Metformin and the intestine

Abstract

To the Editor: The antihyperglycaemic effect of metformin is generally attributed to a decrease in hepatic glucose output, with some additional effects that increase peripheral glucose uptake and utilisation [1]. The intestine also makes an important contribution to the glucose-lowering effect of metformin, but this is often overlooked because of a paucity of clinical data [2]. Animal studies indicate that metformin can cause intestinal glucose absorption to be delayed and occur more distally along the tract [3, 4]. However, animal studies have also shown that metformin increases glucose utilisation by the intestine, particularly anaerobic glucose metabolism [5–7], and this contributes to an apparent shortfall in the passage of glucose from the luminal to the serosal side of the intestine [3]. Extra lactate delivered into the portal vein is at least partly converted into glucose, increasing glucose turnover after administration of metformin [5,7,8]. We demonstrate here that metformin increases lactate production in human intestinal mucosa, similar to reports in animal studies. Animal studies have long established that very high concentrations of metformin accumulate in the wall of the intestine [9], which may at least partly explain the increase in anaerobic metabolism. We provide confirmatory evidence herein that similarly high concentrations of metformin accumulate in the human intestinal mucosa. In the present study, eight recently diagnosed, drug-naive, obese type 2 diabetic patients [five men, three women; age 55±3 years (mean±SEM); BMI 33±1 kg/m] attended on three occasions after an overnight fast. Patients gave informed consent, and ethical approval was granted by the research ethics committee. Avenous blood sample was taken for plasma glucose assay (automated glucose oxidase method), and a mucosal biopsy sample (approximately 25 mg) was taken on each occasion from the proximal jejunum, under light midazolam sedation, using an adapted paediatric gastroscope. On the first occasion, tissue was washed, divided into two portions, weighed and then incubated for 2 h at 37°C in 1 ml of Krebs Ringer bicarbonate buffer supplemented with 20 mg/ml serum albumin, 10 mmol/l glucose, 10 mol/l insulin with or without 10 mol/l metformin hydrochloride, and maintained in an atmosphere of 95% O2, 5% CO2 [4, 5]. Lactate production was measured as the concentration of lactate in the medium (manual spectrophotometric method). Metformin therapy was initiated at a dosage of 850 mg once daily and titrated up to twice daily after 2–3 weeks. Two repeat proximal jejunal mucosal biopsies were obtained after 6–8 weeks of therapy. A pre-dose sample was obtained in the morning, 12–16 h after the last metformin tablet (taken the evening before), and a post-dose sample was taken 3 h after the morning tablet. Tissue samples were washed in buffered saline, blotted and weighed, and then metformin was extracted with acetonitrile and assayed by gas chromatography [10]. The results showed that incubation of the jejunal biopsy tissue with 10 mol/l metformin increased lactate producDiabetologia (2008) 51:1552–1553 DOI 10.1007/s00125-008-1053-5