Mechanism of Metformin Action in Non-Insulin-Dependent Diabetes

Abstract

The mechanism of action of metformin was studied by comparing glucose turnover before and after a 75-g oral glucose load in 10 nonobese men with noninsulin-dependent diabetes mellitus (NIDDM) during metformin and placebo therapy by the combined application of the forearm and double-isotope techniques. During the study, 9 of the 10 patients were regularly receiving glibenclamide therapy. In 5 of the men, the first study was performed during metformin therapy, and the second study was done during placebo administration; in the other 5 subjects, the order was reversed. The interval between the studies was at least 3 mo. The metformin dosage was 1 g twice daily in 9 of the patients and 850 mg thrice daily in the 10th subject. In the basal state, metformin administration reduced plasma glucose levels from 172 ± 14 to 103 ± 9 mg/dl (P < .005), hepatic glucose output (HGO) from 2.67 ± 0.15 to 2.20 ± 0.20 mg · kg−1 · min−1 (P < .02), and forearm glucose uptake (FGU) from 0.106 ± 0.18 to 0.039 ± 0.016 mg · 100 ml−1 forearm · min−1 (P < .005), whereas insulin (23 ± 6 μU ml) and lactate (1.56 ± 0.18 mM) levels were unchanged. Although the oral glucose tolerance curve (OGTC) was significantly lowered by metformin, the incremental area under the curve and the insulin response were unchanged. The systemic appearance of ingested glucose was unaffected by metformin; 64 ± 2% of the load was recovered peripherally in 3 h. The rise in FGU and total glucose disappearance in 3 h after glucose loading was unaffected by metformin. From 0 to 180 min after glucose loading, HGO was suppressed by 45.3 and 44.5% of the corresponding basal value without and with metformin treatment, respectively. Peak lactate levels were noted 90 min after glucose loading and were increased during metformin treatment from 2.10 ± 0.23 to 2.92 ± 0.32 mM (P < .05). We conclude that 1) metformin markedly lowers the OGTC in NIDDM; 2) lowering of the OGTC is due entirely to a fall in the basal glucose concentration; and 3) because fasting insulin levels were unchanged, the reduction in basal HGO and fasting glucose concentrations by metformin is the result of a druginduced increase in hepatic insulin sensitivity.