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Goglia U, Hasballa I, Teti C, Boschetti M, Ferone D, Albertelli M. Ianus Bifrons: The Two Faces of Metformin. Cancers (Basel) 2024; 16:1287. [PMID: 38610965 PMCID: PMC11011026 DOI: 10.3390/cancers16071287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 03/10/2024] [Accepted: 03/20/2024] [Indexed: 04/14/2024] Open
Abstract
The ancient Roman god Ianus was a mysterious divinity with two opposite faces, one looking at the past and the other looking to the future. Likewise, metformin is an "old" drug, with one side looking at the metabolic role and the other looking at the anti-proliferative mechanism; therefore, it represents a typical and ideal bridge between diabetes and cancer. Metformin (1,1-dimethylbiguanidine hydrochloride) is a drug that has long been in use for the treatment of type 2 diabetes mellitus, but recently evidence is growing about its potential use in other metabolic conditions and in proliferative-associated diseases. The aim of this paper is to retrace, from a historical perspective, the knowledge of this molecule, shedding light on the subcellular mechanisms of action involved in metabolism as well as cellular and tissue growth. The intra-tumoral pharmacodynamic effects of metformin and its possible role in the management of different neoplasms are evaluated and debated. The etymology of the name Ianus is probably from the Latin term ianua, which means door. How many new doors will this old drug be able to open?
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Affiliation(s)
- Umberto Goglia
- Endocrinology and Diabetology Unit, Local Health Authority CN1, 12100 Cuneo, Italy
| | - Iderina Hasballa
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy (M.B.); (D.F.); (M.A.)
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties (DiMI), University of Genova, 16132 Genoa, Italy
| | - Claudia Teti
- Endocrinology and Diabetology Unit, Local Health Autorithy Imperia 1, 18100 Imperia, Italy;
| | - Mara Boschetti
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy (M.B.); (D.F.); (M.A.)
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties (DiMI), University of Genova, 16132 Genoa, Italy
| | - Diego Ferone
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy (M.B.); (D.F.); (M.A.)
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties (DiMI), University of Genova, 16132 Genoa, Italy
| | - Manuela Albertelli
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy (M.B.); (D.F.); (M.A.)
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties (DiMI), University of Genova, 16132 Genoa, Italy
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2
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Marx N, Federici M, Schütt K, Müller-Wieland D, Ajjan RA, Antunes MJ, Christodorescu RM, Crawford C, Di Angelantonio E, Eliasson B, Espinola-Klein C, Fauchier L, Halle M, Herrington WG, Kautzky-Willer A, Lambrinou E, Lesiak M, Lettino M, McGuire DK, Mullens W, Rocca B, Sattar N. 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes. Eur Heart J 2023; 44:4043-4140. [PMID: 37622663 DOI: 10.1093/eurheartj/ehad192] [Citation(s) in RCA: 127] [Impact Index Per Article: 127.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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3
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Türk D, Scherer N, Selzer D, Dings C, Hanke N, Dallmann R, Schwab M, Timmins P, Nock V, Lehr T. Significant impact of time-of-day variation on metformin pharmacokinetics. Diabetologia 2023; 66:1024-1034. [PMID: 36930251 PMCID: PMC10163090 DOI: 10.1007/s00125-023-05898-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 01/31/2023] [Indexed: 03/18/2023]
Abstract
AIMS/HYPOTHESIS The objective was to investigate if metformin pharmacokinetics is modulated by time-of-day in humans using empirical and mechanistic pharmacokinetic modelling techniques on a large clinical dataset. This study also aimed to generate and test hypotheses on the underlying mechanisms, including evidence for chronotype-dependent interindividual differences in metformin plasma and efficacy-related tissue concentrations. METHODS A large clinical dataset consisting of individual metformin plasma and urine measurements was analysed using a newly developed empirical pharmacokinetic model. Causes of daily variation of metformin pharmacokinetics and interindividual variability were further investigated by a literature-informed mechanistic modelling analysis. RESULTS A significant effect of time-of-day on metformin pharmacokinetics was found. Daily rhythms of gastrointestinal, hepatic and renal processes are described in the literature, possibly affecting drug pharmacokinetics. Observed metformin plasma levels were best described by a combination of a rhythm in GFR, renal plasma flow (RPF) and organic cation transporter (OCT) 2 activity. Furthermore, the large interindividual differences in measured metformin concentrations were best explained by individual chronotypes affecting metformin clearance, with impact on plasma and tissue concentrations that may have implications for metformin efficacy. CONCLUSIONS/INTERPRETATION Metformin's pharmacology significantly depends on time-of-day in humans, determined with the help of empirical and mechanistic pharmacokinetic modelling, and rhythmic GFR, RPF and OCT2 were found to govern intraday variation. Interindividual variation was found to be partly dependent on individual chronotype, suggesting diurnal preference as an interesting, but so-far underappreciated, topic with regard to future personalised chronomodulated therapy in people with type 2 diabetes.
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Affiliation(s)
- Denise Türk
- Clinical Pharmacy, Saarland University, Saarbrücken, Germany
| | - Nina Scherer
- Clinical Pharmacy, Saarland University, Saarbrücken, Germany
| | - Dominik Selzer
- Clinical Pharmacy, Saarland University, Saarbrücken, Germany
| | | | - Nina Hanke
- Clinical Pharmacy, Saarland University, Saarbrücken, Germany
| | - Robert Dallmann
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany
- Departments of Clinical Pharmacology, Pharmacy and Biochemistry, University of Tübingen, Tübingen, Germany
- Cluster of Excellence iFIT (EXC2180) 'Image-guided and Functionally Instructed Tumor Therapies', University of Tübingen, Tübingen, Germany
| | - Peter Timmins
- Department of Pharmacy, University of Huddersfield, Huddersfield, UK
| | - Valerie Nock
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Thorsten Lehr
- Clinical Pharmacy, Saarland University, Saarbrücken, Germany.
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4
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Research Progress of Population Pharmacokinetic of Metformin. BIOMED RESEARCH INTERNATIONAL 2022; 2022:4071111. [PMID: 36578804 PMCID: PMC9792241 DOI: 10.1155/2022/4071111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/21/2022] [Accepted: 12/03/2022] [Indexed: 12/23/2022]
Abstract
Metformin is commonly used as first-line treatment for T2DM (type2 diabetes mellitus). Owing to the high pharmacokinetic (PK) variability, several population pharmacokinetic (PPK) models have been developed for metformin to explore potential covariates that affect its pharmacokinetic variation. This comprehensive review summarized the published PPK studies of metformin, aimed to summarize PPK models of metformin. Most studies described metformin pharmacokinetics as a 2-compartment (2-CMT) model with 4 study describing its pharmacokinetics as 1-compartment (1-CMT). Studies on metformin PPK have shown that obesity, creatinine clearance (CLCr), gene polymorphism, degree of renal function damage, and pathological conditions all have a certain impact on the PK parameters of metformin. It is particularly important to formulate individualized dosing regimens. For future PPK studies of metformin, we believe that more attention should be paid to special populations.
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5
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Demidowich AP, Batty K, Zilbermint M. Instituting a Successful Discharge Plan for Patients With Type 2 Diabetes: Challenges and Solutions. Diabetes Spectr 2022; 35:440-451. [PMID: 36561646 PMCID: PMC9668725 DOI: 10.2337/dsi22-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Achieving target inpatient glycemic management outcomes has been shown to influence important clinical outcomes such as hospital length of stay and readmission rates. However, arguably the most profound, lasting impact of inpatient diabetes management is achieved at the time of discharge-namely reconciling and prescribing the right medications and making referrals for follow-up. Discharge planning offers a unique opportunity to break through therapeutic inertia, offer diabetes self-management education, and institute an individualized treatment plan that prepares the patient for discharge and promotes self-care and engagement. However, the path to a successful discharge plan can be fraught with potential pitfalls for clinicians, including lack of knowledge and experience with newer diabetes medications, costs, concerns over insurance coverage, and lack of time and resources. This article presents an algorithm to assist clinicians in selecting discharge regimens that maximize benefits and reduce barriers to self-care for patients and a framework for creating an interdisciplinary hospital diabetes discharge program.
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Affiliation(s)
- Andrew P. Demidowich
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Johns Hopkins Community Physicians at Howard County General Hospital, Division of Hospital Medicine, Johns Hopkins Medicine, Columbia, MD
| | - Kristine Batty
- Johns Hopkins Community Physicians at Howard County General Hospital, Division of Hospital Medicine, Johns Hopkins Medicine, Columbia, MD
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Johns Hopkins Community Physicians at Suburban Hospital, Division of Hospital Medicine, Johns Hopkins Medicine, Bethesda, MD
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6
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Syafhan NF, Donnelly R, Harper R, Harding J, Mulligan C, Hogg A, Scott M, Fleming G, Scullin C, Hawwa AF, Chen G, Parsons C, McElnay JC. Adherence to metformin in adults with type 2 diabetes: a combined method approach. J Pharm Policy Pract 2022; 15:61. [PMID: 36224634 PMCID: PMC9554867 DOI: 10.1186/s40545-022-00457-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 10/02/2022] [Indexed: 11/17/2022] Open
Abstract
Background Medication adherence, one of the most important aspects in the process of optimal medicines use, is unfortunately still a major challenge in modern healthcare, and further research is required into how adherence can be assessed and optimised. The aim of this study was to use a combined method approach of self-report and dried blood spot (DBS) sampling coupled with population pharmacokinetic (PopPK) modelling, to assess adherence to metformin in adult patients with type 2 diabetes. Further aims were to assess metformin exposure levels in patients, determine factors associated with non-adherence with prescribed metformin, and to explore the relationship between adherence and therapeutic outcomes. Methods A combined method approach was used to evaluate metformin adherence in patients with type 2 diabetes who had been prescribed metformin for a minimum period of 6 months. Patients were recruited from consultant-led diabetic outpatient clinics at three hospitals in Northern Ireland, UK. Data collection involved self-reported questionnaires [Medication Adherence Report Scale (MARS), Beliefs about Medicines Questionnaire and Centre for Epidemiologic Studies Depression Scale], direct measurement of metformin concentration in DBS samples, and researcher-led patient interviews. The DBS sampling approach was coupled with population pharmacokinetic (PopPK) modelling, which took account of patient characteristics, metformin dosage and type of formulation prescribed (immediate or sustained release). Results The proportion of patients considered to be adherent to their prescribed metformin, derived from self-reported MARS scores and metformin concentration in DBS samples, was 61.2% (74 out of 121 patients). The majority (n = 103, 85.1%) of recruited patients had metformin exposure levels that fell within the therapeutic range. However, 17 patients (14.1%) had low exposure to metformin and one patient (0.8%) had undetectable metformin level in their blood sample (non-exposure). Metformin self-administration and use of a purchased adherence pill box significantly increased the probability of a patient being classified as adherent based on logistic regression analysis. Both HbA1c and random glucose levels (representing poor glycaemic control) in the present research were, however, not statistically linked to non-adherence to metformin (P > 0.05). Conclusions A significant proportion of participating patients were not fully adherent with their therapy. DBS sampling together with the use of a published PopPK model was a useful, novel, direct, objective approach to estimate levels of adherence in adult patients with type 2 diabetes (61.2%). Supplementary Information The online version contains supplementary material available at 10.1186/s40545-022-00457-5.
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Affiliation(s)
- Nadia Farhanah Syafhan
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, Belfast, UK.,Department of Clinical Pharmacy, Faculty of Pharmacy, Universitas Indonesia, Depok, Indonesia
| | - Rosemary Donnelly
- Ulster Hospital, South Eastern Health and Social Care Trust, Belfast, UK
| | - Roy Harper
- Ulster Hospital, South Eastern Health and Social Care Trust, Belfast, UK
| | - Janet Harding
- Ulster Hospital, South Eastern Health and Social Care Trust, Belfast, UK
| | - Ciara Mulligan
- Ulster Hospital, South Eastern Health and Social Care Trust, Belfast, UK
| | - Anita Hogg
- Medicines Optimisation Innovation Centre, Northern Health Social Care Trust, Antrim, Northern Ireland, UK
| | - Michael Scott
- Medicines Optimisation Innovation Centre, Northern Health Social Care Trust, Antrim, Northern Ireland, UK
| | - Glenda Fleming
- Medicines Optimisation Innovation Centre, Northern Health Social Care Trust, Antrim, Northern Ireland, UK
| | - Claire Scullin
- Medicines Optimisation Innovation Centre, Northern Health Social Care Trust, Antrim, Northern Ireland, UK
| | - Ahmed F Hawwa
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, Belfast, UK.,School of Biological Sciences. Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Gaoyun Chen
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Carole Parsons
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - James C McElnay
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, Belfast, UK.
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7
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Nies AT, Schaeffeler E, Schwab M. Hepatic solute carrier transporters and drug therapy: Regulation of expression and impact of genetic variation. Pharmacol Ther 2022; 238:108268. [DOI: 10.1016/j.pharmthera.2022.108268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/25/2022] [Accepted: 08/15/2022] [Indexed: 11/30/2022]
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8
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Corremans R, Neven E, Maudsley S, Leysen H, De Broe ME, D’Haese PC, Vervaet BA, Verhulst A. Progression of established non-diabetic chronic kidney disease is halted by metformin treatment in rats. Kidney Int 2022; 101:929-944. [DOI: 10.1016/j.kint.2022.01.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 01/14/2022] [Accepted: 01/21/2022] [Indexed: 12/14/2022]
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9
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Qureshi R, Nasir K, Dhrolia M, Ahmad A. A Comparative Study of Acidosis in Diabetic Advanced Chronic Kidney Disease Patients on and off Metformin. Cureus 2022; 14:e21291. [PMID: 35186553 PMCID: PMC8846262 DOI: 10.7759/cureus.21291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2022] [Indexed: 11/29/2022] Open
Abstract
Aim The aim of the study is to assess the risk of acidosis in diabetic advanced chronic kidney disease (CKD) patients on and off metformin. Methods This retrospective descriptive study was conducted in the nephrology department in The Kidney Centre Post Graduate Training Institute (TKC PGTI) Karachi from February to April 2020. We reviewed the records of all patients over 18 years old who visited the nephrology outpatient department in three months in 2020 (from February 2020 to April 2020), who had CKD (stage 2-5), are not on dialysis, and had type 2 diabetes. These were divided into two groups: those on metformin for more than one year and those not on metformin. We looked at hospitalizations due to acidosis in the previous one-year period. Results A total of 524 CKD patients had diabetes; out of those, 268 patients were on metformin, and 256 were not on metformin. The male vs. female distribution was 52.1% vs. 47.9%. A total of 114 (21.8%) patients required admission in the previous one-year period, and only 12 hospitalized patients had acidosis, seven (58.3%) were on metformin, and five (41.7%) were not on metformin, which was statistically insignificant. Conclusion Biguanides, especially metformin, is a known oral hypoglycemic drug used for decades to treat type 2 diabetes mellitus (DM). Metformin use is related to a rare but serious adverse event, metformin-associated lactic acidosis (MALA), especially in renal failure patients. In our study, metformin use in CKD diabetic patients did not result in more admissions due to acidosis than non-metformin users.
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10
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Bustamante C, Muskus C, Ochoa R. Rational computational approaches to predict novel drug candidates against leishmaniasis. ANNUAL REPORTS IN MEDICINAL CHEMISTRY 2022. [DOI: 10.1016/bs.armc.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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11
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Mehta K, Spaink HP, Ottenhoff THM, van der Graaf PH, van Hasselt JGC. Host-directed therapies for tuberculosis: quantitative systems pharmacology approaches. Trends Pharmacol Sci 2021; 43:293-304. [PMID: 34916092 DOI: 10.1016/j.tips.2021.11.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 10/26/2021] [Accepted: 11/18/2021] [Indexed: 12/26/2022]
Abstract
Host-directed therapies (HDTs) that modulate host-pathogen interactions offer an innovative strategy to combat Mycobacterium tuberculosis (Mtb) infections. When combined with tuberculosis (TB) antibiotics, HDTs could contribute to improving treatment outcomes, reducing treatment duration, and preventing resistance development. Translation of the interplay of host-pathogen interactions leveraged by HDTs towards therapeutic outcomes in patients is challenging. Quantitative understanding of the multifaceted nature of the host-pathogen interactions is vital to rationally design HDT strategies. Here, we (i) provide an overview of key Mtb host-pathogen interactions as basis for HDT strategies; and (ii) discuss the components and utility of quantitative systems pharmacology (QSP) models to inform HDT strategies. QSP models can be used to identify and optimize treatment targets, to facilitate preclinical to human translation, and to design combination treatment strategies.
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Affiliation(s)
| | | | - Tom H M Ottenhoff
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
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12
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Hanke N, Türk D, Selzer D, Ishiguro N, Ebner T, Wiebe S, Müller F, Stopfer P, Nock V, Lehr T. A Comprehensive Whole-Body Physiologically Based Pharmacokinetic Drug-Drug-Gene Interaction Model of Metformin and Cimetidine in Healthy Adults and Renally Impaired Individuals. Clin Pharmacokinet 2021; 59:1419-1431. [PMID: 32449077 PMCID: PMC7658088 DOI: 10.1007/s40262-020-00896-w] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Metformin is a widely prescribed antidiabetic BCS Class III drug (low permeability) that depends on active transport for its absorption and disposition. It is recommended by the US Food and Drug Administration as a clinical substrate of organic cation transporter 2/multidrug and toxin extrusion protein for drug–drug interaction studies. Cimetidine is a potent organic cation transporter 2/multidrug and toxin extrusion protein inhibitor. Objective The objective of this study was to provide mechanistic whole-body physiologically based pharmacokinetic models of metformin and cimetidine, built and evaluated to describe the metformin-SLC22A2 808G>T drug–gene interaction, the cimetidine-metformin drug–drug interaction, and the impact of renal impairment on metformin exposure. Methods Physiologically based pharmacokinetic models were developed in PK-Sim® (version 8.0). Thirty-nine clinical studies (dosing range 0.001–2550 mg), providing metformin plasma and urine data, positron emission tomography measurements of tissue concentrations, studies in organic cation transporter 2 polymorphic volunteers, drug–drug interaction studies with cimetidine, and data from patients in different stages of chronic kidney disease, were used to develop the metformin model. Twenty-seven clinical studies (dosing range 100–800 mg), reporting cimetidine plasma and urine concentrations, were used for the cimetidine model development. Results The established physiologically based pharmacokinetic models adequately describe the available clinical data, including the investigated drug–gene interaction, drug–drug interaction, and drug–drug–gene interaction studies, as well as the metformin exposure during renal impairment. All modeled drug–drug interaction area under the curve and maximum concentration ratios are within 1.5-fold of the observed ratios. The clinical data of renally impaired patients shows the expected increase in metformin exposure with declining kidney function, but also indicates counter-regulatory mechanisms in severe renal disease; these mechanisms were implemented into the model based on findings in preclinical species. Conclusions Whole-body physiologically based pharmacokinetic models of metformin and cimetidine were built and qualified for the prediction of metformin pharmacokinetics during drug–gene interaction, drug–drug interaction, and different stages of renal disease. The model files will be freely available in the Open Systems Pharmacology model repository. Current guidelines for metformin treatment of renally impaired patients should be reviewed to avoid overdosing in CKD3 and to allow metformin therapy of CKD4 patients. Electronic supplementary material The online version of this article (10.1007/s40262-020-00896-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nina Hanke
- Clinical Pharmacy, Saarland University, Campus C2 2, 66123, Saarbrücken, Germany
| | - Denise Türk
- Clinical Pharmacy, Saarland University, Campus C2 2, 66123, Saarbrücken, Germany
| | - Dominik Selzer
- Clinical Pharmacy, Saarland University, Campus C2 2, 66123, Saarbrücken, Germany
| | - Naoki Ishiguro
- Kobe Pharma Research Institute, Nippon Boehringer Ingelheim Co. Ltd., Kobe, Japan
| | - Thomas Ebner
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Sabrina Wiebe
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany.,Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Fabian Müller
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany.,Institute of Experimental and Clinical Pharmacology and Toxicology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Peter Stopfer
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Valerie Nock
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Thorsten Lehr
- Clinical Pharmacy, Saarland University, Campus C2 2, 66123, Saarbrücken, Germany.
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13
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Induri SNR, Kansara P, Thomas SC, Xu F, Saxena D, Li X. The Gut Microbiome, Metformin, and Aging. Annu Rev Pharmacol Toxicol 2021; 62:85-108. [PMID: 34449247 DOI: 10.1146/annurev-pharmtox-051920-093829] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Metformin has been extensively used for the treatment of type 2 diabetes, and it may also promote healthy aging. Despite its widespread use and versatility, metformin's mechanisms of action remain elusive. The gut typically harbors thousands of bacterial species, and as the concentration of metformin is much higher in the gut as compared to plasma, it is plausible that microbiome-drug-host interactions may influence the functions of metformin. Detrimental perturbations in the aging gut microbiome lead to the activation of the innate immune response concomitant with chronic low-grade inflammation. With the effectiveness of metformin in diabetes and antiaging varying among individuals, there is reason to believe that the gut microbiome plays a role in the efficacy of metformin. Metformin has been implicated in the promotion and maintenance of a healthy gut microbiome and reduces many age-related degenerative pathologies. Mechanistic understanding of metformin in the promotion of a healthy gut microbiome and aging will require a systems-level approach. Expected final online publication date for the Annual Review of Pharmacology and Toxicology, Volume 62 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Sri Nitya Reddy Induri
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY 10010, USA;
| | - Payalben Kansara
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY 10010, USA;
| | - Scott C Thomas
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY 10010, USA;
| | - Fangxi Xu
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY 10010, USA;
| | - Deepak Saxena
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY 10010, USA; .,Department of Surgery, New York University School of Medicine, New York, NY 10016, USA
| | - Xin Li
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY 10010, USA;
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14
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Hu C, Jia W. Multi-omics profiling: the way towards precision medicine in metabolic diseases. J Mol Cell Biol 2021; 13:mjab051. [PMID: 34406397 PMCID: PMC8697344 DOI: 10.1093/jmcb/mjab051] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 12/12/2022] Open
Abstract
Metabolic diseases including type 2 diabetes mellitus (T2DM), non-alcoholic fatty liver disease (NAFLD), and metabolic syndrome (MetS) are alarming health burdens around the world, while therapies for these diseases are far from satisfying as their etiologies are not completely clear yet. T2DM, NAFLD, and MetS are all complex and multifactorial metabolic disorders based on the interactions between genetics and environment. Omics studies such as genetics, transcriptomics, epigenetics, proteomics, and metabolomics are all promising approaches in accurately characterizing these diseases. And the most effective treatments for individuals can be achieved via omics pathways, which is the theme of precision medicine. In this review, we summarized the multi-omics studies of T2DM, NAFLD, and MetS in recent years, provided a theoretical basis for their pathogenesis and the effective prevention and treatment, and highlighted the biomarkers and future strategies for precision medicine.
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Affiliation(s)
- Cheng Hu
- Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus,
Shanghai Clinical Center for Diabetes, Shanghai Jiao Tong University Affiliated Sixth
People's Hospital, Shanghai 200233, China
- Institute for Metabolic Disease, Fengxian Central Hospital, The Third School of
Clinical Medicine, Southern Medical University, Shanghai 201499, China
| | - Weiping Jia
- Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus,
Shanghai Clinical Center for Diabetes, Shanghai Jiao Tong University Affiliated Sixth
People's Hospital, Shanghai 200233, China
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15
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Cattaneo D, Formenti T, Minisci D, Casalini G, Meraviglia P, Gervasoni C. Lack of clinically relevant interactions between bictegravir and metformin in persons with diabetes and HIV. J Antimicrob Chemother 2021; 76:1945-1946. [PMID: 33729482 DOI: 10.1093/jac/dkab077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Dario Cattaneo
- Unit of Clinical Pharmacology, Fatebenefratelli Sacco University Hospital, Milan, Italy.,Gestione Ambulatoriale Politerapie (GAP) outpatient clinic, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Tiziana Formenti
- 3rd Division of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Davide Minisci
- 3rd Division of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Giacomo Casalini
- 3rd Division of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Paola Meraviglia
- 3rd Division of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Cristina Gervasoni
- Gestione Ambulatoriale Politerapie (GAP) outpatient clinic, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy.,3rd Division of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
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16
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Sutkowska E, Fortuna P, Wisniewski J, Sutkowska K, Hodurek P, Gamian A, Kaluza B. Low metformin dose and its therapeutic serum concentration in prediabetes. Sci Rep 2021; 11:11684. [PMID: 34083618 PMCID: PMC8175603 DOI: 10.1038/s41598-021-91174-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/10/2021] [Indexed: 11/17/2022] Open
Abstract
This prospective study aimed to analyze whether the patients with pre-diabetes (pre-DM) reach the TC (therapeutic concentration) of the metformin during repeated, low, constant drug dose. The guidelines do not recommend any metformin dose for this group of patients. Based on the previous study after a dose of 1700 mg/day the patients seem to reach the therapeutic drug concentration, which guarantees the glycemic effect. Twenty patients with new-diagnosed pre-DM were treated with a 1500 mg/day regimen of the metformin for 15 weeks. The serum concentration of the drug was assessed by liquid chromatography-mass spectrometry technique at 6 and 15 week of the treatment. The correlation of the serum metformin concentration with BMI (body mass index) and patients' weight was also performed. The mean metformin concentration was: 4.65 μmol/L (± 2.41) and 5.41 μmol/L (± 3.44) (p = 0.27) after 6 and 15 weeks of the treatment respectively. There was a positive correlation between the serum concentration of the metformin and body weight (but not BMI) in the 15th week of the therapy (p = 0.04)- the higher body weight the higher concentration of the metformin. Patients with pre-diabetes can be successfully treated with a low dose of metformin, to reach the drug's therapeutic concentration. Body weight can impact the metformin serum concentration during long-term treatment what should be taken into consideration when choosing the dose because of its pleiotropic effect e.g. on the cardiovascular system via reduction of the oxidative stress and would be not connected with the drug's hypoglycemic effect.ClinicalTrials.gov number: NCT03398356; date of first registration: 01/07/2018.
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Affiliation(s)
- Edyta Sutkowska
- Department and Division of Medical Rehabilitation, Wroclaw Medical University, Borowska 213, 50-556, Wrocław, Poland.
| | - Paulina Fortuna
- Department of Medical Biochemistry, Wroclaw Medical University, Wrocław, Poland
| | - Jerzy Wisniewski
- Department of Medical Biochemistry, Wroclaw Medical University, Wrocław, Poland
| | | | - Pawel Hodurek
- Department of Medical Biochemistry, Wroclaw Medical University, Wrocław, Poland
| | - Andrzej Gamian
- Department of Medical Biochemistry, Wroclaw Medical University, Wrocław, Poland
- Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wroclaw, Poland
| | - Bernadetta Kaluza
- Department of Internal Medicine, Endocrinology and Diabetology, Central Clinical Hospital of the Ministry of the Interior, Warsaw, Poland
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17
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Pradhan S, Duffull SB, Wilson LC, Kuan IHS, Walker RJ, Putt TL, Schollum JBW, Wright DFB. Does the intact nephron hypothesis provide a reasonable model for metformin dosing in chronic kidney disease? Br J Clin Pharmacol 2021; 87:4868-4876. [PMID: 34004027 DOI: 10.1111/bcp.14919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/20/2021] [Accepted: 05/09/2021] [Indexed: 11/27/2022] Open
Abstract
This research explored the intact nephron hypothesis (INH) as a model for metformin dosing in patients with chronic kidney disease (CKD). The INH assumes that glomerular filtration rate (GFR) will account for all kidney drug handling even for drugs eliminated by tubular secretion like metformin. We conducted two studies: (1) a regression analysis to explore the relationship between metformin clearance and eGFR metrics, and (2) a joint population pharmacokinetic analysis to test the relationship between metformin renal clearance and gentamicin clearance. The relationship between metformin renal clearance and eGFR metrics and gentamicin clearance was found to be linear, suggesting that a proportional dose reduction based on GFR in patients with CKD is reasonable.
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Affiliation(s)
- Sudeep Pradhan
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | | | - Luke C Wilson
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | | | - Robert J Walker
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Tracey L Putt
- Department of Medicine, University of Otago, Dunedin, New Zealand
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18
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Kuan IHS, Wilson LC, Leishman JC, Cosgrove S, Walker RJ, Putt TL, Schollum JBW, Wright DFB. Metformin doses to ensure efficacy and safety in patients with reduced kidney function. PLoS One 2021; 16:e0246247. [PMID: 33600406 PMCID: PMC7891741 DOI: 10.1371/journal.pone.0246247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 01/18/2021] [Indexed: 01/31/2023] Open
Abstract
We aimed to develop a metformin dosing strategy to optimise efficacy and safety in patients with reduced kidney function. Metformin data from two studies stratified by kidney function were analysed. The relationship between metformin clearance and kidney function estimates was explored using a regression analysis. The maintenance dose range was predicted at different bands of kidney function to achieve an efficacy target of 1 mg/L for steady-state plasma concentrations. The dosing strategy was evaluated using simulations from a published metformin pharmacokinetic model to determine the probability of concentrations exceeding those associated with lactic acidosis risk, i.e. a steady-state average concentration of 3 mg/L and a maximum (peak) concentration of 5 mg/L. A strong relationship between metformin clearance and estimated kidney function using the Cockcroft and Gault (r2 = 0.699), MDRD (r2 = 0.717) and CKD-Epi (r2 = 0.735) equations was found. The probability of exceeding the safety targets for plasma metformin concentration was <5% for most doses and kidney function levels. The lower dose of 500 mg daily was required to maintain concentrations below the safety limits for patients with an eGFR of 15-29 mL/min. Our analysis suggests that a maximum daily dose of 2250, 1700, 1250, 1000, and 500 in patients with normal kidney function, CKD stage 2, 3a, 3b and 4, respectively, will provide a reasonable probability of achieving efficacy and safety. Our results support the cautious of use metformin at appropriate doses in patients with impaired kidney function.
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Affiliation(s)
| | - Luke C. Wilson
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Jed C. Leishman
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Samuel Cosgrove
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Robert J. Walker
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Tracey L. Putt
- Department of Medicine, University of Otago, Dunedin, New Zealand
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19
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Abstract
Precise control of monoamine neurotransmitter levels in the central nervous system (CNS) is crucial for proper brain function. Dysfunctional monoamine signaling is associated with several neuropsychiatric and neurodegenerative disorders. The plasma membrane monoamine transporter (PMAT) is a new polyspecific organic cation transporter encoded by the SLC29A4 gene. Capable of transporting monoamine neurotransmitters with low affinity and high capacity, PMAT represents a major uptake2 transporter in the brain. Broadly expressed in multiple brain regions, PMAT can complement the high-affinity, low-capacity monoamine uptake mediated by uptake1 transporters, the serotonin, dopamine, and norepinephrine transporters (SERT, DAT, and NET, respectively). This chapter provides an overview of the molecular and functional characteristics of PMAT together with its regional and cell-type specific expression in the mammalian brain. The physiological functions of PMAT in brain monoamine homeostasis are evaluated in light of its unique transport kinetics and brain location, and in comparison with uptake1 and other uptake2 transporters (e.g., OCT3) along with corroborating experimental evidences. Lastly, the possibility of PMAT's involvement in brain pathophysiological processes, such as autism, depression, and Parkinson's disease, is discussed in the context of disease pathology and potential link to aberrant monoamine pathways.
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20
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Mariano F, Biancone L. Metformin, chronic nephropathy and lactic acidosis: a multi-faceted issue for the nephrologist. J Nephrol 2020; 34:1127-1135. [PMID: 33373028 PMCID: PMC8357762 DOI: 10.1007/s40620-020-00941-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/30/2020] [Indexed: 12/15/2022]
Abstract
Metformin is currently considered a first-line therapy in type 2 diabetic patients. After issuing warnings for decades about the risks of lactic acidosis in patients with chronic nephropathy, metformin is now being re-evaluated. The most recent evidence from the literature has demonstrated both a low, acceptable risk of lactic acidosis and a series of favorable effects, which go beyond its hypoglycemic activity. Patients treated with metformin show a significant mortality reduction and lower progression towards end-stage renal disease in comparison with those treated with other hypoglycemic drugs. Concerning lactic acidosis, in the last few years it has been shown how lactic acidosis almost always developed when patients kept taking the drug in the face of a concomitant disease or situation such as sepsis, fever, diarrhea, vomiting, which reduced metformin renal clearance. Actually, clearance of metformin is mainly renal, both by glomerular filtration and tubular secretion (apparent clearance 933–1317 ml/min, half-life < 3 h). As regards treatment, in cases of lactic acidosis complicated by acute kidney injury, continuous renal replacement therapy (CRRT) plays a crucial role. Besides the elimination of metformin, CRRT improves survival by correcting acidosis, electrolyte alterations, and maintaining fluid balance. Lactic acidosis almost always develops because of preventable drug accumulation. Therefore, prevention is a key factor. Patients should be aware that discontinuation for a limited time does not affect their health, even when it may be inappropriate, but it may avoid a serious, potentially fatal adverse event.
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Affiliation(s)
- Filippo Mariano
- Department of Medical Sciences, University of Turin, Turin, Italy.
| | - Luigi Biancone
- Department of Medical Sciences, University of Turin, Turin, Italy
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21
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Li L, Guan Z, Li R, Zhao W, Hao G, Yan Y, Xu Y, Liao L, Wang H, Gao L, Wu K, Gao Y, Li Y. Population pharmacokinetics and dosing optimization of metformin in Chinese patients with type 2 diabetes mellitus. Medicine (Baltimore) 2020; 99:e23212. [PMID: 33181704 PMCID: PMC7668473 DOI: 10.1097/md.0000000000023212] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Approximately 35% of patients fail to attain ideal initial blood glucose control under metformin monotherapy. The objective of this observational study is to simulate the optimal protocol of metformin according to the different renal function.The population pharmacokinetics of metformin was performed in 125 subjects with type 2 diabetes mellitus. Plasma concentrations of metformin were quantified by high-performance liquid chromatography. A population pharmacokinetic model of metformin was developed using NONMEN (version 7.2, Icon Development Solutions, USA). Monte Carlo simulation was used to simulate the concentration-time profiles for doses of metformin for 1000 times at different stages of renal function.The mean population pharmacokinetic parameters were apparent clearance 53.0 L/h, apparent volume of distribution 438 L, absorption rate constant 1.4 hour and lag-time 0.91 hour. Covariate analyses revealed that estimated glomerular filtration rate (eGFR) and bodyweight as individual factors influencing the apparent oral clearance: CL/F = 53.0 × ( bodyweight/75) × (eGFR/102.5)EXP(0.1797). The results of the simulation showed that patients should be prescribed metformin 2550 mg/d (t.i.d.) vs 3000 mg/d (b.i.d.) as the minimum doses for patients with augmented renal clearance.eGFR had a significant impact on metformin pharmacokinetics. Patients administered metformin twice a day require higher total daily doses than those with a regimen of 3 times a day at each stage of kidney function.
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Affiliation(s)
- Ling Li
- School of Pharmaceutical Sciences, Shandong University
| | - Ziwan Guan
- School of Pharmaceutical Sciences, Shandong University
| | - Rui Li
- School of Pharmaceutical Sciences, Shandong University
| | - Wei Zhao
- School of Pharmaceutical Sciences, Shandong University
| | - Guoxiang Hao
- School of Pharmaceutical Sciences, Shandong University
| | - Yan Yan
- School of Pharmaceutical Sciences, Shandong University
| | - Yuedong Xu
- Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan
| | - Lin Liao
- Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan
| | - Huanjun Wang
- Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan
| | - Li Gao
- School of Pharmaceutical Sciences, Shandong University
- Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan
| | - Kunrong Wu
- School of Pharmaceutical Sciences, Shandong University
| | - Yuxia Gao
- Department of Pharmacy, Shengli Hospital of Shengli Oilfield, Dongying, Shandong, China
| | - Yan Li
- School of Pharmaceutical Sciences, Shandong University
- Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan
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22
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Wahba NS, Ghareib SA, Abdel-Ghany RH, Abdel-Aal M, Alsemeh AE. Vitamin D3 potentiates the nephroprotective effects of metformin in a rat model of metabolic syndrome: role of AMPK/SIRT1 activation and DPP-4 inhibition. Can J Physiol Pharmacol 2020; 99:685-697. [PMID: 33108744 DOI: 10.1139/cjpp-2020-0435] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The current study aimed to investigate the molecular mechanisms of metformin and vitamin D3-induced nephroprotection in a metabolic syndrome (MetS) rat model, evaluating the capacity of vitamin D3 to potentiate metformin action. MetS was induced by 10% fructose in drinking water and 3% salt in the diet. After 6 weeks, serum lipid profile and uric acid were measured, an oral glucose tolerance test (OGTT) was performed, and kidney function was investigated. In conjunction with the same concentrations of fructose and salt feeding, MetS rats with significant weight gain, dyslipidemia, hyperuricemia, and dysglycemia were treated orally with metformin (200 mg/kg), vitamin D3 (10 µg/kg), or both daily for 6 weeks. At the end of the study period, anthropometrical parameters were recorded, OGTT was reperformed, urine and blood samples were collected, and tissue samples were harvested at sacrifice. MetS rats showed dramatically declined renal function, enhanced intrarenal oxidative stress and inflammation, and extravagant renal histopathological damage with interstitial fibrosis. Metformin and vitamin D3 significantly reversed all the aforementioned deleterious effects in MetS rats. The study has verified the nephroprotective effects of metformin and vitamin D3 in MetS, accentuating the critical role of AMP-activated protein kinase/sirtuin-1 activation and dipeptidyl peptidase-4 inhibition. Given the synergistic effects of the combination, vitamin D3 is worth being investigated as an additional therapeutic agent for preventing MetS-induced nephropathy.
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Affiliation(s)
- Nehal S Wahba
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Zagazig University, Zagazig, Egypt
| | - Salah A Ghareib
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Zagazig University, Zagazig, Egypt
| | - Rasha H Abdel-Ghany
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Zagazig University, Zagazig, Egypt
| | - Mohamed Abdel-Aal
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Zagazig University, Zagazig, Egypt
| | - Amira E Alsemeh
- Department of Anatomy and Embryology, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
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23
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Kuan IHS, Savage RL, Duffull SB, Walker RJ, Wright DFB. The Association between Metformin Therapy and Lactic Acidosis. Drug Saf 2020; 42:1449-1469. [PMID: 31372935 DOI: 10.1007/s40264-019-00854-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND OBJECTIVES There is increasing evidence to suggest that therapeutic doses of metformin are unlikely to cause lactic acidosis. The aims of this research were (1) to formally evaluate the association between metformin therapy and lactic acidosis in published case reports using two causality scoring systems, (2) to determine the frequency of pre-existing independent risk factors in published metformin-associated lactic acidosis cases, (3) to investigate the association between risk factors and mortality in metformin-associated lactic acidosis cases, and (4) to explore the relationship between prescribed metformin doses, elevated metformin plasma concentrations and the development of lactic acidosis in cases with chronic renal impairment. METHODS A systematic review was conducted to identify metformin-associated lactic acidosis cases. Causality was assessed using the World Health Organisation-Uppsala Monitoring Centre system and the Naranjo adverse drug reaction probability scale. Compliance to dosing guidelines was investigated for cases with chronic renal impairment as well as the association between steady-state plasma metformin concentrations prior to admission. RESULTS We identified 559 metformin-associated lactic acidosis cases. Almost all cases reviewed (97%) presented with independent risk factors for lactic acidosis. The prescribed metformin dose exceeded published guidelines in 60% of cases in patients with impaired kidney function. Metformin steady-state plasma concentrations prior to admission were predicted to be below the proposed upper limit of the therapeutic range of 5 mg/L. CONCLUSIONS Almost all cases of metformin-associated lactic acidosis reviewed presented with independent risk factors for lactic acidosis, supporting the suggestion that metformin plays a contributory role. The prescribed metformin dose, on average, exceeded the dosing recommendations by 1000 mg/day in patients with varying degrees of renal impairment but the predicted pre-admission plasma concentrations did not exceed the therapeutic range.
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Affiliation(s)
- Isabelle H S Kuan
- School of Pharmacy, University of Otago, PO Box 56, Dunedin, New Zealand
| | - Ruth L Savage
- New Zealand Pharmacovigilance Centre, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.,Department of General Practice, University of Otago, Christchurch, New Zealand
| | - Stephen B Duffull
- School of Pharmacy, University of Otago, PO Box 56, Dunedin, New Zealand
| | - Robert J Walker
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Daniel F B Wright
- School of Pharmacy, University of Otago, PO Box 56, Dunedin, New Zealand.
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24
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Liao MZ, Flood Nichols SK, Ahmed M, Clark S, Hankins GD, Caritis S, Venkataramanan R, Haas D, Quinney SK, Haneline LS, Tita AT, Manuck T, Wang J, Thummel KE, Brown LM, Ren Z, Easterling TR, Hebert MF. Effects of Pregnancy on the Pharmacokinetics of Metformin. Drug Metab Dispos 2020; 48:264-271. [PMID: 31980499 PMCID: PMC7076518 DOI: 10.1124/dmd.119.088435] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 12/30/2019] [Indexed: 12/22/2022] Open
Abstract
This study's primary objective was to fully characterize the pharmacokinetics of metformin in pregnant women with gestational diabetes mellitus (GDM) versus nonpregnant controls. Steady-state oral metformin pharmacokinetics in pregnant women with GDM receiving either metformin monotherapy (n = 24) or a combination with glyburide (n = 30) as well as in nonpregnant women with type 2 diabetes mellitus (T2DM) (n = 24) were determined utilizing noncompartmental techniques. Maternal and umbilical cord blood samples were collected at delivery from 38 women. With both 500- and 1000-mg doses, metformin bioavailability, volume of distribution beta (V β ), clearance, and renal clearance were significantly increased during pregnancy. In addition, in the women receiving metformin 500 mg, significantly higher metformin apparent oral clearance (CL/F) (27%), weight-adjusted renal secretion clearance (64%), and apparent oral volume of distribution beta (V β /F) (33%) were seen during pregnancy. Creatinine clearance was significantly higher during pregnancy. Increasing metformin dose from 500 to 1000 mg orally twice daily significantly increased V β /F by 28%, weight-adjusted V β /F by 32% and CL/F by 25%, and weight-adjusted CL/F by 28% during pregnancy. Mean metformin umbilical cord arterial-to-venous plasma concentration ratio was 1.0 ± 0.1, venous umbilical cord-to-maternal concentration ratio was 1.4 ± 0.5, and arterial umbilical cord-to-maternal concentration ratio was 1.5 ± 0.5. Systemic exposure after a 500-mg dose of metformin was lower during pregnancy compared with the nonpregnant women with T2DM. However, in patients receiving metformin 1000 mg, changes in estimated bioavailability during pregnancy offset the changes in clearance leading to no significant change in CL/F with the higher dose. SIGNIFICANCE STATEMENT: Gestational diabetes mellitus complicates 5%-13% of pregnancies and is often treated with metformin. Pregnant women undergo physiological changes that alter drug disposition. Preliminary data suggest that pregnancy lowers metformin concentrations, potentially affecting efficacy and safety. This study definitively describes pregnancy's effects on metformin pharmacokinetics and expands the mechanistic understanding of pharmacokinetic changes across the dosage range. Here we report the nonlinearity of metformin pharmacokinetics and the increase in bioavailability, clearance, renal clearance, and volume of distribution during pregnancy.
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Affiliation(s)
- Michael Z Liao
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Shannon K Flood Nichols
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Mahmoud Ahmed
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Shannon Clark
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Gary D Hankins
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Steve Caritis
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Raman Venkataramanan
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - David Haas
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Sara K Quinney
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Laura S Haneline
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Alan T Tita
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Tracy Manuck
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Joanne Wang
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Kenneth E Thummel
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Linda Morris Brown
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Zhaoxia Ren
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Thomas R Easterling
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Mary F Hebert
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
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25
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Smith FC, Stocker SL, Danta M, Carland JE, Kumar SS, Liu Z, Greenfield JR, Braithwaite HE, Cheng TS, Graham GG, Williams KM, Day RO. The safety and pharmacokinetics of metformin in patients with chronic liver disease. Aliment Pharmacol Ther 2020; 51:565-575. [PMID: 31960986 DOI: 10.1111/apt.15635] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/16/2019] [Accepted: 12/23/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND The FDA approved 'label' for metformin lists hepatic insufficiency as a risk for lactic acidosis. Little evidence supports this warning. AIMS To investigate the safety and pharmacokinetics of metformin in patients with chronic liver disease (CLD). METHODS Chronic liver disease patients with and without type 2 diabetes mellitus (T2DM) were studied by a cross-sectional survey of patients already prescribed metformin (n = 34), and by a prospective study where metformin (500 mg, immediate release, twice daily) for up to 6 weeks was prescribed (n = 24). Plasma metformin and lactate concentrations were monitored. Individual pharmacokinetics were obtained and compared to previously published values from healthy and T2DM populations without CLD. RESULTS All plasma metformin and lactate concentrations remained below the putative safety thresholds (metformin, 5 mg/L; lactate, 5 mmol/L). Lactate concentrations were unrelated to average steady-state metformin concentrations. In patients with CLD, T2DM was associated with higher plasma lactate concentrations (48% higher than those without T2DM, P < 0.0001). CLD patients with cirrhosis had 23% higher lactate concentrations than those without cirrhosis (P = 0.01). The pharmacokinetics of metformin in CLD patients were similar to patients with T2DM and no liver disease. The ratio of apparent metformin clearance (CLMet /F) to creatinine clearance was marginally lower in CLD patients compared to healthy subjects (median, interquartile range; 12.6, 9.5-15.9 vs 14.9, 13.4-16.4; P = 0.03). CONCLUSIONS The pharmacokinetics of metformin are not altered sufficiently in CLD patients to raise concerns regarding unsafe concentrations of metformin. There were no unsafe plasma lactate concentrations observed in CLD patients receiving metformin (ACTRN12619001292167; ACTRN12619001348145).
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Affiliation(s)
- Felicity C Smith
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,School of Medical Science, University of New South Wales, Kensington, NSW, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Kensington, NSW, Australia
| | - Mark Danta
- St Vincent's Clinical School, University of New South Wales, Kensington, NSW, Australia.,Gastroenterology and Hepatology Department, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Jane E Carland
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Kensington, NSW, Australia
| | - Shaun S Kumar
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Zhixin Liu
- Stats Central, University of New South Wales, Kensington, NSW, Australia
| | - Jerry R Greenfield
- St Vincent's Clinical School, University of New South Wales, Kensington, NSW, Australia.,Department of Diabetes and Endocrinology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,Diabetes and Metabolism, Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
| | - Hannah E Braithwaite
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Tim S Cheng
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Garry G Graham
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,School of Medical Science, University of New South Wales, Kensington, NSW, Australia
| | - Kenneth M Williams
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,School of Medical Science, University of New South Wales, Kensington, NSW, Australia
| | - Richard O Day
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,School of Medical Science, University of New South Wales, Kensington, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Kensington, NSW, Australia
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26
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Sinnappah KA, Kuan IHS, Thynne TRJ, Doogue MP, Wright DFB. The pharmacokinetics of metformin in patients receiving intermittent haemodialysis. Br J Clin Pharmacol 2020; 86:1430-1443. [PMID: 32060931 DOI: 10.1111/bcp.14244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/03/2020] [Accepted: 02/09/2020] [Indexed: 12/23/2022] Open
Abstract
The aims of this study were to characterise the population pharmacokinetics of metformin in patients receiving haemodialysis, and to determine the doses that will maintain median metformin plasma concentrations below 5 mg L-1 for a typical individual. Metformin plasma concentrations from 5 patients receiving thrice weekly intermittent haemodialysis followed by metformin 500 mg postdialysis were fitted to a published pharmacokinetic model. Additional models to describe the dialytic pharmacokinetics of metformin were explored. Doses of 250 and 500 postdialysis were simulated from the model for a typical haemodialysis patient. The published 2-compartment pharmacokinetic model with an additional parameter to describe haemodialysis clearance provided a reasonable fit to the data. Deterministic simulations from the model for a typical individual suggest that metformin doses of 250-500 mg postdialysis and 250 mg given once daily should maintain median metformin plasma concentrations below 5 mg L-1 .
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Affiliation(s)
| | | | - Tilenka R J Thynne
- Department of Clinical Pharmacology, Flinders Medical Centre and Flinders University, Adelaide, Australia
| | - Matthew P Doogue
- Department of Medicine, University of Otago, Christchurch, New Zealand
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27
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Bustamante C, Ochoa R, Asela C, Muskus C. Repurposing of known drugs for leishmaniasis treatment using bioinformatic predictions, in vitro validations and pharmacokinetic simulations. J Comput Aided Mol Des 2019; 33:845-854. [PMID: 31612362 DOI: 10.1007/s10822-019-00230-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 09/28/2019] [Indexed: 11/26/2022]
Abstract
Leishmaniasis is a neglected tropical disease caused by Leishmania parasites and is associated to more than 1.3 million cases annually. Some of the pharmacological options for treating the disease are pentavalent antimonials, pentamidine, miltefosine, and amphotericin B. However, all are associated with a wide range of adverse effects and contraindications, as well as resistance from the parasite. In the present study, we looked for pharmacological alternatives to treat leishmaniasis, with a focus on drug repurposing. This was done by detecting potential homologs between proteins targeted by approved drugs and proteins of the parasite. The proteins were analyzed using an interaction network, and the drugs were subjected to in vitro evaluations and pharmacokinetics simulations to compare probable plasma concentrations with the effective concentrations detected experimentally. This strategy yielded a list of 33 drugs with potential anti-Leishmania activity, and more than 80 possible protein targets in the parasite. From the drugs tested, two reported high in vitro activity (perphenazine EC50 = 1.2 µg/mL and rifabutin EC50 = 8.5 µg/mL). These results allowed us to propose these drugs as candidates for further in vivo studies and evaluations of the effectiveness on their topical forms.
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Affiliation(s)
- Christian Bustamante
- Programa de Estudio y Control de Enfermedades Tropicales-PECET, Faculty of Medicine, University of Antioquia, Medellin, Colombia
| | - Rodrigo Ochoa
- Programa de Estudio y Control de Enfermedades Tropicales-PECET, Faculty of Medicine, University of Antioquia, Medellin, Colombia
- Biophysics of Tropical Diseases, Max Planck Tandem Group, University of Antioquia, Medellin, Colombia
| | - Claudia Asela
- Programa de Estudio y Control de Enfermedades Tropicales-PECET, Faculty of Medicine, University of Antioquia, Medellin, Colombia
| | - Carlos Muskus
- Programa de Estudio y Control de Enfermedades Tropicales-PECET, Faculty of Medicine, University of Antioquia, Medellin, Colombia.
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28
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Fodor A, Cozma A, Suharoschi R, Sitar-Taut A, Roman G. Clinical and genetic predictors of diabetes drug's response. Drug Metab Rev 2019; 51:408-427. [PMID: 31456442 DOI: 10.1080/03602532.2019.1656226] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Diabetes is a major health problem worldwide. Glycemic control is the main goal in the management of type 2 diabetes. While many anti-diabetic drugs and guidelines are available, almost half of diabetic patients do not reach their treatment goal and develop complications. The glucose-lowering response to anti-diabetic drug differs significantly between individuals. Relatively little is known about the factors that might underlie this response. The identification of predictors of response to anti-diabetic drugs is essential for treatment personalization. Unfortunately, the evidence on predictors of drugs response in type 2 diabetes is scarce. Only a few trials were designed for specific groups of patients (e.g. patients with renal impairment or older patients), while subgroup analyses of larger trials are frequently unreported. Physicians need help in picking the drug which provides the maximal benefit, with minimal side effects, in the right dose, for a specific patient, using an omics-based approach besides the phenotypic characteristics.
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Affiliation(s)
- Adriana Fodor
- Department of Diabetes and Metabolic Diseases, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania.,Clinical Center of Diabetes, Nutrition and Metabolic Disease, Cluj-Napoca, Romania
| | - Angela Cozma
- 4th Internal Medicine Department, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | - Ramona Suharoschi
- Department of Food Science, University of Agricultural Sciences and Veterinary Medicine of Cluj-Napoca, Cluj-Napoca, Romania
| | - Adela Sitar-Taut
- 4th Internal Medicine Department, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | - Gabriela Roman
- Department of Diabetes and Metabolic Diseases, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania.,Clinical Center of Diabetes, Nutrition and Metabolic Disease, Cluj-Napoca, Romania
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29
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Stevens A, Hamel J, Toure A, Hadjadj S, Boels D. Metformin overdose: A serious iatrogenic complication—Western France Poison Control Centre Data Analysis. Basic Clin Pharmacol Toxicol 2019; 125:466-473. [DOI: 10.1111/bcpt.13273] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 06/06/2019] [Indexed: 12/31/2022]
Affiliation(s)
| | - Jean‐François Hamel
- Representative of Clinical Research and Innovation Angers University Hospital Angers France
| | - Ali Toure
- Poison Control Centre Angers University Hospital Angers France
| | - Samy Hadjadj
- Department of Endocrinology and Diabetology Nantes University Hospital Nantes France
| | - David Boels
- Poison Control Centre Angers University Hospital Angers France
- Department of Pharmacology and Toxicology Nantes University Hospital Nantes France
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30
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Alnasrallah B, Goh TL, Chan LW, Manley P, Pilmore H. Transplantation and diabetes (Transdiab): a pilot randomised controlled trial of metformin in impaired glucose tolerance after kidney transplantation. BMC Nephrol 2019; 20:147. [PMID: 31035960 PMCID: PMC6489311 DOI: 10.1186/s12882-019-1321-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 03/31/2019] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Post transplantation diabetes mellitus (PTDM) is a common and serious complication after renal transplantation with significant morbidity and mortality. Metformin has proven benefits in the general population and might be advantageous in the prevention and management of PTDM. METHODS Transplantation and Diabetes (Transdiab) is a single-centre, unblinded, pilot randomised controlled trial assessing the feasibility, tolerability and efficacy of metformin after renal transplantation in patients with impaired glucose tolerance (IGT). Participants had an oral glucose tolerance test (OGTT) in the 4-12 weeks post-transplantation; those with IGT were randomised to standard care or standard care and metformin 500 mg twice daily and followed up for 12 months. RESULTS Seventy eight patients had an OGTT over 24 months, 25 of them had IGT, of those, 19 patients were randomised, giving a feasibility of recruitment of 24.4%. Ten patients were randomised to metformin and 9 patients to standard care. Tolerability and efficacy was similar between the 2 groups with no serious adverse events. There was no difference in secondary outcomes relating to the metabolic profile. CONCLUSIONS The use of metformin post renal transplantation appeared feasible and safe. Larger randomised controlled trials (RCTs) are needed to establish and confirm the efficacy and safety of metformin post renal transplantation. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12614001171606 . Date of registration 7/11/2014.
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Affiliation(s)
- Basil Alnasrallah
- Department of Nephrology, Auckland City Hospital, Auckland, 1023, New Zealand.
| | - Tze Liang Goh
- Department of Nephrology, Auckland City Hospital, Auckland, 1023, New Zealand
| | - Lai Wan Chan
- Department of Nephrology, Auckland City Hospital, Auckland, 1023, New Zealand
| | - Paul Manley
- Department of Nephrology, Auckland City Hospital, Auckland, 1023, New Zealand
| | - Helen Pilmore
- Department of Nephrology, Auckland City Hospital, Auckland, 1023, New Zealand.,Department of Medicine, University of Auckland, Auckland, New Zealand
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31
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Mannino GC, Andreozzi F, Sesti G. Pharmacogenetics of type 2 diabetes mellitus, the route toward tailored medicine. Diabetes Metab Res Rev 2019; 35:e3109. [PMID: 30515958 PMCID: PMC6590177 DOI: 10.1002/dmrr.3109] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 11/27/2018] [Accepted: 11/30/2018] [Indexed: 12/11/2022]
Abstract
Type 2 diabetes mellitus (T2DM) is a chronic disease that has reached the levels of a global epidemic. In order to achieve optimal glucose control, it is often necessary to rely on combination therapy of multiple drugs or insulin because uncontrolled glucose levels result in T2DM progression and enhanced risk of complications and mortality. Several antihyperglycemic agents have been developed over time, and T2DM pharmacotherapy should be prescribed based on suitability for the individual patient's characteristics. Pharmacogenetics is the branch of genetics that investigates how our genome influences individual responses to drugs, therapeutic outcomes, and incidence of adverse effects. In this review, we evaluated the pharmacogenetic evidences currently available in the literature, and we identified the top informative genetic variants associated with response to the most common anti-diabetic drugs: metformin, DPP-4 inhibitors/GLP1R agonists, thiazolidinediones, and sulfonylureas/meglitinides. Overall, we found 40 polymorphisms for each drug class in a total of 71 loci, and we examined the possibility of encouraging genetic screening of these variants/loci in order to critically implement decision-making about the therapeutic approach through precision medicine strategies. It is possible then to anticipate that when the clinical practice will take advantage of the genetic information of the diabetic patients, this will provide a useful resource for the prevention of T2DM progression, enabling the identification of the precise drug that is most likely to be effective and safe for each patient and the reduction of the economic impact on a global scale.
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Affiliation(s)
- Gaia Chiara Mannino
- Department of Medical and Surgical SciencesUniversity Magna Graecia of CatanzaroCatanzaroItaly
| | - Francesco Andreozzi
- Department of Medical and Surgical SciencesUniversity Magna Graecia of CatanzaroCatanzaroItaly
| | - Giorgio Sesti
- Department of Medical and Surgical SciencesUniversity Magna Graecia of CatanzaroCatanzaroItaly
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32
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Shi R, Xu Z, Xu X, Jin J, Zhao Y, Wang T, Li Y, Ma Y. Organic cation transporter and multidrug and toxin extrusion 1 co-mediated interaction between metformin and berberine. Eur J Pharm Sci 2019; 127:282-290. [DOI: 10.1016/j.ejps.2018.11.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/29/2018] [Accepted: 11/10/2018] [Indexed: 12/13/2022]
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33
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Stefani M, Roberts DM. Complex decisions in the use of extracorporeal treatments in acute metformin overdose: which modality, when and how to measure the effect. Br J Clin Pharmacol 2018; 84:2689-2691. [PMID: 30194775 PMCID: PMC6255999 DOI: 10.1111/bcp.13762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 08/23/2018] [Accepted: 09/04/2018] [Indexed: 11/29/2022] Open
Affiliation(s)
- Maurizio Stefani
- Department of Clinical Pharmacology and ToxicologySt Vincent's HospitalDarlinghurstNSWAustralia
- St Vincent's Clinical SchoolUniversity of New South WalesDarlinghurstNSWAustralia
| | - Darren M. Roberts
- Department of Clinical Pharmacology and ToxicologySt Vincent's HospitalDarlinghurstNSWAustralia
- St Vincent's Clinical SchoolUniversity of New South WalesDarlinghurstNSWAustralia
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34
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Graham GG. Comment on ''Massive' metformin overdose' by Chiew et al. Br J Clin Pharmacol 2018; 84:2938-2939. [PMID: 30209823 PMCID: PMC6256005 DOI: 10.1111/bcp.13723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 07/22/2018] [Indexed: 11/27/2022] Open
Affiliation(s)
- Garry G. Graham
- Department of Pharmacology, School of Medical SciencesUniversity of New South WalesSydneyAustralia
- Department of Clinical Pharmacology and ToxicologySt Vincent's HospitalDarlinghurstAustralia
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35
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Stage TB, Wellhagen G, Christensen MMH, Guiastrennec B, Brøsen K, Kjellsson MC. Using a semi-mechanistic model to identify the main sources of variability of metformin pharmacokinetics. Basic Clin Pharmacol Toxicol 2018; 124:105-114. [DOI: 10.1111/bcpt.13139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/18/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Tore Bjerregaard Stage
- Clinical Pharmacology and Pharmacy; Department of Public Health; University of Southern Denmark; Odense Denmark
- Pharmacometrics Group; Department of Pharmaceutical Biosciences; Uppsala University; Uppsala Sweden
| | - Gustaf Wellhagen
- Pharmacometrics Group; Department of Pharmaceutical Biosciences; Uppsala University; Uppsala Sweden
| | | | - Benjamin Guiastrennec
- Pharmacometrics Group; Department of Pharmaceutical Biosciences; Uppsala University; Uppsala Sweden
| | - Kim Brøsen
- Clinical Pharmacology and Pharmacy; Department of Public Health; University of Southern Denmark; Odense Denmark
| | - Maria C. Kjellsson
- Pharmacometrics Group; Department of Pharmaceutical Biosciences; Uppsala University; Uppsala Sweden
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36
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Carland JE, Smith FC, Day RO. Lactic Acidosis, Metformin Use, and Dose-Response Association. JAMA Intern Med 2018; 178:1428-1429. [PMID: 30285133 DOI: 10.1001/jamainternmed.2018.4448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jane E Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Felicity C Smith
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
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37
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Dissanayake AM, Wheldon MC, Hood CJ. Pharmacokinetics of metformin in patients with chronic kidney disease stage 4 and metformin-naïve type 2 diabetes. Pharmacol Res Perspect 2018; 6:e00424. [PMID: 30221006 PMCID: PMC6138239 DOI: 10.1002/prp2.424] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 07/09/2018] [Indexed: 01/10/2023] Open
Abstract
The pharmacokinetics of metformin therapy in patients with chronic kidney disease stage 4 (CKD-4) were studied using data from the largest Phase I consecutive cohort trial yet performed in this population. Eighteen metformin-naïve men and women with Type 2 Diabetes and creatinine clearance (CrCl) in the range 18-49 mL/min (eGFR 15-29 mL/min/1.73 m2) were allocated to daily immediate-release metformin of 250 mg, 500 mg, or 1000 mg. A first-dose profile and trough concentrations for 4 weeks were taken on all patients. Pharmacokinetic (PK) parameters were estimated by fitting a first-order compartment model with absorption in a peripheral compartment to concentrations measured 24 hours post-first dose. Single-dose PK parameters time to maximum concentration (tmax) and maximum concentration (Cmax) were consistent with previous observations in patients with normal renal function (healthy and diabetic), as was the association between CrCl and apparent total oral clearance (Cl/F). However, patients with a CrCl below 32 mL/min had trough concentrations that were consistently above the steady-state minimum implied by the population PK model. This suggests the model may not apply to patients with CrCl below 32 mL/min. Metformin in doses of 500-1000 mg/day could be taken by CKD-4 patients. However, the single-compartment model breaks down as CrCl declines below 32 mL/min suggesting that metformin levels should be monitored regularly in progressive stage 4 CKD.
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Affiliation(s)
| | - Mark C. Wheldon
- Auckland University of TechnologyAucklandNew Zealand
- Middlemore Clinical TrialsMiddlemore HospitalAucklandNew Zealand
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38
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Kumar SS, Biltaji E, Bies R, Sherwin CM. The clinical utility of pharmacometric models. Br J Clin Pharmacol 2018; 84:1413-1414. [PMID: 29637580 PMCID: PMC6005593 DOI: 10.1111/bcp.13603] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/30/2018] [Accepted: 04/03/2018] [Indexed: 12/11/2022] Open
Affiliation(s)
- Shaun S. Kumar
- Division of Clinical Pharmacology, Department of PediatricsUniversity of Utah, School of MedicineSalt Lake CityUTUSA
| | - Eman Biltaji
- Division of Clinical Pharmacology, Department of PediatricsUniversity of Utah, School of MedicineSalt Lake CityUTUSA
- Department of Pharmacotherapy, College of PharmacyUniversity of UtahSalt Lake CityUTUSA
| | - Robert Bies
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, Computational and Data Enabled Science and Engineering ProgramState University of New YorkBuffaloNYUSA
| | - Catherine M. Sherwin
- Division of Clinical Pharmacology, Department of PediatricsUniversity of Utah, School of MedicineSalt Lake CityUTUSA
- Department of Pharmacotherapy, College of PharmacyUniversity of UtahSalt Lake CityUTUSA
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39
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Ningrum VD, Ikawati Z, Sadewa AH, Ikhsan MR. Patient-factors associated with metformin steady-state levels in type 2 diabetes mellitus with therapeutic dosage. J Clin Transl Endocrinol 2018; 12:42-47. [PMID: 29892566 PMCID: PMC5992324 DOI: 10.1016/j.jcte.2018.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/07/2018] [Indexed: 01/08/2023] Open
Abstract
AIMS This prospective study aimed to analyze metformin steady-state concentration in repeated constant dosage and the influencing patient-factors as well as to correlate them with glycemic control. METHODS The validated HPLC-UV method was used to examine metformin steady-state concentration, while FBG and glycated albumin were used as the parameters of glycemic control during metformin administration. RESULTS A total of 82 type-2 diabetes patients were involved with 32.1% of them having metformin Cssmin and 84.1% having Cssmax of metformin within the recommended therapeutic range. One patient had metformin Css that exceeded minimum toxic concentration despite his normal renal function and administered therapeutic dosage of metformin. Higher Cssmax was found in patients with metformin monotherapy, while patients with longer duration of metformin use had significantly higher Cssmin. CONCLUSIONS Along with initial hyperglycemia and eGFR, metformin Cssmin became the only parameter that influenced FBG level (P < 0.05). Duration of previous metformin use should be considered in the strategy of optimizing metformin dosage. The type-2 diabetes patients with obesity are more suggested to take shorter interval of metformin administration (or possibly with sustained-release formulation) to keep Cssmin within the therapeutic range.
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Affiliation(s)
| | - Zullies Ikawati
- Faculty of Pharmacy, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia
| | - Ahmad H. Sadewa
- Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia
| | - Mohammad R. Ikhsan
- Department of Internal Medicine, Dr. Sardjito General Hospital, Yogyakarta 55281, Indonesia
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40
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Out M, Becker ML, van Schaik RH, Lehert P, Stehouwer CD, Kooy A. A gene variant near ATM affects the response to metformin and metformin plasma levels: a post hoc analysis of an RCT. Pharmacogenomics 2018; 19:715-726. [PMID: 29790415 DOI: 10.2217/pgs-2018-0010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
AIM To determine the influence of polymorphisms on the effects of metformin on HbA1c, daily dose of insulin and metformin plasma concentration. Methods: In a post hoc analysis of a 4.3 year placebo-controlled randomized trial with 390 patients with Type 2 diabetes already on insulin, we analyzed the influence of polymorphisms in genes coding for ATM and the transporters OCT1 and MATE1. Outcome measures were a combined HbA1c + daily dose of insulin Z score and metformin plasma concentrations. RESULTS rs11212617 (ATM) was associated with an improved Z score and a lower metformin plasma concentration. In addition, the major allele of rs2289669 (MATE1) was also associated with an improved Z score. CONCLUSION The ATM SNP rs11212617 significantly affected the effect of metformin and metformin plasma concentration. Further research is needed to determine the clinical importance of these findings, in particular the effects on metformin plasma concentration.
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Affiliation(s)
- Mattijs Out
- Department of Internal Medicine, Bethesda Hospital Hoogeveen - Care Group Treant, Hoogeveen, The Netherlands.,Bethesda Diabetes Research Center Hoogeveen, Hoogeveen, The Netherlands.,Department of Internal Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Matthijs L Becker
- Department of Clinical Chemistry, Erasmus MC Rotterdam, Rotterdam, The Netherlands.,Pharmacy Foundation of Haarlem Hospitals, Haarlem, The Netherlands
| | - Ron H van Schaik
- Department of Clinical Chemistry, Erasmus MC Rotterdam, Rotterdam, The Netherlands
| | - Philippe Lehert
- Department of Statistics, Faculty of Economics, Louvain Academy, Mons, Belgium
| | - Coen D Stehouwer
- Department of Internal Medicine & Cardiovascular Research, Maastricht University Medical Centre, The Netherlands
| | - Adriaan Kooy
- Department of Internal Medicine, Bethesda Hospital Hoogeveen - Care Group Treant, Hoogeveen, The Netherlands.,Bethesda Diabetes Research Center Hoogeveen, Hoogeveen, The Netherlands.,Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
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41
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Chiew AL, Wright DFB, Dobos NM, McArdle K, Mostafa AA, Newth A, Roberts MS, Isbister GK. 'Massive' metformin overdose. Br J Clin Pharmacol 2018. [PMID: 29534338 DOI: 10.1111/bcp.13582] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Massive metformin overdose can cause metabolic acidosis with hyperlactatemia. A 55-year-old woman presented 5 h after multidrug overdose, including 132 g extended-release metformin. Continuous venovenous haemodiafiltration (CVVHDF) and noradrenaline were commenced due to metabolic acidosis (pH 7.0, lactate 17 mmol l-1 ) and shock. Despite 3 h of CVVHDF, her acidosis worsened (pH 6.83, lactate 24 mmol l-1 ). Intermittent haemodialysis (IHD) improved acidosis (pH 7.13, lactate 26 mmol l-1 ) but again worsened (pH 6.91, lactate 30 mmol l-1 ) with CVVHDF recommencement. IHD (12 h), CVVHDF (26 h) and vasopressor support for 7 days resulted in survival. Measured metformin concentrations were extremely high with a peak of 292 μg ml-1 at 8 h postingestion. IHD, but not CVVHDF in this case, was associated with improvement in metabolic acidosis and hyperlactataemia. Pharmacokinetic analysis of metformin concentrations found a reduced apparent oral clearance of 8.2 l h-1 and a half-life of approximately 30 h. During IHD, the apparent oral clearance increased to 22.2 l h-1 with an approximate half-life of 10 h. The impact of prolonged oral absorption from a pharmacobezoar and redistribution of metformin from peripheral sites (including erythrocytes) on the pharmacokinetic profile cannot be determined from the data available.
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Affiliation(s)
- Angela L Chiew
- New South Wales Poisons Information Centre, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | | | - Nicola M Dobos
- Intensive Care Unit, Western Health, Melbourne, Victoria, Australia
| | - Kylie McArdle
- New South Wales Poisons Information Centre, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Ahmed A Mostafa
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia.,Pharmaceutical Chemistry Department, Helwan University, Helwan, Egypt
| | - Annemarie Newth
- Emergency Department and Victorian Poisons Information Centre, The Austin Hospital, Melbourne, Victoria, Australia
| | - Michael S Roberts
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia.,Translational Research Institute, Diamantina Institute, University of Queensland, Brisbane, Queensland, Australia
| | - Geoffrey K Isbister
- New South Wales Poisons Information Centre, Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Clinical Toxicology Research Group, University of Newcastle, Callaghan, New South Wales, Australia
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Abstract
Metformin has been associated with lactic acidosis. Lactate levels are not commonly tested in clinical practice, and it is unclear to what extent metformin would typically increase lactate levels with chronic use. The aim of this review was to determine whether regular monitoring of the plasma lactate level would be beneficial in avoiding lactate accumulation and, ultimately, minimising the incidence of lactic acidosis in metformin-treated patients.A comprehensive search of PubMed, Embase, Web of Science, Cochrane and International Pharmaceutical Abstracts databases covering the period up to 30 May 2017 was performed. Search terms included combinations of terms and keywords, including "metformin", "lactate", "lactic acid" and "lactic acidosis". Cases series of lactic acidosis or metformin-associated lactic acidosis were excluded.Of 1539 potentially relevant articles, a total of 52 reported lactate levels from routine/regular pathological tests in metformin users. The studies were subdivided into four themes, regarding metformin usage and the reported lactate levels in patients who: (1) did not have contraindications to the use of metformin; (2) had contraindications, or renal impairment but without other contraindications; (3) exercised; or (4) also received any nucleoside reverse transcriptase inhibitor. Studies have reported that metformin treatment could increase lactate level of users. However, most results showed that the lactate level remained in the normal range.No definitive conclusions on the benefits of regular lactate monitoring in patients taking metformin can be made. Future research on larger populations focusing on the measurement of lactate levels with continuous metformin use is warranted.
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43
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Khomitskaya Y, Tikhonova N, Gudkov K, Erofeeva S, Holmes V, Dayton B, Davies N, Boulton DW, Tang W. Bioequivalence of Dapagliflozin/Metformin Extended-release Fixed-combination Drug Product and Single-component Dapagliflozin and Metformin Extended-release Tablets in Healthy Russian Subjects. Clin Ther 2018; 40:550-561.e3. [DOI: 10.1016/j.clinthera.2018.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/30/2018] [Accepted: 02/09/2018] [Indexed: 01/10/2023]
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44
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How Relevant is the Interaction Between Dolutegravir and Metformin in Real Life? J Acquir Immune Defic Syndr 2018; 75:e24-e26. [PMID: 28114188 DOI: 10.1097/qai.0000000000001292] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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45
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Lalau JD, Kajbaf F, Bennis Y, Hurtel-Lemaire AS, Belpaire F, De Broe ME. Metformin Treatment in Patients With Type 2 Diabetes and Chronic Kidney Disease Stages 3A, 3B, or 4. Diabetes Care 2018; 41:547-553. [PMID: 29305402 DOI: 10.2337/dc17-2231] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/11/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study was conducted to define a safe, effective dose regimen for metformin in moderate and severe chronic kidney disease (CKD; stages 3A/3B and 4, respectively), after the lifting of restrictions on metformin use in patients with diabetes with moderate-to-severe CKD in the absence of prospective safety and efficacy studies. RESEARCH DESIGN AND METHODS Three complementary studies were performed: 1) a dose-finding study in CKD stages 1-5, in which blood metformin concentrations were evaluated during a 1-week period after each dose increase; 2) a 4-month metformin treatment study for validating the optimal metformin dose as a function of the CKD stage (3A, 3B, and 4), with blood metformin, lactate, and HbA1c concentrations monitored monthly; and 3) an assessment of pharmacokinetic parameters after the administration of a single dose of metformin in steady-state CKD stages 3A, 3B, and 4. RESULTS First, in the dose-finding study, the appropriate daily dosing schedules were 1,500 mg (0.5 g in the morning [qam] +1 g in the evening [qpm]) in CKD stage 3A, 1,000 mg (0.5 g qam + 0.5 g qpm) in CKD stage 3B, and 500 mg (qam) in CKD stage 4. Second, after 4 months on these regimens, patients displayed stable metformin concentrations that never exceeded the generally accepted safe upper limit of 5.0 mg/L. Hyperlactatemia (>5 mmol/L) was absent (except in a patient with myocardial infarction), and HbA1c levels did not change. Third, there were no significant differences in pharmacokinetic parameters among the CKD stage groups. CONCLUSIONS Provided that the dose is adjusted for renal function, metformin treatment appears to be safe and still pharmacologically efficacious in moderate-to-severe CKD.
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Affiliation(s)
- Jean-Daniel Lalau
- Department of Endocrinology-Nutrition, Amiens University Medical Center, Amiens, France .,INSERM 1088, Université de Picardie Jules Verne, Amiens, France
| | - Farshad Kajbaf
- Department of Endocrinology-Nutrition, Amiens University Medical Center, Amiens, France.,INSERM 1088, Université de Picardie Jules Verne, Amiens, France
| | - Youssef Bennis
- Laboratoire de Pharmacologie Clinique, Amiens University Medical Center, Amiens, France
| | | | - Frans Belpaire
- Heymans Institute of Pharmacology, University of Ghent, Ghent, Belgium
| | - Marc E De Broe
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
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46
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Ceacareanu AC, Brown GW, Moussa HA, Wintrob ZAP. Application of a Pharmacokinetic Model of Metformin Clearance in a Population with Acute Myeloid Leukemia. J Res Pharm Pract 2018; 7:41-45. [PMID: 29755998 PMCID: PMC5934987 DOI: 10.4103/jrpp.jrpp_17_53] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE We aimed to estimate the metformin-associated lactic acidosis (MALA) risk by assessing retrospectively the renal clearance variability and applying a pharmacokinetic (PK) model of metformin clearance in a population diagnosed with acute myeloid leukemia (AML) and diabetes mellitus (DM). METHODS All adults with preexisting DM and newly diagnosed AML at Roswell Park Cancer Institute were reviewed (January 2003-December 2010, n = 78). Creatinine clearance (CrCl) and total body weight distributions were used in a two-compartment PK model adapted for multiple dosing and modified to account for actual intra- and inter-individual variability. Based on this renal function variability evidence, 1000 PK profiles were simulated for multiple metformin regimens with the resultant PK profiles being assessed for safe CrCl thresholds. FINDINGS Metformin 500 mg up to three times daily was safe for all simulated profiles with CrCl ≥25 mL/min. Furthermore, the estimated overall MALA risk was below 10%, remaining under 5% for 500 mg given once daily. CrCl ≥65.25 mL/min was safe for administration in any of the tested regimens (500 mg or 850 mg up to three times daily or 1000 mg up to twice daily). CONCLUSION PK simulation-guided prescribing can maximize metformin's beneficial effects on cancer outcomes while minimizing MALA risk.
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Affiliation(s)
- Alice C Ceacareanu
- Department of Pharmacy Practice, NYS Center of Excellence in Bioinformatics and Life Sciences, University at Buffalo, Buffalo, NY, USA.,Department of Pharmacy, Roswell Park Cancer Institute, Buffalo, NY, USA.,Clinical Services, ROAKETIN Inc., Buffalo, NY, USA
| | - Geoffrey W Brown
- Department of Pharmacy Practice, NYS Center of Excellence in Bioinformatics and Life Sciences, University at Buffalo, Buffalo, NY, USA
| | - Hoda A Moussa
- Department of Pharmacy Practice, NYS Center of Excellence in Bioinformatics and Life Sciences, University at Buffalo, Buffalo, NY, USA.,Clinical Services, ROAKETIN Inc., Buffalo, NY, USA
| | - Zachary A P Wintrob
- Department of Pharmacy Practice, NYS Center of Excellence in Bioinformatics and Life Sciences, University at Buffalo, Buffalo, NY, USA.,Department of Pharmacy, Roswell Park Cancer Institute, Buffalo, NY, USA.,Clinical Services, ROAKETIN Inc., Buffalo, NY, USA
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47
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Duong JK, Kroonen MYAM, Kumar SS, Heerspink HL, Kirkpatrick CM, Graham GG, Williams KM, Day RO. A dosing algorithm for metformin based on the relationships between exposure and renal clearance of metformin in patients with varying degrees of kidney function. Eur J Clin Pharmacol 2017; 73:981-990. [PMID: 28451709 DOI: 10.1007/s00228-017-2251-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 03/30/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE The aims of this study were to investigate the relationship between metformin exposure, renal clearance (CLR), and apparent non-renal clearance of metformin (CLNR/F) in patients with varying degrees of kidney function and to develop dosing recommendations. METHODS Plasma and urine samples were collected from three studies consisting of patients with varying degrees of kidney function (creatinine clearance, CLCR; range, 14-112 mL/min). A population pharmacokinetic model was built (NONMEM) in which the oral availability (F) was fixed to 0.55 with an estimated inter-individual variability (IIV). Simulations were performed to estimate AUC0-τ, CLR, and CLNR/F. RESULTS The data (66 patients, 327 observations) were best described by a two-compartment model, and CLCR was a covariate for CLR. Mean CLR was 17 L/h (CV 22%) and mean CLNR/F was 1.6 L/h (69%).The median recovery of metformin in urine was 49% (range 19-75%) over a dosage interval. When CLR increased due to improved renal function, AUC0-τ decreased proportionally, while CLNR/F did not change with kidney function. Target doses (mg/day) of metformin can be reached using CLCR/3 × 100 to obtain median AUC0-12 of 18-26 mg/L/h for metformin IR and AUC0-24 of 38-51 mg/L/h for metformin XR, with Cmax < 5 mg/L. CONCLUSIONS The proposed dosing algorithm can be used to dose metformin in patients with various degrees of kidney function to maintain consistent drug exposure. However, there is still marked IIV and therapeutic drug monitoring of metformin plasma concentrations is recommended.
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Affiliation(s)
- Janna K Duong
- School of Medical Sciences, Medicine, University of New South Wales, Sydney, Australia. .,Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia. .,Faculty of Pharmacy, The University of Sydney, Sydney, NSW, 2006, Australia.
| | - M Y A M Kroonen
- Department of Pharmacy and Pharmacology, University of Groningen, Groningen, The Netherlands
| | - S S Kumar
- School of Medical Sciences, Medicine, University of New South Wales, Sydney, Australia.,Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - H L Heerspink
- Department of Pharmacy and Pharmacology, University of Groningen, Groningen, The Netherlands
| | - C M Kirkpatrick
- Centre for Medicine Use and Safety, Monash University, Parkville, Australia
| | - G G Graham
- School of Medical Sciences, Medicine, University of New South Wales, Sydney, Australia.,Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - K M Williams
- School of Medical Sciences, Medicine, University of New South Wales, Sydney, Australia.,Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - R O Day
- School of Medical Sciences, Medicine, University of New South Wales, Sydney, Australia.,Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,St Vincent's Clinical School, Medicine, University of New South Wales, Sydney, Australia
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Samsuri NAB, Leech M, Marignol L. Metformin and improved treatment outcomes in radiation therapy - A review. Cancer Treat Rev 2017; 55:150-162. [PMID: 28399491 DOI: 10.1016/j.ctrv.2017.03.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/15/2017] [Accepted: 03/17/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Metformin, a primary treatment for diabetes mellitus (DM) patients, is associated with improved outcomes for diabetic cancer patients fuelling further investigation on its mechanisms of action. The radiosensitising properties of metformin are increasingly reported in pre-clinical studies. This review discusses whether metformin should be offered to radiotherapy (RT) cancer patients as a means to improve their treatment outcomes. MATERIALS AND METHODS A database search was conducted for articles published with metformin as the main intervention between 2010 and 2016. Three groups of RT cancer patients were analysed: diabetic patients using metformin, diabetic patients not using metformin and non-diabetic patients not using metformin. Data on survival and recurrence metrics were extracted. RESULTS Thirteen studies were included. Conflicting evidence exists with regards to the impact of metformin administration on recurrence and survival outcomes following radiotherapy. Three studies reported improved tumour response determined by recurrence rates while five studies did not observe differences or metformin use was not the associated reason. One study revealed inconsistent tumour response results. Metformin was reported as improving survival outcomes in 2 studies and not improving outcomes in 5 studies. 4 studies showed indefinite results. CONCLUSION Although metformin may improve tumour response in the non-randomized, retrospective studies analysed, it may not necessarily confer survival benefits. Future prospective and randomised trials are required to translate the positive impact of metformin documented in pre-clinical and retrospective studies into improve management of RT cancer patients.
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Affiliation(s)
- Nur Atiqah Binte Samsuri
- Applied Radiation Therapy Trinity Research Group, Trinity College Dublin, Ireland; Division of Radiation Oncology, National Cancer Centre, Singapore
| | - Michelle Leech
- Applied Radiation Therapy Trinity Research Group, Trinity College Dublin, Ireland.
| | - Laure Marignol
- Applied Radiation Therapy Trinity Research Group, Trinity College Dublin, Ireland
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Kumar SS, Graham GG, Smith FC, Furlong TJ, Greenfield JR, Stocker SS, Carland JE, Day RO. Could metformin be used in patients with advanced chronic kidney disease? Diabetes Obes Metab 2017; 19:302-303. [PMID: 27735109 DOI: 10.1111/dom.12806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 10/07/2016] [Accepted: 10/07/2016] [Indexed: 12/18/2022]
Affiliation(s)
- Shaun S Kumar
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
- School of Medical Sciences, UNSW Medicine, University of New South Wales, Kensington, New South Wales, Australia
| | - Garry G Graham
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
- School of Medical Sciences, UNSW Medicine, University of New South Wales, Kensington, New South Wales, Australia
| | - Felicity C Smith
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
- School of Medical Sciences, UNSW Medicine, University of New South Wales, Kensington, New South Wales, Australia
| | | | - Jerry R Greenfield
- Diabetes and Metabolism Research Division, Garvan Institute of Medical Research, Sydney, Australia
- St Vincent's Clinical School, UNSW Medicine, St Vincent's Hospital, Sydney, Australia
| | - Sophie S Stocker
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Jane E Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
- School of Medical Sciences, UNSW Medicine, University of New South Wales, Kensington, New South Wales, Australia
- St Vincent's Clinical School, UNSW Medicine, St Vincent's Hospital, Sydney, Australia
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Chowdhury TA, Srirathan D, Abraham G, Oei EL, Fan SL, McCafferty K, Yaqoob MM. Could metformin be used in patients with diabetes and advanced chronic kidney disease? Diabetes Obes Metab 2017; 19:156-161. [PMID: 27690331 DOI: 10.1111/dom.12799] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 09/26/2016] [Accepted: 09/26/2016] [Indexed: 12/26/2022]
Abstract
Diabetes is an important cause of end stage renal failure worldwide. As renal impairment progresses, managing hyperglycaemia can prove increasingly challenging, as many medications are contra-indicated in moderate to severe renal impairment. Whilst evidence for tight glycaemic control reducing progression to renal failure in patients with established renal disease is limited, poor glycaemic control is not desirable, and is likely to lead to progressive complications. Metformin is a first-line therapy in patients with Type 2 diabetes, as it appears to be effective in reducing diabetes related end points and mortality in overweight patients. Cessation of metformin in patients with progressive renal disease may not only lead to deterioration in glucose control, but also to loss of protection from cardiovascular disease in a cohort of patients at particularly high risk. We advocate the need for further study to determine the role of metformin in patients with severe renal disease (chronic kidney disease stage 4-5), as well as patients on dialysis, or pre-/peri-renal transplantation. We explore possible roles of metformin in these circumstances, and suggest potential key areas for further study.
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Affiliation(s)
- Tahseen A Chowdhury
- Department of Diabetes, Barts and the London School of Medicine and Dentistry, The Royal London Hospital, London, UK
| | - Danushan Srirathan
- Department of Diabetes, Barts and the London School of Medicine and Dentistry, The Royal London Hospital, London, UK
| | - Georgi Abraham
- Department of Nephrology, Pondicherry Institute of Medical Sciences, Madras Medical Mission, Chennai, India
| | - Elizabeth L Oei
- Department of Nephrology, Singapore General Hospital, Singapore, Singapore
| | - Stanley L Fan
- Department of Nephrology, Barts and the London School of Medicine and Dentistry, The Royal London Hospital, London, UK
| | - Kieran McCafferty
- Department of Nephrology, Barts and the London School of Medicine and Dentistry, The Royal London Hospital, London, UK
| | - M Magdi Yaqoob
- Department of Nephrology, Barts and the London School of Medicine and Dentistry, The Royal London Hospital, London, UK
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