Aims/hypothesis
Characterisation of genetic variation that influences the response to glucose-lowering medications is instrumental to precision medicine for treatment of type 2 diabetes. The Study to Understand the Genetics of the Acute Response to Metformin and Glipizide in Humans (SUGAR-MGH) examined the acute response to metformin and glipizide in order to identify new pharmacogenetic associations for the response to common glucose-lowering medications in individuals at risk of type 2 diabetes.
Methods
One thousand participants at risk for type 2 diabetes from diverse ancestries underwent sequential glipizide and metformin challenges. A genome-wide association study was performed using the Illumina Multi-Ethnic Genotyping Array. Imputation was performed with the TOPMed reference panel. Multiple linear regression using an additive model tested for association between genetic variants and primary endpoints of drug response. In a more focused analysis, we evaluated the influence of 804 unique type 2 diabetes- and glycaemic trait-associated variants on SUGAR-MGH outcomes and performed colocalisation analyses to identify shared genetic signals.
Results
Five genome-wide significant variants were associated with metformin or glipizide response. The strongest association was between an African ancestry-specific variant (minor allele frequency [MAF
Afr
]=0.0283) at rs149403252 and lower fasting glucose at Visit 2 following metformin (
p
=1.9×10
−9
); carriers were found to have a 0.94 mmol/l larger decrease in fasting glucose. rs111770298, another African ancestry-specific variant (MAF
Afr
=0.0536), was associated with a reduced response to metformin (
p
=2.4×10
−8
), where carriers had a 0.29 mmol/l increase in fasting glucose compared with non-carriers, who experienced a 0.15 mmol/l decrease. This finding was validated in the Diabetes Prevention Program, where rs111770298 was associated with a worse glycaemic response to metformin: heterozygous carriers had an increase in HbA
1c
of 0.08% and non-carriers had an HbA
1c
increase of 0.01% after 1 year of treatment (
p
=3.3×10
−3
). We also identified associations between type 2 diabetes-associated variants and glycaemic response, including the type 2 diabetes-protective C allele of rs703972 near
ZMIZ1
and increased levels of active glucagon-like peptide 1 (GLP-1) (
p
=1.6×10
−5
), supporting the role of alterations in incretin levels in type 2 diabetes pathophysiology.
Conclusions/interpretation
We present a well-phenotyped, densely genotyped, multi-ancestry resource to study gene–drug interactions, uncover novel variation associated with response to common glucose-lowering medications and provide insight into mechanisms of action of type 2 diabetes-related variation.
Data availability
The complete summary statistics from this study are available at the Common Metabolic Diseases Knowledge Portal (
https://hugeamp.org
) and the GWAS Catalog (
www.ebi.ac.uk/gwas/
, accession IDs: GCST90269867 to GCST90269899).
Graphical Abstract...

Genome-wide association analysis identifies ancestry-specific genetic variation associated with acute response to metformin and glipizide in SUGAR-MGH

10.1007/s00125-023-05922-7