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1070

Current Drug Metabolism, 2013, 14, 1070-1082

Pharmacogenetic Variation and Metformin Response


Suning Chen1, Jie Zhou3, Miaomiao Xi1, Yanyan Jia1, Yan Wong1, Jinyi Zhao1, Likun Ding1, Jian Zhang2*
and Aidong Wen1*
1

Department of Pharmacy, Xijing Hospital, The Fourth Military Medical University, Xian, Shaanxi Province, 710032, Peoples
Republic of China; 2The State Key Laboratory of Cancer Biology and The Department of Biochemistry and Molecular Biology, The
Fourth Military Medical University, Xian, Shaanxi Province, 710032, Peoples Republic of China; 3Department of Endocrinology
and Metabolism, Xijing Hospital, The Fourth Military Medical University, Xian, Shaanxi Province, 710032, Peoples Republic of
China
Abstract: Diabetes is a major health problem worldwide, and metformin, a traditional oral anti-hyperglycemic drug, is now believed to
be the most widely prescribed antidiabetic drug. Metformin acts primarily by inhibiting hepatic glucose production and improving insulin
sensitivity. Metformin is absorbed predominately by the small intestine and excreted in an unaltered form in the urine. The pharmacokinetics of metformin is primarily determined by membrane transporters, including the plasma membrane monoamine transporter (PMAT),
the organic cation transporters (OCTs), the multidrug and toxin extrusion (MATE) transporters, and the critical protein kinase AMPactivated protein kinase (AMPK). PMAT may play a role in the uptake of metformin from the gastrointestinal tract, while OCTs mediate
the intestinal absorption, hepatic uptake, and renal excretion of metformin. MATEs are believed to contribute to the hepatic and renal excretion of the drug. The pharmacologic effects of metformin are primarily exerted in the liver, at least partly via the activation of AMPK
and the subsequent inhibition of gluconeogenesis. A considerable amount of pharmacogenetic research has demonstrated that genetic
variation is one of the major factors affecting metformin response. Moreover, it has become increasingly clear that membrane transporters are important determinants of the pharmacokinetics of metformin. In this review, we will discuss the genetic variants of major transporters that purportedly determine the pharmacokinetics of metformin in terms of drug bioavailability, distribution, and excretion, such as
PMAT, OCTs, and MATEs. Understanding how genetic variation affects metformin response will help promote more effective use of the
drug for the treatment of type 2 diabetes (T2D).

Keywords: AMPK, MATE, metformin, OCT, pharmacogenetic, SNP, T2D.


1. INTRODUCTION
Type 2 diabetes (T2D) is a major global health problem of the
21st century. Metformin, a traditional oral anti-hyperglycemic drug,
is widely used as a first-line therapy for T2D treatment and primarily acts by inhibiting hepatic glucose production and improving
insulin sensitivity, thereby decreasing the insulin resistance that is
prevalent in T2D [1]. The other beneficial effects of metformin
include weight loss, reduced lipid levels, the prevention of vascular
complications, and a lower risk of hypoglycemia [2]. The mechanism by which metformin decreases endogenous glucose production in T2D patients has been found to involve the inhibition of
gluconeogenesis and, to a lesser extent, glycogenolysis, resulting in
reduced plasma glucose levels; the effects of metformin have also
been attributed to increased insulin-stimulated glucose uptake in
skeletal muscles and adipocytes [3]. Consistent with these findings,
data from other in vivo studies confirmed the inhibitory effect of
metformin on gluconeogenesis [2]. In contrast to sulfonylureas,
metformin does not lead to hypoglycemia in T2D patients or normal
subjects (except under special conditions) and does not cause hyperinsulinemia. These reduced side effects may be the primary reasons
for the popularity of metformin for T2D therapy worldwide.
The response to a drug is mainly determined by its pharmacokinetic properties [4]. In this regard, the pharmacologic mechanism of
metformin differs from those of other classes of oral antihyperglycemic agents. Chemically, metformin is a hydrophilic base
that exists as a cationic species (>99.9%) under physiological pH
*Address correspondence to these authors at the Department of Pharmacy,
Xijing Hospital, and The State Key Laboratory of Cancer Biology and The
Department of Biochemistry and Molecular Biology, The Fourth Military
Medical University, Xian, Shaanxi Province, 710032, Peoples Republic of
China; Tel: +86 29 84774517-8012; Fax: +86 29 84773947; E-mails: biozhangj@hotmail.com; adwen_2004@hotmail.com


1875-5453/13 $58.00+.00

conditions. The passive diffusion of metformin through cell membranes is therefore very limited. Metformin is absorbed predominately by the small intestine and excreted unchanged in the urine
and bile. In healthy subjects and diabetic patients with good renal
function, the population mean renal clearance (CL(R)) and apparent
total clearance (CL/F) after oral administration of metformin were
estimated to be 510 130 mL/min and 1140 330 mL/min, respectively. Because CL(R) and CL/F decrease approximately in proportion to CL(R), the dosage of metformin should be reduced in patients with renal impairment [5]. The primary reason for this precaution is that metformin does not undergo pharmacokinetic modifications in the body, with negligible hepatic metabolism and biliary excretion [6].
In terms of drug efficacy and toxicity, numerous factors contribute to interindividual variability, including age, gender, nutritional status, life style, and genetic factors [1b]. In this regard, genetic variation is undoubtedly one of the major factors affecting the
response to metformin. Moreover, it has become increasingly clear
that membrane transporters are important determinants of metformin pharmacokinetics [7]. Some patients taking metformin do
not respond sufficiently. In one study, 42% of T2D patients experienced secondary failure within the 2- to 5-year follow-up period,
with an average secondary failure rate of 17.0% per year [8].
Meanwhile, although metformin-induced lactic acidosis is remarkably rare, it represents a serious side effect of the drug. For these
reasons, understanding the potential causes of the different side
effects observed in different patients is a major step in preventing
their occurrence or development. Given the likely influence of genetic variation on the absorption, distribution, and excretion of
many drugs and the dependence of drug concentration maintenance
on transporter activity, it is reasonable to hypothesize that genetic
variants of these transporters have important effects. Reflecting the
importance of metformin for T2D treatment, a number of studies in
2013 Bentham Science Publishers

Pharmacogenetic Variation and Metformin Response

recent decades have focused on the transport efficiency of metformin and analyzed how the pharmacokinetics of the drug are
affected by genetic variants of different transporters. It is highly
likely that the relationship between the pharmacokinetics of metformin and the response to the drug is influenced by interindividual
variability in terms of drug susceptibility, bioavailability, or the
distribution to the pharmacological target tissues [1b].
The available studies in this field have identified the following
membrane transporters as the major determinants of metformin
pharmacokinetics: the plasma membrane monoamine transporter
(PMAT), organic cation transporters (OCTs), and multidrug and
toxin extrusion (MATE) transporters. Most importantly, the pharmacological effect of metformin is reported to be heavily dependent
on AMP-activated protein kinase (AMPK). In this review, we will
summarize the state-ofthe-art research examining genetic variants
of the major molecules that determine the bioavailability, distribution, excretion, and pharmacological effects of metformin, including PMAT, OCTs, MATEs, and AMPK. An improved understanding of the genetic variation in the transporters and the pharmacokinetics of metformin will help improve the drug response and prevent undesired side effects of the drug in T2D patients.
2. PMAT
PMAT is a novel proton-activated organic cation transporter
that was recently cloned and characterized and is mainly distributed
in the human small intestine and kidney. In the small intestine,
PMAT is concentrated on the tips of the mucosal epithelial layer.
Similarly, PMAT is expressed on the apical membranes of renal
epithelial cells in the kidney and specifically expressed in podocytes [9]. From the limited literature available, PMAT appears to
play a role in the intestinal absorption of metformin, using the luminal proton gradient to drive organic cation reabsorption in the
kidney. The available evidence suggests that PMAT-mediated metformin transport is greatly stimulated by acidic pH, with the uptake
rate being 4-fold higher at pH 6.6 than at pH 7.4 [10]. However,
there is little evidence that genetic variation in PMAT affects the
pharmacokinetics of metformin.
3. OCTs
The OCTs consist of three major OCT subtypes, OCT1, OCT2,
and OCT3, which are encoded by the genes SLC22A1, SLC22A2,
and SLC22A3, respectively. OCTs are broad-specificity transporters
critical for the uptake, distribution, and elimination of cationic
drugs. They also participate in the excretion and distribution of
endogenous organic cations, such as choline, creatinine, and cationic neurotransmitters. OCTs are present in many tissues, including
the small intestine, liver, kidney, heart, and skeletal muscle. In
epithelial cells, the OCTs are located in the basolateral or luminal
membranes. In the liver, one crucial function of hepatocytes is to
transform and eliminate various drugs, many of which are organic
cations taken up by OCTs [11]. It is clear that the oral absorption,
hepatic uptake, and renal excretion of metformin are largely mediated by OCTs [5]. Additionally, various in vivo and human studies
have shown that metformin is a good substrate for the organic
cation transporters OCT1 and OCT2 [7c, 12]. It was recently reported that polymorphisms in the OCTs of T2D patients result in
altered metformin pharmacokinetics and drug response [13]. The
identification of polymorphisms in human OCTs therefore permits
the identification of patients with an increased risk of adverse reactions to the drug.
3.1. OCT1
3.1.1. Physiological and Pharmacological Role of OCT1
Human OCT1 is encoded by the SLC22A1 gene, which is expressed in the liver and various other organs, including the small
intestine, lung, mammary gland, and adrenal gland [14]. OCT1 is

Current Drug Metabolism, 2013, Vol. 14, No. 10

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critical for the elimination of many endogenous small organic


cations and a wide range of drugs and environmental toxins. The
substrates of human OCT1 include many cations, such as metformin, tetraethylammonium (TEA), 1-methyl-4-phenylpyridinium
(MPP), and 4-[4-(dimethylamino)-styryl]-N-methylpyridinium (ASP)
[15]. The expression and transport activity of OCT1 dramatically
influences the pharmacokinetics, dose-response, and toxicity of the
drugs transported by OCT1. Wang et al. showed that metformin
levels were greatly reduced in the liver and intestines of Oct1
knockout (KO) mice, whereas only slight differences were observed
for the urinary excretion profile of metformin; these observations
suggest that OCT1 is responsible for the entry of metformin into
hepatocytes and enterocytes, while the renal distribution and excretion of the drug may be governed by other transport proteins [7b].
Many human genetic variants of OCT1 have been identified [13,
16], some of which reduce transport activity. Thus, if the SNPs in
OCT1 alter its activity as a transporter of cationic drugs such as
metformin, different drug responses and therapeutic effects in patients can definitely be attributed to such genetic variants [17].
3.1.2. Effect of OCT1 Genetic Variants
In the studies examining the relationship between SNPs of
OCT1 and metformin pharmacokinetics, some genotypes were
found to have a significant effect on metformin pharmacokinetics.
For example, a greater area under the plasma concentration-time
curve (AUC), a higher maximal plasma concentration (Cmax), and
a lower oral volume of distribution (V/F) were observed in individuals carrying the reduced-function OCT1 alleles R61C, G401S,
M420del, and G465R. The OCT1 SNPs rs2282143 (the T allele)
and rs628031 (the G allele) were more common in Asians and African Americans than in Caucasians (0-2% versus 57.4-60%), which
influences the interindividual variation in clinical responses to metformin therapy [18].
Recent data for 66 Japanese patients with T2D from the 1,000
Genomes Project indicated that P117L and R206C caused a reduced
V(max), whereas Q97K caused an increased K(m) [19]. It is notable that the M420del and R61C variants were more sensitive to
metformin, with IC(50) values up to 23 times lower than those of
the OCT1 reference [13]. Additionally, the OCT1 R61C and
M420del variants were found to have a significant effect on metformin pharmacokinetics, with a higher area under the plasma concentration-time curve (AUC) and a lower oral volume of distribution (V/F) in the T2D patients [4]. In addition to T2D treatment,
metformin has also been used to treat women with polycystic ovary
syndrome (PCOS). Gambineri et al. found that four OCT1 variants
(R61C, G401S, G465R, and M420del) were associated with heterogeneity in the metabolic response to metformin in women with
PCOS [20].
HbA1c levels are critical for evaluating the response to metformin in diabetes mellitus patients. One population-based cohort
study in Rotterdam showed that the minor C allele at rs622342 in
the SLC22A1 gene (OCT1) was associated with 0.28% less reduction in glycated hemoglobin (HbA1c) levels [21]. Additionally, the
rs622342 SNP has been associated with a decreased effect on blood
glucose in heterozygotes and a lack of an effect of metformin on
plasma glucose in homozygotes [5].
To elucidate the pharmacogenetic variations of metformin,
seven polymorphisms in the OCT1, OCT2, and MATE1 genes were
compared in 53 T2D patients exhibiting side effects from metformin and 193 metformin users without obvious symptoms of
discomfort. The results demonstrated that the rs628031 and
rs36056065 SNPs in OCT1 were in strong linkage disequilibrium
and predisposed patients with T2D to the side effects of metformin
[22]. It is therefore critical to evaluate these and other interindividual polymorphisms to predict or prevent the side effects of metformin.

1072 Current Drug Metabolism, 2013, Vol. 14, No. 10

Table 1.

Chen et al.

Genetic Variation in OCT1 (SLC22A1) and Metformin Sensitivity

Variants

Study design

Conclusion

Reference

rs622342 A>C

A population-based cohort study of 102 patients with


diabetes mellitus (Caucasians).

Genetic variation at rs622342 was associated with the


glucose-lowering effect of metformin.

[21]

Q97K, P117L,
and R206C

Used data from the 1,000 Genomes Project and direct


sequencing of selected OCT1 amplicons from 66 DNA
samples from Japanese patients with T2D.

The uptake of metformin in cells expressing Q97K,


P117L, and R206C was significantly reduced relative to
the OCT1 reference.

[19]

R61C, G401S,
G465R, and
420del

Studied 150 Italian PCOS patients aged 18-45 years old.

Genetic variation in OCT1 may be associated with heterogeneity in the metabolic response to metformin in
women with PCOS.

[20]

R61C, G401S,
420del, G465R

Twenty healthy volunteers with known OCT1 genotype


received two oral doses of metformin; blood and urine
samples were subsequently collected.

OCT1 genotype is a determinant of metformin


pharmacokinetics.

[4]

Seven polymorphisms in the OCT1, OCT2, and MATE1


genes were compared in 53 T2D patients experiencing
metformin side effects and 193 metformin users without
metformin intolerance symptoms.

The two genetic variants of OCT1 are in strong linkage


disequilibrium and predispose patients with T2D to an
increased prevalence of metformin side effects.

[22]

rs2282143
rs628031
rs622342

A total of 112 unrelated healthy male and female subjects


of South Indian Tamil origin aged 18-60 years old were
recruited for the analysis of genetic variants of OCT1.

The SNPs rs2282143 (T allele) and rs628031 (G allele)


were more common in Asians and African Americans
than in Caucasians.

[18]

R61C

A total of 3,450 T2D patients were genotyped, and their


metformin responses were assessed by modeling the
maximum A1C reduction.

The R61C and M420del variants do not attenuate HbA1c


reduction resulting from metformin treatment in T2D
patients.

[65]

rs622342 A>C

A multiplicative interaction between the polymorphisms


and changes in HbA1c levels was analyzed in 98 incident
metformin users.

The effect of the MATE1 rs2289669 polymorphism on


the glucose-lowering effect of metformin is larger in
incident users with the OCT1 rs622342 CC genotype than
in incident users with the AA genotype.

[5, 45]

R61C, G401S,
420del, G465R

Investigated the pharmacokinetics of metformin in relation to genetic variants of OCT1, OCT2, OCT3, OCTN1,
and MATE1 in 103 healthy male Caucasians.

Renal OCT1 expression may be important for the response to metformin and other drugs.

[66]

R61C, V408M,
M420del, G465R

HEK293 cells expressing a human OCT1 reference or the


variants R61C, V408M, M420del, and G465R were used
to study the kinetics and inhibition patterns of different
OCT1 substrates.

The M420del and R61C variants were more sensitive to


drug inhibition, with IC(50) values up to 23 times lower
than those of the OCT1 reference.

[13]

R61C
(rs12208357)

Systematically investigated genetic and non-genetic


factors of OCT1/SLC22A1 and OCT3/SLC22A3 expression in liver tissue samples from 150 Caucasian subjects.

The OCT1-R61C variant (rs12208357) was strongly


correlated with decreased OCT1 protein expression.

[11]

Analyzed variants of OCT1 and OCT2 in 33 patients (24


responders and nine non-responders).

OCT1 mRNA levels tended to be lower in human livers


with the 408Met (1222A) variant, but the differences were
not significant.

[23a]

Seven nonsynonymous polymorphisms in OCT1 were


identified and tested for the effects of metformin on glucose tolerance.

Genetic variation of OCT1 contributes to variation in the


response to metformin.

[17b]

Tissue distribution of metformin was determined in Oct1


knockout and wild-type mice.

The distribution of metformin in the liver tissue of Oct1(-/-)


mice is more than 30 times lower than that in wild-type mice.

[7b]

Oct1(+/+)
R61C, G401S,
420del, G465R

Assessed the pharmacokinetic variability of OCT1 variants by comparing healthy subjects and T2D patients.

There was no effect on the pharmacokinetics of metformin in


patients carrying the reduced-function OCT1 allele.

[67]

rs628031
rs36056065

M420del

43T>G;
V408M
(1222A>G)

M420del

Oct1(-/-)

Pharmacogenetic Variation and Metformin Response

Current Drug Metabolism, 2013, Vol. 14, No. 10

1073

Two independent studies found that two polymorphisms in


SLC22A1, -43T>G in intron 1 and 408Met>Val (1222 A>G) in
exon 7, were negative and positive predictors, respectively, of the
efficacy of metformin [23]. Because metformin is not the only drug
transported by OCT1, these genetic variants of OCT1 may also
affect the response to other drugs. Two genetic variants of OCT1
identified in a Korean population, P283L and P341L, were analyzed
using the oocyte expression model and found to decrease lamivudine uptake by 85.1% and 48.7%, respectively, compared to
wild-type OCT1 [24]. However, the OCT1 genetic polymorphisms
had different effects on the uptake of various substrates (including
MPP+, TEA, metformin, and lamivudine), suggesting that the uptake of drugs by OCT1 is substrate dependent.
A number of functional studies have established that many
OCT1 genetic polymorphisms, particularly those in the coding region, decrease OCT1 function and, consequently, metformin uptake
efficiency. For example, as summarized in (Table 1), the C88R,
S189K (rs45607934), G220V (rs45447195), G401S (rs45512393),
G465R (rs45476695), and M420del (rs45545341, rs45465102, and
rs45542538) variants reduce metformin uptake, whereas Ser14Phe
(rs45504100) increases uptake [17b, 25].

808G>T variant, two additional genetic variants of OCT2, 596C>T


and 602C>T, were also found to yield significant differences in
metformin pharmacokinetics; specifically, a higher peak plasma
concentration, a greater area under the curve, and reduced renal
clearance were observed for the variants compared to wild-type
OCT2 [33].
Choi et al. identified several genetic variants of OCT1 and
OCT2, including OCT1-P283L and -P341L and OCT2-T199I, T201M, and -A270S, in a Korean population. Using an in vitro
oocyte expression model system, the uptake of 1-methyl-4phenylpyridinium (MPP+), tetraethyl ammonium (TEA), metformin, and lamivudine was found to be significantly decreased
with the OCT2-T199I, -T201M, and -A270S variants compared to
wild-type OCT2 [24]. Using an in vitro model for the renal proximal tubule and LLC-PK1 cells, Song et al. investigated the effects
of OCT2-T199I, -T201M, and -A270S [34]. As shown in (Table 2),
the finding that these genetic variants decreased the transport activity of metformin is consistent with their contribution to interindividual variation in metformin disposition and the pivotal role of
OCT2 in renal excretion, a major component of metformin disposition [34].

3.2. OCT2
3.2.1. Physiological and Pharmacological Role of OCT2
OCT2 is predominantly expressed in the proximal tubules of
the kidney and mediates the renal secretion of small organic
cations, such as metformin [26]. It is also present in the small intestine, lungs, skin, placenta, brain, and choroid plexus [27]. OCT2
localizes to the basolateral membrane of epithelial cells and the
luminal membrane of epithelial cells in the trachea and bronchi
[27a, 28]. OCT2 is a crucial renal uptake transporter that plays a
key role in the plasma disposition and renal clearance of drugs and
endogenous compounds [29]. In the basolateral membrane of the
distal tubule in the kidney, OCT2 promotes the uptake of organic
cations from the blood to the proximal tubular cells during renal
secretion [30]. Thus, like OCT1, OCT2 can also transport many
organic cations and plays a critical role in the pharmacological,
pharmacokinetic, and toxicological properties of therapeutic agents.
In this regard, altering the expression or transporter activity of
OCT2 may alter the responses to a drug. Several reports have
shown that T2D patients with genetic variations in OCT2 exhibit
different responses to metformin.
3.2.2. Effect of OCT2 Genetic Variants
In a murine experiment, the kidney and circulating metformin
levels were found to be comparable in Oct1/ and control mice
[17b], suggesting that OCT2 rather than OCT1 may be the major
metformin transporter and determinant of renal metformin processing [12]. A study of 23 healthy volunteers, including 14 individuals
homozygous for the OCT2 reference allele (808G/G) and nine individuals heterozygous for a variant allele (808G>T) resulting in
amino acid alteration A270S, was performed to analyze the response to metformin [26]. The metformin concentrations measured
in the plasma and urine indicated that OCT2-808T had a greater
capacity than the reference protein for metformin transport, suggesting that genetic variation in OCT2 plays an important role in
the CL(R) and secretion (SrCL(R)) of metformin in healthy volunteers [26]. By assessing homozygosity for the OCT2-808T tryptophan variant, Song, et al. confirmed gene dosage effects of the
transporter activity and the high linear association with the pharmacokinetic parameters of metformin [31].
A study by Wang et al. was the first to investigate genetic polymorphisms of OCT2 in a Chinese population and revealed that
the 808G>T polymorphism is associated with a reduction in metformin renal or tubular clearance [32]. Moreover, the inhibition of
metformin renal tubular secretion by cimetidine also appeared to
depend on this genetic polymorphism [32]. In addition to the

3.3. OCT3
3.3.1. Physiological and Pharmacological Role of OCT3
The three genes encoding the human cation transporters OCT1,
OCT2, and OCT3 are located in a cluster on chromosome 6. OCT3
is encoded by the SLC22A3 gene, which has a broad tissue distribution, including the skeletal muscle, heart, brain, and placenta. Interestingly, OCT3 is highly expressed on the membranes of skeletal
muscle and liver cells, which are the major target tissues of metformin [35]. OCT3 is a polyspecific transporter whose transport
function is independent of sodium. The known substrates for transport by OCT3 include metformin, histamine, serotonin, norepinephrine, and dopamine. However, the transport capacity and affinity for
these substrates may differ between rats and humans [36]. The
transport activity of OCT3 can be inhibited by many pharmaceutical drugs, including MDMA, amphetamine, methamphetamine, and
cocaine [36a]. Compared to the wealth of research on OCT1 and
OCT2 in terms of the pharmacokinetics of metformin, few studies
have investigated the role of OCT3 in the response to the drug.
However, OCT3 has been identified as an important determinant of
the effects of metformin in skeletal muscle [35]. Specifically, the
effect of metformin on AMPK phosphorylation was greatly inhibited by cimetidine in cultured skeletal muscle cells [37] as well as
OCT3 shRNA [35], indicating that OCT3 may play a major role in
the therapeutic action of metformin [35]. It is therefore reasonable
to hypothesize that genetic variation in OCT3 may also influence
the pharmacokinetics of metformin.
3.3.2. Effect of OCT3 Genetic Variants
Nies, A.T. et al. systematically investigated the genetic and
non-genetic factors of OCT1/SLC22A1 and OCT3/SLC22A3 expression in human liver in 150 Caucasian subjects. The group identified four OCT3 variants (rs2292334, rs2048327, rs1810126, and
rs3088442) that were associated with reduced OCT3 mRNA levels
[11] (Table 1 and Table 4). Using data from the 1,000 Genomes
Project and the Pharmacogenomics of Membrane Transporters project, Chen, L. et al. identified six novel missense variants of OCT3
and tested their transport activity [35]. Three variants, T44M
(c.131C>T), T400I (c.1199C>T), and V423F (c.1267G>T), exhibited altered substrate specificity. Notably, in cells expressing T400I
and V423F, the uptake of metformin and catecholamines was significantly reduced, while the uptake of metformin, MPP+, and histamine increased by more than 50% in cells expressing T44M [35].
It is likely that additional OCT3 SNPs affecting metformin uptake
will be identified and that this type of information will help improve metformin therapy for T2D patients.

1074 Current Drug Metabolism, 2013, Vol. 14, No. 10

Table 2.

Chen et al.

Genetic Variation in OCT2 (SLC22A2) and Metformin Sensitivity

Variants

Study design

Conclusion

Reference

808G>T
(A270S)

Assess the effect of genetic variant OCT2-808G>T on the


pharmacokinetics of metformin.

OCT2 genotype was a significant predictor of metformin


CL(R) and SrCL(R).

[26]

808G>T

Use metabolomics to comprehensively monitor changes in


primary metabolites associated with OCT2 polymorphisms.

Tryptophan can serve as an endogenous substrate of OCT2


as well as a biomarker candidate.

[31]

Evaluate the effects of three variations in OCT2 on the


pharmacokinetics of metformin, particularly renal elimination.

SLC22A2 variants result in reduced metformin CL(R) and


consequently lead to increased plasma concentrations.

[33]

Address the role of OCT2 808G>T in the renal disposition


of endogenous compounds and drugs other than metformin.

OCT2 808G>T significantly alters the uptake of endogenous


compounds and drugs.

[68]

Investigate the effects of genetic variants of OCT1 and


OCT2 on the transport of substrates associated with these
transporters in a Korean population.

The OCT2-T199I, -T201M, and -A270S variants significantly decrease the uptake of MPP+, TEA, metformin, and
lamivudine.

[24]

Genetic variants of OCT2 (OCT2-T199I, -T201M, and A270S) decrease the transport activity of metformin.

[34]

596C>T
602C>T
808G>T
808G>T
(A270S)
T199I
T201M
A270S
T199I,
T201M
A270S

Investigate the effects of genetic variants of OCT2 on


metformin transport using LLC-PK1 as an in vitro model.

808G>T
(A270S)

Direct sequencing of all OCT2 exons and the surrounding


introns was performed using genomic DNA from 112
healthy Chinese participants.

The 808G>T polymorphism is associated with reduced metformin renal or tubular clearance.

[32]

808G>T
(A270S)

The SLC22A2 808G>T variant was genotyped in 400 T2D


patients with or without metformin treatment, and the
fasting plasma lactic acid levels were measured.

The 808G>T variant of OCT2 can affect the plasma lactate


level and the incidence of hyperlactacidemia in T2DM patients undergoing metformin therapy.

[69]

4. MATE
4.1. Physiological and Pharmacological Role of MATEs
Among more than 50 different SLC (solute carrier) families, the
family of multidrug and toxin extrusion proteins (MATEs,
SLC47A) has gained particular attention because MATE transporters use the proton gradient as a driving force for substrate efflux, in
contrast to the ABC efflux pumps driven by ATP hydrolysis [38].
MATE proteins act as proton/cation antiporters at the brush border
membrane of proximal tubule cells in the kidney and in the canalicular membranes of hepatocytes. Through this activity, they
permit the excretion of cationic endogenous substances and xenobiotics, including clinical drugs such as metformin and cimetidine
[39]. The uptake of metformin into the renal epithelial cells from
circulation is primarily facilitated by OCTs, but the renal excretion
of metformin is mediated primarily by MATE1/SLC47A1 and
MATE2-K/SLC47A2 [40]. Thus, MATE1 and MATE2 play important roles in metformin disposition.
To investigate the roles of MATE1/SLC47A1 and MATE2K/SLC47A2 in the renal excretion of metformin, Toyama, K. et al.
analyzed the effects of heterozygous MATE variants on metformin
disposition in both mice and humans. They found that heterozygosity for the MATE variants investigated did not influence metformin disposition in diabetic patients [41]. In another in vivo
study, Tsuda, M. et al. reported an essential role of MATE1 in the
systemic clearance of metformin. The renal clearance and renal
secretory clearance of metformin observed in Mate1 (-/-) mice
were approximately 18% and 14% of the wild-type levels, respectively [42]. Sixty minutes after metformin administration, the
hepatic concentration of metformin was markedly higher in
Mate1(-/-) mice than in Mate1(+/+) mice. Furthermore, MATE1
dysfunction elevated the metformin concentration in the liver and

led to lactic acidosis, indicating that homozygosity for the MATE1


variant analyzed may represent a risk factor for metformininduced lactic acidosis [43].
4.2. Effect of MATE Genetic Variants
Becker et al. investigated the genetic variation of the SLC47A1
gene and its effect on the ability of metformin to lower A1C [44].
As shown in (Table 3), the rs2289669 G>A SNP is associated with
reduced A1C levels, which is consistent with reduced MATE1
transporter activity and indicates an important role of the MATE1
transporter in the pharmacokinetics of metformin [44]. Graham et
al. found that the MATE1 rs2289669 G>A SNP results in a small
increase in the anti-hyperglycemic effect of metformin [5].
Additionally, the effect of the MATE1 rs2289669 polymorphism on
the glucose-lowering effect of metformin was greater in incident
users with the OCT1 rs622342 CC genotype than in incident users
with the AA genotype [45].
Kajiwara, M. et al. sequenced all of the exons of the genes encoding MATE1 and MATE2-K in 89 Japanese subjects and identified coding SNPs (cSNPs) in MATE1 (V10L, G64D, A310V,
D328A, and N474S) and MATE2-K (K64N and G211V) [46]; this
report was the first to demonstrate cSNP-induced functional impairment of the MATE family. These findings suggest that the loss
of transport activity observed in the MATE1 G64D and MATE2-K
G211V variants was due to altered protein expression in cell surface membranes [46]. Chen, Y. et al. found that two single variants
of MATE1, G64D and V480M, resulted in a complete loss of function for all four tested substrates and that three polymorphic variants (allele frequencies greater than or equal to 2%), L125F, V338I,
and C497S, significantly altered MATE1 transport activity in a
substrate-dependent manner. The authors proposed that nonsynonymous variants of MATE1 may alter the drug disposition and

Pharmacogenetic Variation and Metformin Response

Table 3.

Current Drug Metabolism, 2013, Vol. 14, No. 10

1075

Genetic Variation in MATE1 (SLC47A1) and Metformin Sensitivity

Variants

Study design

Conclusion

Reference

rs2289669 G>A

Studied the effect of SNPs in SLC47A1 on the A1Clowering effect of metformin.

Reduced MATE1 transporter activity.

[44, 45]

404T>C 1012G>A

Assessed the cellular accumulation effect of shared


substrates using OCT2 and MATE1 doubletransfected cells.

Altered the renal cationic drug elimination activity of


MATE1.

[70]

G64D and V480M fully eliminated transport function,


while L125F, V338I, and C497S significantly altered
transport capability.

[47]

G64D
V480M
L125F

A population-based cohort study of 272 individuals


(68 Caucasians, 68 African Americans, 68 Asian
Americans, and 68 Mexican Americans).

V338I
C497S
G>A, SNP rs2289669

Analyze the renal clearance and clinical effect of


metformin in diabetes patients with MATE1 variants.

Associated with a small increase in the antihyperglycemic effect of metformin.

[5]

MATE1 (V10L, G64D,


A310V, D328A, and
N474S), MATE2-K
(K64N and G211V)

Sequenced all exons of MATE1 and MATE2-K in 89


Japanese subjects and identified coding SNPs
(cSNPs) in MATE1 (V10L, G64D, A310V, D328A,
and N474S) and MATE2-K (K64N and G211V).

The MATE1 G64D and MATE2-K G211V variants


exhibit a loss of transport activity resulting from altered
protein expression in cell surface membranes.

[46]

Mate1 knockout

Assess the concentration of metformin in Mate1


knockout (-/-), heterozygous (+/-), and wild-type
(+/+) mice.

The hepatic concentration of metformin was markedly


higher in Mate1(-/-) mice than in Mate1(+/+) mice.

[43]

Heterozygous MATE
variants

Evaluate the effects of heterozygous MATE variants


on the disposition of metformin in mice and humans.

Heterozygous MATE variants did not influence the disposition of metformin in diabetic patients.

[41]

Mate1(-/-) mice and


Mate1(+/+) mice

Analyze the renal clearance and renal secretory clearance


of metformin in Mate1(-/-) and wild-type mice.

The renal clearance and renal secretory clearance levels


of metformin in Mate1(-/-) mice were approximately
18% and 14% of those in Mate1(+/+) mice, respectively.

[42]

ultimately affect the clinical drug response [47]. Two nonsynonymous variants of MATE2, 485 C>T and 1177 G>A, were found to
be associated with significantly reduced metformin uptake and
reduced protein expression levels [48]. Diabetic patients homozygous for the -130 G>A SNP of the MATE2-K basal promoter had a
significantly worse response to metformin treatment, as indicated
by the relative change in glycated hemoglobin (HbA1c) compared
to the reference allele [48].
Taken together, these findings indicate that genetic variants of
both MATE1 and MATE2 influence the excretion and disposition
of metformin. The altered expression and function of MATEs may
therefore contribute to interindividual variability in the pharmacokinetics and response to metformin [49].
5. AMPK
5.1. Physiological and Pharmacological Role of AMPK
The enzyme AMPK plays an important role in cellular energy
homeostasis. Three subunits (, , and ) compose the heterotrimeric AMPK protein, which is a functional enzyme conserved
from yeast to humans [50]. Each of these three subunits has a specific role in both the stability and activity of AMPK. The , , and 
subunits are encoded by PRKAA1 and PRKAA2; PRKAB1 and
PRKAB2; and PRKAG1, PRKAG2, and PRKAG3, respectively
[51]. AMPK is expressed in a number of tissues, including the liver,
brain, and skeletal muscle. AMPK activation promotes the oxidation of hepatic fatty acids and inhibits the lipolysis and lipogenesis
of adipocytes and the synthesis of cholesterol. More importantly,
AMPK can stimulate skeletal muscle fatty acid oxidation, muscle

glucose uptake, and insulin secretion by pancreatic beta-cells. Thus,


AMPK acts as a metabolic master switch regulating several intracellular systems, including the cellular uptake of glucose and the oxidation of fatty acids [52].
The energy-sensing capability of AMPK reflects its ability to
detect and react to fluctuations in the AMP:ATP ratio during rest
and energy stress conditions. Under starvation or muscle stimulation, AMP increases while ATP decreases; moreover, the binding of
AMP renders AMPK a good substrate for activation via an upstream AMPKK kinase complex, such as liver kinase B1 (LKB1),
which phosphorylates AMPK at the Thr-172 site [53]. AMPK
activity increases when muscle cells experience metabolic stress
brought about by an extreme cellular demand for ATP. AMPK
activation affects many pathways, generally resulting in ATP conservation and production [54]. Upon activation, AMPK increases
cellular energy levels by inhibiting the energy-consuming anabolic
pathways (e.g., fatty acid synthesis and protein synthesis) and
stimulating energy-producing catabolic pathways (e.g., fatty acid
oxidation and glucose transport).
Notably, recent research has established that metformin can
stimulate AMPK activation in the liver and skeletal muscles [55],
which in turn leads to reduced glucose production in the liver, increased glycogen synthesis, and lower insulin resistance in the
muscle [2, 55]. In isolated hepatocytes, the action of metformin
largely requires the enzymatic activity of AMPK, a master sensor
and regulator of cell energy homeostasis [55a]. Thus, the genes that
encode the various AMPK subunits are intriguing candidates for the
hereditary basis of T2D [56].

1076 Current Drug Metabolism, 2013, Vol. 14, No. 10

Table 4.

Chen et al.

Genetic Variation in Other Genes and Drug Sensitivity


Variants

Study design

Conclusion

Reference

OCT3

Determine the role of OCT3 in the pharmacological action of metformin; identify and functionally
characterize genetic variants of OCT3 in terms of
the uptake of metformin and monoamines.

The uptake of metformin and catecholamines was significantly reduced in cells expressing T400I and V423F, while
a significant increase in metformin uptake was observed in
the T44M group.

[35]

Assess the impact of MATE2-K genetic variants


on the metformin response.

Patients with diabetes who were homozygous for -130


G>A had a significantly worse response to metformin
treatment.

[48]

Examine whether PPARG P12A affects the progression from impaired glucose tolerance to diabetes.

PPARG P12A increases the risk of diabetes in individuals


with impaired glucose tolerance.

[71]

T2D patients with PPARA and PPARG variants


were randomized for 26-week monotherapy regimens with the dual-acting PPAR alpha/gamma
agonist ragaglitazar.

PPARG P12A may be a useful tool for reducing the risk of


PPARG agonist-induced fluid retention and edema in T2D
patients.

[72]

Analyze the association between 1,590 SNPs and


incident diabetes and the response to metformin
or lifestyle interventions in 2,994 DPP participants.

The most significant association with diabetes incidence


was observed for the AMPK subunit gene PRKAG2.

[57]

KCNJ11 E23K

Examine the effect of sulfonylurea treatment on


glycemic control with respect to the KCNJ11
E23K variant.

Carriers of the KCNJ11 K-allele have better therapeutic


responses to gliclazide.

[73]

STK11 (also known as


LKB1; C/C, C/G, and
G/G genotypes)

A total of 312 women with PCOS were included


in the study to identify predictive genetic polymorphisms and other determinants of the ovulatory response.

A polymorphism in the STK11 gene was associated with a


significantly decreased probability of ovulation in women
with PCOS receiving metformin.

[58]

TCF7L2 rs12255372
and rs7903146

A total of 901 incident sulfonylurea users and 945


metformin users were examined to determine the
effect of the TCF7L2 rs12255372 and rs7903146
genotypes on the glycemic response.

TCF7L2 variants influence the therapeutic response to


sulfonylureas but not the response to metformin.

[74]

KCNQ1 rs163184
(T>G)

KCNQ1 genotypes and the effect of 6-month


sulfonylurea therapy in addition to metformin on
glycemic control were evaluated in 87 patients
with T2D.

The FPG response to sulfonylurea was significantly lower


in carriers of the risk-associated GG genotype of KCNQ1
rs163184.

[60]

PRKAA2, PRKAB1,
and PRKAB2

Assess the impact of common variants of the


genes encoding three AMPK subunits on T2D
symptoms and related phenotypes.

An analysis of single-marker and multi-marker tests revealed no associations with T2D, fasting plasma glucose,
or insulin sensitivity.

[56]

Systematically investigated genetic and nongenetic factors of OCT1/SLC22A1 and


OCT3/SLC22A3 expression in human liver.

Four OCT3 variants (rs2292334, rs2048327, rs1810126,


and rs3088442) were associated with reduced OCT3
mRNA levels.

[11]

Investigate the effect of genetic variants of OCT1


and OCT2 identified in a Korean population on
lamivudine transport.

The effect of genetic variation in OCT1 and OCT2 on the


uptake of MPP+, TEA, metformin, and lamivudine was
substrate dependent.

[24]

Evaluate the effect of genetic variation in OCT1,


OCT2, MATE1, MATE 2, and PMAT on the
trough steady-state plasma concentration of metformin and hemoglobin A1c (Hb1Ac).

OCT1 activity affects metformin steady-state pharmacokinetics, and a patients OCT1 genotype influences HbA1c
levels during metformin treatment.

[75]

131C>T (T44M)
1199C>T (T400I)
1267G>T (V423F)
MATE2-K
(SLC47A2)
PPARG P12A
(a target of thiazolidinedione medications)

PPARG and PPARA

PRKAG2

OCT3
rs2292334, rs2048327,
rs1810126, rs3088442
OCT1 (P283L and
P341L)
OCT2 (T199I, T201M,
and A270S)

OCT1, OCT2, MATE1,


MATE 2, and PMAT

Pharmacogenetic Variation and Metformin Response

Current Drug Metabolism, 2013, Vol. 14, No. 10

1077

Table (4) contd

Variants

Study design

Conclusion

Reference

c.404T>C (p.159T>M);

Investigate the interplay between the renal cationic transporters OCT2 and MATE1 and perform
a functional assessment of the genetic variation in
human MATE1.

The coordinate functions of MATE1 and OCT2 likely


contribute to the vectorial renal elimination of organic
cationic drugs.

[70]

FTO rs9939609; INSIG2 rs7566605

FTO SNP rs9939609 and INSIG2 SNP rs7566605


were tested for genotype-treatment interactions in
terms of changes in obesity-related traits in the
DPP.

FTO and INSIG2 are nominally associated with quantitative measures of obesity; the direct association may result
from metformin interaction or lifestyle intervention.

[61]

STK11 rs8111699

Studied the effects of STK11 rs8111699 on endocrine-metabolic and body composition indexes
before and after 1 year of metformin treatment in
85 hyperinsulinemic girls with androgen excess.

The STK11 rs8111699 SNP influences insulin sensitivity


and metformin efficacy in hyperinsulinemic girls with
androgen excess.

[59]

Ataxia telangiectasia
mutated (ATM)
rs11212617

Analyze the glycemic response to metformin and


the rs11212617 SNP at a locus that includes the
ataxia telangiectasia mutated (ATM) gene in
multiple additional populations.

A gene variant of ATM is significantly associated with


response to metformin treatment in T2D patients from the
Netherlands and the UK.

[63]

Ataxia telangiectasia
mutated (ATM)
rs11212617

A genome-wide association study for glycemic


response to metformin in 1,024 Scottish individuals with T2D; two replicate cohorts included
1,783 Scottish individuals and 1,113 individuals
from the UK Prospective Diabetes Study.

ATM plays a role in the effect of metformin upstream of


AMP-activated protein kinase, and variation in ATM affects the glycemic response to metformin.

[64]

Genotyped two GCKR SNPs in 3,346 DPP participants and evaluated the association between
these SNPs and the progression to diabetes.

The GCKR SNP P446 allele appears to enhance responsiveness to the homeostasis model assessment of the insulin resistance (HOMA-IR)-lowering effect of metformin.

[76]

c.1012G>A
(p.338V>A)

GCKR SNP 446L


allele

5.2. Effect of AMPK Genetic Variants


Based on previously reported functional studies, expression
patterns, genetic linkage, and pharmacological evidence, Sun. et al.
selected PRKAA2, PRKAB1, and PRKAB2 from the seven isoforms encoding AMPK because of their higher likelihood of an
association with T2D. After correcting for the testing of multiple
hypotheses by permutation, the group found that the nominal P
values of 0.05 for rs2393550 in PRKAB1 and 0.04 for test 38 in
PRKAB2 no longer indicated statistical significance [56] (Table 4).
BMI (body mass index) comparisons across genotypic groups revealed nominal P values less than 0.05 for several tests in PRKAA2
and PRKAB1, but after correction by permutation testing, the best
results did not retain empirical statistical significance [56]. Using
previous genome-wide association studies (GWASs), Jablonski et
al. analyzed the association between 1,590 SNPs and the incidence
of diabetes and the response to metformin or lifestyle interventions
in 2,994 Diabetes Prevention Program (DPP) participants. The
study confirmed the association of variants of the metformin transporter gene SLC47A1 with metformin response and detected nominal interactions with the AMPK gene STK11, the AMPK subunit
genes PRKAA1 and PRKAA2, and a missense SNP in SLC22A1,
which encodes another metformin transporter. The most significant
association with diabetes incidence was observed for the AMPK
subunit gene PRKAG2 [57]. However, these results need to be confirmed by other independent studies.
6. OTHER DETERMINANTS OF METFORMIN RESPONSE
In addition to PMAT, OCTs, MATEs, and AMPK, many other
genetic variants affect the pharmacokinetics and pharmacodynamics of metformin. Metformin is used to induce ovulation in women

with polycystic ovary syndrome (PCOS). However, the ovulatory


response is variable, and the underlying cause of this variation is
poorly understood. In an analysis of metformin-treated subjects in a
prospective randomized trial, Legro, R.S. et al. showed that a
polymorphism in STK11 (also called LKB1), a kinase expressed in
the liver and implicated in metformin action, is associated with the
ovulatory response to metformin treatment [58]. However, this
association was not found in the other two study groups analyzed,
suggesting that the mechanism may have reflected drug-drug interactions in the combined group rather than metformin metabolism
[58]. Because the serine-threonine kinase STK11 catalyzes the
AMP-activated protein kinase complex, genetic variants of STK11
may also contribute to variations in insulin sensitivity and metformin efficacy. In hyperinsulinemic girls with androgen excess,
the STK11 rs8111699 SNP influences insulin sensitivity and metformin efficacy [59]. Relative to the baseline, the mutated G allele
in STK11 rs8111699 resulted in higher insulin and IGF-I levels.
STK11 GG homozygotes had an improved and robust metabolic
metformin response, while CC homozygotes exhibited almost no
response. Thus, the girls with the least favorable endocrine metabolic profile exhibited the most improvement with metformin therapy [59].
To identify factors predictive of the response to sulfonylurea
treatment, Schroner, Z. et al. analyzed KCNQ1 genotypes (KCNQ1
rs163184 (T>G)) and the quantitative effects of treatment with sulfonylurea in addition to metformin on glycemic control parameters
(Table 4). The results suggest that the magnitude of fasting plasma
glucose (FPG) reduction after 6 months of sulfonylurea treatment in
addition to metformin in T2D patients was affected by variation in
KCNQ1 [60]. Specifically, the FPG response to sulfonylurea was
significantly lower in carriers of the higher-risk GG genotype [60].

1078 Current Drug Metabolism, 2013, Vol. 14, No. 10

Metformin was also used to prevent the development of T2D. In


another study, Franks et al. found that the minor A allele at
rs9939609 of the fat mass and obesity associated gene (FTO) was
positively associated with baseline BMI but not with baseline adiposity. For the rs7566605 genotype of insulin-induced gene 2 (INSIG2), the minor C allele was associated with greater subcutaneous
adiposity [61]. During the follow-up period, CC homozygotes of
INSIG2 rs7566605 lost more weight than G allele carriers. Within
the DPP study population, common variants in FTO and INSIG2
were nominally associated with quantitative measures of obesity,
possibly reflecting direct metformin interaction or lifestyle intervention [61].
Ataxia telangiectasia mutated (ATM) is a serine/threonine protein kinase that is recruited and activated by DNA double-strand
breaks. ATM phosphorylates several key proteins that initiate the
activation of the DNA damage checkpoint leading to cell cycle
arrest and DNA repair or apoptosis [62]. Notably, in a combined
meta-analysis, Zhou, K. et al. observed that the ATM SNP
rs11212617 is associated with metformin treatment success [63]
(Table 4). Furthermore, the inhibition of ATM with KU-55933
attenuated the phosphorylation and activation of AMPK in response
to metformin. Thus, ATM may contribute to the effects of metformin upstream of AMP-activated protein kinase, and the available
evidence indicates that variation in this gene alters the glycemic
response to metformin [64]. In a meta-analysis of three cohorts
analyzed separately or combined with previously published cohorts,
rs11212617 was significantly associated with metformin treatment
response in T2D patients from the Netherlands and the UK [63].

Chen et al.

This was the first robustly replicated common susceptibility locus


to be associated with metformin treatment response.
7. PERSPECTIVE
Metformin is now believed to be the most widely prescribed antidiabetic drug in the world. Accordingly, it has become increasingly
urgent to improve the safety and efficiency of metformin treatment.
In recent decades, considerable advances have been made in our
knowledge of metformin disposition and action. As one example,
numerous genes that influence the pharmacogenetics of metformin
have been discovered. It is well established that the PMAT, OCT, and
MATE membrane transporters regulate metformin transport and excretion. Additionally, the pharmacological effect of metformin is
heavily dependent on AMPK (Fig. 1). There is a great deal of evidence indicating that genetic variation in these transporters and
AMPK affects the response to metformin. With additional advances
in pharmacogenetics, we will continue to learn more about the
relationship between genetic variation affecting critical proteins (such
as transporters and kinases) and the PK/PD of metformin. The
ongoing development of personalized therapy also requires increased
investigation of pharmacogenetic correlations and more detailed
knowledge of the underlying mechanisms, which can subsequently be
used to adjust the prescribed dose of metformin. By ultimately
improving metformin treatment, additional pharmacogenetic information will make it easier for T2D patients to cope with this disease.
However, it is important to be mindful that more SNPs related to
metformin pharmacokinetics have yet to be identified and that further
research in this field is required to meet these goals.

Fig. (1). Key transporters and proteins putatively involved in the absorption, distribution, biological function, and excretion of metformin.
The absorption of metformin from intestinal epithelial cells into the blood may involve PMAT and OCT1. Metformin is subsequently transported into hepatocytes and myocytes via OCT1 and OCT3. The biological function of metformin is primarily dependent on the activation of the LKB1/AMPK pathway, which
inhibits hepatic gluconeogenesis and increases glucose uptake. The therapeutic response to metformin is also affected by other molecules, including GCKR,
ATM, INSIG2, KCNQ1, and PPARG. Finally, metformin is secreted in the urine via transport mediated by OCT2, MATE1, and MATE2-K.

Pharmacogenetic Variation and Metformin Response

Current Drug Metabolism, 2013, Vol. 14, No. 10

CONFLICT OF INTEREST
The authors confirm that this article content has no conflicts of
interest.
ACKNOWLEDGEMENTS
This work was supported by grants from the National Natural
Science Foundation of China (No. 81202091,81202085,81173514
and 81001673) and Key Technologies for New Drug Innovation
and Development of China (No.2012ZXJ09303011 and
No.2012BAK25B00). We also acknowledge the assistance of Ms.
Jingyuan Wang in drawing the summary figure of metformin transportation and secretion.
LIST OF ABBREVIATION
AMPK = AMP-activated protein kinase
ATM
= Ataxia telangiectasia mutated
CL/F
= Apparent total clearance
CL(R)
= Renal clearance
Cmax
= Maximal plasma concentration
DPP
= Diabetes Prevention Program
GCKR
= Glucokinase regulatory protein
INSIG2 = Insulin-induced gene 2
LKB1
= Liver kinase B1
MATE = Multidrug and toxin extrusion transporters
OCTs
= Organic cation transporters
PMAT
= Plasma membrane monoamine transporter
PPARG = Peroxisome proliferator-activated receptor gamma
SLC
= Solute carrier
T2D
= Type 2 diabetes
V/F
= Lower oral volume of distribution

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Received: August 22, 2013

Revised: November 22, 2013

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