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Chan JCN, Yang A, Chu N, Chow E. Current type 2 diabetes guidelines: Individualized treatment and how to make the most of metformin. Diabetes Obes Metab 2024; 26 Suppl 3:55-74. [PMID: 38992869 DOI: 10.1111/dom.15700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 05/24/2024] [Accepted: 05/24/2024] [Indexed: 07/13/2024]
Abstract
Evidence-based guidelines provide the premise for the delivery of quality care to preserve health and prevent disabilities and premature death. The systematic gathering of observational, mechanistic and experimental data contributes to the hierarchy of evidence used to guide clinical practice. In the field of diabetes, metformin was discovered more than 100 years ago, and with 60 years of clinical use, it has stood the test of time regarding its value in the prevention and management of type 2 diabetes. Although some guidelines have challenged the role of metformin as the first-line glucose-lowering drug, it is important to point out that the cardiovascular-renal protective effects of sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide-1 receptor agonists were gathered from patients with type 2 diabetes, the majority of whom were treated with metformin. Most national, regional and international guidelines recommend metformin as a foundation therapy with emphasis on avoidance of therapeutic inertia and early attainment of multiple treatment goals. Moreover, real-world evidence has confirmed the glucose-lowering and cardiovascular-renal benefits of metformin accompanied by an extremely low risk of lactic acidosis. In patients with type 2 diabetes and advanced chronic kidney disease (estimated glomerular filtration rate 15-30 mL/min/1.73m2), metformin discontinuation was associated with an increased risk of cardiovascular-renal events compared with metformin persistence. Meanwhile, it is understood that microbiota, nutrients and metformin can interact through the gut-brain-kidney axis to modulate homeostasis of bioactive molecules, systemic inflammation and energy metabolism. While these biological changes contribute to the multisystem effects of metformin, they may also explain the gastrointestinal side effects and vitamin B12 deficiency associated with metformin intolerance. By understanding the interactions between metformin, foods and microbiota, healthcare professionals are in a better position to optimize the use of metformin and mitigate potential side effects. The United Kingdom Prospective Diabetes Study and the Da Qing Diabetes Prevention Program commenced 40 years ago provided the first evidence that type 2 diabetes is preventable and treatable. To drive real-world impact from this evidence, payors, practitioners and planners need to co-design and implement an integrated, data-driven, metformin-based programme to detect people with undiagnosed diabetes and prediabetes (intermediate hyperglycaemia), notably impaired glucose tolerance, for early intervention. The systematic data collection will create real-world evidence to bring out the best of metformin and make healthcare sustainable, affordable and accessible.
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Affiliation(s)
- Juliana C N Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
- Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Aimin Yang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
- Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Natural Chu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
- Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Elaine Chow
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
- Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
- Phase 1 Clinical Trial Centre, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
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Tocci V, Mirabelli M, Salatino A, Sicilia L, Giuliano S, Brunetti FS, Chiefari E, De Sarro G, Foti DP, Brunetti A. Metformin in Gestational Diabetes Mellitus: To Use or Not to Use, That Is the Question. Pharmaceuticals (Basel) 2023; 16:1318. [PMID: 37765126 PMCID: PMC10537239 DOI: 10.3390/ph16091318] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/12/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
In recent years, there has been a dramatic increase in the number of pregnancies complicated by gestational diabetes mellitus (GDM). GDM occurs when maternal insulin resistance develops and/or progresses during gestation, and it is not compensated by a rise in maternal insulin secretion. If not properly managed, this condition can cause serious short-term and long-term problems for both mother and child. Lifestyle changes are the first line of treatment for GDM, but if ineffective, insulin injections are the recommended pharmacological treatment choice. Some guidance authorities and scientific societies have proposed the use of metformin as an alternative pharmacological option for treating GDM, but there is not yet a unanimous consensus on this. Although the use of metformin appears to be safe for the mother, concerns remain about its long-term metabolic effects on the child that is exposed in utero to the drug, given that metformin, contrary to insulin, crosses the placenta. This review article describes the existing lines of evidence about the use of metformin in pregnancies complicated by GDM, in order to clarify its potential benefits and limits, and to help clinicians make decisions about who could benefit most from this drug treatment.
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Affiliation(s)
- Vera Tocci
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
- Operative Unit of Endocrinology, Diabetes in Pregnancy Ambulatory Care Center, Renato Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Maria Mirabelli
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
- Operative Unit of Endocrinology, Diabetes in Pregnancy Ambulatory Care Center, Renato Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Alessandro Salatino
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
| | - Luciana Sicilia
- Operative Unit of Endocrinology, Diabetes in Pregnancy Ambulatory Care Center, Renato Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Stefania Giuliano
- Operative Unit of Endocrinology, Diabetes in Pregnancy Ambulatory Care Center, Renato Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Francesco S. Brunetti
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
| | - Eusebio Chiefari
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
| | - Giovambattista De Sarro
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
| | - Daniela P. Foti
- Department of Experimental and Clinical Medicine, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy;
| | - Antonio Brunetti
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
- Operative Unit of Endocrinology, Diabetes in Pregnancy Ambulatory Care Center, Renato Dulbecco University Hospital, 88100 Catanzaro, Italy
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Clemmensen KKB, Blond MB, Amadid H, Bruhn L, Vistisen D, Karstoft K, Persson F, Ried-Larsen M, Holst JJ, Wewer Albrechtsen NJ, Torekov SS, Quist JS, Jørgensen ME, Faerch K. No effects of dapagliflozin, metformin or exercise on plasma glucagon concentrations in individuals with prediabetes: A post hoc analysis from the randomized controlled PRE-D trial. Diabetes Obes Metab 2021; 23:530-539. [PMID: 33146457 DOI: 10.1111/dom.14246] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/22/2020] [Accepted: 11/01/2020] [Indexed: 02/06/2023]
Abstract
AIM To assess the effects of dapagliflozin, metformin and exercise treatment on changes in plasma glucagon concentrations in individuals with overweight and HbA1c-defined prediabetes. MATERIALS AND METHODS One-hundred and twenty individuals with overweight (body mass index ≥ 25 kg/m2 ) and prediabetes (HbA1c of 39-47 mmol/mol) were randomized to a 13-week intervention with dapagliflozin (10 mg once daily), metformin (850 mg twice daily), exercise (30 minutes of interval training 5 days per week) or control (habitual living). A 75-g oral glucose tolerance test (OGTT) (0, 30, 60 and 120 minutes) was administered at baseline, at 13 weeks (end of intervention) and at 26 weeks (end of follow-up). Linear mixed effects models with participant-specific random intercepts were used to investigate associations of the interventions with fasting plasma glucagon concentration, insulin/glucagon ratio and glucagon suppression during the OGTT. RESULTS At baseline, the median (Q1; Q3) age was 62 (54; 68) years, median fasting plasma glucagon concentration was 11 (7; 15) pmol/L, mean (SD) HbA1c was 40.9 (2.3) mmol/mol and 56% were women. Compared with the control group, fasting glucagon did not change in any of the groups from baseline to the end of the intervention (dapagliflozin group: -5% [95% CI: -29; 26]; exercise group: -8% [95% CI: -31; 24]; metformin group: -2% [95% CI: -27; 30]). Likewise, there were no differences in insulin/glucagon ratio and glucagon suppression during the OGTT between the groups. CONCLUSIONS In individuals with prediabetes, 13 weeks of treatment with dapagliflozin, metformin or exercise was not associated with changes in fasting or post-OGTT glucagon concentrations.
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Affiliation(s)
| | | | - Hanan Amadid
- Steno Diabetes Center Copenhagen, Copenhagen, Denmark
| | - Lea Bruhn
- Steno Diabetes Center Copenhagen, Copenhagen, Denmark
| | | | - Kristian Karstoft
- The Centre of Inflammation and Metabolism and the Centre for Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Pharmacology, Bispebjerg-Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Mathias Ried-Larsen
- The Centre of Inflammation and Metabolism and the Centre for Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jens J Holst
- NNF Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nicolai J Wewer Albrechtsen
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Biochemistry, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Signe S Torekov
- NNF Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jonas S Quist
- Steno Diabetes Center Copenhagen, Copenhagen, Denmark
| | - Marit E Jørgensen
- Steno Diabetes Center Copenhagen, Copenhagen, Denmark
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Kristine Faerch
- Steno Diabetes Center Copenhagen, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
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van Meijel LA, de Vegt F, Abbink EJ, Rutters F, Schram MT, van der Klauw MM, Wolffenbuttel BHR, Siegelaar S, DeVries JH, Sijbrands EJG, Özcan B, de Valk HW, Silvius B, Schaper N, Stehouwer CDA, Elders PJM, Tack CJ, de Galan BE. High prevalence of impaired awareness of hypoglycemia and severe hypoglycemia among people with insulin-treated type 2 diabetes: The Dutch Diabetes Pearl Cohort. BMJ Open Diabetes Res Care 2020; 8:8/1/e000935. [PMID: 32107264 PMCID: PMC7206921 DOI: 10.1136/bmjdrc-2019-000935] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/03/2019] [Accepted: 12/15/2019] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE People with type 2 diabetes on insulin are at risk for hypoglycemia. Recurrent hypoglycemia can cause impaired awareness of hypoglycemia (IAH), and increase the risk for severe hypoglycemia. The aim of this study was to assess the prevalence and determinants of self-reported IAH and severe hypoglycemia in a Dutch nationwide cohort of people with insulin-treated type 2 diabetes. RESEARCH DESIGN AND METHODS Observational study of The Dutch Diabetes Pearl, a cohort of people with type 2 diabetes treated in primary, secondary and tertiary diabetes care centers. The presence of IAH and the occurrence of severe hypoglycemia in the past year, defined as an event requiring external help to recover, were assessed using the validated Dutch version of the Clarke questionnaire. In addition, clinical variables were collected including age, diabetes duration, hemoglobin A1c, ethnicity and education. RESULTS 2350 people with type 2 diabetes on insulin were included: 59.1% men, mean age 61.1±10.4 years, mean diabetes duration 14.8±9.2 years and 79.5% on basal-bolus therapy. A total of 229 patients (9.7%) were classified as having IAH and 742 patients (31.6%) reported severe hypoglycemia. Increased odds for IAH were found with complex insulin regimens and lower odds with having a partner and body mass index ≥30 kg/m2. Severe hypoglycemia was associated with complex insulin regimens, non-Caucasian ethnicity and use of psychoactive drugs, and inversely with metformin use. CONCLUSIONS In this nationwide cohort, almost one out of ten people with type 2 diabetes on insulin had IAH and >30% had a history of severe hypoglycemia in the past year.
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Affiliation(s)
- Lian A van Meijel
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Femmie de Vegt
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Evertine J Abbink
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Femke Rutters
- Department of Epidemiology & Biostatistics, Amsterdam UMC - Locatie VUMC, Amsterdam, The Netherlands
| | - Miranda T Schram
- Department of Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Melanie M van der Klauw
- Department of Endocrinology, University Medical Center Groningen, Groningen, The Netherlands
| | - Bruce H R Wolffenbuttel
- Department of Endocrinology, University Medical Center Groningen, Groningen, The Netherlands
| | - Sarah Siegelaar
- Department of Internal Medicine, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - J Hans DeVries
- Department of Internal Medicine, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | | | - Behiye Özcan
- Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Harold W de Valk
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bianca Silvius
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nicolaas Schaper
- Department of Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Coen D A Stehouwer
- Department of Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Petra J M Elders
- Department of General Practice and Elderly Care, Amsterdam Public Health Research Institute, Amsterdam UMC - Locatie VUMC, Amsterdam, The Netherlands
| | - Cornelis J Tack
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bastiaan E de Galan
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
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Shen X, Fan B, Hu X, Luo L, Yan Y, Yang L. Metformin Reduces Lipotoxicity-Induced Meta-Inflammation in β-Cells through the Activation of GPR40-PLC-IP3 Pathway. J Diabetes Res 2019; 2019:7602427. [PMID: 31950065 PMCID: PMC6948338 DOI: 10.1155/2019/7602427] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 08/01/2019] [Accepted: 09/04/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND AND PURPOSE Metformin, a widely used antidiabetic drug, has been shown to have anti-inflammatory properties; nevertheless, its influence on β-cell meta-inflammation remains unclear. The following study investigated the effects of metformin on meta-inflammatory in β-cells and whether the underlying mechanisms were associated with the G protein-coupled receptor 40-phospholipase C-inositol 1, 4, 5-trisphosphate (GPR40-PLC-IP3) pathway. MATERIALS AND METHODS Lipotoxicity-induced β-cells and the high-fat diet-induced obese rat model were used in the study. RESULTS Metformin-reduced lipotoxicity-induced β-cell meta-inflammatory injury was associated with the expression of GPR40. GPR40 was involved in metformin reversing metabolic inflammation key marker TLR4 activation-mediated β-cell injury. Furthermore, downstream signaling protein PLC-IP3 of GPR40 was involved in the protective effect of metformin on meta-inflammation, and the above process of metformin was partially regulated by AMPK activity. In addition, the anti-inflammatory effects of metformin were observed in obese rats. CONCLUSION Metformin can reduce lipotoxicity-induced meta-inflammation in β-cells through the regulation of the GPR40-PLC-IP3 pathway and partially via the regulation of AMPK activity.
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Affiliation(s)
- Ximei Shen
- Endocrinology Department, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005 Fujian, China
- Diabetes Research Institute of Fujian Province, Fuzhou, 350005 Fujian, China
| | - Beibei Fan
- Endocrinology Department, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005 Fujian, China
| | - Xin Hu
- Endocrinology Department, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005 Fujian, China
| | - Liufen Luo
- Endocrinology Department, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005 Fujian, China
| | - Yuanli Yan
- Endocrinology Department, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005 Fujian, China
| | - Liyong Yang
- Endocrinology Department, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005 Fujian, China
- Diabetes Research Institute of Fujian Province, Fuzhou, 350005 Fujian, China
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Glycemic increase induced by intravenous glucose infusion fails to affect hunger, appetite, or satiety following breakfast in healthy men. Appetite 2016; 105:562-6. [DOI: 10.1016/j.appet.2016.06.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 06/24/2016] [Accepted: 06/25/2016] [Indexed: 11/20/2022]
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Abstract
We describe a case of hypoglycaemia induced by exercise in a patient with type 2 diabetes taking metformin, who was not taking insulin or sulphonylurea medication. The hypoglycaemia resolved after the dosage of metformin was reduced, despite increased physical activity. A brief review of the literature identifying the frequency of and risk factors for hypoglycaemia during treatment with metformin is discussed.
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Affiliation(s)
- Abdullah Omari
- Diabetes Centre and Department of Endocrinology, Royal Prince Alfred Hospital, Missenden Road, Camperdown NSW 2005, Australia
| | - Dennis K Yue
- Diabetes Centre and Department of Endocrinology, Royal Prince Alfred Hospital, Missenden Road, Camperdown NSW 2005, Australia, Discipline of Medicine, University of Sydney, NSW 2006, Australia
| | - Stephen M Twigg
- Diabetes Centre and Department of Endocrinology, Royal Prince Alfred Hospital, Missenden Road, Camperdown NSW 2005, Australia, , Discipline of Medicine, University of Sydney, NSW 2006, Australia
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Abstract
Metformin has been the mainstay of therapy for diabetes mellitus for many years; however, the mechanistic aspects of metformin action remained ill-defined. Recent advances revealed that this drug, in addition to its glucose-lowering action, might be promising for specifically targeting metabolic differences between normal and abnormal metabolic signalling. The knowledge gained from dissecting the principal mechanisms by which metformin works can help us to develop novel treatments. The centre of metformin's mechanism of action is the alteration of the energy metabolism of the cell. Metformin exerts its prevailing, glucose-lowering effect by inhibiting hepatic gluconeogenesis and opposing the action of glucagon. The inhibition of mitochondrial complex I results in defective cAMP and protein kinase A signalling in response to glucagon. Stimulation of 5'-AMP-activated protein kinase, although dispensable for the glucose-lowering effect of metformin, confers insulin sensitivity, mainly by modulating lipid metabolism. Metformin might influence tumourigenesis, both indirectly, through the systemic reduction of insulin levels, and directly, via the induction of energetic stress; however, these effects require further investigation. Here, we discuss the updated understanding of the antigluconeogenic action of metformin in the liver and the implications of the discoveries of metformin targets for the treatment of diabetes mellitus and cancer.
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Affiliation(s)
- Ida Pernicova
- Department of Endocrinology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London EC1A 6BQ, UK
| | - Márta Korbonits
- Department of Endocrinology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London EC1A 6BQ, UK
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Dejager S, Schweizer A. Minimizing the risk of hypoglycemia with vildagliptin: Clinical experience, mechanistic basis, and importance in type 2 diabetes management. Diabetes Ther 2011; 2:51-66. [PMID: 22127800 PMCID: PMC3144769 DOI: 10.1007/s13300-010-0018-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Indexed: 12/28/2022] Open
Abstract
Even if the true incidence of hypoglycemia in type 2 diabetes mellitus (T2DM) remains difficult to estimate, with highly variable rates reported in the literature, it is likely more common than previously thought. While most hypoglycemic episodes in T2DM are considered "mild," they still have a substantial clinical impact. Severe hypoglycemia also exists in T2DM, with recent landmark studies prompting much debate about the potential role of severe hypoglycemia in cardiovascular morbidity and mortality, even though there is currently no definitive evidence for causality. The challenge in the treatment of T2DM remains the achievement of optimal glycemic control to lower the risk for long-term complications while avoiding hypoglycemia. Successful treatment strategies should therefore include careful selection of therapies to prevent hypoglycemia, starting early in the disease management process, in order to best preserve counterregulation. The dipeptidyl peptidase-4 inhibitor, vildagliptin, is a good treatment option to minimize the risk of hypoglycemia over time, while maintaining good glucose control. Extensive clinical experience is available for vildagliptin, with data published for all stages of the condition and with the low hypoglycemic potential stemming from a solid mechanistic basis.
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Affiliation(s)
- Sylvie Dejager
- Novartis Pharma S.A.S, Clinical Research & Development, 2/4, Rue Lionel Terray, F-92500, Rueil-Malmaison, France,
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Schmid SM, Jauch-Chara K, Hallschmid M, Schultes B. Mild sleep restriction acutely reduces plasma glucagon levels in healthy men. J Clin Endocrinol Metab 2009; 94:5169-73. [PMID: 19837925 DOI: 10.1210/jc.2009-0969] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
BACKGROUND Sleep loss has repeatedly been suggested to affect glucose metabolism adversely, raising the question as to the impact of subtle forms of sleep loss. OBJECTIVE The aim of the study was to assess the effects of a single night of sleep restriction to 4.5 h on endocrine parameters of glucose metabolism. DESIGN We conducted crossover, balanced experiments including two conditions, i.e. one night of 4.5 h and one night of 7 h of sleep. SUBJECTS AND MEASUREMENTS In 10 healthy men, circulating concentrations of insulin, C-peptide, epinephrine, norepinephrine, GH, ACTH, cortisol, and glucagon were measured after sleep and sleep restriction, respectively, during basal rest and a subsequent stepwise hypoglycemic clamp. RESULTS Mild sleep restriction induced a robust reduction in basal plasma glucagon levels that persisted throughout the hypoglycemic clamp (P < 0.03). Basal glucose, insulin, and C-peptide levels were unaffected by sleep restriction. Also, basal and hypoglycemia-stimulated concentrations of epinephrine, norepinephrine, and GH were unchanged after sleep restriction. Concentrations of ACTH (P < 0.05) and cortisol (P < 0.001) were reduced after sleep loss during baseline and at the start of hypoglycemia, but reached roughly comparable levels in both conditions at the end of the clamp (ACTH, P > 0.06; cortisol, P > 0.93). CONCLUSION Our data show that mild restriction of nocturnal sleep to 4.5 h has a reducing effect on circulating glucagon levels. This finding provides further evidence for the notion that glucose homeostasis is sensitive to subtle changes in sleep duration.
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Affiliation(s)
- Sebastian M Schmid
- Department of Internal Medicine I, University of Luebeck, D-23538 Luebeck, Germany
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Schmid SM, Hallschmid M, Jauch-Chara K, Bandorf N, Born J, Schultes B. Sleep loss alters basal metabolic hormone secretion and modulates the dynamic counterregulatory response to hypoglycemia. J Clin Endocrinol Metab 2007; 92:3044-51. [PMID: 17519315 DOI: 10.1210/jc.2006-2788] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Sleep loss has immediate effects on metabolic function that in the long run may contribute to the development of obesity and type 2 diabetes. OBJECTIVE Our objective was to explore the neuroendocrine mechanisms mediating the acute effects of sleep deprivation on blood glucose regulation under basal and hypoglycemic conditions. METHODS In a randomized, crossover study in 10 healthy young men, plasma concentrations of relevant hormones were examined during basal rest, a subsequent stepwise hypoglycemic clamp after one night of total sleep deprivation (SD) and one night of regular sleep. RESULTS Basal glucagon concentrations were decreased (P = 0.022) and C-peptide levels were slightly reduced after SD (P = 0.085), compared with regular sleep. During hypoglycemia after SD, the glucagon increase relative to baseline was enhanced (P = 0.034) and the relative decrease in C-peptide was reduced (P = 0.013). Also, the relative increase in norepinephrine was reduced (P = 0.031). SD did not affect epinephrine, ACTH, cortisol, lactate, beta-hydroxybutyrate, or nonesterified fatty acids during hypoglycemia, but overall, plasma nonesterified fatty acid levels were reduced after SD (P = 0.009). SD markedly increased rated hunger during basal rest (P < 0.008), resulting in a dampened relative increase during hypoglycemia (P < 0.009). Unexpectedly, despite distinct alterations in basal secretory activity, the absolute amplitude of hormonal counterregulation and hunger responses to hypoglycemia was not affected by SD. CONCLUSION Short-term SD distinctly alters hormonal glucose regulation, affecting especially pancreatic islet secretion, and also increases hunger. Immediate perturbations in the dynamic regulation of energy metabolism caused by acute sleep curtailment may contribute to the association between chronic sleep loss and metabolic disorders.
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Schultes B, Oltmanns KM, Kern W, Fehm HL, Born J, Peters A. Modulation of hunger by plasma glucose and metformin. J Clin Endocrinol Metab 2003; 88:1133-41. [PMID: 12629096 DOI: 10.1210/jc.2002-021450] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
The plasma glucose concentration is a major short-term regulator of hunger and food intake. In patients with diabetes, therapies lowering plasma glucose are frequently associated with body weight gain, suggesting that lowered plasma glucose leads to increased feelings of hunger and food intake. However, as many physiological and symptomatic responses to low plasma glucose are attenuated after repeated episodes of hypoglycemia, this may also pertain to feelings of hunger. Here we tested whether the stimulatory effect of low plasma glucose on feelings of hunger is likewise reduced by repeated episodes of hypoglycemia. As metformin has been shown to reduce plasma glucose levels without increasing body weight and also to decrease food intake, we tested for possible interacting effects of this substance with hypoglycemia-induced hunger. Feelings of hunger were assessed by rating scales during 3 consecutive hypoglycemic clamps performed on 2 consecutive d in 15 normal weight men. Subjects were tested once while being treated with 850 mg metformin twice daily and once while receiving placebo. Treatment was started 14 d before the clamp experiments and was performed in a random order and double-blind fashion. Hypoglycemia markedly enhanced feelings of hunger (P < 0.001). However, rated feelings of hunger on the first and last hypoglycemic clamps were comparable (P = 0.304). Compared with placebo, metformin decreased feelings of hunger during hypoglycemia (P = 0.015). This reduction was not associated with a decrease in posthypoglycemic food intake as measured by the number of cookies consumed after the last clamp (P = 0.676). Data indicate that the stimulatory effect of low plasma glucose on hunger is not attenuated after repeated episodes of hypoglycemia, which implies that, in contrast to other symptoms, hunger is not subject to adaptive attenuation upon repeated hypoglycemia. Metformin attenuates hypoglycemia-induced hunger, but does not appear to influence posthypoglycemic food intake.
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Affiliation(s)
- Bernd Schultes
- Department of Internal Medicine I, University of Luebeck, D-23538 Luebeck, Germany.
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Ashwell CM, McMurtry JP. Hypoglycemia and reduced feed intake in broiler chickens treated with metformin. Poult Sci 2003; 82:106-10. [PMID: 12580251 DOI: 10.1093/ps/82.1.106] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The bi-guanide metformin is used to treat noninsulin dependent diabetes in obese patients. In addition to having antihyperglycemic effects, metformin is also anorectic and reduces BW. These studies were performed to determine if metformin possesses similar properties in chickens. Metformin-HCl was administered to 14-day-old broiler chickens at either 300 or 600 mg/kg per day in the drinking water for 10 d while monitoring BW and feed intake. No changes in water intake were observed, while feed intake and daily gains were only significantly reduced by the 600 mg/kg dose. After oral administration of a single dose of 300 mg/kg metformin-HCl, feed intake was significantly reduced by 4 h and remained suppressed for greater than 24 h relative to controls. Plasma hormones and metabolites (glucose, lactate, insulin, glucagon, uric acid, nonesterified fatty acid, and triglycerides) were monitored at 1, 2, 3, 6, and 24 h posttreatment. Significant and acute decreases in blood glucose, insulin, and triglycerides were observed at 3 h posttreatment as compared to controls. Opposing acute increases in glucagon and NEFA levels were also observed at 3 h followed by an increase in uric add 6 h posttreatment. These observations suggest that metformin induces metabolic changes in birds, similar to that observed in mammals and may act in a common manner. Metformin-HCl may be useful in glucose metabolism studies by inducing hypoglycemia, a condition rarely observed in birds.
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Affiliation(s)
- C M Ashwell
- Growth Biology Laboratory, USDA-ARS, 10300 Baltimore Ave., Beltsville, Maryland 20705, USA.
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