PPAR? and Diabetes: Beyond the Genome and Towards Personalized Medicine

Purpose of Review Full and partial synthetic agonists targeting the transcription factor PPAR? are contained in FDA-approved insulin-sensitizing drugs and used for the treatment of metabolic syndrome-related dysfunctions. Here, we discuss the association between PPARG genetic variants and drug efficacy, as well as the role of alternative splicing and post-translational modifications as contributors to the complexity of PPAR? signaling and to the effects of synthetic PPAR? ligands. Recent Findings PPAR? regulates the transcription of several target genes governing adipocyte differentiation and glucose and lipid metabolism, as well as insulin sensitivity and inflammatory pathways. These pleiotropic functions confer great relevance to PPAR? in physiological regulation of whole-body metabolism, as well as in the etiology of metabolic disorders. Accordingly, PPARG gene mutations, nucleotide variations, and post-translational modifications have been associated with adipose tissue disorders and the related risk of insulin resistance and type 2 diabetes (T2D). Moreover, PPAR? alternative splicing isoforms-- generating dominant-negative isoforms mainly expressed in human adipose tissue--have been related to impaired PPAR? activity and adipose tissue dysfunctions. Thus, multiple regulatory levels that contribute to PPAR? signaling complexity may account for the beneficial as well as adverse effects of PPAR? agonists. Further targeted analyses, taking into account all these aspects, are needed for better deciphering the role of PPAR? in human pathophysiology, especially in insulin resistance and T2D. Summary The therapeutic potential of full and partial PPAR? synthetic agonists underlines the clinical significance of this nuclear receptor. PPARG mutations, polymorphisms, alternative splicing isoforms, and post-translational modifications may contribute to the pathogenesis of metabolic disorders, also influencing the responsiveness of pharmacological therapy. Therefore, in the context of the current evidence-based trend to personalized diabetes management, we highlight the need to decipher the intricate regulation of PPAR? signaling to pave the way to tailored therapies in patients with insulin resistance and T2D.