Therapeutic effect of metformin on reversing gastric intestinal metaplasia

BACKGROUND: Currently, standard therapeutic agents are not available for treating gastric intestinal metaplasia (IM). However, emerging evidence suggests the potential efficacy of metformin in addressing this issue. Our aim was to assess the efficacy and safety of metformin in reversing IM. METHODS: We initially investigated the impact of metformin on reversing gastric IM in mice. An open-label, prospective, randomized controlled trial was subsequently conducted at a tertiary hospital in China from April 2022 to May 2023. A total of 140 nondiabetic patients with pathologically confirmed IM and negative Helicobacter pylori tests were recruited. Patients were randomly assigned at a 1:1 ratio to receive either 500 mg of metformin daily for six months or 5 mg of folate three times daily as a control. The primary outcome was defined as the regression rate of IM in different groups at the end of the treatment. RESULTS: Metformin improved gastric mucosal pathology in mice. A total of 158 patients were screened, 140 of whom were randomized to the two groups. Among these, 85/140 (60.7%) were male, and the mean age was 55.9 ± 8.3 years. Six-month follow-up data were available for 129 patients. Compared with folate users (control group), metformin users had a greater rate of regression of IM (48.6% [34/70] vs. 31.4% [22/70]; relative risk [RR] = 1.55, 95% confidence interval [CI] 1.01-2.36; P = 0.04) in the intention-to-treat population. Furthermore, in the per-protocol population, metformin users had a higher rate of regression of IM (53.1% [34/64] vs. 33.9% [22/65]; RR = 1.57, 95% CI 1.04-2.37; P = 0.03). The metformin group had a low incidence of self-alleviating mild adverse reactions. CONCLUSION: This randomized clinical trial revealed that metformin can be safely administered to promote the regression of IM in nondiabetic individuals without Helicobacter pylori infection. REGISTRATION: ClinicalTrials.gov, Identifier: NCT05288153.