Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Diabetes. Dec 15, 2018; 9(12): 230-238
Published online Dec 15, 2018. doi: 10.4239/wjd.v9.i12.230
Effects of glucose-lowering agents on cardiorespiratory fitness
Hidetaka Hamasaki
Hidetaka Hamasaki, Endocrinology and Metabolism, Internal Medicine, Hamasaki Clinic, Kagoshima 890-0046, Japan
ORCID number: Hidetaka Hamasaki (0000-0002-0124-597X).
Author contributions: Hamasaki H wrote the review.
Conflict-of-interest statement: No conflict of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author to: Hidetaka Hamasaki, MD, PhD, Doctor, Endocrinology and Metabolism, Internal Medicine, Hamasaki Clinic, 2-21-4 Nishida, Kagoshima 890-0046, Japan.
Telephone: +81-99-2503535 Fax: +81-99-2501470
Received: August 27, 2018
Peer-review started: August 27, 2018
First decision: October 5, 2018
Revised: October 15, 2018
Accepted: November 26, 2018
Article in press: November 27, 2018
Published online: December 15, 2018


Exercise therapy is essential for the management of type 2 diabetes (T2D). However, patients with T2D show lower physical activity and reduced cardiorespiratory fitness than healthy individuals. It would be ideal for clinicians to co-prescribe glucose-lowering agents that improve cardiorespiratory fitness or exercise capacity in conjunction with exercise therapy. Metformin does not improve cardiorespiratory fitness and may attenuate any beneficial effect of exercise in patients with T2D. In contrast, thiazolidinediones appear to improve cardiorespiratory fitness in patients with T2D. Although evidence is limited, sodium–glucose cotransporter 2 (SGLT2) inhibitors may improve cardiorespiratory fitness in patients with heart failure, and the effect of glucagon-like peptide-1 (GLP-1) receptor agonists on cardiorespiratory fitness is controversial. Recent clinical trials have shown that both SGLT2 inhibitors and GLP-1 receptor agonists exert a favorable effect on cardiovascular disease. It becomes more important to choose drugs that have beneficial effects on the cardiovascular system beyond glucose-lowering effects. Further studies are warranted to determine an ideal glucose-lowering agent combined with exercise therapy for the treatment of T2D.

Key Words: Type 2 diabetes, Glucagon-like peptide l receptor agonist, Cardiorespiratory fitness, Exercise capacity, Metformin, Thiazolidinedione, Sodium-glucose cotransporter 2 inhibitors

Core tip: What is the most effective combination of drugs and exercise for the treatment of type 2 diabetes? It has become increasingly important for clinicians to prescribe drugs that reduce cardiovascular disease and mortality in addition to their glucose-lowering effects. This review summarized the current literature investigating the effect of glucose-lowering agents on cardiorespiratory fitness. Thiazolidinediones, sodium–glucose cotransporter 2 inhibitors, and glucagon-like peptide-l receptor agonists have the potential to improve cardiorespiratory fitness; however, further research will be needed to confirm.


More than 400 million people worldwide suffer from diabetes. Diabetes can lead to microvascular and macrovascular complications and increase the physical and psychological burden in patients[1]. Nutrition and exercise therapy are essential for the management of diabetes, and patients with type 1 and 2 diabetes are recommended to engage in regular moderate-to-vigorous intensity aerobic exercise and resistance training[2]. In addition, higher levels of physical activity are associated with reduced risk of breast cancer (14%), colon cancer (21%), ischemic heart disease (25%), and stroke (26%)[3]. Exercise is a standard component of chronic disease prevention and management[4]. However, patients with diabetes typically exhibit lower energy expenditure, physical activity duration[5], skeletal muscle mass[6], and cardiorespiratory fitness[7], and it can be challenging to effectively and safely incorporate exercise therapy in diabetes patients also presenting with vascular complications and comorbidities. Combined diet and exercise therapy is effective against diabetes; however, in more severe cases, drugs are usually required to intensively improve glycemic control. There are currently nine different groups of glucose-lowering agents available: metformin, thiazolidinediones, sulfonylureas, glinides, α-glucosidase inhibitors, dipeptidyl peptidase-4 (DPP-4) inhibitors, sodium–glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide-l (GLP-1) receptor agonists, and insulin. Of these, metformin[8], SGLT2 inhibitors[9,10], and a GLP-1 receptor agonists[11] have beneficial effects on cardiovascular disease (CVD) as well as glycemic control, making these the drugs of choice for of type 2 diabetes (T2D) treatment[12].

Exercise is important in the primary and secondary prevention of CVD[13] and, thus, should be an integral part of the strategy to reduce CVD risk. Individuals with low cardiorespiratory fitness (< 7.9 metabolic equivalent; MET) have a 1.70-fold and 1.56-fold increased risk of all-cause mortality and cardiovascular events, respectively, compared with those with high cardiorespiratory fitness (≥ 10.8 MET)[14]. Ideally, clinicians should preferably prescribe drugs that improve cardiorespiratory fitness. However, the optimal combination of exercise and glucose-lowering agents remains unclear as the effects of glucose-lowering agents on exercise capacity/cardiorespiratory fitness are not well understood.

This review summarizes the current literature regarding the effects of glucose-lowering agents on cardiorespiratory fitness in humans and aims to highlight the optimum drug selection in the treatment of patients with diabetes who engage in regular exercise.


Metformin is the most widely used oral glucose-lowering drug with known beneficial effects on macrovascular complications in T2D[15]. While the mechanisms of action of metformin remain unclear, it is known to activate the cellular energy sensor, AMP-activated protein kinase (AMPK), suppress proinflammatory cytokine secretion, inhibit hepatic gluconeogenesis and lipogenesis, and stimulate GLP-1 secretion by modulating the gut microbiota[16]. Metformin is a complex drug with multiple mechanisms of action. While it is the first-line medication recommended by the American Diabetes Association and the European Association of the Study of Diabetes[17], clinicians usually also co-prescribe metformin with exercise therapy. It is important to understand whether metformin affects cardiorespiratory fitness/exercise capacity, and the interaction between metformin and exercise has been well studied[18-25].

Johnson et al[18] examined the acute effects of metformin on maximal oxygen consumption (VO2max) during exercise. A cycle ergometer was used for graded maximal exercise tests. Participants cycled at 75–80 rpm with a resistance of 2.0 kp, which was increased by 0.5 kp every 3 min until volitional exhaustion. A single dose (1000 mg) of metformin increased mean VO2 (2.9 ± 0.5 L/min vs 2.8 ± 0.5 L/min) during exercise but not VO2max (4.00 ± 0.58 L/min vs 4.00 ± 0.66 L/min). Braun et al[19] investigated the effect of metformin on aerobic capacity in healthy individuals. Peak aerobic capacity (VO2peak) was measured 7–9 d after administration of either metformin or placebo. An incremental exercise test began using a cycle ergometer at 50–150 W or a treadmill at 6.4–9.6 km/h. The cycle resistance (+25–50 W) and treadmill grade (+2%) were increased every 2 min until exhaustion. The initial dose of metformin was 500 mg/d, which was increased every second day to a maximum of 2000 mg/d. Metformin treatment reduced VO2peak (3.53 ± 0.29 L/min vs 3.63 ± 0.9 L/min for metformin and placebo, respectively; −2.7%), and there was no significant association between the decrease in VO2peak and baseline cardiorespiratory fitness. Although the effect was physiologically subtle, short-term treatment with metformin had a negative effect on cardiorespiratory fitness. The same authors also examined the effect of metformin on fat oxidation during and after exercise[20]. Fat oxidation, which was calculated from respiratory gas composition (volume of oxygen consumption (VO2) and volume of carbon dioxide production (VCO2), was higher with metformin compared with placebo treatment during exercise but lower during recovery. In contrast, metformin increased carbohydrate oxidation after exercise. Oxygen consumption was not different at rest or during exercise with metformin. Therefore, metformin may increase the rate of fat oxidation during exercise via activation of AMPK, but appears to have no effect on cardiorespiratory fitness. Learsi et al[21] examined the effect of metformin on high-intensity, short-duration exercise on anaerobic capacity. Exercise tests comprised a maximal incremental test to evaluate VO2 max, six workload tests with submaximal intensities (40%–90% of maximal power output), and two supramaximal intensity tests (110% of maximal power output). Participants took low-dose metformin (500 mg) or placebo prior to the supramaximal test. Time to exhaustion was improved with metformin (191 ± 33 s vs 167 ± 32 s for metformin and placebo, respectively), but VO2 during the supramaximal test was not different between the groups. Maximum O2 deficit and lactate concentrations did not differ between the groups. The authors concluded that metformin improves exercise performance by mediating the alactic anaerobic system. Table 1 summarizes the effects of metformin on cardiorespiratory fitness in healthy individuals. However, what is known about the interaction between metformin and cardiorespiratory fitness in patients with T2D or insulin resistance? A noteworthy study by Boulé et al[22] investigated the interaction between metformin and exercise on the hormonal response to a standardized meal. The authors studied 10 patients with mild T2D who took metformin or placebo for 28 d, and measured exercise capacity, glucose, lactate, non-esterified fatty acids, insulin, and glucagon levels on the last two days. Resistance and aerobic exercise tests were conducted using an isokinetic dynamometer and treadmill. After performing resistance exercise (leg extensions and flexions), the patients started three bouts of aerobic exercise comprising walking at 3.5 km/h with 0% gradient for 15 min, then increasing the speed and gradient until just below the ventilatory threshold, followed by walking at an intensity above the ventilator threshold for 5 min. The mean respiratory exchange ratio (0.96 ± 0.02 vs 0.98 ± 0.02) was lower, and the mean heart rate (124 ± 9 vs 118 ± 8 beats per min) was higher in the metformin group. Mean VO2 was not affected. As expected, metformin improved glycemic response but glycemic response was attenuated in combination with exercise. In addition, glucagon levels were highest in the metformin plus exercise group. It is surprising that exercise has an opposing effect on the glucose-lowering effect of metformin. High-intensity exercise increases insulin counterregulatory hormones, such as epinephrine, norepinephrine, cortisol, and growth hormone, as well as glucagon, which may further deteriorate glucose response in T2D. Boulé et al[23] also investigated the long-term effects of metformin on glycemic control and physical fitness in participants in the Diabetes Aerobic and Resistance Exercise trial[26]. Subjects were randomly assigned to four groups, namely, aerobic exercise, resistance training, combined aerobic exercise and resistance training, and control. The exercise group performed progressive aerobic exercise, increasing to an intensity of 75% of maximum heart rate for 45 min. Resistance training included seven exercises: abdominal crunches, seated row, seated biceps curls, supine bench presses, leg presses, shoulder presses, and leg extensions. VO2peak increased in the aerobic group by 0.16 L/min and in the combined exercise group by 0.11 L/min without metformin. However, VO2peak did not change in any of the metformin groups. In the aerobic exercise group, HbA1c levels were reduced with metformin. In the combined exercise group, fasting glucose levels decreased with metformin. There were no significant differences in changes in HbA1c and glucose levels with or without metformin. The study concluded that metformin did not impair physical fitness or glycemic control when combined with exercise. The findings of this study are inconsistent with previous short-term studies that have shown that the addition of exercise to metformin showed a negative effect on cardiorespiratory fitness and glycemia. The authors speculated that difference in the characteristics of the study participants, such as duration of metformin treatment and glycemic control at baseline, may explain this discrepancy.

Table 1 Effects of metformin on cardiorespiratory fitness in healthy individuals.
Ref.Study designSubjectsMetformin dose and interventionResults
Johnson et al[18], 2008Randomized, double-blind, placebo-controlled, crossover study11 healthy and active men1000 mg/dVO2max→, ventilator threshold→, maximal heart rate→, time to fatigue→
Age: 29.9 ± 3.7 yrCycle ergometer at the mean intensity of 69 ± 5.5% of VO2maxLactate↓, blood glucose concentrations↓
Sex: All men
BMI: 25.2 ± 2.8 kg/m2
Braun et al[19], 2008Non-randomized, placebo-controlled study18 healthy subjects2000 mg/dVO2peak↓, peak heart rate↓, peak ventilation↓, peak respiratory exchange ratio↓, exercise duration↓
Age: 27.9 ± 3.3 yrTreadmill or cycle ergometerRating of perceived exertion→
Sex: 11 men and 7 women
BMI: 24.1 ± 3.6 kg/m2
Malin et al[20], 2010Non-randomized, double-blind, counterbalanced crossover study15 healthy and active subjects2000 mg/dVO2
Age: 25 ± 4.4 yrCycle exercise at 5 submaximal cycle workloadsDuring exercise: Fat oxidation↑
Sex: 7 men and 8 womenPostexercise: Fat oxidation↓
BMI: 22.8 ± 2.7 kg/m2
Learsi et al[21], 2015Randomized, placebo-controlled, counterbalanced study10 healthy men500 mg/dVO2→, maximal accumulated oxygen deficit→, lactate concentrations→
Age: 23.5 ± 3.6 yrCycle ergometer: An incremental test, 6 submaximal workload test at 40%–90% VO2max, 2 supramaximal tests at 110% VO2maxTime to exhaustion↑, VO2 recovery↑
Sex: All men
BMI: No description (height: 170.4 ± 4.8 cm, weight: 66.4 ± 6.5 kg)

Two clinical studies have investigated metformin and cardiorespiratory fitness in individuals with insulin resistance and metabolic syndrome. Cadeddu et al[25] investigated the effect of metformin, exercise alone, or a combination of metformin and exercise on exercise capacity. Study participants had impaired glucose tolerance and/or impaired fasting glucose and were allocated to one of the three groups. The exercise program comprised 30–50 min cycle ergometry with an intensity of 60%–80% of heart rate reserve based on the age of the subjects. After a 12-wk intervention, the exercise only group had improved VO2peak, whereas the metformin plus exercise therapy group did not. Moreover, metformin plus exercise therapy did not show an improved aerobic threshold compared with the exercise along group. The combination of metformin and exercise was not superior to exercise alone with regard to cardiorespiratory fitness. A recent study in India showed a negative effect of metformin on exercise capacity in patients with newly diagnosed metabolic syndrome[25]. This study was a simple observational study to evaluate changes in VO2, ventilatory anaerobic threshold, and other indicators of cardiorespiratory fitness in response to metformin treatment for 6 wk, and showed that VO2 max decreased from 1.10 ± 0.44 to 0.9 ± 0.39 L/min and ventilatory anaerobic threshold decreased by 1.5 mL/min per kilogram. However, these studies were non-randomized, non-controlled observational studies, and thus, the study design was suboptimal (Table 2).

Table 2 Effects of metformin on cardiorespiratory fitness in patients with type 2 diabetes and metabolic syndrome.
Ref.Study designSubjectsMetformin dose and interventionResults
Boulé et al[22], 2011Randomized, placebo-controlled, crossover study10 patients with type 2 diabetes2000 mg/dVO2→, respiratory exchange ratio↓
Age: 58 ± 6 yrExercise mode: Treadmill at three different submaximal intensitiesHeart rate↑, lactate↑, rating of perceived exertion↑
Sex: 8 men and 2 womenStudy duration: 22 wk
BMI: 28.6 ± 5.3 kg/m2
HbA1c: 6.5 ± 0.6%
Boulé et al[23], 2013Randomized controlled trial (Diabetes Aerobic and Resistance Exercise) trial251 patients with type 2 diabetes (143 patients treated with metformin and 82 patients treated without metformin)Approximately 1600 mg/dVO2peak
Age: 54.9 ± 7.1 yr vs 53.1 ± 6.9 yrExercise mode: Aerobic training, resistance training, and combined aerobic and resistance training
Sex (Men/Women): 100/43 vs 46/36Study duration: 4 wk
BMI: 33.3 ± 5.5 kg/m2 vs 33.3 ± 6.4 kg/m2
Cadeddu et al[25], 2014Non-randomized, non-controlled trialHbA1c: 7.78 ± 0.9% vs 7.47 ± 0.77%1000 mg/dVO2peak
75 patients with insulin resistance30–50 min of cycle exercise at the intensity of 60%–80% of the heart rate reserve
Age: 46.2 ± 11 yr
Sex: 35 men and 40 womenStudy duration: 12 wk
Paul et al[26], 2017Prospective observational studyBMI: 29.8 ± 4.1 kg/m21000 mg/dVO2max
15 patients with metabolic syndromeNo intervention
Age: No descriptionStudy duration: 6 wk
Sex: No description
BMI: No description (weight: 75.4 ± 12.08 kg)

Metformin improves energy metabolism in skeletal muscle and has a cardioprotective effect via AMPK activation[27]. Metformin also inhibits mitochondrial respiratory-chain complex 1 and decreases ATP production[27], which could potentially reduce oxygen consumption during exercise. In addition, metformin increases lactate concentrations and reduces the lactate threshold during exercise[28]; however, lactate accumulation may have a protective effective on skeletal muscle rather than cause fatigue[29]. Previous studies have suggested that the effect of metformin on cardiorespiratory fitness is clinically subtle. However, treatment with metformin does not appear to have a synergetic effect on cardiorespiratory fitness in combination with exercise therapy.


The mechanism of action of thiazolidinediones is mediated by peroxisome proliferator-activated receptors (PPARs)[30]. Thiazolidinediones exert an insulin-sensitizing effect by promoting fatty acid uptake and modulation of secretion of adipokines, such as interleulin-6, tumor necrosis factor-α, and adiponectin[31]. PPAR-γ overactivation by thiazolidinediones increases body weight via fluid retention[30] and stimulatory effect on adipogenesis and adipose tissue accumulation[32]; thus, thiazolidinediones may be associated with increased cardiovascular risk in some patients. However, these drugs appear to improve cardiorespiratory fitness in patients with T2D.

In 2005, a randomized, double-blind, placebo-controlled study reported that rosiglitazone, a thiazolidinedione, improved exercise capacity via improvement in endothelial function in patients with T2D[33]. Twenty patients were divided into rosiglitazone (4 mg/d) and placebo groups. After a 4-mo intervention, VO2 max increased from 1902 ± 603 mL/min (19.8 ± 5.3 mL/kg per minute) to 2074 ± 585 mL/min (21.2 ± 5.1 mL/kg per minute) in rosiglitazone-treated patients, but showed no improvement in controls. In addition, the change in VO2 max negatively correlated with changes in fasting insulin and homeostasis model assessment of insulin resistance (HOMA-IR) was positively correlated with insulin sensitivity, as measured by hyperinsulinemic–euglycemic clamp. Thiazolidinediones may improve VO2 maxvia multiple mechanisms. First, thiazolidinediones enhance gene transcription that promotes adipocyte differentiation and increases fatty acid transport, synthesis, and storage in the adipose tissue by binding to PPARγ. This reduces ectopic fat accumulation in muscle and liver, and improves both cellular lipotoxicity and insulin sensitivity. Second, thiazolidinediones may also activate AMPK, which leads to increased fat oxidation and PPARγ coactivator 1α expression, regulating mitochondrial biogenesis[34]. Mitochondrial dysfunction in patients with T2D is attenuated by thiazolidinediones[35], which may result in an improvement in cardiorespiratory fitness.

Another randomized controlled study investigating the effect of rosiglitazone on cardiorespiratory fitness in patients with T2D was conducted in Greece[36]. Seventy patients (28 men and 42 women) with T2D were randomly assigned to a rosiglitazone (8 mg/d) treatment group or a control group. Rosiglitazone treatment for 6 mo increased VO2peak from 24.47 ± 3.98 to 26.39 ± 4.04 mL/kg per minute. Changes in adiponectin, HOMA-IR, and HbA1c levels were independent predictors of incremental increase in VO2peak. Rosiglitazone, a PPARγ activator, may improve cardiorespiratory fitness via upregulation of adiponectin. Recently, Yokota et al[37] showed that pioglitazone improves cardiorespiratory fitness in Japanese patients with metabolic syndrome. Fourteen male patients with metabolic syndrome received 15 mg/d of pioglitazone for four months. Pioglitazone increased VO2peak from 25.1 ± 4.9 to 27.2 ± 3.9 mL/kg per minute, and the anaerobic threshold from 12.7 ± 1.9 to 13.6 ± 0.6 mL/kg per minute. Pioglitazone also decreased the intramyocellular lipid content in resting calf muscle by 26%, with no concurrent change in the cross-sectional area of the muscle. There was an inverse correlation between the increase in anaerobic threshold and the decrease in intramyocellular lipid content. These data suggest that pioglitazone improves cardiorespiratory fitness via skeletal muscle fatty acid metabolism. In addition, pioglitazone decreased muscle phosphocreatinine loss during exercise, suggesting that altered mitochondrial function contributes to the improvement in skeletal muscle energy metabolism. Taken together, these studies indicate that thiazolidinediones have a beneficial effect on cardiorespiratory fitness in patients with T2D and metabolic syndrome (Table 3).

Table 3 Effects of thiazolidinediones on cardiorespiratory fitness in patients with type 2 diabetes and metabolic syndrome.
Ref.Study designSubjectsThiazolidinedione doseResults
Regensteiner et al[33], 2005Randomized controlled trial20 patients with type 2 diabetes (10 patients received rosiglitazone and 10 patients received a placebo)Rosiglitazone, 4 mg/dVO2↑, insulin sensitivity↑, endothelial function↑
Age: 55 ± 7 yr vs 56 ± 1 yr
Sex (Men/Women): 5/5 vs 5/5
BMI: 32.2 ± 5.6 kg/m2vs 30.4 ± 5.8 kg/m2
HbA1c: 7.2 ± 1.1% vs 7.2 ± 1.0%
Kadoglou et al[36], 2008Randomized controlled trial70 patients with type 2 diabetes (35 patients received rosiglitazone and 35 patients received a placebo)Rosiglitazone, 8 mg/dVO2peak↑, duration of the exercise test↑, oxygen pulse↑
Age: 63.8 ± 7.3 yr vs 66.7 ± 9.6 yrInsulin resistance↓, diastolic blood pressure↓
Sex (Men/Women): 14/21 vs 16/19
BMI: 29.5 ± 3.8 kg/m2vs 29.9 ± 4.3 kg/m2
HbA1c: 8.2 ± 1.2% vs 8 ± 0.8%
Yokota et al[37], 2017Before-after study14 patients with metabolic syndromePioglitazone, 15 mg/dVO2peak↑, anaerobic threshold↑
Age: 52 ± 11 yrIntramyocellular lipid content↓, muscle phosphocreatinine loss during exercise↓
Sex: All men
BMI: 26.6 ± 3.3 kg/m2
HbA1c: 5.7 ± 0.6%

GLP-1 is secreted by the intestine and has multiple physiological effects, including brain neuroprotection, suppressing appetite, cardiovascular protection, improving cardiac function, slowing gastric emptying, decreasing glucose production in the liver, increasing glucose uptake in adipose tissue and skeletal muscle, stimulating insulin secretion, suppressing glucagon secretion, promoting pancreatic β-cell proliferation, and inhibiting pancreatic β-cell apoptosis[38]. Secretion and function of GLP-1 is severely diminished in patients with T2D, and GLP-1 receptor agonists effectively improve diabetes and obesity via pleiotropic effects. Additionally, there could be an interaction between exercise and GLP-1 in patients with T2D[39]. The effect of GLP-1 receptor agonists on exercise capacity/cardiorespiratory fitness remains controversial. Lepore et al[40] investigated whether albiglutide, a long-acting GLP-1 receptor agonist, improved cardiac function and exercise performance in patients with chronic heart failure. Eighty-one patients participated in this multicenter, randomized, placebo-controlled study, and received either 30 mg of albiglutide or placebo for 12 wk. The albiglutide group showed improved VO2peak (from 16.2 ± 0.9 to 17.1 ± 1 mL/kg per minute), an increase of 1.5 mL/min per kilogram compared with the placebo group. However, no significant improvement in cardiac function, 6-min walk test, myocardial glucose, and oxygen use was observed. The authors stated that the improvement in cardiorespiratory fitness may have been mediated by a physiological effect rather than cardiac function due to the administration of albiglutide. Scalzo et al[41] investigated the effect of exenatide on functional exercise capacity in patients with T2D after 3-mo treatment of 10 μg twice-daily exenatide. Exenatide did not improve VO2peak or endothelial function, but diastolic cardiac function and arterial stiffness improved.

The controversial results from these studies may be attributed to patient characteristics. One study was conducted using patients with chronic heart failure (without diabetes) and the other used patients with mild T2D (without heart failure). Although the underlying mechanisms are unknown, the baseline cardiac function may have influenced the change in cardiorespiratory fitness due to the GLP-1 receptor agonist treatment.

A randomized, placebo-controlled, double-blind, parallel group, phase IV trial which aims at examining the effect of liraglutide on physical performance in patients with T2D is currently underway[42], with promising results.

To the best of our knowledge, to date, no human studies have reported the effect of DPP-4 inhibitors on exercise capacity/cardiorespiratory fitness. However, one animal study suggested that exercise capacity and mitochondrial biogenesis in skeletal muscle are improved by the administration of a DPP-4 inhibitor in mice with heart failure[43]. DPP-4 inhibitors may also have the potential to improve exercise capacity/cardiorespiratory fitness in humans.


SGLT2 inhibitors decrease glucose reabsorption at the proximal renal tubules, which increases urinary glucose excretion and improves glycemic control. SGLT2 inhibitors also exert various metabolic effects, including weight loss, insulin sensitivity improvement, blood pressure lowering, renal hemodynamic modulation, and reduction in albuminuria, which leads to cardiovascular and renal protection[44]. Treatment using empagliflozin resulted in a 35% risk reduction in hospitalization for heart failure compared with placebo[9], suggesting that SGLT2 inhibitors also have an effect on cardiorespiratory fitness in patients with T2D.

To date, two pilot studies have investigated whether empagliflozin improves cardiorespiratory fitness in patients with T2D with heart failure. Núñez et al[45] showed that short-term (4 wk) empagliflozin treatment increased VO2peak by 1.21 mL/kg per minute (11.1%) from baseline. Conversely, Carbone et al[46] showed that empagliflozin treatment for 4 wk did not significantly improve VO2peak (14.5 mL/kg vs 15.8 mL/kg per minute). Intriguingly, patients concomitantly treated with loop diuretics demonstrated improved VO2peak (+0.9 mL/kg per minute), whereas those without loop diuretics demonstrated a decrease in VO2peak (−0.9 mL/kg per minute). Indeed, all patients in the study by Núñez et al[45] received loop diuretics. The authors hypothesized that empagliflozin acts on the proximal renal tubules by interacting with sodium/hydrogen exchangers, thereby increasing sodium delivery at the distal renal tubules and enhancing the effect of loop diuretics[47,48]. Carbone et al[46] also speculated that empagliflozin improves cardiorespiratory fitness in patients concomitantly treated with loop diuretics by reducing the activity of the rennin–angiotensin–aldosterone system. Empagliflozin may exert cardiovascular and renal benefits via changes in myocardial and renal energy metabolism. Empagliflozin increases ketone oxidation instead of fat and glucose oxidation, which can improve cardiac and renal work efficiency[49]. Taken together, these studies suggest that SGLT2 inhibitors improve cardiorespiratory fitness in patients with T2D with heart failure (Table 4).

Table 4 Effects of sodium–glucose cotransporter 2 inihibitors on cardiorespiratory fitness in patients with type 2 diabetes.
Ref.Study designSubjectsSGLT2 inhibitors doseResults
Núñez et al[45], 2017Before-after study19 patients with type 2 diabetes and heart failureEmpagliflozin, 10 mg/dVO2peak↑, ventilatory efficiency during exercise↑, 6-minute walking distance↑, ↓antigen carbohydrate 125
Age (median): 72 yr
Sex: 14 men and 5 women
BMI: 30.6 ± 5.5 kg/m2
HbA1c: No description
Carbone et al[46], 2018Before-after study15 patients with type 2 diabetes and heart failureEmpagliflozin, 10 mg/dVO2peak↑ in patients using loop diuretics
Age (median): 60 yrVO2peak↓ in patients without loop diuretics
Sex: 7 men and 8 women
BMI (median): 34 kg/m2
HbA1c (median): 7.8%

Metformin does not improve cardiorespiratory fitness and may attenuate a beneficial effect of exercise on cardiorespiratory fitness in patients with T2D. In contrast, thiazolidinediones appear to improve cardiorespiratory fitness in patients with T2D. The effect of GLP-1 receptor agonists on cardiorespiratory fitness remains controversial and is not fully understood. Notably, SGLT2 inhibitors may improve cardiorespiratory fitness in patients with heart failure by modulating cardiac energy metabolism or via a synergetic effect with loop diuretics. Unfortunately, no human studies have examined the effect of DPP-4 inhibitors, sulfonylureas, glinides, or α-glucosidase inhibitors on cardiorespiratory fitness (Table 5). This review cannot recommend the optimal combination of exercise and glucose-lowering agents with regard to cardiorespiratory fitness in patients with T2D; however, thiazolidinediones, GLP-1 receptor agonists, and SGLT2 inhibitors have the potential to improve both glycemic control and cardiorespiratory fitness without interfering with exercise therapy. Further studies are warranted to demonstrate the clinical benefits of glucose-lowering agents for cardiorespiratory fitness, and to elucidate the underlying mechanisms of action.

Table 5 Effect of glucose-lowering agents on cardiorespiratory fitness.
Glucose-lowering agentsCardiorespiratory fitness
Metformin→ or ↓
DPP-4 inhibitorsUnknown
(↑ in mice with heart failure)
GLP-1 receptor agonists↑ in patients with heart failure
→ in patients with type 2 diabetes
SGLT2 inhibitors↑ in patients treated with loop diuretics

Manuscript source: Invited manuscript

Specialty type: Endocrinology and metabolism

Country of origin: Japan

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1.  Chatterjee S, Khunti K, Davies MJ. Type 2 diabetes. Lancet. 2017;389:2239-2251.  [PubMed]  [DOI]
2.  American Diabetes Association. 4. Lifestyle Management: Standards of Medical Care in Diabetes-2018. Diabetes Care. 2018;41:S38-S50.  [PubMed]  [DOI]
3.  Kyu HH, Bachman VF, Alexander LT, Mumford JE, Afshin A, Estep K, Veerman JL, Delwiche K, Iannarone ML, Moyer ML. Physical activity and risk of breast cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke events: systematic review and dose-response meta-analysis for the Global Burden of Disease Study 2013. BMJ. 2016;354:i3857.  [PubMed]  [DOI]
4.  American College of Sports Medicine. Exercise is Medicine®: A Global Health Initiative.  Available from:  [PubMed]  [DOI]
5.  Fagour C, Gonzalez C, Pezzino S, Florenty S, Rosette-Narece M, Gin H, Rigalleau V. Low physical activity in patients with type 2 diabetes: the role of obesity. Diabetes Metab. 2013;39:85-87.  [PubMed]  [DOI]
6.  Park SW, Goodpaster BH, Lee JS, Kuller LH, Boudreau R, de Rekeneire N, Harris TB, Kritchevsky S, Tylavsky FA, Nevitt M. Excessive loss of skeletal muscle mass in older adults with type 2 diabetes. Diabetes Care. 2009;32:1993-1997.  [PubMed]  [DOI]
7.  Ozdirenç M, Biberoğlu S, Ozcan A. Evaluation of physical fitness in patients with Type 2 diabetes mellitus. Diabetes Res Clin Pract. 2003;60:171-176.  [PubMed]  [DOI]
8.  Anabtawi A, Miles JM. Metformin: nonglycemic effects and potential novel indications. Endocr Pract. 2016;22:999-1007.  [PubMed]  [DOI]
9.  Zinman B, Wanner C, Lachin JM, Fitchett D, Bluhmki E, Hantel S, Mattheus M, Devins T, Johansen OE, Woerle HJ. Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes. N Engl J Med. 2015;373:2117-2128.  [PubMed]  [DOI]
10.  Neal B, Perkovic V, Mahaffey KW, de Zeeuw D, Fulcher G, Erondu N, Shaw W, Law G, Desai M, Matthews DR; CANVAS Program Collaborative Group. Canagliflozin and Cardiovascular and Renal Events in Type 2 Diabetes. N Engl J Med. 2017;377:644-657.  [PubMed]  [DOI]
11.  Marso SP, Daniels GH, Brown-Frandsen K, Kristensen P, Mann JF, Nauck MA, Nissen SE, Pocock S, Poulter NR, Ravn LS. Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med. 2016;375:311-322.  [PubMed]  [DOI]
12.  American Diabetes Association. 8. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes-2018. Diabetes Care. 2018;41:S73-S85.  [PubMed]  [DOI]
13.  Alves AJ, Viana JL, Cavalcante SL, Oliveira NL, Duarte JA, Mota J, Oliveira J, Ribeiro F. Physical activity in primary and secondary prevention of cardiovascular disease: Overview updated. World J Cardiol. 2016;8:575-583.  [PubMed]  [DOI]
14.  Kodama S, Saito K, Tanaka S, Maki M, Yachi Y, Asumi M, Sugawara A, Totsuka K, Shimano H, Ohashi Y. Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: a meta-analysis. JAMA. 2009;301:2024-2035.  [PubMed]  [DOI]
15.  Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352:854-865.  [PubMed]  [DOI]
16.  Rena G, Hardie DG, Pearson ER. The mechanisms of action of metformin. Diabetologia. 2017;60:1577-1585.  [PubMed]  [DOI]
17.  Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, Peters AL, Tsapas A, Wender R, Matthews DR; American Diabetes Association (ADA); European Association for the Study of Diabetes (EASD). Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012;35:1364-1379.  [PubMed]  [DOI]
18.  Johnson ST, Robert C, Bell GJ, Bell RC, Lewanczuk RZ, Boulé NG. Acute effect of metformin on exercise capacity in active males. Diabetes Obes Metab. 2008;10:747-754.  [PubMed]  [DOI]
19.  Braun B, Eze P, Stephens BR, Hagobian TA, Sharoff CG, Chipkin SR, Goldstein B. Impact of metformin on peak aerobic capacity. Appl Physiol Nutr Metab. 2008;33:61-67.  [PubMed]  [DOI]
20.  Malin SK, Stephens BR, Sharoff CG, Hagobian TA, Chipkin SR, Braun B. Metformin’s effect on exercise and postexercise substrate oxidation. Int J Sport Nutr Exerc Metab. 2010;20:63-71.  [PubMed]  [DOI]
21.  Learsi SK, Bastos-Silva VJ, Lima-Silva AE, Bertuzzi R, De Araujo GG. Metformin improves performance in high-intensity exercise, but not anaerobic capacity in healthy male subjects. Clin Exp Pharmacol Physiol. 2015;42:1025-1029.  [PubMed]  [DOI]
22.  Boulé NG, Robert C, Bell GJ, Johnson ST, Bell RC, Lewanczuk RZ, Gabr RQ, Brocks DR. Metformin and exercise in type 2 diabetes: examining treatment modality interactions. Diabetes Care. 2011;34:1469-1474.  [PubMed]  [DOI]
23.  Boulé NG, Kenny GP, Larose J, Khandwala F, Kuzik N, Sigal RJ. Does metformin modify the effect on glycaemic control of aerobic exercise, resistance exercise or both? Diabetologia. 2013;56:2378-2382.  [PubMed]  [DOI]
24.  Sigal RJ, Kenny GP, Boulé NG, Wells GA, Prud’homme D, Fortier M, Reid RD, Tulloch H, Coyle D, Phillips P. Effects of aerobic training, resistance training, or both on glycemic control in type 2 diabetes: a randomized trial. Ann Intern Med. 2007;147:357-369.  [PubMed]  [DOI]
25.  Cadeddu C, Nocco S, Cugusi L, Deidda M, Bina A, Fabio O, Bandinu S, Cossu E, Baroni MG, Mercuro G. Effects of metformin and exercise training, alone or in association, on cardio-pulmonary performance and quality of life in insulin resistance patients. Cardiovasc Diabetol. 2014;13:93.  [PubMed]  [DOI]
26.  Paul AA, Dkhar SA, Kamalanathan S, Thabah MM, George M, Chandrasekaran I, Gunaseelan V, Selvarajan S. Effect of metformin on exercise capacity in metabolic syndrome. Diabetes Metab Syndr. 2017;11 Suppl 1:S403-S406.  [PubMed]  [DOI]
27.  Foretz M, Guigas B, Bertrand L, Pollak M, Viollet B. Metformin: from mechanisms of action to therapies. Cell Metab. 2014;20:953-966.  [PubMed]  [DOI]
28.  DeFronzo R, Fleming GA, Chen K, Bicsak TA. Metformin-associated lactic acidosis: Current perspectives on causes and risk. Metabolism. 2016;65:20-29.  [PubMed]  [DOI]
29.  Lindinger MI. Combating muscle fatigue: extracellular lactic acidosis and catecholamines. J Physiol. 2007;581:419.  [PubMed]  [DOI]
30.  Nanjan MJ, Mohammed M, Prashantha Kumar BR, Chandrasekar MJN. Thiazolidinediones as antidiabetic agents: A critical review. Bioorg Chem. 2018;77:548-567.  [PubMed]  [DOI]
31.  Lehrke M, Lazar MA. The many faces of PPARgamma. Cell. 2005;123:993-999.  [PubMed]  [DOI]
32.  Hauner H. The mode of action of thiazolidinediones. Diabetes Metab Res Rev. 2002;18 Suppl 2:S10-S15.  [PubMed]  [DOI]
33.  Regensteiner JG, Bauer TA, Reusch JE. Rosiglitazone improves exercise capacity in individuals with type 2 diabetes. Diabetes Care. 2005;28:2877-2883.  [PubMed]  [DOI]
34.  LeBrasseur NK, Ruderman NB. Why might thiazolidinediones increase exercise capacity in patients with type 2 diabetes? Diabetes Care. 2005;28:2975-2977.  [PubMed]  [DOI]
35.  Colca JR, McDonald WG, Kletzien RF. Mitochondrial target of thiazolidinediones. Diabetes Obes Metab. 2014;16:1048-1054.  [PubMed]  [DOI]
36.  Kadoglou NP, Iliadis F, Angelopoulou N, Perrea D, Liapis CD, Alevizos M. Beneficial effects of rosiglitazone on novel cardiovascular risk factors in patients with Type 2 diabetes mellitus. Diabet Med. 2008;25:333-340.  [PubMed]  [DOI]
37.  Yokota T, Kinugawa S, Hirabayashi K, Suga T, Takada S, Omokawa M, Kadoguchi T, Takahashi M, Fukushima A, Matsushima S. Pioglitazone improves whole-body aerobic capacity and skeletal muscle energy metabolism in patients with metabolic syndrome. J Diabetes Investig. 2017;8:535-541.  [PubMed]  [DOI]
38.  Gallwitz B. Glucagon-like peptide-1 analogues for Type 2 diabetes mellitus: current and emerging agents. Drugs. 2011;71:1675-1688.  [PubMed]  [DOI]
39.  Hamasaki H. Exercise and glucagon-like peptide-1: Does exercise potentiate the effect of treatment? World J Diabetes. 2018;9:138-140.  [PubMed]  [DOI]
40.  Lepore JJ, Olson E, Demopoulos L, Haws T, Fang Z, Barbour AM, Fossler M, Davila-Roman VG, Russell SD, Gropler RJ. Effects of the Novel Long-Acting GLP-1 Agonist, Albiglutide, on Cardiac Function, Cardiac Metabolism, and Exercise Capacity in Patients With Chronic Heart Failure and Reduced Ejection Fraction. JACC Heart Fail. 2016;4:559-566.  [PubMed]  [DOI]
41.  Scalzo RL, Moreau KL, Ozemek C, Herlache L, McMillin S, Gilligan S, Huebschmann AG, Bauer TA, Dorosz J, Reusch JE. Exenatide improves diastolic function and attenuates arterial stiffness but does not alter exercise capacity in individuals with type 2 diabetes. J Diabetes Complications. 2017;31:449-455.  [PubMed]  [DOI]
42.  Wägner AM, Miranda-Calderín G, Ugarte-Lopetegui MA, Marrero-Santiago H, Suárez-Castellano L, Alberiche-Ruano MDP, Castillo-García N, López-Madrazo MJ, Alemán C, Martínez-Mancebo C. Effect of liraglutide on physical performance in type 2 diabetes (LIPER2): A randomised, double-blind, controlled trial. Contemp Clin Trials Commun. 2016;4:46-51.  [PubMed]  [DOI]
43.  Takada S, Masaki Y, Kinugawa S, Matsumoto J, Furihata T, Mizushima W, Kadoguchi T, Fukushima A, Homma T, Takahashi M. Dipeptidyl peptidase-4 inhibitor improved exercise capacity and mitochondrial biogenesis in mice with heart failure via activation of glucagon-like peptide-1 receptor signalling. Cardiovasc Res. 2016;111:338-347.  [PubMed]  [DOI]
44.  Heerspink HJ, Perkins BA, Fitchett DH, Husain M, Cherney DZ. Sodium Glucose Cotransporter 2 Inhibitors in the Treatment of Diabetes Mellitus: Cardiovascular and Kidney Effects, Potential Mechanisms, and Clinical Applications. Circulation. 2016;134:752-772.  [PubMed]  [DOI]
45.  Núñez J, Palau P, Domínguez E, Mollar A, Núñez E, Ramón JM, Miñana G, Santas E, Fácila L, Górriz JL. Early effects of empagliflozin on exercise tolerance in patients with heart failure: A pilot study. Clin Cardiol. 2018;41:476-480.  [PubMed]  [DOI]
46.  Carbone S, Canada JM, Billingsley HE, Kadariya D, Dixon DL, Trankle CR, Buckley LF, Markley R, Vo C, Medina de Chazal H. Effects of empagliflozin on cardiorespiratory fitness and significant interaction of loop diuretics. Diabetes Obes Metab. 2018;20:2014-2018.  [PubMed]  [DOI]
47.  Packer M, Anker SD, Butler J, Filippatos G, Zannad F. Effects of Sodium-Glucose Cotransporter 2 Inhibitors for the Treatment of Patients With Heart Failure: Proposal of a Novel Mechanism of Action. JAMA Cardiol. 2017;2:1025-1029.  [PubMed]  [DOI]
48.  Perrone-Filardi P, Avogaro A, Bonora E, Colivicchi F, Fioretto P, Maggioni AP, Sesti G, Ferrannini E. Mechanisms linking empagliflozin to cardiovascular and renal protection. Int J Cardiol. 2017;241:450-456.  [PubMed]  [DOI]
49.  Mudaliar S, Alloju S, Henry RR. Can a Shift in Fuel Energetics Explain the Beneficial Cardiorenal Outcomes in the EMPA-REG OUTCOME Study? A Unifying Hypothesis. Diabetes Care. 2016;39:1115-1122.  [PubMed]  [DOI]