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Plowman TJ, Christensen H, Aiges M, Fernandez E, Shah MH, Ramana KV. Anti-Inflammatory Potential of the Anti-Diabetic Drug Metformin in the Prevention of Inflammatory Complications and Infectious Diseases Including COVID-19: A Narrative Review. Int J Mol Sci 2024; 25:5190. [PMID: 38791227 PMCID: PMC11121530 DOI: 10.3390/ijms25105190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
Metformin, a widely used first-line anti-diabetic therapy for the treatment of type-2 diabetes, has been shown to lower hyperglycemia levels in the blood by enhancing insulin actions. For several decades this drug has been used globally to successfully control hyperglycemia. Lactic acidosis has been shown to be a major adverse effect of metformin in some type-2 diabetic patients, but several studies suggest that it is a typically well-tolerated and safe drug in most patients. Further, recent studies also indicate its potential to reduce the symptoms associated with various inflammatory complications and infectious diseases including coronavirus disease 2019 (COVID-19). These studies suggest that besides diabetes, metformin could be used as an adjuvant drug to control inflammatory and infectious diseases. In this article, we discuss the current understanding of the role of the anti-diabetic drug metformin in the prevention of various inflammatory complications and infectious diseases in both diabetics and non-diabetics.
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Affiliation(s)
| | | | | | | | | | - Kota V. Ramana
- Department of Biomedical Sciences, Noorda College of Osteopathic Medicine, Provo, UT 84606, USA
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Yagasaki R, Morita A, Mori A, Sakamoto K, Nakahara T. The Anti-Diabetic Drug Metformin Suppresses Pathological Retinal Angiogenesis via Blocking the mTORC1 Signaling Pathway in Mice (Metformin Suppresses Pathological Angiogenesis). Curr Eye Res 2024; 49:505-512. [PMID: 38251680 DOI: 10.1080/02713683.2024.2302865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 01/03/2024] [Indexed: 01/23/2024]
Abstract
PURPOSE Metformin, a biguanide antihyperglycemic drug, can exert various beneficial effects in addition to its glucose-lowering effect. The effects of metformin are mainly mediated by AMP-activated protein kinase (AMPK)-dependent pathway. AMPK activation interferes with the action of the mammalian target of rapamycin complex 1 (mTORC1), and blockade of mTORC1 pathway suppresses pathological retinal angiogenesis. Therefore, in this study, we examined the effects of metformin on pathological angiogenesis and mTORC1 activity in the retinas of mice with oxygen-induced retinopathy (OIR). METHODS OIR was induced by exposing the mice to 80% oxygen from postnatal day (P) 7 to P10. The OIR mice were treated with metformin, rapamycin (an inhibitor of mTORC1), or the vehicle from P10 to P12 or P14. The formation of neovascular tufts, revascularization in the central avascular areas, expression of vascular endothelial growth factor (VEGF) and VEGF receptor (VEGFR) 2, and phosphorylated ribosomal protein S6 (pS6), a downstream indicator of mTORC1 activity, were evaluated at P10, P13, or P15. RESULTS Neovascular tufts and vascular growth in the central avascular areas were observed in the retinas of P15 OIR mice. The formation of neovascular tufts, but not the revascularization in the central avascular areas, was attenuated by metformin administration from P10 to P14. Metformin had no significant inhibitory effect on the expression of VEGF and VEGFR2, but it reduced the pS6 immunoreactivity in vascular cells at the sites of angiogenesis. Rapamycin completely blocked the phosphorylation of ribosomal protein S6 and markedly reduced the formation of neovascular tufts. CONCLUSIONS These results suggest that metformin partially suppresses the formation of neovascular tufts on the retinal surface by blocking the mTORC1 signaling pathway. Metformin may exert beneficial effects against the progression of ocular diseases in which abnormal angiogenesis is associated with the pathogenesis.
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Affiliation(s)
- Rina Yagasaki
- Department of Molecular Pharmacology, Kitasato University School of Pharmaceutical Sciences, Tokyo, Japan
| | - Akane Morita
- Department of Molecular Pharmacology, Kitasato University School of Pharmaceutical Sciences, Tokyo, Japan
| | - Asami Mori
- Department of Molecular Pharmacology, Kitasato University School of Pharmaceutical Sciences, Tokyo, Japan
| | - Kenji Sakamoto
- Department of Molecular Pharmacology, Kitasato University School of Pharmaceutical Sciences, Tokyo, Japan
| | - Tsutomu Nakahara
- Department of Molecular Pharmacology, Kitasato University School of Pharmaceutical Sciences, Tokyo, Japan
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Chen L, Yin Y, Liu C, Liu J, Zheng M, Tang Y, Yang Q, Liu J, Chen F, Liu L, Liu G. Metformin alleviates bevacizumab-induced vascular endothelial injury in mice through growth differentiation factor 15 upregulation. IRANIAN JOURNAL OF BASIC MEDICAL SCIENCES 2024; 27:343-351. [PMID: 38333748 PMCID: PMC10849206 DOI: 10.22038/ijbms.2023.72759.15827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 11/18/2023] [Indexed: 02/10/2024]
Abstract
Objectives Bevacizumab is a commonly used anticancer drug in clinical practice, but it often leads to adverse reactions such as vascular endothelial damage, hypertension, arterial and venous thrombosis, and bleeding. This study investigated the protective effects of metformin against bevacizumab-induced vascular injury in a mouse model and examined the possible involvement of GDF15/PI3K/AKT/FOXO/PPARγ signaling in the effects. Materials and Methods C57 male mice were purchased. To investigate metformin, the mice were assigned to the saline, bevacizumab (15 mg every 3 days), metformin (1200 mg/day), and bevacizumab+metformin groups. To investigate GDF15, the mice were assigned to the siNC+bevacizumab, siNC+bevacizumab+metformin, siGDF15+bevacizumab, and siGDF15+bevacizumab+metformin groups. Histological staining was used to evaluate vascular injury. Flow cytometry was used to evaluate apoptosis. ELISA was used to measure plasma endothelial injury markers and proinflammatory cytokines. qRT-PCR and western blot were used to determine the expression of GDF15 and PI3K/AKT/FOXO/PPARγ in aortic tissues. Results Metformin alleviated bevacizumab-induced abdominal aortic injury, endothelial cell apoptosis, and systemic inflammation in mice (all P<0.05). Metformin up-regulated GDF15 expression and PI3K/AKT/FOXO/PPARγ signaling in the abdominal aorta of mice treated with bevacizumab (all P<0.05). siGDF15 abolished the vascular protective and anti-inflammatory effects of metformin (all P<0.05). siGDF15 suppressed PI3K/AKT/FOXO/PPARγ signaling in the abdominal aorta of mice treated with bevacizumab (all P<0.05). Conclusion Metformin attenuates bevacizumab-induced vascular endothelial injury, apoptosis, and systemic inflammation by activating GDF15/PI3K/AKT/FOXO/PPARγ signaling.
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Affiliation(s)
- Liqiang Chen
- Department of Cardiovascular, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
- These authors contributed equally to this work
| | - Yajuan Yin
- Department of Cardiovascular, The First Hospital of Hebei Medical University, Shijiazhuang, China
- These authors contributed equally to this work
| | - Chunmiao Liu
- Department of Obstetrics,The Fourth Hospital of Shijiazhuang,Shijiazhuang, China
| | - Junying Liu
- Department of Pathology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Mingqi Zheng
- Department of Cardiovascular, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yida Tang
- Department of Cardiology, Peking University Third Hospital, 49 Huayuanbei Road, Haidian District, Beijing 100191, China
| | - Qing Yang
- Department of Cardiology, Tianjin Medical University General Hospital, 154 Anshan Road, Heping District, Tianjin 300052, China
| | - Jing Liu
- Department of Cardiovascular, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Fan Chen
- Department of Cardiovascular, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lanbo Liu
- Department of Cardiovascular, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Gang Liu
- Department of Cardiovascular, The First Hospital of Hebei Medical University, Shijiazhuang, China
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Liu XK, Qiu QQ, Yu TP, Wang LY, Shi L, Wang B, Sang YQ, Geng HF, Zhang Y, Zhang X, Li L, Li Q, Liang J, Xu W. Effect of metformin on Wnt5a in individuals new-onset type 2 diabetes with different body mass indexes: The evidences from the real word research. J Diabetes Metab Disord 2023; 22:1561-1570. [PMID: 37975126 PMCID: PMC10638164 DOI: 10.1007/s40200-023-01286-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 08/17/2023] [Indexed: 11/19/2023]
Abstract
Aim Metformin is a first-line therapy for the treatment of Type 2 diabetes mellitus (T2DM), due to its inhibition of hepatic gluconeogenesis. Wingless family member 5a (Wnt5a) was significantly decreased in newly diagnosed T2DM patients and regulates secretion of β cells through the Wnt/calcium signalling cascades. This study aims to investigate how metformin works on glucose-lowering effects in diabetes and whether the mechanism underlying it is associated with Wnt5a. Methods A total of 144 participants were enrolled in this study. Serum Wnt5a levels were measured by an enzyme-linked immunosorbent assay (ELISA). The demographic and clinical parameters were evaluated in normal weight, overweight and obese new-onset T2DM subjects grouped. Results Wnt5a was increased in overweight T2DM patients and obese T2DM patients compared with the levels in normal Body Mass Index (BMI) T2DM. The level of Wnt5a gradually increased after 3 and 6 months of metformin treatment. Among the three groups, the most significant improvement in blood glucose was observed in the obese type 2 diabetic patients, and the improvement showed a significant correlation with Wnt5a protein after patients received metformin treatment. Pearson correlation showed that there was a significant relationship between △2hOGTT and Wnt5a. After further adjusting for sex and age, a significant association existed only between Wnt5a and 2-h oral glucose tolerance test(2hOGTT), and this association was negative. Conclusion Our results indicate that Wnt5a may play a role in the mechanism by which metformin improves blood glucose in patients with type 2 diabetes.
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Affiliation(s)
- X. K. Liu
- Department of Endocrinology, Affiliated Hospital of Medical School of Southeast University, Xuzhou Central Hospital, Xuzhou Institute of Medical Sciences, Xuzhou Clinical School of Nanjing Medical University, Jiangsu, China
| | - Q. Q. Qiu
- Department of Endocrinology, Affiliated Hospital of Medical School of Southeast University, Xuzhou Central Hospital, Xuzhou Institute of Medical Sciences, Xuzhou Clinical School of Nanjing Medical University, Jiangsu, China
| | - T. P. Yu
- Department of Endocrinology, Affiliated Hospital of Medical School of Southeast University, Xuzhou Central Hospital, Xuzhou Institute of Medical Sciences, Xuzhou Clinical School of Nanjing Medical University, Jiangsu, China
| | - L. Y. Wang
- Department of Endocrinology, Affiliated Hospital of Medical School of Southeast University, Xuzhou Central Hospital, Xuzhou Institute of Medical Sciences, Xuzhou Clinical School of Nanjing Medical University, Jiangsu, China
| | - Li Shi
- Department of Endocrinology, Affiliated Hospital of Medical School of Southeast University, Xuzhou Central Hospital, Xuzhou Institute of Medical Sciences, Xuzhou Clinical School of Nanjing Medical University, Jiangsu, China
| | - Ben Wang
- Department of Endocrinology, Affiliated Hospital of Medical School of Southeast University, Xuzhou Central Hospital, Xuzhou Institute of Medical Sciences, Xuzhou Clinical School of Nanjing Medical University, Jiangsu, China
| | - Y. Q. Sang
- Department of Endocrinology, Affiliated Hospital of Medical School of Southeast University, Xuzhou Central Hospital, Xuzhou Institute of Medical Sciences, Xuzhou Clinical School of Nanjing Medical University, Jiangsu, China
| | - H. F. Geng
- Department of Endocrinology, Affiliated Hospital of Medical School of Southeast University, Xuzhou Central Hospital, Xuzhou Institute of Medical Sciences, Xuzhou Clinical School of Nanjing Medical University, Jiangsu, China
| | - Yan Zhang
- Xuzhou Medical University, Xuzhou, Jiangsu China
| | - Xia Zhang
- Xuzhou Medical University, Xuzhou, Jiangsu China
| | - Lin Li
- Bengbu Medical College, Bengbu, Anhui China
| | - Qing Li
- Xuzhou Medical University, Xuzhou, Jiangsu China
| | - Jun Liang
- Department of Endocrinology, Affiliated Hospital of Medical School of Southeast University, Xuzhou Central Hospital, Xuzhou Institute of Medical Sciences, Xuzhou Clinical School of Nanjing Medical University, Jiangsu, China
| | - Wei Xu
- Department of Endocrinology, Affiliated Hospital of Medical School of Southeast University, Xuzhou Central Hospital, Xuzhou Institute of Medical Sciences, Xuzhou Clinical School of Nanjing Medical University, Jiangsu, China
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Huang D, Li Y, Chen S, Wang H, Jiang Y, Wei Y, Lin H, Zou S. The onset of adenosine monophosphate-activated protein kinase activity on orthodontic tooth movement in rats with type 2 diabetes. Eur J Oral Sci 2023; 131:e12955. [PMID: 37805702 DOI: 10.1111/eos.12955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/18/2023] [Indexed: 10/09/2023]
Abstract
Adenosine monophosphate-activated protein kinase (AMPK) plays pivotal roles in metabolic diseases including type 2 diabetes. However, the specific role of AMPK for orthodontic tooth movement in type 2 diabetes is unclear. In this study, a diabetic rat model was established through dietary manipulation and streptozocin injection. Examinations were conducted to select qualified type 2 diabetic rats. Then, an orthodontic device was applied to these rats for 0, 3, 7, or 14 days. The distance of orthodontic tooth movement and parameters of alveolar bone were analyzed by micro-computed tomography. Periodontal osteoclastic activity, inflammatory status, and AMPK activity were measured via histological analyses. Next, we repeated the establishment of diabetic rats to investigate whether change of AMPK activity was associated with orthodontic tooth movement under type 2 diabetes. The results showed that diabetic rats exhibited an exacerbated alveolar bone resorption, overactive inflammation, and decreased periodontal AMPK activity during orthodontic tooth movement. Injection of the AMPK agonist alleviated type 2 diabetes-induced periodontal inflammation and alveolar bone resorption, thus normalizing distance of orthodontic tooth movement. Our study indicates that type 2 diabetes decreases periodontal AMPK activity, leading to excessive inflammation elevating osteoclast formation and alveolar bone resorption, which could be reversed by AMPK activation.
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Affiliation(s)
- Danyuan Huang
- State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Yuyu Li
- State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Shuo Chen
- State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Han Wang
- State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Yukun Jiang
- State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Yuanyuan Wei
- State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Hengyi Lin
- State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Shujuan Zou
- State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
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Nishiyama K, Ono M, Tsuno T, Inoue R, Fukunaka A, Okuyama T, Kyohara M, Togashi Y, Fukushima S, Atsumi T, Sato A, Tsurumoto A, Sakai C, Fujitani Y, Terauchi Y, Ito S, Shirakawa J. Protective Effects of Imeglimin and Metformin Combination Therapy on β-Cells in db/db Male Mice. Endocrinology 2023; 164:bqad095. [PMID: 37314160 DOI: 10.1210/endocr/bqad095] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 04/23/2023] [Accepted: 06/13/2023] [Indexed: 06/15/2023]
Abstract
Imeglimin and metformin act in metabolic organs, including β-cells, via different mechanisms. In the present study, we investigated the impacts of imeglimin, metformin, or their combination (Imeg + Met) on β-cells, the liver, and adipose tissues in db/db mice. Imeglimin, metformin, or Imeg + Met treatment had no significant effects on glucose tolerance, insulin sensitivity, respiratory exchange ratio, or locomotor activity in db/db mice. The responsiveness of insulin secretion to glucose was recovered by Imeg + Met treatment. Furthermore, Imeg + Met treatment increased β-cell mass by enhancing β-cell proliferation and ameliorating β-cell apoptosis in db/db mice. Hepatic steatosis, the morphology of adipocytes, adiposity assessed by computed tomography, and the expression of genes related to glucose or lipid metabolism and inflammation in the liver and fat tissues showed no notable differences in db/db mice. Global gene expression analysis of isolated islets indicated that the genes related to regulation of cell population proliferation and negative regulation of cell death were enriched by Imeg + Met treatment in db/db islets. In vitro culture experiments confirmed the protective effects of Imeg + Met against β-cell apoptosis. The expression of Snai1, Tnfrsf18, Pdcd1, Mmp9, Ccr7, Egr3, and Cxcl12, some of which have been linked to apoptosis, in db/db islets was attenuated by Imeg + Met. Treatment of a β-cell line with Imeg + Met prevented apoptosis induced by hydrogen peroxide or palmitate. Thus, the combination of imeglimin and metformin is beneficial for the maintenance of β-cell mass in db/db mice, probably through direct action on β-cells, suggesting a potential strategy for protecting β-cells in the treatment of type 2 diabetes.
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Affiliation(s)
- Kuniyuki Nishiyama
- Laboratory of Diabetes and Metabolic Disorders, Institute for Molecular and Cellular Regulation (IMCR), Gunma University, Maebashi 371-8512, Japan
- Department of Endocrinology and Metabolism, Graduate School of Medicine, Yokohama City University, Yokohama 236-0004, Japan
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, Yokohama 236-0004, Japan
| | - Masato Ono
- Department of Endocrinology and Metabolism, Graduate School of Medicine, Yokohama City University, Yokohama 236-0004, Japan
| | - Takahiro Tsuno
- Laboratory of Diabetes and Metabolic Disorders, Institute for Molecular and Cellular Regulation (IMCR), Gunma University, Maebashi 371-8512, Japan
- Department of Endocrinology and Metabolism, Graduate School of Medicine, Yokohama City University, Yokohama 236-0004, Japan
| | - Ryota Inoue
- Laboratory of Diabetes and Metabolic Disorders, Institute for Molecular and Cellular Regulation (IMCR), Gunma University, Maebashi 371-8512, Japan
- Department of Endocrinology and Metabolism, Graduate School of Medicine, Yokohama City University, Yokohama 236-0004, Japan
| | - Ayako Fukunaka
- Laboratory of Developmental Biology and Metabolism, Institute for Molecular and Cellular Regulation (IMCR), Gunma University, Maebashi 371-8512, Japan
| | - Tomoko Okuyama
- Department of Endocrinology and Metabolism, Graduate School of Medicine, Yokohama City University, Yokohama 236-0004, Japan
| | - Mayu Kyohara
- Department of Endocrinology and Metabolism, Graduate School of Medicine, Yokohama City University, Yokohama 236-0004, Japan
| | - Yu Togashi
- Department of Endocrinology and Metabolism, Graduate School of Medicine, Yokohama City University, Yokohama 236-0004, Japan
| | - Setsuko Fukushima
- Laboratory of Diabetes and Metabolic Disorders, Institute for Molecular and Cellular Regulation (IMCR), Gunma University, Maebashi 371-8512, Japan
| | - Takuto Atsumi
- Laboratory of Diabetes and Metabolic Disorders, Institute for Molecular and Cellular Regulation (IMCR), Gunma University, Maebashi 371-8512, Japan
| | - Aoi Sato
- Laboratory of Diabetes and Metabolic Disorders, Institute for Molecular and Cellular Regulation (IMCR), Gunma University, Maebashi 371-8512, Japan
| | - Asuka Tsurumoto
- Laboratory of Diabetes and Metabolic Disorders, Institute for Molecular and Cellular Regulation (IMCR), Gunma University, Maebashi 371-8512, Japan
| | - Chisato Sakai
- Laboratory of Diabetes and Metabolic Disorders, Institute for Molecular and Cellular Regulation (IMCR), Gunma University, Maebashi 371-8512, Japan
| | - Yoshio Fujitani
- Laboratory of Developmental Biology and Metabolism, Institute for Molecular and Cellular Regulation (IMCR), Gunma University, Maebashi 371-8512, Japan
| | - Yasuo Terauchi
- Department of Endocrinology and Metabolism, Graduate School of Medicine, Yokohama City University, Yokohama 236-0004, Japan
| | - Shuichi Ito
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, Yokohama 236-0004, Japan
| | - Jun Shirakawa
- Laboratory of Diabetes and Metabolic Disorders, Institute for Molecular and Cellular Regulation (IMCR), Gunma University, Maebashi 371-8512, Japan
- Department of Endocrinology and Metabolism, Graduate School of Medicine, Yokohama City University, Yokohama 236-0004, Japan
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Xie EF, Xie B, Nadeem U, D'Souza M, Reem G, Sulakhe D, Skondra D. Using Advanced Bioinformatics Tools to Identify Novel Therapeutic Candidates for Proliferative Vitreoretinopathy. Transl Vis Sci Technol 2023; 12:19. [PMID: 37191619 DOI: 10.1167/tvst.12.5.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
Purpose Proliferative vitreoretinopathy (PVR) is the dreaded cause of failure following retinal detachment repair; however, no cures or preventative therapies exist to date. The purpose of this study was to use bioinformatics tools to identify drugs or compounds that interact with biomarkers and pathways involved in PVR pathogenesis that could be eligible for further testing for the prevention and treatment of PVR. Methods We queried PubMed to compile a comprehensive list of genes described in PVR to date from human studies, animal models, and genomic studies found in the National Center for Biotechnology Information database. Gene enrichment analysis was performed using ToppGene on PVR-related genes against drug-gene interaction databases to construct a pharmacome and estimate the statistical significance of overrepresented compounds. Compounds with no clinical indications were filtered out from the resulting drug lists. Results Our query identified 34 unique genes associated with PVR. Out of 77,146 candidate drugs or compounds in the drug databases, our analysis revealed multiple drugs and compounds that have significant interactions with genes involved in PVR, including antiproliferatives, corticosteroids, cardiovascular agents, antioxidants, statins, and micronutrients. Top compounds, including curcumin, statins, and cardiovascular agents such as carvedilol and enalapril, have well-established safety profiles and potentially could be readily repurposed for PVR. Other significant compounds such as prednisone and methotrexate have shown promising results in ongoing clinical trials for PVR. Conclusions This bioinformatics approach of studying drug-gene interactions can identify drugs that may affect genes and pathways implicated in PVR. Predicted bioinformatics studies require further validation by preclinical or clinical studies; however, this unbiased approach could identify potential candidates among existing drugs and compounds that could be repurposed for PVR and guide future investigations. Translational Relevance Novel repurposable drug therapies for PVR can be found using advanced bioinformatics models.
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Affiliation(s)
- Edward F Xie
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, Chicago, IL, USA
| | - Bingqing Xie
- Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Urooba Nadeem
- Department of Pathology, The University of Chicago, Chicago, IL, USA
| | - Mark D'Souza
- Center for Research Informatics, The University of Chicago, Chicago, IL, USA
| | - Gonnah Reem
- Department of Ophthalmology and Visual Science, The University of Chicago, Chicago, IL, USA
| | - Dinanath Sulakhe
- Department of Ophthalmology and Visual Science, The University of Chicago, Chicago, IL, USA
| | - Dimitra Skondra
- Department of Ophthalmology and Visual Science, The University of Chicago, Chicago, IL, USA
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Karami F, Jamaati H, Coleman-Fuller N, Zeini MS, Hayes AW, Gholami M, Salehirad M, Darabi M, Motaghinejad M. Is metformin neuroprotective against diabetes mellitus-induced neurodegeneration? An updated graphical review of molecular basis. Pharmacol Rep 2023; 75:511-543. [PMID: 37093496 DOI: 10.1007/s43440-023-00469-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 04/25/2023]
Abstract
Diabetes mellitus (DM) is a metabolic disease that activates several molecular pathways involved in neurodegenerative disorders. Metformin, an anti-hyperglycemic drug used for treating DM, has the potential to exert a significant neuroprotective role against the detrimental effects of DM. This review discusses recent clinical and laboratory studies investigating the neuroprotective properties of metformin against DM-induced neurodegeneration and the roles of various molecular pathways, including mitochondrial dysfunction, oxidative stress, inflammation, apoptosis, and its related cascades. A literature search was conducted from January 2000 to December 2022 using multiple databases including Web of Science, Wiley, Springer, PubMed, Elsevier Science Direct, Google Scholar, the Core Collection, Scopus, and the Cochrane Library to collect and evaluate peer-reviewed literature regarding the neuroprotective role of metformin against DM-induced neurodegenerative events. The literature search supports the conclusion that metformin is neuroprotective against DM-induced neuronal cell degeneration in both peripheral and central nervous systems, and this effect is likely mediated via modulation of oxidative stress, inflammation, and cell death pathways.
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Affiliation(s)
- Fatemeh Karami
- Chronic Respiratory Disease Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamidreza Jamaati
- Chronic Respiratory Disease Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Natalie Coleman-Fuller
- Department of Veterinary and Biomedical Sciences, University of Minnesota, Saint Paul, MN, 55108, USA
| | - Maryam Shokrian Zeini
- Chronic Respiratory Disease Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - A Wallace Hayes
- University of South Florida College of Public Health and Institute for Integrative Toxicology, Michigan State University, East Lansing, USA
| | - Mina Gholami
- Chronic Respiratory Disease Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahsa Salehirad
- Cognitive and Neuroscience Research Center (CNRC), Amir-Almomenin Hospital, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Mohammad Darabi
- Chronic Respiratory Disease Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Motaghinejad
- Chronic Respiratory Disease Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Kropp M, Golubnitschaja O, Mazurakova A, Koklesova L, Sargheini N, Vo TTKS, de Clerck E, Polivka J, Potuznik P, Polivka J, Stetkarova I, Kubatka P, Thumann G. Diabetic retinopathy as the leading cause of blindness and early predictor of cascading complications-risks and mitigation. EPMA J 2023; 14:21-42. [PMID: 36866156 PMCID: PMC9971534 DOI: 10.1007/s13167-023-00314-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 01/15/2023] [Indexed: 02/17/2023]
Abstract
Proliferative diabetic retinopathy (PDR) the sequel of diabetic retinopathy (DR), a frequent complication of diabetes mellitus (DM), is the leading cause of blindness in the working-age population. The current screening process for the DR risk is not sufficiently effective such that often the disease is undetected until irreversible damage occurs. Diabetes-associated small vessel disease and neuroretinal changes create a vicious cycle resulting in the conversion of DR into PDR with characteristic ocular attributes including excessive mitochondrial and retinal cell damage, chronic inflammation, neovascularisation, and reduced visual field. PDR is considered an independent predictor of other severe diabetic complications such as ischemic stroke. A "domino effect" is highly characteristic for the cascading DM complications in which DR is an early indicator of impaired molecular and visual signaling. Mitochondrial health control is clinically relevant in DR management, and multi-omic tear fluid analysis can be instrumental for DR prognosis and PDR prediction. Altered metabolic pathways and bioenergetics, microvascular deficits and small vessel disease, chronic inflammation, and excessive tissue remodelling are in focus of this article as evidence-based targets for a predictive approach to develop diagnosis and treatment algorithms tailored to the individual for a cost-effective early prevention by implementing the paradigm shift from reactive medicine to predictive, preventive, and personalized medicine (PPPM) in primary and secondary DR care management.
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Affiliation(s)
- Martina Kropp
- Division of Experimental Ophthalmology, Department of Clinical Neurosciences, University of Geneva University Hospitals, 1205 Geneva, Switzerland ,Ophthalmology Department, University Hospitals of Geneva, 1205 Geneva, Switzerland
| | - Olga Golubnitschaja
- Predictive, Preventive and Personalised (3P) Medicine, Department of Radiation Oncology, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany
| | - Alena Mazurakova
- Clinic of Obstetrics and Gynecology, Jessenius Faculty of Medicine, Comenius University in Bratislava, 036 01 Martin, Slovakia
| | - Lenka Koklesova
- Clinic of Obstetrics and Gynecology, Jessenius Faculty of Medicine, Comenius University in Bratislava, 036 01 Martin, Slovakia
| | - Nafiseh Sargheini
- Max Planck Institute for Plant Breeding Research, Carl-Von-Linne-Weg 10, 50829 Cologne, Germany
| | - Trong-Tin Kevin Steve Vo
- Division of Experimental Ophthalmology, Department of Clinical Neurosciences, University of Geneva University Hospitals, 1205 Geneva, Switzerland ,Ophthalmology Department, University Hospitals of Geneva, 1205 Geneva, Switzerland
| | - Eline de Clerck
- Division of Experimental Ophthalmology, Department of Clinical Neurosciences, University of Geneva University Hospitals, 1205 Geneva, Switzerland ,Ophthalmology Department, University Hospitals of Geneva, 1205 Geneva, Switzerland
| | - Jiri Polivka
- Department of Histology and Embryology, and Biomedical Centre, Faculty of Medicine in Plzen, Charles University, Prague, Czech Republic
| | - Pavel Potuznik
- Department of Neurology, University Hospital Plzen, and Faculty of Medicine in Plzen, Charles University, 100 34 Prague, Czech Republic
| | - Jiri Polivka
- Department of Neurology, University Hospital Plzen, and Faculty of Medicine in Plzen, Charles University, 100 34 Prague, Czech Republic
| | - Ivana Stetkarova
- Department of Neurology, University Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Peter Kubatka
- Department of Medical Biology, Jessenius Faculty of Medicine, Comenius University in Bratislava, 036 01 Martin, Slovakia
| | - Gabriele Thumann
- Division of Experimental Ophthalmology, Department of Clinical Neurosciences, University of Geneva University Hospitals, 1205 Geneva, Switzerland ,Ophthalmology Department, University Hospitals of Geneva, 1205 Geneva, Switzerland
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10
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Li Z, Tong J, Liu C, Zhu M, Tan J, Kuang G. Analysis of independent risk factors for progression of different degrees of diabetic retinopathy as well as non-diabetic retinopathy among type 2 diabetic patients. Front Neurosci 2023; 17:1143476. [PMID: 37090790 PMCID: PMC10115960 DOI: 10.3389/fnins.2023.1143476] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 03/17/2023] [Indexed: 04/25/2023] Open
Abstract
Purpose To study the independent risk factors for development of different degrees of diabetic retinopathy (DR) as well as non-DR (NDR) among type 2 diabetic patients. Methods This cross-sectional study included 218 patients with type 2 diabetes between January 2022 and June 2022. All the patients were divided into two groups: the DR group and the NDR group. The DR group was subdivided into the mild, moderate and severe non-proliferative DR (NPDR) group and the proliferative DR (PDR) group. Data recorded for all patients included age, gender, duration of diabetes, blood pressure, glycated hemoglobin (HbA1c), fasting blood glucose (FBG), blood lipids, best corrected visual acuity (BCVA), intraocular pressure (IOP), axial length (AL), anterior chamber depth (ACD), and renal function. Logistic regression methods were used to analyze the risk factors for DR. Results The prevalence of DR in type 2 diabetes was 28.44%. The duration of diabetes, age, mean arterial pressure (MAP), HbA1c, FBG, urinary albumin/creatinine ratio (UACR), BCVA, AL, and ACD were significantly different between the DR and the NDR groups (p < 0.05). Multivariate logistic regression analysis identified age, FBG, UACR, and AL as the independent risk factors for DR (OR = 0.843, 2.376, 1.049, 0.005; p = 0.034, 0.014, 0.016, p < 0.001). Conclusion Young age, short AL, higher levels of FBG and UACR were the independent risk factors for the progression of DR in type 2 diabetes.
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Affiliation(s)
- Zheng Li
- Department of Ophthalmology, The First People’s Hospital of Chenzhou, Chenzhou, Hunan, China
- Department of Ophthalmology, The Affiliated Chenzhou Hospital, Hengyang Medical School, University of South China, Chenzhou, Hunan, China
| | - Jie Tong
- Department of Spinal Surgery, The First People’s Hospital of Chenzhou, Chenzhou, Hunan, China
- Department of Spinal Surgery, The Affiliated Chenzhou Hospital, Hengyang Medical School, University of South China, Chenzhou, Hunan, China
| | - Chang Liu
- Department of Endocrinology, The First People’s Hospital of Chenzhou, Chenzhou, Hunan, China
| | - Mingqiong Zhu
- Department of Ophthalmology, The First People’s Hospital of Chenzhou, Chenzhou, Hunan, China
- Department of Ophthalmology, The Affiliated Chenzhou Hospital, Hengyang Medical School, University of South China, Chenzhou, Hunan, China
| | - Jia Tan
- Department of Ophthalmology, Xiangya Hospital of Central South University, Changsha, Hunan, China
- *Correspondence: Jia Tan,
| | - Guoping Kuang
- Department of Ophthalmology, The First People’s Hospital of Chenzhou, Chenzhou, Hunan, China
- Department of Ophthalmology, The Affiliated Chenzhou Hospital, Hengyang Medical School, University of South China, Chenzhou, Hunan, China
- Guoping Kuang,
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11
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Picatoste B, Cerro-Pardo I, Blanco-Colio LM, Martín-Ventura JL. Protection of diabetes in aortic abdominal aneurysm: Are antidiabetics the real effectors? Front Cardiovasc Med 2023; 10:1112430. [PMID: 37034348 PMCID: PMC10076877 DOI: 10.3389/fcvm.2023.1112430] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/06/2023] [Indexed: 04/11/2023] Open
Abstract
Aortic aneurysms, including abdominal aortic aneurysms (AAAs), is the second most prevalent aortic disease and represents an important cause of death worldwide. AAA is a permanent dilation of the aorta on its infrarenal portion, pathologically associated with oxidative stress, proteolysis, vascular smooth muscle cell loss, immune-inflammation, and extracellular matrix remodeling and degradation. Most epidemiological studies have shown a potential protective role of diabetes mellitus (DM) on the prevalence and incidence of AAA. The effect of DM on AAA might be explained mainly by two factors: hyperglycemia [or other DM-related factors such as insulin resistance (IR)] and/or by the effect of prescribed DM drugs, which may have a direct or indirect effect on the formation and progression of AAAs. However, recent studies further support that the protective role of DM in AAA may be attributable to antidiabetic therapies (i.e.: metformin or SGLT-2 inhibitors). This review summarizes current literature on the relationship between DM and the incidence, progression, and rupture of AAAs, and discusses the potential cellular and molecular pathways that may be involved in its vascular effects. Besides, we provide a summary of current antidiabetic therapies which use could be beneficial for AAA.
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Affiliation(s)
- Belén Picatoste
- Laboratory of Vascular Pathology, IIS-Fundación Jiménez Díaz, Madrid, Spain
- Biomedicine Department, Alfonso X El Sabio University, Madrid, Spain
- Correspondence: Belén Picatoste ,
| | - Isabel Cerro-Pardo
- Laboratory of Vascular Pathology, IIS-Fundación Jiménez Díaz, Madrid, Spain
| | - Luis M. Blanco-Colio
- Laboratory of Vascular Pathology, IIS-Fundación Jiménez Díaz, Madrid, Spain
- CIBERCV, Madrid, Spain
| | - Jose L. Martín-Ventura
- Laboratory of Vascular Pathology, IIS-Fundación Jiménez Díaz, Madrid, Spain
- CIBERCV, Madrid, Spain
- Medicine Department, Autonoma University of Madrid, Madrid, Spain
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12
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Liang KH, Chen CH, Tsai HR, Chang CY, Chen TL, Hsu WC. Association Between Oral Metformin Use and the Development of Age-Related Macular Degeneration in Diabetic Patients: A Systematic Review and Meta-Analysis. Invest Ophthalmol Vis Sci 2022; 63:10. [PMID: 36484633 DOI: 10.1167/iovs.63.13.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Purpose Metformin is a biguanide derivative that is commonly used for the treatment of diabetes mellitus (DM). It demonstrates antioxidative, anti-inflammatory, and antiangiogenic activity within the ocular tissue and thus may be implicated in the treatment of age-related macular degeneration (AMD). However, epidemiological studies have shown conflicting results. Methods The Ovid MEDLINE/Embase, Cochrane Library, and Web of Science databases were systematically searched from inception through August 3, 2022. Studies reporting the association between metformin use and odds of AMD were enrolled. Adjusted odds ratios (ORs) of AMD were extracted and pooled with random-effects model meta-analysis. Subgroup analyses based on AMD subtypes, ethnicity, study design, sex, and confirmation of AMD diagnosis were conducted. Results A total of 9 observational studies with 1,446,284 participants were included in the analysis. The meta-analysis showed that metformin use was associated with a significant reduction in the odds of AMD (pooled ORs = 0.81, 95% confidence interval [CI] = 0.70-0.93). Subgroup analyses revealed that metformin use was not significantly associated with dry or wet AMD. Black (pooled ORs = 0.61, 95% CI = 0.58-0.64) and Hispanic populations (pooled ORs = 0.85, 95% CI = 0.81-0.89) demonstrated significantly lower odds of AMD. Conclusions This systematic review and meta-analysis found that patients with DM with metformin usage were at lower odds of developing AMD. Future prospective clinical trials are needed to confirm this association.
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Affiliation(s)
- Kai-Hsiang Liang
- Department of Medical Education, Medical Administration Office, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Chih-Hao Chen
- Department of Otolaryngology, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Hou-Ren Tsai
- Department of Ophthalmology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Chun-Yu Chang
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Tai-Li Chen
- Department of Dermatology, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Wei-Cherng Hsu
- School of Medicine, Tzu Chi University, Hualien, Taiwan.,Department of Ophthalmology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
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13
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Gasparini P, Garofolo IC, Telles MM, Oyama LM, Veneza VDM, Moura Veiga TA, Flor Silveira VL, Caperuto LC. Bauhinia forficata link extract attenuates insulin resistance by preserving glucose uptake in gastrocnemius muscle. Nat Prod Res 2022; 37:2031-2036. [PMID: 35997243 DOI: 10.1080/14786419.2022.2113875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Bioactive metabolites from Bauhinia forficata Link (Bf extract) hold therapeutic potential for type 2 diabetes mellitus (T2DM) but the mechanism remains poorly understood. This study aimed to test the extract from Bf leaves obtained by decoction on the prevention of T2DM in vivo. The Bf extract was tested on a streptozotocin-induced T2DM mouse model fed on a high-fat diet. The insulin resistance was attenuated in T2DM animals supplemented with Bf extract, which indicates glucose intolerance reduction and p-AKT/AKT ratio preservation in the gastrocnemius muscle. These observations suggested that Bf extract enhanced glucose uptake. Nevertheless, there was no preservation in β-cell insulin secretion in Bf extract-treated T2DM mice. Interestingly, the Bf extract reduced body weight gain without affecting total energy intake. Hence, Bf extract has a hypoglycemic effect which could attenuate the development of insulin resistance.
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Affiliation(s)
- Patricia Gasparini
- Departamento de Ciências Biológicas; Instituto de Ciências Ambientais, Químicas e Farmacêuticas (ICAQF); Universidade Federal de São Paulo; Diadema, Brazil
| | - Ingrid Candido Garofolo
- Departamento de Ciências Biológicas; Instituto de Ciências Ambientais, Químicas e Farmacêuticas (ICAQF); Universidade Federal de São Paulo; Diadema, Brazil
| | - Monica Marques Telles
- Departamento de Ciências Biológicas; Instituto de Ciências Ambientais, Químicas e Farmacêuticas (ICAQF); Universidade Federal de São Paulo; Diadema, Brazil
| | - Lila Missae Oyama
- Departamento de Fisiologia, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Viviane de Mello Veneza
- Departamento de Química; Instituto de Ciências Ambientais, Químicas e Farmacêuticas (ICAQF); Universidade Federal de São Paulo, Diadema, Brazil
| | - Thiago André Moura Veiga
- Departamento de Química; Instituto de Ciências Ambientais, Químicas e Farmacêuticas (ICAQF); Universidade Federal de São Paulo, Diadema, Brazil
| | - Vera Lucia Flor Silveira
- Departamento de Ciências Biológicas; Instituto de Ciências Ambientais, Químicas e Farmacêuticas (ICAQF); Universidade Federal de São Paulo; Diadema, Brazil
| | - Luciana Chagas Caperuto
- Departamento de Ciências Biológicas; Instituto de Ciências Ambientais, Químicas e Farmacêuticas (ICAQF); Universidade Federal de São Paulo; Diadema, Brazil
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14
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Alfaraidi H, Samaan MC. Metformin therapy in pediatric type 2 diabetes mellitus and its comorbidities: A review. Front Endocrinol (Lausanne) 2022; 13:1072879. [PMID: 36814831 PMCID: PMC9939509 DOI: 10.3389/fendo.2022.1072879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/12/2022] [Indexed: 02/08/2023] Open
Abstract
Type 2 diabetes (T2D) rates in children and adolescents are rising globally. T2D is a complex and aggressive disease in children with several comorbidities, high treatment failure rates, and insulin needs within a few years from diagnosis. While myriads of pharmacotherapies are licensed to treat adults with T2D, treatments accessible to children and adolescents have been limited until recently. Metformin is an old drug with multiple beneficial metabolic health effects beyond glycemic control. This review discusses Metformin's origins, its mechanisms of action, and evidence for its use in the pediatric population to treat and prevent T2D. We also explore the evidence for its use as an obesity therapy, which is the primary driver of T2D, and T2D-driven comorbidities. While emerging therapies create new horizons for managing pediatric T2D, Metformin remains an inexpensive and safe part of the treatment plans of many T2D children globally for its beneficial metabolic effects.
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Affiliation(s)
- Haifa Alfaraidi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- Department of Pediatrics, King Abdullah Specialized Children’s Hospital, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - M. Constantine Samaan
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- Division of Pediatric Endocrinology, McMaster Children’s Hospital, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Michael G. De Groote School of Medicine, McMaster University, Hamilton, ON, Canada
- *Correspondence: M. Constantine Samaan,
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