Metformin with Versus without Concomitant Probiotic Therapy in Newly Diagnosed Patients with Type 2 Diabetes or Prediabetes: A Comparative Analysis in Relation to Glycemic Control, Gastrointestinal Side Effects, and Treatment Compliance

Gastrointestinal adverse effects of old and new antidiabetics: How do we deal with them in real life?

Diabetes is a public health problem with an estimated worldwide prevalence of 10% and a prevalence of 12% in Mexico. The costs resulting from this chronic-degenerative disease are significant. Treatment for diabetes involves different medication groups, some of which can cause significant gastrointestinal adverse effects, such as dyspepsia, nausea, vomiting, bloating, diarrhea, and constipation. The medications most frequently associated with said adverse effects are metformin, acarbose, and GLP-1 agonists. Gastrointestinal adverse effects negatively impact the quality of life and management of patients with diabetes. The factors of visceral neuropathy, acute dysglycemia, dysbiosis, and intestinal bacterial overgrowth contribute to the gastrointestinal symptoms in patients with diabetes, making it necessary to consider multiple etiologic factors in the presence of gastrointestinal symptoms, and not exclusively attribute them to the use of antidiabetics. Personalized treatment, considering gastrointestinal comorbidity and the type of drug utilized, is essential for mitigating the adverse effects and improving the quality of life in patients with diabetes. The aim of the present narrative review was to describe the gastrointestinal adverse effects of the antidiabetic drugs, their pathophysiologic mechanisms, and the corresponding therapeutic measures.

Current type 2 diabetes guidelines: Individualized treatment and how to make the most of metformin

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.

Metabolic Alteration Bridging the Prediabetic State and Colorectal Cancer

Prediabetes and colorectal cancer (CRC) represent compelling health burdens responsible for high mortality and morbidity rates, sharing several modifiable risk factors. It has been hypothesized that metabolic abnormalities linking prediabetes and CRC are hyperglycemia, hyperinsulinemia, and adipokines imbalance. The chronic stimulation related to these metabolic signatures can favor CRC onset and development, as well as negatively influence CRC prognosis. To date, the growing burden of prediabetes and CRC has generated a global interest in defining their epidemiological and molecular relationships. Therefore, a deeper knowledge of the metabolic impairment determinants is compelling to identify the pathological mechanisms promoting the onset of prediabetes and CRC. In this scenario, this review aims to provide a comprehensive overview on the metabolic alterations of prediabetes and CRC as well as an overview of recent preventive and therapeutic approaches for both diseases, focusing on the role of the metabolic state as a pivotal contributor to consider for the development of future preventive and therapeutic strategies.

Bifidobacteria in disease: from head to toe

Bifidobacteria as a strictly anaerobic gram-positive bacteria, is widely distributed in the intestine, vagina and oral cavity, and is one of the first gut flora to colonize the early stages of life. Intestinal flora is closely related to health, and dysbiosis of intestinal flora, especially Bifidobacteria, has been found in a variety of diseases. Numerous studies have shown that in addition to maintaining intestinal homeostasis, Bifidobacteria may be involved in diseases covering all parts of the body, including the nervous system, respiratory system, genitourinary system and so on. This review collects evidence for the variation of Bifidobacteria in typical diseases among various systems, provides mild and effective therapeutic options for those diseases that are difficult to cure, and moves Bifidobacteria from basic research to further clinical applications.

Comparative efficacy and safety of probiotics, prebiotics, and synbiotics for type 2 diabetes management: A systematic review and network meta-analysis

AIMS

To compare the effects of probiotics, prebiotics, and synbiotics for type 2 diabetes (T2D) management.

METHODS

We searched PubMed, Scopus, CENTRAL, and grey literature sources to December 2022 for randomized trials of the impacts of probiotics, prebiotics, or synbiotics in patients with T2D. We performed network meta-analyses with a Bayesian framework to calculate mean difference [MD] and 95 % credible interval [CrI] and rated the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

68 randomised trials were included. All results are presented in comparison to the placebo. Supplementation with probiotics (MD: -0.25 %, 95%CrI: -0.42, -0.08; GRADE = moderate) and synbiotics (MD: -0.31 %, 95%CrI: -0.61, -0.04; GRADE = very low) resulted in a trivial/unimportant decrease in glycated hemoglobin. Supplementation with probiotics (MD: -0.69 mmol/L, 95%CrI: -0.98, -0.40; GRADE = very low) and synbiotics (MD: -0.82 mmol/L, 95%CrI: -1.22, -0.43; GRADE = very low) resulted in a trivial/unimportant decrease in fasting plasma glucose. Supplementation with probiotics resulted in a small but important decrease in low-density lipoprotein cholesterol (MD: -0.19 mmol/L; 95%CrI: -0.34, -0.05; GRADE = very low). Supplementations had moderate effects on serum triglyceride (GRADE = low).

CONCLUSIONS

Existing evidence is uncertain and does not support supplementation with probiotics, prebiotics, and synbiotics for T2D management.

Probiotics and Their Role in the Management of Type 2 Diabetes Mellitus (Short-Term Versus Long-Term Effect): A Systematic Review and Meta-Analysis

Diabetes is a major economic burden and an illness with a rising incidence worldwide. Type 2 diabetes mellitus (T2DM), the most prevalent kind of diabetes, is characterized by insulin resistance and insufficient insulin production. Recent research has implicated gut microbiota dysbiosis as a contributing factor to T2DM pathogenesis. The present study employed a methodology based on randomized controlled trials (RCTs) to assess the therapeutic efficacy of probiotics in the treatment of T2DM. A thorough search was done in PubMed and Medline for articles written in English and published between 2017 and 2023. Studies were chosen based on predetermined inclusion criteria, and the search technique adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) principles. This study also employed a robust assessment instrument, widely recognized in the medical and health sciences, to evaluate the potential presence of bias within the selected research studies. Out of 96 identified articles, 22 RCTs met the eligibility criteria. Both short-term (8 weeks or less) and long-term (12 weeks or more) probiotic administrations were made. The results of the meta-analysis demonstrated a significant improvement in the homeostatic model assessment of insulin resistance (HOMA-IR) following the probiotic intervention (P=0.02) and considerably decreased glycated hemoglobin HbA1c levels (P=0.004) and fasting blood glucose (FBG) levels (P<0.0001) in T2DM patients compared to placebo. This research offers proof that probiotics are clinically effective in the treatment of T2DM. Probiotic supplementation demonstrated favorable effects on glycemic control markers. However, the findings from RCTs were heterogeneous, and some studies showed inconsistent results. To clarify the processes underlying the probiotics' therapeutic benefits and to determine the best probiotic strains, doses, and therapy durations, more research is required. Nevertheless, probiotics offer a promising therapeutic approach for T2DM management and warrant consideration as a potential adjunct therapy in clinical practice.

Pharmacometabolomic Approach to Investigate the Response to Metformin in Patients with Type 2 Diabetes: A Cross-Sectional Study

Metformin constitutes the foundation therapy in type 2 diabetes (T2D). Despite its multiple beneficial effects and widespread use, there is considerable inter-individual variability in response to metformin. Our objective is to identify metabolic signatures associated with poor and good responses to metformin, which may improve our ability to predict outcomes for metformin treatment. In this cross-sectional study, clinical and metabolic data for 119 patients with type 2 diabetes taking metformin were collected from the Qatar Biobank. Patients were empirically dichotomized according to their HbA1C levels into good and poor responders. Differences in the level of metabolites between these two groups were compared using orthogonal partial least square discriminate analysis (OPLS-DA) and linear models. Good responders showed increased levels of sphingomyelins, acylcholines, and glutathione metabolites. On the other hand, poor responders showed increased levels of metabolites resulting from glucose metabolism and gut microbiota metabolites. The results of this study have the potential to increase our knowledge of patient response variability to metformin and carry significant implications for enabling personalized medicine.

Effects of combined treatment of probiotics and metformin in management of Type 2 diabetes: A systematic review and meta-analysis

BACKGROUND

Lifestyle changes and dietary intervention, including the use of probiotics, can modulate dysbiosis of gut microbiome and contribute to the management of type 2 diabetes mellitus (T2DM). This systematic review and meta-analysis aim to assess the efficacy of metformin plus probiotics versus metformin alone on outcomes in patients with T2DM.

METHODS

We searched MEDLINE and EMBASE from inception to February 2023 to identify all randomized controlled trials (RCTs), which compared the use of metformin plus probiotics versus metformin alone in adult patients with T2DM. Data were summarized as mean differences (MD) with 95% confidence interval (CI) and pooled under the random effects model. Findings Fourteen RCTs (17 comparisons, 1009 patients) were included in this systematic review. Pooled results show a significant decrease in fasting glucose (FG) (MD=-0.64, 95% CI=-1.06, -0.22) and HbA1c (MD=-0.29, 95% CI=-0.47, -0.10) levels in patients with T2DM treated with metformin plus probiotics versus metformin alone. The addition of probiotics to metformin resulted in lower odds of gastrointestinal adverse events (Odds ratio=0.18, 95% CI=0.09, 0.3.8; I²=0%).

CONCLUSIONS

The addition of probiotics to metformin therapy is associated with improvement in T2DM outcomes. However, high-quality and adequately reported RCTs are needed in the future to confirm our findings.

Effects of probiotic/synbiotic supplementation on body weight in patients with diabetes: a systematic review and meta-analyses of randomized-controlled trials

OBJECTIVE

The aim of the present study was to assess the effect of probiotic/synbiotic supplementation on anthropometric measures in adults with diabetes, independent of body weight.

METHODS

PubMed, Scopus, Web of Sciences and the Cochrane Library were searched for randomized controlled trials (RCTs) up until December 14, 2022. The effect sizes were pooled using an inverse-variance random-effects model. The methodological quality of studies as well as the quality of evidence was assessed using standard tools.

RESULTS

Thirty-two RCTs met the established inclusion criteria. Overall, compared with the respective control groups, probiotic/synbiotic supplementation resulted in a significant reduction in body weight (weighted mean difference [WMD]: -0.50 kg; 95% CI: -0.83, -0.17; I² = 79.8%, n = 27 studies]), body mass index (WMD: -0.24 kg/m²; 95% CI: -0.39, -0.09; I² = 85.7%, n = 30 studies), and waist circumference (WMD: -0.90 cm; 95% CI: -1.13, -0.52; I² = 0%, n = 11 studies). However, hip circumference and waist to hip ratio were not significantly improved.

CONCLUSIONS

Our analysis revealed that probiotic/synbiotic supplementation may assist with weight management in patients with diabetes, especially when consumed at higher doses, in younger adults, and in participants with obesity. However, more studies are needed to elucidate the anti-obesity effects of specific strains of probiotics/synbiotics.