Early Diagnosis through Estimation of Inflammatory Biomarkers and the Neuroprotective Role of Metformin in Diabetic Peripheral Neuropathy
DOI:
https://doi.org/10.37285/ijpsn.2023.16.2.5Abstract
Purpose: Diabetic peripheral neuropathy (DPN), a chronic neurological complication of type 2 diabetes mellitus (T2DM) with signs and symptoms of peripheral nerve dysfunction such as numbness, tingling or burning sensation, paresthesias etc. Several lacunae exist in relation to the cause and effect of DPN. Therefore diagnosis, as well as treatment of DPN remains unsatisfactory. The involvement of chronic low-grade inflammation in DPN is a rapidly emerging concept and therefore the present study adds weight to it. We estimated some of the biomarkers of inflammation which may be the early markers of DPN. This study is the earliest of its kind to correlate the biomarker levels with metformin, a drug less reported in terms of its anti-inflammatory and neuroprotective activity.
Methods: After approval from the institutional human ethical committee, 90 patients attending the outpatient ward of a tertiary care hospital were included in the study. They were divided into two groups: M- group (patients on non metformin) and M+ group (patients on metformin). 5ml serum sample from each patient was processed for estimation of IL-1, IL-6, IL-8, TNF- α, INF- α, GMCSF and MCP-1 according to the manufacturer’s instructions on the commercially available ELISA kit. Metformin levels in the serum were estimated by HPLC. Data was put into statistical analysis.
Results: Results showed that IL-1, IL-2, IL-6 and TNF- α were significantly higher in the M- group. The difference was statistically significant between the two groups. The level of biomarkers showed a negative correlation with drug levels in the initial 2m treatment with the drug but was not statistically significant. However, after 6m treatment with metformin the correlation was found to be of statistical significance.
Conclusion: we conclude that these biomarkers can be work tested for their clinical utility to be used as diagnostic tools for early detection of DPN and short-term metformin treatment greatly benefits DPN patients. Longitudinal studies may be more insightful as to the long term neuroprotective action of metformin.
Downloads
Metrics
Keywords:
Metformin, inflammation, t2DM, DPN, neuroprotective, biomarkers
Downloads
Published
How to Cite
Issue
Section
References
Maser RE, Steenkiste AR, Dorman JS et al. Epidemiological correlates of diabetic neuropathy. Report from Pittsburgh epidemiology of diabetes complications study. Diabetes. 1989; 38:1456–1461.
Trivedi S, Pandit A, Ganguly G, Das SK. Epidemiology of peripheral neuropathy: an indian perspective. Ann Indian Acad Neurol. 2017; 20(3):173–184.
Tesfaye S, Boulton AJM, Dyck PJ, Freeman R, Horowitz M, Kempler P, Lauria G, Malik RA, Spallone V, Vinik A, Bernardi L, Valensi P. on behalf of the Toronto Diabetic Neuropathy Expert Group Diabetes Care Diabetic neuropathies: update on definitions, diagnostic criteria, estimation of severity, and treatments. Diabetes Care. 2010; 33(12):2725.
American Diabetes Association Standards of medical care in diabetes. Diabetes Care. 2015; 38:S4.
Coppini DV, Bowtell PA, Weng C, Young PJ, Sönksen PH. Showing neuropathy is related to increased mortality in diabetic patients—a survival analysis using an accelerated failure time model. J Clin Epidemiol. 2000; 53(5):519–523.
Pop-Busui R, Ang L, Holmes C, Gallagher K, Feldman EL. Inflammation as a therapeutic target for diabetic neuropathies. Curr Diab Rep. 2016; 16(3):29.
Duncan BB, Schmidt MI, Pankow JS, Ballantyne CM, Couper D, Vigo A, Hoogeveen R, Folsom AR, Heiss G. Atherosclerosis risk in communities study. Low-grade systemic inflammation and the development of type 2 diabetes: the atherosclerosis risk in communities study. Diabetes. 2003; 52(7):1799–1805.
Pradhan AD, Manson JE, Rifai N, Buring JE, Ridker PM. C-reactive protein, interleukin 6, and risk of developing type 2 diabetes mellitus. JAMA. 2001; 286(3):327–334.
Schmidt MI, Duncan BB, Sharrett AR, Lindberg G, Savage PJ, Offenbacher S, Azambuja MI, Tracy RP, Heiss G. Markers of inflammation and prediction of diabetes mellitus in adults (atherosclerosis risk in communities study): a cohort study. Lancet.1999; 353(9165):1649–1652.
Hotamisligil GS. Inflammation and metabolic disorders. Nature. 2006; 444(7121):860–867.
Goldfine AB, Silver R, Aldhahi W, Cai D, Tatro E, Lee J, Shoelson SE. Use of salsalate to target inflammation in the treatment of insulin resistance and type 2 diabetes. Clin Transl Sci. 2008; 1(1):36–43.
Cameron NE, Cotter MA. Pro-inflammatory mechanisms in diabetic neuropathy: focus on the nuclear factor kappa B pathway. Curr Drug Targets. 2008; 9(1):60–67.
Goldberg RB. Cytokine and cytokine-like inflammation markers, endothelial dysfunction, and imbalanced coagulation in development of diabetes and its complications. J Clin Endocrinol Metab. 2009; 94(9):3171–3182.
Shoelson SE, Goldfine AB. Getting away from glucose: fanning the flames of obesity-induced inflammation. Nat Med. 2009; 15(4):373–374.
Kellogg AP, Wiggin TD, Larkin DD, Hayes JM, Stevens MJ, Pop-Busui R Protective effects of cyclooxygenase-2 gene inactivation against peripheral nerve dysfunction and intraepidermal nerve fiber loss in experimental diabetes. Diabetes. 2007; 56(12):2997–3005.
Hotamisligil GS Inflammation and metabolic disorders. Nature. 2006; 444(7121):860–867.
Libby P, Ridker PM, Maseri A. Inflammation and atherosclerosis. Circulation. 2002; 105(9):1135–1143.
Mora C, Navarro JF. Inflammation and diabetic nephropathy. Curr Diab Rep. 2006; 6(6):463–468.
Lopes-Virella MF, Carter RE, Gilbert GE, Klein RL, Jaffa M, Jenkins AJ, Lyons TJ, Garvey WT, Virella G, and the DCCT/EDIC Cohort Study Group. Risk factors related to inflammation and endothelial dysfunction in the DCCT/EDIC cohort and their relationship with nephropathy and macrovascular complications. Diabetes Care. 2008; 31(10):2006–2012.
Rossi et al. Interleukin-8 is associated with acute and persistent dysfunction after optic neuritis. Multiple Sclerosis. 2014; 20(14).DOI:10.1177/1352458514537365
Wile DJ, Toth C. Association of metformin, elevated homocysteine, and methylmalonic acid levels and clinically worsened diabetic peripheral neuropathy. Diabetes Care. 2010; 33(1):156–61
Singh AK, Kumar A, Karmakar D, Jha RK. Association of B12 deficiency and clinical neuropathy with metformin use in type 2 diabetes patients. J Postgrad Med. 2013; 59:253–7. doi:10.4103/0022-3859.123143
Gupta K, Jain A, Rohatgi A. An observational study of vitamin b12 levels and peripheral neuropathy profile in patients of diabetes mellitus on metformin therapy. Diabetes Metab Syndr. 2018; 12:51–8. doi:10.1016/j.dsx.2017.08.014
Russo GT, Giandalia A, Romeo EL, Scarcella C, Gambadoro N, Zingale R, et al. Diabetic neuropathy is not associated with homocysteine, folate, vitamin B12 levels, and MTHFR C677T mutation in type 2 diabetic outpatients taking metformin. J Endocrinol Invest. 2016; 39(3): 305–14.
Chen S, Lansdown AJ, Moat SJ, Ellis R, Goringe A, Dunstan FDJ, et al. An observational study of the effect of metformin on B12 status and peripheral neuropathy. British J Diabetes Vascular Dis. 2012; 12:189–93
Biemans E, Hart HE, Rutten GE, Cuellar Renteria VG, Kooijman-Buiting AM, Beulens JW. Cobalamin status and its relation with depression, cognition and neuropathy in patients with type 2 diabetes mellitus using metformin. Acta Diabetol. 2014; 52(2):383–93. Doi: 10.1007/s00592-014- 0661-4.
Moein Ala, Mahan Ala. Metformin for Cardiovascular Protection, Inflammatory Bowel Disease, Osteoporosis, Periodontitis, Polycystic Ovarian Syndrome, Neurodegeneration, Cancer, Inflammation and Senescence: What Is Next? ACS Pharmacol. Transl. Sci. 2021; 4, 6, 1747–1770. https://doi.org/10.1021/acsptsci.1c00167
de Groot-Kamphuis DM, van Dijk PR, Groenier KH, Houweling ST, Bilo HJ, Kleefstra N. Vitamin B12 deficiency and the lack of its consequences in type 2 diabetes patients using metformin. Neth J Med. 2013; 71:386–90.
Ahmed MA, Muntingh G, Rheeder P. Vitamin B12 deficiency in metformin-treated type-2 diabetes patients, prevalence and association with peripheral neuropathy. BMC Pharmacol Toxicol. 2016; 17:44. doi:10.1186/s40360-016-0088-3
Elhadd T, Ponirakis G, Dabbous Z, Siddique M, Chinnaiyan S and Malik RA. Metformin Use Is Not Associated With B12 Deficiency or Neuropathy in Patients With Type 2 Diabetes Mellitus in Qatar. Front. Endocrinol. 2018; 9:248. doi: 10.3389/fendo.2018.00248
Taylor, A., Westveld, A. H., Szkudlinska, M., Guruguri, P., Annabi, E., Li, Z., et al. The use of metformin is associated with decreased lumbar radiculopathy pain. J Pain Res. 2013; 6, 755–763. doi: 10.2147/JPR.S52205
Megat S, Price TJ. Therapeutic opportunities for pain medicines via targeting of specific translation signaling mechanisms. Neurobiol Pain. 2018; 4:8-19. doi:10.1016/j.ynpai.2018.02.001
Corinne G. Jolivalt, et al. peripheral neuropathy in mouse models of diabetes. curren proto in mouse biol. 2016. doi.org/10.1002/cpmo.11
Qi-Liang Mao-Ying, Annemieke Kavelaars et al. The anti-diabetic drug metformin protects against chemotherapy-induced peripheral neuropathy in a mouse model. Pone. 2014. doi.org/10.1371/journal.pone.0100701
Baeza-Flores GDC, Guzmán-Priego CG, Parra-Flores LI, Murbartián J, Torres-López JE and Granados-Soto V. Metformin: A Prospective Alternative for the Treatment of Chronic Pain. Front. Pharmacol. 2020; 11:558474. doi: 10.3389/fphar.2020.558474
Falcão-Pereira, A., Silva-Pereira, et al. Metformin reduces c-Fos and ATF3 expression in the dorsal root ganglia and protects against oxaliplatin-induced peripheral sensory neuropathy in mice. Neurosci. Lett. 2019; 709:134378. doi: 10.1016/j.neulet.2019.134378
Ludman, T., Melemedjian, O. K. Bortezomib and metformin opposingly regulate the expression of hypoxia-inducible factor alpha and the consequent development of chemotherapy-induced painful peripheral neuropathy. Mol. Pain. 2019; 15:1744806919850043.
doi: 10.1177/1744806919850043
Zhang, M., Feng, R., Yue, J., Qian, C., Yang, M., Liu, W., et al. Effects of metformin and sitagliptin monotherapy on expression of intestinal and renal sweet taste receptors and glucose transporters in a rat model of type 2 diabetes. Horm. Metab. Res. 2020; 52 (5), 329–335. doi: 10.1055/a-1135-9031
Liu, Y., Li, J., Li, H., Shang, Y., Guo, Y., Li, Z., et al. AMP-Activated protein kinase activation in dorsal root ganglion suppresses mTOR/p70S6K signaling and alleviates painful radiculopathies in lumbar disc herniation rat model. Spine. 2019; 44 (15), E865–E872. doi: 10.1097/BRS.000000000000 3005
Yadav, S. K., Nagori, B. P., Desai, P. K. Pharmacological characterization of different fractions of Calotropis procera (Asclepiadaceae) in streptozotocin induced experimental model of diabetic neuropathy. J. Ethnopharmacol. 2014; 152 (2), 349–357. doi: 10.1016/j.jep.2014.01.020
Byrne, F. M., Cheetham, S., Vickers, S., Chapman, V. Characterisation of pain responses in the high fat diet/streptozotocin model of diabetes and the analgesic effects of antidiabetic treatments. J. Diabetes Res. 2015; 2015, 752481. doi: 10.1155/2015/752481
Ma, J., Yu, H., Liu, J., Chen, Y., Wang, Q., Xiang, L. Metformin attenuates hyperalgesia and allodynia in rats with painful diabetic neuropathy induced by streptozotocin. Eur. J. Pharmacol. 2015; 764, 599–606. doi: 10.1016/j.ejphar.2015.06.010.
Hasanvand, A., Amini-Khoei, H., Hadian, M. R., Abdollahi, A., Tavangar, S. M., Tavangar, S. M., et al. Anti-inflammatory effect of AMPK signaling pathway in rat model of diabetic neuropathy. Inflammopharmacology. 2016; 24 (5), 207–219. doi: 10.1007/s10787-016-0275-2
Barragán-Iglesias, P., Oidor-Chan, V. H., Loeza-Alcocer, E., Pineda-Farias, J. B., Velazquez-Lagunas, I., Salinas-Abarca, A. B., et al. Evaluation of the neonatal streptozotocin model of diabetes in rats: Evidence for a model of neuropathic pain. Pharmacol. Rep. 2018; 70 (2), 294–303. doi: 10.1016/j.pharep.2017.09.002
García, G., Gutiérrez-Lara, E. J., Centurión, D., Granados-Soto, V., Murbartián, J. Fructose-induced insulin resistance as a model of neuropathic pain in rats. Neuroscience. 2019; 404, 233–245. doi: 10.1016/j.neuroscience.2019.01.063
Norsted-Gregory, E., Codeluppi, S., Gregory, J. A., Steinauer, J., Svensson, C. Mammalian target of rapamycin in spinal cord neurons mediates hypersensitivity induced by peripheral inflammation. Neuroscience. 2010; 169 (3), 1392–1402. doi: 10.1016/j.neuroscience.2010.05.067
Bullón, P., Alcocer-Gómez, E., Carrión, A. M., Marín-Aguilar, F., Garrido-Maraver, J., Román-Malo, L., et al. AMPK phosphorylation modulates pain by activation of NLRP3 inflammasome. Antioxid. Redox Signal. 2016; 24 (3), 157–170. doi: 10.1089/ars.2014.6120
Inyang, K. E., McDougal, T. A., Ramirez, E. D., Williams, M., Laumet, G., Kavelaars, A., et al. Alleviation of paclitaxel-induced mechanical hypersensitivity and hyperalgesic priming with AMPK activators in male and female mice. Neurobiol. Pain. 2019; 6, 100037. doi: 10.1016/j.ynpai.2019.100037
Burton, M. D., Tillu, D. V., Mazhar, K., Mejia, G. L., Asiedu, M. N., Inyang, K., et al. Pharmacological activation of AMPK inhibits incision-evoked mechanical hypersensitivity and the development of hyperalgesic priming in mice. Neuroscience. 2017; 359, 119–129. doi: 10.1016/j.neuroscience.2017.07.020
Tanaka Y, Uchino H, Shimizu T, et al. Effect of metformin on advanced glycation endproduct formation and peripheral nerve function in streptozotocin-induced diabetic rats. Eur J Pharmacol. 1999; 376:17–22.
Lin JY, Huang XL, Chen J, et al. Stereological study on the number of synapses in the rat spinal dorsal horn with painful diabetic neuropathy induced by streptozotocin. Neuroreport. 2017; 28:319–324.
Lin JY, He YN, Zhu N, et al. Metformin attenuates increase of synaptic number in the rat spinal dorsal horn with painful diabetic neuropathy induced by type 2 diabetes: a stereological study. Neurochem Res. 2018; 43:2232–2239.
Los DB, Oliveira WH, Duarte-Silva E, et al. Preventive role of metformin on peripheral neuropathy induced by diabetes. Int Immunopharmacol. 2019; 74:105672.
Kim SH, Park TS, Jin HY. Metformin preserves peripheral nerve damage with comparable effects to alpha lipoic acid in streptozotocin/high-fat diet induced diabetic rats. Diabetes Metab J. 2020
Alcocer-Gómez, E., Garrido-Maraver et al. Metformin and caloric restriction induce an AMPK-dependent restoration of mitochondrial dysfunction in fibroblasts from fibromyalgia patients. Biochem. Biophys. Acta. 2015;1852 (7), 1257–1267. doi: 10.1016/j.bbadis.2015.03.005
Kothari V, Galdo JA, Mathews ST. Hypoglycemic agents and potential anti-inflammatory activity. J Inflamm Res. 2016; 9:27-38. doi:10.2147/JIR.S86917
Cameron AR, Morrison VL, Levin D, et al. Anti-Inflammatory Effects of Metformin Irrespective of Diabetes Status. Circ Res. 2016; 119(5):652-665. doi:10.1161/CIRCRESAHA.116.308445
Kaneko, N., Kurata, M., Yamamoto, T. et al. The role of interleukin-1 in general pathology. Inflamm Regener. 2019; 39, 12 doi.org/10.1186/s41232-019-0101-5
Fregnan F, Muratori L, Simões AR, Giacobini-Robecchi MG, Raimondo S. Role of inflammatory cytokines in peripheral nerve injury. Neural Regen Res. 2012; 7(29):2259-2266. doi:10.3969/j.issn.1673-5374.2012.29.003
Tanaka T, Narazaki M, Kishimoto T. IL-6 in inflammation, immunity, and disease. Cold Spring Harb Perspect Biol. 2014; 6(10):a016295. doi:10.1101/cshperspect.a016295
DeLeo JA, Colburn RW, Nichols M, Malhotra A. Interleukin-6-mediated hyperalgesia/allodynia and increased spinal IL-6 expression in a rat mononeuropathy model. J Interferon Cytokine Res. 1996; 16:695–700. doi: 10.1089/jir.1996.16.695.
Zhou YQ, Liu Z, Liu ZH, et al. Interleukin-6: an emerging regulator of pathological pain. J Neuroinflammation. 2016; 13(1):141. doi:10.1186/s12974-016-0607-6
Harada A, Sekido N, Akahoshi T, Wada T, Mukaida N, Matsushima K. Essential involvement of interleukin-8 (IL-8) in acute inflammation. J Leukoc Biol. 1994; 56:559–564.
Koch AE, Polverini PJ, Kunkel SL, Harlow LA, DiPietro LA, Elner VM, Elner SG, Strieter RM. Interleukin-8 as a macrophage-derived mediator of angiogenesis. Science. 1992; 258:1798–1801.
Smyth MJ, Zachariae CO, Norihisa Y, Ortaldo JR, Hishinuma A, Matsushima K. IL-8 gene expression and production in human peripheral blood lymphocyte subsets. J Immunol.1991; 146:3815–3823.
Du S-H, Zhang W, Yue X, Luo X-Q, Tan X-H, Liu C, Qiao D-F and Wang H. Role of CXCR1 and Interleukin-8 in Methamphetamine-Induced Neuronal Apoptosis. Front. Cell. Neurosci. 2018; 12:230. doi: 10.3389/fncel.2018.00230
Leung, L., Cahill, C.M. TNF-α and neuropathic pain - a review. J Neuroinflammation. 2010; 7, 27. doi.org/10.1186/1742-2094-7-27
https://www.anogen.net/multiplex-human-cytokine-elisa-kit-inflammatory-1681.html
Vestergaard C et al. Monocyte chemotactic and activating factor (MCAF/MCP-1) has an autoinductive effect in monocytes, a process regulated by IL-10. J Dermatol Sci. 1997; 15(1):14-22. doi: 10.1016/s0923-1811(96)00589-0.
C. Briani, C. Dalla Torre, V. Citton et al. “Cobalamin deficiency: clinical picture and radiological findings,” Nutrients. 2013; 5(11): 4521–4539.
