Metabolic Reprogramming and Ferroptosis: Unlocking New Therapeutic Frontiers in Cancer and Diabetes

Iron metabolism and lipid peroxidation

The dysregulation of iron in the body results in the increase of the labile ferrous (Fe²⁺) pool, which in turn facilitates Fenton chemistry and generation of very reactive hydroxyl radicals that start and lead to lipid peroxidation over membranes (Rochette et al., 2022). The main substrates for peroxidation are the polyunsaturated fatty acids (PUFAs), which are incorporated into phospholipids, and the involvement of the enzymes such as ACSL4 and LPCAT3 in their formation is critical; the limiting cellular loss of phospholipid hydroperoxides does lead to the death of cells through the ferroptotic pathway as the bilayer’s integrity is compromised. The intracellular movement of iron is regulated by transferrin-mediated iron uptake, ferritin-mediated iron storage, iron export via ferroportin, and NCOA4-mediated selective ferritinophagy, which releases stored iron and thus enhances peroxidation (Rochette et al., 2022; Valgimigli, 2023).

The upstream factors that decide the availability of the substrate for peroxidation are driven by PUFA incorporation, which is ACSL4-dependent, and the size of the labile iron pool. Besides this, ferritinophagy (via NCOA4) and the modulators of iron import/export can change the iron supply and thereby act as nodes, which can either enhance or reduce the effect of sensitization (Ortega et al., 2024; Wang et al., 2023b; Zahng et al., 2024). In terms of intervention in the clinic, the approach to iron handling (including the use of iron chelators or the modulation of ferritinophagy) or the blocking of ACSL4-mediated PUFA incorporation are the main strategies because they address the issue at the source of lipid oxidation and can consequently alter the ferroptosis susceptibility across the different tissues (Gensluckner et al., 2024; Pap et al., 2022; Zahng et al., 2024).

GPX4, system Xc^–, and glutathione axis

The GPX4-GSH axis is the main mechanism of cell protection against ferroptosis: GPX4 works together with GSH and hydrogen peroxide to produce lipid alcohols, which are harmless. Availability of intracellular cysteine, which is mainly dependent on the cystine import through system Xc⁻ (SLC7A11/SLC3A2), has been identified as the limiting factor for GSH production (Li et al., 2022a, 2024b). The use of drugs and inhibition of system Xc⁻, such as erastin, leads to the depletion of GSH, the inhibition of GPX4, and a rapid susceptibility of cells to ferroptosis. On the other hand, the induction of SLC7A11 and GSH biosynthesis through transcriptional programs (Nrf2, ATF4) provides cells with higher resistance.

System Xc⁻ (SLC7A11) is a proximal, clinically actionable node since it regulates cysteine supply and thereby influences GPX4 function; the latter is a terminal suppressor whose inhibition strongly activates ferroptosis. Likely, such a combination of treatments that involve partial blocking of cystine uptake and adjusting of parallel antioxidant systems (like CoQ regeneration) will bear more selectivity and less systemic oxidative toxicity (Liu et al., 2021; Shi et al., 2023; Xu et al., 2021).

Crosstalk with other cell death pathways

Ferroptosis is not a stand-alone mechanism of cell death but rather an event that takes place within the network of regulated-death modalities. Regulators with commonality, such as p53, depending on the target gene programs, either make cells more prone to suffer from ferroptosis or protect them (e.g., transcriptional repression of SLC7A11). Autophagy processes—ferritinophagy and lipophagy—control the supply of iron and the composition of lipids, respectively, thus connecting autophagy to the susceptibility of the cell to die by ferroptosis. Necroptosis and pyroptosis meet at the point of common upstream triggers (oxidative and mitochondrial stress) and downstream inflammatory consequences, yet each pathway retains mechanistic differences that can be experimentally differentiated through genetic or pharmacologic rescue (Chen et al., 2024a; Huang et al., 2025c).

Transcriptional regulators (p53, Nrf2) act like master switches determining a cell’s susceptibility to ferroptosis and controlling iron management, antioxidant protection, and lipid restructuring. From a translational point of view, manipulating these master regulators, or the particular autophagy routes that release iron (ferritinophagy), creates a chance to change the death of cells depending on the disease with specificity (Eskander et al., 2025; Lv et al., 2023a; Wang et al., 2023a; Wu et al., 2023).

Emerging regulators and redox nodes

In addition to the GPX4-GSH pathway, other mechanisms work in parallel to prevent lipid peroxidation. FSP1 at the cell membranes regenerates the reduced form of ubiquinol (CoQ10) and offers a radical-trapping mechanism, which is independent of GPX4. Mitochondrial DHODH is involved in CoQ reduction in the inner membrane and thus guards the lipids of the mitochondria. The activities of enzymes like POR, NOX family oxidases, ACSL3, and MBOATs not only affect the amount of ROS but also influence the composition of lipid species, thereby adjusting the cells’ susceptibility to ferroptosis. Nrf2 is still the main transcription factor that dictates the expression of many antioxidant and iron-handling genes, whereas the HO-1 and bilirubin pathways offer further context-dependent buffering (Chen et al., 2021; Dai et al., 2024).

The CoQ-dependent parallel defenses (FSP1 and DHODH) are the most crucial secondary suppressors in the context of tissue-specific sensitivity to ferroptosis, especially in the case of mitochondrial-rich cells. They are therefore very appealing as targets in combination therapies when GPX4 suppression is not enough. In clinical practice, together with methods that change lipid composition or NOX activity, FSP1/DHODH inhibitors or modulators would create promising pathways to increase therapeutic windows while providing more precision in selecting the affected tissue (Du and Guo, 2022; Ni et al., 2023a; Tang et al., 2021b; Wang et al., 2025b; Zhou et al., 2023).

Hallmarks of metabolic reprogramming in cancer and diabetes

Metabolic reprogramming includes variations in glucose, amino acids, and lipid metabolism that make it possible for cells to have energy and building blocks even during stressful situations. The tumor cells use these changes to continue growing and surviving even when the tumor microenvironment (TME) is not very friendly. In diabetes, chronic high glucose levels and insulin resistance lead to a nonadaptive type of remodeling, which decreases mitochondrial function, making it difficult to maintain redox balance. Changes in both diseases result in a similar alteration of the oxidative and antioxidant processes, so that the metabolic state can determine whether susceptibility to ferroptosis is raised or lowered. Therefore, ferroptosis is a redox-sensitive junction that integrates the anabolic remodeling in the various pathologies with the death of the cell by regulation (Hao et al., 2022; Hua et al., 2023; Zeković, 2024).

At the cellular level, the interaction of the three metabolic pathways, that is, cysteine/GSH supply, NADPH/CoQ regeneration, and PUFA availability, mainly determines the threshold limits of ferroptosis. In the treatment of diseases, the modification of these pathways (e.g., via inhibitors of SLC7A11, NADPH/PPP modulators, or ACSL4-directed strategies) would be the most promising targets since these interventions are applied before lipid peroxidation occurs and can be combined with direct ferroptosis inducers to achieve a selective therapeutic outcome (Bosso et al., 2024; Li and Ye, 2024).

Glucose metabolism and ferroptosis regulation

The control of redox state in the cell is dictated by glucose metabolism, which takes place through glycolysis, the pentose phosphate pathway (PPP), and mitochondrial oxidation. Several tumors are using aerobic glycolysis to their advantage and diverting glucose into the PPP to produce NADPH, a reduction power that supports GSH production and CoQ reduction—the two major processes in the fight against lipid peroxidation (Zhang et al., 2024b; Zhu et al., 2024a). On the other hand, redirecting pyruvate into the mitochondria for oxidation leads to the generation of high levels of reactive oxygen species (ROS), and therefore cells may be more susceptible to destruction via lipid peroxidation; the enzyme G6PD, which is part of the PPP, can be inhibited, causing a reduction in the levels of NADPH. Consequently, the tumor cells can become sensitive again to the inducers of ferroptosis. The impact of changing the glucose metabolism route in the cell largely depends on the extent to which this modification shifts the balance of reducing equivalents between the cytosol, where NADPH is being produced, and mitochondrial ROS production (Miao et al., 2023; Yao et al., 2021; Zhong et al., 2023).

The PPP/NADPH axis is a proximal regulator of ferroptosis due to the fact that the availability of NADPH determines the activity of the different antioxidant systems (GSH, FSP1/CoQ) in the cell. Targeting the PPP enzyme like G6PD or employing strategies that direct pyruvate into oxidative phosphorylation are potential clinical approaches to reduce antioxidant capacity and make the cancer cell more sensitive to ferroptosis, but the metabolic heterogeneity of tumors still necessitates the use of biomarkers for patient selection (Jiang et al., 2024a; Peng et al., 2025; Sun et al., 2024).

Amino acid metabolism and redox control

The synthesis of GSH and mitochondrial anaplerosis are primarily regulated by the amino acid flux, which consists of cysteine, glutamate, and glutamine. System Xc⁻ (SLC7A11/SLC3A2) is responsible for the transport of cystine for GSH production. Its overexpression leads to resistance against ferroptosis, whereas its inhibition results in glutathione depletion and more lipid peroxidation. The glutamine decay process has both positive and negative effects depending on the circumstances. The action of the enzyme that converts glutamine to glutamate can facilitate the flow of the TCA cycle and mitochondrial ROS, making cells more sensitive to ferroptosis. On the other hand, glutamate produced from glutamine can help cysteine exchange and antioxidant defense. The process of autophagy (e.g., ferritinophagy, GPX4 degradation) additionally links amino acid metabolism with iron release and GPX4 stability, thus merging protein and iron homeostasis into the regulation of ferroptosis (Chen et al., 2021; Hu et al., 2023b; Li and Zhang, 2024; Wang et al., 2021, 2023d; Yang et al., 2022a).

SLC7A11 has a main role in the process and is considered to be a drug target since it regulates the supply of cysteine for GSH and consequently for the GPX4 process. Glutaminase and autophagy (ferritinophagy) are the secondary modulators, which can either promote or suppress ferroptosis depending on the amino acid flux. The combination of SLC7A11 partial inhibition with glutamine metabolism or autophagy modulation in therapeutic strategies can provide increased selectivity and not be affected by compensatory responses (Liu et al., 2020, 2023a; Yang et al., 2022a; Yao et al., 2021).

Lipid metabolism and ferroptotic vulnerability

The content of PUFA in the membrane represents the biochemical substrate for ferroptosis. ACSL4 and LPCAT3 are responsible for the activation and the incorporation of AA and AdA into phospholipids, which are selectively oxidized to lipid hydroperoxides. The presence of monounsaturated fatty acids (MUFAs) and lipid droplets reduces the availability of the substrate and provides resistance by moving PUFAs away from peroxidation-prone phospholipids. Therefore, the interplay of PUFA synthesis/desaturation, phospholipid remodeling, and lipid storage will decide the susceptibility of membranes to iron-catalyzed oxidation, a phenomenon that can be observed in tumors and diabetic tissues where the alteration of lipid handling makes the oxidative injury worse (Lee et al., 2021; Lin et al., 2021; Naowarojna et al., 2023; Pope and Dixon, 2023).

The incorporation of PUFA, which depends on ACSL4, is a primary factor for the availability of substrates for ferroptosis and a target with high potential. Meanwhile, the enhancement of MUFA production (SCD1) or lipid trapping is a way of protection. The pharmacological intervention of the lipid desaturation/remodeling enzymes gives a straightforward route of changing the ferroptosis levels, especially in cancers having a high expression of ACSL4 (Kim et al., 2023; Lei et al., 2022; Li and Li, 2020).

Tumor microenvironment and immune cell metabolism

The TME is a very different place metabolically. It is an ecosystem where cancer cells, cancer-associated fibroblasts (CAFs), various immune cells, and the extracellular matrix give and take nutrients, metabolites, and redox signals that together determine the sensitivity to ferroptosis (Arner and Rathmell, 2023; Cortellino and Longo, 2023). The exchange of metabolites (e.g., lactate, cysteine/cystine) and the paracrine cytokine signaling act as context-dependent modulators: they can either enhance the tumor’s antioxidant capacity and protect it from ferroptosis or deplete the resources and make the local cells more susceptible to lipid peroxidation. From the point of view of therapeutics, the two strategies of disrupting stromal metabolic support or shielding the antitumor immune effectors from ferroptotic stress are not only orthogonal but also can be used together to achieve the desired effect of increasing tumor selectivity while minimizing the collateral damage to the surrounding tissues (Anderson, 2022; Kalyanaraman et al., 2022).

Impact on ferroptosis sensitivity and therapeutic implications

Metabolic reprogramming and ferroptosis create a bidirectional regulatory loop: metabolic flexibility allows one to stay away from ferroptotic stress, whereas intentional metabolic disruptions can bring back the sensitivity. In the case of cancer, the therapeutic blockade of important metabolic nodes, such as SLC7A11, G6PD (PPP), or SCD1 (MUFA synthesis), not only results in a decrease of antioxidant capacity but also enhances the effect of ferroptosis inducers (Tan et al., 2024). In the case of diabetes, the long-standing oxidative and lipid disturbances make the pancreatic β-cells and the vascular tissues prone to ferroptotic death, thus indicating that the modulation of ferroptosis (inhibition to save cells or selective induction to get rid of dysfunctional cells) may have context-specific therapeutic applicability (Dos Santos et al., 2023; Tang et al., 2021a).

From a translational perspective, the most effective strategies are directed to the upstream metabolic nodes that control substrate availability and reducing power (SLC7A11 → GSH/GPX4; PPP → NADPH; ACSL4 → PUFA-PL), in addition to context-sensitive approaches that take into account the metabolic state of the tissue and immune interactions. It will be necessary to implement biomarker-guided patient selection and combinatorial regimens (metabolic modulators + ferroptosis inducers or immune-protective agents) to optimize the therapeutic index and prevent the injury from off-target oxidative processes (Chen et al., 2024b; Dos Santos et al., 2023; Jin et al., 2024).

Ferroptosis vulnerability in therapy-resistant tumors

Ferroptosis utilizes the imbalance in the redox state of iron and lipids that is present in a number of cancer cells. Thus, it creates a different kind of metabolic liability from what happens when the apoptosis process is disabled. The therapy-resistant tumor populations, drug-tolerant persisters, cancer stem-like cells, and mesenchymal/dedifferentiated phenotypes are usually characterized by high iron content, increased PUFA incorporation into membranes, and higher baseline ROS production, which altogether make them more than ready for ferroptotic death if no antioxidant defenses are present (Lei et al., 2022; Nie et al., 2022; Singh et al., 2025).

For instance, resistance to chemotherapy or radiotherapy often brings about redox changes (overproduction of GSH, increased expression of GPX4 and SLC7A11) that elevate the threshold for ferroptosis, and the cancer cells continue to survive (Zhang et al., 2022a; Zhu et al., 2022a). However, it is noteworthy that the use of drugs or genetic manipulation to inhibit SLC7A11 or GPX4 (for instance, erastin, RSL3) can bring back the sensitivity of the resistant cells and cause the extinction of the drug-tolerant populations in the preclinical models, hence presenting a rational strategy to defeat the failure of conventional therapy to work (Koeberle et al., 2023; Xie et al., 2023; Zhang et al., 2022a; Zhu et al., 2022a). Tumors exhibiting mesenchymal characteristics—triple-negative breast cancer, hepatocellular carcinoma, and pancreatic ductal adenocarcinoma—are often characterized by metabolic changes and lipid alterations leading to increased susceptibility to ferroptosis, thus creating selective therapeutic opportunities (Li et al., 2022b; Wu et al., 2022c).

The upstream determinants, which are the iron load and the incorporation of PUFA through ACSL4, determine the availability of substrates for peroxidation, and the SLC7A11 → GSH → GPX4 pathway is the main protective mechanism. In clinical practice, the most straightforward approach to selectively eliminating tumor cells that are resistant to therapy is by targeting SLC7A11 or GPX4 (either alone or together with metabolic modulators that enhance PUFA availability or promote iron release; Koeberle et al., 2023; Lee and Roh, 2022).

Metabolic rewiring and ferroptosis evasion in cancer cells

To reduce oxidative stress and avoid ferroptosis in cancer cells, change their glucose and lipid metabolism. The process of aerobic glycolysis and the rerouting of glucose into the PPP provide an increased supply of NADPH. It will support GSH regeneration and CoQ reduction, while the inhibition of the mitochondrial OXPHOS will keep the ROS production at a lower level (Wang et al., 2023e; Žalytė, 2023).

The activation of the PI3K/Akt/mTOR–SREBP1 signaling pathway leads to an increase in the production of new lipids and MUFAs through the stearoyl-CoA desaturase (SCD1) enzyme, thus altering the composition of membranes by favoring MUFAs over PUFAs and decreasing the levels of peroxidation substrates. Pushing mitochondrial oxidation or obstructing the PPP and glucose-6-phosphate dehydrogenase (G6PD) can lead to heightened levels of ROS and make the cells more susceptible to the action of ferroptosis inducers (Audrito and Giovannetti, 2025; Lv et al., 2025; Wang et al., 2023e; Zhan et al., 2022).

The energy-sensing enzyme AMP-activated protein kinase (AMPK) has a variable role according to the context. During energetic stress, AMPK hinders PUFA production (thus reducing the availability of substrate), and it also stimulates routes (e.g., Beclin-1-mediated SLC7A11 interaction) that restrict the import of cystine and make the cells more susceptible to ferroptosis (Lv et al., 2025; Wang et al., 2023e; Žalytė, 2023).

The PPP/NADPH pathway and the supply of cysteine controlled by SLC7A11 are the main factors that regulate antioxidant capacity, whereas mTOR/SREBP1 and SCD1 control the lipid composition that affects the susceptibility of cells to oxidative stress. From a therapeutic perspective, the inhibition of either PPP or SCD1 alone, or the combination of metabolic reprogramming (inducing OXPHOS) along with ferroptosis inducers, are all possible interventions—assuming that the selection of patients considers the metabolic heterogeneity of tumors (Audrito and Giovannetti, 2025; Bhowmick et al., 2025; Lee et al., 2020).

Role of cancer-associated fibroblasts and immune cells

Metabolite exchange and paracrine signaling are the two major factors governing the susceptibility of the TME to ferroptosis. The roles of the CAFs are the following: they switch to the glycolytic metabolism, and they provide the tumor cells with the lactate and the cytokines (e.g., IL-6), which in turn are utilized by the tumor cells to enhance the NADPH and GSH production. Hence, the oxidative stress is reduced, and the risk of stem cell death through ferroptosis is minimized (An et al., 2020; Desbois and Wang, 2021). Moreover, the miRNAs (like miR-522) released by the CAFs in exosomes further inhibit the enzymes that are oxidative and more lipid-peroxidizing (ALOX15), thereby providing the tumor cells with a shield against the therapeutic-induced ferroptosis. Immune cells are adaptable: the effector CD8⁺ T cells that are deprived of glucose might develop ROS and become nonviable or dysfunctional through the process of ferroptosis. The Tregs and M2 macrophages are using fatty acid oxidation and antioxidant programs to survive and continue to suppress the immune response. The lipid overload in dendritic cells leads to the impairment of the antigen-presenting function and can be associated with the ferroptotic features, thus weakening the antitumor immunity (Barrett and Puré, 2020; Freeman and Mielgo, 2020; Huang et al., 2023a; Jiang et al., 2025b; Kennel et al., 2023; Mhaidly and Mechta‐Grigoriou, 2021; Sezginer and Unver, 2024; Xiang et al., 2020).

The flux of metabolites from CAFs like lactate and cysteine precursors, along with antioxidant programs in immune cells, is one of the factors that can protect tumors from undergoing ferroptosis. Thus, the strategies that impair stromal metabolic support or protect effector immune cells from suffering ferroptotic stress will be very effective, combined with tumor-directed ferroptosis inducers (Correa‐Gallegos et al., 2021; Montes-Gómez et al., 2020; Wang et al., 2023c).

Therapeutic agents targeting ferroptosis

The pharmacological intervention in the process of ferroptosis has shifted from basic research to clinical applications. System Xc⁻ inhibitors (erastin and its derivatives) cause depletion of cystine and GSH, while direct GPX4 inhibitors (RSL3, ML162) stop the detoxification of lipid hydroperoxide without depending on the supply of cysteine, thus directly inducing ferroptosis (Sun et al., 2023a; Yuan et al., 2021). Drugs that target multiple receptors, like sorafenib, induce ferroptosis to some extent by blocking the import of cystine. FIN56 works by compromising GPX4 stability and draining CoQ, thereby overpowering both the conventional and the nonconventional antioxidant protection (Cheff, 2023; Cheff et al., 2023; Huang et al., 2022a; Liu et al., 2021, 2021; Tang et al., 2020; Wang et al., 2020a). Current therapeutic strategies focus on the rational combinations—metabolic modulators (G6PD/PPP inhibitors, SCD1 inhibitors) or immune-modifying agents together with ferroptosis inducers to improve selectivity for tumors, rupture resistance, and activate immune-mediated clearance (Gao et al., 2022b; Golbashirzadeh et al., 2023; Sun et al., 2021; Yin et al., 2023; Zhao et al., 2022).

Drugs that work on all three fronts, supplying the substrate by blocking SLC7A11, suppressing the terminal step by inhibiting GPX4, and the parallel defense by attacking FSP1/DHODH/CoQ, will have the best chance of getting rid of the tumors permanently and not letting the resistance mechanisms take over. For the treatments to be used in patients, it will be necessary to select the patients according to the biomarkers (e.g., ACSL4 expression, SLC7A11 levels, iron status), optimize the treatments to avoid oxidative toxicity in the whole body, and design the combinations so that the immunity to tumors is not affected (Liu et al., 2022d, 2025b).

Clinical trials and translational potential

β-cell dysfunction and oxidative stress

Diabetes is one of the most serious worldwide metabolic epidemics, posing the greatest threat to oxidative stress and redox state, along with T1DM and T2DM. Pancreatic β-cells have a very low level of endogenous antioxidants and are also vulnerable to oxidative damage that is iron-dependent and includes ferroptosis (Dinić et al., 2022; Miao et al., 2023). An abnormal iron metabolism, elevated serum ferritin, and transferrin saturation promote ROS formation through the Fenton reaction. Therefore, this advances lipid peroxidation and β-cell destruction in T1DM and T2DM. GSH depletion and GPX4 inhibition catalyze and proceed toward inducing ferroptotic death in β-cells, with the ferroptotic death following the excessive accumulation of lipid hydroperoxides in membrane phospholipids. Studies have shown that overexpression of GPX4 and treatment with ferrostatin-1 (Fer-1) to block ferroptosis significantly increase ß-cell viability in hyperglycemic and oxidative environments (Moon, 2023; Stancic et al., 2022a).

Natural products such as berberine and quercetin exhibit potent antiferroptotic action, which can raise GPX4 levels in the tissues while reducing iron overload and lipid peroxidation to protect pancreatic tissues (Bao et al., 2023; Cheng et al., 2024c). Arsenic exposure induces ferroptotic β-cell death via iron accumulation and mitochondrial dysfunction, which can be rescued using antioxidants such as glutathione ethyl ester or iron chelators like deferoxamine, also known as an environmental diabetogenic (Hong et al., 2022; Wei et al., 2020). Such findings make it clear that ferroptosis is a key to β-cell vulnerability and hence imply that redox-modulating therapeutics would preserve islet integrity under diabetic conditions.

Ferroptosis, lipid peroxidation, and insulin resistance

Ferroptosis and insulin resistance are connected in a very similar way to the disturbances in lipid metabolism, iron, and redox balance on the cellular level, which are caused in organs such as the pancreas, liver, adipose tissue, and muscle. Lipid hydroperoxides and some oxidized phospholipids (like PE-OOH) at the molecular level are drawn into the interaction between insulin and its receptor by changing the signaling nodes (IRS-1 and the PI3K–AKT pathway; Wang et al., 2023a; Zhang et al., 2022c). These are either by direct oxidative modification of the signaling proteins or by activating stress kinases (like JNK) that phosphorylate inhibitory sites on the insulin receptor substrates, making it less effective. These then lower the glucose uptake and glycogen synthesis stimulated by insulin, offering a direct biochemical connection from lipid peroxidation to peripheral insulin resistance. Chronic low-grade inflammation acts as a third mechanism that converges with the first one. Chemoattractants and innate immune cell activators, oxidized lipids released from ferroptotic or peroxidation-stressed cells, facilitate the production of cytokines (TNF-α, IL-1β, IL-6) that extend the effect of insulin in adipose and liver cells. In this manner, local ferroptotic survives into the process of inflammation-driven systemic insulin desensitization and metabolic dysfunction. Iron dysregulation reinforces both sides of this loop: a rise in labile iron spurs Fenton chemistry and lipid peroxidation, while iron-induced oxidative stress activates inflammatory signaling and tissue remodeling that diminishes insulin sensitivity (Endale et al., 2023; Moon, 2023; Yu and Huang, 2023).

Cell death processes have made another connection between ferroptosis and glucose metabolism. In the case of pancreatic β-cells, which are naturally deficient in antioxidants, the cell death by ferroptosis results in the reduction of β-cells and in the insulin secretory reserve. This leads to a decrease in circulating insulin and the worsening of hyperglycemia. In addition, the selective killing of adipocytes or hepatocytes through ferroptosis can lead to a shift in the interorgan substrate fluxes (higher NEFA release, changed VLDL secretion, etc.) that in turn lead to greater peripheral insulin resistance (Jiang et al., 2024a; Zhu et al., 2024a).

The mechanistic concepts are the basis for proposing clearly defined and experimentally verifiable strategies. By demonstrating cause and effect relations, as well as showing the role of different tissues in the process (Jiang et al., 2024a; Zhang et al., 2023b, 2024b). It was suggested: (1) combining tissue-specific genetic manipulation (conditional GPX4 or ACSL4 knockout/overexpression in β-cells, hepatocytes, adipocytes, skeletal muscle) with metabolic phenotyping (glucose/insulin tolerance tests, hyperinsulinemic–euglycemic clamps); (2) lipidomic and spatial metabolomic profiling of insulin-sensitive tissues to quantify PE-OOH and related oxylipin signatures that correlate with insulin signaling defects; (3) calibrated measures of labile iron and ferritin dynamics (labile-iron probes, NCOA4/ferritin turnover assays) to link iron flux to both peroxidation and insulin pathway impairment; and (4) interventional rescue studies using lipophilic radical-trapping antioxidants (RTAs; ferrostatin-1, liproxstatin-1), iron chelators, or targeted restoration of GPX4/GSH pools to determine whether blocking ferroptosis restores insulin signaling and whole-body glucose homeostasis. In vivo experiments with human adipose, liver, or pancreatic islet tissue (first subjecting to acute lipotoxic and iron challenges followed by rescue assays) will be especially helpful in transferring the results to human diseases (Lin et al., 2022; Pope and Dixon, 2023; Zhang et al., 2023b).

Two different therapeutic opportunities are suggested by the mechanisms from the translational: (i) cytoprotection—early diabetes-induced insulin secretory and vascular function loss can be prevented by the use of tissue-targeted antioxidants or iron modulators; and (ii) selective clearance—if dysfunctional, senescent, or lipid-overloaded cells are the cause of systemic inflammation, careful application of ferroptosis induction (with tissue targeting) might lead to removal of pathogenic cells and improved metabolic homeostasis (Pope and Dixon, 2023). Both approaches will require supportive preclinical investigations in which cardiac, neural, and renal function evaluations will be done, along with the use of biomarkers (the combined panels of ACSL4, GPX4/SLC7A11 status, PE-OOH lipid signatures, and iron metrics) to stratify patients and monitor on-target versus off-target effects.

Ferroptosis in diabetic cardiomyopathy

Diabetic cardiomyopathy (DCM) stands as the cause of morbidity in diabetes, due to high levels of glucose, oxidative stress, and lipid peroxidation of cardiomyocytes (Lou et al., 2024). Studies in recent years have evaluated ferroptosis as an important front in the onset and development of mitochondrial dysfunction, iron overload takes place, and lipid metabolism gets altered (Song et al., 2024; Zhao et al., 2023b). Hyperglycemia-induced NOX activation, coupled with the impairment of mitochondrial antioxidant defense systems, leads to an increase in ROS generation, thereby driving the ACSL4-facilitated peroxidation of phospholipids. The ferroptotic cell death follows a loss in GPX4 activity, worsening myocardial injury and contractile dysfunction. Therapeutic strategies targeting ferroptosis have demonstrated cardioprotective potential in diabetic models (Fig. 5A; Wu et al., 2024). Curcumin and 6-gingerol activate the Nrf2/HO-1/GPX4 axis, enhancing cellular antioxidant capacity and reducing ferroptotic injury (Shahzad et al., 2025a; Yu et al., 2025). Canagliflozin, a sodium-glucose cotransporter-2 inhibitor, inhibits ferroptosis via activation of the AMPK/Nrf2 signaling pathway, thereby restoring redox balance as well as mitochondrial integrity (Du et al., 2022; Ma et al., 2023b). Recently, the FGF21-ATF4-ferritin axis has been identified as another defense mechanism that favors the stabilization of ferritin and sequestration of iron, preventing excessive lipid oxidation. Meanwhile, inhibition of zinc RNA ZFAS1 has been demonstrated to alleviate ferroptosis in asymptomatic dilated cardiomyopathy (DCM), thus revealing new epigenetic regulatory targets (Lou et al., 2024).

OPEN IN VIEWER

FIG. 5.

Ferroptosis and its pathophysiological role in diabetes mellitus and its complications. This figure summarizes the role of ferroptosis in the onset and progression of diabetes mellitus (DM) and its major complications. Chronic hyperglycemia in DM contributes to redox imbalance and iron overload, enhancing Fenton chemistry and lipid peroxidation. Impaired system Xc⁻ function and glutathione (GSH) depletion reduce GPX4 activity, culminating in ferroptotic cell death. (A) Diabetic cardiomyopathy (DCM): in DCM, high glucose (HG) levels induce iron accumulation, mitochondrial dysfunction, and increased NCOA4-mediated ferritinophagy. Downregulation of the Nrf2/GPX4 antioxidant axis elevates lipid peroxidation and ferroptosis in cardiomyocytes. Ferroptosis inhibitors (e.g., Fer-1, Lip-1), antidiabetic agents (e.g., canagliflozin), and phytochemicals (e.g., sulforaphane) exhibit cardioprotective effects by enhancing Nrf2 signaling and suppressing ferroptosis. (B) Diabetic nephropathy (DN): iron overload, GPX4 suppression, and GSH depletion contribute to renal tubular cell ferroptosis, exacerbating nephron damage and fibrosis. (C) Diabetic retinopathy (DR): iron-mediated oxidative stress contributes to retinal neurovascular damage. Dysregulation of iron transport proteins (e.g., TfR1, DMT1) and antioxidant enzymes promotes ferroptosis in retinal cells. (D) Diabetic foot ulcer (DFU): although underexplored, high glucose leads to lipid peroxidation, local iron overload, and impaired antioxidant capacity in ischemic foot tissue may predispose to ferroptosis, contributing to poor wound healing and tissue necrosis.

Ferroptosis in diabetic nephropathy, retinopathy, and foot ulcers

Being the top cause of chronic kidney failure, diabetic nephropathy (DN) is primarily glomerular-tubular injury mediated by ferroptotic-type signaling. Increased gene expression of ACSL4, PTGS2, and NOX1, coupled with weakened GPX4 activity in diabetic kidney, indicates enhanced ferroptotic activation (Fig. 5B; Li et al., 2023b; Mengstie et al., 2023). Inhibition of ferroptosis with Fer-1, dapagliflozin, or antioxidants like calycosin and ginkgolide B restores redox balance and controls iron transporters ZIP14 and SLC40A1, thereby improving renal function. Lipid peroxide accumulation is also ameliorated through the SIRT3-SOD2-GPX4 mitochondrial axis, a fine underscore on how mitochondrial redox regulation restrains diabetic renal damage (Wang et al., 2020b; Wu et al., 2022b). It is important to indicate that in diabetic retinopathy (DR), ferroptosis causes endothelial and retinal pigment epithelial cell death through degradation of GPX4, overexpression of ACSL4, and ubiquitination of antioxidant enzymes mediated by TRIM46 (Fig. 5C). Lipid peroxidation and autophagic dysregulation are exacerbated by the upregulation of FABP4 and GMFB, while PKCβII-ACSL4 signaling loop intensifies ferroptotic damage (He et al., 2023; Wang et al., 2024b). Ferroptosis can be delayed by antioxidants such as α-lipoic acid, chlorogenic acid, and BMSS309403 inhibitor, rescuing retinal redox balance and preserving visual function (Lu et al., 2024). In a parallel case, diabetic foot ulcers, characterized by defective angiogenesis and associated with a delayed wound healing process, undergo cell death via a ferroptotic manner (Fig. 5D). Either inhibition of this death by Fer-1 or activation of the PI3K/Akt pathway augments cell viability and tissue regeneration. Circular RNAs (circRNAs) packaged in bone marrow stromal cell-derived exosomes further exert inhibitory effects on ferroptosis through the activation of Nrf2 to promote vascular repair and epithelial regeneration (Jiang et al., 2025c; Wang et al., 2022b).

Ferroptosis-related biomarkers and therapeutic targets

The new potential ferroptosis markers in diabetes include increased serum ferritin, MDA, ACSL4, and decreased GPX4 activity, all correlating with the severity of the disease and organ dysfunction. Transcriptomic and proteomic analyses indicate upregulated TFRC, SLC7A11, and PTGS2, acting as molecular signatures of ferroptotic activation in diabetic tissues (Deng et al., 2023b; Yang and Yang, 2022). Targeting of these markers allows for the early detection and assessment of ferroptotic tissue injury. Multiple natural compounds and pharmacologic inhibitors are efficacious in therapy aimed at preventing ferroptosis. Quercetin, berberine, sulforaphane, and curcumin intensify GPX4 and Nrf2 signaling, whereas Fer-1, liproxstatin-1, and DFP scavenge lipid radicals or chelate iron. These contribute to redox homeostasis and reduce lipid peroxidation that would otherwise provide oxidative damage to pancreatic, cardiac, renal, and retinal tissue (Liu et al., 2022b; Ma et al., 2022a).

Drug development landscape: Ferroptosis inhibitors and inducers

Ferroptosis is a form of cell death influenced by redox processes, and it plays a dual role in therapy; preventing it can help cells withstand degenerative and ischemic conditions. So, considered among the new fronts of redox medicine could be pharmacological modulators of ferroptosis (Wang and Xie, 2025). Inhibitors of ferroptosis operate mainly at three mechanistic nodes: (i) inhibiting the system Xc⁻-GSH-GPX4 axis; (ii) promoting lipid peroxidation; and (iii) disturbing iron homeostasis. Typical ferroptosis inhibitors inhibit by removing the import of cystine through erastin, RSL3, and sorafenib. This inhibits GPX4 activity, depletes GSH, and stimulates lipid peroxidation. The ferroptosis inducers sorafenib (approved for hepatocellular and renal carcinoma) and sulfasalazine (used in rheumatoid arthritis), considered clinically relevant agents, act through mechanisms apart from their primary targets to foster ferroptosis, thus underscoring the translational potential of drug repurposing (Takatani-Nakase et al., 2024; Zheng et al., 2021a). Statins decrease mevalonate-derived isopentenyl pyrophosphate formation while impairing selenocysteine synthesis (Zhang et al., 2022b). This destabilizes GPX4 indirectly and sensitizes cancer cells to ferroptosis.

Conversely, ferroptosis inhibitors (ferrostatin-1, liproxstatin-1, and vitamin K hydroquinone) act as lipid RTAs that inhibit peroxidized phospholipid propagation. These inhibitors have been efficacious in ischemia/reperfusion injury, neurodegeneration, and diabetic organ-complication models (Du and Guo, 2022; Zhang et al., 2024a). Edaravone, an FDA-approved antioxidant used for ALS and stroke, is believed to suppress ferroptosis to exercise its clinical effects (Shi et al., 2024a). CuATSM, a similar copper-containing RTA, prevents lipid peroxidation and thus protects neurons in models of Parkinson’s disease (Tang et al., 2025b).

Targeting lipid metabolic enzymes has also been seen as a therapeutic opportunity. ACSL4 inhibitors (rosiglitazone, baicalin) prevent PUFAs from being incorporated into membranes and undergoing peroxidation and tissue injury (Ding et al., 2023; Fan et al., 2021). Inhibitors of ALOX5/12/15, such as zileuton and nordihydroguaiaretic acid, block enzymatic oxidation of lipids, thereby protecting neurons and kidneys (Zhang et al., 2025). In the iron axis, clinically used iron chelators, deferoxamine, deferiprone, and dexrazoxane, alleviate ferroptosis in metabolic and degenerative conditions (Chen et al., 2020). Thus, these constitute a druggable ferroptosis network, including lipid, iron, and redox metabolism, supporting therapeutic strategies that could either protect or kill in a cytotoxic manner.

Delivery systems and tissue-specific targeting

One major difficulty in achieving effective preclinical results is the low bioavailability of ferroptosis-focused drugs, compounded by off-target buildup and differences in redox conditions across the tissues. New nanocarrier-mediated delivery systems, such as lipid nanoparticles, polymeric micelles, and exosome-derived vesicles, are being designed to enhance pharmacokinetics and increase target specificity (Hou et al., 2025; Zhao et al., 2025). Iron oxide nanocarriers can selectively transport ferroptosis inducers to tumors with dysfunctional iron metabolism, enhancing oxidative stress in situ while protecting healthy tissue from systemic toxicity. By contrast, PEGylated nanoparticles and mitochondria-targeted liposomes loaded with ferrostatin-1 or CoQ10 analogs have proven successful in delivering ferroptosis inhibitors to susceptible organs such as the brain, heart, and kidneys. Such organ-targeted approaches can enhance therapeutic indices and abrogate blood–brain barrier restrictions in neurodegenerative models (Lin and Feng, 2025; Liu et al., 2024a; Sun et al., 2023a). Moreover, stimuli-dependent systems, that is, pH-, ROS-, and enzyme-sensitive nanocarriers, provide spatiotemporal induction or suppression of ferroptosis. Such intelligent formulations are likely to exploit context-dependent therapy by inducing ferroptosis within the TME, acidification, and iron enrichment while sparing healthy tissue. Because the redox landscape of every tissue governs its ferroptotic sensitivity, next-generation delivery platforms must be designed for metabolic imaging and redox mapping to provide for the personalized modulation of ferroptosis (Conrad et al., 2021; Wawrzeńczyk et al., 2025).

Biomarker discovery and diagnostic tools

For the translation of ferroptosis-targeted therapeutics, the potency of translation is constrained by the absence of reliable in vivo biomarkers that would distinguish ferroptosis from other modes of RCD. A much more advanced lipidomics, redox proteomics, and iron imaging approach has attempted to medication this problem (Wufuer et al., 2023; Zeng et al., 2023a). Potential biomarkers include malondialdehyde (MDA), 4-hydroxynonenal (4-HNE), and ACSL4 (as a lipid peroxidation driver) or even iron-handling proteins such as ferritin, transferrin receptor (TFRC), and ferroportin (FPN). Contemporary noninvasive tests trace ferroptosis-specific metabolites/lipid peroxidation by-products released into plasma, urine, or cerebrospinal fluid. MRI with iron-sensitive contrast agents, accompanied by fluorescent probes for labile Fe²⁺, enables the real-time observation of ferroptosis processes in vivo (Deng et al., 2022). New biosensors based on BODIPY-C11 or hydropersulfide-reactive fluorophores dynamically monitor lipid peroxidation flux in living cells. Integration of the multiomics data and pattern recognition technologies based on machine learning will lead to digital ferroptosis signatures, tying metabolite and gene expression patterns to specific disease states (Ficiarà et al., 2021; Tong et al., 2022b). Such signatures can then drive the creation of diagnostic companion tools for identifying those diseases driven by ferroptosis, stratifying patient populations, and selecting therapeutic regimes. They will find applications in oncology, diabetes, and neurodegenerative diseases (Li et al., 2022c).

Safety, specificity, and off-target effects

Despite the increasing therapeutic interest, specificity and safety still pestilence the development of ferroptosis-targeting drugs (Blomme et al., 2025). Numerous small molecules, such as erastin or RSL3, exhibit off-target generation of ROS and mitochondrial toxicity, thereby making it difficult to attribute mechanisms of death or risk profiles unequivocally. While liproxstatin-1 and other ferroptosis inhibitors are very potent, the cytochrome P450 enzymes and metabolism of drugs are also inhibited by these compounds. This gives considerable safety concerns when patients are taking an overdose of the drugs (Shirley, 2021; Zou and Schreiber, 2020). In addition, the application of iron-chelating therapies can cause anemia can be toxic to the kidneys or even become immunosuppressive with chronic use. Mechanistically, ferroptosis intersects with apoptosis, necroptosis, and pyroptosis through shared signaling components (e.g., Nrf2, p53, HO-1), making pathway-selective modulation difficult (Liu et al., 2024a; Shirley, 2021). In the future, more emphasis should be put on-target validation through genetic models and structure-guided drug design to confer greater selectivity. In parallel, the development of ferroptosis-specific molecular probes will remain crucial for dissecting redox-driven effects from general oxidative damage. Given that ferroptosis shares common signaling components also involved in apoptosis, necroptosis, and pyroptosis (such as Nrf2, p53, and HO-1), it increasingly makes modulation intended to be particular for a given pathway a much harder task (Dawi et al., 2025; Liu et al., 2024a). Thereby, the next endeavors must shift into the validation of anti-targets by using genetic models and on structure-aided drug design, resulting in more selective agents. To differentiate the effects of redox specificity from nonspecific oxidative injury, the parallel development of molecular probes for ferroptosis is going to be very crucial. These systems must also include redox balance, lipid flux, and iron metabolism, being envisaged through the systems pharmacology approach to ensure the translational safety and prediction of toxicity potential across organs. Most likely, combination approaches might titrate scenarios where the combination of ferroptosis inducers with antioxidant co-treatments, such as NAC or CoQ10, to establish better therapeutic openings (Wang et al., 2025a; Xu et al., 2025). Finally, actual clinical success will depend on the design of clinical-context-aware ferroptosis therapies, where either induction or inhibition is delicately controlled based on the tissue redox status, disease state, and patient-specific metabolic features.

The regulation of ferroptosis therapy is closely linked to high metabolic activity, redox processes, and pharmacology. The increasing use of small-molecule modulators of ferroptosis, enhanced by nanotechnology delivery systems and emerging diagnostic tools, anticipates the dawn of the delivery of redox medicine (Pope and Dixon, 2023; Wei et al., 2023). Thus, the clinical translation needs numerous details on the mode of action and dependable biomarkers through intimate knowledge of tissue-specific redox networks. Such modes of ferroptosis-targeted therapy discovery can be expedited via molecular design, exploitation of omics-driven discovery, and computational modeling from benchtop experimentation to bedside application in the fight against cancer, diabetes, or even other degenerative diseases (Zheng et al., 2021b).

CRISPR-based gene editing for ferroptosis regulators

Ferroptosis regulators are being analyzed with pinpoint accuracy using the CRISPR-Cas9 genome editing system. Such technologies can be engaged in knocking out, activating, or altering at least one base of any gene involved in iron metabolism (TFRC, FTH1, FPN), lipid peroxidation (ACSL4, ALOX15), and antioxidant defense (GPX4, SLC7A11). Beyond known mediators, high-throughput CRISPR screening has also identified novel modulators like FSP1, GCH1, and DHODH involved in parallel to GPX4 in controlling redox homeostasis (Chen et al., 2022; Pan et al., 2024). Such a revelation and concomitant evidence are shifting the perception of ferroptosis into an antioxidant mechanism spread across multiple layers instead of being a single enzyme-dependent process.

Advanced methodologies based on CRISPR, such as CRISPRi/CRISPRa, will provide systemic dissection of gene networks regulating ferroptotic sensitivity in cancer and metabolic-disease model systems. Coupling CRISPR-based approaches with single-cell RNA-seq will allow for ferroptotic responses to be elucidated down to cell-type-specific responses and may even uncover heterogeneity in the TME. Furthermore, CRISPR-lipidomics integration will take this even further, providing the resolution to understand how altered phospholipid composition modulates ferroptosis thresholds so that ferroptosis-modifying therapeutics might be discovered faster.

Metabolomics and proteomics for ferroptosis pathway mapping

Omics technologies provide the whole mapping of ferroptosis at both protein and metabolite levels. Metabolomics provides a snapshot of metabolic reprogramming of the cell before ferroptosis, that is, GSH flux, NADPH flux, and PUFA metabolism. In addition, proteomic profiling indicates the adaptive enzyme changes, that is, those in ACSL4, LPCAT3, and GPX4, and oxidative post-translational modifications mediating ferroptotic signaling (Rodríguez-Graciani et al., 2022; Wang, 2024).

Multiomics profiling allowed the identification of distinct ferroptotic phenotypes in cancer, diabetes, and neurodegeneration, thereby uncovering disease-specific metabolic vulnerabilities. A synergistic combination of redox proteomics and iron trace-element imaging would be a thrilling quantitative look at labile iron pools and lipid peroxidation intermediates within subcellular compartments. The further processing of multiomics datasets through computational network modeling will also facilitate the prioritization of the tribes that regulate ferroptosis. Redox signaling can be putatively linked to metabolic flux and to organelle-specific stress responses at the systems level. These studies will be of utmost importance to biomarker discovery, early diagnosis, and pharmacodynamic monitoring of ferroptosis in the clinical setting.

Integration with artificial intelligence and machine learning for predictive modeling

Artificial intelligence and other forms of machine learning are considered advanced technologies. In fact, they are a toolkit used to analyze complex regulatory networks in ferroptosis. Machine learning techniques applied to large-scale datasets such as transcriptomics, metabolomics, and imaging can uncover previously unknown links between ferroptosis indicators and cell phenotypes in different disease contexts. Predictive deep learning neural networks, for example, in silico simulate ferroptosis induction and predict how the cells respond to drugs targeting ferroptosis (e.g., erastin, RSL3, sorafenib; Chen et al., 2024c; Cheng et al., 2024b; Huang et al., 2025b).

Incorporating AI-powered analytics into drug-discovery pipelines helps fast-track the identification of emerging ferroptosis modulators for the optimization of therapeutic combinations in light of probable off-target toxicity. For instance, structure-based ML-guided virtual screening has already identified some structural analogs of the GPX4 inhibitors having more selectivity and bioavailability. Alternatively, AI-powered image cytometry might offer real-time assessments of lipid peroxidation dynamics and consequently observe ferroptotic progression in live cells. The connection between such computational platforms and experimental models is going to entirely change the realm of redox medicine—from being merely descriptive biological investigation into predictive.

Personalized medicine approaches

On the clinical front of translation of advances in ferroptosis research, personalized redox medicine is considered the final goal. Patient-specific data from omics analyses reveal substantial interindividual differences in the ferroptotic response with variants in genes governing iron regulatory genes, lipid metabolic enzymes, and/or antioxidant pathways. This heterogeneity requires therapies targeting ferroptosis to be individualized based on metabolic and genomic backgrounds (Li et al., 2024b; Shi et al., 2024b).

Potentially, patient-derived organoids, iPSC models, and precision lipidomics offer the possibility to perform several ex vivo assays for ferroptosis inducers or inhibitors in human-relevant systems. Furthermore, ferroptosis-based biomarkers such as circulating ACSL4, 4-HNE, or MDA might well present diagnostics and prognostics for examples of redox imbalance in cancer and diabetes. Stratified biomarker profiling ought to subsequently be incorporated into future clinical trial designs to best predict treatment response and circumvent adverse effects. Personalized ferroptosis modulation might pave the way for metabolically guided cancer therapy and complication-specific diabetes treatment, eventually placing redox-targeting cures in the realm of precision medicine.

With treatment strategies focusing on manipulating ferroptosis, future research in this area is likely to move beyond basic understanding and toward real-world therapeutic developments over the next decade. Hence, ferroptosis shifts from its former status as an independent cell death pathway to the metaphoric “redox axis” mediating regulation in metabolic diseases, upon combining CRISPR-based gene editing, omics-based pathological mapping of pathways, AI-mediated prediction, and preexisting frameworks of personalized medicine. Addressing pathway selectivity, biomarker validation, and translational modeling will be at the top of the priority list. Embarking on ferroptosis as yet another therapeutic target will mark the inception of systems biology, computational sciences, and clinical pharmacology toward precision redox medicine.

Candidate markers to improve specificity for ferroptosis

It is suggested that the candidate markers to improve ferroptosis specificity should be used as a multiplexed panel rather than individually. The targeted PE-OOH species (oxidized phosphatidylethanolamines) are the most specific ones in the mechanism and should be measured by validated LC–MS/MS. The ACSL4 protein level or activity indicates the availability of PUFA-PL substrate and corresponds to sensitivity (Sae-Fung et al., 2022). The abundance and enzyme activity of GPX4, along with the GSH: GSSG ratio, indicate the antioxidant capacity as per the conventional definition. Markers of ferritinophagy and iron mobilization (NCOA4, TFRC, dynamic ferritin turnover, calibrated labile-iron probes) record the iron supply that is responsible for Fenton chemistry. Meanwhile, broad lipid-peroxidation readouts (MDA, 4-HNE) are nonspecific and therefore should be paired with selective oxylipin signatures (Hu et al., 2022c; Ma et al., 2022a). Functional rescue experiments have pointed to very strong evidence of the occurrence of ferroptosis, as the death was only prevented by lipophilic RTAs (like ferrostatin-1), but not by caspase inhibitors. One of the major limitations of this study was the need for strict and proper handling of samples for lipidomics, dynamic iron measures that vary by tissue, and the necessity of analytic standardization across labs. Hence, we recommend a tiered approach of (1) molecular panel (ACSL4, SLC7A11, GPX4, NCOA4/TFRC), (2) targeted lipidomics for PE-OOH and related oxylipins, and (3) standardized functional rescue assays. We also suggest embedding pre-analytical SOPs (Standard Operating Procedures) (rapid quench, antioxidant stabilization), and in cases where it is possible, adding spatial lipidomics or imaging mass spectrometry to capture tissue heterogeneity (Li et al., 2025b; Yunchu et al., 2023). This synergistic approach will offer the highest specificity and provide the most useful clinical application in differentiating ferroptosis from other redox processes.

Context-dependence of ferroptotic susceptibility

Ferroptosis sensitivity across different tissues, cancer types, cell differentiation stages, metabolism, and even microenvironment (e.g., oxygen, nutrients, and stroma) differs significantly. It is still uncertain whether a particular combination of characteristics (like high ACSL4, low SLC7A11, and increased labile iron) will always be the same for a “ferroptosis-susceptible” signature throughout different diseases (Wang et al., 2025e; Yan et al., 2023). To unravel this, we suggest that systematic, comparative experiments be conducted by using (i) isogenic cell lines with known oncogenic changes (such as RAS, MYC, and p53 variants) that are subjected to controlled metabolic shifts (such as changes in glucose, glutamine, or lipid supply); (ii) organoid and patient-derived xenograft models from various tumor types that are analyzed for lipid profile, iron status, and antioxidant networks; and (iii) single-cell multiomic approaches (e.g., scRNA-seq combined with lipidomics or spatial metabolomics) to reveal intratumor heterogeneity. These investigations will establish the conditions under which ferroptosis represents a genuine weakness of the tumor rather than merely a result of the specific environment or experimental conditions (Tatode et al., 2025).

Biomarker specificity and standardization

An important unmet requirement is now a validated need for precise biomarkers that can tell apart ferroptosis from other forms of cell death or general oxidation damage. The widely used readouts (MDA, 4-HNE) are not specific. The focused signatures like oxidized phosphatidylethanolamine species (PE-OOH) and the co-regulated expression of ACSL4/GPX4/SLC7A11 are promising, but they are not yet standardized and clinically validated (Chen et al., 2024b; Panczyszyn et al., 2024). We suggest a multitiered biomarker strategy: (i) analytical standardization of lipidomic assays (sample handling, internal standards) for PE-OOH species; (ii) orthogonal validation combining molecular markers (ACSL4, SLC7A11, GPX4 protein), functional pharmacology (rescue by ferrostatin-1/lipophilic RTAs ex vivo), and iron metrics (TFRC/ferritin dynamics); and (iii) pilot clinical correlative studies embedding these assays in early-phase trials to evaluate predictive and pharmacodynamic utility. Before biomarkers can be used to reliably select patients, agreement protocols and inter-laboratory ring trials will be vital.

Compensatory antioxidant networks and redundancy

Inhibition of a single ferroptosis pathway often results in the activation of the compensatory mechanism (for instance, upregulation of FSP1 occurs after GPX4 inhibition; reduction of CoQ in mitochondria occurs due to DHODH). The amount of contribution from the respective systems, such as FSP1/CoQ, DHODH, NADPH-dependent reductases, NOX/POR, is not clearly determined across the different tissues (Poltorack and Dixon, 2022; Punziano et al., 2024). To uncover the overlapping functions of these systems, it is necessary to conduct highly controlled experimentation that combines genetic and pharmacologic perturbation in relevant physiological models, such as through simultaneous knockdowns of GPX4 and FSP1 or by combining GPX4 inhibition with DHODH blockade and assessing the effects across different cell types and compartments in vivo. The acute inhibition followed by transcriptomic and metabolomic profiling at different time points would provide insights into compensatory responses and would help in identifying secondary vulnerabilities for rational combination therapy (Glibetic and Weichhaus, 2025).

Quantitative thresholds and dynamics of lethal lipid peroxidation

The area is devoid of numerical, physiologically relevant definitions for lipid-peroxide load, iron concentration, or NAD(P)H imbalance that unambiguously led to ferroptosis in vivo. To tackle this issue, the use of calibrated and quantitative assays is indispensable (absolute lipid-peroxide quantification through targeted MS, calibrated intracellular labile-iron probes, NADPH/NADP⁺ ratio measurements) in time-course experiments performed under physiological oxygen tension (Farmer et al., 2022; von Krusenstiern et al., 2023; Xing et al., 2024). The combination of live-cell imaging with genetically encoded redox reporters and single-cell lipidomics can determine if ferroptosis occurs randomly or is a result of reaching a certain threshold, and if temporary damage can be repaired in a clinical setting.

Translational safety, delivery, and therapeutic index

Since ferroptosis is reliant on essential redox chemistry, the whole-body induction might lead to undesired effects on the normal tissues (brain, heart, kidney, pancreatic islets). The preclinical safety profiling should not only consider acute toxicity but also include longer-term functional assays (cardiac/neurological function, glucose homeostasis) in immunocompetent models (Hao et al., 2023a; Luo et al., 2022). The methods for increasing the therapeutic index—such as tumor-targeted delivery (nanocarriers, prodrugs activated by tumor proteases), local administration, and temporally limited dosing combined with protective agents for sensitive tissues—should be given priority during lead optimization. Rigorous PK/PD, biodistribution, and multiplex biomarker panels to detect both on-target and off-target oxidative injury must be integrated into the early-phase clinical trials (Sun et al., 2023a; Yu et al., 2024b).

Immune consequences—friend or foe

Ferroptotic cells excrete oxidized lipids and DAMPs, which may act as immune activators in certain situations but as immune suppressors in others (e.g., dendritic-cell dysfunction due to lipid presence). To solve this dilemma, it is necessary to perform coculture and in vivo studies, where ferroptosis is induced along with thorough immune profiling done by single-cell immune phenotyping, cytokine panels, and antigen-presentation capacity (Ni et al., 2023b; Wu et al., 2022d; Zheng et al., 2023b). Preclinical combination studies should determine whether the induction of ferroptosis has a synergistic effect with checkpoint blockade or whether immune cell protection (with local antioxidants or selective rescue strategies) is necessary to maintain the antitumor immunity.

Clinical trial design and patient stratification

In the end, the progress of clinical translation relies on the well-thought-out and designed trials that involve biomarker-guided enrollment and adaptive endpoints. The first trials should target very specific patient populations with similar biological mechanisms (e.g., tumors with high ACSL4 and low SLC7A11; drug-resistant states) and choose window-of-opportunity or neoadjuvant designs that allow for the study of the drug’s effect on the tumor tissue (Gao et al., 2022a; Wu et al., 2022a). Trial designs that are adaptive with biomarker readouts will speed up the process of making go/no-go decisions and will also allow the early detection of signs of toxicity.