Abstract

Research Article

The Synergistic Effect of Combined Linagliptin and Metformin Improves Hepatic Function in High-fat Diet/Streptozotocin-induced Diabetic Rats

Folasade Omobolanle Ajao*, Ifedolapo Opeyemi Adeyeye, Noheem Olaoluwa Kalejaiye, Sodik Olasunkami Mukaila and Olalekan Samson Agboola

Published: 02 June, 2025 | Volume 9 - Issue 1 | Pages: 004-012

Background: Monotherapy for liver dysfunction in diabetes is less effective. This study investigated the effect of combined linagliptin and metformin therapy on liver function in diabetic rats. 
Methods and materials: Sixty-four matured male (200-300 g) Wistar rats were used. Diabetes was induced with 35 mg/kb.wt streptozotocin injected intraperitoneally. The rats were grouped into eight groups (n = 8). Group I: control; Group II: control + 10 mg/kg body weight linagliptin; Group III: control + 200 mg/kg body weight metformin; Group IV; control + 10 mg/kg body weight linagliptin + 200 mg/kg body weight metformin; Group V: diabetic; Group VI: diabetic + 10 mg/kg body weight linagliptin; Group VII: diabetic + 200 mg/kg body weight metformin; Group VIII: diabetic + 10 mg/kg body weight linagliptin + 200 mg/kg body weight metformin. After the animal was sacrificed, blood and liver samples were collected for biochemical assay. 
Results: Insulin, blood glucose, glycated hemoglobin, total cholesterol, triglycerides, low-density lipoprotein cholesterol (LDL-cholesterol), liver enzymes (alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, lactate dehydrogenase, pyruvate kinase, glucose-6-phosphatase dehydrogenase, malondialdehyde and inflammatory makers increased (p < 0.05) significantly. High-density lipoprotein-cholesterol (HDL-cholesterol), liver antioxidant, glycogen, and glycogen synthase were reduced significantly in diabetic rats. Linagliptin and metformin administration single and combined reduced the insulin, blood glucose, glycated hemoglobin, total cholesterol, triglycerides, LDL-cholesterol, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, lactate dehydrogenase, pyruvate kinase, glucose-6-phosphatase dehydrogenase, malondialdehyde, inflammatory makers and increased the HDL-cholesterol, liver antioxidant, glycogen and glycogen synthase in diabetic rats.
Conclusion: Linagliptin monotherapy alone efficiently controls hyperglycemia and remarkably improves liver functions. Combining linagliptin and metformin could be used as safe and effective therapy for liver dysfunction progression in diabetes.

Read Full Article HTML DOI: 10.29328/journal.acgh.1001050 Cite this Article Read Full Article PDF

Keywords:

Diabetes; Liver function; Dyslipidemia; Oxidative stress and inflammation; Linagliptin-metformin

References

  1. International Diabetes Federation. IDF Diabetes Atlas. 10th ed. Belgium: International Diabetes Federation; 2021. Available from: https://www.diabetesatlas.org
  2. Banday M, Sameer AS, Nissar S. Pathophysiology of diabetes: An overview. Avicenna J Med. 2020;10(4):174–88. Available from: https://doi.org/10.4103/ajm.ajm_53_20
  3. Yongxia L, Wang W, Liu J, Xie M, Liu Q, Li S. Vascular Complications of Diabetes: A Narrative Review. Medicine (Baltimore). 2023;102(40):e35285. Available from: https://doi.org/10.1097/md.0000000000035285
  4. Zhang Q, Lu L, Wang J, Lu M, Liu D, Zhou C, et al. Metabolomic profiling reveals the step-wise alteration of bile acid metabolism in patients with diabetic kidney disease. Nutr Diabetes. 2024;14:85. Available from: https://doi.org/10.1038/s41387-024-00315-0
  5. Yu MG, Gordin D, Fu J, Park K, Li Q, King GL. Protective Factors and the Pathogenesis of Complications in Diabetes. Endocr Rev. 2024;45:227–52. Available from: https://doi.org/10.1210/endrev/bnad030
  6. Jiang S, Young JL, Wang K, Qian Y, Cai L. Diabetic induced alterations in hepatic glucose and lipid metabolism: The role of type 1 and type 2 diabetes mellitus (Review). Mol Med Rep. 2020;22(2):603–11. Available from: https://doi.org/10.3892/mmr.2020.11175
  7. Vakilpour A, Amini-Salehi E, Soltani Moghadam A, Keivanlou MH, Letafatkar N, Habibi A, et al. The effects of gut microbiome manipulation on glycemic indices in patients with non-alcoholic fatty liver disease: a comprehensive umbrella review. Nutr Diabetes. 2024;14(1):25. Available from: https://doi.org/10.1038/s41387-024-00281-7
  8. Chan WK, Wong VWS, Adams LA, Nguyen MH. MAFLD in adults: non-invasive tests for diagnosis and monitoring of MAFLD. Hepatol Int. 2024;18:909–21. Available from: https://doi.org/10.1007/s12072-024-10661-x
  9. Amini-Salehi E, Hassanipour S, Joukar F, Daryagasht AA, Khosousi MJ, Aleali MS, et al. Risk factors of non-alcoholic fatty liver disease in the Iranian adult population: a systematic review and meta-analysis. Hepat Mon. 2023;23:e131523. Available from: https://doi.org/10.5812/hepatmon-131523
  10. Powell EE, Wong VW-S, Rinella M. Non-alcoholic fatty liver disease. Lancet. 2021;397:2212–24. Available from: https://doi.org/10.1016/s0140-6736(20)32511-3
  11. Naidoo K, Khathi A. Investigating the Effects of Gossypetin on Liver Health in Diet-Induced Pre-Diabetic Male Sprague Dawley Rats. Molecules. 2025;30(8):1834. Available from: https://doi.org/10.3390/molecules30081834
  12. Lian CY, Zhai ZZ, Li ZF, Wang L. High fat diet-triggered non-alcoholic fatty liver disease: A review of proposed mechanisms. Chem Biol Interact. 2020;330:109199. Available from: https://doi.org/10.1016/j.cbi.2020.109199
  13. American Diabetes Association. Standards of medical care in diabetes—2020 abridged for primary care providers. Diabetes Care. 2020;43(Suppl 1):S1–212. Available from: https://doi.org/10.2337/cd20-as01
  14. American Diabetes Association. Pharmacologic approaches to glycemic treatment: standards of medical care in diabetes – 2021. Diabetes Care. 2021;44(Suppl 1):S111–24. Available from: https://doi.org/10.2337/dc21-s009
  15. Ide M, Sonoda N, Inoue T, Kimura S, Minami Y, Makimura H, et al. The dipeptidyl peptidase-4 inhibitor, linagliptin, improves cognitive impairment in streptozotocin-induced diabetic mice by inhibiting oxidative stress and microglial activation. PLoS One. 2020;15:e0228750. Available from: https://doi.org/10.1371/journal.pone.0228750
  16. Siddiqui N, Ali J, Parvez S, Zameer S, Najmi AK, Akhtar M. Linagliptin, a DPP-4 inhibitor, ameliorates A beta (1-42) peptides induced neurodegeneration and brain insulin resistance (BIR) via insulin receptor substrate-1 (IRS-1) in rat model of Alzheimer’s disease. Neuropharmacology. 2021;195:108662. Available from: https://doi.org/10.1016/j.neuropharm.2021.108662
  17. Inzucchi S, Bergenstal R, Buse J, Diamant M, Ferrannini E, Nauck M, et al. Management of hyperglycemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2012;55:1577–96. Available from: https://doi.org/10.1007/s00125-012-2534-0
  18. Arab HH, Eid AH, Mahmoud AM, Senousy MA. Linagliptin mitigates experimental inflammatory bowel disease in rats by targeting inflammatory and redox signaling. Life Sci. 2021;273:119295. Available from: https://doi.org/10.1016/j.lfs.2021.119295
  19. Tsuprykov O, Ando R, Reichetzeder C, von Websky K, Antonenko V, Sharkovska Y, et al. The dipeptidyl peptidase inhibitor linagliptin and the angiotensin II receptor blocker telmisartan show renal benefit by different pathways in rats with 5/6 nephrectomy. Kidney Int. 2016;89:1049–61. Available from: https://doi.org/10.1016/j.kint.2016.01.016
  20. Arab HH, Elhemiely AA, El-Sheikh AAK, Khabbaz HJA, Arafa EA, Ashour AM, et al. Repositioning Linagliptin for the Mitigation of Cadmium-Induced Testicular Dysfunction in Rats: Targeting HMGB1/TLR4/NLRP3 Axis and Autophagy. Pharmaceuticals. 2022;15:852. Available from: https://doi.org/10.3390/ph15070852
  21. Kadowaki T, Wang G, Rosenstock J, Yabe D, Peng Y, Kanasaki K, et al. Effect of linagliptin, a dipeptidyl peptidase-4 inhibitor, compared with the sulfonylurea glimepiride on cardiovascular outcomes in Asians with type 2 diabetes: subgroup analysis of the randomized CAROLINA® trial. Diabetol Int. 2021;12:87–100. Available from: https://doi.org/10.1007/s13340-020-00447-5
  22. Nirwan N, Vohora D. Linagliptin in Combination With Metformin Ameliorates Diabetic Osteoporosis Through Modulating BMP-2 and Sclerostin in the High-Fat Diet Fed C57BL/6 Mice. Front Endocrinol (Lausanne). 2022;13:944323. Available from: https://doi.org/10.3389/fendo.2022.944323
  23. Lv Q, Shen J, Miao L, Ye B, Schepers C, Plat A, et al. Early Combination Therapy with Linagliptin and Metformin in People with Type 2 Diabetes Improves Glycemic Control to HbA1c ≤ 6.5% without Increasing Hypoglycemia: Pooled Analysis of Two Randomized Clinical Trials. Diabetes Ther. 2020;11(6):1317–30. Available from: https://doi.org/10.1007/s13300-020-00819-9
  24. Li Q, Wang X, Guo A, Zheng W, Bi J, He Y, Luo Q. The curative effect of metformin and linagliptin in newly-diagnosed type 2 diabetes patients with non-alcoholic fatty liver disease. Int J Clin Exp Med. 2021;14(1):391–8.
  25. Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem. 1972;18(6):499–502. Available from: https://doi.org/10.1093/clinchem/18.6.499
  26. Behzadifar S, Hosseini M, Mohammadnejad J, Asiabanha M. A new colorimetric assay for sensitive detection of glucose-6-phosphate dehydrogenase deficiency based on silver nanoparticles. Nanotechnology. 2021;33(5). Available from: https://doi.org/10.1088/1361-6528/ac2fe5
  27. Tan X, Testoni G, Sullivan MA, López-Soldado I, Vilaplana F, Gilbert RG, et al. Glycogenin is dispensable for normal liver glycogen metabolism and body glucose homeostasis. Int J Biol Macromol. 2025;291:139084. Available from: https://doi.org/10.1016/j.ijbiomac.2024.139084
  28. Krishnan B, Ganesan AR, Balasubramani R, Nguyen DD, Chang SW, Wang S, et al. Chrysoeriol ameliorates hyperglycemia by regulating the carbohydrate metabolic enzymes in streptozotocin-induced diabetic rats. Food Sci Hum Wellness. 2020;9(4):346–54. Available from: http://dx.doi.org/10.1016/j.fshw.2020.05.014
  29. Pouwels S, Sakran N, Graham Y, Leal A, Pintar T, Yang W, et al. Non-alcoholic fatty liver disease (NAFLD): a review of pathophysiology, clinical management and effects of weight loss. BMC Endocr Disord. 2022;22(1):63. Available from: https://doi.org/10.1186/s12902-022-00980-1
  30. Perreault L, Skyler JS, Rosenstock J. Novel therapies with precision mechanisms for type 2 diabetes mellitus. Nat Rev Endocrinol. 2021;17:364–77. Available from: https://doi.org/10.1038/s41574-021-00489-y
  31. Galicia-Garcia U, Benito-Vicente A, Jebari S, Larrea-Sebal A, Siddiqi H, Uribe KB, et al. Pathophysiology of type 2 diabetes mellitus. Int J Mol Sci. 2020;21(17):6275. Available from: https://doi.org/10.3390/ijms21176275
  32. Panelvrushabh S, Kondalkar PP, Polshettiwar GB, Choudhari AT, Vishnu P, Choudhari P. Evaluation of antidiabetic potential, cardio, pancreatic, nephroprotective effect, and herb-herb-drug interaction of Madhukiran formulations in T2 diabetic rats. Phytomed Plus. 2025:100756. Available from: https://doi.org/10.1016/j.phyplu.2025.100756
  33. Ferdaoussi M. Metabolic and Molecular Amplification of Insulin Secretion. Adv Anat Embryol Cell Biol. 2024;239:117–39. Available from: https://doi.org/10.1007/978-3-031-62232-8_5
  34. Li J, Yan H, Xiang R, Yang W, Ye J, Yin R, et al. ATP Secretion and Metabolism in Regulating Pancreatic Beta Cell Functions and Hepatic Glycolipid Metabolism. Front Physiol. 2022;13:918042. Available from: https://doi.org/10.3389/fphys.2022.918042
  35. Casadei G, Filippini M, Brognara L. Glycated Hemoglobin (HbA1c) as a Biomarker for Diabetic Foot Peripheral Neuropathy. Diseases. 2021;9:6. Available from: https://doi.org/10.3390/diseases9010016
  36. Alatawi KA, Alshubaily FA. Coconut products alleviate hyperglycaemic, hyperlipidimic and nephropathy indices in streptozotocin-induced diabetic wistar rats. Saudi J Biol Sci. 2021;28(8):4224–31. Available from: https://doi.org/10.1016/j.sjbs.2021.06.060
  37. Faramarzi E, Mehrtabar S, Molani-Gol R, Dastgiri S. The relationship between hepatic enzymes, prediabetes, and diabetes in the Azar cohort population. BMC Endocr Disord. 2025;25:41. Available from: https://doi.org/10.1186/s12902-025-01871-x
  38. Attia MS, Ayman F, Attia MS, Yahya G, Zahra MH, Khalil MMI, et al. Mitigating diabetes-related complications: Empowering metformin with cholecalciferol and taurine supplementation in type 2 diabetic rats. World J Diabetes. 2024;15(8):1778–92. Available from: https://dx.doi.org/10.4239/wjd.v15.i8.1778
  39. Bi Y, Yang Y, Yuan X, Wang J, Wang T, Liu Z, et al. Association between liver enzymes and type 2 diabetes: a real world study. Front Endocrinol (Lausanne). 2024;15:1340604. Available from: https://doi.org/10.3389/fendo.2024.1340604
  40. Tang L, Yang Q, Ma R, Zhou P, Peng C, Xie C, et al. Association between lactate dehydrogenase and the risk of diabetic kidney disease in patients with type 2 diabetes. Front Endocrinol (Lausanne). 2024;15:1369968. Available from: https://doi.org/10.3389/fendo.2024.1369968
  41. Dore MP, Parodi G, Portoghese M, Pes GM. The Controversial Role of Glucose-6-Phosphate Dehydrogenase Deficiency on Cardiovascular Disease: A Narrative Review. Oxid Med Cell Longev. 2021;2021:5529256. Available from: https://doi.org/10.1155/2021/5529256
  42. Çelik R, Mert H, Comba B, Mert N. Effects of cinnamaldehyde on glucose-6-phosphate dehydrogenase activity, some biochemical and hematological parameters in diabetic rats. Biomarkers. 2022;27(3):270–7. Available from: https://doi.org/10.1080/1354750X.2022.2032351
  43. Fuentes-Lemus E, Usgame K, Fierro A, López-Alarcón C. Enzymes of glycolysis and the pentose phosphate pathway as targets of oxidants: Role of redox reactions on the carbohydrate catabolism. Redox Biochem Chem. 2025;11:100049. Available from: https://doi.org/10.1016/j.rbc.2025.100049
  44. Mustafa I, Anwar H, Irfan S, Muzaffar H, Ijaz MU. Attenuation of carbohydrate metabolism and lipid profile by methanolic extract of Euphorbia helioscopia and improvement of beta cell function in a type 2 diabetic rat model. BMC Complement Med Ther. 2022;22:23. Available from: https://doi.org/10.1186/s12906-022-03507-2
  45. Katz A. The role of glycogen phosphorylase in glycogen biogenesis in skeletal muscle after exercise. Sports Med Health Sci. 2023;5(1):29–33. Available from: https://doi.org/10.1016/j.smhs.2022.11.001
  46. Kelley DE, Mandarino LJ. Hyperglycemia normalizes insulin-stimulated skeletal muscle glucose oxidation and storage in noninsulin-dependent diabetes mellitus. J Clin Invest. 1990;86:1999–2007. Available from: https://doi.org/10.1172/jci114935
  47. Govindarajan S, Babu SN, Vijayalakshmi MA, Manohar P, Noor A. Aloe vera carbohydrates regulate glucose metabolism through improved glycogen synthesis and down-regulation of hepatic gluconeogenesis in diabetic rats. J Ethnopharmacol. 2021;281:114556. Available from: https://doi.org/10.1016/j.jep.2021.114556
  48. Unger RH, Cherrington AD. Glucagonocentric restructuring of diabetes: a pathophysiologic and therapeutic makeover. J Clin Invest. 2012;122:4–12. Available from: https://doi.org/10.1172/jci60016
  49. Kalra S, Raizada N. Dyslipidemia in diabetes. Indian Heart J. 2024;76(1):S80–S82. Available from: https://doi.org/10.1016/j.ihj.2023.11.002
  50. Hoekstra M, Van Eck M. High-density lipoproteins and non-alcoholic fatty liver disease. Atheroscler Plus. 2023;53:33–41. Available from: https://doi.org/10.1016/j.athplu.2023.08.001
  51. Komorizono Y, Hosoyamada K, Imamura N, Kajiya S, Hashiguchi Y, Ueyama N, et al. Metformin dose increase versus added linagliptin in non-alcoholic fatty liver disease and type 2 diabetes: an analysis of the JLINK study. Diabetes Obes Metab. 2021;23(3):832–7. Available from: https://doi.org/10.1111/dom.14263
  52. Lin YY, Weng SF, Hsu CH, Huang CL, Lin YP, Yeh MC, et al. Effect of metformin monotherapy and dual or triple concomitant therapy with metformin on glycemic control and lipid profile management of patients with type 2 diabetes mellitus. Front Med (Lausanne). 2020;9:995944. Available from: https://doi.org/10.3389/fmed.2022.995944
  53. Obafemi TO, Jaiyesimi KF, Olomola AA, Olasehinde OR, Olaoye OA, Adewumi FD, et al. Combined effect of metformin and gallic acid on inflammation, antioxidant status, endoplasmic reticulum (ER) stress and glucose metabolism in fructose-fed streptozotocin-induced diabetic rats. Toxicol Rep. 2021;8:1419–27. Available from: https://doi.org/10.1016/j.toxrep.2021.07.011
  54. Palsamy P, Sivakumar S, Subramanian S. Resveratrol attenuates hyperglycemia-mediated oxidative stress, proinflammatory cytokines and protects hepatocytes ultrastructure in streptozotocin-nicotinamide-induced experimental diabetic rats. Chem Biol Interact. 2010;186(2):200–10. Available from: https://doi.org/10.1016/j.cbi.2010.03.028
  55. Zeng F, Luo J, Han H, Xie W, Wang L, Han R, et al. Allopurinol ameliorates liver injury in type 1 diabetic rats through activating Nrf2. Int J Immunopathol Pharmacol. 2021;35:1–13. Available from: https://doi.org/10.1177/20587384211031417
  56. Xi J, Wang S, Chen J, Law JC, Fan Z, Lv G. The role of C-reactive protein to lymphocyte ratio in NAFLD and mortality among NAFLD patients. BMC Gastroenterol. 2025;25:327. Available from: https://doi.org/10.1186/s12876-025-03924-w
  57. Lodhi S, Vadnere GP, Patil KD, Patil TP. Protective effects of luteolin on injury induced inflammation through reduction of tissue uric acid and proinflammatory cytokines in rats. J Tradit Complement Med. 2020;10(1):60–9. Available from: https://doi.org/10.1016/j.jtcme.2019.02.004

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