Finding the sweet spot for metformin in 18F-FDG-PET

The effect of additional acarbose on metformin-associated artificially high 18F-Fluorodeoxyglucose uptake in positron emission tomography/computed tomography

AIM

Metformin causes diffuse and intense fluorodeoxyglucose (FDG) uptake more frequently in the colon and less frequently in the small intestine. In this study, we aimed to investigate the effect of simultaneous use of acarbose and metformin on FDG uptake in positron emission tomography/computed tomography (PET/CT), which has not been investigated previously.

METHODS

Totally 145 patients with a median age of 65 years (range: 18-80 years), who underwent FDG PET/CT in the Department of Nuclear Medicine of Erciyes University Medical School between 2018 and 2021, were involved in the study. The patients undergoing PET/CT were categorized as metformin plus acarbose users (group MA), metformin users (group M), and control subjects without diabetes (group C). The maximum and mean standard uptake values (SUVmax and SUVmean) of FDG uptake of the all intestine segments were measured separately.

RESULTS

The number of participants in each group was 35, 51 and 59 in group MA, group M and group C, respectively. The FDG uptake of all intestine was significantly higher in group MA and group M than in group C. The FDG uptake of ascending, transverse, descending, and sigmoid colon was significantly lower in group MA than in group M. The FDG uptake of the small intestine was not different between group MA and group M. The FDG uptake of the rectum was lower in group MA than group M and it was significant for SUVmean, but not significant for SUVmax.

CONCLUSION

The addition of acarbose to metformin therapy decreased SUV and artificially high FDG uptake in the colon and may be an alternative recommendation to discontinuing metformin in patients going to PET/CT imaging.

Effect of metformin on 18F-fluorodeoxyglucose uptake and positron emission tomographic imaging

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.