• Francesca Polverino, Tianshi David Wu, Joselyn Rojas-Quintero, Xiaoyun Wang, Jonathan Mayo, Michael Tomchaney, Judy Tram, Samuel Packard, Duo Zhang, Kristan H Cleveland, Elizabeth Cordoba-Lanus, Caroline A Owen, Ashraf Fawzy, Greg L Kinney, Craig P Hersh, Nadia N Hansel, Kevin Doubleday, Maor Sauler, Yohannes Tesfaigzi, Julie G Ledford, Ciro Casanova, Jaroslaw Zmijewski, John Konhilas, Paul R Langlais, Rick Schnellmann, Irfan Rahman, Meredith McCormack, and Bartolome Celli.
• Asthma and Airway Disease Research Center and.
• Am. J. Respir. Crit. Care Med. 2021 Sep 15; 204 (6): 651666651-666.

AbstractRationale: Cigarette smoke (CS) inhalation triggers oxidative stress and inflammation, leading to accelerated lung aging, apoptosis, and emphysema, as well as systemic pathologies. Metformin is beneficial for protecting against aging-related diseases. Objectives: We sought to investigate whether metformin may ameliorate CS-induced pathologies of emphysematous chronic obstructive pulmonary disease (COPD). Methods: Mice were exposed chronically to CS and fed metformin-enriched chow for the second half of exposure. Lung, kidney, and muscle pathologies, lung proteostasis, endoplasmic reticulum (ER) stress, mitochondrial function, and mediators of metformin effects in vivo and/or in vitro were studied. We evaluated the association of metformin use with indices of emphysema progression over 5 years of follow-up among the COPDGene (Genetic Epidemiology of COPD) study participants. The association of metformin use with the percentage of emphysema and adjusted lung density was estimated by using a linear mixed model. Measurements and Main Results: Metformin protected against CS-induced pulmonary inflammation and airspace enlargement; small airway remodeling, glomerular shrinkage, oxidative stress, apoptosis, telomere damage, aging, dysmetabolism in vivo and in vitro; and ER stress. The AMPK (AMP-activated protein kinase) pathway was central to metformin's protective action. Within COPDGene, participants receiving metformin compared with those not receiving it had a slower progression of emphysema (-0.92%; 95% confidence interval [CI], -1.7% to -0.14%; P = 0.02) and a slower adjusted lung density decrease (2.2 g/L; 95% CI, 0.43 to 4.0 g/L; P = 0.01). Conclusions: Metformin protected against CS-induced lung, renal, and muscle injury; mitochondrial dysfunction; and unfolded protein responses and ER stress in mice. In humans, metformin use was associated with lesser emphysema progression over time. Our results provide a rationale for clinical trials testing the efficacy of metformin in limiting emphysema progression and its systemic consequences.

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