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This metabolic downregulation is also important when generating and/or maintaining persister cells, which are transiently dormant, drug-tolerant phenotypes that can reseed biofilms when they are no longer under drug pressure

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Combined with the hormonal responses to hypoglycemia and starvation chronic ethanol intake leads to reduced insulin production and increased catecholamine, cortisol, glucagon, and growth hormone release

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However, determining clinically beneficial doses of metformin is challenging due to the unknown portal vein and liver concentrations of metformin following oral ingestion in humans (Lamoia and Shulman, 2021)