1
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Zhang B, Cao Y, Qu Z, Sun Y, Tian X. The impact of metformin on mortality in patients with type 2 diabetes mellitus: a prospective cohort study. Endocrine 2024:10.1007/s12020-024-04012-x. [PMID: 39190051 DOI: 10.1007/s12020-024-04012-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Accepted: 08/19/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND Metformin, a widely used antihyperglycemic drug, has shown efficacy in treating type 2 diabetes mellitus (T2DM) and is associated with potential benefits beyond glycemic control. This study investigates the impact of metformin on mortality in T2DM patients using a prospective cohort design utilizing data from the National Health and Nutrition Examination Survey (NHANES). METHODS In NHANES 1999-2014, a total of 5813 representative participants aged 20 and above with T2DM were included in the analysis. We utilized Kaplan-Meier survival curves and multivariate Cox regression analysis to investigate the impact of metformin on both all-cause mortality and cause-specific mortality among patients with T2DM. RESULTS Kaplan-Meier analysis showed a significant reduction in all-cause and cause-specific mortality in metformin users compared to non-users (p < 0.05). Multivariate Cox regression confirmed these findings, indicating that metformin use was associated with a 18% reduction in all-cause mortality (HR = 0.82, 95% CI = 0.73-0.92, p < 0.001) and 25% reduction in cardiovascular mortality (HR = 0.75, 95% CI = 0.60-0.94, p = 0.01). CONCLUSION Our results suggest that metformin significantly reduces all-cause and cardiovascular mortality in T2DM patients, highlighting its potential benefits beyond glycemic control. These results contribute to the existing literature by providing robust evidence from a large prospective cohort study. However, further research is needed to validate these findings and elucidate the underlying mechanisms controlling the effects of metformin on mortality outcomes in individuals with T2DM.
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Affiliation(s)
- Bocheng Zhang
- Second Affiliated Hospital, Dalian Medical University, Dalian, China
| | - Ying Cao
- Second Affiliated Hospital, Dalian Medical University, Dalian, China
| | - Zhenan Qu
- Affiliated Zhongshan Hospital, Dalian University, Dalian, Liaoning, China
| | - Yulan Sun
- Anshan Central Hospital, Anshan, Liaoning, China
| | - Xiaoyuan Tian
- Second Affiliated Hospital, Dalian Medical University, Dalian, China.
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2
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Taha M, Azhary A, Hajhamed NM, Sir Alkhatim WA, Bakheit AM, Ahmed AE. A case report of metformin-associated lactic acidosis. Clin Case Rep 2024; 12:e9255. [PMID: 39091620 PMCID: PMC11291296 DOI: 10.1002/ccr3.9255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 07/03/2024] [Accepted: 07/06/2024] [Indexed: 08/04/2024] Open
Abstract
Key Clinical Message Metformin-associated lactic acidosis is a rare but serious complication in patients with type 2 diabetes, especially those with multiple health conditions. Prompt recognition and treatment, including potential renal replacement therapy, are crucial for managing severe acidosis and improving patient outcomes. Abstract Metformin (MTF) is commonly prescribed as a first-line treatment for diabetes, effectively preventing microvascular and macrovascular complications. However, metformin-associated lactic acidosis is a rare yet severe complication, associated with a mortality rate of up to 50%. We encountered a case involving a 73-year-old woman with type 2 diabetes, mental illness, and hypothyroidism, who developed life-threatening lactic acidosis while on metformin therapy. Upon presenting to the emergency department with complaints of weakness, nausea, and decreased urination for 5 days, she also reported abdominal pain and shortness of breath. Hypotension was noted with a blood pressure of 80/50 mmHg. Initial laboratory results revealed severe acidosis, prompting discontinuation of MTF. Despite resuscitation efforts and vasopressor therapy, severe acidemia persisted, leading to the initiation of renal replacement therapy. Following treatment with continuous renal replacement therapy, her acidemia resolved, and she was discharged from the hospital on the sixth day without complications, with normal kidney function.
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Affiliation(s)
- Mohammed Taha
- Department of Internal MedicineUniversity of GeziraGeziraSudan
| | - Ayman Azhary
- Department of Medical Microbiology, Faculty of Medical Laboratory SciencesOmdurman Islamic UniversityKhartoumSudan
- Molecular Biology UnitSirius Training and Research CentreKhartoumSudan
| | - Nooh Mohamed Hajhamed
- Department of Medical Microbiology, Faculty of Medical Laboratory SciencesOmdurman Islamic UniversityKhartoumSudan
- Molecular Biology UnitSirius Training and Research CentreKhartoumSudan
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3
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See KC. Metformin-associated lactic acidosis: A mini review of pathophysiology, diagnosis and management in critically ill patients. World J Diabetes 2024; 15:1178-1186. [PMID: 38983827 PMCID: PMC11229964 DOI: 10.4239/wjd.v15.i6.1178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 04/04/2024] [Accepted: 04/23/2024] [Indexed: 06/11/2024] Open
Abstract
Metformin is a common diabetes drug that may reduce lactate clearance by inhibiting mitochondrial oxidative phosphorylation, leading to metformin-associated lactic acidosis (MALA). As diabetes mellitus is a common chronic metabolic condition found in critically ill patients, pre-existing metformin use can often be found in critically ill patients admitted to the intensive care unit or the high dependency unit. The aim of this narrative mini review is therefore to update clinicians about MALA, and to provide a practical approach to its diagnosis and treatment. MALA in critically ill patients may be suspected in a patient who has received metformin and who has a high anion gap metabolic acidosis, and confirmed when lactate exceeds 5 mmol/L. Risk factors include those that reduce renal elimination of metformin (renal impairment from any cause, histamine-2 receptor antagonists, ribociclib) and excessive alcohol consumption (as ethanol oxidation consumes nicotinamide adenine dinucleotides that are also required for lactate metabolism). Treatment of MALA involves immediate cessation of metformin, supportive management, treating other concurrent causes of lactic acidosis like sepsis, and treating any coexisting diabetic ketoacidosis. Severe MALA requires extracorporeal removal of metformin with either intermittent hemodialysis or continuous kidney replacement therapy. The optimal time to restart metformin has not been well-studied. It is nonetheless reasonable to first ensure that lactic acidosis has resolved, and then recheck the kidney function post-recovery from critical illness, ensuring that the estimated glomerular filtration rate is 30 mL/min/1.73 m2 or better before restarting metformin.
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Affiliation(s)
- Kay Choong See
- Department of Medicine, National University Hospital, Singapore 119228, Singapore
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4
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Hall RK, Kazancıoğlu R, Thanachayanont T, Wong G, Sabanayagam D, Battistella M, Ahmed SB, Inker LA, Barreto EF, Fu EL, Clase CM, Carrero JJ. Drug stewardship in chronic kidney disease to achieve effective and safe medication use. Nat Rev Nephrol 2024; 20:386-401. [PMID: 38491222 DOI: 10.1038/s41581-024-00823-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2024] [Indexed: 03/18/2024]
Abstract
People living with chronic kidney disease (CKD) often experience multimorbidity and require polypharmacy. Kidney dysfunction can also alter the pharmacokinetics and pharmacodynamics of medications, which can modify their risks and benefits; the extent of these changes is not well understood for all situations or medications. The principle of drug stewardship is aimed at maximizing medication safety and effectiveness in a population of patients through a variety of processes including medication reconciliation, medication selection, dose adjustment, monitoring for effectiveness and safety, and discontinuation (deprescribing) when no longer necessary. This Review is aimed at serving as a resource for achieving optimal drug stewardship for patients with CKD. We describe special considerations for medication use during pregnancy and lactation, during acute illness and in patients with cancer, as well as guidance for the responsible use of over-the-counter drugs, herbal remedies, supplements and sick-day rules. We also highlight inequities in medication access worldwide and suggest policies to improve access to quality and essential medications for all persons with CKD. Further strategies to promote drug stewardship include patient education and engagement, the use of digital health tools, shared decision-making and collaboration within interdisciplinary teams. Throughout, we position the person with CKD at the centre of all drug stewardship efforts.
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Affiliation(s)
- Rasheeda K Hall
- Division of Nephrology, Department of Medicine, and Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | | | | | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, Australia
| | | | | | - Sofia B Ahmed
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lesley A Inker
- Division of Nephrology, Department of Internal Medicine, Tufts Medical Center, Boston, MA, USA
| | | | - Edouard L Fu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, USA
| | - Catherine M Clase
- Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Ontario, Canada
| | - Juan J Carrero
- Medical Epidemiology and Biostatistics, Karolinska Institutet, and Division of Nephrology, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden.
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5
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Rottura M, Drago SFA, Gianguzzo VM, Molonia A, Pallio G, Scoglio R, Marino S, Alibrandi A, Imbalzano E, Squadrito F, Irrera N, Arcoraci V. Chronic kidney disease progression in diabetic patients: Real world data in general practice. Heliyon 2024; 10:e30787. [PMID: 38765038 PMCID: PMC11096917 DOI: 10.1016/j.heliyon.2024.e30787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 05/21/2024] Open
Abstract
Aims the aim of the study was to analyze glomerular filtration ratio (GFR) changes in diabetic patients assisted by General Practitioners (GPs) evaluating the risk factors related to glomerular function. Methods patients with diabetes with at least three recorded values of creatinine were recruited in the study and GFR values were estimated. The quarterly percentage change in GFR for each patient was estimated. Nephrotoxic drugs were identified, and glucose-lowering drugs use was described. Linear regression analyses were performed to identify eGFR changes predictors. Results a total of 545 patients with diabetes were selected. According to the last eGFR values 64 (11.7 %) patients were classified in G1 stage, 277 (50,8 %) in G2, 175 (32.1 %) in G3a, 25 (4.6 %) in G3b and only 4 (0.7 %) in G4. Patients treated with at least one glucose-lowering drugs were 479 (87.9 %), most of them with biguanides (67.0 %). At least one nephrotoxic drug prescription was recorded in 524 (96.1 %) patients; proton pump inhibitors (74.7 %) and NSAIDs (71.6 %) were the most prescription classes. Heart failure, diabetes duration and preserved GFR values were related to reduced eGFR values. Conclusions patients with diabetes should be more carefully observed regardless of kidney risk factors and GFR values in clinical practice.
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Affiliation(s)
- Michelangelo Rottura
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125, Messina, Italy
| | - Selene Francesca Anna Drago
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125, Messina, Italy
| | - Viviana Maria Gianguzzo
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Messina, Italy
| | - Antonino Molonia
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125, Messina, Italy
| | - Giovanni Pallio
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
| | | | | | - Angela Alibrandi
- Department of Economics Section of Statistical and Mathematical Sciences, University of Messina, Via dei Verdi, 98122, Messina, Italy
| | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125, Messina, Italy
| | - Francesco Squadrito
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125, Messina, Italy
| | - Natasha Irrera
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125, Messina, Italy
| | - Vincenzo Arcoraci
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125, Messina, Italy
| | - Audit & Research Messina Primary Care Group
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125, Messina, Italy
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Messina, Italy
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
- Italian Society of General Practice (SIMG), Messina, Italy
- Department of Economics Section of Statistical and Mathematical Sciences, University of Messina, Via dei Verdi, 98122, Messina, Italy
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6
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Scott B, Day EA, O'Brien KL, Scanlan J, Cromwell G, Scannail AN, McDonnell ME, Finlay DK, Lynch L. Metformin and feeding increase levels of the appetite-suppressing metabolite Lac-Phe in humans. Nat Metab 2024; 6:651-658. [PMID: 38499765 PMCID: PMC11052712 DOI: 10.1038/s42255-024-01018-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 02/22/2024] [Indexed: 03/20/2024]
Abstract
Metformin, a widely used first-line treatment for type 2 diabetes (T2D), is known to reduce blood glucose levels and suppress appetite. Here we report a significant elevation of the appetite-suppressing metabolite N-lactoyl phenylalanine (Lac-Phe) in the blood of individuals treated with metformin across seven observational and interventional studies. Furthermore, Lac-Phe levels were found to rise in response to acute metformin administration and post-prandially in patients with T2D or in metabolically healthy volunteers.
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Affiliation(s)
- Barry Scott
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Emily A Day
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Katie L O'Brien
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - John Scanlan
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Grace Cromwell
- Division of Endocrinology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aine Ni Scannail
- Division of Endocrinology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marie E McDonnell
- Division of Endocrinology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David K Finlay
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
- School of Pharmacy and Pharmaceutical Sciences, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Lydia Lynch
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland.
- Division of Endocrinology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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7
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Mikhail ES, Jankowski M, Alexander D, Pandya D, Kunadi A. Survival and Vision Restoration Following Severe Metformin-associated Metabolic Acidosis With Transient Blindness: A Case Report and Review of the Literature. J Community Hosp Intern Med Perspect 2024; 14:96-99. [PMID: 38966499 PMCID: PMC11221438 DOI: 10.55729/2000-9666.1321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/20/2023] [Accepted: 01/05/2024] [Indexed: 07/06/2024] Open
Abstract
Metformin-associated lactic acidosis (MALA) is a life-threatening condition that may occur as a side effect of biguanides. This condition has a mortality rate of approximately 55 % depending on the severity. Typical symptoms include abdominal pain, nausea, vomiting, and diarrhea, but may also manifest with severe symptoms such as blindness, distributive shock, and renal failure requiring ICU level care. We present the case of a female in her early 70s who arrived at the emergency department with altered mental status and new-onset blindness, later diagnosed with severe acidosis (pH 6.607). She was intubated for hemodynamic instability and continuous renal replacement therapy (CRRT) was started to address her acid-base status. Her metformin concentration was found to be exceptionally high at 34 mcg/ml, significantly surpassing the normal range of 1-2 mcg/ml. Fortunately, the patient survived and was subsequently transferred to the medical floors in stable condition. Physicians should perform medication review and consider "MALA" as a potential etiology of severe acidosis when forming a differential diagnosis.
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Affiliation(s)
- Elizabeth S. Mikhail
- Department of Internal Medicine, McLaren Health Care/Michigan State University, Flint, MI,
USA
| | - Matthew Jankowski
- Department of Internal Medicine, McLaren Health Care/Michigan State University, Flint, MI,
USA
| | - Dheeraj Alexander
- Department of Internal Medicine, McLaren Health Care/Michigan State University, Flint, MI,
USA
| | - Dhwani Pandya
- Department of Pulmonary and Critical Care, McLaren Health Care/Michigan State University, Flint, MI,
USA
| | - Arvind Kunadi
- Department of Internal Medicine, McLaren Health Care/Michigan State University, Flint, MI,
USA
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8
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Monteiro Lopes S, Maia A, Melo P, Abreu S, Paiva I, Barros L. [Non-Insulin Antidiabetic Agents in the Management of Hyperglycaemia of Non-Critical Hospitalized Patients]. ACTA MEDICA PORT 2024; 37:207-214. [PMID: 38316163 DOI: 10.20344/amp.20858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/16/2024] [Indexed: 02/07/2024]
Abstract
Hyperglycaemia affects more than 30% of adults hospitalized for non-critical illness and is associated with an increased risk of adverse clinical outcomes. Insulin therapy is widely used for its safety and efficacy. However, given the growing availability of new drugs and new classes of antidiabetic agents with benefits beyond glycaemic control, challenges arise regarding their use in the hospital setting. This article aims to review and summarize the most recently available evidence and recommendations on the role of non-insulin antidiabetic agents in the management of hyperglycaemia in hospitalized patients. Insulin therapy remains the method of choice. Dipeptidyl peptidase 4 inhibitors can be considered in mild to moderate hyperglycaemia. Glucagon-like peptide 1 receptor agonists have recently shown promising results, with high efficacy in glycaemic control and low risk of hypoglycaemia. There are concerns regarding the increased risk of acidosis with metformin use, especially in cases of acute illness, although there is no evidence to support its suspension in selected patients with relative clinical stability. Sodium-glucose cotransporter-2 inhibitors should be discontinued in clinical situations that may predispose to ketoacidosis, including episodes of acute illness. The hospital use of sulfonylureas and thiazolidinediones is not advised.
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Affiliation(s)
- Sofia Monteiro Lopes
- Grupo de Estudos de Diabetes. Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo. Lisboa; Serviço de Endocrinologia, Diabetes e Metabolismo. Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal
| | - Ariana Maia
- Grupo de Estudos de Diabetes. Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo. Lisboa; Serviço de Endocrinologia. Centro Hospitalar Universitário do Porto. Porto. Portugal
| | - Pedro Melo
- Grupo de Estudos de Diabetes. Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo. Lisboa; Serviço de Endocrinologia. Unidade Local de Saúde de Matosinhos. Portugal
| | - Silvestre Abreu
- Grupo de Estudos de Diabetes. Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo. Lisboa; Serviço Regional de Saúde da Região Autónoma da Madeira. Funchal. Portugal
| | - Isabel Paiva
- Grupo de Estudos de Diabetes. Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo. Lisboa; Serviço de Endocrinologia, Diabetes e Metabolismo. Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal
| | - Luísa Barros
- Grupo de Estudos de Diabetes. Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo. Lisboa; Serviço de Endocrinologia, Diabetes e Metabolismo. Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal
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9
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Mohri T, Okamoto S, Nishioka Y, Myojin T, Kubo S, Higashino T, Okada S, Akai Y, Noda T, Ishii H, Imamura T. Risk of Lactic Acidosis in Hospitalized Diabetic Patients Prescribed Biguanides in Japan: A Retrospective Total-Population Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5300. [PMID: 37047916 PMCID: PMC10093879 DOI: 10.3390/ijerph20075300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/12/2023] [Accepted: 03/13/2023] [Indexed: 06/19/2023]
Abstract
Patient data from the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) are used to assess the effect of biguanide administration on rates of lactic acidosis (LA) in hospitalized diabetes mellitus (DM) patients. In this retrospective cohort study (from April 2013 to March 2016), we compare DM inpatients prescribed biguanides to DM inpatients who were not prescribed biguanides to quantify the association between biguanides and incidence of LA. In total, 8,111,848 DM patient records are retrieved from the NDB. Of the 528,768 inpatients prescribed biguanides, 782 develop LA. Of the 1,967,982 inpatients not prescribed biguanides, 1310 develop LA. The rate ratio of inpatients who develop LA and are administered biguanides to those who developed LA without receiving biguanides is 1.44 (95% CI, 1.32-1.58). Incidence rates and rate ratios for both sexes are elevated in the group prescribed biguanides for patients aged 70 years and older, markedly in those 80 years and older: 40.12 and 6.31 (95% CI, 4.75-8.39), respectively, for men and 34.96 and 5.40 (95% CI, 3.91-7.46), respectively, for women. Biguanides should be used conservatively in patients older than 70 years, particularly for those with comorbidities, and with caution in patients 80 years and older.
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Affiliation(s)
- Takako Mohri
- Department of Diabetes and Endocrinology, Nara Medical University Hospital, Nara 634-8522, Japan
| | - Sawako Okamoto
- Department of Public Health, Health Management and Policy, Nara Medical University, Nara 634-8521, Japan
- Education Development Center, Nara Medical University, Nara 634-8521, Japan
| | - Yuichi Nishioka
- Department of Public Health, Health Management and Policy, Nara Medical University, Nara 634-8521, Japan
| | - Tomoya Myojin
- Department of Public Health, Health Management and Policy, Nara Medical University, Nara 634-8521, Japan
| | - Shinichiro Kubo
- Department of Public Health, Health Management and Policy, Nara Medical University, Nara 634-8521, Japan
| | - Tsuneyuki Higashino
- Healthcare and Wellness Division, Mitsubishi Research Institute Inc., Tokyo 100-8141, Japan
| | - Sadanori Okada
- Department of Diabetes and Endocrinology, Nara Medical University Hospital, Nara 634-8522, Japan
| | - Yasuhiro Akai
- Department of Community-Based Medicine, Nara Medical University, Nara 634-8521, Japan
| | - Tatsuya Noda
- Department of Public Health, Health Management and Policy, Nara Medical University, Nara 634-8521, Japan
| | - Hitoshi Ishii
- Department of Doctor-Patient Relationships, Nara Medical University, Nara 634-8521, Japan
| | - Tomoaki Imamura
- Department of Public Health, Health Management and Policy, Nara Medical University, Nara 634-8521, Japan
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10
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Harada M, Kondo Y, Sugiyama M, Ohira A, Ichikawa M, Akiyama T, Orime K, Takai T, Yamakawa T, Terauchi Y. The METRO study: a retrospective analysis of the efficacy of metformin for type 2 diabetes in Japan. Endocr J 2023; 70:121-128. [PMID: 36261368 DOI: 10.1507/endocrj.ej22-0330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Metformin monotherapy as first-line treatment for patients with type 2 diabetes (T2D) has been shown to effectively improve blood glucose levels and motivation to undergo treatment and prevent complications. However, no studies have reported its effect when combined with other drugs or compared the effect based on administration time. This study aimed to investigate the effect of metformin administration in Japanese patients with T2D, examine how the introduction line impacts the effect of metformin, and examine the characteristics of patients demonstrating improved blood glucose levels. Data on characteristics of patients who were newly prescribed metformin with no shifting of hypoglycemic agents in the subsequent 24-week observation period, and their age [mean, 56.8 years], body mass index [mean, 27.5 kg/m2], glycated hemoglobin [HbA1c] [mean, 8.1%], and duration of diabetes [mean, 3.0 years] were obtained from the medical records of 201 patients. The changes in HbA1c by introduction line after 24 weeks were -1.59%, -0.91%, -0.89%, and -0.65% in the first, second, third, and fourth induction lines, respectively; earlier introduction more significantly improved blood glucose. The factors significantly associated with HbA1c changes were early introduction, high baseline HbA1c, high estimated glomerular filtration rate, decreased insulin secretion, short estimated duration of diabetes, and increased metformin dose. Furthermore, factors contributing to the largest HbA1c improvement by metformin were high baseline HbA1c and early administration. Metformin is expected to lower blood glucose levels in Japanese patients with T2D, even in those with decreased insulin secretion, due to its early introduction as a first-line drug.
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Affiliation(s)
- Marina Harada
- Department of Endocrinology and Diabetes, Yokohama City University Medical Center, Yokohama 232-0024, Japan
| | - Yoshinobu Kondo
- Tsunashima East Internal Medicine and Diabetes Clinic, Yokohama 223-0052, Japan
| | - Mai Sugiyama
- Department of Endocrinology and Diabetes, Yokohama City University Medical Center, Yokohama 232-0024, Japan
| | - Akeo Ohira
- Department of Endocrinology and Diabetes, Yokohama City University Medical Center, Yokohama 232-0024, Japan
| | - Masahiro Ichikawa
- Department of Endocrinology and Diabetes, Yokohama City University Medical Center, Yokohama 232-0024, Japan
| | - Tomoaki Akiyama
- Department of Endocrinology and Diabetes, Yokohama City University Medical Center, Yokohama 232-0024, Japan
| | - Kazuki Orime
- Department of Endocrinology and Diabetes, Yokohama City University Medical Center, Yokohama 232-0024, Japan
| | - Takanori Takai
- Urafune Kanazawa Internal Medicine Clinic, Yokohama 232-0024, Japan
| | - Tadashi Yamakawa
- Department of Endocrinology and Diabetes, Yokohama City University Medical Center, Yokohama 232-0024, Japan
| | - Yasuo Terauchi
- Department of Endocrinology and Metabolism, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
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11
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Reitz KM, Althouse AD, Forman DE, Zuckerbraun BS, Vodovotz Y, Zamora R, Raffai RL, Hall DE, Tzeng E. MetfOrmin BenefIts Lower Extremities with Intermittent Claudication (MOBILE IC): randomized clinical trial protocol. BMC Cardiovasc Disord 2023; 23:38. [PMID: 36681798 PMCID: PMC9862509 DOI: 10.1186/s12872-023-03047-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/05/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Peripheral artery disease (PAD) affects over 230 million people worldwide and is due to systemic atherosclerosis with etiology linked to chronic inflammation, hypertension, and smoking status. PAD is associated with walking impairment and mobility loss as well as a high prevalence of coronary and cerebrovascular disease. Intermittent claudication (IC) is the classic presenting symptom for PAD, although many patients are asymptomatic or have atypical presentations. Few effective medical therapies are available, while surgical and exercise therapies lack durability. Metformin, the most frequently prescribed oral medication for Type 2 diabetes, has salient anti-inflammatory and promitochondrial properties. We hypothesize that metformin will improve function, retard the progression of PAD, and improve systemic inflammation and mitochondrial function in non-diabetic patients with IC. METHODS 200 non-diabetic Veterans with IC will be randomized 1:1 to 180-day treatment with metformin extended release (1000 mg/day) or placebo to evaluate the effect of metformin on functional status, PAD progression, cardiovascular disease events, and systemic inflammation. The primary outcome is 180-day maximum walking distance on the 6-min walk test (6MWT). Secondary outcomes include additional assessments of functional status (cardiopulmonary exercise testing, grip strength, Walking Impairment Questionnaires), health related quality of life (SF-36, VascuQoL), macro- and micro-vascular assessment of lower extremity blood flow (ankle brachial indices, pulse volume recording, EndoPAT), cardiovascular events (amputations, interventions, major adverse cardiac events, all-cause mortality), and measures of systemic inflammation. All outcomes will be assessed at baseline, 90 and 180 days of study drug exposure, and 180 days following cessation of study drug. We will evaluate the primary outcome with linear mixed-effects model analysis with covariate adjustment for baseline 6MWT, age, baseline ankle brachial indices, and smoking status following an intention to treat protocol. DISCUSSION MOBILE IC is uniquely suited to evaluate the use of metformin to improve both systematic inflammatory responses, cellular energetics, and functional outcomes in patients with PAD and IC. TRIAL REGISTRATION The prospective MOBILE IC trial was publicly registered (NCT05132439) November 24, 2021.
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Affiliation(s)
- Katherine M Reitz
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | | | - Daniel E Forman
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Geriatrics Research, Education, and Clinical Care, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Brian S Zuckerbraun
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
- Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA
- Center for Systems Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ruben Zamora
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | | | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Geriatrics Research, Education, and Clinical Care, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Wolff Center, UPMC, Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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12
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Bramante CT, Buse JB, Liebovitz D, Nicklas J, Puskarich MA, Cohen K, Belani H, Anderson B, Huling JD, Tignanelli C, Thompson J, Pullen M, Siegel L, Proper J, Odde DJ, Klatt N, Sherwood N, Lindberg S, Wirtz EL, Karger A, Beckman K, Erickson S, Fenno S, Hartman K, Rose M, Patel B, Griffiths G, Bhat N, Murray TA, Boulware DR. Outpatient treatment of Covid-19 with metformin, ivermectin, and fluvoxamine and the development of Long Covid over 10-month follow-up. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2022:2022.12.21.22283753. [PMID: 36597543 PMCID: PMC9810227 DOI: 10.1101/2022.12.21.22283753] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Long Covid is an emerging chronic illness potentially affecting millions, sometimes preventing the ability to work or participate in normal daily activities. COVID-OUT was an investigator-initiated, multi-site, phase 3, randomized, quadruple-blinded placebo-controlled clinical trial (NCT04510194). The design simultaneously assessed three oral medications (metformin, ivermectin, fluvoxamine) using two by three parallel treatment factorial assignment to efficiently share placebo controls and assessed Long Covid outcomes for 10 months to understand whether early outpatient treatment of SARS-CoV-2 with metformin, ivermectin, or fluvoxamine prevents Long Covid. Methods This was a decentralized, remotely delivered trial in the US of 1,125 adults age 30 to 85 with overweight or obesity, fewer than 7 days of symptoms, and enrolled within three days of a documented SARS-CoV-2 infection. Immediate release metformin titrated over 6 days to 1,500mg per day 14 days total; ivermectin 430mcg/kg/day for 3 days; fluvoxamine, 50mg on day one then 50mg twice daily through 14 days. Medical-provider diagnosis of Long Covid, reported by participant by day 300 after randomization was a pre-specified secondary outcome; the primary outcome of the trial was severe Covid by day 14. Result The median age was 45 years (IQR 37 to 54), 56% female of whom 7% were pregnant. Two percent identified as Native American; 3.7% as Asian; 7.4% as Black/African American; 82.8% as white; and 12.7% as Hispanic/Latino. The median BMI was 29.8 kg/m2 (IQR 27 to 34); 51% had a BMI >30kg/m2. Overall, 8.4% reported having received a diagnosis of Long Covid from a medical provider: 6.3% in the metformin group and 10.6% in the metformin control; 8.0% in the ivermectin group and 8.1% in the ivermectin control; and 10.1% in the fluvoxamine group and 7.5% in the fluvoxamine control. The Hazard Ratio (HR) for Long Covid in the metformin group versus control was 0.58 (95% CI 0.38 to 0.88); 0.99 (95% CI 0.592 to 1.643) in the ivermectin group; and 1.36 in the fluvoxamine group (95% CI 0.785 to 2.385). Conclusions There was a 42% relative decrease in the incidence of Long Covid in the metformin group compared to its blinded control in a secondary outcome of this randomized phase 3 trial.
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Affiliation(s)
| | - John B Buse
- Endocrinology, University of North Carolina, Chapel Hill, ND
| | - David Liebovitz
- General Internal Medicine, Northwestern University, Chicago, IL
| | - Jacinda Nicklas
- General Internal Medicine, University of Colorado, Denver, CO
| | | | - Ken Cohen
- UnitedHealth Group, Optum Labs, Minnetonka, MN
| | - Hrishikesh Belani
- Department of Medicine, Olive View - University of California, Los Angeles, CA
| | - Blake Anderson
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia; Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Jared D Huling
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | | | - Jennifer Thompson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew Pullen
- Infectious Diseases, University of Minnesota Medical School, Minneapolis, MN
| | - Lianne Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Jennifer Proper
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - David J Odde
- Department of Biomedical Engineering University of Minnesota, Minneapolis, MN
| | - Nichole Klatt
- Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN
| | - Nancy Sherwood
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Sarah Lindberg
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Esteban Lemus Wirtz
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Amy Karger
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN
| | - Kenny Beckman
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN
| | - Spencer Erickson
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Sarah Fenno
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Katrina Hartman
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Michael Rose
- General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Barkha Patel
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | | | - Neeta Bhat
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - David R Boulware
- Infectious Diseases, University of Minnesota Medical School, Minneapolis, MN
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13
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Samir GM, Ghallab MAEA, Ibrahim DA. Intravenous bolus-infusion versus sliding scale of insulin for intra-operative glycemic control in elective laparotomy surgeries. AIN-SHAMS JOURNAL OF ANESTHESIOLOGY 2022; 14:86. [DOI: 10.1186/s42077-022-00288-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 11/11/2022] [Indexed: 09/02/2023]
Abstract
Abstract
Background
The aim of this study was to assess the bolus-infusion to the sliding scale of insulin approaches, regarding percentage of the operative time with the target capillary blood glucose (CBG) range, total insulin units given to the patients, development of hypoglycemia, and the peri-operative changes in serum potassium (s.k) in elective laparotomy surgeries. Sixty patients, American Society of Anesthesiologists (ASA) physical status II, were randomly divided to either the bolus-insulin infusion (BII) group, or the sliding scale of insulin (SSI) group.
Results
The intra-operative target CBG range was achieved in both groups, with no statistically significant difference between them. However, in the post anesthesia care unit (PACU), the number of patients who achieved the target CBG range was significantly more in the BII group. The decrease in the CBG was statistically significant in the SSI group than in the BII group; starting from 30 minutes after the initial intra-venous (IV) insulin injected, to 240 minutes intra-operatively and in the PACU. No patient in either groups developed hypoglycemia. The mean intra-operative time needed to achieve the target CBG range was statistically significant less in the SSI group. The mean percentage of the operative time with the target CBG range was statistically non-significant higher in the SSI group. The mean total insulin units given were statistically non-significant higher in the SSI group. The peri-operative changes in s.k were statistically non-significant between the two groups.
Conclusions
The BII approach slowly achieved the target CBG range intra-operatively and maintained this target in the PACU, with mean 54.6 ± 28.9% operative time with the target CBG range, and with less mean total insulin units needed than the SSI approach.
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14
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Dodd S, Sominsky L, Siskind D, Bortolasci CC, Carvalho AF, Maes M, Walker AJ, Walder K, Yung AR, Williams LJ, Myles H, Watson T, Berk M. The role of metformin as a treatment for neuropsychiatric illness. Eur Neuropsychopharmacol 2022; 64:32-43. [PMID: 36191545 DOI: 10.1016/j.euroneuro.2022.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 09/04/2022] [Accepted: 09/07/2022] [Indexed: 12/12/2022]
Abstract
Advances in psychopharmacology have been significantly slower to evolve than in other disciplines of medicine and therefore investigation into novel therapeutic approaches is required. Additionally, concurrent metabolic conditions are prevalent among people with mental disorders. Metformin is a widely used hypoglycaemic agent that is now being studied for use beyond diabetes management. Evidence is emerging that metformin has multiple effects on diverse neurobiological pathways and consequently may be repurposed for treating mental illness. Metformin may have beneficial neuroimmunological, neuroplastic, neuro-oxidative and neuro-nitrosative effects across a range of psychiatric and neurodegenerative illnesses. Mechanisms include glucose lowering effects and effects on AMP-activated protein kinase (AMPK) signalling, however the best evidence for clinical benefit is through the glucose lowering effects, with other mechanisms less supported by the current evidence base. This narrative review aims to draw together the existing evidence for use of metformin as a psychopharmaceutical and present the role of metformin in the context of physical and psychiatric ill health, including metabolic, endocrinological and cancer domains. It not only has therapeutic potential in medical comorbidity but may have potential in core illness domains.
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Affiliation(s)
- Seetal Dodd
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia; Department of Psychiatry, the University of Melbourne, Parkville, VIC, Australia; Centre for Youth Mental Health, University of Melbourne, Parkville, VIC, Australia.
| | - Luba Sominsky
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia; Barwon Health Laboratory, University Hospital Geelong, Barwon Health, VIC, Australia
| | - Dan Siskind
- Metro South Addiction and Mental Health Service, MIRT, Level 2, 228 Logan Rd, Woolloongabba, Brisbane, Qld 4102, Australia University of Queensland School of Clinical Medicine, Brisbane, Australia Queensland Centre for Mental Health Research, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Chiara C Bortolasci
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia
| | - Andre F Carvalho
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia
| | - Michael Maes
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia
| | - Adam J Walker
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia
| | - Ken Walder
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia
| | - Alison R Yung
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia; Centre for Youth Mental Health, University of Melbourne, Parkville, VIC, Australia; School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Lana J Williams
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia
| | - Hannah Myles
- Discipline of Psychiatry, Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia; Northern Adelaide Mental Health Service, Salisbury, SA, Australia
| | - Tayler Watson
- Mental Health, Drugs and Alcohol Service, Barwon Health, Geelong VIC, Australia
| | - Michael Berk
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia; Department of Psychiatry, the University of Melbourne, Parkville, VIC, Australia; Centre for Youth Mental Health, University of Melbourne, Parkville, VIC, Australia; Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia
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15
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Kuwahara M, Otagaki H, Imanaka H. Three Cases of Lactic Acidosis Caused by Biguanides. Cureus 2022; 14:e31419. [PMID: 36523728 PMCID: PMC9744419 DOI: 10.7759/cureus.31419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2022] [Indexed: 11/14/2022] Open
Abstract
Biguanides may cause lactic acidosis (LA) in elderly patients. We report three cases of LA after the administration of biguanides. Case 1 was an 85-year-old man with no hepatic dysfunction who was discharged, case 2 was a 67-year-old man with no hepatic dysfunction who was discharged, and case 3 was a 77-year-old woman with hepatic dysfunction who died. Therefore, caution should be exercised in administering biguanides to elderly patients with hepatic dysfunction.
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Affiliation(s)
- Masaatsu Kuwahara
- Department of Emergency Medicine, Takarazuka City Hospital, Takarazuka, JPN
| | - Hiroko Otagaki
- Department of Emergency Medicine, Takarazuka City Hospital, Takarazuka, JPN
| | - Hideaki Imanaka
- Department of Emergency Medicine, Takarazuka City Hospital, Takarazuka, JPN
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16
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ÇİFTÇİOĞLU M. Shouldn't Stage 4 And 5 Chronic Kidney Disease Patients Use Metformin? KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2022. [DOI: 10.17517/ksutfd.1181458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Metformin is the first place anti-diabetic agent recommended with life style changes in many guidelines for the treatment of patients with type 2 diabetes mellitus (DM). The mechanism of effect of the drug is to increase insulin sensitivity in peripheral tissue and reduce glucose secretion from the liver. Metformin is a low cost, effective and safe drug. Although its frequent side effects are gastrointestinal side effects and the most feared side effect is lactic acidosis. Due to this side effect, its use is limited in many guidelines in patients with chronic kidney disease (CKD). In this article, we examined the use of metformin in all stages of CKD. We investigated the incidence of metformin-associated lactic acidosis (MALA). Shouldn't stage 4 and 5 chronic kidney disease patients use metformin? We sought an answer to question. As a result, we decided that side effects like MALA are extremely rare. We observed that these side effects occur mostly in the presence of diseases in which tissue perfusion is impaired such as infections, serious cardiovascular events, and hypotension. We came to the conclusion that metformin should be used in patients with stage 4 and 5 CKD patients, without much fear, considering the profit and loss relationship.
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17
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Benes J, Kotrc M, Kroupova K, Wohlfahrt P, Kovar J, Franekova J, Hegarova M, Hoskova L, Hoskova E, Pelikanova T, Jarolim P, Kautzner J, Melenovsky V. Metformin treatment is associated with improved outcome in patients with diabetes and advanced heart failure (HFrEF). Sci Rep 2022; 12:13038. [PMID: 35906276 PMCID: PMC9338272 DOI: 10.1038/s41598-022-17327-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 07/25/2022] [Indexed: 11/17/2022] Open
Abstract
The role of metformin (MET) in the treatment of patients with advanced HFrEF and type 2 diabetes mellitus (DM) is not firmly established. We studied the impact of MET on metabolic profile, quality of life (QoL) and survival in these patients. A total of 847 stable patients with advanced HFrEF (57.4 ± 11.3 years, 67.7% NYHA III/IV, LVEF 23.6 ± 5.8%) underwent clinical and laboratory evaluation and were prospectively followed for a median of 1126 (IQRs 410; 1781) days for occurrence of death, urgent heart transplantation or mechanical circulatory support implantation. A subgroup of 380 patients (44.9%) had DM, 87 of DM patients (22.9%) were treated with MET. Despite worse insulin sensitivity and more severe DM (higher BMI, HbA1c, worse insulin resistance), MET-treated patients exhibited more stable HF marked by lower BNP level (400 vs. 642 ng/l), better LV and RV function, lower mitral and tricuspid regurgitation severity, were using smaller doses of diuretics (all p < 0.05). Further, they had higher eGFR (69.23 vs. 63.34 ml/min/1.73 m2) and better QoL (MLHFQ: 36 vs. 48 points, p = 0.002). Compared to diabetics treated with other glucose-lowering agents, MET-treated patients had better event-free survival even after adjustment for BNP, BMI and eGFR (p = 0.035). Propensity score-matched analysis with 17 covariates yielded 81 pairs of patients and showed a significantly better survival for MET-treated subgroup (p = 0.01). MET treatment in patients with advanced HFrEF and DM is associated with improved outcome by mechanisms beyond the improvement of blood glucose control.
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Affiliation(s)
- Jan Benes
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Videnska 1958/9, 140 21, Praha 4, Czech Republic.
| | - Martin Kotrc
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Videnska 1958/9, 140 21, Praha 4, Czech Republic
| | - Katerina Kroupova
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Videnska 1958/9, 140 21, Praha 4, Czech Republic
| | - Peter Wohlfahrt
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Videnska 1958/9, 140 21, Praha 4, Czech Republic
| | - Jan Kovar
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Videnska 1958/9, 140 21, Praha 4, Czech Republic
| | - Janka Franekova
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Videnska 1958/9, 140 21, Praha 4, Czech Republic
| | - Marketa Hegarova
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Videnska 1958/9, 140 21, Praha 4, Czech Republic
| | - Lenka Hoskova
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Videnska 1958/9, 140 21, Praha 4, Czech Republic
| | - Eva Hoskova
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Videnska 1958/9, 140 21, Praha 4, Czech Republic
| | - Terezie Pelikanova
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Videnska 1958/9, 140 21, Praha 4, Czech Republic
| | - Petr Jarolim
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Videnska 1958/9, 140 21, Praha 4, Czech Republic
| | - Vojtech Melenovsky
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Videnska 1958/9, 140 21, Praha 4, Czech Republic
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18
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Namvarjah F, Shokri-Afra H, Moradi-Sardareh H, Khorzoughi RB, Pasalar P, Panahi G, Meshkani R. Chlorogenic acid improves anti-lipogenic activity of metformin by positive regulating of AMPK signaling in HepG2 cells. Cell Biochem Biophys 2022; 80:537-545. [PMID: 35704155 DOI: 10.1007/s12013-022-01077-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/06/2022] [Indexed: 11/25/2022]
Abstract
Metformin improves lipid profile, however, combination therapy is developing to increase its effectiveness and reduce the deleterious effects of metformin. Chlorogenic acid (CGA) has exhibited lipid-lowering effects. This study aimed to investigate the combined effect of metformin and CGA on lipid accumulation, as well as to elucidate the engaged mechanism in HepG2 cells. To find the non-lethal doses of metformin and CGA, MTT assay was performed. High Glucose (HG) at 33 mM was used to induce lipogenesis in HepG2 cells. Following treatment with different concentrations of metformin and CGA, total lipid content (Oil Red O-staining), triglyceride level, the genes expression of SREBP-1c and FAS, and phosphorylation of AMPK and ACC were measured. Both Metformin and CGA decreased HG-induced lipid accumulation individually, by decreasing total lipid content and triglyceride level. The lowest effective doses of metformin and CGA were 0.25 mM and 5 μM, respectively, which significantly reduced SREBP-1c and FAS genes expression. The combination of these concentrations reinforced these effects. The phosphorylation of AMPK and ACC were more increased by metformin in combination with CGA than both individually. Our findings suggest that CGA synergistically enhances metformin lipid reducing action via the regulating of involved factors in fatty acid synthesis. Therefore, co-administration of metformin with CGA may have further medical value in treating lipid metabolism disorders.
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Affiliation(s)
- Fatemeh Namvarjah
- Department of Clinical Biochemistry, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Hajar Shokri-Afra
- Gut and Liver Research Center, Non-communicable Disease Institute, Mazandaran University of Medical Sciences, Sari, Iran.
| | | | - Reyhaneh Babaei Khorzoughi
- Department of Clinical Biochemistry, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Parvin Pasalar
- Department of Clinical Biochemistry, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ghodratollah Panahi
- Department of Clinical Biochemistry, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Meshkani
- Department of Clinical Biochemistry, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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19
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Kao TW, Lee KH, Chan WP, Fan KC, Liu CW, Huang YC. Continuous use of metformin in patients receiving contrast medium: what is the evidence? A systematic review and meta-analysis. Eur Radiol 2022; 32:3045-3055. [PMID: 34837099 DOI: 10.1007/s00330-021-08395-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 10/09/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Substantial inconsistencies exist in current guidelines regarding recommendations of metformin usage with the administration of a contrast medium. We aimed to perform a meta-analysis to determine whether the risks of contrast-induced acute kidney injury (CI-AKI) and lactic acidosis increase with metformin use in diabetic patients receiving a contrast medium. METHODS Studies were retrieved from databases from inception to May 15, 2021. Studies that compared the outcomes of using metformin with not using metformin during contrast medium administration were included. The primary outcomes were incidence of CI-AKI and lactic acidosis. The secondary outcomes were renal function changes from baseline. Data analysis was using risk ratio (RR) for dichotomous outcomes and mean differences (MD) with 95% confidence intervals (CI) for continuous outcomes. RESULTS Analyses of two randomized controlled trials and four retrospective cohorts examining a total of 1459 patients revealed no significant differences in the incidence of CI-AKI (RR = 1.08; 95% CI, 0.72 to 1.63) and in changes in renal function measurements (serum creatinine: MD = 0.00 mg/dL, 95% CI, - 0.05 to 0.05; estimated glomerular filtration rate: MD = 0.22, 95% CI, - 2.47 to 2.91) after contrast medium administration between patients using and not using metformin. CONCLUSIONS There is no evidence that continuing metformin during contrast medium administration is associated with a higher risk of CI-AKI, lactic acidosis, or renal function deterioration compared to patients who discontinued metformin or who were not metformin users. The limited quality of the included studies may compromise the strength of evidence provided in this meta-analysis. KEY POINTS There is no need to discontinue metformin either before or after intravenous contrast medium exposure in patients with eGFR > 30 mL/min/1.73 m2. In patients receiving intra-arterial contrast medium with first-pass renal exposure, there is no need to withhold metformin if eGFR is above 60 mL/min/1.73 m2. For patients who have an eGFR level between 30 and 60 mL/min/1.73 m2 and are receiving intra-arterial contrast medium with first-pass renal exposure, no case of lactic acidosis was observed based on present data, but further evidence is needed to make a strong suggestion regarding its safety.
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Affiliation(s)
- Ting-Wan Kao
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Kuo-Hua Lee
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wing P Chan
- Department of Radiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Kang-Chih Fan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Che-Wei Liu
- Department of Orthopedics, Cathay General Hospital, Taipei, Taiwan
- Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yu-Chen Huang
- Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
- Department of Dermatology, Wan Fang Hospital, Taipei Medical University, No. 111, Sec. 3, Xinglong Rd., Wenshan Dist., Taipei City, Taiwan.
- Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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20
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Kim MH, Oh HJ, Kwon SH, Jeon JS, Noh H, Han DC, Kim H, Ryu DR. Metformin use and cardiovascular outcomes in patients with diabetes and chronic kidney disease: a nationwide cohort study. Kidney Res Clin Pract 2021; 40:660-672. [PMID: 34922433 PMCID: PMC8685353 DOI: 10.23876/j.krcp.20.222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Metformin has recently been shown not to increase the risk of lactic acidosis in patients with chronic kidney disease (CKD). Thus, the criteria for metformin use in this population has expanded. However, the relationship between metformin use and clinical outcomes in CKD remains controversial. METHODS This study considered data from 97,713 diabetes patients with an estimated glomerular filtration rate of <60 mL/min/1.73 m2. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), and the secondary outcomes were all-cause mortality and incident end-stage renal disease (ESRD). RESULTS Metformin users had a significantly higher risk of MACCE than non-users (hazard ratio [HR], 1.20; 95% confidence interval [CI], 1.14-1.26; p < 0.001). However, metformin users had a lower risk of all-cause mortality (HR, 0.78; 95% CI, 0.74-0.81; p < 0.001) and ESRD (HR, 0.44; 95% CI, 0.42-0.47; p < 0.001) during follow-up than non-users did. The relationships between metformin use and clinical outcomes remained consistent in propensity score matching analyses and subgroup analyses of patients with adequate adherence to anti-diabetes medication. CONCLUSION Treatment with metformin was associated with an increased risk of MACCE in patients with diabetes and CKD. However, metformin users had a lower risk of all-cause mortality and ESRD during follow-up than non-users did. Therefore, metformin needs to be carefully used in patients with CKD.
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Affiliation(s)
- Min-Ho Kim
- Ewha Institute of Convergence Medicine, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Hyung Jung Oh
- Department of Nephrology, Sheikh Khalifa Specialty Hospital, Ras Al Khaimah, UAE
| | - Soon Hyo Kwon
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
- Hyonam Kidney Laboratory, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Jin Seok Jeon
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
- Hyonam Kidney Laboratory, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Hyunjin Noh
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
- Hyonam Kidney Laboratory, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Dong Cheol Han
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
- Hyonam Kidney Laboratory, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Hyoungnae Kim
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
- Hyonam Kidney Laboratory, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Dong-Ryeol Ryu
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Republic of Korea
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21
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Johansson I, Dicembrini I, Mannucci E, Cosentino F. Glucose-lowering therapy in patients undergoing percutaneous coronary intervention. EUROINTERVENTION 2021; 17:e618-e630. [PMID: 34596567 PMCID: PMC9724943 DOI: 10.4244/eij-d-20-01250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2021] [Indexed: 01/08/2023]
Abstract
The number of individuals with diabetes and pre-diabetes is constantly increasing. These conditions are overrepresented in patients undergoing percutaneous coronary intervention and are associated with adverse prognosis. Optimal glycaemic control during an acute coronary syndrome is a relevant factor for the improvement of longer-term outcomes. In addition, the implementation of newer glucose-lowering drugs with proven cardiovascular benefits has a remarkable impact on recurrence of events, hospitalisations for heart failure and mortality. In this narrative review, we outline the current state-of-the art recommendations for glucose-lowering therapy in patients with diabetes undergoing coronary intervention. In addition, we discuss the most recent evidence-based indications for revascularisation in patients with diabetes as well as the targets for glycaemic control post revascularisation. Current treatment goals for concomitant risk factor control are also addressed. Lastly, we acknowledge the presence of knowledge gaps in need of future research.
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Affiliation(s)
- Isabelle Johansson
- Cardiology Unit, Department of Medicine Solna, Karolinska Institute Heart & Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
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22
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Singh AK, Singh R, Chakraborty PP. Diabetes Monotherapies versus Metformin-Based Combination Therapy for the Treatment of Type 2 Diabetes. Int J Gen Med 2021; 14:3833-3848. [PMID: 34335049 PMCID: PMC8318007 DOI: 10.2147/ijgm.s295459] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/13/2021] [Indexed: 02/05/2023] Open
Abstract
Step-wise addition of antihyperglycemic agents (AHA) after the initiation of metformin monotherapy has been the traditional approach for the treatment of type 2 diabetes mellitus (T2DM) world-wide. Emerging evidence increasingly suggests that metformin-based combination therapy, especially with the newer AHA that lowers HbA1c glucose-dependently and do not potentiate hypoglycemia, could be a potentially better option for durable glycemic control with good tolerability compared to diabetes monotherapy. In this review, we descriptively analyzed the evidence available from the systematic reviews and meta-analyses of randomized head-to-head trials that reported the efficacy and safety outcomes of diabetes monotherapy, metformin-based combination therapies, and monotherapy versus metformin-based combination therapies.
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Affiliation(s)
- Awadhesh K Singh
- Department of Diabetes & Endocrinology, G.D Hospital & Diabetes Institute, Kolkata, India
| | - Ritu Singh
- Department of Diabetes & Endocrinology, G.D Hospital & Diabetes Institute, Kolkata, India
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23
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Meligi NM, Dyab AKF, Paunov VN. Sustained In Vitro and In Vivo Delivery of Metformin from Plant Pollen-Derived Composite Microcapsules. Pharmaceutics 2021; 13:1048. [PMID: 34371742 PMCID: PMC8309045 DOI: 10.3390/pharmaceutics13071048] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 12/29/2022] Open
Abstract
We developed a dual microencapsulation platform for the type 2 diabetes drug metformin (MTF), which is aimed to increase its bioavailability. We report the use of Lycopodium clavatum sporopollenin (LCS), derived from their natural spores, and raw Phoenix dactylifera L. (date palm) pollens (DPP) for MTF microencapsulation. MTF was loaded into LCS and DPP via a vacuum and a novel method of hydration-induced swelling. The loading capacity (LC) and encapsulation efficiency (EE) percentages for MTF-loaded LCS and MTF-loaded DPP microcapsules were 14.9% ± 0.7, 29.8 ± 0.8, and 15.2% ± 0.7, 30.3 ± 1.0, respectively. The release of MTF from MTF-loaded LCS microcapsules was additionally controlled by re-encapsulating the loaded microcapsules into calcium alginate (ALG) microbeads via ionotropic gelation, where the release of MTF was found to be significantly slower and pH-dependent. The pharmacokinetic parameters, obtained from the in vivo study, revealed that the relative bioavailability of the MTF-loaded LCS-ALG beads was 1.215 times higher compared to pure MTF, following oral administration of a single dose equivalent to 25 mg/kg body weight MTF to streptozotocin (STZ)-induced diabetic male Sprague-Dawley rats. Significant hypoglycemic effect was obtained for STZ-induced diabetic rats orally treated with MTF-loaded LCS-ALG beads compared to control diabetic rats. Over a period of 29 days, the STZ-induced diabetic rats treated with MTF-loaded LCS-ALG beads showed a decrease in the aspartate aminotransferase (AST), alanine aminotransferase (ALT), triglycerides, cholesterol, and low-density lipoprotein-cholesterol (LDL-C) levels, as well as an increase in glutathione peroxidase (GPx) and a recovery in the oxidative stress biomarker, lipid peroxidation (LPx). In addition, histopathological studies of liver, pancreas, kidney, and testes suggested that MTF-loaded LCS-ALG beads improved the degenerative changes in organs of diabetic rats. The LCS-ALG platform for dual encapsulation of MTF achieved sustained MTF delivery and enhancement of bioavailability, as well as the improved biochemical and histopathological characteristics in in vivo studies, opening many other intriguing applications in sustained drug delivery.
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Affiliation(s)
- Noha M. Meligi
- Zoology Department, Faculty of Science, Minia University, Minia 61519, Egypt;
| | - Amro K. F. Dyab
- Colloids & Advanced Materials Group, Chemistry Department, Faculty of Science, Minia University, Minia 61519, Egypt;
| | - Vesselin N. Paunov
- Department of Chemistry, School of Sciences and Humanities, Nazarbayev University, Nursultan 010000, Kazakhstan
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Rupprecht B, Stöckl A, Stöckl S, Dietrich C. [Treatment of diabetes mellitus in perioperative medicine-an update]. Anaesthesist 2021; 70:451-465. [PMID: 33141238 DOI: 10.1007/s00101-020-00875-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2020] [Indexed: 12/15/2022]
Abstract
Patients with diabetes who undergo a surgical intervention have an increased risk of metabolic derailment, anesthesiological complications, postoperative infections and cardiovascular events. The treatment of diabetes mellitus is subject to a continuous further development due to pharmaceutical and technical innovations. This article presents the implications of the current concepts of diabetes treatment for perioperative medicine, particularly the changes due to new oral antidiabetic agents and insulin pump treatment. Some of the currently available guidelines are discussed with respect to the care of diabetes patients in childhood and adulthood in connection with an operation. Finally, possible perspectives in the field of monitoring and treatment of diabetes patients are discussed.
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Affiliation(s)
- B Rupprecht
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| | - A Stöckl
- Gemeinschaftspraxis Diedorf, Zertifiziertes Diabeteszentrum DDG Dres. Huß, Baur, Ziesing und Kollegen, Bei den Zäunen 2, 86420, Diedorf, Deutschland
| | - S Stöckl
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
| | - C Dietrich
- Pädiatrische Anästhesiologie, Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum St. Marien Amberg, Mariahilfbergweg 7, 92224, Amberg, Deutschland
- Pädiatrische Anästhesiologie, Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Weiden - Kliniken Nordoberpfalz AG, Söllnerstr. 16, 92637, Weiden, Deutschland
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25
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Migdalis IN, Papanas N, Ioannidis IM, Sotiropoulos AE, Raptis AE, Dimitriadis GD. Antidiabetic and Other Therapies Used in Subjects with Diabetes and Chronic Kidney Disease in a Hospital-Based Clinic Population in Greece. J Clin Med 2021; 10:2104. [PMID: 34068380 PMCID: PMC8153603 DOI: 10.3390/jcm10102104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/07/2021] [Accepted: 05/10/2021] [Indexed: 01/14/2023] Open
Abstract
(1) Background: Type 2 diabetes mellitus (T2DM) is the main cause of chronic kidney disease (CKD). In Greece, in a population from hospital-based diabetes clinics (n = 1759), the overall prevalence of diabetic chronic kidney disease (DCKD) was 45% including mild, moderate, and severe CKD. The aim of this study was to describe and analyze how T2DM patients with mild-to-severe CKD are managed by diabetologists in Greece and assess the achievement rates in glycemic, blood pressure and low-density lipoprotein-cholesterol (LDL-C) control. (2) Methods: This cross-sectional multicenter study took place from June 2015 to March 2016 and collected data from diabetes centers in public hospitals all over Greece. (3) Results: With regard to the anti-diabetes treatment, most participants were on metformin, DPP-4 (Dipeptidyl Peptidase-4 inhibitors) inhibitors and insulin. Angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers were the most prescribed medications for hypertension. For the management of dyslipidemia, most participants were on statins. For patients with DCKD, the levels of HbA1c, blood pressure and LDL-C were 7.2%, 137.7/76.9 mmHg and 95.9 mg/dL, respectively (mean values). (4) Conclusions: The outcomes of this study suggest that management of DCKD can be further improved and should be enhanced. These results may contribute to the whole health care system in Greece. In addition, the better understanding of therapeutic strategies used by diabetologists treating these patients offers educational benefits to primary care physicians, which can result in an overall more successful and efficient management of subjects with T2DM and DCKD.
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Affiliation(s)
- Ilias N. Migdalis
- Second Medical Department and Diabetes Centre, NIMTS Hospital, 11521 Athens, Greece
| | - Nikolaos Papanas
- Second Department of Internal Medicine and Diabetes Centre, University Hospital of Alexandroupolis, Democritus University of Thrace, 68132 Alexandroupolis, Greece;
| | - Ioannis M. Ioannidis
- First Department of Internal Medicine and Diabetes Centre, General Hospital of Nea Ionia Konstantopoulio-Patision, 14233 Athens, Greece;
| | | | - Athanasios E. Raptis
- Second Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.E.R.); (G.D.D.)
| | - George D. Dimitriadis
- Second Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.E.R.); (G.D.D.)
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Alamgir J, Yajima M, Ergas R, Chen X, Hill N, Munir N, Saeed M, Gersing K, Haendel M, Chute CG, Abid MR. Drug repositioning candidates identified using in-silico quasi-quantum molecular simulation demonstrate reduced COVID-19 mortality in 1.5M patient records. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2021:2021.03.22.21254110. [PMID: 33851170 PMCID: PMC8043466 DOI: 10.1101/2021.03.22.21254110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Drug repositioning is a key component of COVID-19 pandemic response, through identification of existing drugs that can effectively disrupt COVID-19 disease processes, contributing valuable insights into disease pathways. Traditional non in silico drug repositioning approaches take substantial time and cost to discover effect and, crucially, to validate repositioned effects. Methods Using a novel in-silico quasi-quantum molecular simulation platform that analyzes energies and electron densities of both target proteins and candidate interruption compounds on High Performance Computing (HPC), we identified a list of FDA-approved compounds with potential to interrupt specific SARS-CoV-2 proteins. Subsequently we used 1.5M patient records from the National COVID Cohort Collaborative to create matched cohorts to refine our in-silico hits to those candidates that show statistically significant clinical effect. Results We identified four drugs, Metformin, Triamcinolone, Amoxicillin and Hydrochlorothiazide, that were associated with reduced mortality by 27%, 26%, 26%, and 23%, respectively, in COVID-19 patients. Conclusions Together, these findings provide support to our hypothesis that in-silico simulation of active compounds against SARS-CoV-2 proteins followed by statistical analysis of electronic health data results in effective therapeutics identification.
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Affiliation(s)
| | - Masanao Yajima
- Boston University, Department of Mathematics and Statistics
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27
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Nagai Y, Kazumori K, Takeshima T, Iwasaki K, Tanaka Y. A Claims Database Analysis of Dose-Dependency of Metformin and Incidence of Lactic Acidosis in Japanese Patients with Type 2 Diabetes. Diabetes Ther 2021; 12:1129-1141. [PMID: 33677755 PMCID: PMC7994465 DOI: 10.1007/s13300-021-01029-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/10/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Patients with type 2 diabetes (T2D) in Japan are prescribed a lower dose of metformin that their counterparts in Western countries due to concerns for the risk of lactic acidosis incidence. Here we report our study on the association between high-dose metformin administration and the incidence of lactic acidosis in Japanese patients with T2D. METHODS A Japanese claims database (April 2008-November 2018) was analyzed. Factors associated with the incidence of lactic acidosis were first identified from the database records by conducting a case-control study, and these were then used as confounding factors in subsequent analyses. The association between high-dose metformin administration (≥ 1000 mg/day) and the incidence of lactic acidosis was compared with that between low-dose metformin (< 1000 mg/day) or no metformin administration and lactic acidosis incidence by using the following approaches: a logistic regression analysis hypothesizing that metformin-associated lactic acidosis is short term; a time-dependent proportional hazard model hypothesizing that the influence of metformin is cumulative; and a case-control study in which lactic acidosis incidence was the case and metformin administration within 3 months prior to the incidence of lactic acidosis (or corresponding date for the control) was the exposure. RESULTS Prescriptions for biguanide and vitamin B complex and volume depletion were identified as factors associated with the incidence of lactic acidosis. The incidence rate was higher in patients prescribed metformin than in those not receiving metformin; however, it was not higher in those prescribed high-dose metformin compared to those prescribed low-dose metformin. The estimated regression coefficient for high-dose metformin administration was 0.816 (p < 0.001); this was not higher than those for low-dose metformin (1.047), vitamin B complex (2.725) and volume depletion (3.301). The time-dependent proportional hazard analysis did not indicate any effect of metformin prescription. CONCLUSION The results suggest an association between metformin administration and the incidence of lactic acidosis, but an increase in the incidence rate of lactic acidosis was not observed in those patients receiving high-dose metformin compared to those receiving low-dose metformin.
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Affiliation(s)
- Yoshio Nagai
- Department of Medicine, Metabolism and Endocrinology, St. Marianna University School of Medicine, Kanagawa, Japan
| | | | | | | | - Yasushi Tanaka
- Diabetes Center, Yokohama General Hospital, Kanagawa, Japan
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Rysz J, Franczyk B, Radek M, Ciałkowska-Rysz A, Gluba-Brzózka A. Diabetes and Cardiovascular Risk in Renal Transplant Patients. Int J Mol Sci 2021; 22:3422. [PMID: 33810367 PMCID: PMC8036743 DOI: 10.3390/ijms22073422] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/05/2021] [Accepted: 03/08/2021] [Indexed: 02/06/2023] Open
Abstract
End-stage kidney disease (ESKD) is a main public health problem, the prevalence of which is continuously increasing worldwide. Due to adverse effects of renal replacement therapies, kidney transplantation seems to be the optimal form of therapy with significantly improved survival, quality of life and diminished overall costs compared with dialysis. However, post-transplant patients frequently suffer from post-transplant diabetes mellitus (PTDM) which an important risk factor for cardiovascular and cardiovascular-related deaths after transplantation. The management of post-transplant diabetes resembles that of diabetes in the general population as it is based on strict glycemic control as well as screening and treatment of common complications. Lifestyle interventions accompanied by the tailoring of immunosuppressive regimen may be of key importance to mitigate PTDM-associated complications in kidney transplant patients. More transplant-specific approach can include the exchange of tacrolimus with an alternative immunosuppressant (cyclosporine or mammalian target of rapamycin (mTOR) inhibitor), the decrease or cessation of corticosteroid therapy and caution in the prescribing of diuretics since they are independently connected with post-transplant diabetes. Early identification of high-risk patients for cardiovascular diseases enables timely introduction of appropriate therapeutic strategy and results in higher survival rates for patients with a transplanted kidney.
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Affiliation(s)
- Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-549 Lodz, Poland; (J.R.); (B.F.)
| | - Beata Franczyk
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-549 Lodz, Poland; (J.R.); (B.F.)
| | - Maciej Radek
- Department of Neurosurgery, Surgery of Spine and Peripheral Nerves, Medical University of Lodz, 90-549 Lodz, Poland;
| | | | - Anna Gluba-Brzózka
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-549 Lodz, Poland; (J.R.); (B.F.)
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29
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Ponticelli C, Favi E, Ferraresso M. New-Onset Diabetes after Kidney Transplantation. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:250. [PMID: 33800138 PMCID: PMC7998982 DOI: 10.3390/medicina57030250] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 02/25/2021] [Accepted: 03/05/2021] [Indexed: 02/07/2023]
Abstract
New-onset diabetes mellitus after transplantation (NODAT) is a frequent complication in kidney allograft recipients. It may be caused by modifiable and non-modifiable factors. The non-modifiable factors are the same that may lead to the development of type 2 diabetes in the general population, whilst the modifiable factors include peri-operative stress, hepatitis C or cytomegalovirus infection, vitamin D deficiency, hypomagnesemia, and immunosuppressive medications such as glucocorticoids, calcineurin inhibitors (tacrolimus more than cyclosporine), and mTOR inhibitors. The most worrying complication of NODAT are major adverse cardiovascular events which represent a leading cause of morbidity and mortality in transplanted patients. However, NODAT may also result in progressive diabetic kidney disease and is frequently associated with microvascular complications, eventually determining blindness or amputation. Preventive measures for NODAT include a careful assessment of glucose tolerance before transplantation, loss of over-weight, lifestyle modification, reduced caloric intake, and physical exercise. Concomitant measures include aggressive control of systemic blood pressure and lipids levels to reduce the risk of cardiovascular events. Hypomagnesemia and low levels of vitamin D should be corrected. Immunosuppressive strategies limiting the use of diabetogenic drugs are encouraged. Many hypoglycemic drugs are available and may be used in combination with metformin in difficult cases. In patients requiring insulin treatment, the dose and type of insulin should be decided on an individual basis as insulin requirements depend on the patient's diet, amount of exercise, and renal function.
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Affiliation(s)
- Claudio Ponticelli
- Nephrology, Dialysis and Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Evaldo Favi
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
- Department of Clinical Sciences and Community Health, Università Degli Studi di Milano, 20122 Milan, Italy
| | - Mariano Ferraresso
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
- Department of Clinical Sciences and Community Health, Università Degli Studi di Milano, 20122 Milan, Italy
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Drzewoski J, Hanefeld M. The Current and Potential Therapeutic Use of Metformin-The Good Old Drug. Pharmaceuticals (Basel) 2021; 14:122. [PMID: 33562458 PMCID: PMC7915435 DOI: 10.3390/ph14020122] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/02/2021] [Accepted: 02/02/2021] [Indexed: 02/07/2023] Open
Abstract
Metformin, one of the oldest oral antidiabetic agents and still recommended by almost all current guidelines as the first-line treatment for type 2 diabetes mellitus (T2DM), has become the medication with steadily increasing potential therapeutic indications. A broad spectrum of experimental and clinical studies showed that metformin has a pleiotropic activity and favorable effect in different pathological conditions, including prediabetes, type 1 diabetes mellitus (T1DM) and gestational diabetes mellitus (GDM). Moreover, there are numerous studies, meta-analyses and population studies indicating that metformin is safe and well tolerated and may be associated with cardioprotective and nephroprotective effect. Recently, it has also been reported in some studies, but not all, that metformin, besides improvement of glucose homeostasis, may possibly reduce the risk of cancer development, inhibit the incidence of neurodegenerative disease and prolong the lifespan. This paper presents some arguments supporting the initiation of metformin in patients with newly diagnosed T2DM, especially those without cardiovascular risk factors or without established cardiovascular disease or advanced kidney insufficiency at the time of new guidelines favoring new drugs with pleotropic effects complimentary to glucose control. Moreover, it focuses on the potential beneficial effects of metformin in patients with T2DM and coexisting chronic diseases.
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Affiliation(s)
- Józef Drzewoski
- Central Teaching Hospital of Medical University of Lodz, 92-213 Lodz, Poland
| | - Markolf Hanefeld
- Medical Clinic III, Department of Medicine Technical University Dresden, 01307 Dresden, Germany;
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Masur S, Eisert A, Freitag M. [Metformin Therapy During Surgical Interventions and Iodinated Contrast Agent Use]. Dtsch Med Wochenschr 2021; 146:121-127. [PMID: 33465808 DOI: 10.1055/a-1241-2407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Metformin as first-line treatment in type 2 diabetes mellitus (T2 D) shows benefits in terms of reducing cardiovascular events, but the risk of a lactic acidosis as a serious adverse event especially in patients with decreased renal function is still relevant. Since the perioperative management of Metformin or its use in diagnostic procedures with contrast agents is inconsistent in literature and different in practice, the results of various guidelines are reviewed below showing the current state of evidence. Despite many guidelines, the evidence on both issues is low, as they are mainly based on consensus recommendations. The guidelines are still based on weak data and many international recommendations have clearly different statements. A fundamental problem with drugs is that expert information does specify eGFR limits for dose reduction, but not the method to be used. Depending on the formula, this can then lead to different treatment decisions. At present, it is not possible to give reliable recommendations for practice with the aim of minimising the interruption of therapy. For this reason, only a strictly conservative approach with 48-hour breaks before and after both measures can be recommended at present. For the situations mentioned in this overview, the question of the right approach has not yet been conclusively and definitely answered, therefore further studies should be carried out.
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Singh AK, Singh R, Saboo B, Misra A. Non-insulin anti-diabetic agents in patients with type 2 diabetes and COVID-19: A Critical Appraisal of Literature. Diabetes Metab Syndr 2021; 15:159-167. [PMID: 33352455 PMCID: PMC7832723 DOI: 10.1016/j.dsx.2020.12.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 12/13/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND & AIMS Several observational studies have recently reported the outcomes of non-insulin anti-diabetic agents (ADA) in patients with T2DM and coronavirus disease 2019 (COVID-19). We sought to review the literature to appraise the clinicians on these outcomes. METHODS A literature search using the specific keywords was carried out in the database of PubMed, MedRxiv and Google Scholar up till December 11, 2020 applying Boolean method. Full text of all the relevant articles that reported the outcomes of ADA in patients with T2DM and COVID-19 were retrieved. Subsequently, an appraisal of literature report was narratively presented. RESULTS Available studies that reported the outcomes of ADA are either case series or retrospective cohorts or prospective observational studies, in absence of the randomized controlled trials (RCTs). Results from these observational studies suggest that amongst all the non-insulin ADA, metformin users prior to the hospitalization had improved outcomes compared to the non-users. Data for dipeptidyl-peptidase-4 inhibitors (DPP-4i) are encouraging although inconsistent. No documentation of any harm or benefit has been observed for sulfonylureas (SUs), sodium glucose co-transporter-2 inhibitors (SGLT-2i) and glucagon-like peptide receptor agonists (GLP-1RAs). No data is yet available for pioglitazone. CONCLUSION Metformin and DPP-4i should be continued in patients with T2DM until hospitalization or unless contraindicated. No evidence of harm suggests that SUs, SGLT-2i or GLP-1RAs may not be stopped unless very sick, hospitalized or contraindicated. The results from RCTs are needed to claim any meaningful benefit with either metformin or DPP-4i in patients with T2DM and COVID-19.
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Affiliation(s)
| | - Ritu Singh
- G.D Hospital & Diabetes Institute, Kolkata, India
| | | | - Anoop Misra
- Fortis CDOC Hospital for Diabetes and Allied Science, Chirag Enclave, New Delhi, India; National Diabetes, Obesity and Cholesterol Foundation, New Delhi, India; Diabetes Foundation (India), New Delhi, India
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Mariano F, Biancone L. Metformin, chronic nephropathy and lactic acidosis: a multi-faceted issue for the nephrologist. J Nephrol 2020; 34:1127-1135. [PMID: 33373028 PMCID: PMC8357762 DOI: 10.1007/s40620-020-00941-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/30/2020] [Indexed: 12/15/2022]
Abstract
Metformin is currently considered a first-line therapy in type 2 diabetic patients. After issuing warnings for decades about the risks of lactic acidosis in patients with chronic nephropathy, metformin is now being re-evaluated. The most recent evidence from the literature has demonstrated both a low, acceptable risk of lactic acidosis and a series of favorable effects, which go beyond its hypoglycemic activity. Patients treated with metformin show a significant mortality reduction and lower progression towards end-stage renal disease in comparison with those treated with other hypoglycemic drugs. Concerning lactic acidosis, in the last few years it has been shown how lactic acidosis almost always developed when patients kept taking the drug in the face of a concomitant disease or situation such as sepsis, fever, diarrhea, vomiting, which reduced metformin renal clearance. Actually, clearance of metformin is mainly renal, both by glomerular filtration and tubular secretion (apparent clearance 933–1317 ml/min, half-life < 3 h). As regards treatment, in cases of lactic acidosis complicated by acute kidney injury, continuous renal replacement therapy (CRRT) plays a crucial role. Besides the elimination of metformin, CRRT improves survival by correcting acidosis, electrolyte alterations, and maintaining fluid balance. Lactic acidosis almost always develops because of preventable drug accumulation. Therefore, prevention is a key factor. Patients should be aware that discontinuation for a limited time does not affect their health, even when it may be inappropriate, but it may avoid a serious, potentially fatal adverse event.
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Affiliation(s)
- Filippo Mariano
- Department of Medical Sciences, University of Turin, Turin, Italy.
| | - Luigi Biancone
- Department of Medical Sciences, University of Turin, Turin, Italy
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Koltai T. Targeting the pH Paradigm at the Bedside: A Practical Approach. Int J Mol Sci 2020; 21:E9221. [PMID: 33287221 PMCID: PMC7730959 DOI: 10.3390/ijms21239221] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 11/27/2020] [Accepted: 11/28/2020] [Indexed: 02/07/2023] Open
Abstract
The inversion of the pH gradient in malignant tumors, known as the pH paradigm, is increasingly becoming accepted by the scientific community as a hallmark of cancer. Accumulated evidence shows that this is not simply a metabolic consequence of a dysregulated behavior, but rather an essential process in the physiopathology of accelerated proliferation and invasion. From the over-simplification of increased lactate production as the cause of the paradigm, as initially proposed, basic science researchers have arrived at highly complex and far-reaching knowledge, that substantially modified that initial belief. These new developments show that the paradigm entails a different regulation of membrane transporters, electrolyte exchangers, cellular and membrane enzymes, water trafficking, specialized membrane structures, transcription factors, and metabolic changes that go far beyond fermentative glycolysis. This complex world of dysregulations is still shuttered behind the walls of experimental laboratories and has not yet reached bedside medicine. However, there are many known pharmaceuticals and nutraceuticals that are capable of targeting the pH paradigm. Most of these products are well known, have low toxicity, and are also inexpensive. They need to be repurposed, and this would entail shorter clinical studies and enormous cost savings if we compare them with the time and expense required for the development of a new molecule. Will targeting the pH paradigm solve the "cancer problem"? Absolutely not. However, reversing the pH inversion would strongly enhance standard treatments, rendering them more efficient, and in some cases permitting lower doses of toxic drugs. This article's goal is to describe how to reverse the pH gradient inversion with existing drugs and nutraceuticals that can easily be used in bedside medicine, without adding toxicity to established treatments. It also aims at increasing awareness among practicing physicians that targeting the pH paradigm would be able to improve the results of standard therapies. Some clinical cases will be presented as well, showing how the pH gradient inversion can be treated at the bedside in a simple manner with repurposed drugs.
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Affiliation(s)
- Tomas Koltai
- Centro de Diagnostico y Tratamiento de la Obra Social del Personal de la Alimentacion, Talar de Pacheco, Buenos Aires 1617, Argentina
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35
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Ahmad E, Sargeant JA, Zaccardi F, Khunti K, Webb DR, Davies MJ. Where Does Metformin Stand in Modern Day Management of Type 2 Diabetes? Pharmaceuticals (Basel) 2020; 13:E427. [PMID: 33261058 PMCID: PMC7761522 DOI: 10.3390/ph13120427] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 02/06/2023] Open
Abstract
Metformin is the most commonly used glucose-lowering therapy (GLT) worldwide and remains the first-line therapy for newly diagnosed individuals with type 2 diabetes (T2D) in management algorithms and guidelines after the UK Prospective Diabetes Study (UKPDS) showed cardiovascular mortality benefits in the overweight population using metformin. However, the improved Major Adverse Cardiovascular Events (MACE) realised in some of the recent large cardiovascular outcomes trials (CVOTs) using sodium-glucose co-transporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) have challenged metformin's position as a first-line agent in the management of T2D. Many experts now advocate revising the existing treatment algorithms to target atherosclerotic cardiovascular disease (ASCVD) and improving glycaemic control as a secondary aim. In this review article, we will revisit the major cardiovascular outcome data for metformin and include a critique of the UKPDS data. We then review additional factors that might be pertinent to metformin's status as a first-line agent and finally answer key questions when considering metformin's role in the modern-day management of T2D.
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Affiliation(s)
- Ehtasham Ahmad
- Diabetes Research Centre, University of Leicester, Leicester LE5 4PW, UK; (J.A.S.); (F.Z.); (K.K.); (D.R.W.); (M.J.D.)
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and the University of Leicester, Leicester LE5 4PW, UK
| | - Jack A. Sargeant
- Diabetes Research Centre, University of Leicester, Leicester LE5 4PW, UK; (J.A.S.); (F.Z.); (K.K.); (D.R.W.); (M.J.D.)
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and the University of Leicester, Leicester LE5 4PW, UK
| | - Francesco Zaccardi
- Diabetes Research Centre, University of Leicester, Leicester LE5 4PW, UK; (J.A.S.); (F.Z.); (K.K.); (D.R.W.); (M.J.D.)
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and the University of Leicester, Leicester LE5 4PW, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester LE5 4PW, UK; (J.A.S.); (F.Z.); (K.K.); (D.R.W.); (M.J.D.)
- NIHR Applied Research Collaborations (ARC), East Midlands, Leicester LE5 4PW, UK
| | - David R. Webb
- Diabetes Research Centre, University of Leicester, Leicester LE5 4PW, UK; (J.A.S.); (F.Z.); (K.K.); (D.R.W.); (M.J.D.)
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and the University of Leicester, Leicester LE5 4PW, UK
| | - Melanie J. Davies
- Diabetes Research Centre, University of Leicester, Leicester LE5 4PW, UK; (J.A.S.); (F.Z.); (K.K.); (D.R.W.); (M.J.D.)
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and the University of Leicester, Leicester LE5 4PW, UK
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Peralta S, Pinto M, Arguello T, Garcia S, Diaz F, Moraes CT. Metformin delays neurological symptom onset in a mouse model of neuronal complex I deficiency. JCI Insight 2020; 5:141183. [PMID: 33148885 PMCID: PMC7710273 DOI: 10.1172/jci.insight.141183] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/21/2020] [Indexed: 12/24/2022] Open
Abstract
Complex I (also known as NADH-ubiquinone oxidoreductase) deficiency is the most frequent mitochondrial disorder present in childhood. NADH-ubiquinone oxidoreductase iron-sulfur protein 3 (NDUFS3) is a catalytic subunit of the mitochondrial complex I; NDUFS3 is conserved from bacteria and essential for complex I function. Mutations affecting complex I, including in the Ndufs3 gene, cause fatal neurodegenerative diseases, such as Leigh syndrome. No treatment is available for these conditions. We developed and performed a detailed molecular characterization of a neuron-specific Ndufs3 conditional KO mouse model. We showed that deletion of Ndufs3 in forebrain neurons reduced complex I activity, altered brain energy metabolism, and increased locomotor activity with impaired motor coordination, balance, and stereotyped behavior. Metabolomics analyses showed an increase of glycolysis intermediates, suggesting an adaptive response to the complex I defect. Administration of metformin to these mice delayed the onset of the neurological symptoms but not of neuronal loss. This improvement was likely related to enhancement of glucose uptake and utilization, which are known effects of metformin in the brain. Despite reports that metformin inhibits complex I activity, our findings did not show worsening a complex I defect nor increases in lactic acid, suggesting that metformin should be further evaluated for use in patients with mitochondrial encephalopathies. Metformin delays onset of mitochondrial encephalopathy in a CNS model of mitochondrial oxidative phosphorylation defect.
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Affiliation(s)
| | | | | | | | | | - Carlos T Moraes
- Department of Neurology and.,Department of Cell Biology, Miller School of Medicine, University of Miami, Miami, Florida, USA
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37
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Arutiunov GP, Tarlovskaia EI, Koziolova NA, Boldina MV, Batiushin MM, Ametov AS, Arutiunov AG, Belevskii AS, Galstian GR, Grigor'eva NI, Dzhunusbekova GA, Esaian AM, Mal'chikova SV, Mit'kovskaia NP, Mkrtumian AM, Orlova IA, Petrova MM, Rebrov AP, Ruzanov DI, Salukhov VV, Sisakian AS, Skibitskii VV, Sugraliev AB, Fomin IV, Khalimov IS, Chesnikova AI, Shaposhnik II, Shestakova MV. [The agreed experts' position of the Eurasian Association of Therapists on tactics of management of patients with comorbid pathology infected with SARS-Cov-2]. TERAPEVT ARKH 2020; 92:108-124. [PMID: 33346439 DOI: 10.26442/00403660.2020.09.000703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/13/2020] [Indexed: 01/08/2023]
Abstract
The agreement of experts of the Eurasian Association of Therapists (EAT) discusses pathogenesis and treatment of COVID-19. Modern data on the characteristics of cardiovascular, kidney, respiratory damage in SARS-infected CoV-2 are presented. The tactics of managing patients initially having cardiovascular diseases, diabetes mellitus, chronic obstructive pulmonary disease, bronchial asthma, chronic kidney disease are discussed in detail. The article presents data on drug interaction of drugs.
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Affiliation(s)
- G P Arutiunov
- Pirogov Russian National Research Medical University
| | | | | | | | | | - A S Ametov
- Russian Medical Academy of Continuous Professional Education
| | - A G Arutiunov
- Pirogov Russian National Research Medical University
| | - A S Belevskii
- Pirogov Russian National Research Medical University
| | | | | | | | - A M Esaian
- Pavlov First Saint Petersburg State Medical University
| | | | | | - A M Mkrtumian
- Yevdokimov Moscow State University of Medicine and Dentistry
| | | | - M M Petrova
- Voino-Yasenetski Krasnoyarsk State Medical University
| | - A P Rebrov
- Razumovsky Saratov State Medical University
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Hu Y, Lei M, Ke G, Huang X, Peng X, Zhong L, Fu P. Metformin Use and Risk of All-Cause Mortality and Cardiovascular Events in Patients With Chronic Kidney Disease-A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2020; 11:559446. [PMID: 33117278 PMCID: PMC7575818 DOI: 10.3389/fendo.2020.559446] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 09/15/2020] [Indexed: 02/05/2023] Open
Abstract
Background To evaluate whether metformin use assuredly alters overall all-cause death in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD). Methods Pubmed, Web of Science, Embase, and Cochrane Central Register of Controlled Trials were systematically searched from inception to Feb. 29, 2020 with no language restriction. All related articles comparing all-cause death of T2DM and CKD patients after metformin use (monotherapy or combination) versus non-metformin treatment were identified. Pooled risk ratios (RR) and 95% confidence intervals (CI) were computed using random-effects models regardless of the heterogeneity quantified by Cochrane χ2 and I2 statistics. Results Totally 13 studies (9 cohort studies [CSs], 3 subanalyses or post-hoc analyses of randomized controlled trials [RCTs], and 1 nested case-control article) involving 303,540 patients were included. Metformin-based treatments relative to any other measure displayed significantly lower risks of all-cause mortality (Pooled RRs 0.71, 95%CI 0.61 to 0.84; I2 = 79.0%) and cardiovascular events (Pooled RRs 0.76, 95%CI 0.60 to 0.97; I2 = 87.0%) in CKD patients at stage G1-3, with substantial heterogeneity. Metformin use was not significantly related with these end points in advanced CKD patients. Conclusions Metformin use is connected with significantly less risks of all-cause mortality and cardiovascular events in patients with T2DM and mild/moderate CKD. However, RCTs with large sample sizes are warranted in the future to assess whether these key benefits extend to later stages of CKD by dose adjustment.
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Affiliation(s)
- Yao Hu
- Department of Medicine Renal Division, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
- Department of Medicine Renal Division, Affiliated Hospital & Clinical Medical College of Chengdu University, Chengdu, China
| | - Min Lei
- Department of Medicine Renal Division, Affiliated Hospital & Clinical Medical College of Chengdu University, Chengdu, China
| | - Guibao Ke
- Department of Medicine Renal Division, Affiliated Hospital & Clinical Medical College of Chengdu University, Chengdu, China
| | - Xin Huang
- Department of Medicine Renal Division, Affiliated Hospital & Clinical Medical College of Chengdu University, Chengdu, China
| | - Xuan Peng
- Department of Medicine Renal Division, Affiliated Hospital & Clinical Medical College of Chengdu University, Chengdu, China
| | - Lihui Zhong
- Department of Medicine Renal Division, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Ping Fu
- Department of Medicine Renal Division, West China Hospital, West China School of Medicine, Sichuan University, Kidney Research Institute, Chengdu, China
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Sinnappah KA, Kuan IH, Thynne TR, Doogue MP, Wright DF. The pharmacokinetics of metformin in patients receiving intermittent haemodialysis. Br J Clin Pharmacol 2020; 86:1430-1443. [PMID: 32060931 PMCID: PMC7319002 DOI: 10.1111/bcp.14244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/03/2020] [Accepted: 02/09/2020] [Indexed: 12/23/2022] Open
Abstract
The aims of this study were to characterise the population pharmacokinetics of metformin in patients receiving haemodialysis, and to determine the doses that will maintain median metformin plasma concentrations below 5 mg L-1 for a typical individual. Metformin plasma concentrations from 5 patients receiving thrice weekly intermittent haemodialysis followed by metformin 500 mg postdialysis were fitted to a published pharmacokinetic model. Additional models to describe the dialytic pharmacokinetics of metformin were explored. Doses of 250 and 500 postdialysis were simulated from the model for a typical haemodialysis patient. The published 2-compartment pharmacokinetic model with an additional parameter to describe haemodialysis clearance provided a reasonable fit to the data. Deterministic simulations from the model for a typical individual suggest that metformin doses of 250-500 mg postdialysis and 250 mg given once daily should maintain median metformin plasma concentrations below 5 mg L-1 .
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Affiliation(s)
| | | | - Tilenka R.J. Thynne
- Department of Clinical PharmacologyFlinders Medical Centre and Flinders UniversityAdelaideAustralia
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Tuttle KR, McGill JB. Evidence-based treatment of hyperglycaemia with incretin therapies in patients with type 2 diabetes and advanced chronic kidney disease. Diabetes Obes Metab 2020; 22:1014-1023. [PMID: 32009296 PMCID: PMC7317405 DOI: 10.1111/dom.13986] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 01/20/2020] [Accepted: 01/30/2020] [Indexed: 01/14/2023]
Abstract
Type 2 diabetes is the leading cause of chronic kidney disease (CKD). The prevalence of CKD is growing in parallel with the rising number of patients with type 2 diabetes globally. At present, the optimal approach to glycaemic control in patients with type 2 diabetes and advanced CKD (categories 4 and 5) remains uncertain, as these patients were largely excluded from clinical trials of glucose-lowering therapies. Nonetheless, clinical trial data are available for the use of incretin therapies, dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists, for patients with type 2 diabetes and advanced CKD. This review discusses the role of incretin therapies in the management of these patients. Because the presence of advanced CKD in patients with type 2 diabetes is associated with a markedly elevated risk of cardiovascular disease (CVD), treatment strategies must include the reduction of both CKD and CVD risks because death, particularly from cardiovascular causes, is more probable than progression to end-stage kidney disease. The management of hyperglycaemia is essential for good diabetes care even in advanced CKD. Current evidence supports an individualized approach to glycaemic management in patients with type 2 diabetes and advanced CKD, taking account of the needs of each patient, including the presence of co-morbidities and concomitant therapies. Although additional studies are needed to establish optimal strategies for glycaemic control in patients with type 2 diabetes and advanced CKD, treatment regimens with currently available pharmacotherapy can be individually tailored to meet the needs of this growing patient population.
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Affiliation(s)
- Katherine R. Tuttle
- Providence Medical Research CenterProvidence Health CareSpokaneWashington
- Division of Nephrology, Kidney Research Institute, and Institute of Translational Health SciencesUniversity of WashingtonSeattleWashington
| | - Janet B. McGill
- Division of Endocrinology, Metabolism and Lipid ResearchWashington University School of MedicineSt. LouisMissouriUnited States
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Gnesin F, Thuesen ACB, Kähler LKA, Madsbad S, Hemmingsen B. Metformin monotherapy for adults with type 2 diabetes mellitus. Cochrane Database Syst Rev 2020; 6:CD012906. [PMID: 32501595 PMCID: PMC7386876 DOI: 10.1002/14651858.cd012906.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Worldwide, there is an increasing incidence of type 2 diabetes mellitus (T2DM). Metformin is still the recommended first-line glucose-lowering drug for people with T2DM. Despite this, the effects of metformin on patient-important outcomes are still not clarified. OBJECTIVES To assess the effects of metformin monotherapy in adults with T2DM. SEARCH METHODS We based our search on a systematic report from the Agency for Healthcare Research and Quality, and topped-up the search in CENTRAL, MEDLINE, Embase, WHO ICTRP, and ClinicalTrials.gov. Additionally, we searched the reference lists of included trials and systematic reviews, as well as health technology assessment reports and medical agencies. The date of the last search for all databases was 2 December 2019, except Embase (searched up 28 April 2017). SELECTION CRITERIA We included randomised controlled trials (RCTs) with at least one year's duration comparing metformin monotherapy with no intervention, behaviour changing interventions or other glucose-lowering drugs in adults with T2DM. DATA COLLECTION AND ANALYSIS Two review authors read all abstracts and full-text articles/records, assessed risk of bias, and extracted outcome data independently. We resolved discrepancies by involvement of a third review author. For meta-analyses we used a random-effects model with investigation of risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We assessed the overall certainty of the evidence by using the GRADE instrument. MAIN RESULTS We included 18 RCTs with multiple study arms (N = 10,680). The percentage of participants finishing the trials was approximately 58% in all groups. Treatment duration ranged from one to 10.7 years. We judged no trials to be at low risk of bias on all 'Risk of bias' domains. The main outcomes of interest were all-cause mortality, serious adverse events (SAEs), health-related quality of life (HRQoL), cardiovascular mortality (CVM), non-fatal myocardial infarction (NFMI), non-fatal stroke (NFS), and end-stage renal disease (ESRD). Two trials compared metformin (N = 370) with insulin (N = 454). Neither trial reported on all-cause mortality, SAE, CVM, NFMI, NFS or ESRD. One trial provided information on HRQoL but did not show a substantial difference between the interventions. Seven trials compared metformin with sulphonylureas. Four trials reported on all-cause mortality: in three trials no participant died, and in the remaining trial 31/1454 participants (2.1%) in the metformin group died compared with 31/1441 participants (2.2%) in the sulphonylurea group (very low-certainty evidence). Three trials reported on SAE: in two trials no SAE occurred (186 participants); in the other trial 331/1454 participants (22.8%) in the metformin group experienced a SAE compared with 308/1441 participants (21.4%) in the sulphonylurea group (very low-certainty evidence). Two trials reported on CVM: in one trial no CVM was observed and in the other trial 4/1441 participants (0.3%) in the metformin group died of cardiovascular reasons compared with 8/1447 participants (0.6%) in the sulphonylurea group (very low-certainty evidence). Three trials reported on NFMI: in two trials no NFMI occurred, and in the other trial 21/1454 participants (1.4%) in the metformin group experienced a NFMI compared with 15/1441 participants (1.0%) in the sulphonylurea group (very low-certainty evidence). One trial reported no NFS occurred (very low-certainty evidence). No trial reported on HRQoL or ESRD. Seven trials compared metformin with thiazolidinediones (very low-certainty evidence for all outcomes). Five trials reported on all-cause mortality: in two trials no participant died; the overall RR was 0.88, 95% CI 0.55 to 1.39; P = 0.57; 5 trials; 4402 participants). Four trials reported on SAE, the RR was 0,95, 95% CI 0.84 to 1.09; P = 0.49; 3208 participants. Four trials reported on CVM, the RR was 0.71, 95% CI 0.21 to 2.39; P = 0.58; 3211 participants. Three trial reported on NFMI: in two trials no NFMI occurred and in one trial 21/1454 participants (1.4%) in the metformin group experienced a NFMI compared with 25/1456 participants (1.7%) in the thiazolidinedione group. One trial reported no NFS occurred. No trial reported on HRQoL or ESRD. Three trials compared metformin with dipeptidyl peptidase-4 inhibitors (one trial each with saxagliptin, sitagliptin, vildagliptin with altogether 1977 participants). There was no substantial difference between the interventions for all-cause mortality, SAE, CVM, NFMI and NFS (very low-certainty evidence for all outcomes). One trial compared metformin with a glucagon-like peptide-1 analogue (very low-certainty evidence for all reported outcomes). There was no substantial difference between the interventions for all-cause mortality, CVM, NFMI and NFS. One or more SAEs were reported in 16/268 (6.0%) of the participants allocated to metformin compared with 35/539 (6.5%) of the participants allocated to a glucagon-like peptide-1 analogue. HRQoL or ESRD were not reported. One trial compared metformin with meglitinide and two trials compared metformin with no intervention. No deaths or SAEs occurred (very low-certainty evidence) no other patient-important outcomes were reported. No trial compared metformin with placebo or a behaviour changing interventions. Four ongoing trials with 5824 participants are likely to report one or more of our outcomes of interest and are estimated to be completed between 2018 and 2024. Furthermore, 24 trials with 2369 participants are awaiting assessment. AUTHORS' CONCLUSIONS There is no clear evidence whether metformin monotherapy compared with no intervention, behaviour changing interventions or other glucose-lowering drugs influences patient-important outcomes.
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Affiliation(s)
- Filip Gnesin
- Department of Endocrinology, Diabetes and Metabolism, Department 7652, Rigshospitalet, Copenhagen, Denmark
| | - Anne Cathrine Baun Thuesen
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Novo Nordisk Foundation Center for Basic Metabolic Research, Copenhagen, Denmark
| | | | - Sten Madsbad
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Bianca Hemmingsen
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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Alauddin T, Petite SE. Evaluation of the Safety and Efficacy of Metformin Use in Hospitalized, Non-Critically Ill Patients. J Pharm Technol 2020; 36:102-109. [PMID: 37927306 PMCID: PMC10621675 DOI: 10.1177/8755122520911689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Background: Contraindications and precautions to metformin have limited inpatient use, and limited evidence exists evaluating metformin in hospitalized patients. Objective: This study aimed to determine the safety and efficacy of inpatient metformin use. Methods: This study was an observational, retrospective, cohort study at an academic medical center between June 1, 2016, and May 31, 2018. Hospitalized adults with type 2 diabetes mellitus receiving at least 1 metformin dose were included. The primary endpoint was to identify hospitalized patients using metformin with at least 1 contraindication or precautionary warning against use. Secondary endpoints included assessing metformin efficacy with glycemic control, characterizing adverse outcomes of inpatient metformin, and comparing the efficacy of metformin-containing regimens. Results: Two hundred patients were included. There were 126 incidences of potentially unsafe use identified in 111 patients (55.5%). The most common reasons were age ≥65 years (47%), heart failure diagnosis (7.5%), and metformin within 48 hours of contrast (6%). Metformin was contraindicated in 2 patients (1%) with an estimated glomerular filtration rate ≤30 mL/min/1.73 m2. The overall median daily blood glucose was 146 mg/dL (interquartile range [IQR] = 122-181). Patients were divided into 3 groups: metformin monotherapy, metformin plus oral antihyperglycemic therapy, and metformin plus insulin. The median daily blood glucoses were 129 mg/dL (IQR = 110-152), 154 mg/dL (IQR = 133-178), and 174 mg/dL (IQR = 142-203; P < .001), respectively. Two patients (1%) developed acute kidney injury, and no patients developed lactic acidosis. Conclusions: Metformin was associated with goal glycemic levels in hospitalized patients with no adverse outcomes. These results suggest the potential for metformin use in hospitalized, non-critically ill patients.
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Toxicities Associated With Metformin/Ritonavir Combination Treatment in Relapsed/Refractory Multiple Myeloma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e667-e672. [PMID: 32631779 DOI: 10.1016/j.clml.2020.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/20/2020] [Accepted: 05/21/2020] [Indexed: 11/21/2022]
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Kuan IHS, Savage RL, Duffull SB, Walker RJ, Wright DFB. The Association between Metformin Therapy and Lactic Acidosis. Drug Saf 2020; 42:1449-1469. [PMID: 31372935 DOI: 10.1007/s40264-019-00854-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND OBJECTIVES There is increasing evidence to suggest that therapeutic doses of metformin are unlikely to cause lactic acidosis. The aims of this research were (1) to formally evaluate the association between metformin therapy and lactic acidosis in published case reports using two causality scoring systems, (2) to determine the frequency of pre-existing independent risk factors in published metformin-associated lactic acidosis cases, (3) to investigate the association between risk factors and mortality in metformin-associated lactic acidosis cases, and (4) to explore the relationship between prescribed metformin doses, elevated metformin plasma concentrations and the development of lactic acidosis in cases with chronic renal impairment. METHODS A systematic review was conducted to identify metformin-associated lactic acidosis cases. Causality was assessed using the World Health Organisation-Uppsala Monitoring Centre system and the Naranjo adverse drug reaction probability scale. Compliance to dosing guidelines was investigated for cases with chronic renal impairment as well as the association between steady-state plasma metformin concentrations prior to admission. RESULTS We identified 559 metformin-associated lactic acidosis cases. Almost all cases reviewed (97%) presented with independent risk factors for lactic acidosis. The prescribed metformin dose exceeded published guidelines in 60% of cases in patients with impaired kidney function. Metformin steady-state plasma concentrations prior to admission were predicted to be below the proposed upper limit of the therapeutic range of 5 mg/L. CONCLUSIONS Almost all cases of metformin-associated lactic acidosis reviewed presented with independent risk factors for lactic acidosis, supporting the suggestion that metformin plays a contributory role. The prescribed metformin dose, on average, exceeded the dosing recommendations by 1000 mg/day in patients with varying degrees of renal impairment but the predicted pre-admission plasma concentrations did not exceed the therapeutic range.
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Affiliation(s)
- Isabelle H S Kuan
- School of Pharmacy, University of Otago, PO Box 56, Dunedin, New Zealand
| | - Ruth L Savage
- New Zealand Pharmacovigilance Centre, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.,Department of General Practice, University of Otago, Christchurch, New Zealand
| | - Stephen B Duffull
- School of Pharmacy, University of Otago, PO Box 56, Dunedin, New Zealand
| | - Robert J Walker
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Daniel F B Wright
- School of Pharmacy, University of Otago, PO Box 56, Dunedin, New Zealand.
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Blumenberg A, Benabbas R, Sinert R, Jeng A, Wiener SW. Do Patients Die with or from Metformin-Associated Lactic Acidosis (MALA)? Systematic Review and Meta-analysis of pH and Lactate as Predictors of Mortality in MALA. J Med Toxicol 2020; 16:222-229. [PMID: 31907741 PMCID: PMC7099117 DOI: 10.1007/s13181-019-00755-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/04/2019] [Accepted: 12/15/2019] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Metformin-associated lactic acidosis (MALA) may occur after acute metformin overdose, or from therapeutic use in patients with renal compromise. The mortality is high, historically 50% and more recently 25%. In many disease states, lactate concentration is strongly associated with mortality. The aim of this systematic review and meta-analysis is to investigate the utility of pH and lactate concentration in predicting mortality in patients with MALA. METHODS We searched PubMed, EMBASE, and Web of Science from their inception to April 2019 for case reports, case series, prospective, and retrospective studies investigating mortality in patients with MALA. Cases and studies were reviewed by all authors and included if they reported data on pH, lactate, and outcome. Where necessary, authors of studies were contacted for patient-level data. Receiver operating characteristic (ROC) curves were generated for pH and lactate for predicting mortality in patients with MALA. RESULTS Forty-four studies were included encompassing 170 cases of MALA with median age of 68.5 years old. Median pH and lactate were 7.02 mmol/L and 14.45 mmol/L, respectively. Overall mortality was 36.2% (95% CI 29.6-43.94). Neither lactate nor pH was a good predictor of mortality among patients with MALA. The area under the ROC curve for lactate and pH were 0.59 (0.51-0.68) and 0.43 (0.34-0.52), respectively. CONCLUSION Our review found higher mortality from MALA than seen in recent studies. This may be due to variation in standard medical practice both geographically and across the study interval, sample size, misidentification of MALA for another disease process and vice versa, confounding by selection and reporting biases, and treatment intensity (e.g., hemodialysis) influenced by degree of pH and lactate derangement. The ROC curves showed poor predictive power of either lactate or pH for mortality in MALA. With the exception of patients with acute metformin overdose, patients with MALA usually have coexisting precipitating illnesses such as sepsis or renal failure, though lactate from MALA is generally higher than would be considered survivable for those disease states on their own. It is possible that mortality is more related to that coexisting illness than MALA itself, and many patients die with MALA rather than from MALA. Additional work looking solely at MALA in healthy patients with acute metformin overdose may show a closer relationship between lactate, pH, and mortality.
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Affiliation(s)
- Adam Blumenberg
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, NY, USA.
- Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA.
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA.
| | - Roshanak Benabbas
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, NY, USA
- Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Richard Sinert
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, NY, USA
- Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Amy Jeng
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, NY, USA
- Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Sage W Wiener
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, NY, USA
- Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
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Shin NR, Gu N, Choi HS, Kim H. Combined effects of Scutellaria baicalensis with metformin on glucose tolerance of patients with type 2 diabetes via gut microbiota modulation. Am J Physiol Endocrinol Metab 2020; 318:E52-E61. [PMID: 31770016 DOI: 10.1152/ajpendo.00221.2019] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Metformin is a widely prescribed antidiabetic agent, whereas Scutellaria baicalensis (SB) is a commonly used medicinal herb for treatment of type 2 diabetes (T2D). Gut microbiota is involved in pathophysiology of metabolic diseases including T2D, and intestinal microbiota may be one of the important therapeutic targets for the ailment. This study was conducted to investigate the effects of SB combined with metformin on treatment of T2D while evaluating changes in the gut microbiota composition. Patients with T2D were randomized into control and treatment groups. Subjects who had already been prescribed metformin were allotted to additional SB (3.52 g/day) group or placebo group. The initial treatment session was 8 wk, and after washout period for 4 wk they were crossed over to the opposite treatment for another 8 wk. The influence of SB and placebo on the intestinal microbiota was analyzed by MiSeq system based on 16S rRNA gene. Glucose tolerance was lower in the SB group than the placebo group. Similarly, the relative RNA expression of TNF-α was significantly reduced after SB treatment. SB treatment influenced the gut microbiota, especially Lactobacillus and Akkermansia, which showed remarkable increases after SB treatment. Some subjects showed high liver enzyme levels after SB treatment, and their microbiota composition at baseline differed with subjects whose liver enzymes were not affected. We also predicted that selenocompound metabolism was increased and naphthalene degradation was decreased after SB treatment. These results suggest that SB with metformin treatment may improve the glucose tolerance and inflammation and influence the gut microbiota community in T2D.
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Affiliation(s)
- Na Rae Shin
- Department of Rehabilitation Medicine of Korean Medicine, Dongguk University, Siksa, Goyang, Gyeonggi-do, Republic of Korea
| | - Namyi Gu
- Department of Clinical Pharmacology and Therapeutics, Clinical Trial Center, Dongguk University College of Medicine and Ilsan Hospital, Siksa, Goyang, Gyeonggi-do, Republic of Korea
| | - Han Seok Choi
- Department of Endocrinology, Dongguk University, Dongguk-ro, Goyang, Gyeonggi-do, Republic of Korea
| | - Hojun Kim
- Department of Rehabilitation Medicine of Korean Medicine, Dongguk University, Siksa, Goyang, Gyeonggi-do, Republic of Korea
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Flory JH, Hennessy S, Bailey CJ, Inzucchi SE. Reports of Lactic Acidosis Attributed to Metformin, 2015-2018. Diabetes Care 2020; 43:244-246. [PMID: 31597667 PMCID: PMC7011199 DOI: 10.2337/dc19-0923] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 09/16/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE In 2016, the U.S. Food and Drug Administration (FDA) revised metformin's label to permit use in patients with mild-moderate chronic kidney disease. We sought to determine whether this change was associated with increased reports of metformin-associated lactic acidosis (MALA) to the FDA's Adverse Event Reporting System (FAERS). RESEARCH DESIGN AND METHODS Publicly available FAERS reports were analyzed. RESULTS MALA reports increased from 521 in 2015 to 1,939 in 2018. After restriction to U.S. reports, absolute and relative increase in MALA reports was less, from 111 to 243. The proportionate reporting ratio (PRR), a measure adjusted for rates of other adverse event reports, was stable. CONCLUSIONS The increased reports deserve attention, but the PRR's stability and FAERS's known limitations, including lack of a denominator or control group, do not permit the conclusion that U.S. MALA rates have increased. Further study with more robust data sources is needed.
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Affiliation(s)
- James H Flory
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Sean Hennessy
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Clifford J Bailey
- School of Life and Health Sciences, Aston University, Birmingham, U.K
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Madsen KS, Chi Y, Metzendorf M, Richter B, Hemmingsen B. Metformin for prevention or delay of type 2 diabetes mellitus and its associated complications in persons at increased risk for the development of type 2 diabetes mellitus. Cochrane Database Syst Rev 2019; 12:CD008558. [PMID: 31794067 PMCID: PMC6889926 DOI: 10.1002/14651858.cd008558.pub2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The projected rise in the incidence of type 2 diabetes mellitus (T2DM) could develop into a substantial health problem worldwide. Whether metformin can prevent or delay T2DM and its complications in people with increased risk of developing T2DM is unknown. OBJECTIVES To assess the effects of metformin for the prevention or delay of T2DM and its associated complications in persons at increased risk for the T2DM. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Scopus, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform and the reference lists of systematic reviews, articles and health technology assessment reports. We asked investigators of the included trials for information about additional trials. The date of the last search of all databases was March 2019. SELECTION CRITERIA We included randomised controlled trials (RCTs) with a duration of one year or more comparing metformin with any pharmacological glucose-lowering intervention, behaviour-changing intervention, placebo or standard care in people with impaired glucose tolerance, impaired fasting glucose, moderately elevated glycosylated haemoglobin A1c (HbA1c) or combinations of these. DATA COLLECTION AND ANALYSIS Two review authors read all abstracts and full-text articles and records, assessed risk of bias and extracted outcome data independently. We used a random-effects model to perform meta-analysis and calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We assessed the certainty of the evidence using GRADE. MAIN RESULTS We included 20 RCTs randomising 6774 participants. One trial contributed 48% of all participants. The duration of intervention in the trials varied from one to five years. We judged none of the trials to be at low risk of bias in all 'Risk of bias' domains. Our main outcome measures were all-cause mortality, incidence of T2DM, serious adverse events (SAEs), cardiovascular mortality, non-fatal myocardial infarction or stroke, health-related quality of life and socioeconomic effects.The following comparisons mostly reported only a fraction of our main outcome set. Fifteen RCTs compared metformin with diet and exercise with or without placebo: all-cause mortality was 7/1353 versus 7/1480 (RR 1.11, 95% CI 0.41 to 3.01; P = 0.83; 2833 participants, 5 trials; very low-quality evidence); incidence of T2DM was 324/1751 versus 529/1881 participants (RR 0.50, 95% CI 0.38 to 0.65; P < 0.001; 3632 participants, 12 trials; moderate-quality evidence); the reporting of SAEs was insufficient and diverse and meta-analysis could not be performed (reported numbers were 4/118 versus 2/191; 309 participants; 4 trials; very low-quality evidence); cardiovascular mortality was 1/1073 versus 4/1082 (2416 participants; 2 trials; very low-quality evidence). One trial reported no clear difference in health-related quality of life after 3.2 years of follow-up (very low-quality evidence). Two trials estimated the direct medical costs (DMC) per participant for metformin varying from $220 to $1177 versus $61 to $184 in the comparator group (2416 participants; 2 trials; low-quality evidence). Eight RCTs compared metformin with intensive diet and exercise: all-cause mortality was 7/1278 versus 4/1272 (RR 1.61, 95% CI 0.50 to 5.23; P = 0.43; 2550 participants, 4 trials; very low-quality evidence); incidence of T2DM was 304/1455 versus 251/1505 (RR 0.80, 95% CI 0.47 to 1.37; P = 0.42; 2960 participants, 7 trials; moderate-quality evidence); the reporting of SAEs was sparse and meta-analysis could not be performed (one trial reported 1/44 in the metformin group versus 0/36 in the intensive exercise and diet group with SAEs). One trial reported that 1/1073 participants in the metformin group compared with 2/1079 participants in the comparator group died from cardiovascular causes. One trial reported that no participant died due to cardiovascular causes (very low-quality evidence). Two trials estimated the DMC per participant for metformin varying from $220 to $1177 versus $225 to $3628 in the comparator group (2400 participants; 2 trials; very low-quality evidence). Three RCTs compared metformin with acarbose: all-cause mortality was 1/44 versus 0/45 (89 participants; 1 trial; very low-quality evidence); incidence of T2DM was 12/147 versus 7/148 (RR 1.72, 95% CI 0.72 to 4.14; P = 0.22; 295 participants; 3 trials; low-quality evidence); SAEs were 1/51 versus 2/50 (101 participants; 1 trial; very low-quality evidence). Three RCTs compared metformin with thiazolidinediones: incidence of T2DM was 9/161 versus 9/159 (RR 0.99, 95% CI 0.41 to 2.40; P = 0.98; 320 participants; 3 trials; low-quality evidence). SAEs were 3/45 versus 0/41 (86 participants; 1 trial; very low-quality evidence). Three RCTs compared metformin plus intensive diet and exercise with identical intensive diet and exercise: all-cause mortality was 1/121 versus 1/120 participants (450 participants; 2 trials; very low-quality evidence); incidence of T2DM was 48/166 versus 53/166 (RR 0.55, 95% CI 0.10 to 2.92; P = 0.49; 332 participants; 2 trials; very low-quality evidence). One trial estimated the DMC of metformin plus intensive diet and exercise to be $270 per participant compared with $225 in the comparator group (94 participants; 1 trial; very-low quality evidence). One trial in 45 participants compared metformin with a sulphonylurea. The trial reported no patient-important outcomes. For all comparisons there were no data on non-fatal myocardial infarction, non-fatal stroke or microvascular complications. We identified 11 ongoing trials which potentially could provide data of interest for this review. These trials will add a total of 17,853 participants in future updates of this review. AUTHORS' CONCLUSIONS Metformin compared with placebo or diet and exercise reduced or delayed the risk of T2DM in people at increased risk for the development of T2DM (moderate-quality evidence). However, metformin compared to intensive diet and exercise did not reduce or delay the risk of T2DM (moderate-quality evidence). Likewise, the combination of metformin and intensive diet and exercise compared to intensive diet and exercise only neither showed an advantage or disadvantage regarding the development of T2DM (very low-quality evidence). Data on patient-important outcomes such as mortality, macrovascular and microvascular diabetic complications and health-related quality of life were sparse or missing.
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Affiliation(s)
- Kasper S Madsen
- University of CopenhagenFaculty of Health and Medical SciencesBlegdamsvej 3BCopenhagen NDenmark2200
| | - Yuan Chi
- University Hospital Zurich and University of ZurichInstitute for Complementary and Integrative MedicineSonneggstrasse 6ZurichBeijingSwitzerland8006
| | - Maria‐Inti Metzendorf
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
| | - Bernd Richter
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
| | - Bianca Hemmingsen
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
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Tseng C. Metformin Use Is Associated With a Lower Risk of Hospitalization for Heart Failure in Patients With Type 2 Diabetes Mellitus: a Retrospective Cohort Analysis. J Am Heart Assoc 2019; 8:e011640. [PMID: 31630591 PMCID: PMC6898844 DOI: 10.1161/jaha.118.011640] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 09/10/2019] [Indexed: 12/19/2022]
Abstract
Background A beneficial effect of metformin on heart failure requires confirmation. Methods and Results Patients with new-onset type 2 diabetes mellitus during 1999 to 2005 were enrolled from Taiwan's National Health Insurance database and followed up from January 1, 2006, until December 31, 2011. Main analyses were conducted in an unmatched cohort (172 542 metformin ever users and 43 744 never users) and a propensity score matched-pair cohort (matched cohort I, 41 714 ever users and 41 714 never users). Hazard ratios were estimated by Cox hazard regression incorporated with the inverse probability of treatment weighting using the propensity score in the unmatched cohort and by naïve method in the matched cohort I. Results showed that the respective incidence rates of heart failure hospitalization in ever users and never users were 304.25 and 864.31 per 100 000 person-years in the unmatched cohort (hazard ratio, 0.350; 95% CI, 0.329-0.373) and were 469.66 and 817.01 per 100 000 person-years in the matched cohort I (hazard ratio, 0.571; 95% CI, 0.526-0.620). A dose-response pattern was consistently observed while estimating hazard ratios for the tertiles of cumulative duration of metformin therapy. Findings were supported by another propensity score-matched cohort created after excluding 10 potential instrumental variables in the estimation of propensity score (matched cohort II). An approximately 40% lower risk was consistently observed among ever users in different models derived from the matched cohorts I and II, but models from the matched cohort II were less subject to model misspecification. Conclusions Metformin use is associated with a lower risk of heart failure hospitalization.
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Affiliation(s)
- Chin‐Hsiao Tseng
- Department of Internal MedicineNational Taiwan University College of MedicineTaipeiTaiwan
- Division of Endocrinology and MetabolismDepartment of Internal MedicineNational Taiwan University HospitalTaipeiTaiwan
- Division of Environmental Health and Occupational MedicineNational Health Research InstitutesZhunanTaiwan
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Jeon JW, Choi W, Kim HR, Ham YR, Choi DE, Na KR, Lee KW, Bae SY, Kim SH. Transient Blindness in a Patient with Severe Metformin-Associated Lactic Acidosis (MALA). Electrolyte Blood Press 2019; 17:16-20. [PMID: 31338110 PMCID: PMC6629602 DOI: 10.5049/ebp.2019.17.1.16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 05/12/2019] [Accepted: 05/13/2019] [Indexed: 11/13/2022] Open
Abstract
A 68-year-old man presented at the emergency room with sudden blindness. The day before, he had eaten sashimi and eel and drank alcohol for dinner. He experienced nausea, vomiting, and dizziness afterward. His medical history included hypertension and diabetes, and the latter was treated with metformin. Initial laboratory tests revealed severe metabolic acidosis (lactic acidosis). Massive hydration and intravenous sodium bicarbonate replacement therapies were initiated, but severe metabolic acidosis (lactic acidosis) did not resolve, in turn, leading to hemodialysis, which decreased metabolic acidosis. The patient's blindness improved, and his vision gradually recovered. As it is not easy to distinguish between blindness related to metformin-associated lactic acidosis (MALA) and blindness related to other causes, rapid correction of metabolic acidosis through hemodialysis might be helpful in differentiating this from of blindness from blindness related to other causes.
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Affiliation(s)
- Jae Wan Jeon
- Division of Nephrology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Wonjung Choi
- Division of Nephrology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Hae Ri Kim
- Division of Nephrology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Young Rok Ham
- Division of Nephrology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Dae Eun Choi
- Division of Nephrology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Ki Ryang Na
- Division of Nephrology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Kang Wook Lee
- Division of Nephrology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Soo Ya Bae
- Department of Internal Medicine, Busan Bumin Hospital, Busan, Korea
| | - Seong Hoon Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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