Review Article | Open Access
The Effect of Metformin in Experimentally Induced Animal Models of Epileptic Seizure
Background. Epilepsy is one of the common neurological illnesses which affects millions of individuals globally. Although the majority of epileptic patients have a good response for the currently available antiepileptic drugs (AEDs), about 30-40% of epileptic patients are developing resistance. In addition to low safety profiles of most of existing AEDs, there is no AED available for curative or disease-modifying actions for epilepsy so far. Objectives. This systematic review is intended to evaluate the effect of metformin in acute and chronic animal models of an epileptic seizure. Methods. We searched PubMed, SCOPUS, Sciences Direct, and grey literature in order to explore articles published in English from January 2010 to November 2018, using key terms “epilepsy,” “seizure,” “metformin,” “oral hypoglycemic agents,” and “oral antidiabetic drugs”. The qualities of all the included articles were assessed according to the Collaborative Approach to Meta-Analysis and Review of Animal Data from Experimental Studies (CAMARADES). Results. Out of six hundred fifty original articles retrieved, eleven of them fulfilled the inclusion criteria and were included for final qualitative analysis. In these studies, metformin showed to control seizure attacks by attenuating seizure generation, delaying the onset of epilepsy, reducing hippocampal neuronal loss, and averting cognitive impairments in both acute and chronic models of an epileptic seizure. The possible mechanisms for its antiseizure or antiepileptic action might be due to activation of AMPK, antiapoptotic, antineuroinflammatory, and antioxidant properties, which possibly modify disease progression through affecting epileptogenesis. Conclusion. This review revealed the benefits of metformin in alleviating symptoms of epileptic seizure and modifying different cellular and molecular changes that affect the natural history of the disease in addition to its good safety profile.
Epilepsy is a highly prevalent neurological condition characterized by an abnormality in electrical excitability of a group of neurons. This disease threatens about 50 million people worldwide, and approximately three fourths of them reside in low-income countries. The disease has neurobiological, cognitive, psychological, and social consequences leading to a substantial morbidity, mortality, and low quality of life . This problem gets worse in developing countries where approximately 90% of epileptic patients are not receiving proper antiepileptic drugs. As a result, people with epilepsy remain to be stigmatized and have a lower quality of life (QoL) compared to people with other chronic medical disorders [2–4].
Various medical conditions including seizure incidence and severity, antiepileptic drug-associated adverse effects, and psychological factors such as depression, anxiety, fear of losing control, worries about seizure occurrence, and negative coping are among the contributing factors for poor outcomes of epilepsy .
In spite of the availability of a dozen of antiepileptic drugs (AEDs) with varying mechanisms, the overall outcome and quality of life of epileptic patients have not been improved substantially. This might because of the following reasons: (i) the currently available AEDs provide only a symptomatic relief without influencing the epileptogenesis. (ii) They have low safety profile particularly with the old-generation AEDs [6–10]; hence, the safety issue of existing AEDs is questionable in pregnant and lactating mothers who are receiving more than one AED. (iii) Nearly one third to one half of patients with epilepsy failed to respond to the currently available AED, “drug-resistant epilepsy” [5, 11], of which 70% were patients who have temporal lobe epilepsy. Temporal lobe epilepsy (TLE), in turn, is highly associated with poor quality of life, intensified psychological and physical morbidities, and increased sudden and unexplained mortality . Drug resistance in epilepsy is related to increased rates of death, disability, psychosocial illness, and compromised QoL. Besides, it has significant implications in terms of costs . (iv) Most of the existing AEDs are highly associated with marked adverse effects , which can contribute to drug discontinuation because of intolerance to adverse effects. (v) Many of the existing AEDs were also reported to have complex drug-drug interactions [14, 15] that adversely contribute for underdosing (treatment failure) or overdosing of their own or other concomitantly administered medications. Considering these limitations of existing drugs, exploring new antiepileptic drugs having a better efficacy and safety remains important.
Metformin is the first-line antidiabetic agent which is primarily used for the treatment of type II diabetes mellitus because of its efficacy and tolerability [16, 17]. In addition, recent studies have shown its anticancer [18–20], antitubercular [21, 22], antioxidant properties [23–25], and neuroprotective  actions. Multifarious molecular and cellular events are thought to involve in the initiation and progression of epileptogenesis. Numerous studies have shown the potential role of metformin to modify these cellular and molecular alterations in an animal model of various neurological disorders [27–31], including improvement in spatial memory, learning, cognition, and neuronal plasticity [32–36] and modulation of proinflammatory cytokines as well as markers of oxidative stress [36–38].
2.1. Searching Strategies
Articles were retrieved through a systematic search using different electronic databases, including PubMed, SCOPUS, and Sciences Direct as well as manual search from grey literature. The keywords/phrases employed were metformin and oral hypoglycemic and antidiabetic agents in combination with epilepsy and seizure, then search terms were combined using either “AND” or “OR” between two or more terms (Table 1). The searches were restricted to articles published in English language only.
2.2. Inclusion and Exclusion Criteria
All studies that are intended to assess the effect of metformin in acute and/or chronic epileptic seizure models and published from January 2010 to November 2018 were included in this systematic review. The search was limited to original articles published in English language only irrespective of the sample size used and/or duration of follow-up. All articles with the intervention of metformin attempt to control chemical-induced seizure in animal epileptic seizure models were included as long as the outcomes were clearly documented. From the included studies, the effects of metformin on seizure frequency, onset, severity, or complete seizures termination were taken as primary outcomes. Conversely, the effects of metformin in chemical-induced and electrical kindling epileptic seizure related to oxidative stress, apoptosis, neuroinflammation, neurogenesis/neurodegeneration, and other markers associated with epileptic seizures were considered as secondary outcomes. However, duplicated articles and studies with incomplete, redundant, and unclearly defined outcome measures were excluded.
2.3. Data Extraction and Synthesis
The initial screening of the articles by title, abstract, and full text was carried out by two authors (EMY and AS) independently based on the predefined inclusion and exclusion criteria. After each selection round (title, abstract, and full texts), the authors met and resolved any discrepancy by discussion, while potential disagreements were solved by the involvement of the third author (AKG). The lists of reference of the entire full-text articles were appraised to ascertain additional articles of relevance that were necessary to retrieve the full text. The qualities of all the included studies were substantiated. Finally, all the included accessible full-text article data were extracted to assemble appropriate information on study designs/protocols, interventions given, and main treatment outcomes.
2.4. Quality Assessment
The methodological quality of all the included articles was assessed in accordance to the Collaborative Approach to Meta-Analysis and Review of Animal Data from Experimental Studies (CAMARADES) with slight modification  of the 10-item quality checklists as follows: (1) peer-reviewed publication, (2) assignment of experimental and control groups, (3) housing and husbandry conditions, (4) intervention/exposure group procedure, (5) random allocation of animals to the assigned group, (6) concealment of allocation, (7) blind assessment of treatment outcomes, (8) biochemical evaluation, (9) histopathological assessment, and (10) description of statistical analysis (Table 2). Each item was given either one point if it satisfied the criteria or zero if insufficiently described or not explained at all. The two authors have independently assessed the study quality, and the final result was cross-checked and arbitrated by discussion in case of disagreement. Finally, the overall quality score was calculated and expressed as error of the mean. A total of 11 articles were reviewed for this qualitative analysis (Figure 1).
(I) Publication in peer-reviewed journal, (II) number of experimental and control groups, (III) housing and husbandry conditions, (IV) details of intervention/exposure group procedures, (V) random allocation to groups, (VI) concealment of allocation, (VII) blinded assessment of outcomes, (VIII) biochemical evaluations, (IX) histopathological evaluations, and (X) statistical analysis. 1: criterion is satisfied, 0: the criterion is insufficiently described or not explained at all; the mean quality score is expressed as error of the mean (SEM) and (minimum and maximum score).
3. Results and Discussion
In the present review, we extracted data related to the potential effects of metformin in experimentally induced acute and chronic epileptic seizure of animal models. A total of 650 articles were retrieved from different sources, of which eleven of them were included for the final qualitative analysis (Figure 1).
3.1. Study Quality Assessment
The quality appraisal was undertaken for each of the included studies independently according to the Collaborative Approach to Meta-Analysis and Review of Animal Data from Experimental Studies (CAMARADES) before data extraction. According to the CAMARADES quality assessment obtained, all articles included were published in peer-reviewed journal, an intervention/exposure group allocation was clearly stated, and a proper and well-explained statistical analysis was applied. The quality scores for all the included studies were within acceptable range (greater than or equal to 5), but none of the studies reported the allocation concealment (blinded induction of the model and assessment of the outcome). The studies conducted by Mehrabi et al.  and Zhao et al.  scored the highest score (9/10). However, two studies done by Sánchez-Elexpuru et al.  and Bibi et al.  have earned the lowest scores (5/10), while the remaining seven studies scored between six and eight. The overall mean quality score of the articles was 7.36 with 0.43 standard error of the mean [5–9] (Table 2).
Animal models of epileptic seizures have played an indispensable role in advancement of our knowledge on the basic mechanisms of epileptogenesis and have been instrumental in the preclinical development of new antiepileptic agents . Among different chemicals used to induce an epileptic seizure in animals, kainic acid and pilocarpine have been the most commonly used agents to induce temporal lobe epilepsy (TLE), status epilepticus, and other epilepsy types and provide a better understanding of the process of epileptogenesis [52–54].
Metformin is a well-known first-line oral antidiabetic agent, but recent studies also showed the benefits of metformin in neurological disorders including epilepsy. Several studies have shown the antiseizure activity of metformin against experimentally induced (chemicals or electrical kindling) acute and chronic animal models of epileptic seizure (Table 3). Evidence from these studies suggested that metformin has a pronounced antiepileptic potential in PTZ-induced acute seizure as well as kainic acid and pilocarpine-induced epileptic seizure models via delaying the onset seizure, reducing seizure frequency and duration, facilitating seizure termination, and attenuating oxidative stress, neuroinflammatory markers, and different proteins which primarily evolved in the initiation or propagation of epileptic seizure. Metformin-treated animals also showed improved behavioral and cognitive performance, reduced PTZ-induced mortality, and suppressed α-synuclein expression in the hippocampal CA3 region.
SE = status epilepticus; TC: total cholesterol; TP: total protein; SLE: seizure-like events; SLA = seizure-like activity; AMPK: adenosine monophosphate-activated protein kinase; p-AMPK: phosphorylated AMPK; PTZ: pentylenetetrazole; IP: intraperitoneally; TLE: temporal lobe epilepsy; MDA: malondialdehyde; GSH: glutathione; D. melanogaster = Drosophila melanogaster; 4-PBA = 4-phenylbutyric acid; KO = knockout; PAS+ = periodic acid-Schiff (+ indicates the presence of polyglucosan inclusions or LB); CHOP = C/EBP homologous protein; eIF2α = eukaryotic initiation factor 2α; PERK = protein kinase RNA-like endoplasmic reticulum kinase; CR = caloric restriction; mTOR = mammalian target of rapamycin; AL = ad libitum; AM = ad libitum plus metformin; CM = caloric restriction plus metformin.
In this review, we have also included the effects of metformin in experimentally induced lafora disease (LD). We included these studies since LD is a rare and progressive myoclonic seizure characterized by focal and generalized seizure, neurological dysfunction, myoclonic and absence seizure, and cognitive decline [42, 55], and more importantly, the outcome measure of these studies was seizure-like activity and neurological and mortality outcomes of metformin treatment, which are the primary interest of this review.
There is also some evidence that pointed out that diabetes mellitus is expressively associated with increased risk of epilepsy compared to nondiabetic patients [56–58]. Hence, it is fascinating that metformin might be a potential and promising pharmacological agent particularly for patients who have concurrent conditions of diabetes mellitus and epilepsy. Owning to this foresight, continual clinical studies are essential to be carried out in order to make sure the efficacy of metformin in epileptic patients as well as in patients who have comorbidities of diabetes and epilepsy.
3.2. Possible Mechanisms of Antiseizure/Antiepileptic Actions of Metformin
After induction of seizure either by chemicals or by electrical kindling, it is known that animals exhibit behavioral changes before or after the actual onset of seizure. In the long term, seizures also cause cognitive impairments. However, in these studies metformin treatment reduced behavioral manifestations including touch-response, pick-up, and finger snap and improved cognitive decline. Moreover, metformin reduced seizure severity parameters including mortality, seizure score, and duration of seizure experience while it increased the latency for the first onset of seizure. All these evidences suggested the potential roles of metformin to prevent the symptoms associated with epilepsy.
To date, there is no AED available for curative or disease-modifying actions of epilepsy. Hence, the present therapeutic approach is symptomatic management and supportive care in order to improve the longevity and quality of life of the patients [59, 60]. The epileptogenesis process involves several molecular and cellular changes which can be used as the potential targets for treatment and prevention of epilepsy, though most of the currently available drugs work just by suppression of seizure without affecting the underlying pathological conditions. Metformin was found to prevent some of the cellular changes that underlie the epileptogenesis process including neuronal cell loss, gliosis, and apoptosis which are among the well-known cellular changes observed in epilepsy [61–63]. Metformin is also capable of deterring the molecular alterations including oxidative stress which is a peculiar factor that plays an enormous role in the initiation and progression of epileptogenesis [64, 65].
Mitochondrial dysfunction and abnormal gene expression of oxidative markers involved in scavenging reactive oxygen and nitrogen species have resulted in a profound increment of free radicals and impairment of brain mitochondrial oxygen consumption. All these are suggested to contribute to epileptogenesis [65–69]. Several clinical studies also showed that there is an impairment of biological enzymatic and nonenzymatic antioxidants and overexpression of free radicals in epileptic patients compared to normal control. Most of these epileptic patients who displayed an imbalance oxidative status were refractory to existing AEDs [70–74]. Furthermore, antioxidant agents and targeting oxidative stress were showing a promising antiepileptic potential by attenuating seizure generation, delaying the onset of epilepsy, arresting disease progression, reducing hippocampal neuronal damage, and averting cognitive impairments in different animal models of an epileptic seizure [64, 70, 75]. Interestingly, metformin showed antioxidant activities through attenuation of oxidative free radicals including lipid peroxidation (thiobarbituric acid-reactive substances and malondialdehyde) and advanced glycation end-products and improved the antioxidant defense system including superoxide dismutase, catalase, and glutathione levels [23, 25, 41, 50, 76] in addition to its effects on seizure outcomes.
There is also growing evidence that suggests the activation of inflammatory processes in patients and animal models of epilepsy and the epileptogenic effect of several inflammatory mediators acting on glia and neurons both directly and indirectly to influence neuronal excitability [77–79]. All these evidences are further strengthened by the beneficial effects of nonsteroidal anti-inflammatory drugs and other anti-inflammatory molecules on epileptic and epileptogenic outcomes against animal models of epileptic seizure [77, 80, 81]. Similarly, various studies showed the ability of metformin in mitigating the release and production of endogenous proinflammatory mediators including Phospho-IkBα, tumor necrosis factor alpha (TNFα), interleukin 1 beta (IL-1β), IL-6, and vascular endothelial growth factor (VEGF) [82–85].
Selective neuronal loss from the limbic brain area and hippocampal CA1/CA3 subregion is the major neurobiological feature noted in epileptic patients and animal models of epilepsy. In two thirds of patients with TLE, seizures arise from foci in the hippocampus, amygdala, and piriform cortex, which are the areas of extensive neuronal loss [53, 86]. This shows the possible involvement of neurodegeneration in epilepsy. Metformin is reported to prevent neuronal loss via inhibition of microglia activation-mediated inflammation via NF-κB and mitogen-activated protein kinase (MAPK) signaling pathway . The long-term upregulation of the brain-derived neurotrophic factor (BDNF) in the hippocampus showed to enhance epileptogenesis [88, 89], while metformin treatment attenuated the PTZ-induced overexpression of BDNF and its receptor . Metformin also exhibited a substantial reduction of cellular apoptosis induced by PTZ by modifying the expression of caspase-3 and -9 in metformin-pretreated epileptic mice . The observed antiepileptic effect of metformin could be as the result of its effect on all or some of the stated changes. Hence, the therapeutic approach towards molecular apoptosis (either intrinsic or extrinsic pathway) and neuroinflammation can be an emerging area that potentially serves as the neuroprotective role in epilepsy [90, 91].
Impairment in tricarboxylic acid (TCA) cycle turnover was noted in animal models of epilepsy [92, 93]. This suggests an alteration of amino acid and glucose metabolism during the course of epileptogenesis . Alvestad et al. have also shown the reduction of glucose metabolism to glutamate in the hippocampal formation and entorhinal cortex of kainic acid-induced epileptic rats which indicate TCA cycle dysfunction . On the contrary, metformin reduced the glucose level in the animal model of epilepsy which may attribute for better outcomes in epilepsy . This might also be via CtBP mediated as metformin was found to increase CtBP, which is known to have antiglycolytic activity . In addition, metformin reduced the albumin level  which is known to contribute to neuronal death observed in epilepsy [97, 98].
The molecular mechanism of metformin behind these effects could be due to its capacity to activate MAPK thereby inhibiting the downstream signaling pathway including mammalian target of rapamycin (mTOR) signaling, PI3K/Akt signaling, neuroinflammation via suppression of MAPK-NF-κB, the release of reactive oxygen species, and production of toxic proteins [46, 48, 99]. Conversely, a recent study conducted by Rubio Osornio et al. showed that metformin administration alone or along with caloric restriction suppressed the expression of the mTOR gene in an electrical kindling TLE mouse model, which might be a compensatory mechanism due to inhibition of the mTOR pathway . Similarly, there are a number of studies that demonstrate the role of metformin in neuroprotection, enhancement of spatial memory, and neurogenesis, which is mediated through the AMPK and atypical protein kinase C and aPKC-CBP pathway in various models of CNS disorders [27, 34, 100–102].
Despite that the neurobiological basis of α-synuclein protein aggregation in epilepsy is inconclusive, there is growing of evidence that showed its association with both intractable and newly diagnosed epileptic patients [103, 104]. A study conducted by Hussein et al. showed that metformin treatment significantly downregulated α-synuclein expression in a PTZ-induced animal model of epileptic seizure , which requires further studies to establish the association of this protein and an epileptic seizure and also the persistent suppression of metformin against α-synuclein accumulation.
Generally, this review revealed that metformin can alleviate symptoms of epileptic seizure in addition to its potential roles to modify the molecular and cellular changes including oxidative stress, neuroinflammation, apoptosis, and neuronal loss observed during the initiation and progression of the disease. The good safety profile coupled with the multiple mechanisms of metformin counteracting epileptic seizure is a promising aspect of the drug in the treatment of epilepsy. However, available evidences so far are preliminary; further preclinical and clinical studies are required in order to determine its long-term efficacy and safety in epilepsy.
|AMPK:||Adenosine monophosphate-activated protein kinase|
|CAMARADES:||Collaborative approach to meta-analysis and review of animal data from experimental studies|
|mTOR:||Mechanistic target of rapamycin|
|QoL:||Quality of life|
|TLE:||Temporal lobe epilepsy|
|BDNF:||Brain-derived neurotrophic factor|
|MAPK:||Mitogen-activated protein kinase.|
Conflicts of Interest
We declare that there is no conflict of interest and financial support from any institution or organization.
EMY developed the research conception and took the initiatives of this work and drafted the manuscript. EMY, AW, ABG, and DZW provided a greater contribution towards collecting, extracting, and organizing relevant data and also revising the review paper and agreed to be accountable for all aspects of the work.
- R. S. Fisher, W. van Emde Boas, W. Blume et al., “Epileptic seizures and epilepsy: definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE),” Epilepsia, vol. 46, no. 4, pp. 470–472, 2005.
- R. A. Scott, S. D. Lhatoo, and J. W. A. S. Sander, “The treatment of epilepsy in developing countries: where do we go from here?” Bulletin of the World Health Organization, vol. 79, no. 4, pp. 344–351, 2001.
- H. Kaur, B. Kumar, and B. Medhi, “Antiepileptic drugs in development pipeline : a recent update,” eNeurologicalSci, vol. 4, pp. 42–51, 2016.
- L. Santulli, A. Coppola, S. Balestrini, and S. Striano, “The challenges of treating epilepsy with 25 antiepileptic drugs,” Pharmacological Research, vol. 107, pp. 211–219, 2016.
- R. Michaelis, V. Tang, J. L. Wagner et al., “Psychological treatments for people with epilepsy,” Cochrane Database of Systematic Reviews, vol. 10, 2017.
- T. Tomson and D. Battino, “Teratogenic effects of antiepileptic drugs,” Seizure, vol. 17, no. 2, pp. 166–171, 2008.
- F. J. E. Vajda, J. Graham, A. Roten, C. M. Lander, T. J. O’Brien, and M. Eadie, “Teratogenicity of the newer antiepileptic drugs – the Australian experience,” Journal of Clinical Neuroscience, vol. 19, no. 1, pp. 57–59, 2012.
- D. S. Hill, B. J. Wlodarczyk, A. M. Palacios, and R. H. Finnell, “Teratogenic effects of antiepileptic drugs,” Expert Review of Neurotherapeutics, vol. 10, no. 6, pp. 943–959, 2011.
- Q. Nie, B. Su, and J. Wei, “Neurological teratogenic effects of antiepileptic drugs during pregnancy,” Experimental and Therapeutic Medicine, vol. 12, no. 4, pp. 2400–2404, 2016.
- B. T. Güveli, R. Ö. Rosti, A. Güzelta, E. B. Tuna, D. Atakl, and S. Sencer, “Teratogenicity of antiepileptic drugs,” Clinical Psychopharmacology and Neuroscience, vol. 15, no. 1, pp. 19–27, 2017.
- A. Golyala and P. Kwan, “Drug development for refractory epilepsy : the past 25 years and beyond,” Seizure, vol. 44, pp. 147–156, 2017.
- K. D. Laxer, E. Trinka, L. J. Hirsch et al., “The consequences of refractory epilepsy and its treatment,” Epilepsy & Behavior, vol. 37, pp. 59–70, 2014.
- P. Karimzadeh and V. Bakrani, “Antiepileptic drug-related adverse reactions and factors influencing these reactions,” Iranian Journal of Child Neurology, vol. 7, no. 3, pp. 25–29, 2013.
- S. I. Johannessen and C. Johannessen Landmark, “Antiepileptic drug interactions-principles and clinical implications,” Current Neuropharmacology, vol. 8, no. 3, pp. 254–267, 2010.
- D. Ekstein, M. Tirosh, Y. Eyal, and S. Eyal, “Drug interactions involving antiepileptic drugs: assessment of the consistency among three drug compendia and FDA-approved labels,” Epilepsy & Behavior, vol. 44, pp. 218–224, 2015.
- M. P. van der Aa, V. Hoving, E. M. W. van de Garde, A. de Boer, C. A. J. Knibbe, and M. M. J. van der Vorst, “The effect of eighteen-month metformin treatment in obese adolescents: comparison of results obtained in daily practice with results from a clinical trial,” Journal of Obesity, vol. 2016, Article ID 7852648, 7 pages, 2016.
- K. M. Levri, E. Slaymaker, A. Last et al., “Metformin as treatment for overweight and obese adults: a systematic review,” The Annals of Family Medicine, vol. 3, no. 5, pp. 457–461, 2005.
- J. Kasznicki, A. Sliwinska, and J. Drzewoski, “Metformin in cancer prevention and therapy,” Annals of Translational Medicine, vol. 2, no. 6, p. 57, 2014.
- Y. K. Chae, A. Arya, M.-K. Malecek et al., “Repurposing metformin for cancer treatment: current clinical studies,” Oncotarget, vol. 7, no. 26, pp. 40767–40780, 2016.
- C. Coyle, F. H. Cafferty, C. Vale, and R. E. Langley, “Metformin as an adjuvant treatment for cancer : a systematic review and meta-analysis,” Annals of Oncology, vol. 27, no. 12, pp. 2184–2195, 2016.
- S. Marupuru, P. Senapati, S. Pathadka, S. S. Miraj, M. K. Unnikrishnan, and M. K. Manu, “Protective effect of metformin against tuberculosis infections in diabetic patients : an observational study of south Indian tertiary healthcare facility,” The Brazilian Journal of Infectious Diseases, vol. 21, no. 3, pp. 312–316, 2017.
- Y.-J. Lee, S. K. Han, J. H. Park et al., “The effect of metformin on culture conversion in tuberculosis patients with diabetes mellitus,” The Korean Journal of Internal Medicine, vol. 33, no. 5, pp. 933–940, 2018.
- A. Chakraborty, S. Chowdhury, and M. Bhattacharyya, “Effect of metformin on oxidative stress, nitrosative stress and inflammatory biomarkers in type 2 diabetes patients,” Diabetes Research and Clinical Practice, vol. 93, no. 1, pp. 56–62, 2011.
- B. C. Obi, T. C. Okoye, V. E. Okpashi, C. N. Igwe, and E. O. Alumanah, “Comparative study of the antioxidant effects of metformin, glibenclamide, and repaglinide in alloxan-induced diabetic rats,” Journal of Diabetes Research, vol. 2016, Article ID 1635361, 5 pages, 2016.
- A. Esteghamati, D. Eskandari, H. Mirmiranpour et al., “Effects of metformin on markers of oxidative stress and antioxidant reserve in patients with newly diagnosed type 2 diabetes: a randomized clinical trial,” Clinical Nutrition, vol. 32, no. 2, pp. 179–185, 2013.
- M. M. Chung, Y. L. Chen, D. Pei et al., “The neuroprotective role of metformin in advanced glycation end product treated human neural stem cells is AMPK-dependent,” Biochimica et Biophysica Acta (BBA)-Molecular Basis of Disease, vol. 1852, no. 5, pp. 720–731, 2015.
- J. Wang, D. Gallagher, L. M. DeVito et al., “Metformin activates an atypical PKC-CBP pathway to promote neurogenesis and enhance spatial memory formation,” Cell Stem Cell, vol. 11, no. 1, pp. 23–35, 2012.
- M. Guo, J. Mi, Q.-M. Jiang et al., “Metformin may produce antidepressant effects through improvement of cognitive function among depressed patients with diabetes mellitus,” Clinical and Experimental Pharmacology and Physiology, vol. 41, no. 9, pp. 650–656, 2014.
- J. Jia, J. Cheng, J. Ni, and X. Zhen, “Neuropharmacological actions of metformin in stroke,” Current Neuropharmacology, vol. 13, no. 3, pp. 389–394, 2015.
- A. M. Koenig, D. Mechanic-Hamilton, S. X. Xie et al., “Effects of the insulin sensitizer metformin in Alzheimer disease,” Alzheimer Disease & Associated Disorders, vol. 31, no. 2, pp. 107–113, 2017.
- Y. Lin, K. Wang, C. Ma et al., “Evaluation of metformin on cognitive improvement in patients with non-dementia vascular cognitive impairment and abnormal glucose metabolism,” Frontiers in Aging Neuroscience, vol. 10, 2018.
- W. B. Potter, K. J. O'Riordan, D. Barnett et al., “Metabolic regulation of neuronal plasticity by the energy sensor AMPK,” PLoS One, vol. 5, no. 2, article e8996, 2010.
- H. Pintana, N. Apaijai, W. Pratchayasakul, N. Chattipakorn, and S. C. Chattipakorn, “Effects of metformin on learning and memory behaviors and brain mitochondrial functions in high fat diet induced insulin resistant rats,” Life Sciences, vol. 91, no. 11-12, pp. 409–414, 2012.
- M. B. Potts and D. A. Lim, “An old drug for new ideas: metformin promotes adult neurogenesis and spatial memory formation,” Cell Stem Cell, vol. 11, no. 1, pp. 5-6, 2012.
- M. Asadbegi, P. Yaghmaei, I. Salehi, A. Ebrahim-Habibi, and A. Komaki, “Neuroprotective effects of metformin against Aβ-mediated inhibition of long-term potentiation in rats fed a high-fat diet,” Brain Research Bulletin, vol. 121, pp. 178–185, 2016.
- M. Markowicz-Piasecka, J. Sikora, A. Szydłowska, A. Skupień, E. Mikiciuk-Olasik, and K. M. Huttunen, “Metformin – a future therapy for neurodegenerative diseases,” Pharmaceutical Research, vol. 34, no. 12, pp. 2614–2627, 2017.
- Z. Ou, X. Kong, X. Sun et al., “Metformin treatment prevents amyloid plaque deposition and memory impairment in APP/PS1 mice,” Brain, Behavior, and Immunity, vol. 69, pp. 351–363, 2018.
- D. K. Mostafa, C. A. Ismail, and D. A. Ghareeb, “Differential metformin dose-dependent effects on cognition in rats: role of Akt,” Psychopharmacology, vol. 233, no. 13, pp. 2513–2524, 2016.
- M. Cascella, S. Bimonte, A. Barbieri et al., “Dissecting the potential roles of Nigella sativa and its constituent thymoquinone on the prevention and on the progression of Alzheimer’s disease,” Frontiers in Aging Neuroscience, vol. 10, 2018.
- S. Mehrabi, N. Sanadgol, M. Barati et al., “Evaluation of metformin effects in the chronic phase of spontaneous seizures in pilocarpine model of temporal lobe epilepsy,” Metabolic Brain Disease, vol. 33, no. 1, pp. 107–114, 2018.
- R.-r. Zhao, X.-c. Xu, F. Xu et al., “Metformin protects against seizures, learning and memory impairments and oxidative damage induced by pentylenetetrazole-induced kindling in mice,” Biochemical and Biophysical Research Communications, vol. 448, no. 4, pp. 414–417, 2014.
- G. Sánchez-Elexpuru, J. M. Serratosa, P. Sanz, and M. P. Sánchez, “4-Phenylbutyric acid and metformin decrease sensitivity to pentylenetetrazol-induced seizures in a Malin knockout model of Lafora disease,” Neuroreport, vol. 28, no. 5, pp. 268–271, 2017.
- F. Bibi, I. Ullah, M. O. Kim, and M. I. Naseer, “Metformin attenuate PTZ-induced apoptotic neurodegeneration in human cortical neuronal cells,” Pakistan Journal of Medical Sciences, vol. 33, no. 3, pp. 581–585, 2017.
- M. R. Macleod, T. O’Collins, D. W. Howells, and G. A. Donnan, “Pooling of animal experimental data reveals influence of study design and publication bias,” Stroke, vol. 35, no. 5, pp. 1203–1208, 2004.
- O. H. Azeez, “Effect of some antidiabetic drugs on biochemical parameters in experimentally induced epileptic rats,” Assiut Veterinary Medical Journal, vol. 60, no. 142, pp. 54–63, 2014.
- Y. Yang, B. Zhu, F. Zheng et al., “Chronic metformin treatment facilitates seizure termination,” Biochemical and Biophysical Research Communications, vol. 484, no. 2, pp. 450–455, 2017.
- B. Stone, B. Burke, J. Pathakamuri, J. Coleman, and D. Kuebler, “A low-cost method for analyzing seizure-like activity and movement in Drosophila,” Journal of Visualized Experiments, no. 84, 2014.
- A. Berthier, M. Payá, A. M. García-Cabrero et al., “Pharmacological interventions to ameliorate neuropathological symptoms in a mouse model of Lafora disease,” Molecular Neurobiology, vol. 53, no. 2, pp. 1296–1309, 2016.
- J. Chen, G. Zheng, H. Guo et al., “The effect of metformin treatment on endoplasmic reticulum (ER) stress induced by status epilepticus (SE) via the PERK-eIF2α-CHOP pathway,” Bosnian Journal of Basic Medical Sciences, vol. 18, no. 1, p. 49, 2017.
- A. M. Hussein, M. Eldosoky, M. El-Shafey et al., “Effects of metformin on apoptosis and α-synuclein in a rat model of pentylenetetrazole-induced epilepsy,” Canadian Journal of Physiology and Pharmacology, vol. 97, no. 1, pp. 37–46, 2019.
- M. del Carmen Rubio Osornio, V. C. Ramírez, D. Calderón Gámez, C. P. Tres, K. G. Carvajal Aguilera, and B. V. Phillips Farfán, “Metformin plus caloric restriction show anti-epileptic effects mediated by mTOR pathway inhibition,” Cellular and Molecular Neurobiology, vol. 38, no. 7, pp. 1425–1438, 2018.
- W. Löscher, “Critical review of current animal models of seizures and epilepsy used in the discovery and development of new antiepileptic drugs,” Seizure, vol. 20, no. 5, pp. 359–368, 2011.
- M. Lévesque and M. Avoli, “The kainic acid model of temporal lobe epilepsy,” Neuroscience & Biobehavioral Reviews, vol. 37, no. 10, pp. 2887–2899, 2013.
- D. Reddy and R. Kuruba, “Experimental models of status epilepticus and neuronal injury for evaluation of therapeutic interventions,” International Journal of Molecular Sciences, vol. 14, no. 9, pp. 18284–18318, 2013.
- Ö. Bektaş, A. Yılmaz, A. H. Okcu, S. Teber, E. Aksoy, and G. Deda, “A type of progressive myoclonic epilepsy, Lafora disease: a case report,” Eastern Journal of Medicine, vol. 18, no. 1, pp. 34–36, 2013.
- D. Yan, E. Zhao, H. Zhang, X. Luo, and Y. Du, “Association between type 1 diabetes mellitus and risk of epilepsy: a meta-analysis of observational studies,” vol. 11, no. 3, pp. 146–151, 2017.
- I. C. Chou, C. H. Wang, W. D. Lin, F. J. Tsai, C. C. Lin, and C. H. Kao, “Risk of epilepsy in type 1 diabetes mellitus : a population-based cohort study,” Diabetologia, vol. 59, no. 6, pp. 1196–1203, 2016.
- M. Baviera, M. C. Roncaglioni, M. Tettamanti et al., “Diabetes mellitus: a risk factor for seizures in the elderly—a population-based study,” Acta Diabetologica, vol. 54, no. 9, pp. 863–870, 2017.
- R. M. Kaminski, M. A. Rogawski, and H. Klitgaard, “The potential of antiseizure drugs and agents that act on novel molecular targets as antiepileptogenic treatments,” Neurotherapeutics, vol. 11, no. 2, pp. 385–400, 2014.
- B. L. Clossen and D. S. Reddy, “Novel therapeutic approaches for disease-modification of epileptogenesis for curing epilepsy,” Biochimica et Biophysica Acta (BBA) - Molecular Basis of Disease, vol. 1863, no. 6, pp. 1519–1538, 2017.
- J. S. Farrell, M. D. Wolff, and G. C. Teskey, “Neurodegeneration and pathology in epilepsy: clinical and basic perspectives,” in Neurodegenerative Diseases, pp. 317–334, Springer, 2017.
- J. L. Loewen, M. L. Barker-Haliski, E. J. Dahle, H. S. White, and K. S. Wilcox, “Neuronal injury, gliosis, and glial proliferation in two models of temporal lobe epilepsy,” Journal of Neuropathology & Experimental Neurology, vol. 75, no. 4, pp. 366–378, 2016.
- L. Ren, R. Zhu, and X. Li, “Silencing miR-181a produces neuroprotection against hippocampus neuron cell apoptosis post-status epilepticus in a rat model and in children with temporal lobe epilepsy,” Genetics and Molecular Research, vol. 15, no. 1, 2016.
- A. Pauletti, G. Terrone, T. Shekh-Ahmad et al., “Targeting oxidative stress improves disease outcomes in a rat model of acquired epilepsy,” Brain, vol. 140, no. 7, pp. 1885–1899, 2017.
- B. Martinc, I. Grabnar, and T. Vovk, “The role of reactive species in epileptogenesis and influence of antiepileptic drug therapy on oxidative stress,” Current Neuropharmacology, vol. 10, no. 4, pp. 328–343, 2012.
- J. Pearson-Smith and M. Patel, “Metabolic dysfunction and oxidative stress in epilepsy,” International Journal of Molecular Sciences, vol. 18, no. 11, 2017.
- M. Morimoto, T. Hashimoto, T. Kitaoka, and S. Kyotani, “Impact of oxidative stress and newer antiepileptic drugs on the albumin and cortisol value in severe motor and intellectual disabilities with epilepsy,” Journal of Clinical Medicine Research, vol. 10, no. 2, pp. 137–145, 2018.
- C. C. T. Aguiar, A. B. Almeida, P. V. P. Araújo et al., “Oxidative stress and epilepsy: literature review,” Oxidative Medicine and Cellular Longevity, vol. 2012, Article ID 795259, 12 pages, 2012.
- E.-J. Shin, J. H. Jeong, Y. H. Chung et al., “Role of oxidative stress in epileptic seizures,” Neurochemistry International, vol. 59, no. 2, pp. 122–137, 2011.
- U. Geronzi, F. Lotti, and S. Grosso, “Oxidative stress in epilepsy,” Expert Review of Neurotherapeutics, vol. 18, no. 5, pp. 427–434, 2018.
- G. M. de Araújo Filho, D. P. Martins, A. M. Lopes et al., “Oxidative stress in patients with refractory temporal lobe epilepsy and mesial temporal sclerosis: possible association with major depressive disorder?” Epilepsy & Behavior, vol. 80, pp. 191–196, 2018.
- M. R. Ashrafi, R. Azizi Malamiri, S. Shams et al., “Serum total antioxidant capacity of epileptic children before and after monotherapy with sodium valproate, carbamazepine, and phenobarbital,” Iranian Journal of Child Neurology, vol. 12, no. 3, pp. 24–31, 2018.
- O. Ethemoglu, H. Ay, I. Koyuncu, and A. Gönel, “Comparison of cytokines and prooxidants/antioxidants markers among adults with refractory versus well-controlled epilepsy: a cross-sectional study,” Seizure, vol. 60, pp. 105–109, 2018.
- J. Folbergrová, P. Ješina, H. Kubová, and J. Otáhal, “Effect of resveratrol on oxidative stress and mitochondrial dysfunction in immature brain during epileptogenesis,” Molecular Neurobiology, vol. 55, no. 9, pp. 7512–7522, 2018.
- B. Martinc, I. Grabnar, and T. Vovk, “Antioxidants as a preventive treatment for epileptic process: a review of the current status,” Current Neuropharmacology, vol. 12, no. 6, pp. 527–550, 2014.
- D. D. Vilela, L. G. Peixoto, R. R. Teixeira et al., “The role of metformin in controlling oxidative stress in muscle of diabetic rats,” Oxidative Medicine and Cellular Longevity, vol. 2016, Article ID 6978625, 9 pages, 2016.
- A. Vezzani, “Anti-inflammatory drugs in epilepsy: does it impact epileptogenesis?” Expert Opinion on Drug Safety, vol. 14, no. 4, pp. 583–592, 2015.
- L. Walker and G. J. Sills, “Inflammation and epilepsy: the foundations for a new therapeutic approach in epilepsy?” Epilepsy Currents, vol. 12, no. 1, pp. 8–12, 2012.
- A. Rana and A. E. Musto, “The role of inflammation in the development of epilepsy,” Journal of Neuroinflammation, vol. 15, no. 1, p. 144, 2018.
- A. Dey, X. Kang, J. Qiu, Y. Du, and J. Jiang, “Anti-inflammatory small molecules to treat seizures and epilepsy: from bench to bedside,” Trends in Pharmacological Sciences, vol. 37, no. 6, pp. 463–484, 2017.
- B. M. Radu, F. B. Epureanu, M. Radu, P. F. Fabene, and G. Bertini, “Nonsteroidal anti-inflammatory drugs in clinical and experimental epilepsy,” Epilepsy Research, vol. 131, pp. 15–27, 2017.
- T. Horiuchi, N. Sakata, Y. Narumi et al., “Metformin directly binds the alarmin HMGB1 and inhibits its proinflammatory activity,” Journal of Biological Chemistry, vol. 292, no. 20, pp. 8436–8446, 2017.
- A. R. Cameron, V. L. Morrison, D. Levin et al., “Anti-inflammatory effects of metformin irrespective of diabetes status,” Circulation Research, vol. 119, no. 5, pp. 652–665, 2016.
- Y. Hattori, K. Hattori, and T. Hayashi, “Pleiotropic benefits of metformin: macrophage targeting Its anti-inflammatory mechanisms,” Diabetes, vol. 64, no. 6, pp. 1907–1909, 2015.
- W. H. Oliveira, A. K. Nunes, M. E. R. França et al., “Effects of metformin on inflammation and short-term memory in streptozotocin-induced diabetic mice,” Brain Research, vol. 1644, pp. 149–160, 2016.
- J. Kapur, “Role of neuronal loss in the pathogenesis of recurrent spontaneous seizures,” Epilepsy Currents, vol. 3, no. 5, pp. 166-167, 2003.
- L. Tao, D. Li, H. Liu et al., “Neuroprotective effects of metformin on traumatic brain injury in rats associated with NF-κB and MAPK signaling pathway,” Brain Research Bulletin, vol. 140, pp. 154–161, 2018.
- C. Heinrich, S. Lähteinen, F. Suzuki et al., “Increase in BDNF-mediated TrkB signaling promotes epileptogenesis in a mouse model of mesial temporal lobe epilepsy,” Neurobiology of Disease, vol. 42, no. 1, pp. 35–47, 2011.
- D. K. Binder, “The role of BDNF in epilepsy and other diseases of the mature nervous system,” in Recent Advances in Epilepsy Research, pp. 34–56, Springer, Boston, MA.
- D. C. Henshall and R. P. Simon, “Epilepsy and apoptosis pathways,” Journal of Cerebral Blood Flow & Metabolism, vol. 25, no. 12, pp. 1557–1572, 2005.
- K. M. Webster, M. Sun, P. Crack, T. J. O’Brien, S. R. Shultz, and B. D. Semple, “Inflammation in epileptogenesis after traumatic brain injury,” Journal of Neuroinflammation, vol. 14, no. 1, p. 10, 2017.
- M. N. Bainbridge, E. Cooney, M. Miller et al., “Analyses of SLC13A5-epilepsy patients reveal perturbations of TCA cycle,” Molecular Genetics and Metabolism, vol. 121, no. 4, pp. 314–319, 2017.
- T. S. McDonald and K. Borges, “Impaired hippocampal glucose metabolism during and after flurothyl-induced seizures in mice: Reduced phosphorylation coincides with reduced activity of pyruvate dehydrogenase,” Epilepsia, vol. 58, no. 7, pp. 1172–1180, 2017.
- O. B. Smeland, M. G. Hadera, T. S. Mcdonald, U. Sonnewald, and K. Borges, “Brain mitochondrial metabolic dysfunction and glutamate level reduction in the pilocarpine model of temporal lobe epilepsy in mice,” Journal of Cerebral Blood Flow & Metabolism, vol. 33, no. 7, pp. 1090–1097, 2013.
- S. Alvestad, J. Hammer, E. Eyjolfsson, H. Qu, O. P. Ottersen, and U. Sonnewald, “Limbic structures show altered glial–neuronal metabolism in the chronic phase of kainate induced epilepsy,” Neurochemical Research, vol. 33, no. 2, pp. 257–266, 2008.
- M. Garriga-Canut, B. Schoenike, R. Qazi et al., “2-Deoxy-D-glucose reduces epilepsy progression by NRSF-CtBP–dependent metabolic regulation of chromatin structure,” Nature Neuroscience, vol. 9, no. 11, pp. 1382–1387, 2006.
- I. Weissberg, L. Wood, L. Kamintsky et al., “Albumin induces excitatory synaptogenesis through astrocytic TGF-β/ALK5 signaling in a model of acquired epilepsy following blood–brain barrier dysfunction,” Neurobiology of Disease, vol. 78, pp. 115–125, 2015.
- Z. Liu, J. Liu, S. Wang, S. Liu, and Y. Zhao, “Neuronal uptake of serum albumin is associated with neuron damage during the development of epilepsy,” Experimental and Therapeutic Medicine, vol. 12, no. 2, pp. 695–701, 2016.
- C. Rotermund, G. Machetanz, and J. C. Fitzgerald, “The therapeutic potential of metformin in neurodegenerative diseases,” Frontiers in Endocrinology, vol. 9, 2018.
- I. Arbeláez-Quintero and M. Palacios, “To use or not to use metformin in cerebral ischemia: a review of the application of metformin in stroke rodents,” Stroke Research and Treatment, vol. 2017, Article ID 9756429, 13 pages, 2017.
- J. MENENDEZ and A. Vazquez-Martin, “Rejuvenating regeneration: metformin activates endogenous adult stem cells,” Cell Cycle, vol. 11, no. 19, pp. 3521-3522, 2012.
- P. Dadwal, N. Mahmud, L. Sinai et al., “Activating endogenous neural precursor cells using metformin leads to neural repair and functional recovery in a model of childhood brain injury,” Stem Cell Reports, vol. 5, no. 2, pp. 166–173, 2015.
- A. Surguchov, I. Surgucheva, M. Sharma, R. Sharma, and V. Singh, “Pore-forming proteins as mediators of novel epigenetic mechanism of epilepsy,” Frontiers in Neurology, vol. 8, 2017.
- H. Rong, L. Jin, W. Wei, X. Wang, and Z. Xi, “Alpha-synuclein is a potential biomarker in the serum and CSF of patients with intractable epilepsy,” Seizure, vol. 27, pp. 6–9, 2015.
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