Impact of metformin on tyrosine kinase inhibitor response in chronic myeloid leukemia

Metformin in Combination with Standard Therapy in Patients with Diffuse Large B-Cell Lymphoma: A Randomized Phase II Clinical Trial

BACKGROUND

Metformin has been shown to have antitumor activity in different tumor types. In DLBCL (Diffuse large B cell lymphoma), using metformin with front-line chemotherapy & immunotherapy resulted in improved clinical outcomes.

OBJECTIVES

To assess the effectiveness of incorporating metformin into the standard initial treatment regimen of R-CHOP for patients with DLBCL. The evaluation metrics included response rate, toxicity, progression-free survival (PFS), and overall survival (OS).

PATIENTS AND METHODS

This prospective phase 2 trial included 100 adult patients with histopathological evidence of DLBCL, eligible for first-line treatment with R-CHOP, life expectancy of at least 6 months, and performance status (PS) ≤ 2. Patients were randomized to receive either metformin plus R-CHOP or R-CHOP alone.

RESULTS

Each group included 50 patients. The metformin arm had more females than the standard arm (p=0.016). Nausea was significantly higher in the test arm than the standard arm (p=0.008). Metformin group had higher rates of complete remission (CR) at the end of treatment (92% vs 74%; p=0.017), lower rates of relapse/progression (10% vs 36%; p=0.002), and lower rates of overall mortality (4% vs 20%; p=0.014). The mean disease-free survival (DFS) was 24.5 months in the metformin group versus 20.2 months in the control arm (p=0.023). Likewise, the mean progression-free survival (PFS) was 25.91 versus 19.81 months and the mean overall survival (OS) was 27.39 versus 23.8 months (p-values= 0.002, and 0.013 respectively). By multivariate analysis of response and relapse, the use of metformin was an independent prognostic factor of CR and relapse.

CONCLUSIONS

The addition of metformin to standard R-CHOP could improve clinical outcomes in patients with DLBCL with a tolerable safety profile.

Research Progress on the Use of Metformin in Leukemia Treatment

OPINION STATEMENT

Metformin is a first-line drug in the clinical treatment of type 2 diabetes. Its main molecular mechanism involves the activation of adenosine 5'-monophosphate-activated protein kinase (AMPK), which regulates cell energy metabolism. Many clinical studies have shown that metformin can reduce the incidence and mortality of cancer in patients with or without diabetes. In vitro studies also confirmed that metformin can inhibit proliferation, promote apoptosis, and enhance the response of cells to chemical drugs and other anticancer effects on a variety of leukemia cells. In recent years, leukemia has become one of the most common malignant diseases. Although great progress has been made in therapeutic approaches for leukemia, novel drugs and better treatments are still needed to improve the therapeutic efficacy of these treatments. This article reviews the application status and possible mechanism of metformin in the treatment of leukemia to further understand the anticancer mechanism of metformin and expand its clinical application.

Repurposing Metformin in hematologic tumor: State of art

Metformin is an ancient drug for the treatment of type 2 diabetes, and many studies now suggested that metformin can be used as an adjuvant drug in the treatment of many types of tumors. The mechanism of action of metformin for tumor treatment mainly involves: 1. activation of AMPK signaling pathway 2. inhibition of DNA damage repair in tumor cells 3. downregulation of IGF-1 expression 4. inhibition of chemoresistance and enhancement of chemotherapy sensitivity in tumor cells 5. enhancement of antitumor immunity 6. inhibition of oxidative phosphorylation (OXPHOS). Metformin also plays an important role in the treatment of hematologic tumors, especially in leukemia, lymphoma, and multiple myeloma (MM). The combination of metformin and chemotherapy enhances the efficacy of chemotherapy, and metformin reduces the progression of monoclonal gammopathy of undetermined significance (MGUS) to MM. The purpose of this review is to summarize the anticancer mechanism of metformin and the role and mechanism of action of metformin in hematologic tumors. We mainly summarize the studies related to metformin in hematologic tumors, including cellular experiments and animal experiments, as well as controlled clinical studies and clinical trials. In addition, we also focus on the possible side effects of metformin. Although a large number of preclinical and clinical studies have been performed and the role of metformin in preventing the progression of MGUS to MM has been demonstrated, metformin has not been approved for the treatment of hematologic tumors, which is related to the adverse effects of its high-dose application. Low-dose metformin reduces adverse effects and has been shown to alter the tumor microenvironment and enhance antitumor immune response, which is one of the main directions for future research.

Action Mechanism of Metformin and Its Application in Hematological Malignancy Treatments: A Review

Hematologic malignancies (HMs) mainly include acute and chronic leukemia, lymphoma, myeloma and other heterogeneous tumors that seriously threaten human life and health. The common effective treatments are radiotherapy, chemotherapy and hematopoietic stem cell transplantation (HSCT), which have limited options and are prone to tumor recurrence and (or) drug resistance. Metformin is the first-line drug for the treatment of type 2 diabetes (T2DM). Recently, studies identified the potential anti-cancer ability of metformin in both T2DM patients and patients that are non-diabetic. The latest epidemiological and preclinical studies suggested a potential benefit of metformin in the prevention and treatment of patients with HM. The mechanism may involve the activation of the adenosine monophosphate-activated protein kinase (AMPK) signaling pathway by metformin as well as other AMPK-independent pathways to exert anti-cancer properties. In addition, combining current conventional anti-cancer drugs with metformin may improve the efficacy and reduce adverse drug reactions. Therefore, metformin can also be used as an adjuvant therapeutic agent for HM. This paper highlights the anti-hyperglycemic effects and potential anti-cancer effects of metformin, and also compiles the in vitro and clinical trials of metformin as an anti-cancer and chemosensitizing agent for the treatment of HM. The need for future research on the use of metformin in the treatment of HM is indicated.

Metformin and Cancer, an Ambiguanidous Relationship

The deregulation of energetic and cellular metabolism is a signature of cancer cells. Thus, drugs targeting cancer cell metabolism may have promising therapeutic potential. Previous reports demonstrate that the widely used normoglycemic agent, metformin, can decrease the risk of cancer in type 2 diabetics and inhibit cell growth in various cancers, including pancreatic, colon, prostate, ovarian, and breast cancer. While metformin is a known adenosine monophosphate-activated protein kinase (AMPK) agonist and an inhibitor of the electron transport chain complex I, its mechanism of action in cancer cells as well as its effect on cancer metabolism is not clearly established. In this review, we will give an update on the role of metformin as an antitumoral agent and detail relevant evidence on the potential use and mechanisms of action of metformin in cancer. Analyzing antitumoral, signaling, and metabolic impacts of metformin on cancer cells may provide promising new therapeutic strategies in oncology.