Impact of Berberine Hydrochloride-assisted Metformin on the Metabolism of Glycolipids and Serum Levels of TIMP-1 and TGF-β1 in Individuals with Type 2 Diabetes

Introduction

The primary characteristics of type 2 diabetes mellitus (T2DM), a metabolic disease interacting with environmental factors and genetics, are abnormalities in the metabolism of fats and carbohydrates. Its primary pathophysiology involves insulin resistance (IR) and an absolute or relative deficit of islet beta cells. IR affects the body’s glucose and lipid metabolism problems and is linked to the development of related issues brought on by the disease’s continued aggravation (Harrison et al., 2021; Zhang et al., 2020). Because of changes in living conditions and lifestyle, the number of persons with diabetes in our nation has been increasing annually in recent years (Wang et al., 2022).

Early blood glucose management, averting acute and chronic problems, and enhancing the function of insulin receptors and islet β cells can effectively manage the progression of diabetes and enhance patient outcomes (Harrison et al., 2021; Wang et al., 2022). Everyone knows that the most essential and basic treatment for type 2 diabetes patients to maintain stable blood sugar levels is a long-term, sustainable, and healthy lifestyle (Xu et al., 2021). Research has indicated that a nutritious diet, particularly the Mediterranean diet, together with different fasting protocols, a low glycemic index diet, and a balanced diet, can effectively regulate caloric intake, enhance blood sugar and lipid levels, preserve insulin secretion, lessen abdominal obesity, and ultimately improve IR (Xie et al., 2022). However, it can be challenging to break long-standing poor eating habits in the near term, and the hunger in fasting, blood sugar, cholesterol, and other metabolic markers vary, leading to weight regain after retaliatory overeating and significantly decreasing scientific diet compliance (Xie et al., 2022; Xu et al., 2021).

For blood sugar control, medication therapy in conjunction with food modification and exercise therapy remains the most successful approach. Met, the most fundamental first-line medication for T2DM, has been used extensively in clinics for a long time. Because of its shown efficacy and safety, it holds a significant place in both domestic and international guidelines (Habtemariam, 2020). Commonly referred to as “berberine,” berberine hydrochloride (BBR) is an isoquinoline alkaloid extracted from Coptis chinensis. It is an inexpensive medication that is effective in detoxifying, clearing heat, regulating intestinal flora, and having a broad spectrum of antibacterial activity that can either kill or inhibit a variety of gram-positive and gram-negative bacteria as well as fungi. Due to its ability to alleviate the symptoms of diarrhea, it is frequently utilized in clinics (Och et al., 2022). However, several studies conducted recently have demonstrated that BBR also has a significant role in enhancing blood lipids, blood sugar, and immune regulation (Habtemariam, 2020; Och et al., 2022). Using diabetic rats as test subjects, some research has eventually determined that BBR can enhance the phosphatidylinositol 3 kinase (PI3-K)’s glucose transporter 4 (GLUT4) expression and increase GLUT4’s circulation rate in the body, both of which improve IR (Habtemariam, 2020; Liang et al., 2019; Och et al., 2022). Unfortunately, there is a dearth of convincing data from extensive clinical experimental research, and these investigations are mostly based on animal experiments. Based on this, the effort aims to screen for the effects of BBR plus Met on glucose and lipid metabolism, serum TIMP-1, and TGF-β1 in T2DM patients, as well as the efficacy of this combination.

Materials and Methods

Results

A Comparison of the Two Groups’ Clinical Efficacy

Table 1 illustrates that the experimental group’s treatment effective rate was 96.00% greater than the untreated group’s (p < 0.05).

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Table 1.

Clinical Efficacy Comparison Between the Two Groups.

Group	Cases	Obvious Effect	Effective	Ineffective	Effective Rate [n (%)]
Untreated group	50	12	29	9	41 (82.00%)
Experimental group	50	21	27	2	48 (96.00%)*

Note: Compared with the untreated group, *p < 0.05.

Comparison of the Two Groups’ Lipid and Glucose Metabolism

Before therapy, there was a lack of discernible variation among the two groups’ lipid and glucose metabolism (p > 0.05). Following treatment, both groups’ blood levels of FPG, HbA_lc, and HOMA-IR were lower than pretreatment (p < 0.05), and the experimental group’s levels were lower than those of the untreated group. Following the intervention, both groups’ serum levels of TC, TG, and LDL-C were lower than they were prior to treatment; additionally, the experimental group’s levels were lesser compared to those of the untreated group, and the experimental group’s levels of HDL-C were higher than those of the untreated group (p < 0.05) (Table 2).

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Table 2.

Comparison of Glucose and Lipid Metabolism Among the Two Groups.

Group	Time	FPG (mmol/L)	HbA1c (%)	HOMA-IR	TC (mmol/L)	TG (mmol/L)	LDL-C (mmol/L)	HDL-C (mmol/L)
Control group	Before treatment	7.86 ± 0.47	7.86 ± 0.58	4.46 ± 0.31	6.81 ± 0.73	2.87 ± 0.21	4.41 ± 0.38	0.83 ± 0.11
	After treatment	6.65 ± 0.28*	6.84 ± 0.60*	3.38 ± 0.23*	4.81 ± 0.42*	2.28 ± 0.41*	3.36 ± 0.24*	1.21 ± 0.17*
Observation group	Before treatment	8.11 ± 0.34	7.81 ± 0.45	4.39 ± 0.42	6.73 ± 0.68	2.81 ± 0.23	4.34 ± 0.26	0.78 ± 0.14
	After treatment	6.24 ± 0.38*#	6.16 ± 0.52*#	3.03 ± 0.21*#	4.03 ± 0.32*#	1.88 ± 0.32*#	2.85 ± 0.18*#	1.38 ± 0.13*#

Notes: FPG: Fasting blood glucose; HbA_1c: Glycosylated hemoglobin; HDL-C: High-density lipoprotein cholesterol; HOMA-IR: Homeostatic model assessment of insulin resistance; LDL-C: Low-density lipoprotein cholesterol; TC: Total cholesterol; TG: Triglyceride. Compared with before treatment, *p < 0.05; compared with the untreated group, #p < 0.05.

Renal Function Index Comparison Between the Two Groups

Before therapy, there was a lack of discernible variation in the renal function indices among the two groups (p > 0.05). Following therapy, there was a decrease in blood CysC, urine ALB, UAER, and β2-MG levels in both groups compared to pretreatment values, with a remarkable variation between the experimental and untreated groups (p < 0.05) (Table 3).

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Table 3.

Comparison of Renal Function Indexes Among Two Groups.

Group	Time	Urinary ALB (mg/L)	Urinary UAER (µg/min)	Urinary β2-MG (µg/L)	Blood CysC (mg/L)
Control group	Before treatment	80.04 ± 9.62	80.82 ± 10.64	0.36 ± 0.04	1.16 ± 0.13
	After treatment	54.11 ± 6.32*	69.78 ± 6.52*	0.23 ± 0.06*	0.81 ± 0.11*
Observation group	Before treatment	79.85 ± 8.78	82.57 ± 9.42	0.38 ± 0.05	1.11 ± 1.18
	After treatment	41.65 ± 4.13*#	57.24 ± 5.81*#	0.16 ± 0.08*#	0.63 ± 0.08*#

Notes: ALB: Urinary microalbumin; Cys-C: serum cystatin; UAER: urine albumin excretion rate. Compared with before treatment, *p < 0.05; compared with the untreated group, #p < 0.05.

Renal Fibrosis Index Comparison Between the Two Groups

Prior to treatment, there was no discernible difference in TGF-β1, MMP-9, or TIMP-1 levels between the two groups (p > 0.05). Following therapy, both groups’ blood levels of MMP-9 and TGF-β1 were lower than they were prior to treatment, with the experiment group having lower levels than the untreated group. TIMP-1 levels were higher than they were prior to treatment, with the experiment group having higher levels than the untreated group (p < 0.05) (Table 4).

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Table 4.

Comparison of Renal Fibrosis Indexes Among Two Groups.

Group	Time	TGF-β1 (ng/mL)	MMP-9 (ng/mL)	TIMP-1 (ng/mL)
Control group	Before treatment	50.68 ± 4.86	131.45 ± 12.87	265.81 ± 31.45
	After treatment	43.76 ± 4.53*	113.42 ± 12.58*	312.47 ± 27.96*
Observation group	Before treatment	50.07 ± 5.12	128.31 ± 13.45	259.34 ± 25.73
	After treatment	40.25 ± 3.96*#	101.71 ± 10.89*#	335.18 ± 29.65*#

Notes: MMP-9: Matrix metalloproteinase-9; TGF-β: Transforming growth factor-β; TIMP-1: Tissue inhibitor of metalloproteinase-1. Compared with before treatment, *p < 0.05; compared with the untreated group, #p < 0.05.

Discussion

With the change in unhealthy lifestyles, such as sitting down, staying up late, and eating a high-fat diet, metabolic diseases such as T2DM have skyrocketed in developing countries. Based on the International Diabetes Federation Diabetes Atlas, approximately 400 million people worldwide have T2DM, and 10 million people are diagnosed with diabetes yearly (Liang et al., 2019; Och et al., 2022). With the prolonged course of T2DM, insulin secretion function decreases and IR persists, resulting in hyperglycemia toxicity, which can lead to fatal and disabling diabetic chronic complications such as diabetic retinopathy, kidney disease, cardiovascular and cerebrovascular diseases, which is not good for the patient’s physical and mental health, seriously decreases the life’s quality, and enhances the economic burden of patients and their families as well as society (Liang et al., 2019; Zhang et al., 2019).

Metformin (Met) was introduced into the clinic 60 years ago, and its discovery dates back to the 17th century when it was used to relieve the intense urination of medieval diabetes. At present, Met plays a significant part in many diabetes guidelines at home and abroad (Zhang et al., 2019). Many guidelines recommend that Met be recommended for patients with obesity or normal BMI and no obvious abnormalities in renal function. If combination drugs are required, one of them should include Met (Chen et al., 2023). Recently, more studies have proved that Met can be applied to other diseases, such as obesity, hyperlipidemia, and tumors (Chen et al., 2023; Zhang et al., 2022). BBR is an isoquinoline alkaloid commonly isolated from plants and was originally used to treat diarrhea and dysentery. So far, BBR has not only been used to treat diarrhea but also has been used as an OTC drug in the clinic to treat stomatitis and hepatitis (Cortez-Navarrete et al., 2023; Zhang et al., 2022). In recent years, many studies have confirmed that BBR is effective in the treatment of hyperglycemia, hypertension, and hyperlipidemia, and can also assist in cardiovascular diseases, hyperuricemia treatment, and other clinical effects (Araj-Khodaei et al., 2023; Cortez-Navarrete et al., 2023; Zhang et al., 2022). Although much research has shown that the hypoglycemic effect of BBR is similar to that of Met, it has not been widely used in diabetes treatment.

In this work, the effective rate of treatment in the experimental group was greater compared to that in the untreated group, representing that BBR combined with Met can further enhance the clinical symptoms of patients and improve clinical efficacy. In addition, in the pretreatment of this study, the FPG, HbA_lc, and HOMA-IR levels in the untreated group were lesser compared to before treatment, which may be related to the hypoglycemic mechanism of Met. In the BBR combined with the Met treatment group, the above indexes decreased significantly, and the degree of decline was better than that of Met monotherapy, suggesting that BBR has a definite hypoglycemic effect. Previous studies have confirmed that BBR has the same or better effect than Met in reducing FBG in diabetic rats (Pei et al., 2019). The mechanism of BBR hypoglycemia may have the following aspects: (a) It can activate glucagon-like peptide 1 (GLP-1) receptor in pancreatic beta cells, increase insulin receptor expression, further activate AMPK and PI-3K pathway, and increase glucose transport and utilization in peripheral tissues (Araj-Khodaei et al., 2023; Cortez-Navarrete et al., 2023). (b) The expression of insulin receptor mRNA can be increased through upregulation of protein kinase C (PKC) (Araj-Khodaei et al., 2023). (c) BBR can activate GLUT1-mediated glucose uptake by 3T3-L1 adipocytes via EPK and AMPK pathways (Pei et al., 2019). (d) Suppression of multiple transcription factors leads to inhibition of gluconeogenesis of two rate-limiting enzymes, glucose-6-phosphatase and phosphoenolpyruvate carboxykinase (Di et al., 2021). BBR reduces blood sugar levels by reducing glucose production and increasing glucose uptake, transport, and utilization. BBR monotherapy in treating T2DM still has limitations, and its efficacy and safety lack a large sample of randomized controlled clinical studies. The combination of BBR and Met is an economical and effective alternative hypoglycemic program, worthy of clinical promotion (Di et al., 2021; Pei et al., 2019; Wang et al., 2021).

Abdominal obesity and excessive visceral fat, as the soil and core of IR, increase the risk of T2DM and play a significant role in the pathogenesis of T2DM (Nematollahi et al., 2022). This research showed that BBR combined with Met could enhance the TC, TG, LDL-C, and HDL-C levels in patients in addition to improving IR and hypoglycemia. In terms of lipid-lowering mechanism, BBR varies from statins in that it can upregulate LDLR expression by stabilizing LDLR message ribonucleic acid (mRNA) and suppressing the transcription of pre-protein converting enzyme (PCSK-9) (Nematollahi et al., 2022; Wu et al., 2021; Xu et al., 2020). Meanwhile, BBR can also activate the AMPK-SIRT1-PPARα pathway. Inhibition of macrophage expression of lectin-like oxidized low-density lipoprotein receptor-1 (Lox-1) reduces the formation of foam cells (Wu et al., 2021; Xu et al., 2020). In addition, BBR can also reduce TG by activating AMPK and blocking the MAPK/ERK pathway, which can decrease the translocation of the nucleus and the binding activity of the NF-κB pathway activated by LPS (Xu et al., 2020). Presently, preliminary animal and human trials have shown that BBR can improve the lipid profile. A large study pointed out that BBR can reduce LDL, TC, and TG in patients with dyslipidemia, which is compatible with the results (Khater et al., 2023; Senesi et al., 2021).

The kidney is the nature of congenital, and the main essence, the main water, and the main gas, T2DM patients with kidney disease dysfunction, blood stasis, phlegm turbidness, water, and other pathological products formation, kidney deficiency caused by kidney essence loss in storage, proteinuria, and a series of symptoms, if early detection and timely treatment of patients with renal damage can effectively enhance the prognosis of patients (Ai et al., 2021; He et al., 2022; Senesi et al., 2021). Serum CysC can reflect the state of ultra-early renal function with high sensitivity and specificity. In addition, urine β2-MG, UAER, and ALB are markers of renal function injury (Noh et al., 2022; Shinjyo et al., 2020). The study found that BBR can enhance the level of kidney function in T2DM patients with kidney disease (Noh et al., 2022). In this study, urinary ALB, UAER, β2-MG, and blood CysC levels in the posttreatment experimental group were lesser compared to those in the untreated group, indicating that BBR can effectively reduce ALB and improve renal function in patients, which is consistent with the above findings. Further comparison of renal fibrosis indexes among the two groups pre- and posttreatment showed that among many MMP family members, MMP-9 could degrade renal basement membrane collagen and other cellular matrix, which was most correlated with the occurrence of T2DM complicated kidney disease (Mi et al., 2019; Shrivastava et al., 2023). TIMP is a natural specific inhibitor of MMPs, which can interact with the active site of MMPs and prevent the interaction between MMPs and substrate. Among them, TIMP-l can inhibit the degradation of MMP-9, decrease the expression of MMP-9, or increase the TIMP-1 expression (Mi et al., 2019; Xuan et al., 2020). Both can cause MMP-9/TIMP-1 dysregulation and accelerate glomerular sclerosis (Xuan et al., 2020). TGF-β1 in renal tissue is secreted by glomerular and tubular epithelial cells. In the occurrence and development of T2DM with renal disease, a variety of factors promote the abnormal increase of TGF-β1 expression and stimulate the synthesis of collagen and other cell matrix components (Yao et al., 2020; Zhao et al., 2021). In this study, serum levels of MMP-9 and TGF-β1 decreased and TIMP-l increased in the two groups after treatment, and the effect of the experimental group was better compared to that of the untreated group, indicating that BBR combined with Met can further prevent glomerular sclerosis, delay renal interstitial fibrosis, and improve renal function by regulating the cellular matrix metabolic system. In the course of treatment, no serious ADR occurred in the two groups, indicating that BBR combined with Met treatment is safe.

Conclusion

BBR combined with Met can effectively regulate the glucose and lipid metabolism of type 2 diabetes patients, regulate the TGF-β1, MMP-9, and TIMP-1 levels, delay renal interstitial fibrosis, and enhance kidney function, with significant effects and high safety.

Abbreviations

ALB: Urinary microalbumin; β2-MG: Urinary β2 microglobulin; BBR: Berberine hydrochloride; Cys-C: Cystatin C; FBG: Fasting blood glucose; GLUT4: Glucose transporter 4; HbA_1c: Glycosylated hemoglobin; HDL-C: High-density lipoprotein cholesterol; HOMA-IR: Homeostatic model assessment of insulin resistance; IR: Insulin resistance; LDL-C: Low-density lipoprotein cholesterol; Met: Metformin; MMP-9: Matrix metalloproteinase-9; T2DM: Type 2 diabetes mellitus; TC: Total cholesterol; TG: Triglyceride; TGF-β: Transforming growth factor-β; TIMP-1: Tissue inhibitor of metalloproteinase-1; UAER: Urine albumin excretion rate.