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Ng CYJ, Zhao Y, Wang N, Chia KL, Teo CH, Peh W, Yeo P, Zhong LLD. A multi-center cross-sectional study of Chinese Herbal Medicine-Drug adverse reactions using active surveillance in Singapore's Traditional Chinese Medicine clinics. Chin Med 2024; 19:44. [PMID: 38454483 PMCID: PMC10918936 DOI: 10.1186/s13020-024-00915-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 02/27/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND This study aimed to investigate the rates and causality of patient-reported adverse events (AEs) associated with concomitant Chinese Herbal Medicine (CHM) and Western Medicine prescription drug (WMPD) consumption through active surveillance in Singapore's Traditional Chinese Medicine (TCM) clinics. METHODS A cross-sectional study was conducted at five TCM clinics across Singapore from 8th May till 8th July 2023. Patients were screened to determine rates of CHM and WMPD consumption, and then interviewed if an AE was reported. An expert committee assessed the AE reports to determine causality. Along with descriptive statistics, odds ratios were calculated to determine AE occurrence likelihoods for patients who consumed both CHM and WMPD compared to CHM consumption alone. RESULTS 1028 patients were screened and 62.65% of them reported concurrent CHM-WMPD consumption. Patients who consumed CHM and WMPD were 3.65 times more likely to experience an AE as compared to CHM consumption alone. 18 AE reports were adjudicated, with most AEs deemed unlikely due to CHM consumption. CONCLUSIONS A large proportion of patients consumed CHM and WMPD concurrently, thus increasing their risk of experiencing AEs compared to those consuming CHM only. Active surveillance is applicable for detecting AEs, collecting data for causality assessment, and analysis.
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Affiliation(s)
- Chester Yan Jie Ng
- School of Biological Sciences, Nanyang Technological University, 60 Nanyang Drive, Singapore, 637551, Singapore
| | - Yan Zhao
- School of Biological Sciences, Nanyang Technological University, 60 Nanyang Drive, Singapore, 637551, Singapore
| | - Ning Wang
- School of Chinese Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Kwan Leung Chia
- Woodcroft Medical Centre, 1 Sir James Hardy Way, Woodcroft, SA, 5162, Australia
| | - Chun Huat Teo
- Singapore Thong Chai Medical Institution, 50 Chin Swee Road #01-01, Singapore, 169874, Singapore
| | - William Peh
- Operation and Medical Department, Singapore Chung Hwa Medical Institution, 640 Lorong 4 Toa Payoh, Singapore, 319522, Singapore
| | - Pansy Yeo
- Chong Hoe Healthcare, 144 Upper Bukit Timah Rd, #02-14, Singapore, 588177*, Singapore
| | - Linda L D Zhong
- School of Biological Sciences, Nanyang Technological University, 60 Nanyang Drive, Singapore, 637551, Singapore.
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2
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Xie W, Li J, Kong C, Luo W, Zheng J, Zhou Y. Metformin-Cimetidine Drug Interaction and Risk of Lactic Acidosis in Renal Failure: A Pharmacovigilance-Pharmacokinetic Appraisal. Diabetes Care 2024; 47:144-150. [PMID: 37948503 DOI: 10.2337/dc23-1344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/17/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE This study aimed to evaluate lactic acidosis (LA) risk when using metformin combined with histamine H2 receptor inhibitors (H2RI) in patients with renal failure (RF). RESEARCH DESIGN AND METHODS This study analyzed FDA Adverse Event Reporting System data (2012Q4 to 2022Q4) to characterize reports of LA associated with metformin alone or combined with H2RI. Using a disproportionality approach, LA risk signal in the overall population and in patients with RF was assessed. A physiologically based pharmacokinetic (PBPK) model was developed to predict metformin and cimetidine pharmacokinetic changes following conventional doses of the combinations in patients with various degrees of RF. To explore its correlation with LA risk, a peak plasma metformin concentration of 3 mg/L was considered the threshold. RESULTS Following the 2016 U.S. Food and Drug Administration metformin approval for mild-to-moderate RF, the percentage of patients with RF reporting LA associated with metformin combined with H2RI increased. Disproportionality analysis showed reported LA risk signal associated with metformin and cimetidine in the overall population within the study timeframe only. Furthermore, with PBPK simulations, for metformin (1,000 mg b.i.d.) with cimetidine (300 mg q.i.d. or 400 mg b.i.d.) in stage 1 of chronic kidney disease, metformin (1,000 mg b.i.d.) with cimetidine (300 mg q.i.d. or 400 mg b.i.d. or 800 mg q.d.) in stage 2, and most combinations in stage 3, the peak plasma metformin concentrations exceeded the 3 mg/L threshold. CONCLUSIONS Metformin combined with cimetidine at conventional doses may cause LA in patients with mild-to-moderate RF.
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Affiliation(s)
- Wenhuo Xie
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Jianbin Li
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Chenghua Kong
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Wei Luo
- Department of Rehabilitation Medicine, School of Health, Fujian Medical University, Fuzhou, China
| | - Jiaping Zheng
- Department of Rehabilitation Medicine, School of Health, Fujian Medical University, Fuzhou, China
| | - Yu Zhou
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fujian Medical University, Fuzhou, China
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Sohn JT. The elimination half-life of metformin during metformin overdose. Am J Emerg Med 2023; 70:183-184. [PMID: 37423821 DOI: 10.1016/j.ajem.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 07/01/2023] [Indexed: 07/11/2023] Open
Affiliation(s)
- Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 beon-gil, Jinju-si, Gyeongsangnam-do 52727, Republic of Korea; Institute of Medical Sciences, Gyeongsang National University, Jinju-si 52727, Republic of Korea.
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Mohammed T, Bowe M, Plant A, Perez M, Alvarez CA, Mortensen EM. Metformin Use Is Associated With Lower Mortality in Veterans With Diabetes Hospitalized With Pneumonia. Clin Infect Dis 2023; 76:1237-1244. [PMID: 36575139 PMCID: PMC10319762 DOI: 10.1093/cid/ciac900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Recent studies suggest that metformin use may be associated with improved infectious disease-related outcomes, whereas other papers suggest potentially worse outcomes in serious bacterial infections. Our purpose was to examine the association of prior outpatient prescription of metformin on 30- and 90-day mortality for older veterans with pre-existing diabetes hospitalized with pneumonia. METHODS We conducted a retrospective cohort study using national Department of Veterans Affairs data of patients ≥65 years with a prior history of diabetes who were hospitalized with pneumonia over a 10-year period (fiscal years 2002-2012.) For our primary analysis, we created a propensity score and matched metformin users to nonusers 1:1. RESULTS We identified 34 759 patients who met the inclusion criteria, 20.3% of whom were prescribed metformin. Unadjusted 30-day mortality was 9.6% for those who received metformin versus 13.9% in nonusers (P < .003), and 90-day mortality was 15.8% for those who received metformin versus 23.0% for nonusers (P < .0001). For the propensity score model, we matched 6899 metformin users to 6899 nonusers. After propensity matching, both 30-day (relative risk [RR]: .86; 95% confidence interval [CI]: .78-.95) and 90-day (RR: .85; 95% CI: .79-.92) mortality was significantly lower for metformin users. CONCLUSIONS Prior receipt of metformin was associated with significantly lower mortality after adjusting for potential confounders. Additional research is needed to examine the safety and potential benefits of metformin use in patients with respiratory infections.
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Affiliation(s)
- Turab Mohammed
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Michael Bowe
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Alexandria Plant
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Mario Perez
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Carlos A Alvarez
- Department of Medicine, VA North Texas Health Care System, Dallas, Texas, USA
- Department of Medicine, Texas Tech University Health Sciences Centre, Jerry H. Hodge School of Pharmacy, Dallas, Texas, USA
| | - Eric M Mortensen
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
- Department of Medicine, VA North Texas Health Care System, Dallas, Texas, USA
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5
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Metformin, a biological and synthetic overview. Bioorg Med Chem Lett 2023; 86:129241. [PMID: 36933671 DOI: 10.1016/j.bmcl.2023.129241] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 03/03/2023] [Accepted: 03/12/2023] [Indexed: 03/18/2023]
Abstract
Metformin is the most widely known anti-hyperglycemic, officially acquired by the USA government in 1995 and in 2001 it became the most prescribed treatment for type II diabetes. But how did it become the must-use drug for this disease in such a short period of time? it all started with traditional medicine, by using a plant known as "goat's rue" for the reduction of blood glucose levels. Its use arose in 1918 and evolved to the metformin synthesis in laboratories a couple of years later, using very rudimentary methods which involved melting and strong heating. Thus, a first synthetic route that allowed the preparation of the initial metformin derivates was established. Some of these resulted toxics, and others outperformed the metformin, reducing the blood glucose levels in such efficient way. Nevertheless, the risk and documented cases of lactic acidosis increased with metformin derivatives like buformin and phenformin. Recently, metformin has been widely studied, and it has been associated and tested in the treatment of type II diabetes, cancer, polycystic ovarian syndrome, cell differentiation to oligodendrocytes, reduction of oxidative stress in cells, weight reduction, as anti-inflammatory and even in the recent COVID-19 disease. Herein we briefly review and analyze the history, synthesis, and biological applications of metformin and its derivates.
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Klein EJ, Oh CS, Karim M, Shapiro J, Lo Sicco K. A practical approach to the management of hair loss in patients with polycystic ovary syndrome. J Eur Acad Dermatol Venereol 2023; 37:1480-1489. [PMID: 36606524 DOI: 10.1111/jdv.18842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/13/2022] [Indexed: 01/07/2023]
Abstract
Female patterned hair loss (FPHL) is a common form of androgenetic alopecia in women and is characterized by a hormonally directed diffuse hair loss on the scalp. Management of FPHL is well described in the literature; however, treatment of FPHL in patients with co-morbid polycystic ovarian syndrome (PCOS), an endocrinologic condition found in reproductive-aged women, has not yet been reviewed. Due to the different pathomechanism of the diseases and complexity of FPHL in PCOS patients, this study aimed to review current diagnosis and management approaches for hair loss in PCOS patients specifically and highlight the growing need for more research in this growing patient population.
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Affiliation(s)
- Elizabeth J Klein
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York, USA
| | - Christina S Oh
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York, USA
| | - Maria Karim
- Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Jerry Shapiro
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York, USA
| | - Kristen Lo Sicco
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York, USA
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Triggle CR, Mohammed I, Bshesh K, Marei I, Ye K, Ding H, MacDonald R, Hollenberg MD, Hill MA. Metformin: Is it a drug for all reasons and diseases? Metabolism 2022; 133:155223. [PMID: 35640743 DOI: 10.1016/j.metabol.2022.155223] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 05/22/2022] [Accepted: 05/25/2022] [Indexed: 12/15/2022]
Abstract
Metformin was first used to treat type 2 diabetes in the late 1950s and in 2022 remains the first-choice drug used daily by approximately 150 million people. An accumulation of positive pre-clinical and clinical data has stimulated interest in re-purposing metformin to treat a variety of diseases including COVID-19. In polycystic ovary syndrome metformin improves insulin sensitivity. In type 1 diabetes metformin may help reduce the insulin dose. Meta-analysis and data from pre-clinical and clinical studies link metformin to a reduction in the incidence of cancer. Clinical trials, including MILES (Metformin In Longevity Study), and TAME (Targeting Aging with Metformin), have been designed to determine if metformin can offset aging and extend lifespan. Pre-clinical and clinical data suggest that metformin, via suppression of pro-inflammatory pathways, protection of mitochondria and vascular function, and direct actions on neuronal stem cells, may protect against neurodegenerative diseases. Metformin has also been studied for its anti-bacterial, -viral, -malaria efficacy. Collectively, these data raise the question: Is metformin a drug for all diseases? It remains unclear as to whether all of these putative beneficial effects are secondary to its actions as an anti-hyperglycemic and insulin-sensitizing drug, or result from other cellular actions, including inhibition of mTOR (mammalian target for rapamycin), or direct anti-viral actions. Clarification is also sought as to whether data from ex vivo studies based on the use of high concentrations of metformin can be translated into clinical benefits, or whether they reflect a 'Paracelsus' effect. The environmental impact of metformin, a drug with no known metabolites, is another emerging issue that has been linked to endocrine disruption in fish, and extensive use in T2D has also raised concerns over effects on human reproduction. The objectives for this review are to: 1) evaluate the putative mechanism(s) of action of metformin; 2) analyze the controversial evidence for metformin's effectiveness in the treatment of diseases other than type 2 diabetes; 3) assess the reproducibility of the data, and finally 4) reach an informed conclusion as to whether metformin is a drug for all diseases and reasons. We conclude that the primary clinical benefits of metformin result from its insulin-sensitizing and antihyperglycaemic effects that secondarily contribute to a reduced risk of a number of diseases and thereby enhancing healthspan. However, benefits like improving vascular endothelial function that are independent of effects on glucose homeostasis add to metformin's therapeutic actions.
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Affiliation(s)
- Chris R Triggle
- Department of Pharmacology, Weill Cornell Medicine in Qatar, P.O. Box 24144, Education City, Doha, Qatar; Department of Medical Education, Weill Cornell Medicine in Qatar, P.O. Box 24144, Education City, Doha, Qatar.
| | - Ibrahim Mohammed
- Department of Medical Education, Weill Cornell Medicine in Qatar, P.O. Box 24144, Education City, Doha, Qatar
| | - Khalifa Bshesh
- Department of Medical Education, Weill Cornell Medicine in Qatar, P.O. Box 24144, Education City, Doha, Qatar
| | - Isra Marei
- Department of Pharmacology, Weill Cornell Medicine in Qatar, P.O. Box 24144, Education City, Doha, Qatar
| | - Kevin Ye
- Department of Biomedical Physiology & Kinesiology, Simon Fraser University, Burnaby, British Columbia V5A 1S6, Canada
| | - Hong Ding
- Department of Pharmacology, Weill Cornell Medicine in Qatar, P.O. Box 24144, Education City, Doha, Qatar; Department of Medical Education, Weill Cornell Medicine in Qatar, P.O. Box 24144, Education City, Doha, Qatar
| | - Ross MacDonald
- Distribution eLibrary, Weill Cornell Medicine in Qatar, P.O. Box 24144, Education City, Doha, Qatar
| | - Morley D Hollenberg
- Department of Physiology & Pharmacology, a Cumming School of Medicine, University of Calgary, T2N 4N1, Canada
| | - Michael A Hill
- Dalton Cardiovascular Research Center, Department of Medical Pharmacology & Physiology, School of Medicine, University of Missouri, Columbia 65211, MO, USA
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8
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Vakili-Ghartavol R, Mehrabian A, Mirzavi F, Rezayat SM, Mashreghi M, Farhoudi L, Kharrazi S, Sadri K, Jaafari MR. Docetaxel in combination with metformin enhances antitumour efficacy in metastatic breast carcinoma models: a promising cancer targeting based on PEGylated liposomes. J Pharm Pharmacol 2022; 74:1307-1319. [PMID: 35833585 DOI: 10.1093/jpp/rgac048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 06/14/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Metformin has been shown to kill cancer stem-like cells in genetically various types of breast carcinoma. With the aim to simultaneously eradicate the bulk population of tumour cells and the rare population of cancer stem-like cells in breast cancer tissues, we used the combination chemotherapy of docetaxel (DTX) with metformin (MET). Furthermore, we introduce an active loading method based on ammonium sulphate 250 mM (SA) for encapsulating docetaxel into liposomes. METHODS Docetaxel and metformin encapsulated into PEGylated liposomes with two different methods based on remote or passive loading methods, respectively. The size and surface charge of the liposomes were characterized. DTX content in the nanoliposomes was measured by the high-performance liquid chromatography method. The drug release profiles were evaluated in phosphate-buffered dextrose 5% with the pH of 6.5 and 7.4. We examined the antitumour activity of Taxotere (TAX), and liposomal formulation of DTX and MET as a monotherapy or combination therapy. The biodistribution of liposomes was also investigated using 99mTc hexamethyl propylene amine oxime method in BALB/c mice bearing 4T1 breast carcinoma tumours. KEY FINDINGS The final formulations were prepared according to the best physicochemical characteristics which were HSPC/mPEG2000-DSPE/Chol (DTX liposomes) and HSPC/DPPG/mPEG2000-DSPE/Chol (MET liposomes), at molar ratios of 85/5/10 and (55/5/5/35), respectively. In vivo experiments showed that when free or liposomal metformin used in combination with liposomal docetaxel, they prolonged median survival time (MST) from 31 in the control group to 46 days, which demonstrates their promising effects on the survival of the 4T1 breast carcinoma mice models. Moreover, combination therapies could significantly increase life span in comparison with phosphate-buffered saline (PBS) and Taxotere groups at the same dose. Furthermore, in the combination therapy study, treatment with DTX liposomes prepared by ammonium sulphate 250 mM buffer alone resulted in similar therapeutic efficacy to combination therapy. The biodistribution study exhibited significant accumulation of DTX liposomes in the tumours due to the Enhanced Permeability and Retention effect. CONCLUSIONS This study also showed that metformin-based combinatorial chemotherapies have superior efficacy versus their corresponding monotherapy counterparts at same doses. The findings confirm that liposomes based on ammonium sulphate 250 mM could be as a promising formulation for efficient DTX delivering and cancer targeting and therefore merit further investigations.
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Affiliation(s)
- Roghayyeh Vakili-Ghartavol
- Department of Medical Nanotechnology, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Medical Nanotechnology, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Amin Mehrabian
- Department of Pharmaceutical Nanotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Farshad Mirzavi
- Cardiovascular Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Seyed Mahdi Rezayat
- Department of Medical Nanotechnology, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran.,Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mashreghi
- Department of Pharmaceutical Nanotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Leila Farhoudi
- Nanotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sharmin Kharrazi
- Department of Medical Nanotechnology, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Kayvan Sadri
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahmoud Reza Jaafari
- Department of Pharmaceutical Nanotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.,Nanotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
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9
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Biguanide Pharmaceutical Formulations and the Applications of Bile Acid-Based Nano Delivery in Chronic Medical Conditions. Int J Mol Sci 2022; 23:ijms23020836. [PMID: 35055022 PMCID: PMC8775521 DOI: 10.3390/ijms23020836] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/04/2022] [Accepted: 01/11/2022] [Indexed: 12/21/2022] Open
Abstract
Biguanides, particularly the widely prescribed drug metformin, have been marketed for many decades and have well-established absorption profiles. They are commonly administered via the oral route and, despite variation in oral uptake, remain commonly prescribed for diabetes mellitus, typically type 2. Studies over the last decade have focused on the design and development of advanced oral delivery dosage forms using bio nano technologies and novel drug carrier systems. Such studies have demonstrated significantly enhanced delivery and safety of biguanides using nanocapsules. Enhanced delivery and safety have widened the potential applications of biguanides not only in diabetes but also in other disorders. Hence, this review aimed to explore biguanides’ pharmacokinetics, pharmacodynamics, and pharmaceutical applications in diabetes, as well as in other disorders.
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Szunerits S, Melinte S, Barras A, Pagneux Q, Voronova A, Abderrahmani A, Boukherroub R. The impact of chemical engineering and technological advances on managing diabetes: present and future concepts. Chem Soc Rev 2021; 50:2102-2146. [PMID: 33325917 DOI: 10.1039/c9cs00886a] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Monitoring blood glucose levels for diabetic patients is critical to achieve tight glycaemic control. As none of the current antidiabetic treatments restore lost functional β-cell mass in diabetic patients, insulin injections and the use of insulin pumps are most widely used in the management of glycaemia. The use of advanced and intelligent chemical engineering, together with the incorporation of micro- and nanotechnological-based processes have lately revolutionized diabetic management. The start of this concept goes back to 1974 with the description of an electrode that repeatedly measures the level of blood glucose and triggers insulin release from an infusion pump to enter the blood stream from a small reservoir upon need. Next to the insulin pumps, other drug delivery routes, including nasal, transdermal and buccal, are currently investigated. These processes necessitate competences from chemists, engineers-alike and innovative views of pharmacologists and diabetologists. Engineered micro and nanostructures hold a unique potential when it comes to drug delivery applications required for the treatment of diabetic patients. As the technical aspects of chemistry, biology and informatics on medicine are expanding fast, time has come to step back and to evaluate the impact of technology-driven chemistry on diabetics and how the bridges from research laboratories to market products are established. In this review, the large variety of therapeutic approaches proposed in the last five years for diabetic patients are discussed in an applied context. A survey of the state of the art of closed-loop insulin delivery strategies in response to blood glucose level fluctuation is provided together with insights into the emerging key technologies for diagnosis and drug development. Chemical engineering strategies centered on preserving and regenerating functional pancreatic β-cell mass are evoked in addition as they represent a permanent solution for diabetic patients.
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Affiliation(s)
- Sabine Szunerits
- Univ. Lille, CNRS, Centrale Lille, Univ. Polytechnique Hauts-de-France, UMR 8520-IEMN, F-59000 Lille, France.
| | - Sorin Melinte
- Institute of Information and Communication Technologies, Electronics and Applied Mathematics, Université catholique de Louvain, 1348 Louvain-la-Neuve, Belgium
| | - Alexandre Barras
- Univ. Lille, CNRS, Centrale Lille, Univ. Polytechnique Hauts-de-France, UMR 8520-IEMN, F-59000 Lille, France.
| | - Quentin Pagneux
- Univ. Lille, CNRS, Centrale Lille, Univ. Polytechnique Hauts-de-France, UMR 8520-IEMN, F-59000 Lille, France.
| | - Anna Voronova
- Univ. Lille, CNRS, Centrale Lille, Univ. Polytechnique Hauts-de-France, UMR 8520-IEMN, F-59000 Lille, France.
| | - Amar Abderrahmani
- Univ. Lille, CNRS, Centrale Lille, Univ. Polytechnique Hauts-de-France, UMR 8520-IEMN, F-59000 Lille, France.
| | - Rabah Boukherroub
- Univ. Lille, CNRS, Centrale Lille, Univ. Polytechnique Hauts-de-France, UMR 8520-IEMN, F-59000 Lille, France.
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11
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Jeong YS, Jusko WJ. Meta-Assessment of Metformin Absorption and Disposition Pharmacokinetics in Nine Species. Pharmaceuticals (Basel) 2021; 14:545. [PMID: 34200427 PMCID: PMC8226464 DOI: 10.3390/ph14060545] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 05/24/2021] [Accepted: 05/28/2021] [Indexed: 12/15/2022] Open
Abstract
The objective of this study was to systematically assess literature datasets and quantitatively analyze metformin PK in plasma and some tissues of nine species. The pharmacokinetic (PK) parameters and profiles of metformin in nine species were collected from the literature. Based on a simple allometric scaling, the systemic clearances (CL) of metformin in these species highly correlate with body weight (BW) (R2 = 0.85) and are comparable to renal plasma flow in most species except for rabbit and cat. Reported volumes of distribution (VSS) varied appreciably (0.32 to 10.1 L/kg) among species. Using the physiological and anatomical variables for each species, a minimal physiologically based pharmacokinetic (mPBPK) model consisting of blood and two tissue compartments (Tissues 1 and 2) was used for modeling metformin PK in the nine species. Permeability-limited distribution (low fd1 and fd2) and a single tissue-to-plasma partition coefficient (Kp) value for Tissues 1 and 2 were applied in the joint mPBPK fitting. Nonlinear regression analysis for common tissue distribution parameters along with species-specific CL values reasonably captured the plasma PK profiles of metformin across most species, except for rat and horse with later time deviations. In separate fittings of the mPBPK model to each species, Tissue 2 was considered as slowly-equilibrating compartment consisting of muscle and skin based on in silico calculations of the mean transit times through tissues. The well-fitted mPBPK model parameters for absorption and disposition PK of metformin for each species were compared with in vitro/in vivo results found in the literature with regard to the physiological details and physicochemical properties of metformin. Bioavailability and absorption rates decreased with the increased BW among the species. Tissues such as muscle dominate metformin distribution with low permeability and partitioning while actual tissue concentrations found in rats and mice show likely transporter-mediated uptake in liver, kidney, and gastrointestinal tissues. Metformin has diverse pharmacologic actions, and this assessment revealed allometric relationships in its absorption and renal clearance but considerable variability in actual and modeled tissue distribution probably caused by transporter differences.
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Affiliation(s)
| | - William J. Jusko
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, NY 14214, USA;
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12
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Undercover Toxic Ménage à Trois of Amylin, Copper (II) and Metformin in Human Embryonic Kidney Cells. Pharmaceutics 2021; 13:pharmaceutics13060830. [PMID: 34204936 PMCID: PMC8229594 DOI: 10.3390/pharmaceutics13060830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/14/2022] Open
Abstract
In recent decades, type 2 diabetes complications have been correlated with amylin aggregation, copper homeostasis and metformin side effects. However, each factor was analyzed separately, and only in some rare cases copper/amylin or copper/metformin complexes were considered. We demonstrate for the first time that binary metformin/amylin and tertiary copper (II)/amylin/metformin complexes of high cellular toxicity are formed and lead to the formation of aggregated multi-level lamellar structures on the cell membrane. Considering the increased concentration of amylin, copper (II) and metformin in kidneys of T2DM patients, our findings on the toxicity of amylin and its adducts may be correlated with diabetic nephropathy development.
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Bennis Y, De Broe ME, Lalau JD. The authors reply. Crit Care Med 2021; 49:e464-e465. [PMID: 33731624 DOI: 10.1097/ccm.0000000000004902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Youssef Bennis
- Department of Clinical Pharmacology, Amiens University Hospital, Amiens, France
- MP3CV Laboratory, EA7517, University of Picardie Jules Verne, Amiens, France
| | - Marc E De Broe
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | - Jean-Daniel Lalau
- Department of Endocrinology-Diabetology-Nutrition, Amiens University Hospital, Amiens, France
- PériTox UMR_I 01, University of Picardie Jules Verne, Amiens, France
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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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Sutkowska E, Fortuna P, Kałuża B, Sutkowska K, Hodurek P, Fleszar MG. The impact of Sample Handling Time on metformin serum concentration. Biomed Pharmacother 2020; 133:110971. [PMID: 33248407 DOI: 10.1016/j.biopha.2020.110971] [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: 10/08/2020] [Revised: 10/30/2020] [Accepted: 11/01/2020] [Indexed: 10/22/2022] Open
Abstract
This is an informative article which can help research providers to arrange and conduct studies dedicated to the assessment of metformin serum concentrations. If there is a problem with coordination of sample preparation and it is necessary to measure metformin concentration, two hours gap between blood drain and centrifugation has no impact on the results.
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Affiliation(s)
- Edyta Sutkowska
- Department and Division of Medical Rehabilitation, Wroclaw Medical University, Poland.
| | - Paulina Fortuna
- Department of Medical Biochemistry, Wroclaw Medical University, Poland.
| | - Bernadetta Kałuża
- Department of Internal Medicine, Endocrinology and Diabetology, Central Clinical Hospital of the Ministry of the Interior, Warsaw, Poland.
| | | | - Paweł Hodurek
- Department of Medical Biochemistry, Wroclaw Medical University, Poland.
| | - Mariusz G Fleszar
- Department of Medical Biochemistry, Wroclaw Medical University, Poland; Łukasiewicz Research Network, PORT Polish Center for Technology Development, Poland.
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A Study of Associations Between Plasma Metformin Concentration, Lactic Acidosis, and Mortality in an Emergency Hospitalization Context. Crit Care Med 2020; 48:e1194-e1202. [DOI: 10.1097/ccm.0000000000004589] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Metformin as a Potential Agent in the Treatment of Multiple Sclerosis. Int J Mol Sci 2020; 21:ijms21175957. [PMID: 32825027 PMCID: PMC7503488 DOI: 10.3390/ijms21175957] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/16/2020] [Accepted: 08/17/2020] [Indexed: 12/18/2022] Open
Abstract
Metformin, a synthetic derivative of guanidine, is commonly used as an oral antidiabetic agent and is considered a multi-vector application agent in the treatment of other inflammatory diseases. Recent studies have confirmed the beneficial effect of metformin on immune cells, with special emphasis on immunological mechanisms. Multiple Sclerosis (MS) is an autoimmune disease of the central nervous system (CNS) characterized by various clinical courses. Although the pathophysiology of MS remains unknown, it is most likely a combination of disturbances of the immune system and biochemical pathways with a disruption of blood-brain barrier (BBB), and it is strictly related to injury of intracerebral blood vessels. Metformin has properties which are greatly desirable for MS therapy, including antioxidant, anti-inflammatory or antiplatelet functions. The latest reports relating to the cardiovascular disease confirm an increased risk of ischemic events in MS patients, which are directly associated with a coagulation cascade and an elevated pro-thrombotic platelet function. Hence, this review examines the potential favourable effects of metformin in the course of MS, its role in preventing inflammation and endothelial dysfunction, as well as its potential antiplatelet role.
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Harding SA, Biary R, Hoffman RS, Su MK, Howland MA. A Pharmacokinetic Analysis of Hemodialysis for Metformin-Associated Lactic Acidosis. J Med Toxicol 2020; 17:70-74. [PMID: 32789583 DOI: 10.1007/s13181-020-00802-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 07/26/2020] [Accepted: 07/28/2020] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE Although hemodialysis is recommended for patients with severe metformin-associated lactic acidosis (MALA), the amount of metformin removed by hemodialysis is poorly documented. We analyzed endogenous clearance and hemodialysis clearance in a patient with MALA. METHODS A 62-year-old man with a history of type II diabetes mellitus presented after several days of vomiting and diarrhea and was found to have acute kidney injury (AKI) and severe acidemia. Initial serum metformin concentration was 315.34 μmol/L (40.73 μg/mL) (typical therapeutic concentrations 1-2 μg/mL). He underwent 6 h of hemodialysis. We collected hourly whole blood, serum, urine, and dialysate metformin concentrations. Blood, urine, and dialysate samples were analyzed, and clearances were determined using standard pharmacokinetic calculations. RESULTS The total amount of metformin removed by 6 h of hemodialysis was 888 mg, approximately equivalent to one therapeutic dose. Approximately 142 mg of metformin was cleared in the urine during this time. His acid-base status and creatinine improved over the following days. No further hemodialysis was required. CONCLUSION We report a case of MALA likely secondary to AKI and severe volume depletion. The patient improved with supportive care, sodium bicarbonate, and hemodialysis. Analysis of whole blood, serum, urine, and dialysate concentrations showed limited efficacy of hemodialysis in the removal of metformin from blood, contrary to previously published data. Despite evidence of acute kidney injury, a relatively large amount of metformin was eliminated in the urine while the patient was undergoing hemodialysis. These data suggest that clinical improvement is likely due to factors besides removal of metformin.
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Affiliation(s)
- Stephen A Harding
- Division of Medical Toxicology, Henry J.N. Taub Department of Emergency Medicine, Baylor College of Medicine, 1504 Ben Taub Loop, Houston, TX, 77030, USA.
| | - Rana Biary
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, NY, USA
- New York City Poison Control Center, New York, NY, USA
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, NY, USA
- New York City Poison Control Center, New York, NY, USA
| | - Mark K Su
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, NY, USA
- New York City Poison Control Center, New York, NY, USA
| | - Mary Ann Howland
- New York City Poison Control Center, New York, NY, USA
- St. John's University College of Pharmacy and Health Sciences, New York, NY, USA
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Renal Trapping in Accidental Metformin Intoxication. Kidney Int Rep 2020; 5:1525-1528. [PMID: 32954078 PMCID: PMC7486141 DOI: 10.1016/j.ekir.2020.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 06/03/2020] [Accepted: 06/09/2020] [Indexed: 12/03/2022] Open
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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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Comparison of the gamma-Pareto convolution with conventional methods of characterising metformin pharmacokinetics in dogs. J Pharmacokinet Pharmacodyn 2019; 47:19-45. [PMID: 31865474 PMCID: PMC7040082 DOI: 10.1007/s10928-019-09666-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 11/23/2019] [Indexed: 12/25/2022]
Abstract
A model was developed for long term metformin tissue retention based upon temporally inclusive models of serum/plasma concentration (\documentclass[12pt]{minimal}
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\begin{document}$$ C $$\end{document}C) having power function tails called the gamma-Pareto type I convolution (GPC) model and was contrasted with biexponential (E2) and noncompartmental (NC) metformin models. GPC models of \documentclass[12pt]{minimal}
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\begin{document}$$ C $$\end{document}C. The GPC, E2 and NC models were applied to a total of 148 serum samples drawn from 20 min to 72 h following bolus intravenous metformin in seven healthy mongrel dogs. The GPC model was used to calculate area under the curve (AUC), clearance (\documentclass[12pt]{minimal}
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\begin{document}$$ CL $$\end{document}CL), and functions of time, f(t), for drug mass remaining (M), apparent volume of distribution (\documentclass[12pt]{minimal}
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\begin{document}$$ CL $$\end{document}CL-values of 104.7% and 123.7% of RPF, respectively. The GPC plasma/serum only model predicted 78.9% drug \documentclass[12pt]{minimal}
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Tian R, Li R, Liu Y, Liu J, Pan T, Zhang R, Liu B, Chen E, Tang Y, Qu H. Metformin ameliorates endotoxemia-induced endothelial pro-inflammatory responses via AMPK-dependent mediation of HDAC5 and KLF2. Biochim Biophys Acta Mol Basis Dis 2019; 1865:1701-1712. [PMID: 31002870 DOI: 10.1016/j.bbadis.2019.04.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 12/20/2018] [Accepted: 01/06/2019] [Indexed: 12/12/2022]
Abstract
Exaggerated endothelial pro-inflammatory response is a hallmark in the early stage of sepsis and contributes to the subsequent tissue injury and organ failure. The anti-inflammatory effects of AMP-activated protein kinase (AMPK) activator metformin in sepsis has been revealed. However, the underlying mechanisms remain not fully understood. In the present study, the potential roles of histone deacetylase 5 (HDAC5) and kruppel-like factor 2 (KLF2) in the effects of metformin on endothelial pro-inflammatory responses were investigated. The results showed that metformin pretreatment increased the phosphorylation of HDAC5 at serine 498, leading to the upregulation of KLF2, and eliminated lipopolysaccharide (LPS) and tumor necrosis factor ⍺ (TNF⍺)-induced upregulation of vascular cell adhesion molecule 1 (VCAM1). Furthermore, the adhesion of HL60 leukocytes to endothelial monolayer was effectively inhibited by metformin. In addition, the in vivo data confirmed that AMPK activation attenuated local and systemic inflammation in endotoxic mice induced by LPS via mediating phosphorylating HDAC5 and restoring KLF2 expression. Our findings revealed that AMPK activation-mediated HDAC5 phosphorylation and KLF2 restoration is, at least partially, responsible to the anti-inflammatory effects of metformin in endotoxemia-induced endothelial cells, which has important implications for the future development of interfering therapies of sepsis.
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Affiliation(s)
- Rui Tian
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, PR China
| | - Ranran Li
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, PR China.
| | - Yiyun Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, PR China
| | - Jialin Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, PR China
| | - Tingting Pan
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, PR China
| | - Ruyuan Zhang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, PR China
| | - Bingya Liu
- Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, PR China
| | - Erzhen Chen
- Department of emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, PR China
| | - Yaoqing Tang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, PR China
| | - Hongping Qu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, PR China.
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Greco P, Regolisti G, Maggiore U, Ferioli E, Fani F, Locatelli C, Parenti E, Maccari C, Gandolfini I, Fiaccadori E. Sustained low-efficiency dialysis for metformin-associated lactic acidosis in patients with acute kidney injury. J Nephrol 2018; 32:297-306. [PMID: 30523561 DOI: 10.1007/s40620-018-00562-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 11/14/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND The choice of the specific modality and treatment duration of renal replacement therapy (RRT) to adopt in metformin-associated lactic acidosis (MALA) is still debated. We aimed to verify if sustained low-efficiency dialysis (SLED) is a rational choice in patients with MALA and acute kidney injury (AKI). METHODS We collected serial serum metformin measurements, clinical parameters, and outcome data in ten consecutive patients (mean age 77 years [range 58-88], 5 males) admitted to our renal intensive care unit for suspected MALA associated with AKI and hemodynamic instability. Patients underwent a 16-h SLED session performed with either conventional dialysis machines or machines for continuous RRT (CRRT). A 2-compartment open-infusion pharmacokinetic model with first-order elimination was fitted to each subject's serum concentration-time data to model post-SLED rebound and predict the need for further treatments. RESULTS Two patients died within 24 h after SLED start. Three patients needed one further dialysis session. Surviving patients (n = 8) were dialysis-free at discharge. Metformin levels were in the toxic range at baseline (median [range] 32.5 mg/l [13.6-75.6]) and decreased rapidly by the end of SLED (8.1 mg/l [4.5-15.8], p < 0.001 vs. baseline), without differences according to the dialysis machine used (p = 0.84). We observed a slight 4-h post-SLED rebound (9.7 mg/l [3.5-22.0]), which could be predicted by our pharmacokinetic model. Accordingly, we predicted that the majority of patients would need one additional dialysis session performed the following day to restore safe metformin levels. CONCLUSIONS A 16-h SLED session, performed with either conventional dialysis machines or CRRT machines, allows effective metformin removal in patients with MALA and AKI. However, due to possible post-SLED rebound in serum metformin levels, one additional dialysis treatment is required the following day in the majority of patients.
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Affiliation(s)
- Paolo Greco
- Acute and Chronic Renal Failure Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Giuseppe Regolisti
- Acute and Chronic Renal Failure Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Umberto Maggiore
- Renal Transplant Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Elena Ferioli
- Acute and Chronic Renal Failure Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Filippo Fani
- Acute and Chronic Renal Failure Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Carlo Locatelli
- Poison Control Centre and National Toxicology Information Centre, Toxicology Unit, Istituti Clinici Scientifici Maugeri Spa-SB, IRCCS Pavia Hospital and University of Pavia, Pavia, Italy
| | - Elisabetta Parenti
- Acute and Chronic Renal Failure Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Caterina Maccari
- Acute and Chronic Renal Failure Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Ilaria Gandolfini
- Renal Transplant Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Enrico Fiaccadori
- Acute and Chronic Renal Failure Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
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Novel Calcium Phosphate Cement with Metformin-Loaded Chitosan for Odontogenic Differentiation of Human Dental Pulp Cells. Stem Cells Int 2018; 2018:7173481. [PMID: 30598667 PMCID: PMC6288571 DOI: 10.1155/2018/7173481] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 09/13/2018] [Indexed: 12/18/2022] Open
Abstract
Metformin is an old and widely accepted first-line drug for treating type 2 diabetes. Our previous studies demonstrate that metformin can stimulate the osteo/odontogenic differentiation of human-induced pluripotent stem cell-derived mesenchymal stem cells and human dental pulp cells (DPCs). Due to the rapid dilution of metformin from the defect area, the aim of this study was to develop a drug delivery system with controlled release of metformin to promote cell viability and odontogenic differentiation of DPCs favoring dentin regeneration. Calcium phosphate cement (CPC) containing chitosan and metformin as a scaffold was synthesized. DPCs were seeded onto the scaffold, and the viability and proliferation were evaluated at several time points. For osteogenic differentiation analysis, alkaline phosphatase (ALP) activity was tested, cells were stained with Alizarin Red, and the expression of odontogenic markers was evaluated by real-time polymerase chain reaction. DPCs remained viable and attached well to the CPC-chitosan composite scaffold. Moreover, the addition of metformin to the CPC-chitosan composite did not adversely affect cell proliferation, compared to that of CPC control. Our data further revealed that the novel CPC-chitosan-metformin composite enhanced the odontogenic differentiation of DPCs, as evidenced by higher ALP activity, elevated expression of odontoblastic markers, and strong mineral deposition. These results suggest that the new CPC-chitosan-metformin composite is a highly promising scaffold with the potential for tissue engineering applications including dentin regeneration.
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25
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Govender K, Adamson JH, Owira P. The development and validation of a LC-MS/MS method for the quantitation of metformin, rifampicin and isoniazid in rat plasma using HILIC chromatography. J Chromatogr B Analyt Technol Biomed Life Sci 2018; 1095:127-137. [DOI: 10.1016/j.jchromb.2018.07.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 07/27/2018] [Accepted: 07/29/2018] [Indexed: 12/27/2022]
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Development of an Injectable Slow-Release Metformin Formulation and Evaluation of Its Potential Antitumor Effects. Sci Rep 2018; 8:3929. [PMID: 29500390 PMCID: PMC5834504 DOI: 10.1038/s41598-018-22054-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 02/16/2018] [Indexed: 12/23/2022] Open
Abstract
Metformin is an antidiabetic drug which possesses antiproliferative activity in cancer cells when administered at high doses, due to its unfavorable pharmacokinetics. The aim of this work was to develop a pharmacological tool for the release of metformin in proximity of the tumor, allowing high local concentrations, and to demonstrate the in vivo antitumor efficacy after a prolonged metformin exposition. A 1.2% w/w metformin thermoresponsive parenteral formulation based on poloxamers P407 and P124, injectable at room temperature and undergoing a sol-gel transition at body temperature, has been developed and optimized for rheological, thermal and release control properties; the formulation is easily scalable, and proved to be stable during a 1-month storage at 5 °C. Using NOD/SCID mice pseudo-orthotopically grafted with MDA-MB-231/luc+ human breast cancer cells, we report that multiple administrations of 100 mg of the optimized metformin formulation close to the tumor site cause tissue accumulation of the drug at levels significantly higher than those observed in plasma, and enough to exert antiproliferative and pro-apoptotic activities. Our results demonstrate that this formulation is endowed with good stability, tolerability, thermal and rheological properties, representing a novel tool to be pursued in further investigations for adjuvant cancer treatment.
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Jacob T, Garrick R, Goldberg MD. Recurrent lactic acidosis and hypoglycemia with inadvertent metformin use: a case of look-alike pills. Endocrinol Diabetes Metab Case Rep 2018; 2018:17-0148. [PMID: 29340159 PMCID: PMC5763280 DOI: 10.1530/edm-17-0148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 11/30/2017] [Indexed: 01/07/2023] Open
Abstract
Metformin is recommended as the first-line agent for the treatment of type 2 diabetes. Although this drug has a generally good safety profile, rare but potentially serious adverse effects may occur. Metformin-associated lactic acidosis, although very uncommon, carries a significant risk of mortality. The relationship between metformin accumulation and lactic acidosis is complex and is affected by the presence of comorbid conditions such as renal and hepatic disease. Plasma metformin levels do not reliably correlate with the severity of lactic acidosis. We present a case of inadvertent metformin overdose in a patient with both renal failure and hepatic cirrhosis, leading to two episodes of lactic acidosis and hypoglycemia. The patient was successfully treated with hemodialysis both times and did not develop any further lactic acidosis or hypoglycemia, after the identification of metformin tablets accidentally mixed in with his supply of sevelamer tablets. Early initiation of renal replacement therapy is key in decreasing lactic acidosis-associated mortality. LEARNING POINTS When a toxic ingestion is suspected, direct visualization of the patient's pills is advised in order to rule out the possibility of patient- or pharmacist-related medication errors.Though sending a specimen for determination of the plasma metformin concentration is important when a metformin-treated patient with diabetes presents with lactic acidosis, complex relationships exist between metformin accumulation, hyperlactatemia and acidosis, and the drug may not always be the precipitating factor.Intermittent hemodialysis is recommended as the first-line treatment for metformin-associated lactic acidosis (MALA).An investigational delayed-release form of metformin with reduced systemic absorption may carry a lower risk for MALA in patients with renal insufficiency, in whom metformin therapy may presently be contraindicated.
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Affiliation(s)
- Tess Jacob
- Divisions of Endocrinology, Department of Medicine, Westchester Medical Center , Valhalla, New York, USA
| | - Renee Garrick
- Divisions of Nephrology, Department of Medicine, Westchester Medical Center , Valhalla, New York, USA
| | - Michael D Goldberg
- Divisions of Endocrinology, Department of Medicine, Westchester Medical Center , Valhalla, New York, USA
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29
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Barrella N, Eisenberg B, Simpson SN. Hypoglycemia and severe lactic acidosis in a dog following metformin exposure. Clin Case Rep 2017; 5:2097-2104. [PMID: 29225865 PMCID: PMC5715605 DOI: 10.1002/ccr3.1255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 09/01/2017] [Accepted: 10/06/2017] [Indexed: 01/18/2023] Open
Abstract
Hypoglycemia and lactic acidosis are rare complications with metformin use in humans. As metformin is not commonly used in veterinary medicine, severe adverse effects secondary to exposure are not known. Awareness of potentially life‐threatening complications with metformin exposure is an important addition to the veterinary literature.
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Affiliation(s)
- Nicole Barrella
- Massachusetts Veterinary Referral Hospital Woburn Massachusetts 01801 USA.,Present address: Bulger Veterinary Hospital North Andover Massachusetts 01845 USA
| | - Beth Eisenberg
- Massachusetts Veterinary Referral Hospital Woburn Massachusetts 01801 USA
| | - Stephanie Nicole Simpson
- Massachusetts Veterinary Referral Hospital Woburn Massachusetts 01801 USA.,Present address: VCA Roberts Animal Hospital Hanover Massachusetts 02339 USA
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30
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Lalau JD, Kajbaf F, Protti A, Christensen MM, De Broe ME, Wiernsperger N. Metformin-associated lactic acidosis (MALA): Moving towards a new paradigm. Diabetes Obes Metab 2017; 19:1502-1512. [PMID: 28417525 DOI: 10.1111/dom.12974] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/03/2017] [Accepted: 04/11/2017] [Indexed: 12/15/2022]
Abstract
Although metformin has been used for over 60 years, the balance between the drug's beneficial and adverse effects is still subject to debate. Following an analysis of how cases of so-called "metformin-associated lactic acidosis" (MALA) are reported in the literature, the present article reviews the pitfalls to be avoided when assessing the purported association between metformin and lactic acidosis. By starting from pathophysiological considerations, we propose a new paradigm for lactic acidosis in metformin-treated patients. Metformin therapy does not necessarily induce metformin accumulation, just as metformin accumulation does not necessarily induce hyperlactatemia, and hyperlactatemia does not necessarily induce lactic acidosis. In contrast to the conventional view, MALA probably accounts for a smaller proportion of cases than either metformin-unrelated lactic acidosis or metformin-induced lactic acidosis. Lastly, this review highlights the need for substantial improvements in the reporting of cases of lactic acidosis in metformin-treated patients. Accordingly, we propose a check-list as a guide to clinical practice.
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Affiliation(s)
- Jean-Daniel Lalau
- Department of Endocrinology-Nutrition, Amiens University Hospital, Amiens, France
| | - Farshad Kajbaf
- Department of Endocrinology-Nutrition, Amiens University Hospital, Amiens, France
| | - Alessandro Protti
- Department of Anesthesia and Intensive Care, IRCCS Fondazione Ca' Granda, Maggiore Policlinico Hospital, Milan, Italy
| | - Mette M Christensen
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Marc E De Broe
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
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31
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Blumrich EM, Dringen R. Metformin Accelerates Glycolytic Lactate Production in Cultured Primary Cerebellar Granule Neurons. Neurochem Res 2017; 44:188-199. [PMID: 28688035 DOI: 10.1007/s11064-017-2346-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/19/2017] [Accepted: 06/27/2017] [Indexed: 12/13/2022]
Abstract
Metformin is the most frequently used drug for the treatment of type-II diabetes. As metformin has been reported to cross the blood-brain barrier, brain cells will encounter this drug. To test whether metformin may affect the metabolism of neurons, we exposed cultured rat cerebellar granule neurons to metformin. Treatment with metformin caused a time- and concentration-dependent increase in glycolytic lactate release from viable neurons as demonstrated by the three-to fivefold increase in extracellular lactate concentration determined after exposure to metformin. Half-maximal stimulation of lactate production was found after incubation of neurons for 4 h with around 2 mM or for 24 h with around 0.5 mM metformin. Neuronal cell viability was not affected by millimolar concentrations of metformin during acute incubations in the hour range nor during prolonged incubations, although alterations in cell morphology were observed during treatment with 10 mM metformin for days. The acute stimulation of neuronal lactate release by metformin was persistent upon removal of metformin from the medium and was not affected by the presence of modulators of adenosine monophosphate activated kinase activity. In contrast, rabeprazole, an inhibitor of the organic cation transporter 3, completely prevented metformin-mediated stimulation of neuronal lactate production. In summary, the data presented identify metformin as a potent stimulator of glycolytic lactate production in viable cultured neurons and suggest that organic cation transporter 3 mediates the uptake of metformin into neurons.
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Affiliation(s)
- Eva-Maria Blumrich
- Centre for Biomolecular Interactions Bremen, Faculty 2 (Biology/Chemistry), University of Bremen, P.O. Box 330440, 28334, Bremen, Germany.,Centre for Environmental Research and Sustainable Technology, University of Bremen, Bremen, Germany
| | - Ralf Dringen
- Centre for Biomolecular Interactions Bremen, Faculty 2 (Biology/Chemistry), University of Bremen, P.O. Box 330440, 28334, Bremen, Germany. .,Centre for Environmental Research and Sustainable Technology, University of Bremen, Bremen, Germany.
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32
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Regolisti G, Antoniotti R, Fani F, Greco P, Fiaccadori E. Treatment of Metformin Intoxication Complicated by Lactic Acidosis and Acute Kidney Injury: The Role of Prolonged Intermittent Hemodialysis. Am J Kidney Dis 2017; 70:290-296. [PMID: 28223003 DOI: 10.1053/j.ajkd.2016.12.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 12/13/2016] [Indexed: 12/25/2022]
Abstract
Metformin intoxication with lactic acidosis, a potentially lethal condition, may develop in diabetic patients when the drug dose is inappropriate and/or its clearance is reduced. Diagnosis and therapy may be delayed due to nonspecific symptoms at presentation, with severe anion gap metabolic acidosis and elevated serum creatinine values being the most prominent laboratory findings. Confirmation requires measurement of serum metformin by high-performance liquid chromatography-tandem mass spectrometry, but this technique is available only at specialized institutions and cannot be relied on as a guide to immediate treatment. Thus, based on strong clinical suspicion, renal replacement therapy must be started promptly to achieve efficient drug clearance and correct the metabolic acidosis. However, because metformin accumulates in the intracellular compartment with prolonged treatment, a rebound in serum concentrations due to redistribution is expected at the end of dialysis. We report a case of metformin intoxication, severe lactic acidosis, and acute kidney injury in a diabetic patient with pre-existing chronic kidney disease stage 3, treated effectively with sustained low-efficiency dialysis. We discuss the pathophysiology, differential diagnosis, and treatment options and highlight specific pharmacokinetic issues that should be considered in selecting the appropriate modality of renal replacement therapy.
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Affiliation(s)
- Giuseppe Regolisti
- Acute and Chronic Renal Failure Unit, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy.
| | - Riccardo Antoniotti
- Acute and Chronic Renal Failure Unit, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | - Filippo Fani
- Acute and Chronic Renal Failure Unit, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | - Paolo Greco
- Acute and Chronic Renal Failure Unit, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | - Enrico Fiaccadori
- Acute and Chronic Renal Failure Unit, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
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Synergistic effects of vancomycin and β-lactams against vancomycin highly resistant Staphylococcus aureus. J Antibiot (Tokyo) 2017; 70:771-774. [PMID: 28196977 DOI: 10.1038/ja.2017.7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 01/11/2017] [Accepted: 01/15/2017] [Indexed: 12/14/2022]
Abstract
We previously reported isolating vancomycin (VAN) highly resistant Staphylococcus aureus (VRSA) strains from clinical methicillin-resistant S. aureus strains by repeating steps of in vitro mutagenesis and VAN selection. Here we describe that the in vitro susceptibility of these VRSA strains to VAN was markedly increased by combined treatment with β-lactams such as ceftriaxone and oxacillin. Furthermore, in an in vivo silkworm infection model with VRSA, a combination of VAN and ceftriaxone exhibited therapeutic effects, whereas a combination of VAN and oxacillin did not. These findings suggest that combining VAN with an appropriate β-lactam, such as ceftriaxone, is therapeutically effective against infectious diseases caused by VRSA.
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34
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Moioli A, Maresca B, Manzione A, Napoletano AM, Coclite D, Pirozzi N, Punzo G, Menè P. Metformin associated lactic acidosis (MALA): clinical profiling and management. J Nephrol 2016; 29:783-789. [PMID: 26800971 DOI: 10.1007/s40620-016-0267-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 01/09/2016] [Indexed: 12/20/2022]
Abstract
Metformin (MF) accumulation during acute kidney injury is associated with high anion gap lactic acidosis type B (MF-associated lactic acidosis, MALA), a serious medical condition leading to high mortality. Despite dose adjustment for renal failure, diabetic patients with chronic kidney disease (CKD) stage III-IV are at risk for rapid decline in renal function by whatever reason, so that MF toxicity might arise if the drug is not timely withdrawn. Sixteen consecutive patients were admitted to our Hospital's Emergency Department with clinical findings consistent with MALA. Fifteen had prior history of CKD, 60 % of them with GFR between 30 and 60 ml/min. Of these, 5 required mechanical ventilation and cardiovascular support; 3 promptly recovered renal function after rehydration, whereas 10 (62 %) required continuous veno-venous renal replacement treatment. SOFA and SAPS II scores were significantly related to the degree of lactic acidosis. In addition, lactate levels were relevant to therapeutic choices, since they were higher in dialyzed patients than in those on conservative treatment (11.92 mmol/l vs 5.7 mmol/l, p = 0.03). The overall death rate has been 31 %, with poorer prognosis for worse acidemia, as serum pH was significantly lower in non-survivors (pH 6.96 vs 7.16, p > 0.04). Our own data and a review of the literature suggest that aged, hemodynamically frail patients, with several comorbidities and CKD, are at greater risk of MALA, despite MF dosage adjustment. Moreover, renal replacement therapy rather than simple acidosis correction by administration of alkali seems the treatment of choice, based on eventual renal recovery and overall outcome.
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Affiliation(s)
- Alessandra Moioli
- Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy.,Chair and Division of Nephrology, Sant'Andrea University Hospital, Rome, Italy
| | - Barbara Maresca
- Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy.,Chair and Division of Nephrology, Sant'Andrea University Hospital, Rome, Italy
| | - Andrea Manzione
- Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy.,Chair and Division of Nephrology, Sant'Andrea University Hospital, Rome, Italy
| | | | | | - Nicola Pirozzi
- Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy.,Chair and Division of Nephrology, Sant'Andrea University Hospital, Rome, Italy
| | - Giorgio Punzo
- Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy.,Chair and Division of Nephrology, Sant'Andrea University Hospital, Rome, Italy
| | - Paolo Menè
- Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy. .,Chair and Division of Nephrology, Sant'Andrea University Hospital, Rome, Italy. .,UOC Nefrologia, A.O. Sant'Andrea, Via di Grottarossa 1035-1039, 00189, Rome, Italy.
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