. In addition, elevated CRP was linked to the increased risk for pneumonia. Only patients in the pneumonia group had SGLT-2 inhibitor use. During follow-up, 91 patients died. In Cox regression analysis, low Glasgow Coma Scale score, and increased lactate dehydrogenase levels were identified as significant independent risk factors for mortality.

CONCLUSION

The study indicated that DPP-4 inhibitor used and elevated CRP level were associated with pneumonia development. Only patients in the pneumonia group had SGLT-2 inhibitor use. No oral anti-diabetics was found to be associated with COVID-19 related death.

The effect of metformin on mortality and severity in COVID-19 patients with diabetes mellitus

AIM

COVID-19 has spread globally with heavy impact on most countries and our therapeutic strategies in COVID-19 patients with diabetes are still limited. Recently, some new information was added to this field. We performed this updated meta-analysis to reveal the underlying effect of metformin on COVID-19 patients with diabetes.

METHODS

We searched the PubMed, Embase and CNKI (China National Knowledge Infrastructure) databases for all articles. The odds ratio (OR) corresponding to the 95% confidence interval (95% CI) was used to assess the effect of metformin on COVID-19 patients with diabetes. The statistical heterogeneity among studies was assessed with the Q-test and I² statistics.

RESULTS

We collected 17 studies including 20,719 COVID-19 patients with diabetes. Our results found that metformin was associated with significantly decreased mortality and severity in COVID-19 patients with diabetes (OR = 0.64, 95% CI = 0.51-0.79 for mortality, and OR = 0.81, 95% CI = 0.66-0.99 for severity).

CONCLUSIONS

Our meta-analysis indicated that following metformin treatment might benefit the patients with T2DM, both the mortality and severity. However, patients with severe COVID-19 should be monitored closely for the development of lactic acidosis, acidosis, and decreased kidney function.