Metformin is the first-line antidiabetic drug and one
of the most
prescribed medications worldwide. Because of its ubiquitous occurrence
in global waters and demonstrated ecotoxicity, metformin, as with
other pharmaceuticals, has become a concerning emerging contaminant.
Metformin is subject to transformation, producing numerous problematic
transformation byproducts (TPs). The occurrence, removal, and toxicity
of metformin have been continually reviewed; yet, a comprehensive
analysis of its transformation pathways, byproduct generation, and
the associated change in adverse effects is lacking. In this review,
we provide a critical overview of the transformation fate of metformin
during water treatments and natural processes and compile the 32 organic
TPs generated from biotic and abiotic pathways. These TPs occur in
aquatic systems worldwide along with metformin. Enhanced toxicity
of several TPs compared to metformin has been demonstrated through
organism tests and necessitates the development of complete mineralization
techniques for metformin and more attention on TP monitoring. We also
assess the potential of metformin to indicate overall contamination
of pharmaceuticals in aquatic environments, and compared to the previously
acknowledged ones, metformin is found to be a more robust or comparable
indicator of such overall pharmaceutical contamination. In addition,
we provide insightful avenues for future research on metformin.