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Di Magno L, Di Pastena F, Bordone R, Coni S, Canettieri G. The Mechanism of Action of Biguanides: New Answers to a Complex Question. Cancers (Basel) 2022; 14:cancers14133220. [PMID: 35804992 PMCID: PMC9265089 DOI: 10.3390/cancers14133220] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/20/2022] [Accepted: 06/23/2022] [Indexed: 01/27/2023] Open
Abstract
Biguanides are a family of antidiabetic drugs with documented anticancer properties in preclinical and clinical settings. Despite intensive investigation, how they exert their therapeutic effects is still debated. Many studies support the hypothesis that biguanides inhibit mitochondrial complex I, inducing energy stress and activating compensatory responses mediated by energy sensors. However, a major concern related to this “complex” model is that the therapeutic concentrations of biguanides found in the blood and tissues are much lower than the doses required to inhibit complex I, suggesting the involvement of additional mechanisms. This comprehensive review illustrates the current knowledge of pharmacokinetics, receptors, sensors, intracellular alterations, and the mechanism of action of biguanides in diabetes and cancer. The conditions of usage and variables affecting the response to these drugs, the effect on the immune system and microbiota, as well as the results from the most relevant clinical trials in cancer are also discussed.
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Affiliation(s)
- Laura Di Magno
- Department of Molecular Medicine, Sapienza University of Rome, 00189 Rome, Italy; (L.D.M.); (F.D.P.); (R.B.); (S.C.)
| | - Fiorella Di Pastena
- Department of Molecular Medicine, Sapienza University of Rome, 00189 Rome, Italy; (L.D.M.); (F.D.P.); (R.B.); (S.C.)
| | - Rosa Bordone
- Department of Molecular Medicine, Sapienza University of Rome, 00189 Rome, Italy; (L.D.M.); (F.D.P.); (R.B.); (S.C.)
| | - Sonia Coni
- Department of Molecular Medicine, Sapienza University of Rome, 00189 Rome, Italy; (L.D.M.); (F.D.P.); (R.B.); (S.C.)
| | - Gianluca Canettieri
- Department of Molecular Medicine, Sapienza University of Rome, 00189 Rome, Italy; (L.D.M.); (F.D.P.); (R.B.); (S.C.)
- Istituto Pasteur—Fondazione Cenci—Bolognetti, 00161 Rome, Italy
- Correspondence:
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Zhang X, Ogihara T, Zhu M, Gantumur D, Li Y, Mizoi K, Kamioka H, Tsushima Y. Effect of metformin on 18F-fluorodeoxyglucose uptake and positron emission tomographic imaging. Br J Radiol 2022; 95:20200810. [PMID: 34705528 PMCID: PMC8822544 DOI: 10.1259/bjr.20200810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Metformin is widely used to treat diabetes, but induces changes in glucose uptake in both normal organs and tumors. Here, we review the effects of metformin on the uptake of 18F-fludeoxyglucose (18F-FDG) in tissues and tumors, and its influence on 18F-FDG positron emission tomographic imaging (18F-FDG PET), as well as the mechanisms involved. This is an important issue, because metformin has diverse effects on tissue uptake of 18F-FDG, and this can affect the quality and interpretation of PET images. Metformin increases glucose uptake in the gastrointestinal tract, cerebral white matter, and the kidney, while regions of the cerebrum associated with memory show decreased glucose uptake, and the myocardium shows no change. Hepatocellular carcinoma and breast cancer show increased glucose uptake after metformin administration, while thyroid cancer shows decreased uptake, and colon and pancreatic cancers show no change. A high-energy diet increases 18F-FDG uptake, but this effect is blocked by metformin. Withdrawal of metformin 48 h before PET image acquisition is widely recommended. However, based on our review of the literature, we propose that the differentiation of metformin discontinuation could be reasonable. But future clinical trials are still needed to support our viewpoint.
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Affiliation(s)
| | | | - Min Zhu
- Weifang Community Health Service Center, Pudong New District, Shanghai, China
| | - Dolgormaa Gantumur
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Yang Li
- Gunma University Heavy Ion Medical Center, Maebashi, Gunma, Japan
| | - Kenta Mizoi
- Laboratory of Biopharmaceutics, Department of Pharmacology, Faculty of Pharmacy, Takasaki University of Health and Welfare, Takasaki, Gunma, Japan
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Gelston D, Brosler SC, Vazquez J, Sorci O, Griffith AH, Chatterjee S, Buchner A, Høilund-Carlsen PF, Alavi A, Rajapakse CS. Utility of FDG PET/CT in assessing bowel inflammation. AMERICAN JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING 2021; 11:271-279. [PMID: 34513280 PMCID: PMC8414397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 06/14/2021] [Indexed: 06/13/2023]
Abstract
PURPOSE To develop a methodology for the quantification of gastrointestinal (GI) inflammation as indicated by 2-deoxy-2-(18F)fluoro-D-glucose (FDG) uptake on positron-emissions tomography/computed tomography (PET/CT) imaging. This is intended to investigate the feasibility of using standard uptake value (SUV) levels to assess levels of GI inflammation in humans. METHODS 131 participants were injected with a weight-controlled dose of FDG 180 minutes prior to PET/CT scanning. Operator-guided software was used to segment the GI tract and perform (SUV) calculations. Regions of interest (ROIs) were created using CT images and stacked to create three dimensional volumes of interest (VOIs). These VOIs defined 6 sections of the GI tract: esophagus, stomach, descending colon, ascending and transverse colon, bowel below the ilium and small bowel above the ilium. RESULTS This study found a significant correlation between age and average FDG uptake (avg-SUV) of the GI tract (P=.0003) with the esophagus showing the highest significance. Correlations were found between avg-SUV of the sigmoid segment and the group average (P<.0001), and between the descending colon VOI and the group (P<.0001). Intra-operator reproducibility over 3 trials showed a coefficient of variation (CV) of .63%. Inter-operator CV over 5 randomly selected patients was 5.6% over the entire GI tract. CONCLUSION This study shows that FDG-PET/CT imaging is a promising technique for quantifying bowel inflammation, despite the fact that age related inflammation may not be of clinical utility. The fact that we were able to detect these subtle changes indicates this as an avenue for potential future investigation.
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Affiliation(s)
- David Gelston
- Department of Radiology, University of PennsylvaniaPhiladelphia, PA, USA
| | - Samantha C Brosler
- Department of Radiology, University of PennsylvaniaPhiladelphia, PA, USA
| | - Jennifer Vazquez
- Department of Radiology, University of PennsylvaniaPhiladelphia, PA, USA
| | - Olivia Sorci
- Department of Radiology, University of PennsylvaniaPhiladelphia, PA, USA
| | | | - Shampa Chatterjee
- Department of Physiology, University of PennsylvaniaPhiladelphia, PA, USA
| | - Anna Buchner
- Department of Radiology, University of PennsylvaniaPhiladelphia, PA, USA
| | | | - Abass Alavi
- Department of Nuclear Medicine, Odense University HospitalOdense, Denmark, USA
| | - Chamith S Rajapakse
- Department of Radiology, University of PennsylvaniaPhiladelphia, PA, USA
- Department of Orthopaedic Surgery, University of PennsylvaniaPhiladelphia, PA, USA
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Moasses-Ghafari B, Fallahi B, Esfehani AF, Eftekhari M, Rahmani K, Eftekhari A, Geramifar P. Effect of Diet on Physiologic Bowel 18F-FDG Uptake. J Nucl Med Technol 2021; 49:241-245. [PMID: 34244224 DOI: 10.2967/jnmt.120.257857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 03/26/2021] [Indexed: 12/30/2022] Open
Abstract
Intestinal 18F-FDG uptake is variable in whole-body PET/CT. In cancer patients, particularly those suspected of relapse or metastasis, 18F-FDG absorption might interfere with scan interpretation. This study evaluated the effect of diet on intestinal 18F-FDG absorption. Methods: In total, 214 patients referring for oncologic 18F-FDG PET/CT participated. They were randomly divided into 2 groups and asked to follow either a routine diet (RD) or a low-carbohydrate, high-fat diet (LCHFD) for 24 h before the study. The small bowel and different parts of the colon (the cecum; the ascending, transverse, and descending segments; and the hepatic and splenic flexures) were evaluated and visually interpreted by nuclear medicine experts. Bowel uptake was graded through comparison with that in the liver as absent, mild, moderate, or severe. Results: Significantly higher 18F-FDG uptake in the descending colon (P = 0.001) and small intestine (P = 0.01) was observed in the RD group than in the LCHFD group. After patients with bowel cancer were omitted from the statistical analysis, no significant differences in the final results were seen. Conclusion: An LCHFD for 24 h before 18F-FDG PET imaging resulted in lower 18F-FDG uptake in the descending colon and small bowel than did an RD, assisting the interpreting physician by reducing the intestinal activity interference for more accurate diagnostic interpretation.
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Affiliation(s)
| | - Babak Fallahi
- Research Center for Nuclear Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Armaghan Fard Esfehani
- Research Center for Nuclear Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Eftekhari
- Research Center for Nuclear Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Khaled Rahmani
- Social Determinants of Health Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran; and
| | - Arash Eftekhari
- Diagnostic Radiology/Nuclear Medicine, Surrey Memorial Hospital and Jim Pattison Outpatient Care and Surgery Centre, Surrey, British Columbia, Canada
| | - Parham Geramifar
- Research Center for Nuclear Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran;
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Sachpekidis C, Kopp-Schneider A, Pan L, Papamichail D, Haberkorn U, Hassel JC, Dimitrakopoulou-Strauss A. Interim [ 18F]FDG PET/CT can predict response to anti-PD-1 treatment in metastatic melanoma. Eur J Nucl Med Mol Imaging 2021; 48:1932-1943. [PMID: 33336264 PMCID: PMC8113306 DOI: 10.1007/s00259-020-05137-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/24/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE In an attempt to identify biomarkers that can reliably predict long-term outcomes to immunotherapy in metastatic melanoma, we investigated the prognostic role of [18F]FDG PET/CT, performed at baseline and early during the course of anti-PD-1 treatment. METHODS Twenty-five patients with stage IV melanoma, scheduled for treatment with PD-1 inhibitors, were enrolled in the study (pembrolizumab, n = 8 patients; nivolumab, n = 4 patients; nivolumab/ipilimumab, 13 patients). [18F]FDG PET/CT was performed before the start of treatment (baseline PET/CT) and after the initial two cycles of PD-1 blockade administration (interim PET/CT). Seventeen patients underwent also a third PET/CT scan after administration of four cycles of treatment. Evaluation of patients' response by means of PET/CT was performed after application of the European Organization for Research and Treatment of Cancer (EORTC) 1999 criteria and the PET Response Evaluation Criteria for IMmunoTherapy (PERCIMT). Response to treatment was classified into 4 categories: complete metabolic response (CMR), partial metabolic response (PMR), stable metabolic disease (SMD), and progressive metabolic disease (PMD). Patients were further grouped into two groups: those demonstrating metabolic benefit (MB), including patients with SMD, PMR, and CMR, and those demonstrating no MB (no-MB), including patients with PMD. Moreover, patterns of [18F]FDG uptake suggestive of radiologic immune-related adverse events (irAEs) were documented. Progression-free survival (PFS) was measured from the date of interim PET/CT until disease progression or death from any cause. RESULTS Median follow-up from interim PET/CT was 24.2 months (19.3-41.7 months). According to the EORTC criteria, 14 patients showed MB (1 CMR, 6 PMR, and 7 SMD), while 11 patients showed no-MB (PMD). Respectively, the application of the PERCIMT criteria revealed that 19 patients had MB (1 CMR, 6 PMR, and 12 SMD), and 6 of them had no-MB (PMD). With regard to PFS, no significant difference was observed between patients with MB and no-MB on interim PET/CT according to the EORTC criteria (p = 0.088). In contrary, according to the PERCIMT criteria, patients demonstrating MB had a significantly longer PFS than those showing no-MB (p = 0.045). The emergence of radiologic irAEs (n = 11 patients) was not associated with a significant survival benefit. Regarding the sub-cohort undergoing also a third PET/CT, 14/17 patients (82%) showed concordant responses and 3/17 (18%) had a mismatch of response assessment between interim and late PET/CT. CONCLUSION PET/CT-based response of metastatic melanoma to PD-1 blockade after application of the recently proposed PERCIMT criteria is significantly correlated with PFS. This highlights the potential ability of [18F]FDG PET/CT for early stratification of response to anti-PD-1 agents, a finding with possible significant clinical and financial implications. Further studies including larger numbers of patients are necessary to validate these results.
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Affiliation(s)
- Christos Sachpekidis
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69210, Heidelberg, Germany.
| | | | - Leyun Pan
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69210, Heidelberg, Germany
| | - Dimitrios Papamichail
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69210, Heidelberg, Germany
| | - Uwe Haberkorn
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69210, Heidelberg, Germany
- Department of Nuclear Medicine, University of Heidelberg, Heidelberg, Germany
| | - Jessica C Hassel
- Department of Dermatology and National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Germany
| | - Antonia Dimitrakopoulou-Strauss
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69210, Heidelberg, Germany
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Patient Preparation and Patient-related Challenges with FDG-PET/CT in Infectious and Inflammatory Disease. PET Clin 2020; 15:125-134. [PMID: 32145883 DOI: 10.1016/j.cpet.2019.11.001] [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: 11/20/2022]
Abstract
Several factors that influence physiologic 18F-fluorodeoxyglucose (FDG) uptake and general FDG distribution may affect PET/CT imaging in infection and inflammation. The general impact of hyperglycemia on the diagnostic performance of FDG-PET/CT is probably less in infection/inflammation than in malignancy. Patient preparation may reduce physiologic FDG uptake, but recommendations are less established than in malignancy. Local implementation of various patient preparatory measures should reflect the specific patient population and indications. This article outlines some of the challenges with physiologic FDG distribution, focusing on infectious and inflammatory diseases, and potential countermeasures and patient preparation to limit physiologic uptake before scan.
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Abstract
International colon cancer guidelines suggest F-FDG PET/CT in a few circumstances: (1) at disease presentation in case of suspected or proven metastatic synchronous adenocarcinoma; (2) in the workup of recurrent colon cancer with metachronous metastases documented by CT, MRI, or biopsy and in case of serial CEA elevation with negative colonoscopy and negative CT; and (3) in case of contraindication to iodine- and gadolinium-based contrast agents. However, review of the literature has shown that PET/CT can also be used in other scenarios with significant levels of diagnostic advantage. This review aims to emphasize differences between guidelines and scientific literature for the use of PET/CT in colon cancer.
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Metabolic Responses to Metformin in Inoperable Early-stage Non-Small Cell Lung Cancer Treated With Stereotactic Radiotherapy: Results of a Randomized Phase II Clinical Trial. Am J Clin Oncol 2020; 43:231-235. [PMID: 31990759 DOI: 10.1097/coc.0000000000000632] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Metformin reduces glucose uptake in physiologic tissues and has been shown to affect non-small cell lung cancer (NSCLC) metabolism. We hypothesized that positron emission tomography (PET) scans could detect the impact of metformin on glucose uptake in NSCLC and we sought to test this hypothesis in a prospective clinical trial. MATERIALS AND METHODS A single-blinded phase II clinical trial was performed with subjects randomized 6:1 to 3 to 4 weeks of metformin versus placebo for inoperable early-stage NSCLC. PET scans were performed at baseline, mid-treatment (after 2 wk study medication), and 6 months postradiation. The primary endpoint of the trial was tumor metabolic response to metformin by PERCIST before definitive radiation. Stereotactic body radiotherapy to 50 Gy in 4 fractions was used for peripheral tumors and 70 Gy in 10 fractions for central tumors. RESULTS There were 14 subjects randomized to the metformin and 1 to placebo. Histologies were 60% adenocarcinoma, 33.3% squamous cell carcinoma, and 6.7% poorly differentiated carcinoma. At mid-treatment PET scan, 57% of subjects randomized to metformin met PERCIST criteria for metabolic response, of which 75% had progressive metabolic disease and 25% had partial metabolic response, whereas the placebo subject had stable metabolic disease. At 6 months, the metformin arm had 69% complete metabolic response, 23% partial metabolic response and 1 progressive metabolic disease, and the subject treated with placebo had a complete metabolic response. There were no CTCAE grade ≥3 toxicities. CONCLUSIONS Despite low accrual, majority of subjects treated with metformin had metabolic responses by PERCIST criteria on PET imaging. Contrary to the effect of metformin on most physiologic tissues, most tumors had increased metabolic activity in response to metformin.
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Chang HS, Kim SJ, Kim YH. Association Between Colonic 18F-FDG Uptake and Glycemic Control in Patients with Diabetes Mellitus. Nucl Med Mol Imaging 2020; 54:168-174. [PMID: 32831962 DOI: 10.1007/s13139-020-00647-6] [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: 04/07/2020] [Revised: 05/21/2020] [Accepted: 06/11/2020] [Indexed: 12/29/2022] Open
Abstract
Purpose Positron emission tomography/computed tomography (PET/CT) with 18F-fluorodeoxyglucose (FDG) is a useful imaging modality that visualizes glucose utilization. Diffuse colonic FDG uptake is frequently observed in patients being treated for diabetes mellitus (DM), especially with metformin. The aim of this study was to evaluate whether patients without increased colonic FDG uptake after taking oral hypoglycemic agents (OHA) are associated with insufficient glycemic control. Methods A total of 279 subjects who underwent FDG PET/CT scans for health examinations and had been diagnosed with DM and taken an OHA before the day of the FDG PET/CT were included. Colonic FDG uptake in the study subjects was visually assessed, and the maximal and mean standard uptake value (SUV) was measured. Fasting blood glucose and glycated hemoglobin A1c (HbA1c) levels at both baseline and follow-up visits as well as DM management were compared according to the colonic FDG uptake. Results The mean age of study subjects was 48.8 years old, and 251 of subjects were male. Positive colonic FDG uptake was observed in 200 (71.7%) subjects. Fasting blood glucose and Hb1Ac levels on the day of FDG PET/CT were higher in subjects without positive colonic FDG uptake than those with positive colonic FDG uptake (p ≤ 0.001). But there was no significant difference between the two groups at follow-up visits. Conclusions Patients with DM who did not show increased colonic FDG uptake after taking OHA were associated with higher fasting blood glucose and HbA1c levels on the day of FDG PET/CT.
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Affiliation(s)
- Hyung Seok Chang
- Department of Nuclear Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29, Saemunan-ro, Jongno-gu, Seoul, 03181 Republic of Korea
| | - Soo Jeong Kim
- Department of Nuclear Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29, Saemunan-ro, Jongno-gu, Seoul, 03181 Republic of Korea
| | - Young Hwan Kim
- Department of Nuclear Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29, Saemunan-ro, Jongno-gu, Seoul, 03181 Republic of Korea
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Pharmacology of metformin - An update. Eur J Pharmacol 2019; 865:172782. [PMID: 31705902 DOI: 10.1016/j.ejphar.2019.172782] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/24/2019] [Accepted: 11/04/2019] [Indexed: 02/06/2023]
Abstract
Despite being a successful diabetes type 2 drug for more than a half-century in Europe, the mode of action of metformin is still debated. It is the purpose of this review to inform the reader about most recent findings for metformin with respect to its antidiabetic activity as well as proposed benefits beyond glucose control in humans. Clinical evidence now suggests that most of metformin benefits originate from its actions in the gut, involving hormone signaling by glucagon-like peptide 1 and peptide YY. Growth differentiation factor 15, also mainly produced in the gut, was first identified as a biomarker for metformin use but is now suggested to play a significant role in e.g. weight loss of prediabetics. The pharmacokinetics of the drug in humans as basis for pharmacodynamics, resulting in high tissue levels of the intestinal wall, including the colon, proven by biopsies, is presented. A critical survey of metformin actions on mitochondria, increasing the AMP/ATP ratio but also acting as a mild uncoupler, and of postulated new cellular targets (lysosomes) is included.
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Zilov AV, Abdelaziz SI, AlShammary A, Al Zahrani A, Amir A, Assaad Khalil SH, Brand K, Elkafrawy N, Hassoun AA, Jahed A, Jarrah N, Mrabeti S, Paruk I. Mechanisms of action of metformin with special reference to cardiovascular protection. Diabetes Metab Res Rev 2019; 35:e3173. [PMID: 31021474 PMCID: PMC6851752 DOI: 10.1002/dmrr.3173] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 04/01/2019] [Accepted: 04/18/2019] [Indexed: 12/17/2022]
Abstract
Management guidelines continue to identify metformin as initial pharmacologic antidiabetic therapy of choice for people with type 2 diabetes without contraindications, despite recent randomized trials that have demonstrated significant improvements in cardiovascular outcomes with newer classes of antidiabetic therapies. The purpose of this review is to summarize the current state of knowledge of metformin's therapeutic actions on blood glucose and cardiovascular clinical evidence and to consider the mechanisms that underlie them. The effects of metformin on glycaemia occur mainly in the liver, but metformin-stimulated glucose disposal by the gut has emerged as an increasingly import site of action of metformin. Additionally, metformin induces increased secretion of GLP-1 from intestinal L-cells. Clinical cardiovascular protection with metformin is supported by three randomized outcomes trials (in newly diagnosed and late stage insulin-treated type 2 diabetes patients) and a wealth of observational data. Initial evidence suggests that cotreatment with metformin may enhance the impact of newer incretin-based therapies on cardiovascular outcomes, an important observation as metformin can be combined with any other antidiabetic agent. Multiple potential mechanisms support the concept of cardiovascular protection with metformin beyond those provided by reduced blood glucose, including weight loss, improvements in haemostatic function, reduced inflammation, and oxidative stress, and inhibition of key steps in the process of atherosclerosis. Accordingly, metformin remains well placed to support improvements in cardiovascular outcomes, from diagnosis and throughout the course of type 2 diabetes, even in this new age of improved outcomes in type 2 diabetes.
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Affiliation(s)
- Alexey V. Zilov
- Department of EndocrinologySechenov's First Moscow State Medical UniversityMoscowRussia
| | | | - Afaf AlShammary
- Diabetes Center, Department of MedicineKing Abdulaziz Medical CityRiyadhKingdom of Saudi Arabia
| | - Ali Al Zahrani
- Department of Medicine, Molecular Endocrinology Section, Department of Molecular Oncology, Research CenterKing Faisal Specialist Hospital & Research CentreRiyadhKingdom of Saudi Arabia
| | - Ashraf Amir
- Department of Family MedicineInternational Medical CenterJeddahKingdom of Saudi Arabia
| | - Samir Helmy Assaad Khalil
- Department of Internal Medicine, Unit of Diabetology, Lipidology & Metabolism, Alexandria Faculty of MedicineAlexandria UniversityAlexandriaEgypt
| | - Kerstin Brand
- Global Medical AffairsMerck Healthcare KGaADarmstadtGermany
| | - Nabil Elkafrawy
- Diabetes and Endocrinology UnitMenoufia UniversityAl MinufyaEgypt
| | | | - Adel Jahed
- Gabric Diabetes Education Association, Tehran, Iran and Consultant EndocrinologistTehran General HospitalTehranIran
| | - Nadim Jarrah
- Internal Medicine DepartmentThe Specialty HospitalAmmanJordan
| | - Sanaa Mrabeti
- General Medicine and EndocrinologyMedical Affairs EMEA Merck Serono Middle East FZ‐LLCDubaiUnited Arab Emirates
| | - Imran Paruk
- Department of Diabetes and Endocrinology, Nelson R Mandela School of MedicineUniversity of KwaZulu‐NatalDurbanSouth Africa
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Zhou T, Xu X, Du M, Zhao T, Wang J. A preclinical overview of metformin for the treatment of type 2 diabetes. Biomed Pharmacother 2018; 106:1227-1235. [PMID: 30119191 DOI: 10.1016/j.biopha.2018.07.085] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 07/14/2018] [Accepted: 07/15/2018] [Indexed: 12/23/2022] Open
Abstract
Type 2 diabetes (T2D) is the most common type of diabetes mellitus and is mainly characterized by insulin resistance, β-cell dysfunction, and elevated hepatic glucose output. Metformin is a first-line antihyperglycemic agent that works mainly by regulating hepatic glucose production and peripheral insulin sensitivity. Metformin has been clinically applied for more than half a century, although the underlying pharmacological mechanisms remain elusive. This current review mainly focused on the development history of metformin and related preclinical studies on structural modification, pharmacological mechanisms for treatment of T2D, toxicology, pharmacokinetics, and pharmaceutics. The pharmacological function of metformin in lowering hyperglycemia suggests that multi-targeting could be an effective strategy for the discovery of new anti-diabetic drugs. A number of discoveries have revealed the pharmacologic mechanisms of metformin; however, precise mechanisms remain unclear. Deeper investigations on the biological features of metformin are expected to provide more rational applications and indications of this evergreen anti-T2D agent, which will in turn help to better understand the complicated pathogenesis of T2D.
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Affiliation(s)
- Tingting Zhou
- Wuxi School of Medicine, Jiangnan University, 1800 Lihu Road, Wuxi 214122, China; Shanghai Institute of Material Medica, Chinese Academy of Sciences, 555 Zuchongzhi Road, Shanghai 201203, China.
| | - Xin Xu
- Shanghai Institute of Material Medica, Chinese Academy of Sciences, 555 Zuchongzhi Road, Shanghai 201203, China
| | - Mengfan Du
- Wuxi School of Medicine, Jiangnan University, 1800 Lihu Road, Wuxi 214122, China
| | - Tong Zhao
- State Key Laboratory Cultivation Base for TCM Quality and Efficacy, School of Medicine and Life Sciences, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing 210023, China
| | - Jiaying Wang
- State Key Laboratory Cultivation Base for TCM Quality and Efficacy, School of Medicine and Life Sciences, Nanjing University of Chinese Medicine, 138 Xianlin Road, Nanjing 210023, China.
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Ribeiro-Parenti L, Cavin JB, Le Gall M. Intestinal adaptations following bariatric surgery: towards the identification of new pharmacological targets for obesity-related metabolic diseases. Curr Opin Pharmacol 2017; 37:29-34. [PMID: 28822847 DOI: 10.1016/j.coph.2017.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 07/24/2017] [Accepted: 08/01/2017] [Indexed: 12/22/2022]
Abstract
Although the gastrointestinal tract is the primary target of bariatric surgery, its contributions to the metabolic changes observed after surgery are still underestimated. Changes in the number of incretin-producing cells could result in the modified hormonal response seen after surgery. Additionally, the rate of absorption and consumption of glucose could contribute to the ameliorated glycaemia. Moreover, decreased intestinal permeability could prevent endotoxemia. Recently, numerous studies have focused on intestinal adaptation following bariatric surgeries. These studies bring new insight into the different roles the GI tract plays in the metabolic outcomes of bariatric surgery and open new avenues for therapeutic treatments.
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Affiliation(s)
- Lara Ribeiro-Parenti
- Inserm UMR 1149, UFR de Médecine Paris Diderot, Université Paris Diderot, Sorbonne Paris Cité, DHU Unity APHP, F-75890 Paris, France
| | - Jean-Baptiste Cavin
- Inserm UMR 1149, UFR de Médecine Paris Diderot, Université Paris Diderot, Sorbonne Paris Cité, DHU Unity APHP, F-75890 Paris, France; Department of Physiology and Pharmacology, Hotchkiss Brain Institute, University of Calgary, Alberta, T2N4N1 Calgary, Canada
| | - Maude Le Gall
- Inserm UMR 1149, UFR de Médecine Paris Diderot, Université Paris Diderot, Sorbonne Paris Cité, DHU Unity APHP, F-75890 Paris, France.
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