A purinergic mechanism underlying metformin regulation of hyperglycemia

Metformin, created in 1922, has been the first-line therapy for treating type 2 diabetes mellitus for almost 70 years; however, its mechanism of action remains controversial, partly because most prior studies used supratherapeutic concentrations exceeding 1 mM despite therapeutical blood concentrations of metformin being less than 40 μM. Here we report metformin, at 10-30 μM, blocks high glucose-stimulated ATP secretion from hepatocytes mediating its antihyperglycemic action. Following glucose administration, mice demonstrate increased circulating ATP, which is prevented by metformin. Extracellular ATP through P2Y2 receptors (P2Y2R) suppresses PIP3 production, compromising insulin-induced AKT activation while promoting hepatic glucose production. Furthermore, metformin-dependent improvements in glucose tolerance are abolished in P2Y2R-null mice. Thus, removing the target of extracellular ATP, P2Y2R, mimics the effects of metformin, revealing a new purinergic antidiabetic mechanism for metformin. Besides unraveling long-standing questions in purinergic control of glucose homeostasis, our findings provide new insights into the pleiotropic actions of metformin.