Antioxidant effects of astaxanthin and metformin combined therapy in type 2 diabetes mellitus patients: a randomized double-blind controlled clinical trial

Nikoo Roustaei Rad , Ahmad Movahedian, Awat Feizi, Ashraf Aminorroaya, Mohammad Hosein Aarabi


Background and purpose: Since the critical role of oxidative stress in the pathogenesis and complications of type 2 diabetes mellitus (T2DM) has been proven, antioxidant therapy is considered an applicable strategy to control T2DM development. This study aimed at evaluating the effect of astaxanthin (AST) supplementation combined with metformin on oxidative indices and antioxidant defenses in T2DM patients.

Experimental approach: In this randomized, double-blind placebo-controlled trial, 50 T2DM subjects receiving metformin were supplemented with 10 mg/day AST or placebo for 12 weeks. Malondialdehyde concentration and serum total antioxidant capacity (TAC) were assessed as oxidative indices. We also evaluated NF-E2-related factor2 (Nrf2) as the most critical transcription factor of antioxidant defense. Moreover, the activity of antioxidant enzymes, superoxide dismutase (SOD), and catalase were calculated. 

Findings/Results: AST supplementation-metformin combination caused a significant increase in SOD and catalase activities, as well as inducing Nrf2 protein expression compared to the placebo group.

Significant changes in serum malondialdehyde and TAC between the AST group and placebo group after supplementation were not observed, although a significant increase was observed in TAC within the AST group after supplementation (32.67 ± 6.73) to before (25.86 ± 5.98). These results remained without change after adjustment for potential confounders. 

Conclusion and implications: Our study demonstrated that AST supplementation controlled oxidative stress through a synergistic effect with metformin and ameliorated overall antioxidant capacity by inducing Nrf2 transcription factor and activating SOD and catalase in T2DM patients. As a result, AST and metformin combination therapy can be considered beneficial in modifying oxidative stress and preventing T2DM complications. 


Astaxanthin; Malondialdehyde; Nrf2; Oxidative stress; Superoxide dismutase; T2DM.

Full Text:



Goharinia M, Zareei A, Rahimi M, Mirkhani H. Can allopurinol improve retinopathy in diabetic rats? Oxidative stress or uric acid; which one is the culprit? Res Pharm Sci. 2017;12(5):401-408.

DOI: 10.4103/1735-5362.213985.

Ursoniu S, Sahebkar A, Serban MC, Banach M. Lipid profile and glucose changes after supplementation with astaxanthin: a systematic review and meta-analysis of randomized controlled trials. Arch Med Sci. 2015;11(2):253-266.

DOI: 10.5114/aoms.2015.50960.

Bolignano D, Cernaro V, Gembillo G, Baggetta R, Buemi M, D’Arrigo G. Antioxidant agents for delaying diabetic kidney disease progression: a systematic review and meta-analysis. PLoS One. 2017;12(6):e0178699.

DOI: 10.1371/journal.pone.0178699.

Panahi Y, Khalili N, Sahebi E, Namazi S, Karimian MS, Majeed M, et al. Antioxidant effects of curcuminoids in patients with type 2 diabetes mellitus: a randomized controlled trial. Inflammopharmacology. 2017;25(1):25-31.

DOI: 10.1007/s10787-016-0301-4.

Gawlik K, Naskalski JW, Fedak D, Pawlica-Gosiewska D, Grudzień U, Dumnicka P, et al. Markers of antioxidant defense in patients with type 2 diabetes. Oxid Med Cell Longev. 2016;2016:2352361.

DOI: 10.1155/2016/2352361.

Samimi F, Baazm M, Eftekhar E, Rajabi S, Goodarzi MT, Jalali Mashayekhi F. Possible antioxidant mechanism of coenzyme Q10 in diabetes: impact on Sirt1/Nrf2 signaling pathways. Res Pharm Sci. 2019;14(6):524-533.

DOI: 10.4103/1735-5362.272561.

Wu P, Yan Y, Ma LL, Hou BY, He YY, Zhang L, et al. Effects of the Nrf2 protein modulator salvianolic acid A alone or combined with metformin on diabetes-associated macrovascular and renal injury. J Biol Chem. 2016;291(42):288-301.

DOI: 10.1074/jbc.M115.712703.

Behrouz V, Dastkhosh A, Hedayati M, Sedaghat M, Sharafkhah M, Sohrab G. The effect of crocin supplementation on glycemic control, insulin resistance and active AMPK levels in patients with type 2 diabetes: a pilot study. Diabetol Metab Syndr. 2020;12:59-67.

DOI: 10.1186/s13098-020-00568-6.

Giacco F, Brownlee M. Oxidative stress and diabetic complications. Circ Res. 2010;107(9):1058-1070.

PMID: 21030723.

Yaribeygi H, Sathyapalan T, Atkin SL, Sahebkar A. Molecular mechanisms linking oxidative stress and diabetes mellitus. Oxid Med Cell Longev. 2020;2020:8609213.

DOI: 10.1155/2020/8609213.

Zhang J, Ding C, Zhang S, Xu Y. Neuroprotective effects of astaxanthin against oxygen and glucose deprivation damage via the PI3K/Akt/GSK3β/Nrf2 signalling pathway in vitro. J Cell Mol Med. 2020;24(16):8977-8985.

DOI: 10.1111/jcmm.15531.

Jia Y, Wu C, Kim J, Kim B, Lee SJ. Astaxanthin reduces hepatic lipid accumulations in high-fat-fed C57BL/6J mice via activation of peroxisome proliferator-activated receptor (PPAR) alpha and inhibition of PPAR gamma and Akt. J Nutr Biochem. 2016;28:9-18.

DOI: 10.1016/j.jnutbio.2015.09.015.

Landon R, Gueguen V, Petite H, Letourneur D, Pavon-Djavid G, Anagnostou F. Impact of astaxanthin on diabetes pathogenesis and chronic complications. Mar Drugs. 2020;18(7):357-376.

DOI: 10.3390/md18070357.

Kogure K. Novel antioxidative activity of astaxanthin and its synergistic effect with vitamin E. J Nutr Sci Vitaminol (Tokyo). 2019;65(Supplement):109-112.

DOI: 10.3177/jnsv.65.S109.

Higuera-Ciapara I, Félix-Valenzuela L, Goycoolea FM. Astaxanthin: a review of its chemistry and applications. Crit Rev Food Sci Nutr. 2006;46(2):185-196.

DOI: 10.1080/10408690590957188.

Abdelsamia EM, Khaleel SA, Balah A, Abdel Baky NA. Curcumin augments the cardioprotective effect of metformin in an experimental model of type I diabetes mellitus; impact of Nrf2/HO-1 and JAK/STAT pathways. Biomed Pharmacother. 2019;109:2136-2144.

DOI: 10.1016/j.biopha.2018.11.064.

Apostolova N, Iannantuoni F, Gruevska A, Muntane J, Rocha M, Victor VM. Mechanisms of action of metformin in type 2 diabetes: effects on mitochondria and leukocyte-endothelium interactions. Redox Biol. 2020;34:101517.

DOI: 10.1016/j.redox.2020.101517.

Sadeghi H, Jahanbazi F, Sadeghi H, Omidifar N, Alipoor B, Kokhdan EP, et al. Metformin attenuates oxidative stress and liver damage after bile duct ligation in rats. Res Pharm Sci. 2019;14(2):122-129.

DOI: 10.4103/1735-5362.253359.

American Diabetes Association. 10. Cardiovascular disease and risk management: standards of medical care in diabetes-2021. Diabetes Care. 2021;44(Supplement_1):S125-S150.

DOI: 10.2337/dc21-S010.

Shokri-Mashhadi N, Tahmasebi M, Mohammadi-Asl J, Zakerkish M, Mohammadshahi M. The antioxidant and anti-inflammatory effects of astaxanthin supplementation on the expression of miR-146a and miR-126 in patients with type 2 diabetes mellitus: a randomised, double-blind, placebo-controlled clinical trial. Int J Clin Pract. 2021;75(5):e14022.

DOI: 10.1111/ijcp.14022.

Hadwan MH, Abed HN. Data supporting the spectrophotometric method for the estimation of catalase activity. Data Brief. 2015;6:194-199.

DOI: 10.1016/j.dib.2015.12.012.

Hou X, Song J, Li XN, Zhang L, Wang X, Chen L, et al. Metformin reduces intracellular reactive oxygen species levels by upregulating expression of the antioxidant thioredoxin via the AMPK-FOXO3 pathway. Biochem Biophys Res Commun. 2010;396(2):199-205.

DOI: 10.1016/j.bbrc.2010.04.017.

Miller NJ, Rice-Evans C, Davies MJ, Gopinathan V, Milner A. A novel method for measuring antioxidant capacity and its application to monitoring the antioxidant status in premature neonates. Clin Sci (Lond). 1993;84(4):407-412.

DOI: 10.1042/cs0840407.

Jabarpour M, Siavashi V, Asadian S, Babaei H, Jafari SM, Nassiri SM. Hyperbilirubinemia-induced pro-angiogenic activity of infantile endothelial progenitor cells. Microvasc Res. 2018;118:49-56.

DOI: 10.1016/j.mvr.2018.02.005.

Bajaj S, Khan A. Antioxidants and diabetes. Indian J Endocrinol Metab. 2012;16(Suppl 2):S267-S271.

DOI: 10.4103/2230-8210.104057.

Dehkordi AH, Abbaszadeh A, Mir S, Hasanvand A. Metformin and its anti-inflammatory and anti-oxidative effects; new concepts. J Renal Inj Prev. 2018;8(1):54-61.

DOI: 10.15171/jrip.2019.11.

Esteghamati A, Eskandari D, Mirmiranpour H, Noshad S, Mousavizadeh M, Hedayati M, 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. Clin Nutr. 2013;32(2):179-185.

DOI: 10.1016/j.clnu.2012.08.006.

Bruckbauer A, Zemel MB. Synergistic effects of metformin, resveratrol, and hydroxymethylbutyrate on insulin sensitivity. Diabetes Metab Syndr Obes. 2013;6:93-102.

DOI: 10.2147/DMSO.S40840.

Kohandel Z, Farkhondeh T, Aschner M, Samarghandian S. Nrf2 a molecular therapeutic target for astaxanthin. Biomed Pharmacother. 2021;137:111374.

DOI: 10.1016/j.biopha.2021.111374.

Lin CW, Yang CM, Yang CH. Protective effect of astaxanthin on blue light light-emitting diode-induced retinal cell damage via free radical scavenging and activation of PI3K/Akt/Nrf2 pathway in 661W cell model. Mar Drugs. 2020;18(8):387-402.

DOI: 10.3390/md18080387.

Negi CK, Jena G. Nrf2, a novel molecular target to reduce type 1 diabetes associated secondary complications: the basic considerations. Eur J Pharmacol. 2019;843:12-26.

DOI: 10.1016/j.ejphar.2018.10.026.

Naito Y, Uchiyama K, Aoi W, Hasegawa G, Nakamura N, Yoshida N, et al. Prevention of diabetic nephropathy by treatment with astaxanthin in diabetic db/db mice. Biofactors. 2004;20(1):49-59.

DOI: 10.1002/biof.5520200105.

Manabe E, Handa O, Naito Y, Mizushima K, Akagiri S, Adachi S, et al. Astaxanthin protects mesangial cells from hyperglycemia-induced oxidative signaling. J Cell Biochem. 2008;103(6):1925-1937.

DOI: 10.1002/jcb.21583.

Ranga Rao A, Sarada R, Shylaja MD, Ravishankar GA. Evaluation of hepatoprotective and antioxidant activity of astaxanthin and astaxanthin esters from microalga-Haematococcus pluvialis. J Food Sci Technol. 2015;52(10):6703-6710.

DOI: 10.1007/s13197-015-1775-6.

El-Baz FK, Salama A, Ali SI, Elgohary R. Haematococcus pluvialis carotenoids enrich fractions ameliorate liver fibrosis induced by thioacetamide in rats: modulation of metalloproteinase and its inhibitor. Biomed Res Int. 2021;2021:1-16.

DOI: 10.1155/2021/6631415.

American Diabetes Association. Cardiovascular disease and risk management: standards of medical care in diabetes-2021. Diabetes Care. 2021;44(Suppl 1):S125-S150.

DOI: 10.2337/dc21-S010.

Yoshida H, Yanai H, Ito K, Tomono Y, Koikeda T, Tsukahara H, et al. Administration of natural astaxanthin increases serum HDL-cholesterol and adiponectin in subjects with mild hyperlipidemia. Atherosclerosis. 2010;209(2): 520-523.

DOI: 10.1016/j.atherosclerosis.2009.10.012.

Augusti PR, Quatrin A, Somacal S, Conterato GM, Sobieski R, Ruviaro AR, et al. Astaxanthin prevents changes in the activities of thioredoxin reductase and paraoxonase in hypercholesterolemic rabbits. J Clin Biochem Nutr. 2012;51(1):42-49.

DOI: 10.3164/jcbn.11-74.


  • There are currently no refbacks.

Creative Commons LicenseThis work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly.