CYP2C19 and their relationship with clinical efficacy have not included South Asian populations.Cytochrome P450 family 2 subfamily C member 19 (CYP2C19) is a hepatic enzyme involved in the metabolism of clopidogrel from a prodrug to its active metabolite. Prior studies of genetic polymorphisms in CYP2C19 genotype polymorphisms in a British–South Asian population and correlate these with recurrent myocardial infarction risk in participants prescribed clopidogrel.The objective of this study was to assess prevalence of common CYP2C19 diplotypes were assessed using array data. Multivariable logistic regression was used to test for association between genetically inferred CYP2C19 metabolizer status and recurrent myocardial infarction, controlling for known cardiovascular disease risk factors, percutaneous coronary intervention, age, sex, and population stratification.The Genes & Health cohort of British Bangladeshi and Pakistani ancestry participants were studied. CYP2C19 allele. The prevalence of poor metabolizers carrying 2 CYP2C19 loss-of-function alleles is 13%, which is higher than that in previously studied European (2.4%) and Central/South Asian populations (8.2%). Sixty-nine percent of the cohort who were diagnosed with an acute myocardial infarction were prescribed clopidogrel. Poor metabolizers were significantly more likely to have a recurrent myocardial infarction .Genes & Health cohort participants  have a high prevalence (57%) of intermediate or poor CYP2C19 metabolizers, with at least 1 loss-of-function A pharmacogenomic-driven approach to clopidogrel prescribing has the potential to impact significantly on clinical management and outcomes in individuals of Bangladeshi and Pakistani ancestry.  Pharmacogenomics (PGx) explores how genetic variants contribute to interindividual variation in medication response.CYP2C19 gene that codes for the enzyme is highly polymorphic. Three key single nucleotide polymorphisms (SNPs) are referred to as ∗2, ∗3, and ∗17.,,Cytochrome P450 family 2 subfamily C member 19 (CYP2C19) is a hepatic enzyme crucial to the 2-stage sequential oxidation of clopidogrel (inactive prodrug) to the active metabolite.,Clopidogrel is an P2Y12-inhibiting antiplatelet medication licensed to treat acute coronary syndrome (ACS), stroke, and peripheral vascular disease.,CYP2C19 testing in clinical care in the United Kingdom’s (UK) National Health Service (NHS), but this is likely to change as the National Institute for Health and Care Excellence recommends testing in the context of ischemic stroke.Regulatory bodies and PGx consortia have given disparate guidance. The U.S. Food and Drug Administration recommends considering an alternate drug in PMs, while the European Medicines Agency merely discourages the co-use of CYP2C19 inhibiting drugs with clopidogrel.,,CYP2C19 genotypes in a British–South Asian ancestry cohort and to correlate inferred metabolizer phenotypes with recurrent myocardial infarction (MI) events in participants prescribed clopidogrel.South Asian populations represents almost 25% of the world’s population and 9% of the United Kingdom.The Genes & Health (G&H) resource was accessed after approval by the G&H Access Review Committee. G&H is a UK cohort study, including those of Bangladeshi and Pakistani ancestry.The ∗2 SNP was imputed, and the imputation quality was very high as assessed by imputation quality metric  score (0.99). The ∗3 allele and ∗17 allele were genotyped. imputation quality score, minor allele frequency (MAF), Hardy-Weinberg equilibrium (HWE), and missingness for these 3 SNPs are shown in CYP2C19∗2, CYP2C19∗3 and CYP2C19∗17 SNPs influencing CYP2C19 enzymatic function were ascertained. SNPs were extracted from the data set using PLINK 2.0.,Prevalence of the well-validated PGx Subsequent analysis was done using Rstudio.Curated data sets from G&H were used for clinical phenotypes including acute MI , subsequent MI (ICD-10 I22), Diabetes (DM) , dyslipidemia (ICD-10 code E78), obesity (ICD-10 code E66), chronic kidney disease (ICD-10 code N18), and hypertension (ICD-10 code I10). These phenotypes were defined using ICD-10 codes, SNOMED codes, and Office of Population Censuses and Surveys codes from linkage with electronic health records, including Barts Health, NHS digital, Bradford teaching hospitals, and primary care clinical commissioning groups (CCGs). Participating CCGs included Barking, Havering and Redbridge, Tower Hamlets, Waltham Forest, and Newham.The methodology used to generate these curated phenotypes is based on UK Biobank methodology and described in prior publications; the code is available on the G&H website.Medication data were obtained by linkage with primary care data. We limited our analyses to participants who had medication data available from participating CCGs . Participants diagnosed with an acute MI who had been prescribed 75 mg clopidogrel in primary care were assessed for recurrent MI events.Smoking status was defined in primary care records by using SNOMED codes to distinguish never-smokers from those who had ever smoked . Four levels were used for the CYP2C19 inferred metabolizer type variable: PM, IM, and ultrarapid metabolizers, with normal and rapid metabolizers as the reference group. Sex, age at enrollment, and known cardiovascular disease comorbidities  were included as covariates. As the published literature suggests higher risk of in-stent thrombosis in PMs or IMs on clopidogrel, and a lower percentage of those who had stents were prescribed clopidogrel, PCI with stent insertion was also included as a covariate.This was a cross-sectional analysis. Multivariable logistic regression was performed to look for association of Sensitivity analysis was undertaken using the principal component analysis inferred ethnicity curated by G&H. 20 G&H curated principal components were included as covariates in a second logistic regression to control for population stratification. The G&H team have prior published data underpinning these variables, which they have made available to all researchers.CYP2C19 LOF diplotypes were parametrized to a continuous variable where the unit was LOF alleles, 0 for none, 1 for one (IM), 2 for two (PM). Multivariable logistic regression analysis was then performed as above, controlled for age, sex, cardiovascular disease risk factors , percutaneous coronary intervention, and 20 principal components. The 11 ultrarapid metabolizers were excluded from this analysis as outliers. This was undertaken to elucidate the impact of LOF alleles more clearly in absence of the ultrarapid diplotype which is an outlier in the trend of interaction between metabolizer type and clinical outcome.A further analysis was undertaken in which The ∗2 SNP was very common in the G&H cohort , with 56% of the population having at least 1 copy present. The ∗3 allele was less common, with 1.2% having at least 1 copy. In addition, 27.6% of the cohort had at least 1 copy of the ∗17 increased function allele.PMs or IMs, carrying at least 1 LOF allele (∗2 or ∗3), comprised 57% of the cohort. Thirteen percent of participants were PMs, with 2 LOF alleles, while 44% were IMs, with 1 LOF allele . Further31Medication data were available for those participants with linked primary care records (participating CCGs), which represented 84.4% of the acute MI cohort. We only included participants with prescribing data in our analysis. As antiplatelet choice post-MI is led by tertiary centers there is not expected to be any bias based on CCG linkage. The percentage of those who had an acute MI who were prescribed clopidogrel was 69.3% . For theP = 0.019) and ultrarapid CYP2C19 metabolizers , and recurrent MI. IM status was not significantly associated with recurrent MI (P = 0.36)  . Reclasspidogrel . Diagnospidogrel . Table 4CYP2C19 LOF variants contributing to clopidogrel resistance, the 11 ultrarapid metabolizers were excluded and LOF diplotypes changed to a continuous variable where the unit was LOF allele . This was undertaken to elucidate the impact of LOF alleles more clearly in absence of the ultrarapid diplotype which is an outlier in the trend of interaction between metabolizer type and clinical outcome (P = 0.011]) per LOF allele  were not. This is perhaps not surprising as the participants all have coronary artery disease already by definition but highlights the utility of CYP2C19 genotyping as compared with clinical risk stratification.Given the increased cardiometabolic risk in this cohort, these participants therefore have both a higher risk of having an indication for clopidogrel and a higher risk of clopidogrel failure due to increased prevalence of ,,British–South Asians in the G&H cohort are very likely to receive clopidogrel, with more than 2 in every 3 participants diagnosed with an acute MI in the G&H cohort receiving clopidogrel. International data suggest that this high prevalence of clopidogrel prescribing may be representative.P = 0.04).A pragmatic and often cited counter argument to genotype-guided antiplatelet prescribing is universal prescription of ticagrelor or prasugrel. However, the POPular genetics RCT trial has conclusively demonstrated that a genotype guided de-escalation of antiplatelet therapy, where poor or intermediate CYP2C19 metabolizers are given ticagrelor or prasugrel and others are given clopidogrel, is noninferior to universal ticagrelor/prasugrel prescription in terms of thrombotic events.While these data convincingly demonstrate an increased risk of failed secondary prevention for CYP2C19 PMs prescribed clopidogrel, lack of signal for the IMs should not be taken as conclusive, given the limitations of the study that may mask such a signal . In the context of prior work showing that the lack of clopidogrel efficacy in carriers of LOF alleles is dose dependent, a finer tuned approach would likely be needed to detect a signal in intermediate metabolizers if one is indeed present. Likewise, the fact that only 60% of this cohort had PCI and only 44% of the PCI cohort overall was prescribed clopidogrel would be anticipated to lead to a weaker signal, as prior research suggests risk associated with in-stent thrombosis.The data for risk to the small number of ultrarapid metabolizers in this cohort, taken in combination with prior pharmacokinetic studies and clinical trial data, suggest that they may be at higher risk of discontinuation due to adverse effects, but we cannot confirm or disprove this hypothesis with the data available. The risk of clopidogrel intolerance and discontinuation in ∗17/∗17 ultrarapid metabolizers has not been adequately assessed in clinical studies; future RCTs should genotype for ∗17 and assess for discontinuation rates and compliance in this subgroup as well as bleed-related adverse events. The number of patients who were ultrarapid metabolizers was very small (11 with acute MI and 3 with recurrent MI). Therefore, while showing an interesting real world data signal, these findings may be spurious and need to be validated in other studies. If validated it may capture a compliance risk that may not be equally represented in a controlled trial environment, which would have implications clinically . The large OR associated with ultrarapid metabolizer status, if due to discontinuation, would be consistent with pharmacokinetic and platelet aggregation evidence that suggests poor metabolizers may still have some active metabolite and thus some benefit from clopidogrel. In other words, that being a poor CYP2C19 metabolizer taking clopidogrel probably offers more protection than not taking clopidogrel or an alternative antiplatelet agent.CYP2C19 LOF alleles in the G&H cohort, this study supports genotyping in South Asian ancestry populations to guide antiplatelet prescription. It confirms that PMs have an elevated risk of failed secondary prevention of MI when receiving clopidogrel (P < 0.001).P = 0.005).Given the prevalence of pidogrel . It combLack of action in terms of more diverse representation in trial cohorts and research cohorts risks perpetuating existing inequalities. More effort should be made to encourage publication of ethnic composition of research/trial cohorts especially in a setting where a PGx interaction between gene variants and a drug is probable and there is known transancestry differences in PGx variant prevalence.Although the use of this real-world data has many advantages there are also some limitations. We did not have access to the dates of the index presentation and recurrent MI. Therefore, we cannot confirm that the recurrence of MI was during the time frame that the participants were prescribed clopidogrel. Furthermore, the risk of in-stent thrombosis after PCI is highest in the first 3 months poststent insertion, and this was not analyzed due to lack of timeline data. Limitation regarding timeline is mitigated by 2 factors: 1) built in temporality between index event and recurrent MI; and 2) the limited duration of dual antiplatelet therapy post-MI .Cause specific mortality data may also have refined our model, as a composite endpoint of recurrent MI or cardiovascular death could be considered, but these data were not available.Furthermore, we did not consider coprescriptions that may cause drug-drug interactions or phenoconversion . This was due to our lack of timeline data and relatively small cohort. Comorbidities may also cause phenoconversion, for example diabetes is known to be associated with decreased CYP2C19 function.We did not have data to assess adverse events which may lead to clopidogrel discontinuation, for example significant gastrointestinal or intracranial bleed. However, the lack of the above data would be expected to mask any existing association between genotype and outcomes, meaning that our analysis would underrepresent rather than overrepresent a signal.This study shows high rates of genetically determined impaired clopidogrel activation in a large South Asian ancestry population with high risk of cardiovascular disease. Poor CYP2C19 activation of clopidogrel was correlated with an increased risk of recurrent MI. This “real-world” data show that clopidogrel is frequently prescribed and this appears to be particularly detrimental in individuals of South Asian ancestry due to the high proportion of PMs. Therefore, a pharmacogenomic-driven approach to antiplatelet prescribing has the potential to improve clinical management of MI and outcomes in individuals of Bangladeshi and Pakistani ancestry. High-quality health economic studies have shown that this approach is affordable.In absence of a PGx approach, prescribing non–CYP2C19-dependent antiplatelet agents is likely to have a disproportionate benefit in this British-Bangladeshi and British-Pakistani population.PERSPECTIVESCOMPETENTCY IN PATIENT CARE: This work supports routine implementation of pharmacogenomic testing prior to prescribing clopidogrel for ACS. It links high prevalence of LOF genetic polymorphisms in the CYP2C19 gene, which encodes the enzyme that converts clopidogrel to its active metabolite, with increased risk of re-current MI in a South Asian population. Furthermore, the study illustrates how systemic underrepresentation of this ancestral group in therapeutics trials has obscured the intersection of risks impacting this community. Pharmacogenomic testing prior to prescribing clopidogrel can improve health inequality and patient care.TRANSLATIONAL OUTLOOK: To implement PGx equitably on a national and internationally scale, engagement work must take place so that prescribers and patients can build communication and data management pathways that are fit for purpose.This study illustrates how socioeconomic deprivation, ethnic differences in pharmacogenes, and poor representation in research studies can intersect to compound ill health in an already disadvantaged subpopulation. Further analysis of such effects in clinical medicine are needed.This work is part of the portfolio of research at the National Institute for Health Research (NIHR) Barts Biomedical Research Centre. Genes & Health is core-funded by Wellcome , the Medical Research Council (UK) (M009017), Higher Education Funding Council for England Catalyst, Barts Charity (845/1796), Health Data Research UK (for London substantive site), and research delivery support from the NHS National Institute for Health Research Clinical Research Network (North Thames). Genes & Health is/has recently been funded by Alnylam Pharmaceuticals, Genomics PLC; and a Life Sciences Industry Consortium of Bristol-Myers Squibb Company, GlaxoSmithKline Research and Development Limited, Maze Therapeutics Inc, Merck Sharp & Dohme LLC, Novo Nordisk A/S, Pfizer Inc, Takeda Development Centre Americas Inc. Dr Magavern is funded by Barts Charity. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.


The present study was aimed at developing a dental material with antibacterial properties by combining titanium oxide NPs using ginger and rosemary extracts.Introduction: Titanium oxide  compared to control and antibiotic groups against Streptococcus, highlighting the potent antibacterial and antibiofilm properties of the greenly generated combination of titanium oxide NPs with herbs. This was also confirmed by moderate minimum inhibitory concentration at 100 μL.Conclusion: The present study suggests that there is a bactericidal process at play, leading to a reduction in the overall bacterial count. It can be concluded that the ginger and rosemary-mediated titanium oxide NPs serve as potential antibacterial agents against S. aureus. This study can be used as a preliminary study, and further studies can be conducted to use this formulation in the field of medicine. Indeed, the development of nanotechnology has led to significant advancements in various fields, including medicine, electronics, and materials science. Nanoparticles (NPs), defined as objects with at least one dimension ranging from 1 to 100 nanometers, have unique physicochemical properties compared to larger particles of the same composition. One of the significant advantages of NPs is their high surface-to-volume ratio ,3.The green synthesis of NPs requires the selection of environmentally friendly solvents (such as water or ethanol), non-toxic reducing agents, and safe stabilizing substances. Traditional chemical routes for NP synthesis involve toxic and hazardous chemicals, posing environmental risks and high costs. In contrast, green synthesis offers a safe, biocompatible, and eco-friendly approach to producing NPs for various applications, including biomedicine . Plant-d2) or titania can be found as a thin film or as a fine, white powder. TiO2, brookite, anatase, and rutile are the four naturally occurring crystal forms of TiO2. TiO2 NPs are renowned for their desirable qualities, which include mechanical, electrical, optical, rheological, thermal, physicochemical, and biological properties. With their antimicrobial properties, TiO2 NPs effectively combat oral pathogens associated with dental caries and periodontal diseases. They disrupt bacterial cell walls and membranes, leading to increased permeability and cell death [2 NPs render them exceptionally valuable in restorative materials, dental adhesives, sealants, cements, and various other dental applications. By incorporating TiO2 NPs, dental products can effectively prevent microbial colonization, thus significantly reducing the risk of infections [Titanium oxide  has been esteemed for its medicinal virtues, with a history of utilization spanning centuries. This esteemed herb has garnered a reputation for its multifaceted potency, particularly in its role as an antimicrobial agent, among other remarkable biological activities. These exceptional attributes are attributed to the presence of bioactive compounds such as gingerol, paradol, shogaols, and zingerone, which collectively contribute to the vast array of therapeutic benefits found within this botanical gem. The diverse pharmacological potential of ginger continues to captivate researchers and practitioners alike, offering promising avenues for harnessing its powerful natural remedies in a plethora of health applications and holistic wellness practices. Notably, a study highlighted the antimicrobial potential of a 10% ethanolic ginger extract against pathogens . FurtherThe primary aim of the present study is to formulate an antibacterial concoction by incorporating extracts from ginger and rosemary, along with titanium oxide NPs. The study seeks to explore the synergistic antibacterial potential of these natural extracts and NPs against Staphylococcus aureus. The objectives of the study are to extract bioactive compounds from ginger and rosemary, synthesize titanium oxide NPs, and combine them to create an antibacterial mixture. To characterize the concoction's chemical composition, NP dispersion, and antibacterial activity against S. aureus and to investigate the synergistic effects of minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC), and antibacterial mechanisms contributing to understanding natural extract and NP applications. Through achieving these objectives, this study aims to provide insights into the feasibility of utilizing ginger and rosemary extracts in combination with titanium oxide NPs for developing effective antibacterial agents against S. aureus, potentially leading to novel strategies in combating bacterial infections in the oral cavity.Study settingThe investigation was conducted within the Nanomedicine Laboratory, situated in the Department of Pharmacology at Saveetha Dental College and Hospitals, which is part of Saveetha Institute of Medical and Technical Sciences located in Chennai, Tamil Nadu, India. Prior to commencing the study, approval was obtained from the Scientific Review Board (SIMATS/Ph.D.Regn./A4/2022/406-06). The experiment was initiated in June 2023 and was conducted within a time period of two weeks from acquiring the raw products, titanium dioxide NPs, and performing antibacterial tests.For the current study, the oral pathogen S. aureus was utilized to assess the antibacterial activity and was sourced from the Nanobiomedicine Laboratory's culture laboratory which is affiliated with Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India.Preparation of the plant extractThe raw products for the preparation of plant extract were acquired from a local market. One gram of ginger  and one gram of rosemary powder  were taken and mixed together with a quantity of 100 mL of distilled water. The solution was boiled at 600 ℃ for a period of 10-15 minutes. The solution was filtered into a flask using No.1 size Whatman filter paper. The final extract was cooled to room temperature and was stored in an airtight storage box.2 NPsSynthesis of TiO2 NPs, TiO2 powder of 6.26 mM was taken; 0.5 grams of TiO2 powder was dissolved in 50 mL of distilled water to be made as a precursor. Fifty milliliters of the prepared rosemary and ginger extract was added to the prepared mixture. The solution was kept in a magnetic stirrer for 48 hours. The change in the color of the solution was observed, and readings were taken using a UV spectrometer. After the synthesis of NPs, it was centrifuged for 10 minutes. The pellets of TiO2 NPs enriched with ginger and rosemary were collected and used for further analysis  with 50% water, it was added to well culture plates that contained a four-hour culture of S. aureus at 370C. The sample grouping was a test group and a positive control group. The number of test samples used was 4 for each concentration i.e. 25, 50, and 100 μL, respectively. The positive control group antibiotic was Amoxyrite. The culture plate was incubated and the readings of the zone of inhibition were noted  and then exported to IBM SPSS Statistics for Windows, Version 25  for statistical analysis. The level of significance was <0.005 for one-way ANOVA.The phenomenon of optical density entails the measurement of light scattering produced by bacteria present within a culture plate. As the concentration of bacteria increases, the scattering of light also intensifies proportionally. As the graph Figure  depicts,The concentration with the least optical density indicates less bacterial growth and high bactericidal activity in comparison with the control Table . 2 NPs, specifically at 25 μL, 50 μL, and 100 μL dilutions, on the growth inhibition of S. aureus. The zones of inhibition, which indicate the effectiveness of the test solutions in restraining bacterial growth, were observed and compared. At 25 μL dilution of TiO2 NPs, the zone of inhibition observed for S. aureus was relatively less evident. This suggests that at this lower concentration, the TiO2 NPs may have a limited inhibitory effect on bacterial growth. Comparatively when the test solution was prepared with a 50 μL dilution of TiO2 NPs, a similar outcome was observed, with a less evident zone of inhibition for S. aureus implying that even at a slightly higher concentration, the inhibitory effect of the TiO2 NPs remains relatively modest. However, at 100 μL dilution of TiO2 NPs, a more promising result emerged. S. aureus displayed a moderately sized zone of inhibition, indicating that at this concentration, the TiO2-NPs exhibited a stronger inhibitory effect on bacterial growth compared to the lower dilutions. Lastly, the control experiment involving Amoxyrite showed a moderately sized zone of inhibition as well, serving as a reference point for comparison.The experiment aimed to assess the impact of different concentrations of TiO2-NPs in inhibiting S. aureus growth is concentration-dependent. While lower dilutions exhibited less evident inhibition, a 100 μL dilution of TiO2-NPs showed a moderately sized zone of inhibition, indicating potential antibacterial properties comparable to the control.In summary, the experiment demonstrated that the effectiveness of TiOIn recent times, there has been a growing fascination among researchers with diverse plant-derived compounds in the scientific community. Natural products are attracting significant attention due to their remarkable tolerance profiles compared to some synthetic alternatives, making them an essential source of potential drugs. One prominent aspect of these natural compounds is their ability to act as antimicrobial agents, providing valuable means to control various microorganisms.These botanical wonders have a wide range of benefits, with their antimicrobial properties being particularly crucial in fields like pharmacology, medicine, and agriculture. Scholars are eager to understand the intricate mechanisms and therapeutic potentials of these bioactive substances, as they offer promising solutions to combat microbial challenges. Exploring nature's pharmacy opens up new possibilities for innovative and sustainable healthcare solutions. Hence, we have embraced the concept of green synthesis in the current study which enables us to capitalize on the advantages of NPs while concurrently mitigating environmental impacts and fostering sustainable practices for a greener future . S. aure2 NPs on a pathogenic strain of Escherichia coli. Their research revealed that TiO2 NPs induce the formation of tiny pores in the bacterial cell walls, resulting in heightened permeability and ultimately leading to cell death. This mechanism contributes to the impressive antimicrobial efficacy of TiO2 NPs, making them a promising option for combating microbial threats in dental settings [2 NPs is primarily attributed to their photocatalytic properties. On exposure to ultraviolet (UV) light, TiO2 NPs can generate reactive oxygen species (ROS), like hydroxyl radicals consisting of strong oxidative capabilities. These ROS can cause damage to bacterial cell membranes and biomolecules, leading to cell death [Numerous scholarly works have examined the antimicrobial effectiveness of titanium dioxide NPs against a range of bacteria, encompassing both Gram-positive and Gram-negative bacteria. Some studies have reported promising results, demonstrating the ability of TiO2 NPs to inhibit bacterial growth and effectively kill bacteria. Titanium dioxide NPs have been widely studied for their antibacterial properties . Haghi esettings . This coll death .2 NPs against various bacterial strains. As the concentrations of TiO2 NPs increased, the optical density exhibited a slight decrease across all the tested strains. According to Khashan et al., the optimal concentration of TiO2 NPs to prevent bacterial growth was discovered to be at 1000 µg mL-1 with an inhibition rate of 42, 25, 15, 30% 42%, 25.5%, 15.05%, and 30.5% respectively, whereas the inhibition rates of TiO2 NPs at 400 µg mL-1 were 21%, 3.5%, 5.3%, and 4.9% against E. coli, S. aureus, Pseudomonas aeruginosa, and P. vulgaris, respectively. According to these investigations, titanium oxide itself has bactericidal properties against several bacterial strains [In addition to this, a study by Khashan et al. also represents the optical density of TiO2 NPs augmented with clove and ginger may be employed as an antibacterial agent against Lactobacillus species. This indicates that the TiO2 NPs serve as a potential candidate as an antibacterial agent against lactobacillus [2 NPs to study their antimicrobial properties. The majority of the studies illustrating the antibacterial activity of the NPs were demonstrated by suspension of TiO2 into the solution and thereby studied bacterial inhibition and its activity [2 NPs and cadmium oxide NPs, the TiO2 NPs had a better antibacterial activity than the cadmium oxide NP, and 0.1% of TiO2 NPs inhibited bacterial growth that was tested on E. coli. This evidence substantiates the superior benefits of titanium oxide NPs, making them a more favorable choice for exploring metallic oxide NPs in the creation of novel dental varnishes incorporating both NPs and herbal ingredients [Another article of 2023 suggests that TiObacillus . In the activity . In a stredients .Conducting in vivo studies, involving animal models or human subjects, is essential for a more realistic understanding of how these NPs behave within biological systems. Understanding the precise interactions between the NPs and bacterial cells, as well as the specific cellular pathways affected, could provide deeper insights into potential applications.LimitationsThe study's scope is limited as it solely focuses on the antibacterial effectiveness of the synthesized NPs against S. aureus. While S. aureus is important, a comprehensive evaluation should encompass a broader spectrum of bacterial strains, including both Gram-positive and Gram-negative types. The study is conducted entirely in a controlled laboratory environment, which is valuable for initial insights. However, it lacks the complexity of interactions occurring within living organisms. The study also lacks a thorough exploration of the mechanisms driving the observed antibacterial activity.The investigation establishes the bactericidal efficacy of a combination comprising ginger and rosemary-infused titanium oxide NPs, resulting in a reduction of bacterial counts when evaluated across varying concentrations  in relation to S. aureus. The results have proved that as the bacterial concentration increased, there was a proportional intensification in light scattering indicating that the optical density was notably high and comparable to the control group which gradually when the concentration reached 100μL. This was supported by the values of zones of inhibition with moderate inhibition at the concentration 100μL in comparison with 25 and 50 μL concentrations of the herbal and nanoparticle mixture. This preliminary research lays the foundation for future medical applications, warranting subsequent investigations for practical use in the field of medicine.


Cancer cells characterized by uncontrolled growth and proliferation require altered metabolic processes to maintain this characteristic. Metabolic reprogramming is a process mediated by various factors, including oncogenes, tumor suppressor genes, changes in growth factors, and tumor–host cell interactions, which help to meet the needs of cancer cell anabolism and promote tumor development. Metabolic reprogramming in tumor cells is dynamically variable, depending on the tumor type and microenvironment, and reprogramming involves multiple metabolic pathways. These metabolic pathways have complex mechanisms and involve the coordination of various signaling molecules, proteins, and enzymes, which increases the resistance of tumor cells to traditional antitumor therapies. With the development of cancer therapies, metabolic reprogramming has been recognized as a new therapeutic target for metabolic changes in tumor cells. Therefore, understanding how multiple metabolic pathways in cancer cells change can provide a reference for the development of new therapies for tumor treatment. Here, we systemically reviewed the metabolic changes and their alteration factors, together with the current tumor regulation treatments and other possible treatments that are still under investigation. Continuous efforts are needed to further explore the mechanism of cancer metabolism reprogramming and corresponding metabolic treatments. This article presented the metabolic reprogramming of tumor cells to adapt to their microenvironment distinct from normal cells. And this study reviewed the driving factors of metabolic reprogramming, the specific metabolic pathway changes affected, and the related treatment options, in order to provide some suggestions for future tumor treatment. The related changes promote the transformation of normal cells into malignant phenotypes. The microenvironment of malignant cells is different from that of normal cells. To adapt to hypoxia and nutritional deficiency, tumor cells must reprogram metabolic pathways to fulfill the energy, biosynthesis and redox needs of tumor cells.At present, tumor therapy for metabolism regulation can be divided into medication therapy and nutrition intervention therapy according to different intervention methods. Many drugs targeting metabolic reprogramming have been studied and are expected to become emerging strategies of metabolic regulation therapy for tumors aimed at metabolic complexity by acting on key proteins in related signaling pathways. Nutritional intervention is considered a traditional adjuvant treatment strategy for tumors. It changes the utilization rate of nutrients in the body cell microenvironment, including tumor cells, through diet regulation, thereby regulating many physiological processes of tumor cells. At the same time, an increasing number of studies have indicated that the combination of multiple strategies is also considered to be a promising treatment.This paper reviews the growth characteristics of tumor cells and analyzes the metabolic mechanisms to adapt to the special growth needs of tumor cells from three aspects, glucose metabolism, lipid metabolism, and amino acid metabolism, and summarizes the driving factors of tumor metabolism reprogramming, the specific conditions of the changes in the three metabolic pathways, and the treatment targets available in metabolism reprogramming. Notably, this paper summarizes the factors driving reprogramming from the perspective of gene, protein and cell‒cell relationships and comprehensively summarizes the detailed drugs for each metabolic pathway target based on tumor metabolism reprogramming for the first time, which provides a promising direction for future tumor treatment.2The tumor microenvironment (TME) is an internal environment with low oxygen content, acidic content and high permeability that tumor cells rely on for survival.2.1Oncogenes and tumor suppressor genes can affect the glucose metabolism of tumor cells through a variety of mechanisms, which are the primary factors that cause tumorigenesis and drive reprogramming of glucose metabolism. Activation of oncogenes leads to metabolic reprogramming, while tumor suppressor genes lead to reprogramming through mutations or deletions. Tumor suppressor genes such as p53 have a negative regulatory effect on cell metabolism changes caused by excessive activation of oncogenes and inhibit cell biosynthesis and metabolism and energy supply pathways.2.1.12.1.1.1The cellular myelocytomatosis oncogene (c‐MYC) is related to tumor development by participating in metabolism, cell cycle regulation, cell adhesion, protein synthesis, cytoskeleton, apoptosis, and angiogenesis, and its expression in normal cells is strictly controlled, but it is highly expressed in most tumors. As a transcription factor, c‐MYC promotes many cells proliferation‐related target genes, such as cyclin‐dependent kinase 4 (CDK4) and RNA polymerase III. Therefore, upregulation of MYC expression in cells will contribute to cell hyperproliferation.l‐lactate dehydrogenase A (LDHA), hexokinase (HK) 2, phosphofructokinase (PFK), muscle (PFKM), pyruvate dehydrogenase kinase 1 (PDK1), and α‐enolase. In addition, MYC can directly activate the gene transcription of monocarboxylate transporter 1/2 (MCT1/MCT2) or by inhibiting miRNA .In carcinogenesis, MYC enhances glycolysis by regulating the expression of glycolysis genes and related metabolic enzymes, including glucose transporter 1 (GLUT1),In conclusion, MYC plays a significant role in the biological process of tumor cells by promoting glycolysis, glutamine decomposition, nucleotide synthesis, fatty acid metabolism and other pathways to promote the proliferation of tumor cells.2.1.1.2As one of the most frequently mutated oncogenes in cancer, approximately 30% of all human cancers have Kirsten‐ras oncogene (KRAS) mutations, which have extensive effects on tumor transformation. Recent studies have indicated that KRAS plays a key role in coordinating tumor metabolic reprogramming by upregulating the transcription of multiple key glycolysis enzymes, such as HK1/2, PFK1, LDHA, and GLUT1. It is also responsible for reprogramming various aspects of central carbon metabolism. These metabolic changes are crucial for the growth of KRAS‐mutated tumors.KRAS mutation can increase glucose uptake by regulating glucose transporters and glycolytic enzymes,2.1.1.3The AK mouse plus transforming or thymoma (AKT) oncogene can encode a Ser/Thr‐specific protein kinase that mediates the PI3K signaling pathway. The upstream signaling pathway, the epidermal growth factor receptor (EGFR) signaling pathway, participates in the control of tumor cell proliferation, inhibits cell apoptosis, and promotes cell cycle progression. Constitutive activation of the PI3K/AKT signaling pathway by AKT1 occurs in various cancers. Gene amplifications or activation mutations of the AKT gene lead to its overactivation and transformation of tumor cells. Growth factor receptor tyrosine kinase, PI3K, or Ras can also promote AKT activity. Activation of AKT is likely to contribute to the elevation of glycolysis metabolism in cancer cells.2.1.1.4Mutations in isocitrate dehydrogenase (IDH)1/2 alter enzyme activity and result in the conversion of protein from α‐KG to 2‐hydroxyglutarate (2‐HG). 2‐HG isomers are structurally similar to α‐KG, which can competitively inhibit the α‐KG‐dependent dioxygenase family, such as 5‐methylcytosine. IDH1/2 participates in changes in tumor metabolism through glutamine metabolism reprogramming.2.1.1.5The phosphatidylinositol 3‐kinase (PIK3CA) gene is located on chromosome 3 and belongs to the PI3K/AKT signaling pathway. It is responsible for encoding protein P110α, which is one of the catalytic subunits of the PI3K enzyme. Mutation of PIK3CA can activate PI3K continuously and enhance intracellular signal transduction, which leads to disorder of the whole pathway and carcinogenesis.2.1.1.6Mutations of the EGFR change its structure and remain active constantly. It plays an important role in tumorigenesis by regulating cell metabolism and inducing glycolysis, PPP, pyrimidine biosynthesis, and redox metabolism. Mutated EGFR reprograms the metabolism of tumor cells through the PI3K/AKT/mTOR pathway.2.1.1.7Octamer‐binding transcription factor (Oct4), an oncogene, plays significant roles during cancer initiation, progression, drug resistance, and relapse. It enhances the expression levels of Oct4 metabolic programming by reprogramming differentiated cells into cancer stem cells and plays an oncogenic role when pathologically hijacked. Some studies have identified that overexpressed Oct4 redirects glucose catabolism to the glycolysis pathway and to the oxidative PPP. Nevertheless, there are limited data on Oct4‐induced metabolic reprogramming and a lack of direct evidence to prove that Oct4 reprograms the metabolome at all metabolic levels.2.1.2Apart from the overactivation of oncogenes, the inactivation of tumor suppressor genes is also an important initiating factor of tumor metabolic reprogramming. The tumor suppressor genes p53, liver kinase B1 (LKB1), and tuberous sclerosis complex 2 (TSC2) have negative regulatory effects on cell metabolism changes and inhibit cell bio‐anabolism and energy supply pathways.2.1.2.1p53, the most frequently mutated gene in human cancer, regulates the transcription of many target genes, which can not only promote DNA damage repair and cell survival but also promote apoptosis and remove unrepairable cells, thereby maintaining genomic integrity and playing a role in inhibiting the occurrence and development of tumors. It plays an important role in glucose metabolism, lipid metabolism, and oxidative phosphorylation (OXPHOS). However, mutations or deletions can lead to the loss of functions, thus promoting metabolic reprogramming. The specific mechanism of p53 during reprogramming to inhibit tumor metabolism is as follows.C oxidative synthase 2 and other enzymes to inhibit tumor development. In the PPP, p53 inhibits its activity by binding with glucose‐6‐phosphate (G6P) dehydrogenase, thus inhibiting the PPP. It reduces the generation of 5‐phosphoribose and NADPH and the generation of raw materials for malignant tumor growth. For glutamine metabolism, p53 increased glutamate and α‐ketoglutaric acid contents, enhanced mitochondrial oxidative respiration,Under physiological conditions, p53 can directly inhibit the gene expressionC oxidase‐2 promote the occurrence and development of tumors.In conclusion, p53 is closely related to tumor cell metabolism. P53 can inhibit tumors by regulating the expression or activity of related metabolic enzymes, inhibiting aerobic glycolysis of glucose, inhibiting PPP, enhancing OXPHOS of glucose, and inhibiting de novo fatty acid synthesis. Mutation of p53 leads to a decline in all its activities. The enhancement of glycolysis flux, PPP, lipid metabolism, and declination of mitochondrial respiratory activity through loss of synthesis of cytochrome 2.1.2.2As a cancer suppressor gene, phosphatase and tensin homolog deleted on chromosome ten (PTEN) has dual specificity phosphatase activity and inhibits cancer through apoptosis, cell cycle arrest, cell migration, and so on. The balance of the PI3K/AKT signaling pathway is the key to regulating these functions.2.1.2.3LKB1, a serine/threonine kinase, can regulate cell polarity, energy metabolism, proliferation, and migration. Mutations and disorders of LKB1 can be observed in a variety of cancers.Deletion of LKB1 can plunge cells into an energy/oxidative stress‐induced crisis, which contributes to the activation of carcinogenic pathways so that the cell energy levels can be maintained. Silencing LKB1 can reduce the phosphorylation of AMPK, thereby increasing the phosphorylation of protein kinase B and promoting tumor cell proliferation. Thus, the migration and invasion of colon cancer cells are enhanced. In addition, the increase in LKB1 promoter methylation frequency is another major mechanism of LKB1 inactivation. Moreover, LKB1 can regulate AMPK  to transduce the signal to promote metabolism in response to energy metabolic stress. Therefore, deletion of LKB1 in tumor cells is sensitive to energy metabolic stress. In addition, deletion of LKB1 can lead to metabolic changes in HIF‐1‐dependent proliferating cells. HIF‐1 accumulates in LKB1‐deficient cells and leads to increased absorption and utilization of glucose and glutamine,2.1.2.4TSC2 functions as a negative regulator of mTOR signaling. When the TSC2 gene is mutated, the mTOR complex 1 (mTORC1) signal transduction pathway is abnormally activated.2.1.3In addition to oncogenes and tumor suppressor genes, noncoding RNAs (ncRNAs) are important participants in the reprogramming mechanisms of cancer metabolism. Although ncRNAs were initially thought to lack biological function due to their inability to encode proteins, they can play a role in cancer progression by regulating enzymes and pathways involved in cancer cell metabolic reprogramming. This regulation occurs mainly through glucose, glutamine, and lipid metabolism and involves two types of ncRNA,2.1.3.1lncRNAs are a heterogeneous group of nonprotein coding transcripts with a length greater than 200 nucleotides. lncRNAs are newly discovered regulatory factors involved in regulating gene expression and a variety of physiological and pathological processes. Studies have shown that lncRNAs play a complex and precise regulatory role in the occurrence and development of cancer by exerting oncogene or tumor suppressor gene activity or sometimes functioning as these genes.2.1.3.2miRNAs are a class of 22 bp small single‐stranded ncRNAs that regulate gene expression at the posttranscriptional level and are widely involved in various physiological and pathological processes. The abnormal expression of miRNA in tumor development is closely related to tumor progression. In cancer, miRNAs regulate enzymes associated with glucose metabolism. For example, HK2 expression is downregulated by miR‐199a‐5p and miR‐125b, and low expression of these ncRNAs corresponds to the enhancement of tumor growth.2.22.2.1Of the various growth factors, transforming growth factor β (TGF‐β), which controls growth and differentiation, plays an important role in carcinogenesis. Under physiological conditions, TGF‐β is involved in the regulation of some important cellular functions, such as differentiation, amplification, migration, and immune monitoring.2.2.2The hypoxic microenvironment is an important feature of solid tumor tissue and has an important influence on tumor extracellular matrix structure, immune response, angiogenesis, metastasis and other processes. Hyperglycolysis and reduced OXPHOS are the main adaptive changes in tumor metabolic reprogramming induced by hypoxia. HIF‐1 is an oxygen‐sensitive transcription factor and is one of the main regulatory factors of tumor metabolic reprogramming that promotes hypoxia‐induced gene expression and induces a specific response of the body tissue to hypoxia. It is highly expressed in many tumors, such as colorectal cancer,Other growth factors with less research are also involved in tumor processes. For example, epidermal growth factor (EGF) promotes the EMT process through metabolic reprogramming and promotes PDK1 expression through the EGFR/PI3K/HIF‐1 axis, thus promoting glycolysis. EGF also promotes lipid synthesis by providing acetyl‐CoA with glutamine and regulates the synthesis of monounsaturated fatty acids by phosphorylation of SCD1.2.2.3Forkhead box (Fox) proteins are a large family of transcription factors that play an important role in various biological processes. Based on the similarity of genes in the Fox family, Fox proteins can be divided into 19 subfamilies, from FoxA to FoxS. Among them, the FoxO and FoxM subfamilies are most closely related to tumor metabolism. The FoxO transcription factor family controls the occurrence and development of tumors by influencing tumor metabolism, such as glucose metabolism, glutamine metabolism and lipid metabolism. In terms of glucose metabolism, FoxO inhibits glycolysis gene expression, glucose uptake, and lactic acid production by regulating MYC and affects the Warburg effect.2.2.4E2F transcription factor 1 (E2F1) is a member of the cell cycle‐related transcription factor family. It not only affects cell cycle progression and cell proliferation through transcriptional regulation but is also closely related to metabolism.2.2.5High mobility group box 1 (HMGB1) is a nonhistone chromosomal binding protein existing in eukaryotic nuclei. HMGB1 regulates inflammatory pathways, immunity, genomic stability, cell proliferation, migration, apoptosis, and autophagy2.2.6mTOR is a highly conserved serine/threonine protein kinase in the PI3K‐related kinase family that plays an important role in regulating cell proliferation and metabolism. mTORC1 regulates cellular metabolism from protein synthesis, lipid synthesis and mitochondrial activity by receiving upstream signals related to nutrients and hormones. mTORC2 promotes cell survival by activating AKT, regulates cytoskeletal dynamics by activating PKCα, and controls ion transport and growth through phosphorylation of serum and glucocorticoid‐regulated kinase 1 (SGK1).2.2.7The insulin‐like growth factor (IGF) signaling pathway is a complex network consisting of two ligands (IGF‐1 and IGF‐2), two receptors (IGF‐1R and IGF‐2R) and six IGF‐binding proteins (IGF‐BP1‐6). IGF‐1R is upregulated in most malignant tumors, and its combination with the ligands IGF‐1 or IGF‐2 can activate the PI3K/AKT and Ras/Raf/MEK/ERK/MAPK signaling pathways, thereby promoting tumor proliferation, differentiation, and migration and playing a role in fine‐cell apoptosis inhibition. On the one hand, the downstream signaling pathway of IGF‐1R has multiple crossing sites with oncogenes such as Ras and c‐MYC, which can regulate each other to play a role in leading to tumor formation. On the other hand, it can also interact with EGFR and vascular EGFR pathways to regulate cell proliferation and differentiation. Activation of IGF‐1R leads to upregulation of HIF 1α protein synthesis and thus leads to expression of VEGF, a core mediator of angiogenesis.2.3Reprogramming of metabolic pathways in cancer is not only limited to the tumor cells themselves but also involves the interaction of tumor cells with the host cells themselves.Nutrient recycling between tumor cells and fibroblasts is vital for tumor growth. Fibroblasts mainly produce and secrete extracellular matrix components, such as collagen, which can be absorbed by tumor cells for metabolism. Cancer‐associated fibroblasts (CAFs)In addition, competition between tumors and host cells can affect tumor growth. To obtain the energy needed for their growth and development, tumor cells, host cells, and stromal cells have a competitive relationship, and due to the weak competitiveness of immune cells,Tumor cells undergo metabolic reprogramming to adapt to their physiological characteristics of low oxygen demand and rapid proliferation. There are many driving factors, but they can be roughly divided into three aspects: gene, protein, and cell. Specific changes in cellular metabolism are discussed in detail in the following sections.33.1Glucose metabolic reprogramming is one of the representative metabolic features in tumors. The mechanism of energy metabolism is different between tumor cells and normal cells, in which the former does not utilize mitochondrial OXPHOS capacity even under aerobic conditions, and the active aerobic glycolysis phenomenon is recognized as the Warburg effect.3.1.1In contrast to normal cells, approximately 50% of ATP is synthesized through the glycolysis pathway in tumor cells, which is why glycolysis can supply tumor cells with sufficient energy.The glycolytic pathway consists of 10 steps, including three irreversible steps: HK, PFK, and PKM 1/2‐induced reactions. Targeted inhibition of the main enzymes in glycolytic metabolism can inhibit the growth of tumor cells by inhibiting the glycolytic pathway.3.1.2Mitochondria are the center of cellular energy metabolism, where the TCA cycle occurs. The TCA cycle is a common metabolic pathway in aerobic organisms, and its main functions are to produce precursors for biological macromolecule synthesis.Through glycolysis, glucose can generate pyruvate. It enters mitochondria and is converted into acetyl‐CoA by pyruvate dehydrogenase (PDH). Acetyl‐CoA and oxaloacetate (OAA) are transformed to citrate‐by‐citrate synthase (CS). Isocitrate is then converted to α‐ketoglutarate (α‐KG) by IDH. α‐KG dehydrogenase catalyzes α‐KG to succinyl‐CoA. After that, succinate is catalyzed by succinate dehydrogenase (SDH) to fumarate, and fumarate hydratase (FH) is catalyzed to produce malate. MDH can catalyze malate to form OAA, and OAA can be reduced to phosphoenolpyruvate (PEP) by phosphoenolpyruvate carboxykinase 2.Apparently, a variety of enzymes are involved in the TCA cycle, and these enzymes can affect the TCA cycle through the effect of metabolic reprogramming, among which SDH, FH, and IDH are noteworthy. Mutations in SDH and IDH can increase ROS production, thereby promoting tumorigenesis and transformation. Meanwhile, mutations of FH can lead to accumulation of fumaric acid and increased dependence on glycolysis and glutamine recovery.3.1.3To maintain abnormal requirements for malignant proliferation of tumors, glycolysis intermediates can also be metabolized by other branched pathways, including the PPP and HBP. PPP is mainly used for nucleotide synthesis and the production of reductive NADPH. Meanwhile, the metabolites of HBP can form glycans for protein glycosylation modification.3.1.3.1The PPP is a branch of glycolysis that plays an important role in glucose metabolism and acts as a bridge between glucose metabolism, NADPH production and nucleotide precursor synthesis. It also plays a key role in the elimination of cellular ROS and reductive biosynthesis by providing R5P and NADPH.When glucose enters the cell, it is first phosphorylated by HK to form G6P. G6P can produce ATP and other intermediate metabolites through the glycolytic pathway and can also be metabolized through the PPP. When G6P enters the PPP, it can be dehydrogenated by G6PD to produce 6‐phosphogluconic acid (6PG). 6PG is catalyzed by 6‐phosphogluconate dehydrogenase (6PGD) to R5P. NADP+ acts as an electron acceptor in the oxygenation stage of the PPP pathway to receive hydrogen ions and generate NADPH, which provides power for cells to remove ROS.Metabolic reprogramming significantly increased the expression of G6PD, RPIA, and TKT, which proves the presence of high‐flow PPP in human cancer cells. In addition, cancer cells can reduce glycolytic flow and enhance the use of glucose in the PPP to produce more NADPH for antioxidant defense under oxidative stress.3.1.3.2The HBP can mediate the synthesis of the nucleotide sugar UDP‐GlcNAc. It can satisfy the intake demand of various molecules, such as glucose, uridine triphosphate, and acetate, through the regulation of the PPP and AMPK signaling pathways. Therefore, this pathway is recognized as a sensor of bioenergy and metabolism.In response to metabolic reprogramming of tumor cells, increased uptake of glutamine and glucose can synergistically enhance the activities of HBP. Even though glucose involved in the HBP pathway only occupies a small fraction of intracellular glucose, it is still crucial to the survival of tumor cells. The HBP plays an essential role in the posttranscriptional modification of both tumor suppressor genes and oncogenes.3.1.4The activity and protein expression levels of metabolic enzymes in the glycolysis pathway of tumor cells are upregulated significantly, including HK, PFK, and PK. An increasing number of studies have proven that the main enzymes of tumor glucose metabolism are potential targets for tumor treatment, such as GLUT1, HK2, PFKFB3, and PKM2.3.1.4.1C.In most cancer tissues, the expression of the HK family, especially HK2, is significantly increased. HK2, a member of the HK family, is the first key rate‐limiting enzyme in glycolysis and can phosphorylate glucose to glucose 6‐phosphate.3.1.4.2PK oversees catalyzing the final step of glycolysis as a rate‐limiting enzyme. It can catalyze the dephosphorylation of PEP in the glycolysis pathway to form pyruvate and produce ATP. Meanwhile, it is also one of the rate‐limiting enzymes in the glycolysis pathway. Four subtypes of PK are known, including L, R, M1, and M2. Among them, PKM2 is a signature isoenzyme in vigorous nucleic acid synthesis cells.3.1.4.3PFK is also one of the rate‐limiting enzymes in glycolysis and can catalyze the reaction of F6P to fructose 1,6‐diphosphate. PFK2/PFKFB, as an allosteric activator of PFK1, is a main regulator of glycolysis. Its isoform PFKFB3 activates PFK1 allosterically, which promotes the synthesis of fructose 2,6‐diphosphate and the tumor glycolysis process. It is highly related to the survival and proliferation of tumor cells and has been found to be highly expressed in a variety of tumors. Due to metabolic reprogramming, the expression of PFK2 increases significantly. PFK2 can catalyze the conversion of F6P to fructose 1,6‐diphosphate and promote the tetramerization of PK, which later transforms into a glycolytic enzyme complex. Ultimately, glycolysis is promoted. In addition, PFK1 and PFKFB3 are related to the biosynthesis of tumor cells.3.1.4.4The glucose transport protein (GLUT) family consists of 13 members, among which GLUT 1–4 are the basic glucose transporters. GLUT 1 is a glucose transporter on the erythrocyte membrane. Expression of the glucose transporter GLUT1 in tumor cells. GLUT 4 is an insulin‐sensitive glucose transport carrier that is expressed in insulin‐sensitive tissues such as fat and muscle tissues.3.1.53.1.5.1AKT is one of the main regulators of cellular energy metabolism. It can stimulate aerobic glycolysis in tumor cells, which causes those tumor cells to rely heavily on aerobic glycolysis for survival and proliferation. AKT can also enhance glycolysis through a variety of other cellular mechanisms.3.1.5.2mTOR is a highly conserved serine/threonine protein kinase that is activated in response to nutrients, growth factors, and cellular energy. Dysregulation of mTOR has been implicated in many diseases, including cancer, metabolic diseases, neurological disorders and inflammation.mTOR is composed of two different complexes, called mTORC1 and mTOR complex 2 (mTORC2). mTORC2 induces glucose transport by favoring glucose transporter exocytosis  in muscle. In addition, mTORC2 positively regulates glycolysis in skeletal muscle and liver through the same mechanism that requires AKT activation. Studies have also found that mTORC2 can control aerobic glycolysis in cancer cells (Warburg effect).3.1.5.3AMPK is a kinase regulated by AMP (adenylate‐activated protein), which is highly conserved in mammals. AMPK can promote ATP production and regulate ATP consumption and therefore is known as a “metabolic and energy receptor.” As a metabolic sensor, AMPK is involved in maintaining energy homeostasis by phosphorylating and regulating proteins that participate in many physiological processes. AMPK can inhibit energy consumption processes and promote energy production pathways to maintain energy homeostasis and ensure the survival of cells under stress conditions. Taking ACC as an example, AMPK can phosphorylate ACC and restrain its activity, decreasing malonyl‐CoA production and reducing fatty acid synthesis. Similarly, the metabolic functions of AMPK in the glycolysis pathway, the TCA cycle, and other carbohydrate metabolism pathways have been widely studied. It has also been found that AMPK plays an important role in glycolysis by regulating PFK and other enzymes that promote glycolysis in cancer cells and uptake glucose by increasing the expression of GLUT.In addition, AMPK has been implicated as a tumor suppressor because it can control the cell cycle promoter and regulate epigenetic regulators, which can intercept the cell cycle. The serine/threonine protein kinase B‐Raf (BRAF) is phosphorylated by AMPK at Ser729, which changes its binding partner from Ras kinase inhibitor (KSR1) to 14‐3‐3 protein, thereby blocking cell cycle progression and cell proliferation. Likewise, AMPK can disrupt the cell cycle by inducing the expression of p27, p21, p53, and pRb proteins, which play an essential role in regulating cell growth and division. It is obvious that the AMPK signaling pathway plays an indispensable role in tumor glucose metabolism.3.1.6Even under restricted energy resources and other adverse circumstances, tumors show the ability to reprogram metabolism to promote cell growth and proliferation. Studies have shown that NAD+/NADH and NADP+/NADPH ratios are higher in tumors than in nontumors, which implies that NAD+ plays an important role in metabolic conversion.Glucose uptake by cancer cells is significantly increased, which provides sufficient energy for cancer cells to support their uncontrolled proliferation. As both the GAPDH conversion and lactate production steps depend on NAD+, its level must be increased to meet the requirement of high glycolysis. In addition, the secretion of lactic acid can acidify the TME, which contributes to the invasiveness of tumors. Therefore, NAD metabolism is believed to indirectly affect the growth and invasiveness of tumors.Moreover, some glycolytic intermediates are also involved in other metabolic pathways that are closely related to NAD metabolism. As in the PPP pathway mentioned earlier, the first step of this pathway is NADP+ dependent and is the main source of NADPH in cells. As a vital cofactor for various antioxidant proteins, NADPH helps combat oxidative stress resulting from accelerated metabolism, induced hypoxia, and accumulation of DNA damage in cancer cells. Apart from that, the serine synthesis pathway (SSP) is also dependent on NAD+. The glycolytic intermediate 3‐PG bypasses glycolysis to produce serine by using NAD+ as a redox cofactor.NAD+ is not only essential in energy metabolism but also involved in important cell signal transduction processes, which is an important bridge between the two. As an essential component in cancer cell metabolism, NAD+ is involved in deacetylation reactions carried out by deacetylase enzymes such as sirtuins (SIRTs) and polyADP ribose polymerases (PARPs) and generates calcium ions to mobilize molecular cyclic ADP nucleic acid sugar and NAADP. These signaling events are involved in cell cycle progression, transcriptional regulation and DNA repair and have therefore been identified as potential targets for tumor treatment.It can be concluded that NAD+ plays a central role in the tumor cell metabolic signaling pathway; therefore, NAD+‐dependent processes are highly promising targets for therapeutic applications to treat cancer.3.2Amino acids play important roles in tumor cell growth and survival, including providing carbon sources for TCA, nitrogen sources for base synthesis, and regulating the redox balance. Similar to glucose, energy metabolism and biosynthesis of tumor cells both require the participation of amino acids, and therefore, targeting amino acid metabolism has become one of the focuses of modern cancer therapies.3.2.1For decades, researchers have found that glutamine metabolism is crucial for tumor cell growth and proliferation by supporting biomacromolecule synthesis and maintaining bioenergetics and redox homeostasis. Glutamine is the second key source of energy for tumor cells, so it is closely connected with the occurrence and development of tumors. The utilization of glutamine by tumor cells is significantly increased. Glutamine metabolism can promote tumor cell proliferation and inhibit cell death, thereby promoting tumor growth.Glutamine also provides a nitrogen source for nucleotide synthesis of purines and pyrimidines and participates in the synthesis of hexosamine and nonessential amino acids (NEAAs). Glutamine is an indispensable factor for promoting tumor cell proliferation because it can provide raw materials for the synthesis of biological macromolecules. As the amino acid demand of cancer cells increases, glutamine always depends on the exogenous supply, which is known as the “glutamine addiction” phenomenon.The effects of glutamine metabolism on tumors are closely related to intracellular signaling pathways. Many studies have shown that glutamine is required for the activation of mTORC1. Inhibition of the SLC1A5 transporter reduces the uptake of glutamine by cells, which is unable to activate mTORC1. Enhanced glutamine metabolism in tumor cells leads to an increase in α‐KG production, which can promote the translocation and activation of mTORC1 to lysosomes. Therefore, the growth and proliferation of tumor cells can be promoted, and the autophagy process can be inhibited. The regulatory relationships between mTORC1 and glutamine metabolism in tumor cells are complicated. The AMPK pathway acts as a metabolic regulator in tumor cells to maintain intracellular energy homeostasis, activate autophagy, and inhibit adipose synthesis and mTORC1 activation.Moreover, glutamine metabolism can affect the occurrence and development of tumors by affecting autophagy. Autophagy‐associated protein and its upstream signaling molecules can regulate autophagy. Among them, mTORC1 can affect autophagy by regulating metabolism and the cell environment. The α‐KG produced by glutamine metabolism promotes the translocation of mTORC1 to the lysosomal surface by activating RRAG in the presence of EGLNs and activates mTORC1 in the presence of RHEB, which then induces the phosphorylation of ULK1 and TFEB and inhibits autophagy.Tumor cells take up many glutamines to maintain mitochondrial metabolism. It is not only an important source of nitrogen and carbon but also a regulator of intracellular redox homeostasis and signal transduction. Glutamine plays an important role in cell function, growth and proliferation. Although glutamine metabolism has been investigated for years, its complex metabolic regulatory mechanism still needs to be further explored to prove that glutamine metabolism is a potential target for cancer diagnosis and treatment.3.2.2Serine is extremely important for the proliferation of tumor cells, and some of its metabolites or key enzymes can regulate the growth of tumor cells. When serine supplementation is insufficient, tumor cells can produce endogenous serine through the SSP.In cancer cells, phosphoglycerate triphosphate, a product of glycolysis, can generate phosphopyruvate by having phosphoglycerate dehydrogenase (PHGDH) and NADPH participate in the reaction process. Then, serine is generated through a series of reactions. PKM2 is expressed during tumor proliferation, and its activity is affected by serine. When the number of serine residues drops, PKM2 is less active. Pyruvate produced by glycolysis is reduced, and therefore, the conversion of 3‐phosphoglycerate (3‐PG) to serine is enhanced.Although serine is an NEAA, it plays an essential role in metabolism. One‐carbon units of tumors are mainly derived from serine. Tumor cells can increase the supply of one‐carbon units by rapidly taking in exogenous serine. When exogenous serine is lacking, tumor cells can activate SSP to generate serine. These two pathways allow tumor cells to acquire enough serine to maintain their maximum growth rate. In most rapidly proliferating cells, serine is mainly catalyzed by SHMT2 to produce one carbon unit. It enters the cytoplasm in the form of formic acid to participate in nucleotide synthesis.3.2.3Amino acids such as leucine, isoleucine and valine are known as branched chain amino acids (BCAAs) due to the branched methyl groups in their hydrophobic side chains. As essential amino acids for the body, they can be directly involved in the composition of tissue proteins. In addition, branched‐chain ketoacids and glutamate can branch out through the metabolism of BCAA aminotransferase (BCAT).It is believed that BCAA catabolism plays a major role in human cancer. Studies have shown that low BCAA catabolism contributes to cancer progression, and changes in BCAA levels in cancer patients have been a concern for a long period of time.Metabolic reprogramming of BCAAs changes the levels of these essential metabolites. These metabolites provide nutrients to tumors and build basic substances of the cytoskeleton. The signaling pathways are activated, and the epigenetic profile is reshaped. Thus, the drug resistance of tumors is enhanced, ultimately leading to the survival and rapid invasion of cancer cells. Based on the importance of BCAA metabolic reprogramming in tumor progression, it is believed that enzymes involved in BCAA metabolism may be potential targets for future cancer therapy.3.2.43.2.4.1Aspartate (Asp) is an NEAA that can be synthesized to replenish intracellular stores and degraded from asparagine. Maintenance of asparagine and Asp homeostasis is important to the growth of tumors. In tumor cells, Asp and asparagine not only participate in the proliferation of tumor cells but also regulate signal transduction in cancer cells.3.2.4.2Asparagine (Asn) is an important regulator of amino acid homeostasis, anabolism, and proliferation in tumor cells. Asparagine takes aspartic acid as the substrate and uses glutamine to form the amino group produced by the conversion of ammonia during glutamic acid formation. Under the action of asparagine synthetase (ASNS), asparagine is formed by combining ATP. Intracellular asparagine is known as an amino acid exchange factor that can balance other extracellular amino acids in cells, including glycine, histidine, threonine, and serine.3.2.4.3As a multifunctional amino acid, arginine has a variety of biological functions in metabolism and signaling pathways. Its quantity in cancer cells and related metabolic pathways have an important impact on the growth of tumor cells. Arginine participates in the protein synthesis of tumor cells and is also a precursor for the synthesis of several molecules, including urea, nitric oxide, polyamines, proline, and agmatine.3.2.4.4Proline is important in tumor metabolic reprogramming, which can affect the occurrence and development of cancer. Proline metabolism is associated with ATP production, protein and nucleotide synthesis, and redox homeostasis in tumor cells. Cell clonogenesis and tumorigenesis are inhibited by proline starvation or inhibition of proline biosynthesis. Meanwhile, some cancer cells that depend on exogenous proline showed hyperactivation of the 4E‐binding protein 1  signal axis, which is mediated by mTORC1. Supplementation with exogenous proline can alleviate endoplasmic reticulum (ER) stress and promote cell homeostasis and clone formation.3.2.4.5Cysteine is a class of semi‐essential amino acids that are involved in protein synthesis. Cysteine and cystine in tumor cells not only provide energy for tumor cell proliferation but also mediate tumor growth by regulating tumor cell signaling. Apart from being involved in protein synthesis, cysteine is also the rate‐limiting precursor of intracellular GSH synthesis, thus affecting cellular redox homeostasis. Cysteine is unstable in vitro, and the two cysteines are easily oxidized to form cysteines containing disulfide bonds. Most cancer cells mainly take up extracellular cystine through the glutamate/cystine transporter system. Cystine can be rapidly reduced to cysteine in the cell. Some of the cysteines are involved in the synthesis of GSH, and the other part is oxidized out of the cell as cysteine to re‐participate in the system circulation. In the process of cysteine metabolism, cysteine dioxygenase is associated with drug resistance and poor prognosis of tumors. At the same time, cystathionine‐beta‐synthase in the process of its metabolism has also been proven to be related to the proliferation, migration and spread of malignant tumors.3.2.4.6Alanine is synthesized by alanine aminotransferase and is associated with the central hub of carbon metabolism. It is believed that alanine metabolism is important in cancer. Its biosynthesis is associated with proliferation, which implies that it is important in the metabolism of proliferating cells.3.3Enhancement of fatty acid synthesis is another important metabolic feature of tumors that is closely related to glycolysis metabolism.Regardless of the level of extracellular fatty acids in tumor cells, most tumor cells can synthesize fatty acids at a high rate. Some researchers found that almost all esterified fatty acids in tumors came from de novo synthesis.3.3.1There are two main sources of fatty acids: exogenous intake and endogenous synthesis (de novo synthesis of fatty acids). Most normal cells obtain FA through exogenous pathways, while FA in tumor cells is usually endogenously synthesized de novo, and those key enzymes in the synthesis pathway can be regulated. After entering the bioactive pool, FA can activate the modification of CoA by fatty acyl‐CoA synthetase. Triglycerides (TGs) or sterol esters (SEs) are generated and stored in lipid droplets (LDs). FAs can be used for many purposes in cells, such as being raw material for the activity of the cell membrane, signaling molecules or oxidating carbon dioxide as an energy source. This indicates that FA plays an important role in tumorigenesis and development. The de novo synthesis of fatty acids in tumor cells occurs in several processes. The continuous activation of glycolysis produces a large amount of pyruvate, which enters the mitochondria and is catalyzed by PDH to produce acetyl‐CoA, followed by acetyl‐CoA and OAA to produce citric acid under the action of CS. Some of the citric acid then enters the TCA cycle, while others can cross the mitochondrial membrane and enter the cytoplasm. Acetyl‐CoA and oxaloacetic acid were catalyzed by ATP‐citrate lyase (ACLY). Acetyl‐CoA is an important precursor for the synthesis of fatty acids in the cytoplasm. ACC catalyzes the formation of malonyl‐CoA from partial acetyl‐CoA. Subsequently, one acetyl‐CoA molecule and seven malonyl‐CoA molecules were condensed continuously to produce palmitic acid under the action of FASN Figure . PalmitiMetabolic pathways to promote specific lipid accumulation in tumor growth can be upregulated by tumors. For example, several key lipid metabolic enzymes in tumors, such as ACC, FASN, and ACLY, were upregulated. Inhibition of these enzymes involved in FA synthesis can suppress tumor growth and metastasis. ACC is the rate‐limiting enzyme of FA synthesis and is highly expressed in breast and prostate cancers, and inhibition of ACC leads to decreased adipose synthesis and apoptosis.Although de novo fatty acid synthesis is also present in normal cells, it is limited to the liver, adipose tissue, and breast during lactation. De novo fatty acid synthesis is an important metabolic feature that distinguishes cancer cells from normal cells. It is of great significance to explore the regulatory mechanism of fatty acid synthesis and its role in the development of tumors for a more comprehensive understanding of the pathogenesis and treatment of tumors.3.3.2The enhancement of the de novo fatty acid synthesis pathway is the main manifestation of lipid metabolism reprogramming in tumor cells, which involves a variety of key enzymes, mainly including increased expression of ACLY, ACC, and FASN.3.3.2.1ACLY is the first key enzyme in the de novo synthesis of fatty acids, which can catalyze the production of acetyl‐CoA from citric acid and serves as a crucial bridge between glucose metabolism and lipid metabolism in cells. Citric acid enters the cytoplasm from the mitochondria, and ACLY can catalyze it to produce acetyl‐CoA, which is an important raw material for fatty acid synthesis. Therefore, with changes in the energy metabolism of cancer cells, the increase in glucose uptake and the acceleration of glycolytic flux will inevitably lead to an increase in citric acid production and ultimately promote fatty acid synthesis in cells. The expression of ACLY in tumors is greater than that in normal tissue and is closely related to tumor stage and prognosis.3.3.2.2ACC can catalyze acetyl‐CoA to produce malonyl‐CoA, which is upregulated by citric acid and glutamic acid and downregulated by acyl‐coenzyme A  in cells.3.3.2.3FASN is the third key enzyme in fatty acid synthesis. It catalyzes a continuous condensation reaction to produce palmitate ester by using acetyl‐CoA and malonyl‐CoA as substrates. FASN is the most investigated fatty acid metabolism enzyme in cancer at present. The increase in fatty acid synthesis caused by the increased expression of FASN in cancer has been confirmed by a number of studies,3.43.4.1Lactate has been considered in the past as a biomarker of metabolic waste products produced by cellular glycolysis and malignancy. However, recent studies have found that extratumoral lactate accumulation is associated with a higher incidence` of metastasis and decreased overall survival. In addition, lactate can act as an important signaling molecule affecting surrounding cells and plays an essential role in regulating metabolism.Tumors tend to produce large amounts of lactic acid during glycolysis. Glucose is absorbed and converted to lactic acid by glycolysis, which is recognized as the Warburg effect. To avoid excessive cytosolic acidification, tumor cells must transport lactate out of the cell via MCTs. Reversible proton/lactate cotransporters MCT1 and MCT4 are the main lactate transporters in tumor tissues and can be regulated by intracellular and extracellular monocarboxylate and proton concentration gradients that are prevalent on both sides of the cell membrane.In addition, some scholars have proposed the “reverse Warburg effect”, which occurs in tumor‐associated fibroblasts (TAFs).Increased levels of lactate, glycolysis metabolites, and lactate shuttling between TAF and tumor cells promoted cancer cell proliferation and metastasis, suggesting that lactate may be a novel target for cancer therapy.3.4.2Inside cells, nucleotides are involved in a number of important biological processes, including RNA production and DNA replication, to ensure protein synthesis at different stages of the cell cycle. Nucleotide synthesis requires intermediate or end products of various metabolic pathways to provide carbon and nitrogen precursors, and the related metabolic enzymes synthesized by nucleotide synthesis are regulated in various ways, including transcriptional regulation, allosteric regulation, and feedback regulation. There are two main approaches to nucleotide synthesis in organisms: de novo synthesis and nucleotide salvage.The substrates in nucleotide biosynthesis are derived from carbon and nitrogen precursors provided by glycolysis, PPP, the serine‐glycine pathway, the TCA cycle, and glutamine transaminase reactions, including aspartic acid, glutamine, serine and glycine, and CO2. Therefore, in tumor cells, the regulation of these metabolic pathways often leads to changes in nucleotide metabolic pathways. Taking the change in carbon in metabolism as an example, the change in nucleotide metabolism will lead to a change in nucleotide metabolism, and the mechanism regulating the flow of carbon sources into one‐carbon metabolism is the allosteric activation of PKM2 mediated by serine. In addition, in tumor cells, the decrease or loss of argininosuccinate synthase 1 (ASS1), an important metabolic enzyme in the urea cycle, induces the accumulation of aspartic acid, an important substrate in pyrimidine synthesis, which enhances the activity of carbamoyl‐phosphate synthetase (CAD), leads to an increase in pyrimidine synthesis, and finally promotes the proliferation of tumor cells.3.4.3Apart from glucose metabolism, glutamine metabolism, and lipid metabolism, cancer cells can also metabolize exogenous acetate to obtain resources for growth under nutrient‐limited conditions.3.5Metabolic reprogramming in tumors induces several changes in metabolism, including abnormalities in metabolites and metabolic enzymes. As a variety of metabolic intermediates are used as substrates during the epigenetic process, changes in tumor metabolic reprogramming can activate or inhibit epigenetic trimming, which affects the expression of epigenetics, such as DNA or histone methylation and histone acetylation Figure . EpigeneCellular epigenetics can be influenced by tumor metabolism through at least three different mechanisms. First and foremost, the reprogramming of metabolic pathways leads to altered levels of metabolites, some of which are important cofactors or substrates of key enzymes for epigenetic modification. The second mechanism is related to metabolic products produced after metabolic enzymes are transported into the nucleus. In addition, it is believed that the production of cometabolites can be controlled by regulating the activity of several potent epigenetic enzymes.For histone acetylation, an acetyl group is shifted from acetyl‐CoA to lysine residues by histone acetyltransferases (HATs),With the further study of epigenetics, its role in the development of malignant tumors has been recognized. Therefore, epigenetic therapy based on DNA or histone methylation and histone acetylation is also a hot topic in the future treatment of tumors.3.6Complex metabolic patterns similar to those of tumor cells also exist in immune cells. There are significant differences in the energy consumption patterns of immune cells between the resting state and the activated state. At rest, immature T cells mainly produce ATP through OXPHOS, and when activated into effector T cells, they mainly produce energy through glycolysis. In addition, different immune cells mainly produce energy in different ways, so the differentiation of immune cell subsets can be affected by diverse metabolic patterns.Interactions between tumor cells and immune cells affect metabolic reprogramming. On the one hand, tumor cells compete to consume nutrients in the immune microenvironment, such as glucose; on the other hand, tumor cells secrete various metabolites, which affect gene expression and signal transduction in tumor cells and reshape the tumor immune microenvironment.4Surgery, chemotherapy, and radiotherapy have long been the conventional options for cancer treatment. The choice of treatment varies, depending on the type, extent, and progression rate of cancer and the condition and treatment response of the patient. Although the above options are available for cancer therapy, different cancer cells exhibit diverse and multiple unpredictable responses toward different treatments, and cancers will contribute to progress when the current treatments fail. Therefore, it is crucial to explore alternative therapeutic options for cancer.At present, based on the method of intervention, therapeutic approaches are basically divided into two types: nutritional treatments by dietary‐related modulation4.1As research progresses, knowledge and understanding of the multiple targets of metabolic reprogramming is gradually increasing, which has facilitated the development of targeted drug therapies for various aspects of metabolism. Therefore, the targeting of relevant metabolic pathways with specific drugs has the potential to significantly reduce the growth and proliferation of cancer cells. Various drugs classified according to different metabolic pathways, including glucose metabolism, amino acid metabolism, one‐carbon metabolism, lipid metabolism and other metabolic and growth pathways, are summarized in Table 4.2Metabolic reprogramming facilitates metabolic pathways for multiple metabolites, which then in turn serve the metabolic pathways above, thereby promoting the growth and proliferation of tumors and inhibiting tumor apoptosis. As a result, cancer is also considered to be a metabolic disease, and this view influences the approach to cancer management and prevention.Based on the increasing understanding of the metabolic mechanism and the nutritional demands of tumors, dietary nutritional modification has therefore been proposed to serve as a complement to conventional cancer therapies.Notably, cancer cells are highly metabolically heterogeneous. Nutritional intervention must be precise, as different cancer cells show significant differences in the metabolism of the same nutrients. Therefore, nutritional intervention requires precision. Additionally, when one metabolic pathway is blocked, cancer cells can usually switch or activate other pathways to escape stress damage. Hence, various metabolic therapies should be integrated for multiple metabolic pathways to improve therapeutic efficacy. Before dietary intervention becomes a common approach for cancer treatment, further preclinical studies and clinical trials are still required to better understand the dietary changes in metabolic reprogramming.5Tumors are a complex metabolic disease. Starting from the understanding of the “Warburg effect,” great progress has been made in the field of cancer metabolism, and research on relevant metabolic pathways is becoming increasingly extensive. With the deepening of tumor metabolism research, the mechanism of tumor generation and development has been further clarified; that is, metabolic reprogramming plays an important role in the growth and proliferation of tumors. Through the interaction of a variety of circulatory and metabolic pathways, as well as the use of alternative substrates, the metabolic plasticity of tumors is endowed. Moreover, tumor cells undergo metabolic regulation to adapt to changes in their growth environment, which can be a target for tumor therapy. For tumor therapy, in addition to traditional nutritional interventions, drug therapies targeting key proteins in related signaling pathways are also expected to become emerging approaches. Therefore, studying the important metabolic pathways and key metabolic enzymes of tumors is of great significance for the diagnosis and treatment of tumors, providing more potential tumor treatment options. The combination of multiple strategies is also considered to be a promising treatment. However, this review only summarized the mechanisms and potential applications of metabolic reprogramming for tumor therapy based on existing studies. More research and technological development are still necessary, and more evidence and further exploration of metabolic changes are needed to formulate targeted anticancer strategies and explore the possibility of more tumor treatments.S. N., X. H., and X. M. selected the topic of the review, performed the literature search, and wrote the manuscript. Y. X., Y. Q., K. S., J. Y., and T. Z. contributed to include literature and helped to edit the final manuscript. K. T. and Y. W. designed the figures and modified the manuscript. All authors read and approved the final version of the manuscript.There are no conflict of interest to declare.This review does not address ethical issues.The authors declare that there was no funding for the study.


Arthrogryposis multiplex congenita forms a broad group of clinically and etiologically heterogeneous disorders characterized by congenital joint contractures that involve at least two different parts of the body. Neurological and muscular disorders are commonly underlying arthrogryposis. Here, we report five affected individuals from three independent families sharing an overlapping phenotype with congenital contractures affecting shoulder, elbow, hand, hip, knee and foot as well as scoliosis, reduced palmar and plantar skin folds, microcephaly and facial dysmorphism. Using exome sequencing, we identified homozygous truncating variants in FILIP1 in all patients. FILIP1 is a regulator of filamin homeostasis required for the initiation of cortical cell migration in the developing neocortex and essential for the differentiation process of cross-striated muscle cells during myogenesis. In summary, our data indicate that bi-allelic truncating variants in FILIP1 are causative of a novel autosomal recessive disorder and expand the spectrum of genetic factors causative of arthrogryposis multiplex congenita. Arthrogryposis multiplex congenita (AMC) refers to a wide range of congenital conditions defined by joint contractures in at least two body areas  has first been identified as a protein regulating the start of cortical cell migration in the developing neocortex through filamin A (FLNa) degradation. In this function, FILIP1 induces degradation of FLNa and suppresses radial cell migration out of the ventricular zone in neocortical neurons  approach, we were able to show that all affected individuals carry homozygous truncating variants in All five affected individuals reported herein were born to healthy, consanguineous parents and presented with an overlapping arthrogryposis phenotype. We used the GeneMatcher  of the Cologne Center for Genomics . We obtained a mean coverage of 58–63 reads, and 95.8–96.2% of targets were covered more than 10x. Sanger sequencing was used to validate the homozygous variant in the three affected brothers and the heterozygous carrier state in both parents.In family 1, we performed ES on genomic DNA extracted from peripheral blood lymphocytes of the affected brothers III.1 and III.2. Exonic and adjacent intronic sequences were enriched using the Agilent SureSelect Human All Exon V6 enrichment kit and were run on an Illumina HiSeq4000 sequencer. Data analysis and filtering of mapped target sequences were conducted by the exome and genome analysis pipeline “Varbank 2.0” . Variants were assessed for clinical phenotypic match and according to the American College of Medical Genetics and Genomics (ACMG) guidelines  using Applied Biosystems StepOne™ Real-Time PCR System, PowerUp SYBR Green PCR Master Mix and StepOne Software v2.3 for data analysis. The relative exon copy number was calculated by the expression 2 × 2(−ΔΔCt).In family 3, we initiated trio-ES on genomic DNA obtained from peripheral blood lymphocytes of the patient III.3 and his parents. The exonic and flanking genomic regions were captured using Agilent SureSelect Clinical Research Exome V2 capture kit. Exome sequencing had an average coverage of 100 to 130 × , and 95% of bases covered at a minimum of 20 × with 90% sensitivity , and not annotated in the in-house WES datasets of the CCG. Using these filter criteria, we identified only one homozygous truncating variant shared by the bothers III.1 and III.2 that is predicted to have a severe impact on protein function and to be most likely deleterious. The variant, c.463G>T, is located in exon 4 of the FILIP1 gene (GenBank: NM_015687.4) and induces the formation of a premature stop codon at the amino acid position 155 (p.(Glu155*))  in individual III.1 and a homozygous stretch of 29.2 Mb  in individual III.2. We confirmed the presence of the homozygous variant in all three affected brothers III.1, III.2 and III.3 as well as the heterozygous carrier status of the parents by Sanger sequencing  < 1.0% in the gnomAD database (FILIP1 that induces the formation of a premature stop codon at the amino acid position 889 (p.(Arg889*)) in exon 5 . In accordance with the ACMG guidelines  spanning FILIP1 gene. The phenotypic analysis of our cohort highlights that the most common clinical findings are elbow contracture, camptodactyly and feet anomalies such as club feet and rocker bottom feet present in all three families. Movement restrictions also involve shoulder, hip, knee and other large joints. Further frequent features include scoliosis, reduced palmar and plantar skin folds, translucent skin with prominent veins as well as craniofacial dysmorphism. Interestingly, three patients share microcephaly and a fourth affected individual presented with a head circumference within low standard range. Except for reduced fine motor skills due to finger contractures and gait impairment caused by feet deformities, motor development was normal. Delayed speech development was observed in the three affected individuals of family 1, whereas all other patients did not show any speech abnormalities. Overall, we observed a clinical variability even within the same family, which might be caused by modifying factors. To characterize the spectrum of phenotypic features in more detail, a larger patient cohort is needed.In this study, we describe a novel arthrogryposis phenotype in five patients from three unrelated families characterized by variable severity of multiple congenital joint contractures and associated with homozygous putatively deleterious variants in the FILIP1 has not only been observed in the central nervous system , but a robust gene expression has also been detected in heart, skeletal and smooth muscle, suggesting that FILIP1 might also be involved in myogenesis. In addition, low expression levels of FILIP1 were detected in lung, skeletal muscle, ovary, testis, kidney, and fetal brain  has first been identified as a protein regulating the start of cortical cell migration in the developing neocortex through filamin A (FLNa) degradation. FILIP1 induces degradation of FLNa and suppresses radial cell migration out of the ventricular zone in neocortical neurons  at its N-terminus and an additional central structural maintenance of chromosome (SMC) domain Fig.  Nagano . Apart fFILIP1 nonsense variants and a deletion affecting exons 3–6 of FILIP1 in patients with multiple joint contractures. The variant c.463G>T (p.(Glu155*)) in family 1 is located within the CortBP2 domain, whereas the variant c.2665C>T (p.(Arg889*)) in family 2 is related to FLNa- and RhoD-binding motifs  24 alleles with nonsense variants, all in heterozygous state, were reported in the gnomAD database in contrast to 48.3 that were expected to be observed in the > 250,000 alleles. In addition, no bi-allelic CNVs encompassing FILIP1 have been reported so far in the DECIPHER database, the Database of Genomic Variants (DGV) and the structural variant (SV) dataset of gnomAD. Until now, the functional and clinical significance of CortBP2 and SMC domains has remained unclear. Since both nonsense variants and the deletion are located within different parts of the protein and cause a similar arthrogryposis phenotype in our cohort, it is most likely that all variants induce loss of FILIP1 function, either by leading to nonsense-mediated mRNA decay, inducing protein instability and subsequent degradation of truncated FILIP1, or by functional impairment based on the loss of essential domains of FILIP1.In this study, we identified two FLNA gene on the X chromosome. Remodeling actin cytoskeleton, FLNa is involved in a variety of cellular functions, such as signal transduction, cellular proliferation, differentiation and migration  MyoD, Myogenin and Myolinc in differentiating myoblasts , a DNA/RNA-binding protein that is localized to the nuclei of myotubes and acts as a transcriptional regulator influencing the expression of several muscle-specific genes  (Reimann et al. FLNC gene cause skeletal muscle disorders such as myofibrillar myopathy, distal myopathy and limb girdle muscular dystrophy, whereas associated cardiac defects mainly include dilated, restrictive and hypertrophic cardiomyopathies, and cardiac arrhythmias (Mao and Nakamura FILIP1 expression has also been detected in heart muscle (Nagano et al. Interaction of FILIP1 with FLNc in skeletal and cardiac muscle cells plays an important role in Z-disc formation to connect sarcomeres (Thompson et al.  FLNC missense variants an additional arthrogryposis phenotype was described (Kiselev et al. FILIP1 inhibits the formation of multi-nucleated myotubes and decreases the expression levels of MRFs MyoD, Myogenin and Myolinc in differentiating myoblasts (Militello et al. FILIP1 leading to a premature stop of protein synthesis and probably to a loss of protein function result in significant impairment in embryonic muscle differentiation giving rise to a congenital disorder with multiple joint contractures in our patient cohort.In three patients presenting with a combination of early-onset restrictive cardiomyopathy and congenital myopathy due to de novoFILIP1 gene cause a novel autosomal recessive arthrogryposis phenotype with microcephaly. The contractural features in combination with microcephaly in our patients strongly support that FILIP1 plays a significant role in both, skeletal muscle cell differentiation and brain development, during embryonic development. However, further functional studies are necessary to clarify the detailed pathophysiological mechanisms leading to arthrogryposis; this might pave the way for novel treatment strategies.In summary, we provide clinical and genetic evidence that bi-allelic deleterious variants in the