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REVIEW article

Front. Pharmacol., 23 December 2021
Sec. Ethnopharmacology
This article is part of the Research Topic Insights in Ethnopharmacology: 2021 View all 12 articles

Approaches to Decrease Hyperglycemia by Targeting Impaired Hepatic Glucose Homeostasis Using Medicinal Plants

  • Laboratorio de Etnofarmacología, Departamento de Biología Celular, Facultad de Ciencias, Universidad Nacional Autónoma de México, Mexico City, Mexico

Liver plays a pivotal role in maintaining blood glucose levels through complex processes which involve the disposal, storage, and endogenous production of this carbohydrate. Insulin is the hormone responsible for regulating hepatic glucose production and glucose storage as glycogen, thus abnormalities in its function lead to hyperglycemia in obese or diabetic patients because of higher production rates and lower capacity to store glucose. In this context, two different but complementary therapeutic approaches can be highlighted to avoid the hyperglycemia generated by the hepatic insulin resistance: 1) enhancing insulin function by inhibiting the protein tyrosine phosphatase 1B, one of the main enzymes that disrupt the insulin signal, and 2) direct regulation of key enzymes involved in hepatic glucose production and glycogen synthesis/breakdown. It is recognized that medicinal plants are a valuable source of molecules with special properties and a wide range of scaffolds that can improve hepatic glucose metabolism. Some molecules, especially phenolic compounds and terpenoids, exhibit a powerful inhibitory capacity on protein tyrosine phosphatase 1B and decrease the expression or activity of the key enzymes involved in the gluconeogenic pathway, such as phosphoenolpyruvate carboxykinase or glucose 6-phosphatase. This review shed light on the progress made in the past 7 years in medicinal plants capable of improving hepatic glucose homeostasis through the two proposed approaches. We suggest that Coreopsis tinctoria, Lithocarpus polystachyus, and Panax ginseng can be good candidates for developing herbal medicines or phytomedicines that target inhibition of hepatic glucose output as they can modulate the activity of PTP-1B, the expression of gluconeogenic enzymes, and the glycogen content.

Introduction

Diabetes mellitus (DM) is a chronic metabolic disease characterized by high blood sugar levels (hyperglycemia), caused by insulin malfunctioning, deficient insulin secretion, or both (Liu et al., 2019). Type 2 diabetes (T2D) is the most important type of DM due to its high worldwide prevalence (American Diabetes Association, 2021). It is characterized by insulin resistance, which is defined as a poor response of insulin-sensitive tissues to normal insulin concentration (Mlinar et al., 2007). The main cause of insulin resistance has been associated to an obesogenic environment in which large amounts of free fatty acids and adipokines are responsible for impairing insulin signaling by increasing serine phosphorylation that inhibits tyrosine phosphorylation of insulin receptor (IR) and insulin receptor substrates (IRSs) (DeFronzo et al., 2015). However, it has also been reported that protein tyrosine phosphatases (PTPs) could have a more important role since they are upregulated in insulin resistant states. Insulin action is negative regulated by PTPs, particularly the PTP-1B, because they promote the dephosphorylation of tyrosine residues of IR and IRSs (Saltiel and Kahn, 2001). When insulin signaling is impaired in liver by either insulin resistance or low insulin levels, the glucose storage and production is dysregulated, increasing the hepatic glucose output rates yielding hyperglycemia in diabetic patients.

Liver represents a crucial therapeutic target for treating hyperglycemia in T2D because hepatic glucose output is the pathophysiological abnormality that contributes the most to the hyperglycemic state in fasting and postprandial state as a consequence of hepatic insulin resistance (Sharabi et al., 2015). During the overnight fast (postabsorptive state), the liver of a normal person produces glucose at a rate of approximately 1.8–2 mg/kg. min. However, this rate increases around 0.5 mg/kg min in a patient with T2D, promoting a significant rise in the basal state of glucose production (Cersosimo et al., 2018). After food ingestion and the subsequent increase in insulin levels, the suppression of glucose production is slower in a diabetic patient, promoting an evident postprandial hyperglycemia due to the excess of glucose produced in addition to that from the exogenous source (Rizza, 2010).

Medicinal plants and natural products have shown to have numerous benefits on processes involved in glucose and lipid metabolism, leading to correct homeostasis imbalances that promote metabolic diseases such as T2D (Li J. et al., 2018; Xu L. et al., 2018; Saadeldeen et al., 2020). Unlike the classic “on-target” paradigm in pharmacology, namely a drug with a specific target, the polypharmacology approach, or the binding of a drug to more than one target, could be more effective against a disease as complex as T2D due to its multiple pathophysiological abnormalities (Reddy and Zhang, 2013). In this context, extract plants and phytochemicals isolated from medicinal plants exhibit multiple mechanisms of action on assorted metabolic targets that are involved in glucose homeostasis. Therefore, efforts have been made to describe all the beneficial effects on metabolism of these extracts and molecules in recent years.

The current review summarizes the medicinal plants reported from 2015 that can potentially decrease hyperglycemia resulting from imbalance in hepatic glucose metabolism by two different approaches: improving hepatic insulin resistance by inhibiting PTP-1B and decreasing hepatic glucose output by inhibiting rate-limiting enzymes involved in the storage and production of glucose.

Methodology

Two separate searches were performed based on the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) (Page et al., 2021) in the following databases: Scopus, Clarivate and PubMed (Figure 1). The first involved studies related to extracts or phytochemicals tested against the activity or expression of PTP-1B enzyme, while in the second, studies with extracts or phytochemicals with an effect on the glucose-producing pathways were sought. Only records related to the study of medicinal plants and their isolated compounds were considered.

FIGURE 1
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FIGURE 1. PRISMA flowchart. PTP-1B: protein tyrosine phosphatase 1B; HGP: hepatic glucose production.

Therapeutic Approaches to Reduce Hyperglycemia Resulting From Impaired Hepatic Glucose Homeostasis

Each insulin-sensitive tissue presents abnormal characteristics that contribute to hyperglycemia in an insulin-resistant state. The underlying mechanisms that give rise to insulin resistance converge on deficient insulin signalling that limits the activation of factors involved in energy metabolism. In obesity and T2D, insulin resistance has been linked mainly to defects in the signalling pathway of phosphatidylinositol 3-kinase and protein kinase B (PI3K/Akt), particularly to the Akt2 isoform (Cusi et al., 2000; Krook et al., 2000).

In normal conditions, the insulin secreted by pancreatic β cell binds to its receptor in the target cell, activating the tyrosine kinase activity, which promotes the receptor autophosphorylation and the subsequent phosphorylation of IRSs, mainly IRS-1 and IRS-2, in tyrosine residues. Afterwards, the enzyme P13K is recruited and activated by IRS to convert phosphatidylinositol 4,5-bisphosphate (PIP2) from the plasma membrane to phosphatidylinositol 3,4,5-triphosphate (PIP3), which facilitates the phosphorylation and activation of Akt at two important sites: by phosphoinositide-dependent kinase 1 (PDK1) at residue Thr308 of the catalytic domain, and by mammalian target rapamycin complex 2 (mTORC2) at residue Ser473 of the regulatory domain (Schultze et al., 2012). Specifically in liver, the activated Akt enzyme is responsible for phosphorylating different factors that are involved in the regulation of processes such as glycogen synthesis, gluconeogenesis, and glycogenolysis, which are activated or inhibited under different nutritional circumstances (Dimitriadis et al., 2021).

Due to hepatic insulin resistance, this hormone losses its ability to regulate glucose metabolism in liver, resulting in enhanced glucose output that contributes greatly to fasting and postprandial hyperglycemia, namely glycogen synthesis is reduced, and production of glucose is increased (Figure 2). Therefore, we proposed two approaches by which medicinal plants could ameliorated hyperglycemia through enhancing hepatic glucose metabolism: improving the function of insulin in the liver by inhibiting the enzyme PTP-1B and modulating the hepatic production/storage of glucose by regulating the enzymes involved in gluconeogenesis, glycogenolysis, and glycogenesis.

FIGURE 2
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FIGURE 2. Impaired hepatic glucose homeostasis by insulin resistance. When insulin does not work properly either due to overexpression of PTP-1B or other factors, glucose production in liver is upregulated generating a hyperglycemic state. Both gluconeogenesis and glycogenolysis are enhanced due to poor insulin signaling, namely genetic expression of gluconeogenic enzymes is not repressed and enzymes related to glycogen metabolism are not adequately regulated. Akt functions: green color indicates positive regulation, red color indicates negative regulation, and blue color represents direct or indirect regulation by phosphorylation or allosterism. IR: insulin receptor; IRS: insulin receptor substrate; PI3K: phosphoinositide 3-kinase; PIP2: phosphatidylinositol 4,5-bisphosphate; PIP3: phosphatidylinositol 3,4,5-triphosphate; PDK: phosphoinositide-dependent kinase; Akt: protein kinase B; PTP-1B: protein tyrosine phosphatase 1B; PC: pyruvate carboxylase; OAA: oxalacetate; PEPCK: phosphoenolpyruvate carboxykinase; PK: pyruvate kinase; FBPase: fructose 1,6-bisphosphatase; PFK: phosphofructokinase; GS: glycogen synthase; GP: glycogen phosphorylase; PP1: protein phosphatase 1; GSK3: glycogen synthase kinase-3; GK: glucokinase; G6Pase: glucose 6-phosphatase; GLUT2: glucose transporter 2.

Inhibition of Protein Tyrosine Phosphatase 1B

The modification of proteins through phosphorylation and dephosphorylation of tyrosine residues represents one of the main mechanisms of cell signaling regulation (Alonso et al., 2016), which is carried out by two superfamilies of enzymes: protein tyrosine kinases (PTKs), and PTPs. In this regard, the classical PTP subfamily possess a domain of 240–250 amino acids characterized by a conserved site that exhibits a catalytic mechanism based on cysteine (Denu and Dixon, 1998). Specifically, the enzyme PTP-1B is a classic intracellular PTP widely distributed in mammalian tissues that is anchored on the cytoplasmic side of the endoplasmic reticulum membrane. Despite its localization, the PTP-1B enzyme can access its substrates located on the surface of the plasma membrane during endocytosis, biosynthesis, and by the movement of the endoplasmic reticulum towards the plasma membrane in specific regions (Bakke and Haj, 2015).

Since its first isolation from the human placenta in 1988 by Tonks et al., 1988 PTP-1B has become an attractive research object due to its direct link with the etiopathogenesis of insulin resistance. In addition to the processes promoted by the obesogenic inflammatory environment, such as the serine/threonine phosphorylation of IR and IRS, and their proteasomal degradation (Mlinar et al., 2007; Ahmed et al., 2021), the dephosphorylation of these components by PTP-1B has also been implied to the termination of the insulin signal (Ahmad et al., 1995; Kenner et al., 1996; Chen et al., 1997).

Experimental data obtained from various studies have shown that the PTP-1B enzyme is one of the main negative regulators of the insulin signaling pathway. For instance, studies performed in PTP-1B knock-out mice have been shown that the absence of this enzyme produces healthy organisms that exhibit enhanced insulin sensitivity, protection against the weight gain generated by high-fat diet, and increased hepatic phosphorylation of IR and IRS after an intraperitoneal insulin injection (Elchebly et al., 1999; Klaman et al., 2000). On the other hand, it has been reported an increased PTP-1B activity in hepatic cytosolic fractions isolated from streptozotocin (STZ)-hyperglycemic rats (Meyerovitch et al., 1989), while augmented hepatic microsomal enzyme activity, content of protein, and mRNA levels have only been observed after 2 weeks of insulin treatment in these insulinopenic organisms, suggesting that elevated insulin levels are necessary to modify PTP-1B content and activity, namely hyperinsulinemia caused by insulin resistance may lead to altered PTP-1B expression and activity (Ahmad and Goldstein, 1995). Additionally, it has also been shown that insulin rises hepatic microsomal PTP-1B activity in rat hepatoma cells (Hashimoto and Goldstein, 1992). Likewise, abnormal expression and activity of PTP-1B have been reported in skeletal muscle of insulin-resistant obese people (Ahmad et al., 1997), as well as in non-obese Goto-Kakizaki rats with spontaneously generated insulin resistance (Dadke et al., 2000), and in STZ-hyperglycemic rats fed with high-fat diet (Wu et al., 2005).

Based on the aforementioned, the PTP-1B inhibition represents a good therapeutic target for the treatment of insulin resistance-related diseases, such as DM2 (Zhang et al., 2006). Hence, an arsenal of molecules with inhibitory capacity of PTP-1B activity has been generated in recent years. The methodological approaches that have been applied are the rational design of synthetic phospho-(tyrosine)-mimetic molecules to be used as competitive inhibitors, considering the structural characteristics of the protein, and the search for molecules from natural sources (Sun et al., 2018). The latter is based on the statement that nature has a great variety of structures that present diverse pharmacological effects (Atanasov et al., 2021), so natural products can be used as a starting point for the creation of powerful inhibitors.

Table 1 summarizes all medicinal plants and their identified compounds that have proved to inhibit the activity or expression of PTP-1B since 2015. It was obtained a total of 125 medicinal plants used in various traditional medicine systems around the world, mainly represented in eastern folk, such as Chinese and Vietnamese. Morus alba L. (Moraceae), a plant used in the traditional Chinese system, has been the most evaluated for this purpose. In addition to direct PTP-1B activity inhibition and molecular docking studies, some extracts and compounds were assessed to improve glucose and lipid metabolism in vivo, such as lowering blood glucose levels, improved insulin resistance and glucose intolerance, and improved lipid profile. Furthermore, their effect on glucose uptake and phosphorylation of some components of insulin signaling, such as IR, IRS, and Akt, was evaluated in cell cultures under insulin-resistant conditions.

TABLE 1
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TABLE 1. Medicinal plants and their phytochemicals with PTP-1B inhibitory capacity.

Inhibition of Hepatic Glucose Output by Modulating Glucose Metabolism in Liver

The liver is a key organ that plays a crucial role in the regulation of blood glucose because it manages both storage and synthesis of glucose. The latter involves two metabolic pathways: glycogenolysis and gluconeogenesis, which constitute total hepatic glucose production (HGP) (Lee et al., 2015). Glycogenolysis consists of glycogen breakdown into glucose, being half of the basal HGP in fasting and decreasing the glycogen concentration at an almost linear rate during the first 22 h (Rothman et al., 1991; Cersosimo et al., 2018). In fasting, it is controlled by glucagon and epinephrine that activate glycogen phosphorylase (GP), the major enzyme responsible for digesting glycogen by releasing glucose 1-phosphate. In feeding condition, insulin inhibits glycogen breakdown and promotes glycogen synthesis through the activation of Akt and protein phosphatase 1 (PP1), leading the deactivation of both GP and glycogen synthase kinase-3 (GSK3), which in its active form (dephosphorylated), inactivates glycogen synthase (GS) (Han et al., 2016).

Gluconeogenesis, on the other hand, is defined as the production of glucose from a molecule that is not a carbohydrate. Its main substrates are pyruvate, glycerol, and amino acids such as alanine (Hanson and Owen, 2013). Another way to denote gluconeogenesis is as “reverse glycolysis” since both share not only substrates and final products, but also many enzymes. However, the direction of the reactions catalyzed in gluconeogenesis goes in the opposite direction, so the steps that are not shared with glycolysis can be determined as regulatory steps. These reactions are catalyzed by four rate-limiting enzymes: pyruvate carboxylase (PC), which is responsible for converting pyruvate into oxaloacetate; phosphoenolpyruvate carboxykinase (PEPCK), that converts oxaloacetate to phosphoenolpyruvate; fructose 1,6-bisphosphatase (FBPase), that dephosphorylates fructose 1,6-bisphosphate obtaining fructose 6-phosphate; and glucose 6-phosphatase (G6Pase), which is responsible for removing the phosphate group from glucose 6-phosphate, yielding novo synthesized glucose (Postic et al., 2004).

In the diabetic state, increased rates of HGP are observed as a result of an imbalance of various factors, such as the augmented availability of gluconeogenic substrates, the resistance of the liver to the action of insulin, and elevated levels of glucagon that activate HGP (Sharabi et al., 2015). Due to all these factors, the inhibition of HGP turns out to be an important therapeutic target for the reduction of hyperglycemia observed in T2D patients. In this regard, Table 2 summarizes the works made between 2015 and 2021 with extracts or natural products from 47 medicinal plants that showed to modulate hepatic glucose metabolism by inhibiting glucose production or promoting glycogen synthesis. As it can be observed, decreasing the expression of PEPCK and G6Pase is the principal mechanism related to gluconeogenesis inhibition, while phosphorylation of GSK3, promotion of GS activity, and inhibition of GP are the main mechanisms involved in glycogen breakdown and synthesis. Furthermore, although PI3K/Akt pathway stands out as a good pharmacological target to reduce insulin resistance, medicinal plants and their phytochemicals can also decrease HGP through AMP-activated protein kinase (AMPK).

TABLE 2
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TABLE 2. Medicinal plants and their phytochemicals capable to modulate hepatic glucose metabolism.

Discussion

Insulin resistance in liver leads to the release of large amounts of glucose into the bloodstream that affects long-term homeostasis. The regulation of hepatic glucose output represents a good pharmacological target for the control of metabolic diseases such as T2D, which are characterized by the presence of this pathophysiological phenomenon. The search for new molecules capable of regulating hepatic glucose metabolism from medicinal plants has focused on screening for phytochemicals that can directly inhibit key enzymes in glucose-producing pathways. However, considering compounds with the ability to also decrease the activity of the enzymes involved in terminating the insulin signal could result in more effective glycemic control.

According to the bibliographic search, plants used in different systems of traditional medicine have shown the ability to inhibit the activity or expression of PTP-1B, which could indicate that they have a potential inhibitory effect on HGP. The determination of biological activity of full extracts and compounds isolated from medicinal plants has been approached through different perspectives. Generally, the medicinal plant is first identified using an ethnopharmacological approach. Afterwards, different types of extracts are elaborated (aqueous, ethanolic, methanolic, etc.) and then tested on the biological activity to be evaluated following several paths: 1) direct inhibition enzymatic assays, which can be complemented with structure-activity relationship (SAR) studies and molecular docking analysis to find the possible structures responsible for the bioactivity, relating them with the binding of amino acid residues present at the catalytic or regulatory sites (regarding isolated compounds); 2) the use of cell cultures to evaluate the effect of the extract or compound on the expression and protein levels of key enzymes; and 3) in vivo studies, where diabetic (hyperglycemic) animals induced with STZ or alloxan, or insulin-resistant animals generated by the consumption of high-fat diet are used.

Regarding PTP-1B, most of the studies published between 2015 and 2021 focused on conducting enzyme activity assays, and few of them had a multidisciplinary approach that encompassed enzyme assays and in vitro or in vivo studies. The main problem with the first type of studies is that, although the inhibition potency and selectivity of the molecule over the enzyme are directly evaluated, the pharmacokinetic properties of the compound are omitted. This particularity stands out since it has been reported that, despite having excellent inhibitory activity, many compounds lack adequate cellular permeability, namely they present poor absorption and low bioavailability (Zhang et al., 2017). Another aspect to highlight is that PTP-1B is almost identical to TC-PTP, another member of the PTP family with 74% identity at the catalytic site, so it is important that the identified inhibitors have a high selectivity towards PTP-1B to avoid unwanted effects (Dewang et al., 2005). Considering these facts, it would be necessary in the future to carry out more studies involving as many approaches as possible to obtain a more integrative panorama and to be able to evaluate potential inhibitors considering their pharmacokinetic properties and selectivity. Also, it is encouraged to directly evaluate the effect of medicinal plants and their compounds with reported PTP-1B inhibitory capacity on hepatic glucose metabolism.

In addition to exhibiting PTP-1B inhibitory capacity, some of the medicinal plants reported in Table 1 also improved hepatic glucose metabolism by promoting glucose consumption and glycogen synthesis, upregulating activity or expression of GS, decreasing activity or expression of key enzymes involved in glycogenolysis and gluconeogenesis such as GSK3, GP, PEPCK, FBPase, and G6Pase, and by modulating insulin signaling. The compounds isolated from these plants could have a greater modulatory capacity of hepatic glucose metabolism because they are capable of directly reducing both insulin resistance and glucose production. These species were Astragalus mongholicus (astragaloside IV), Chaenomeles japonica, Duranta erecta, Eriobotrya japonica (maslinic acid, corosolic acid, oleanolic acid, and ursolic acid), Symplocos cochinchinensis, Thonningia sanguinea (2′-O- (3-O-galloyl-4,6-O-Sa-hexahydroxydiphenoyl-β-d-glucopyranosyl)-3-hydroxyphloretin, 4′-O-(4,6-O-Sa-hexahydroxydiphenoyl-β-d-glucopyranosyl)- phloretin, 2′-O-(3-O-galloyl-4,6-O-Sa-hexahydroxydiphenoyl-β-d-glucopyranosyl)phloretin, thonningianin A, and thonningianin B), Vaccinium uliginosum (cyanidin-3-arabinoside, delphinidin-3-glucoside, cyanidin-3-galactoside, cyanidin-3-glucoside, malvidin-3-galactoside, petunidin-3-glucoside, procyanidin B1, and procyanidin B2), and Vigna radiata. On the other hand, since Coreopsis tinctoria, Lithocarpus polystachyus, and Panax ginseng were documented in both Tables 1, 2, their isolated compounds may have better glycemic control.

This work focused on summarizing the medicinal plants with the potential capacity to reduce hyperglycemia resulting from an imbalance in the hepatic metabolism of glucose, encompassing two different approaches: the inhibition of PTP-1B (improvement of hepatic insulin resistance), and the modulation of enzymes involved in gluconeogenesis and glycogenolysis/glycogenesis (decreased hepatic glucose output). In recent years, PTP-1B research has focused on the characterization of different phytochemicals from medicinal plants, such as phenolic compounds, terpenes, and alkaloids. The main methodology used was to carry out direct enzyme inhibition tests to evaluate the potency of these molecules, omitting important aspects such as selectivity or pharmacokinetics. Therefore, it is proposed to use of multidisciplinary approaches that involve in vitro studies, such as the use of cell lines or primary culture to evaluate the effect of the extracts and compounds on expression and protein levels, and in vivo studies, where the concentration of the compound in systemic circulation and its duration is determined, as well as the transformation processes involved. In this regard, not only the inhibitory activity of the compounds is evaluated, but also the impact on other pharmacological aspects that can only be observed using animal models.

On the other hand, research on medicinal plants that modulate hepatic glucose metabolism has primary focused on testing full extracts rather than compounds. However, it is worth mentioning that mixtures could have synergistic effects capable of regulating multiple targets (Caesar and Cech, 2019) and therefore compound fractions may exhibit more bioactivity than isolated molecules. Further studies are needed to identify potential multi-target phytochemicals in plants listed in Table 2. Finally, it is expected that this review will provide greater knowledge of medicinal plants and compounds for the development of drugs that improving hepatic glucose metabolism as a therapeutic target for the treatment of T2D.

We suggest that Coreopsis tinctoria, Lithocarpus polystachyus, and Panax ginseng can be good candidates for developing herbal medicines or phytomedicines that target inhibition of hepatic glucose output as they can modulate the activity of PTP-1B, the expression of gluconeogenic enzymes, and the glycogen content. However, only their full extracts are tested until now. Therefore, compounds responsible for the effects mentioned above have not been identified, and pharmacological and toxicological tests in animal models are required to assess their efficacy and safety, with the aim of moving forward to carry out clinical studies.

Author Contributions

GM-T and FE-H performed the bibliographical research summarized in tables and wrote the first version of the manuscript. AA-C reviewed and edited the manuscript. All authors have read and agreed to the published version of the manuscript.

Funding

This project was partially sponsored by DGAPA PAPIIT IN226719 and IN213222.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

Authors acknowledge “Consejo Nacional de Ciencia y Tecnología (CONACyT)” for the doctoral scholarship of GM-T and FE-H.

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Keywords: medicinal plants, hyperglycemia, hepatic glucose output, insulin resistance, PTP-1B inhibitors, natural products

Citation: Mata-Torres G, Andrade-Cetto A and Espinoza-Hernández F (2021) Approaches to Decrease Hyperglycemia by Targeting Impaired Hepatic Glucose Homeostasis Using Medicinal Plants. Front. Pharmacol. 12:809994. doi: 10.3389/fphar.2021.809994

Received: 05 November 2021; Accepted: 30 November 2021;
Published: 23 December 2021.

Edited by:

Valentina Echeverria Moran, Bay Pines VA Healthcare System, United States

Reviewed by:

Luis Goya, Spanish National Research Council (CSIC), Spain
Sakina Mohamed Yagi, University of Khartoum, Sudan

Copyright © 2021 Mata-Torres, Andrade-Cetto and Espinoza-Hernández. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Adolfo Andrade-Cetto, aac@ciencias.unam.mx

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