Long-term metformin therapy and vitamin B12 deficiency: An association to bear in mind

Glycation in Alzheimer's Disease and Type 2 Diabetes: The Prospect of Dual Drug Approaches for Therapeutic Interventions

As global life expectancy increases, the prevalence of neurodegenerative diseases like Alzheimer's disease (AD) continues to rise. Since therapeutic options are minimal, a deeper understanding of the pathophysiology is essential for improved diagnosis and treatments. AD is marked by the aggregation of Aβ proteins, tau hyperphosphorylation, and progressive neuronal loss, though its precise origins remain poorly understood. Meanwhile, type 2 diabetes mellitus (T2DM) is characterized by chronic hyperglycemia, leading to the formation of advanced glycation end products (AGEs), which are implicated in tissue damage and neurotoxicity. These AGEs can be resistant to proteolysis and, therefore, accumulate, exacerbating AD pathology and accelerating neurodegeneration. Insulin resistance, a hallmark of T2DM, further complicates AD pathogenesis by promoting tau hyperphosphorylation and Aβ plaque accumulation. Additionally, gut microbiome dysbiosis in T2DM fosters AGE accumulation and neuroinflammation, underscoring the intricate relationship between metabolic disorders, gut health, and neurodegenerative processes. This complex interplay presents both a challenge and a potential avenue for therapeutic intervention. Emerging evidence suggests that antidiabetic medications may offer cognitive benefits in AD, as well as in other neurodegenerative conditions, pointing to a shared pathophysiology. Thus, we posit that targeting AGEs, insulin signaling, and gut microbiota dynamics presents promising opportunities for innovative treatment approaches in AD and T2DM.

Association between vitamin B12 deficiency and metformin use in type 2 diabetic patients: a cross-sectional study in a South Vietnam tertiary hospital

OBJECTIVES

Vitamin B12 deficiency is a common and neglected adverse effect experienced by type 2 diabetic patients treated with metformin. A lack of vitamin B12 may have severe consequences, such as fatigue, macrocytic anaemia and worsened peripheral diabetic neuropathy. This study aims to identify the rate of vitamin B12 deficiency and the associated factors in type 2 diabetic patients treated with metformin.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

This study involved 145 type 2 diabetic patients treated with metformin in Cho Ray hospital, a tertiary healthcare centre in South Vietnam. The levels of vitamin B12 and associated clinical and paraclinical parameters were measured and collected.

RESULTS

The study population's mean age was 61.5 years, of which 51.7% were women. The median duration of metformin use was 10 years, and the median metformin dose was 1700 mg. The vitamin B12 deficiency rate was 22.1%. HbA1c, duration of metformin use and metformin dose were independent factors statistically associated with vitamin B12 deficiency.

CONCLUSIONS

This study identified the rate of vitamin B12 deficiency and associated factors in type 2 diabetic patients treated with metformin. These findings can be helpful in screening patients and replacing vitamin B12 in high-risk populations with vitamin B12 deficiency.

TRIAL REGISTRATION NUMBER

Ethical Committee of Cho Ray Hospital (approval number 1711/CN-HĐĐĐ).

Impact of Metformin Therapy on Vitamin B12 Levels in Patients With Type 2 Diabetes Mellitus

INTRODUCTION

Diabetes mellitus (DM) is a serious health condition affecting people worldwide with a high prevalence rate. DM is classified according to its aetiology into type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM); several risk factors contribute to the development of T2DM, such as age, genetic predisposition and obesity. Metformin is a proven drug of choice, and it is used as a first-line treatment for patients with T2DM to improve their glycaemic levels. Vitamin B12 is an important water-soluble vitamin, and its deficiency can lead to megaloblastic anaemia.

MATERIAL AND METHODS

A Cross-sectional retrospective study was conducted on patients with T2DM in a Sedi Hussein diabetic polyclinic in Benghazi, Libya. The total sample was 381 patients: T1DM 15 (n), and T2DM 366 (n). T1DM was excluded from our results. Patients with T2DM were divided into two groups: the control group (not on metformin) consisted of 71 patients, and the group that received metformin (M group) consisted of 295 patients.

AIMS OF THE STUDY

To assess serum vitamin B12 levels in patients with T2DM and evaluate the prevalence of vitamin B12 deficiency among those receiving metformin treatment.

RESULTS

The M group significantly decreased vitamin B12 serum levels by 443.56 mg/mL versus the control group of 541.33 pg/mL (p = 0.003). The prevalence of patients with vitamin B12 deficiency under the metformin treatment was 23.84%. There was no significant difference in correlation between serum vitamin B12 levels and both doses of metformin and the duration of diabetes mellitus.

CONCLUSION

Vitamin B12 was significantly decreased in patients with T2DM receiving metformin.

Dose dependent relationship of metformin use and diabetic peripheral neuropathy risk in patients with type 2 diabetes mellitus

This study investigated the correlation between metformin use and diabetic peripheral neuropathy (DPN) risk in patients with type 2 diabetes mellitus (T2DM) and its dose-dependent relationship. The study included new-onset T2DM patients from 2002 to 2013. Patients were divided into two groups based on metformin treatment, and DPN risk was assessed at 2- and 5-year follow-ups. After adjusting for various factors, two logistic models, metformin cumulative defined daily dose (cDDD) and metformin treatment intensity (defined daily dose [DDD]/month), evaluated the metformin-DPN risk association. Results showed that patients with metformin cDDD < 300, 300-500, and > 500 had higher DPN risk at both follow-ups. Odds ratios (ORs) and confidence intervals (CIs) for DPN were 1.74 (1.69-1.79), 2.05 (1.81-2.32), and 2.36 (1.34-4.16) at 2 years and 1.63 (1.60-1.65), 1.82 (1.69-1.96), and 2.17 (1.56-3.03) at 5 years. Similarly, patients with < 10, 10-25, and > 25 DDD/month had higher DPN risk at both follow-ups. Metformin use correlated with DPN risk in T2DM patients, with a dose-dependent relationship. Higher metformin cDDD or treatment intensity increased DPN risk. However, the absence of vitamin B12 data limits the understanding of the underlying mechanisms. Well-designed, large-scale studies are required to evaluate the potential risks of metformin therapy for DPN in patients with T2DM.

The direct targets of metformin in diabetes and beyond

Metformin, an oral antihyperglycemic drug that has been in use for over 60 years, remains a first-line therapy for type 2 diabetes (T2D). Numerous studies have suggested that metformin promotes health benefits beyond T2D management, including weight loss, cancer prevention and treatment, and anti-aging, through several proposed mechanistic targets. Here we discuss the established effects of metformin and the progress made in identifying its direct targets. Additionally, we emphasize the importance of elucidating the structural bases of the drug and its direct targets. Ultimately, this review aims to highlight the current state of knowledge regarding metformin and its related emerging discoveries, while also outlining critical future research directions.

Treatment of endothelial cell dysfunction in atherosclerosis: a new perspective integrating traditional and modern approaches

Atherosclerosis (AS), a prime causative factor in cardiovascular disease, originates from endothelial cell dysfunction (ECD). Comprising a vital part of the vascular endothelium, endothelial cells play a crucial role in maintaining vascular homeostasis, optimizing redox balance, and regulating inflammatory responses. More evidence shows that ECD not only serves as an early harbinger of AS but also exhibits a strong association with disease progression. In recent years, the treatment strategies for ECD have been continuously evolving, encompassing interventions ranging from lifestyle modifications to traditional pharmacotherapy aimed at reducing risk factors, which also have demonstrated the ability to improve endothelial cell function. Additionally, novel strategies such as promising biotherapy and gene therapy have drawn attention. These methods have demonstrated enormous potential and promising prospects in improving endothelial function and reversing AS. However, it is essential to remain cognizant that the current treatments still present significant challenges regarding therapeutic efficacy, long-term safety, and ethical issues. This article aims to provide a systematic review of these treatment methods, analyze the mechanisms and efficacy of various therapeutic strategies, with the goal of offering insights and guidance for clinical practice, and further advancing the prevention and treatment of cardiovascular diseases.

Metformin as a potential antidepressant: Mechanisms and therapeutic insights in depression

Depression is one of the most disabling psychiatric disorders, whose pathophysiology has not been fully understood. Increasing numbers of preclinical studies have highlighted that metformin, as the first-line hypoglycaemic agent, has a potential pleiotropic effect on depression. Moreover, there is emerging evidence that metformin shows antidepressant activity and improves depressive symptoms in rodent models of depression. However, the exact role and underlying mechanism of metformin in depression remain unclear and still need to be investigated. Recent studies suggest that metformin not only improves neuronal damage and structural plasticity in the hippocampus but also enhances the antidepressant effect of antidepressants. Therefore, in this review, we summarize the existing evidence for the use of metformin as a psychopharmaceutical and elaborate on the underlying mechanisms of metformin in mitigating the onset and progression of depression, as well as the associated biochemical signaling pathways and targets involved in the pathogenesis of depression. After reviewing several studies, we conclude that metformin helps reduce depressive symptoms by targeting multiple pathways, including the regulation of neurotransmitters, enhanced neurogenesis, anti-inflammatory effects, and changes in gut microbiota. We aim to gain a deeper understanding of the mechanism of action of metformin and provide new insights into its clinical value in the prevention and therapy of depression.

Recent Advances on the Role of B Vitamins in Cancer Prevention and Progression

Water-soluble B vitamins, mainly obtained through dietary intake of fruits, vegetables, grains, and dairy products, act as co-factors in various biochemical processes, including DNA synthesis, repair, methylation, and energy metabolism. These vitamins include B1 (Thiamine), B2 (Riboflavin), B3 (Niacin), B5 (Pantothenic Acid), B6 (Pyridoxine), B7 (Biotin), B9 (Folate), and B12 (Cobalamin). Recent studies have shown that besides their fundamental physiological roles, B vitamins influence oncogenic metabolic pathways, including glycolysis (Warburg effect), mitochondrial function, and nucleotide biosynthesis. Although deficiencies in these vitamins are associated with several complications, emerging evidence suggests that excessive intake of specific B vitamins may also contribute to cancer progression and interfere with therapy due to impaired metabolic and genetic functions. This review discusses the tumor-suppressive and tumor-progressive roles of B vitamins in cancer. It also explores the recent evidence on a comprehensive understanding of the relationship between B vitamin metabolism and cancer progression and underscores the need for further research to determine the optimal balance of B vitamin intake for cancer prevention and therapy.

2-Hydroxyisobutyric acid targeted binding to MT-ND3 boosts mitochondrial respiratory chain homeostasis in hippocampus to rescue diabetic cognitive impairment

BACKGROUND

The prevalence of diabetic cognitive impairment (DCI) is significant, some studies have shown that it is related to mitochondrial respiratory chain homeostasis, but the specific mechanism is not clear. 2-hydroxyisobutyric acid (2-HIBA) is a novel short-chain fatty acid with potential applications in the treatment of metabolic diseases because it can regulate mitochondrial disorders. Our aim was to explore a novel mechanism of action for 2-HIBA in the treatment of DCI in mitochondrial respiratory chain homeostasis.

METHODS

Metabolic substances and differentially active metabolic pathways in the serum of diseased mice were identified based on multi-omics analysis. The nanoLC-Obitrap-MS technology was utilized to detect the content of selected small molecules with differential metabolic activity in the hippocampus and mitochondria of mice to evaluate their permeability through the blood-brain barrier (BBB) and outer mitochondrial membrane. A combination of behavioral, proteomic, and molecular biology approaches was used to explore specific regulatory mechanisms and identify potential pharmacological targets. Additionally, using techniques such as protein thermal shift, drug affinity responsive target stability (DARTS), hydrolase stability, and surface plasmon resonance (SPR) experiments, we demonstrated the direct binding effects of small molecule metabolites with protein targets.

RESULTS

2-HIBA was found to directly ameliorate cognitive dysfunction in db/db mice by penetrating the blood-brain barrier and reversing the decrease in the protein content of NADH dehydrogenase 3 (MT-ND3) in the hippocampus through direct binding to ND3. This action helps maintain the stability of NAD+/NADH and regulate the mitochondrial respiratory chain balance. Furthermore, a combined medication plant agonist of 2-HIBA can enhance the expression of MT-ND3, thereby improving cognitive dysfunction in mice.

CONCLUSION

MT-ND3 is a crucial target for improving diabetic cognitive dysfunction, and 2-HIBA can directly bind to the MT-ND3 protein to alleviate the functional impairment of the mitochondrial respiratory chain in mice to treat DCI.

Vitamin B12: prevention of human beings from lethal diseases and its food application

Vitamin B12, a water-soluble essential micronutrient, plays a pivotal role in numerous physiological processes in the human body. This review meticulously examines the structural complexity and the diverse mechanisms through which vitamin B12 exerts its preventive effects against a spectrum of health conditions, including pernicious anaemia, neurological disorders, obesity, diabetes, dyslipidaemia and complications in foetal development. The selection of articles for this review was conducted through a systematic search across multiple scientific databases, including PubMed, Scopus and Web of Science. Criteria for inclusion encompassed relevance to the biochemical impact of vitamin B12 on health, peer-reviewed status and publication within the last decade. Exclusion criteria were non-English articles and studies lacking empirical evidence. This stringent selection process ensured a comprehensive analysis of vitamin B12's multifaceted impact on health, covering its structure, bioavailable forms and mechanisms of action. Clinical studies highlighting its therapeutic potential, applications in food fortification and other utilizations are also discussed, underscoring the nutrient's versatility. This synthesis aims to provide a clear understanding of the integral role of vitamin B12 in maintaining human health and its potential in clinical and nutritional applications. © 2024 The Author(s). Journal of The Science of Food and Agriculture published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry.

Natural resources, quantification, microbial bioconversion, and bioactivities of vitamin B12 for vegetarian diet

Vitamin B12 is a water-soluble vitamin with a complex chemical structure. It can participate in the synthesis and repair of DNA in the human body and plays an important role in regulating the nervous system. The deficiency of vitamin B12 will lead to megaloblastic anemia and neuropathy. Traditionally, animal foods have been the main dietary source of vitamin B12. However, this review points to certain plant sources (such as algae, mushrooms, fermented vegetables, and fermented beans) as viable vitamin B12 supplements for vegetarians. These sources validate our initial hypothesis that a plant-based diet can adequately provide essential nutrients previously thought to be available only through animal products. In terms of quantification, since the content of vitamin B12 in food samples is low and is easily interfered by impurities, highly sensitive and specific analytical methods are used for the quantification of vitamin B12. The findings from this review could be instrumental in developing fortified plant-based foods that could prevent B12 deficiency in vegetarians and vegans, thereby broadening the scope of nutritional options available to those on plant-based diets.

Diabetes and cardiovascular disease in older adults

An aging population combined with a rapidly increasing prevalence of diabetes foreshadows a global epidemic of cardiovascular and kidney disease that threatens to halt improvements in life and health-span and will have particularly severe consequences in older adults. The management of diabetes has been transformed with the recent development of newer anti-hyperglycemic agents that have demonstrated superior efficacy. However, the utility of these drugs extends beyond glycemic control to benefits for managing obesity, cardiovascular disease (CVD), chronic kidney disease, and heart failure. Numerous cardiovascular and kidney outcomes trials of these drugs have played an instrumental role in shaping current guidelines for the management of diabetes and CVD. Older adults with diabetes are diverse in terms of their comorbidities, diabetic complications, and cognitive and functional status. Therefore, there is an unmet need for personalized management of diabetes and CVD in this population. In this review, we provide an overview of the epidemiological burden and management of diabetes and CVD in older adults. We then focus on randomized cardiovascular and kidney outcome trials with anti-hyperglycemic agents to propose an evidence-based approach to the management of diabetes in older adults with high risk of cardiovascular and kidney disease.

Frequency of comorbid diseases with high serum Vitamin B12 levels in patients attending King Salman Medical City (KSAMC), at Madinah

Objectives

Vitamin B12 (Cobalamin or Cbl) plays a crucial role in normal human growth and development, as well as in neurological, cardiovascular, and immune systems. Previous studies reported association of high levels of cobalamin with solid cancers, hematological disorders, and liver diseases. Reporting the frequency of comorbid diseases with high serum Vitamin B12 level in patients attending KSAMC at Madinah.

Methods

This is a retrospective, cross-sectional study on data collected during 1 year (May 2022-May 2023) from 3511 report, patients with high cobalamin blood level (normal upper limit 771 pg/mL) as determined in our laboratory on COBAS® were included. Patient's clinical diagnosis, medication history and other laboratory parameters performed were also checked for disease comorbidities.

Results

Our results revealed statistically significant increase in serum Vitamin B12 in patients with diabetes mellitus, with the use of this vitamin as supplement therapy 53.2% (the predominant comorbidity), together with liver, blood, chest, kidney, thyroid and neurological diseases, and various solid tumors. A positive correlation was found between serum Vitamin B12, age and laboratory parameters including aspartate aminotransferase, gamma-glutamyl transferase, and direct bilirubin, and a negative correlation was seen between serum Vitamin B12 level, serum albumin (ALB), red blood cell count, hemoglobin, and free T3 (FT3). While, no significant correlation with the rest of the checked parameters was detected.

Conclusion

This study found high serum level of Vitamin B12 associated with various disease entities, for example, (diabetes mellitus treated with Vitamin B12 as supplement therapy, liver, blood, chest, kidney, thyroid, neurological diseases, and various solid tumors), so when Vitamin B12 is high, further investigations will be recommended. Most of the comorbidities were benign in Saudis, followed by Egyptians with predominance of female-aged 50-70 year old.

Update on the therapeutic role of metformin in the management of polycystic ovary syndrome: Effects on pathophysiologic process and fertility outcomes

Influential guidelines have supported the role of metformin in the management of polycystic ovary syndrome (PCOS) for a number of years. However, regulatory approvals for this therapeutic indication are still exceptional and exist only in a few countries, including for the originator, Glucophage®. PCOS is an insulin-resistant state, which drives hyperandrogenism and anovulatory infertility. The metabolic action of metformin involves amelioration of insulin resistance, which helps to resolve hormonal and metabolic disturbances and increases ovulation, pregnancy, and live birth rates relative to placebo. A combination of metformin with clomifene citrate (another widely used treatment for PCOS) is more effective than either alone and is a useful option in women with clomifene-resistant PCOS. Combining metformin with letrozole (1st-line agent for ovulation induction in women with PCOS and no other infertility risk factors) is not more effective than letrozole alone. Continuing metformin to the end of the 1st trimester at an effective dose (e.g. 1000-2000 mg/day) may help to reduce the rate of miscarriages. Metformin also has an adjunctive role in women with PCOS receiving assisted reproduction technology (ART) using the long gonadotrophin-releasing hormone agonist protocol, where it appears to increase the pregnancy rate and to reduce the risk of ovarian hyperstimulation syndrome. There is no role for metformin in women receiving short ART protocols. Where a successful pregnancy is achieved, metformin is generally safe for the mother and neonate. Further research is needed to define with greater precision the optimal dosage and times to initiate and discontinue metformin in women with PCOS who achieve pregnancy.

Exceeding the Limits with Nutraceuticals: Looking Towards Parkinson's Disease and Frailty

One of the most pressing challenges facing society today is the rising prevalence of physical and cognitive frailty. This geriatric condition makes older adults more vulnerable to disability, illness, and a heightened risk of mortality. In this scenario, Parkinson's disease (PD) and geriatric frailty, which share several common characteristics, are becoming increasingly prevalent worldwide, underscoring the urgent need for innovative strategies. Nutraceuticals are naturally occurring bioactive compounds contained in foods, offering health benefits over and above essential nutrition. By examining the literature from the past decade, this review highlights how nutraceuticals can act as complementary therapies, addressing key processes, such as oxidative stress, inflammation, and neuroprotection. Notably, the antioxidant action of nutraceuticals appears particularly beneficial in regard to PD and geriatric frailty. For instance, antioxidant-rich nutraceuticals may mitigate the oxidative damage linked to levodopa therapy in PD, potentially reducing the side effects and enhancing treatment sustainability. Similarly, the antioxidant effects of nutraceuticals may amplify the benefits of physical activity, enhancing muscle function, cognitive health, and resilience, thereby reducing the risk of frailty. This review proposes a holistic approach integrating nutraceuticals with exercise, pharmacotherapy, and lifestyle adjustments. It promises to transform the management of ARD, prolong life, and improve the quality of life and well-being of older people.

Movement disorders related to antidiabetic medications: a real-world pharmacovigilance study

BACKGROUND

Diabetic Mellitus (DM) has progressively emerged as a worldwide health problem, leading to the widespread deployment of antidiabetic drugs as the primary therapy in the global population. The incidence of diabetes medications-related movement disorders (drMD) is noteworthy but underestimated by clinical practitioners.

RESEARCH DESIGN AND METHODS

In order to address the incidence of drMD in DM patients and realize the serious outcomes associated with drMD, we conducted a real-world pharmacovigilance study of 612,043 DM patients using the FDA Adverse Event Reporting System (FAERS) database from January 2004 to September 2023. Reporting Odd Ratio (ROR) was calculated to reflect the risk of drMD. A multivariable logistic regression analysis was employed to adjust crude ROR with the mixed factors including age, sex and various antidiabetic treatments. Afterward, a Mendelian Randomization (MR) study was performed to elucidate the underlying genetic correlation between the genetically proxied targets of antidiabetic drugs and motor disorders.

RESULTS

Among 11,729 cases of motor adverse events in DM patients, six categories of drMD were significantly associated with DM medications. Noticeably, metformin was revealed to drastically increase the incidence of parkinsonism (adjusted ROR:3.97; 95 %CI (3.03, 5.19), p = 5.68e-24), bradykinesia (adjusted ROR:1.69; 95 %CI (1.07,2.59), p = 0.02) and irregular hyperkinesia, including chorea, choreoathetosis and athetosis. Insulin/insulin analogues and GLP-1 analogues presented notably higher odds of tremor: the adjusted ROR (aROR) of insulin and GLP-1 analogue is respectively 1.24 (95 %CI (1.15,1.34), p = 2.51e-08) and 1.78 (95 %CI (1.65,1.91), p = 5.64e-54). The combined therapeutic effects of multiple genetic variants of metformin, especially AMP-activated protein kinase (AMPK) were markedly linked to a greater likelihood of developing secondary parkinsonism (OR:10.816, p = 0.049) according to MR analyses.

CONCLUSION

The use of antidiabetic medications was significantly related to an increased incidence of movement disorders in DM patients. Moreover, MR analyses provided further genetic evidence for the pharmacovigilance study. This comprehensive investigation might help physicians recognize neurological adverse events associated with antidiabetic treatments and administer effective interventions.

Flavin mononucleotide, a potent inhibitor of insulin-degrading enzyme: an in-silico study

Diabetes Mellitus is a metabolic disorder which has affected over 476 million people globally with projections indicating a further increase in this number. Despite the availability of treatment therapies, maintaining optimal blood glucose levels remains a critical task. During literature survey, we came across Insulin degrading enzyme (IDE) which is responsible for insulin degradation in the body and inhibition of this enzyme could increase the bioavailability of insulin in the body. Therefore, a library of phytoconstituents isolated from anti-diabetic plants was prepared and screened against the IDE by using various in silico tools. This screening suggested Flavin mononucleotide (derivative of Vitamin B12) to possess the highest affinity towards IDE which interacted with a binding energy value of -332.686 kcal/mol. Moreover, molecular dynamic simulations and MMGBSA studies confirms the stability of Compound Flavin mononucleotide-IDE complex for at least 200 ns. These findings suggest that Compound Flavin mononucleotide has ability to halt the activity of this enzyme, but this study also underscores the need for confirming the anti-diabetic action of Flavin mononucleotide via in vitro assay and subsequent in vivo studies.

Revolutionary drug repositioning: the preventive and therapeutic potential of metformin and other antidiabetic drugs in age-related macular degeneration

Age-related macular degeneration (AMD) is a leading cause of blindness among the elderly worldwide. Anti-vascular endothelial growth factor (anti-VEGF) injections remain the first-line therapy for AMD. However, their high cost and the need for frequent administration pose challenges to long-term adherence, highlighting the need for accessible and cost-effective preventive strategies. Emerging evidence suggests that traditional antidiabetic drugs, such as metformin, sulfonylureas, and thiazolidinediones, may offer neuroprotective benefits, opening new avenues for AMD prevention. Among these, metformin has emerged as the most promising candidate, demonstrating significant potential in reducing AMD risk, even at low cumulative doses, primarily through AMP-activated protein kinase (AMPK) activation. Sulfonylureas, although effective in stimulating insulin secretion, carry risks such as hypoglycemia, hyperinsulinemia, and a possible association with increased cancer risk. Similarly, thiazolidinediones, while improving insulin sensitivity, are associated with adverse effects, including cardiovascular risks and macular edema, limiting their broader application in AMD prevention. This paper explores the preventive potential and underlying mechanisms of these antidiabetic drugs in AMD and discusses the role of artificial intelligence in optimizing individualized prevention strategies. By advancing precision medicine, these approaches may improve public health outcomes and reduce the burden of aging-related vision loss.

The Gut Microbiome's Influence on Incretins and Impact on Blood Glucose Control

Obesity and type 2 diabetes mellitus (T2DM) have been increasing in prevalence, causing complications and strain on our healthcare systems. Notably, gut dysbiosis is implicated as a contributing factor in obesity, T2DM, and chronic inflammatory diseases. A pharmacology exists which modulates the incretin pathway to improve glucose control; this has proven to be beneficial in patients with obesity and T2DM. However, it is unclear how the gut microbiome may regulate insulin resistance, glucose control, and metabolic health. In this narrative review, we aim to discuss how the gut microbiome can modulate incretin pathways and related mechanisms to control glucose. To investigate this, Google Scholar and PubMed databases were searched using key terms and phrases related to the microbiome and its effects on insulin and glucose control. Emerging research has shown that several bacteria, such as Akkermansia and MN-Gup, have GLP-1-agonistic properties capable of reducing hyperglycemia. While more human research is needed to prove clinical benefit and identify long-term implications on health, the usage of pre-, pro-, and postbiotics has the potential to improve glucose control.

Effects of chitosan guanidine on blood glucose regulation and gut microbiota in T2DM

Diabetes mellitus (DM) is a chronic metabolic disease characterized by hyperglycemia. Type 2 diabetes mellitus (T2DM) represents approximately 90 % of all DM cases and is primarily caused by an imbalance in blood glucose homeostasis due to inadequate insulin secretion or insulin resistance. This study explores the potential therapeutic effects of chitosan guanidine (CSG) on a T2DM mouse model. The findings reveal that CSG significantly enhances oral glucose tolerance (OGTT) and insulin sensitivity (ITT), reduces fasting blood glucose (FBG) levels, and suppresses the expression of proinflammatory cytokines in T2DM mice. These changes improve insulin resistance and diminish inflammation. Additionally, CSG markedly ameliorates lipid metabolism disorders, lowers total cholesterol (TC) and triglyceride (TG) levels, and inhibits hepatic fat accumulation. 16S rRNA and Spearman correlation analyses indicate that CSG promotes the relative abundance of probiotic genera such as Bacteroidota, Patescibacteria, Actinobacteria, and Cyanobacteria. These bacteria are positively correlated with short-chain fatty acids (SCFAs) and high-density lipoprotein cholesterol (HDLC) levels. Conversely, CSG reduces the relative abundance of pathogenic bacteria, including Proteobacteria and Ralstonia, leading to an improved intestinal microbial community composition in T2DM mice and alleviating T2DM symptoms. These results suggest that CSG holds significant potential as a non-insulin therapeutic agent for diabetes management.

The Prevalence of Vitamin B12 Deficiency Among Diabetic Patients Who Use Metformin

BACKGROUND AND AIM

Vitamin B12 deficiency is a recognized concern among patients with type 2 diabetes mellitus (T2DM) using metformin due to its potential impact on health outcomes. This study investigates the prevalence of vitamin B12 deficiency among diabetic patients using metformin at Dr. Sulaiman Al Habib Medical Group (HMG) hospitals.

METHODS

This retrospective cohort study utilized electronic medical records from the VIDA system (www.cloudsolutions.com) over a one-year period. Participants included adult T2DM patients managed with metformin therapy. Data collection involved demographic details, medical history, medication usage, and serum vitamin B12 levels. Statistical analyses included descriptive statistics and comparative tests to assess deficiency prevalence across demographics.

RESULTS

Among the study population (N=37,781), vitamin B12 deficiency prevalence ranged from 460 (4.6%) to 507 (5.5%) across four quarters of 2023. Females exhibited a higher prevalence than males (P < 0.05), particularly in the second and fourth quarters. Age-related analyses identified younger and middle-aged groups (≤25 years and 36-45 years) as having higher deficiency rates (P < 0.001). Medication use, specifically metformin, correlated with increased deficiency prevalence (P < 0.001).

DISCUSSION

The findings underscore the significance of gender, age, and medication use in influencing vitamin B12 status among diabetic patients using metformin. The study highlights the need for tailored monitoring strategies and interventions to mitigate deficiency risks and optimize patient outcomes. Future research should explore mechanisms underlying these associations and expand findings to broader populations.

CONCLUSION

This study provides critical insights into the epidemiology of vitamin B12 deficiency among diabetic patients using metformin at HMG hospitals. The results emphasize the importance of personalized healthcare approaches to address nutrient deficiencies and improve overall patient care. This study summarizes the key elements of your research paper, focusing on the prevalence of vitamin B12 deficiency in relation to metformin use among diabetic patients.

Metformin Use and Vitamin B12 Deficiency in People with Type 2 Diabetes. What Are the Risk Factors? A Mini-systematic Review

Background and Aim: Metformin is recommended as the first-line agent for the management of type 2 diabetes following lifestyle and dietary changes. The long-term use of metformin has been associated with vitamin B12 deficiency. The aim of this review is to investigate the effect of metformin on vitamin B12 levels and identify any risk factors. Method: A literature search was conducted using MEDLINE, PubMed and ProQuest Central. Selected articles were peer-reviewed articles, written in English and published from 2015 and onwards. Excluded articles were case reports, reviews or meta-analyses, as well as those with no access to full text. Results: In total, 21 articles were included. There was a significant association between metformin use and vitamin B12 levels in 17 studies, while 4 studies found no such association. The risk factors examined were metformin dose, treatment duration, patient age and patient ethnicity. Conclusion: In summary, metformin use was associated with lower vitamin B12 concentrations, and higher doses and longer durations of treatment increase the risk of vitamin B12 deficiency. Routine vitamin B12 screening is recommended, prioritizing higher-risk patients. Further research is needed to identify when to initiate monitoring.

The reference value of serum vitamin B12 among An-Najah National University

Background

Serum vitamin B12 plays a crucial role in cellular growth, DNA synthesis, and maintaining a healthy nervous system. Its deficiency can lead to various health issues, including cardiovascular problems. The reference range for vitamin B12 varies between populations due to cultural, genetic, and dietary differences.

Methods

A cross-sectional study was conducted on 127 healthy An-Najah National University students aged between 18 and 25. Blood samples were collected, and a questionnaire assessed factors affecting vitamin B12 levels. Serum vitamin B12 levels were measured using ACCUBIND ELIZA microwells.

Results

The study found a reference range for serum vitamin B12 of 136-640 pg/mL (5th to 95th percentile) among the studied population, which differed from the manufacturer's claimed range of 200-835 pg/mL. Gender did not significantly affect the reference intervals.

Conclusion

The study highlights the importance of establishing local reference values for laboratory tests like vitamin B12 due to variations in demographics. Further research in different Palestinian regions and age groups with larger sample sizes is recommended to refine these reference values.

Vitamin B12 Deficiency in Patients Taking Metformin: Pathogenesis and Recommendations

Metformin is a cornerstone therapy for type 2 diabetes mellitus due to its glucose-lowering efficacy and additional benefits such as reducing cardiovascular mortality. However, accumulating evidence suggests an association between long-term metformin use and vitamin B12 deficiency, which can lead to serious clinical consequences. This review aims to synthesize current knowledge on the pathogenesis, prevalence, clinical implications, and management of metformin-induced vitamin B12 deficiency. Given the significant clinical implications, it is crucial to monitor and manage vitamin B12 levels in patients using metformin. This review emphasizes the importance of early detection and supplementation to prevent adverse outcomes. By analyzing the current evidence, the review aims to inform healthcare professionals about best practices for managing vitamin B12 deficiency in patients on metformin, offering insights to guide future clinical practices and research directions.

Targeting multiple hallmarks of mammalian aging with combinations of interventions

Aging is currently viewed as a result of multiple biological processes that manifest themselves independently, reinforce each other and in their totality lead to the aged phenotype. Genetic and pharmaceutical approaches targeting specific underlying causes of aging have been used to extend the lifespan and healthspan of model organisms ranging from yeast to mammals. However, most interventions display only a modest benefit. This outcome is to be expected if we consider that even if one aging process is successfully treated, other aging pathways may remain intact. Hence solving the problem of aging may require targeting not one but many of its underlying causes at once. Here we review the challenges and successes of combination therapies aimed at increasing the lifespan of mammals and propose novel directions for their development. We conclude that both additive and synergistic effects on mammalian lifespan can be achieved by combining interventions that target the same or different hallmarks of aging. However, the number of studies in which multiple hallmarks were targeted simultaneously is surprisingly limited. We argue that this approach is as promising as it is understudied.

Metformin: Therapeutic profile in the treatment of type 2 diabetes

Metformin (dimethyl-biguanide) can claim its origins in the use of Galega officinalis as a plant treatment for symptoms ascribed to diabetes. Since the first clinical use of metformin as a glucose-lowering agent in 1957, this medicine has emerged as a first-line pharmacological option to support lifestyle interventions in the management of type 2 diabetes (T2D). It acts through multiple cellular pathways, principally in the gut, liver and muscle, to counter insulin resistance and lower blood glucose without weight gain or risk of overt hypoglycaemia. Other effects include improvements in lipid metabolism, decreased inflammation and lower long-term cardiovascular risk. Metformin is conveniently combined with other diabetes medications, can be prescribed in prediabetes to reduce the risk of progression to T2D, and is used in some regions to assist glycaemic control in pregnancy. Consistent with its diversity of actions, established safety profile and cost-effectiveness, metformin is being assessed for further possible clinical applications. The use of metformin requires adequate renal function for drug elimination, and may cause initial gastrointestinal side effects, which can be moderated by taking with meals or using an extended-release formulation. Thus, metformin serves as a valuable therapeutic resource for use throughout the natural history of T2D.

Vitamin B12 Metabolism: A Network of Multi-Protein Mediated Processes

The water-soluble vitamin, vitamin B12, also known as cobalamin, plays a crucial role in cellular metabolism, particularly in DNA synthesis, methylation, and mitochondrial functionality. Its deficiency can lead to hematological and neurological disorders; however, the manifestation of these clinical outcomes is relatively late. It leads to difficulties in the early diagnosis of vitamin B12 deficiency. A prolonged lack of vitamin B12 may have severe consequences including increased morbidity to neurological and cardiovascular diseases. Beyond inadequate dietary intake, vitamin B12 deficiency might be caused by insufficient bioavailability, blood transport disruptions, or impaired cellular uptake and metabolism. Despite nearly 70 years of knowledge since the isolation and characterization of this vitamin, there are still gaps in understanding its metabolic pathways. Thus, this review aims to compile current knowledge about the crucial proteins necessary to efficiently accumulate and process vitamin B12 in humans, presenting these systems as a multi-protein network. The epidemiological consequences, diagnosis, and treatment of vitamin B12 deficiency are also highlighted. We also discuss clinical warnings of vitamin B12 deficiency based on the ongoing test of specific moonlighting proteins engaged in vitamin B12 metabolic pathways.

Metformin-Induced Vitamin B12 Deficiency in Patients with Type 2 Diabetes: A Narrative Review with a Practical Approach for Screening, Diagnosing, and Managing Vitamin B12 Deficiency

Metformin is the most widely used antihyperglycemic drug in patients with type 2 diabetes (T2D). Over the past 2 decades, several studies have highlighted a substantial increase in the risk of vitamin B12 deficiency in patients with T2D on metformin therapy. This can lead to several complications and induce or exacerbate peripheral neuropathy. Despite these data, there are no definite guidelines for screening, diagnosing, and treating vitamin B12 deficiency in patients with T2D on metformin therapy. Therefore, in this narrative review, we aimed to suggest a practical diagnostic and therapeutic strategy to address vitamin B12 deficiency in patients with T2D receiving metformin treatment. Clinical evidence supporting an increased risk of vitamin B12 deficiency in patients with T2D on metformin therapy and its risk factors and potential complications are also discussed.

A Comprehensive Approach to Parkinson's Disease: Addressing Its Molecular, Clinical, and Therapeutic Aspects

Parkinson's disease (PD) is a gradually worsening neurodegenerative disorder affecting the nervous system, marked by a slow progression and varied symptoms. It is the second most common neurodegenerative disease, affecting over six million people in the world. Its multifactorial etiology includes environmental, genomic, and epigenetic factors. Clinical symptoms consist of non-motor and motor symptoms, with motor symptoms being the classic presentation. Therapeutic approaches encompass pharmacological, non-pharmacological, and surgical interventions. Traditional pharmacological treatment consists of administering drugs (MAOIs, DA, and levodopa), while emerging evidence explores the potential of antidiabetic agents for neuroprotection and gene therapy for attenuating parkinsonian symptoms. Non-pharmacological treatments, such as exercise, a calcium-rich diet, and adequate vitamin D supplementation, aim to slow disease progression and prevent complications. For those patients who have medically induced side effects and/or refractory symptoms, surgery is a therapeutic option. Deep brain stimulation is the primary surgical option, associated with motor symptom improvement. Levodopa/carbidopa intestinal gel infusion through percutaneous endoscopic gastrojejunostomy and a portable infusion pump succeeded in reducing "off" time, where non-motor and motor symptoms occur, and increasing "on" time. This article aims to address the general aspects of PD and to provide a comparative comprehensive review of the conventional and the latest therapeutic advancements and emerging treatments for PD. Nevertheless, further studies are required to optimize treatment and provide suitable alternatives.

Trends in Vitamin B12 Level Testing in Patients on Metformin From 2000 to 2020

Background and Objectives

Metformin is one of the primary pharmacologic agents for managing type 2 diabetes mellitus (T2DM). However, it has been associated with interference in vitamin B12 absorption and deficiency. Vitamin B12 deficiency and T2DM can present diagnostic challenges for polyneuropathy. Diagnosis is essential for guiding treatment, yet the use of vitamin B12 level testing in this population may have dwindled over time amid changing practice guidelines. This study examines trends over time in the use of vitamin B12 level testing among patients on metformin.

Methods

This retrospective trend analysis used data from TriNetX, a real-world, longitudinal clinical database. Patients treated with metformin from 2000 to 2020 were identified using Rx Concept Unique Identifier codes. The number of patients who underwent vitamin B12 level testing at any time after 1 month from metformin initiation was tabulated. Patients were grouped by the year of B12 level testing. Trends in B12 level testing were assessed using the Jonckheere-Terpstra statistical test (P<.05).

Results

Out of 4,203,020 patients prescribed metformin, 1,055,995 (25.1%) underwent B12 level testing. The highest proportion of patients tested was in 2000 to 2002 (39.6%), while the lowest proportion was in 2018 to 2020 (20.1%). B12 testing utilization declined significantly by 19.5% from 2000-2002 to 2018-2020 (P=.001).

Conclusions

In this study, we found that the use of vitamin B12 level testing in patients on metformin has significantly declined over the years, potentially impacting early detection of B12 deficiency. Future studies with more granular data from real-life practice are recommended to understand the precise reasons and impact of this trend.

A, Sarma DK, Verma V, Nagpal R, Mohania D, Tiwari R, Kumar M. Deciphering the complex interplay of risk factors in type 2 diabetes mellitus: A comprehensive review

The complex and multidimensional landscape of type 2 diabetes mellitus (T2D) is a major global concern. Despite several years of extensive research, the precise underlying causes of T2D remain elusive, but evidence suggests that it is influenced by a myriad of interconnected risk factors such as epigenetics, genetics, gut microbiome, environmental factors, organelle stress, and dietary habits. The number of factors influencing the pathogenesis is increasing day by day which worsens the scenario; meanwhile, the interconnections shoot up the frame. By gaining deeper insights into the contributing factors, we may pave the way for the development of personalized medicine, which could unlock more precise and impactful treatment pathways for individuals with T2D. This review summarizes the state of knowledge about T2D pathogenesis, focusing on the interplay between various risk factors and their implications for future therapeutic strategies. Understanding these factors could lead to tailored treatments targeting specific risk factors and inform prevention efforts on a population level, ultimately improving outcomes for individuals with T2D and reducing its burden globally.

Metformin Use in Type 2 Diabetics and Delirium After Noncardiac Surgery: A Retrospective Cohort Analysis

INTRODUCTION

The cause of postoperative delirium is unknown, but it is thought to result at least in part from inflammation. Metformin, besides its hypoglycemic properties, demonstrates anti-inflammatory effects systemically and in the brain. We tested the primary hypothesis that chronic metformin use in adults with type 2 diabetes is associated with less delirium during the first 5 days after major noncardiac surgery. Secondary outcomes were a composite of serious complications (myocardial infarction, cardiac arrest, stage 2-3 acute kidney injury [AKI], and mortality) and time to discharge alive.

METHODS

We considered adults with type 2 diabetes who did or did not routinely use metformin daily and had noncardiac surgery. Delirium was assessed by Confusion Assessment Method for Intensive Care Unit (CAM-ICU) or brief Confusion Assessment Method (bCAM) for 5 postoperative days. Postoperative AKI was defined by Kidney Disease Improving Global Guidelines. Logistic regression and generalized estimating equation models accounted for within-patient correlation across multiple surgeries and explored the association between metformin use and postoperative delirium and complications. Inverse propensity score weighting and propensity score calibration (PSC) adjusted for confounding variables.

RESULTS

No significant difference was observed in the incidence of postoperative delirium between the 2 groups, with 260 of 4744 cases (5.5%) among metformin users and 502 of 5918 cases (8.5%) cases in nonmetformin users, for an odds ratio of 0.88 (95% confidence interval [CI], 0.73-1.05; P = .155), number-needed-to-expose = 118 patients. Similarly, there were fewer composite complications in metformin users (3.3%) than in nonusers (11.7%); However, the common-effect odds ratio of 0.67 was not statistically significant (97.5% CI, 0.39-1.17; P = .106). Discharge from the hospital was significantly faster in patients who took metformin (3 [interquartile range, IQR, 1-5] days for metformin users and 3 [IQR, 2-6] days for nonmetformin users), with a hazard ratio of 1.07 for early discharge, and tight CIs (1.01-1.13).

CONCLUSIONS

Chronic metformin use was associated with slightly and nonsignificantly less delirium. However, patients who used metformin had clinically meaningfully fewer major complications, mostly stage 2 to 3 kidney injury. While not statistically significant, the reduction was substantial and warrants further investigation because there is currently no effective preventive measure for perioperative renal injury. Benefit would be especially meaningful if it could be produced by acute perioperative treatment. Finally, metformin was associated with faster hospital discharge, although not by a clinically meaningful amount.

Vitamin B12 Supplementation in Psychiatric Practice

PURPOSE OF REVIEW

Vitamin B12 (B12, cobalamin) deficiency has been associated with neuropsychiatric symptoms, suggesting a role for B12 supplementation both as a treatment for psychiatric symptoms due to B12 deficiency and as an augmentation strategy for pharmacological treatments of psychiatric disorders. This critical review discusses the major causes of B12 deficiency, the range of psychiatric and non-psychiatric manifestations of B12 deficiency, the indications for testing B12 levels, and the evidence for B12 supplementation for major psychiatric disorders.

RECENT FINDINGS

We find that high-quality evidence shows no benefit to routine B12 supplementation for mild depressive symptoms or to prevent depression. There is very limited evidence on the role of B12 supplementation to augment antidepressants. No high-quality evidence to date suggests a role for routine B12 supplementation in any other major psychiatric disorder. No formal guidelines indicate when clinicians should test B12 levels for common psychiatric symptoms, in the absence of major risk factors for deficiency or cardinal symptoms of deficiency. No robust evidence currently supports routine B12 supplementation for major psychiatric disorders. However, psychiatrists should be aware of the important risk factors for B12 deficiency and should be able to identify symptoms of B12 deficiency, which requires prompt testing, medical workup, and treatment. Testing for B12 deficiency should be considered for atypical or severe psychiatric presentations.

Water-soluble vitamins and trace elements in children with chronic kidney disease stage 5d

Children receiving maintenance dialysis (chronic kidney disease (CKD) stage 5d) have unique risk factors for micronutrient deficiency or toxicity. Children receiving chronic dialysis often require specialized diet plans that may provide more than the recommended daily allowance (RDA) of water-soluble vitamins and micronutrients, with or without the addition of a kidney-friendly vitamin. The following is a comprehensive review of current literature on disorders of micronutrients in this population including those of water-soluble vitamins (vitamin C and vitamin B complexes) and trace elements (copper, selenium, and zinc) and has three areas of focus: (1) the risk factors and clinical presentations of disorders of micronutrients, both deficiency and toxicity, (2) the tools to evaluate micronutrient status, and (3) the central role of renal dietitians in optimizing nutritional status from a micronutrient perspective.

Vitamin B12 deficiency in diabetic patients treated with metformin: A cross-sectional study

Metformin is a cornerstone medication in the management of type 2 diabetes. Metformin is safe, effective, and inexpensive; however, it is associated with vitamin B12 deficiency. This study set out to evaluate the rate of vitamin B12 deficiency in Vietnamese patients with type 2 diabetes who were treated with metformin and to investigate factors associated with vitamin B12 deficiency. This is a cross-sectional study that was conducted in Vinmec Central Park Hospital from February to June 2023. The clinical and paraclinical characteristics of the participants were recorded, and the levels of vitamin B12 and folate were measured. The rate of vitamin B12 deficiency in patients treated with metformin was found to be 18.6%. Further, the duration of diabetes, duration of metformin use, metformin dose, and hemoglobin levels were statistically associated with vitamin B12 deficiency with OR (95% CI) = 1.12 (1.03-1.19), 1.01 (1.00-1.02), 1.002 (1.001-1.002), 0.74 (0.55-0.99), respectively. After adjusting for covariates, a metformin dose greater than the median dose remained the only parameter associated with vitamin B12 deficiency, with OR (95% CI) = 4.10 (1.62-10.36). Moreover, when combining both long-term use of metformin and a metformin dose greater than the median dose, the OR increased to 5.25 (95% CI: 2.11-13.15). These results demonstrate that vitamin B12 deficiency in patients treated with metformin is quite prevalent in Vietnam and that those with long-term use of metformin (48 months or more) and high metformin dose (1000 mg/day or more) are at high risk of experiencing this adverse effect and so require screening.

View on Metformin: Antidiabetic and Pleiotropic Effects, Pharmacokinetics, Side Effects, and Sex-Related Differences

Metformin is a synthetic biguanide used as an antidiabetic drug in type 2 diabetes mellitus, achieved by studying the bioactive metabolites of Galega officinalis L. It is also used off-label for various other diseases, such as subclinical diabetes, obesity, polycystic ovary syndrome, etc. In addition, metformin is proposed as an add-on therapy for several conditions, including autoimmune diseases, neurodegenerative diseases, and cancer. Although metformin has been used for many decades, it is still the subject of many pharmacodynamic and pharmacokinetic studies in light of its extensive use. Metformin acts at the mitochondrial level by inhibiting the respiratory chain, thus increasing the AMP/ATP ratio and, subsequently, activating the AMP-activated protein kinase. However, several other mechanisms have been proposed, including binding to presenilin enhancer 2, increasing GLP1 release, and modification of microRNA expression. Regarding its pharmacokinetics, after oral administration, metformin is absorbed, distributed, and eliminated, mainly through the renal route, using transporters for cationic solutes, since it exists as an ionic molecule at physiological pH. In this review, particular consideration has been paid to literature data from the last 10 years, deepening the study of clinical trials inherent to new uses of metformin, the differences in effectiveness and safety observed between the sexes, and the unwanted side effects. For this last objective, metformin safety was also evaluated using both VigiBase and EudraVigilance, respectively, the WHO and European databases of the reported adverse drug reactions, to assess the extent of metformin side effects in real-life use.

Metformin-Associated Vitamin B12 Deficiency: An Underrecognized Complication

Metformin-associated vitamin B12 deficiency is a well-established side effect, especially in patients taking higher doses of metformin or who have existing risk factors. Severe deficiency causes a wide range of systemic disorders. Gait instability, which leads to frequent falling, is usually an underrecognized side effect. Older patients are more likely to develop chronic subdural hematoma even with minor trauma. We present a case of 84-year-old man with type 2 diabetes mellitus with acute-on-chronic subdural hematoma from frequent falls. Metformin therapy at dose of 1700 mg/day was given for more than 25 years. He had been in his usual state of health until 10 months ago when he began to have frequent fallings and fatigue. Physical examination in this admission revealed new-onset impaired vibratory sensation and proprioception in both feet and positive Romberg test. Subsequent evaluations demonstrated undetectable plasma vitamin B12 level and elevated plasma homocysteine. Improvement in neurological symptoms occurred within 1 week of vitamin B12 replacement and surgical hematoma evacuation. This case highlights the importance of awareness and periodic monitoring of vitamin B12 status among older patients taking metformin.

Metformin and the risks of cellulitis, foot infections, and amputation in patients with type 2 diabetes

BACKGROUND

Patients with diabetes tend to have cellulitis, foot infections, and amputation. We conducted this research to compare the risks of cellulitis, foot infections, and amputation between metformin no-use and use in persons with type 2 diabetes.

METHODS

Using propensity score matching, we identified 23 234 pairs of metformin nonusers and users from the National Health Insurance Research Database of Taiwan, since January 1, 2000, to December 31, 2017. Cox proportional hazards models were adopted to examine the risks of incident cellulitis, recurrent cellulitis, foot infections, and amputation between metformin use and no-use.

RESULTS

The mean follow-up period of metformin use and no-use was 6.31 (3.93) and 5.54 (3.97) years, respectively. Compared with metformin no-use, the adjusted hazard ratio and 95% confidence interval for metformin use in cellulitis development, recurrent cellulitis, foot infections, and amputation were 1.08 (1.04-1.12), 1.33 (1.14-1.55), 1.91 (1.75-2.09), and 1.88 (1.35-2.62), respectively. The longer cumulative duration of metformin usage had association with higher risks of these outcomes than metformin no-use.

CONCLUSION

This population-based cohort study revealed that metformin use had association with significantly higher risks of incident cellulitis, recurrent cellulitis, foot infections, and amputation than metformin no-use in patients with type 2 diabetes.

Impact of metformin treatment on cobalamin status in persons with type 2 diabetes

Over the last decades, low vitamin B12 status has been reported in individuals with type 2 diabetes mellitus (T2DM). Metformin, the first-line therapy for lowering blood glucose, is the main driving factor behind this association. Although the relationship between vitamin B12 deficiency and metformin is well established, results of studies on the exact effect of the dose and duration of the therapy remain inconsistent. Additionally, a lack of consensus on the definition of vitamin B12 deficiency adds to the conflicting literature. The objectives of this review were to analyze and synthesize the findings on the effects of metformin dose and duration on vitamin B12 status in patients with T2DM and to outline the potential mechanisms underlying metformin's effect on vitamin B12. Metformin therapy has adversely affected serum vitamin B12 concentrations, a marker of vitamin B12 status. The metformin usage index (a composite score of metformin dose and duration) might serve as a potential risk assessment tool for vitamin B12 screening in patients with T2DM. Considering the health implications of suboptimal vitamin B12 status, vitamin B12 concentrations should be monitored periodically in high-risk patients, such as vegans who are receiving metformin therapy for T2DM. Additionally, it is prudent to implement lifestyle strategies concurrent with metformin therapy in individuals with T2DM, promoting an overall synergistic effect on their glycemic control.

Influence of metabolic state and body composition on the action of pharmacological treatment of migraine

Migraine is a disabling neurovascular disorder among people of all ages, with the highest prevalence in the fertile years, and in women. Migraine impacts the quality of life of affected individuals tremendously and, in addition, it is associated with highly prevalent metabolic diseases, such as obesity, diabetes mellitus and thyroid dysfunction. Also, the clinical response to drugs might be affected in patients with metabolic disease due to body composition and metabolic change. Therefore, the efficacy of antimigraine drugs could be altered in patients with both migraine and metabolic disease. However, knowledge of the pharmacology and the related clinical effects of antimigraine drugs in patients with metabolic disease are limited. Therefore, and given the clinical relevance, this article provides a comprehensive overview of the current research and hypotheses related to the influence of metabolic state and body composition on the action of antimigraine drugs. In addition, the influence of antimigraine drugs on metabolic functioning and, vice versa, the influence of metabolic diseases and its hormonal modulating medication on migraine activity is outlined. Future exploration on personalizing migraine treatment to individual characteristics is necessary to enhance therapeutic strategies, especially given its increasing significance in recent decades.

Individuals Diagnosed With Type 2 Diabetes Mellitus and the Status of Vitamin B12 Deficiency: A Review

Type 2 diabetes mellitus (T2DM) is a complex metabolic disorder with a multifactorial etiology and a significant global burden. In recent years, emerging evidence has suggested a potential link between T2DM and vitamin B12 deficiency, raising concerns about its impact on disease progression, management, and associated complications. This comprehensive review critically examines the current understanding of the prevalence, risk factors, clinical implications, and management strategies related to vitamin B12 deficiency in individuals diagnosed with T2DM. The review begins by providing an overview of the epidemiology of T2DM and its associated complications, underscoring the need for comprehensive management approaches. Subsequently, it delves into the physiology of vitamin B12, including its sources, absorption mechanisms, and biological functions, laying the groundwork for understanding the potential implications of deficiency in T2DM. A thorough analysis of the literature is conducted to elucidate the prevalence and risk factors of vitamin B12 deficiency in individuals with T2DM, considering factors such as age, duration of diabetes, medication use (e.g., metformin), dietary patterns, and comorbidities. Special attention is given to the role of metformin, the first-line therapy for T2DM, in precipitating or exacerbating vitamin B12 deficiency through mechanisms involving alterations in the gut microbiota and intestinal absorption. The review further explores the clinical manifestations and diagnostic challenges associated with vitamin B12 deficiency in the context of T2DM, emphasizing the importance of recognizing subtle symptoms and implementing appropriate screening protocols. It discusses the potential implications of vitamin B12 deficiency on glycemic control, diabetic neuropathy, cognitive function, cardiovascular health, and overall quality of life in individuals with T2DM. In addressing the management of vitamin B12 deficiency in T2DM, the review examines various therapeutic strategies, including oral and parenteral supplementation, dietary modifications, and lifestyle interventions. It critically evaluates the evidence supporting routine screening for vitamin B12 deficiency in individuals with T2DM and discusses controversies surrounding optimal supplementation protocols, dosing regimens, and monitoring strategies. Furthermore, the review highlights gaps in current knowledge and identifies areas for future research, such as the long-term effects of vitamin B12 supplementation on clinical outcomes in T2DM, the impact of genetic factors on vitamin B12 metabolism, and the potential role of personalized interventions. Overall, this review consolidates existing evidence and provides insights into the complex relationship between T2DM and vitamin B12 deficiency, aiming to inform clinical practice, enhance patient care, and guide future research endeavors in this important area of metabolic medicine.

Prevalence and characteristics of diabetic symmetric sensorimotor polyneuropathy in Japanese patients with type 2 diabetes: The Japan Diabetes Complication and its Prevention Prospective study (JDCP study 10)

This study aimed to investigate the prevalence and characteristics of diabetic symmetric sensorimotor polyneuropathy (DSPN) in patients with type 2 diabetes registered in the Japan Diabetes Complication and its Prevention Prospective study. In the study, 6,338 patients with diabetes who had been treated by diabetes specialists were registered in 2007-2009. Of these, patients with type 2 diabetes who could be evaluated for DSPN were analyzed using the t-test, χ2 -test and logistic regression analyses. DSPN was diagnosed using the Simple Diagnostic Criteria for Diabetic Polyneuropathy proposed by the Diabetic Neuropathy Study Group in Japan. Of the total participants, 5,451 patients (mean age 61.4 years, duration of diabetes 10.8 years) were analyzed. Based on the criteria, 35.8% of patients were diagnosed with DSPN. The prevalence of sensory symptoms was 25.8%. The following factors increased the risk for DSPN: age (odds ratio [OR] 1.57, 95% confidence interval [CI] 1.42-1.73), duration of diabetes (OR 1.32, 95% CI 1.21-1.43), body mass index (OR 1.19, 95% CI 1.09-1.30), systolic blood pressure (OR 1.06, 95% CI 1.01-1.10), hemoglobin A1c (OR 1.15, 95% CI 1.09-1.22), biguanides (OR 1.22, 95% CI 1.06-1.39) and insulin therapy (OR 1.59, 95% CI 1.36-1.84). The following factors decreased the risk for DSPN: total cholesterol (OR 0.98, 95% CI 0.96-1.00) and exercise therapy (OR 0.85, 95% CI 0.73-0.98). The baseline survey clarified the prevalence and characteristics of DSPN in Japanese patients with type 2 diabetes. The survey also showed the risk factors of DSPN.

Nutrition at the Intersection between Gut Microbiota Eubiosis and Effective Management of Type 2 Diabetes

Nutrition is one of the most influential environmental factors in both taxonomical shifts in gut microbiota as well as in the development of type 2 diabetes mellitus (T2DM). Emerging evidence has shown that the effects of nutrition on both these parameters is not mutually exclusive and that changes in gut microbiota and related metabolites such as short-chain fatty acids (SCFAs) and branched-chain amino acids (BCAAs) may influence systemic inflammation and signaling pathways that contribute to pathophysiological processes associated with T2DM. With this background, our review highlights the effects of macronutrients, carbohydrates, proteins, and lipids, as well as micronutrients, vitamins, and minerals, on T2DM, specifically through their alterations in gut microbiota and the metabolites they produce. Additionally, we describe the influences of common food groups, which incorporate varying combinations of these macronutrients and micronutrients, on both microbiota and metabolic parameters in the context of diabetes mellitus. Overall, nutrition is one of the first line modifiable therapies in the management of T2DM and a better understanding of the mechanisms by which gut microbiota influence its pathophysiology provides opportunities for optimizing dietary interventions.

Prevalence and Time Trends of Low Serum B12 Levels and Inadequate B12 Dietary Intake in Lebanese Adults amidst the Food Insecurity Situation: Findings from a Nationally Representative Cross-Sectional Study

Rising food insecurity (FI) and the increased prices of animal-based foods could compromise vitamin B12 (B12) intake and serum levels in food-insecure people. Our study aims to determine the prevalence of low levels of serum B12 and its inadequate dietary intake among a nationally representative sample of Lebanese adults aged 18 to 64 years, while exploring the impact of FI and identifying other potential predictors. The B12 intake was assessed using a food frequency questionnaire and the mean of two non-consecutive 24 h recalls. The B12 serum levels were also examined. To examine the time trends in the B12 serum levels and dietary intake, the data from a large representative digitized database of 6290 participants were collected, along with the examination of FAOSTAT food consumption data both before and during the economic crisis period. Our findings revealed that 47.3% of households in Lebanon experienced FI. The inadequate intake of B12 food sources was prevalent in 52.5% of participants, and 61.1% presented with low (23%) or intermediate (38.1%) levels of serum B12. The food-secure households had a higher proportion of B12 intake from meats (p = 0.004), while traditional foods contributed more to food-insecure households (p = 0.000). The participants who were female, unemployed, food-insecure, and had low dietary diversity were about two to three times more likely to have inadequate B12 intake. The predictors of low levels of serum B12 included residing in Beqaa (OR = 2.856 and 95% CI = 1.018-8.01) and having inadequate B12 intake (OR = 1.788 and 95% CI = 1.2-2.65). The findings from observing the time trends in the consumption and the serum levels of B12 indicate a considerable decline in the consumption of most animal-based foods compared to the pre-crisis period, associated with a decline in the serum levels of B12. In conclusion, an alarming prevalence of low dietary intake and low serum levels of B12 was revealed among Lebanese adults, and the indirect effect of FI on B12 serum levels mediated through B12 intake was inferred.

Effects of vitamin B12 supplementation on oxidative stress markers and pro-inflammatory cytokines during pregnancy and postpartum among Bangladeshi mother-child pairs

BACKGROUND

There is limited research to determine whether vitamin B12 (B12) supplementation during pregnancy and lactation is protective against oxidative stress and pro-inflammatory cytokines and whether this effect is transferred to breastfed infants via milk. In addition, associations among maternal plasma/ milk and infant B12 status and immune function markers are poorly characterized.

OBJECTIVES

To evaluate effects of oral B12 supplementation during pregnancy and postpartum on maternal and infant 8-hydroxy-2'-deoxyguanosine (8-OH-dG, an oxidative stress marker) and proinflammatory cytokine levels, and examine associations between maternal plasma, breastmilk and infant B12 status as well as immune function markers.

METHOD

In a blinded, placebo-controlled trial, Bangladeshi women (n = 68, 18-35 years, hemoglobin < 11 g/dL, gestational weeks 11-14) received either 250 μg/day B12 or placebo throughout pregnancy up to 3-months postpartum. Samples were collected from mothers at baseline and 3-months postpartum and from infants at 3-months to measure B12 status indicators, 8-OH-dG and proinflammatory cytokines.

RESULTS

Maternal postpartum B12 was positively associated with infant plasma B12. Higher milk B12 concentrations were associated with increased infant B12 (beta (β) = 277, 95% confidence interval (CI) = (132, 423), p<0.001) and lower total homocysteine (β = -7.63, 95% CI = (-12.40, -2.86), p = 0.002) levels. Maternal B12 supplementation reduced plasma 8-OH-dG concentrations among postpartum mothers and infants compared to the placebo group. Supplementation increased plasma TNF-α and IL-6 levels among mothers and IL-10 and IFN-γ levels among infants.

CONCLUSION

Milk and maternal plasma B12 at 3 months were associated with infant B12. Maternal B12 supplementation modulates 8-OH-dG and several cytokines which may protect against immune response-induced oxidative stress.

TRIAL REGISTRATION

(clinicaltrials.gov: NCT01795131- 1st posted on 20/02/2013).

Prevalence and characteristics of diabetic symmetric sensorimotor polyneuropathy in Japanese patients with type 2 diabetes: the Japan Diabetes Complication and its Prevention Prospective study (JDCP study 10)

Aim/introduction

This study aims to investigate the prevalence and characteristics of diabetic symmetric sensorimotor polyneuropathy (DSPN) in patients with type 2 diabetes registered in the Japan Diabetes Complication and its Prevention Prospective (JDCP) study.

Materials and methods

In the study, 6338 patients with diabetes who had been treated by diabetes specialists were registered in 2007-2009. Of these, patients with type 2 diabetes who could be evaluated for DSPN were analyzed using t test, chi-square test, and logistic regression analyses. DSPN was diagnosed using the Simple Diagnostic Criteria for Diabetic Polyneuropathy proposed by the Diabetic Neuropathy Study Group in Japan.

Results

Of the total participants, 5451 patients (mean age 61.4 years old and duration of diabetes 10.8 years) were analyzed. Based on the criteria, 35.8% of patients were diagnosed with DSPN. The prevalence of sensory symptoms was 25.8%. The following factors increased risk for DSPN: age [odds ratio (OR) 1.57, 95% confidence intervals (CI) 1.42-1.73], duration of diabetes (OR 1.32, 95% CI 1.21-1.43), body mass index (OR 1.19, 95% CI 1.09-1.30), systolic blood pressure (OR 1.06, 95% CI 1.01-1.10), hemoglobin A1c (OR 1.15, 95% CI 1.09-1.22), biguanides (OR 1.22, 95% CI 1.06-1.39), and insulin therapy (OR 1.59, 95% CI 1.36-1.84). The following factors decreased risk for DSPN: total cholesterol (OR 0.98, 95% CI 0.96-1.00) and exercise therapy (OR 0.85, 95% CI 0.73-0.98).

Conclusions

The baseline survey clarified the prevalence and characteristics of DSPN in Japanese patients with type 2 diabetes. The survey also revealed the risk factors of DSPN.

The importance of neurotropic vitamins in the prevention and adjuvant therapy of peripheral neuropathy - A pharmacist's comprehensive view

The importance of neurotropic vitamins in the prevention and adjuvant therapy of peripheral neuropathy - A pharmacist's comprehensive view Peripheral neuropathy is one of the most common neurological diseases of the peripheral nervous system. According to current statistics, it affects 2.4% of the Czech population, and its prevalence continues to increase with age. The possibilities of its treatment are to a large extent limited, and its effectiveness and the patient's tolerance of pharmacotherapy are individual. Neurotropic vitamins, which support the function of neurons and contribute to their protection and regeneration, represent a promising possibility for prevention and use in adjuvant therapy for patients suffering from this disease. Despite the fact that the diagnosis and treatment of peripheral neuropathy belong to the doctor, the role of the pharmacist can be crucial not only in the area of ensuring effective and safe pharmacotherapy and adherence to it, but also in pre-screening of at-risk persons visiting pharmacies. The primary aim of the article is therefore to familiarize readers with the significance of neurotropic vitamins in the prevention and adjunct therapy of peripheral neuropathy, as well as the role of the pharmacist in the care of patients suffering from this condition.