Metformin, which is used primarily as an anti-diabetic therapeutic, has recently been studied largely in many other diseases, including those of in the brain and the bones. Given the role of diabetes in the development of age-related cognitive decline, many anti-diabetic medications, especially metformin, recently have been tested for their efficacy on cognitive improvement [
71]. In a longitudinal follow-up study in diabetic patients, long-term use of metformin was found to decrease the risk of developing cognitive decline [
72]. Similarly, in the Diabetes Prevention Program (DPP), metformin-treated subjects were found to be at lower risk of developing cognitive malfunction compared to the placebo group. Moreover, the treatment was also found to be cognitively safe, which was, however, found otherwise in other studies [
73]. In animal models of cognitive impairments and dementia, metformin has been shown to be fruitful through a number of factors. For example, in a recent study on mice, metformin was shown to alleviate spatial memory loss through an enhanced number of post-mitotic NeuN
+ neurons (
i.e. enhanced neurogenesis) [
74]. Another study showed that metformin, either alone or in combination with ursolic acid, ameliorated stress-induced changes in behavioral changes, accompanied with insulin sensitivity, inflammatory and oxidative changes in mice [
75]. Interestingly, metformin has also been implicated to be beneficial in PD-related mouse model [
76]. Insulin sensitivity, which is an important factor in regulation of cognition, can be increased by higher OCN level in clinical diabetic patients [
77,
78]. Now the question remains whether there could be a putative link between such beneficial effects of metformin and OCN signaling in cognition. Interestingly, OCN and its related bone diseases have been shown to be affected by metformin.
Liu et al.
(2018) found that in a model of ketogenic diet-induced osteoporosis, metformin could attenuate bone loss which correlated with increased level of OCN [
79]. The drug has also been shown to improve osteogenic functions of adipose-derived stromal cells, which show increased bone regeneration capability through increasing expression of OCN,
via a mechanism related to AMPK [
80], which is a well known regulator of brain energy metabolism [
81] that regulates both cognition and motor coordination [
82]. AMPK is known to inhibit NF-κB signaling and inflammation [
83], which are related to cognitive and motor impairments, as discussed already before. Moreover, it is of an interesting note that metformin is effective in regulation of behavior through the upregulation of BDNF [
76,
84], a brain neurotrophic factor that is related to the beneficial actions of OCN in age-related memory loss [
11,
12]. These findings suggest that there might be a putative link between metformin therapy and brain functions wherein OCN may act as a facilitator of the improved cognitive functions by metformin through improvement of neurotrophic signaling and energy metabolism, and through modulation of inflammatory reactions (Fig.
2). However, it should be noted that metformin therapy has also been found to be adverse or ineffective for cognitive functions [
85] as well as for the regulation of OCN levels [
86]. Therefore, more studies with acute and chronic treatment of the drug in models of cognitive loss and/or its relation with OCN would be needed to understand the role of metformin on OCN/cognition regulatory axis.